Thursday, June 28, 2007

IM VERSUS ER

Happyman referred me to 911doc's column about the downfall of Internal Medicine and Generalists... but then proceeds to rip Primary Care doctors a new one, including hospitalists (which I was for the last 5 years) because they demand "completeness". He faults IM and FP's for punting to the ER for many different complaints, unwilling to take on the "liability". He laments how we don't want to run codes anymore.

So much is wrong and/or asinine about the column, I hardly know what to say. Being the Angry Doctor, I've decided to say the following: you are full of garbage, 911doc!

Let me tell you my personal favorite story concerning the ER:

One evening, I was admitting an 80 year old female who had multiple medical problems including heart failure, asthma, cancer, etc... yet despite this, she was a sweet old lady and still functioning well. I'm called to see her up on the floor at around 6 PM. I walk in and the woman is gasping practically. I check the ER "workup" sheet. This woman had gotten an X ray, the ubiquitus troponin, and Tylenol. Yes folks, they gave her only Tylenol for her shortness of breath.

OK, so I slap oxygen on her, I go review the X ray, and then I whip down to the ER to confront the physician who sent her upstairs. The attending physician listened to my diatribe, and then called over his resident and said "Dr. Angry wants to talk with you."

Fine, I said, if you want to sacrifice your resident to me, be that way.

I begin my tirade: "Ms. so-and-so is gasping upstairs. You didn't do anything down here for her, so obviously you couldn't have been that concerned. Why did you admit her?"

"Shortness of breath.", the resident replied.

"Well, she had a history of asthma. Did you give her any nebulizers?"
"No." he repsonds.
"Why not?"
"Because she wasn't wheezing."
"So then why did you admit her?"

"Shortness of breath" he replies.

"Her X ray was reported to have an infiltrate on it. Did you think about giving antibiotics?" I mused.
"Yeah, my attending and I looked at it, and we just didn't think she had pneumonia. She had no fever or cough."
"So why did you admit her?"

"Shortness of breath" he replies.

"She has a history of cancer. Did you consider a pulmonary embolus?" I ask.
"Yeah, she just didn't seem like she had a P.E."
"So why did you admit her?"

"Shortness of breath" he replied.

"She has a history of heart failure. Did you give any lasix?"
"No. There was no congestion on the X ray."
"So what did you admit her for?"

Do I even need to type his reply?

I was shocked. Usually my complaint about the ER is that they perform and administer many unnecessary things, making it harder for those lazy internists upstairs to make a diagnosis. Here was the exact opposite: they had done NOTHING! (Oh, except they gave Tylenol. I forgot.)

So I turn up her oxygen, I give her nebulizers, I give her antibiotics. I gave her lasix.

It doesn't occur to them that maybe she doesn't have a fever because she's immunocompromised from cancer. It doesn't occur to them to check for a blood clot, even with her unexplained dyspnea and history of cancer. That maybe she's not wheezing because she's having what they used to call stage IV asthma.

I get called two hours later and the nurses are like "she's still very short of breath." I say "OK, give her lovenox and get a stat CT angiogram" And guess what... she had THREE PULMONARY EMBOLI in her lungs. (Gee, good thing its not an emergency, right ER docs?)

So it's just as easy for me to make disparaging remarks about the ER's complete lack of motivation to diagnose (DISPO DISPO DISPO... the mantra goes, right?) as it is for these ER heads to lament how lazy primary care docs have become. Why all the intellectual dishonesty? We all know the truth: the REAL reason ER docs didn't do primary care is because they don't want to deal with chronically ill patients and their paperwork! If they had to look at a patient for more than twelve hours, they would start yelling "Why isn't this patient upstairs???" The worst time to BE a patient is that lull between ER admission and going upstairs because everybody knows the ER doc has lost interest in you.

My best friend is an ER doctor. And I did rotations through ER as a medical student and a resident. (I actually did more shifts than the ER residents themselves.. their way of dumping on the IM residents I imagine). It's a tough job and it requires real skill. But don't pretend that primary care doctors aren't doing exactly what they're supposed to be doing.

Part II of this rant tomorrow.

64 comments:

Happyman said...

brilliant.

i too have seen disasters mis-triaged from ER. I think probably 10% of patients admitted to the med-surg floors during residency needed ICU transfer within 12 hrs. This will inevitably get worse with the growing use of mid-levels and cookbook medicine as ERs get more overloaded.

And I really don't get the whole "PCPs abusing the ER" thing - isn't their WHOLE PURPOSE to be open & available 24/7, and to get a quick rule-out of something life-threatening and/or expedite the initiation of necessary treatments????

So what exactly is wrong with sending a cellulitis to the hospital thru the ER from the PCPs office? If the guy needs IV antibiotics, I suppose I could admit him "directly" to the floor, but realistically the guy won't have orders for like 4 hrs, a blood culture or IV line for like another 2 hrs, the first dose of antibiotics the next day, and all the while the ER docs will have missed out on a piece of their productivity bonus!

i suppose i could get together with a bunch of colleagues, open an urgent-care center, do our own labs, buy a ct scanner, and stay open 24/7. but if i wanted to do that, i would've just become an ER doc & worked for a hospital instead.

the fact that ER docs (and especially nurses) cannot see the value in PCPs managing chronic conditions and keeping patients OUT of the ER is part of a vicious cycle. As fewer docs do primary care, and ERs get more crowded, ER docs will become de facto primary care doctors for a larger and larger (and fatter and sicker) percentage of the population.

then they can bitch all they want about primary care, but they'll only be talking to themselves.

Anonymous said...

Well said, Happyman!

Eagerly awaiting that time of my salvation...

Anonymous said...

I can certainly sympathize with your commentary on ER mis-diagnosis; I've seen worse, but your presentation is highly exaggerated if you present this as the de-facto standard by which ER physicians practice. For the most part, we are compelled by QI regulation and internal desire to develop a diagnosis that makes sense, and generally do what we can to initiate appropriate treatment in a timely manner. Not all diagnoses are immediately obvious, as you demonstrated (Lasix, abx, nebs...then you finally clued in on the PE). Pure shotgun medicine at its finest. Seems a bit cheeky to condemn for not packaging that patient perfectly for you. But then of course, that was the reason for the original post from 911doc.

I do take issue with the flurry of patients that stream from clinics and urgent care centers in the name of CYA medicine. Staff members tell patients with a swollen ankle to go to the ER to rule out DVT; Present to an urgent care with fever, cough, sore throat and neck pain, and you get sent to the ER to rule out acute bacterial meningitis. Back pain for one year? Ran out of your MS contin or fentanyl patches? Go to the ER for a stat MRI ... at 8pm!! Yep... seen that end of things too.

Oh yes, and before I forget, sending a patient to be admitted to the hospital via the ER so they can get abx in under 4 hours is ridiculous when some ER waiting rooms have >6 hour wait times! Perhaps if you didn't consider the ER to be an extension of your outpatient clinics, the wait time might be less. Next time, just save us all a big hassle and follow these few tips:

1. Try to examine the patient thoroughly before punting to the ER
2. Consider the possibility that Derm does not take ER call
3. Perhaps the elective CT or ultrasound is NOT an emergency
4. If you tell the patient that you will meet them in the ER, ACTUALLY show up
5. Don't send the note explaining how to work up pneumonia
6. Explain to your mid-levels that iron-deficiency anemia with a hgb of 9 does not require an ER workup and emergency transfusion.

Mike said...

Pure shotgun medicine? Au contrair. Thats what the ER DOES!!! They aren't CAPABLE of fine tuning a diagnosis, as you so vividly point out. I just was treating the obvious. There was an infiltrate on the CXR as I said. And mild edema might not be obvious on an X ray. I didn't want to give lovenox if it wasn't necessary, as it has a lot of side effects.

Point is, for every bad PCP story, I've got a bad ER story. For every bit of "advice" you have for us, I've got a DAMN WHOLE LOT for you.

Happyman said...

"Explain to your mid-levels that iron-deficiency ..."

what f---ing pcp can afford a mid-level??? you must be on crack.

i'm on the phone with PAs and NPs in an ER at a WORLD FAMOUS MAJOR ACADEMIC MEDICAL CENTER in NY explaining how to work up simple shit all the time.

and not sending ankle swelling to the ER? am i supposed to use my x-ray vision??? what error rate is acceptable to you? ie. is my clinical judgment acceptable to you and your undertrained mid-levels & egotistical nurses if only 25% of the swollen legs i send to you are positive for dvt? because the lower that number, the more that i DON'T send that are positive - simple statistics, get it?

Happyman said...

and what if the iron deficiency with a hb of 9, is a 30 yr old with one week of rectal bleeding, dizziness, and a baseline hb=15? is THAT an appropriate ER transfer?

i bet if it was your brother it'd be okay.

i love when the ER notes on admitted patients say shit like "hb stable at 10" - how can something be STABLE (whether labs, vitals, or whatever) when there's only ONE reading???

Mike said...

Awesome analysis Happyman.

I love all the "friendly advice" from the ER heads. Its dripping with sarcasm of course.

Thanks for advising us to "thouroughly examine the patients". Before I was just touching their shoulder. I'll be more diligent next time.

Anonymous said...

Mike, I live and practice in the real world, and despite your practice environment, many clinics and PCP providers are using mid-levels to keep costs down and increase profit margins. It is becoming the reality of primary care, as PCP's are forced to minimize patient contact and maximize patient throughput to keep the staff paid and the electricity on. You really need to start going to more conferences and talking to your colleagues so you can find out what is really going on. Many mid-levels out there are running their own clinics "under" a supervising doc, but funny enough, the patients think the PA is a real physician, and the PCP is happy to keep it that way. Volume baby, Volume!

Don't kid yourself by saying no shotgun medicine! You gave every treatment available except the lovenox, and without a diagnosis. Look hard enough, and every CXR has an infiltrate. Kudos for ordering the CTPA, but don't blame the ER, cause you didn't think of it at first EITHER.

Happyman:
The 30 year old patient that shows up with a hgb of 10, clearly iron deficiency, previously 15, likely did NOT have rectal bleeding for one week. More like one month. One again, please don't exaggerate to prove your point. Are you concerned with diverticulosis, rectal cancer, or IBD? Still doesn't require an ER workup. Patient symptomatic? Dizzy, hypotensive, traumatic injury, AVM? abdominal pain? Now we're talking, pal. In all seriousness, we get patients with a routine lab, hgb of 10, no prior labs, no outpatient workup, no symptoms, just a note on a script pad sayin..."please evaluate and manage" WTF!!!

Sending a patient with a legitimate concern for DVT is one thing (risk factors, LEG/Calf swelling, Homan's sign, etc), but if YOU don't see the patient and your staff just shotgun tells the patient calling in to "just go to the ER" for a swollen ankle, well then, I guess you'll never miss a DVT now will you. Good medicine, buddy!

Your chest starts hurting, or you get rear-ended on your way to the clinic, you're more than happy to see us, and all too angry that the waiting room is full of your clinic dumps.

Anonymous said...

"Are you concerned with diverticulosis, rectal cancer, or IBD? Still doesn't require an ER workup...."

How utterly laughable since on my hospitalist shift today I admitted one of these from an ER doc who just "couldn't d/c him". The difference between me and you is I have spent significant time in ER's (as a hospitalist and a moonlighter in places that couldn't afford/attract a "board certified" ER doc). How much time have you spent on the wards/office SINCE YOUR RESIDENCY. I've often thought places like UW have the right idea for you egotistical self absorbed jackasses. Let the surgeons/IM docs/pediatricians run the ER's and leave you guys and your 12-14 shifts per month the hell out of it all together. Frankly any of us can manage issues in our own specialty better than you can anyways.

Anonymous said...

OK Anonymous internist. Highly doubt you spent more time in the ED than me, as you don't know my age, but whatever makes you feel better. Can't argue with you if you admitted diverticulosis to the hospital (unless you can't tell the difference between diverticulosis and diverticulitis.) That would never fly at my hospital, and nobody I practice with would try to sell that to an internist who knew his anus from an earthen rent.

You seem like you haven't a clue about emergency medicine or what it entails.

Believe me, when the time came to perform an emergency crich or a thoracotomy, very few internists would be willing to stand up and make the first cut. Perhaps you would, and perhaps you chose the wrong profession. Not my fault. I rather enjoy my 12-14 shifts per month.

Mike said...

Anon 11:28

As I said in my post, I DID think of PE, as I chided the obviously bored ER resident for not thinking of it. He did his job though.. he admitted her. Thats all an ER monkey has to do,right? Dispo dispo dispo.

As for midlevels, I never comment on that in my post, so I dont know what your beef is.

And the RADIOLOGIST said there was an infiltrate. So I disagree with your asesertion that EVERY CXR has an infiltrate. Face the fact.. these clowns weren't interested unless she had a bullet wound or something. Thats why people go into ER. Or did you somehow convince yourself otherwise since you did your residency?

As Shakespeare said "To thine own self be true".

Happyman said...

anon ER guy-

1- i DID say the 30yo was dizzy (even otherwise i don't think this is an inappropriate ER referral at all)

2- without all the stuff in the ER you feel is non-emergent, you'd be out of a job. being so oblivious to the business end of your job, you're either an ER intern/resident, a salaried PA or NP, or very inexperienced and not aware how much money the insured patient without DVT makes you, and how little the uninsured patient s/p MVA does.

3- every CXR has an infiltrate??? Now I'd be SHOCKED if you were actually a seasoned ER attending. how ridiculous - the VAST MAJORITY of CXRs done in the ER are negative (ask your attending if you don't believe me); any experienced physician in the ER or anywhere knows that. stating otherwise is proof that your role is just triage, as you can always justify admitting for "r/o pneumonia" when no criteria exist otherwise & you're afraid to dispo to home.

I'm sorry you are annoyed with some of the less glamorous stuff in the ER - maybe you should've gone for trauma surgery residency instead.

Anonymous said...

Ok, happyman and Mike. You guys need some coffee. Clearly the xray comment is dripping with sarcasm, but if you want to take things literally, well, I pity your patients that you can't see the forest for the trees.

Mike, the comment about midlevels is a generalized comment, meant specifically for the large numbers of pcp's out there that utilize them and let them abuse the system. Believe me, there are many more emergencies out there than the trauma, but since you have little knowledge of that, well, shame on you. It is amazing that your arrogance for your specialty makes you believe that all internists are somehow qualified to handle emergency care. Primarily, they go running away from codes and intubations. Maybe you don't, but don't be so arrogant to assume that your brethren are as qualified as EM physicians to handle these things.

Happyman, you are just too ridiculous to even return the comment.

Mike said...

As I said in my post, I did a month of ER during residency. And a month as a med student. Been there, done that.

How much clinic time, however, have YOU done?

Anonymous said...

Mike, may it surprise you to know that I have a great deal of experience in clinic settings, initially in family practice, then after seeing the light, in residency. Now, as a medical student, I rotated through weeks of clinics, from FP, to IM (as a student, I spent a year - yes, a year - at the VA hospital in the same clinic, seeing patients, and rotating them through every 3 months for repeat visits. OB/GYN, Cardiology, Peds, IM, FP, Ortho, Surgery, Burn care. I have far more experience in clinics than you could ever have in the ER. That is neither here nor there. Mike, this is not an adversarial post, only to demonstrate that I am more familiar than you think, and I, once again, defer to the arrogance you and Happyman display with regard to your colleagues. If you are comfortable handling emergencies, well then, great! But don't assume that IM/FP physicians are comfortable with emergencies, especially in this medical environment that forces them to punt EVERYTHING to subspecialty care. Blog about that!

Happyman said...

anon 3:34-

i didn't say i wanted to handle emergencies - that's why i'm not an ER doctor.

and how do you do residency BEFORE being a med student???

Anonymous said...

Happyman, it wouldn't hurt you to try to decipher a bit more information before acting, perhaps you might send a few less people to the ER unnecessarily. I'll try to explain this carefully for you. Medical school, family practice residency, private practice, saw the light, emergency medicine residency, several years in a successful group practice in a community ER.

Suffice it to say, I've seen both sides of the fence, and I know how the system works. The system is broken. We turf everything to someone else so that no one carries a coffin alone. Or at least that is the mindset that is shared amongst physicians here in the US. the litiginous nature, and the profit-mongering legal community have put the fear into the practice of medicine, and stolen the art. I'm just asking you to remember the art of medicine. The job cannot start and stop in the ER.

Happyman said...

anon ER guy-
why do you highlight all your med student clinic experience in the post above (3:34), if you've done an ENTIRE family practice residency & practiced FP?

i assure you that, practically speaking, it's IMPOSSIBLE to simply turf every rash to derm & every earache to ENT and still maintain a viable practice. Internal medicine is becoming geriatrics by default, and most patients will not put up with being given the runaround. And that generation also has a greater appreciation for longitudinal care.

And if they're too sick to be cared for without hospitalization, then so be it, they're sent to the ER (even if they're octogenarians).

Anonymous said...

Happyman, the above post goes to illustrate that your blanket statements about ER physicians (residency trained) are ridiculous and un-informed. Even without the FP residency and practice, the level of clinic time and training rises well above the level of ER training which you so indignantly tout as your "expertise" in emergency medicine. This is the standard for most medical students, and all ACGME-approved EM residency programs. Some programs require a transitional year or prior internship before starting the additional 3 year residency. Some are 4-year programs and are very intensive in clinic and inpatient/ICU care training.

To get back to the original point, there are certainly mishaps occurring in ED's regularly, and it would serve you well to understand the complexities of the ED, from medico-legal standpoints, to practical issues of patient flow. The staff/physicians at King/Harbor are realizing this, as are many other departments that are in a state of crisis throughout the US. We, as physicians, must recognize that ED's are improperly used at all levels, from over-cautious practitioners, to under-medicated patients who are seeking unencumbered narcosis. There are so many other layers in between to complicate things, and as leaders in the medical community, we must step forward and do what we can to improve the flow of patients through the ER, or else it might be one of your patients to suffer and die in the waiting room. This starts with the mentality that everything must go through the ER to get things done faster. Your original post alluded to no concerns over this practice. Sure, we would love to see everyone, and maximize what we can, but with a limited system, limited nursing resources, limited beds, and limited time, we have to balance that with patient safety, comfort, and satisfaction. It is distressing that a man with a kidney stone must wait 5 hours to be seen and treated because the cellulitis you sent is taking up a bed. How fair is that?

Anonymous said...

Angrydoc,

You're perfectly right in being frustrated as to how this ER worked up your patient. In fact, they didn't - they merely shipped her upstairs with no diagnosis.

That having been said, you triaged the patient as a proper ER would have. SOB? In the setting of cancer? With a history of asthma? With an infiltrated on CXR? In a febrile patient?

Alright, so based on what is known, where are we? PE vs PNA vs neutropenic fever vs asthma exacerbation. Let's get a ct-chest, d-dimer, cbc. While we're at it, let's get basic lytes and cardiac enzymes since she's 80, postmenopausal, we don't have access to 10 years worth of clinic medical records, and we don't want to get sued.

Once we have those results, let's spend some time thinking about what we now know, and then move on to what is possible, then to what is true.

The thinking I've seen in IM and FM starts with wasting a whole lot of time with what is possible, invariably including a whole lot of what isn't possible, even some things that are blatantly ridiculous; only when Harrisons has been re-written piecemeal on the way to constructing an absurdly long differential diagnosis list can we start to think about what is actually going on.

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