Sunday, July 1, 2007


Here are four scenarios:

1)A patient has their PCP paged at 6:30 PM, after hours, when the PCP is on the way home. They complain of diarrhea and abdominal pain that seems mild, but has not stopped.

2)An older patient comes in without an appointment and complains she saw blood in her toilet. She has felt dizzy and wanted to run in to see her PCP. But the office is swamped and she’d have to wait. There is no nurse to draw blood.

3)The lab calls with an emergency value. The potassium is 3.3.

4)It’s the weekend. The lab calls: INR is 5.

So what should a PCP do? Should he:

a)Tell these patients to wait until they can be seen
b)Tell them to go to the Emergency Room?

I don’t feel there is any other answer to the question than ‘B’. And I’ll tell you why. Because momma raised me to NEVER DIAGNOSE OVER THE PHONE! That is just something a doctor should not do under any circumstances. And unless the office has a nurse and a lab, as well as NG tubes, central line kits, and blood, you’d have to accept the fact that most PCP’s offices are not equipped to deal with these situations anyway.

Case one is based on an actual gastroenterologist in Florida who was told by a man’s wife he was having these symptoms. He advised Maalox and see him the following day. He ended up having IBD and dying that night. Oops. Malpractice ensued of course.

Case two is common enough. And I don’t want to personally wait on a CBC for a whole day, even with negative orthostatics, as that physical exam finding is notoriously unreliable (I can cite an ER doc who made this statement at a conference if anyone takes umbrage with that.)

Cases three and four speak for themselves. Even if I called the patient with low potassium at home and asked him to check his pulse, I’d STILL not take a chance. Same goes for the INR patient.

911doc made the following statement:

Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me. What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.

I say “Yeah, so what?" Is there something different an internist or FP could do in the office for these patients? I fail to understand the point and what should be different. What is an emergency room for? If the chest pain is even remotely possibly cardiac, that’s an emergency. At least for me it would be.

Whether the PCP shows up at the ER, whether the PCP sends a note, whether the PCP’s midlevel made the call are all complaints that have NOTHING TO DO with the point 911doc is making, which I find is false and hollow.

The fact is, is that hospital care doesn’t pay enough for the time spent. So if a PCP hasn’t placed a central line since residency, so what? An ER doctor probably doesn’t remember a lot of other things they once learned in medical school. Because they don’t need to know them anymore. And even if I placed a central line in my office, then what? I don’t have a 24 hour center in my office. Even if I ran a code, they still have to go to the hospital.

I had an ER attending tell me he wouldn’t do a paracentesis because he wasn’t covered for that under his liability insurance. The resident under him couldn’t believe it any more than I could. He probably just hadn’t done one in years. And you know what? Big deal. So I did it. And now it’s been years, and I probably would have to remember how.

Big deal.

Hey 911doc, here is your generalist. And nothing has happened to me! Your head just got a little too big.


Happyman said...

good post angrydoc.

Again, the point seemingly cannot be made enough: Primary care is for the ongoing management of chronic disease and preventive maintenance. It is a role that ER folks will continue to denigrate as long as they feel superior in their comparatively controlled & supported environment. Somehow the more senior experienced attendings are MUCH more respectful of internal medicine & primary care than the newbies.

Of course, all doctors should be somewhat skilled in managing emergencies, but the purpose of the ER is to rule out the potentially life-threatening quickly and/or initiate needed treatment expeditiously.

That some of it is "non-emergent" like calf swelling over the weekend that results in a negative doppler, is necessary "error" - without that we'd be missing stuff that IS emergent, ie. it is impossible to be 100% accurate in the office by history/physical alone, so it's better to err on the side of caution and assume it could be emergent & initiate the necessary workup quickly.

scalpel said...

As a board-certified internist myself, I would laugh at you if you sent an asymptomatic patient to the ER for a potassium of 3.3 (assuming normal is 3.5-5.5).

And I might even suggest to your patient (after their 6-8 hour wait to see me) that they might want to find another physician.

What do you think we are going to do? Give them an IV infusion? Sheesh.

Mike said...

scalpel... I wish you would be honest withyourself. A patient with a K outside of normal should have a repeat stat K. Most board certified internists would agree.

As for advising them to find another doctor, yeah, I wouldn't want them to have a careful doctor who was worried about an important electrolyte. Let em sweat it out with a more cavalier doctor. Good one.

scalpel said...

I think you are overcautious, but it would obviously depend on the specific patient.

A cardiomyopathy patient with a history of ventricular tachycardia who is scheduled for AICD placement next week....sure.

A housewife whose only medical condition is mild hypertension who takes a thiazide....give me a break. Tell her to eat a banana and see her in the morning.

Here is what happens if you send her. You get the lab result at 5 pm. She goes to the ER at 8 pm (the busiest time). There are 20 people waiting to be seen. Her vitals are stable and she is asymptomatic, so she is last on the list. Maybe the triage nurse has time to draw her blood, maybe not. She certainly isn't getting a cardiac monitor.

So she waits, and waits, and finally gets back to a room at 2 am. Blood is drawn, and she is discharged at 4 am with a potassium of 3.5 (now normal). Or maybe it has dropped to 3.1, so she is given 50meQ of oral potassium and told to go see you in the morning. I might even call you to wake you up to tell you the disposition.

The chance of a healthy person suffering a problem from a potassium barely abnormal (and probably within the range of error of the instrument) is negligible.

Her anger at your improper management is less so.

scalpel said...

I don't want to seem argumentative, because I agree with the other points in the original post. But the potassium issue is ridiculous.

Anonymous said...

Scalpel, Angry Doc. is not the only Doc. who see's this level as being a possible emergency. This just happened to hit home for me, is the only reason I am posting this.

Last year, I saw a Dr. At Cleveland CLinc for a workup. I had alot of blood work done that day. By the time we had made the 3.5 hr. drive home, there was a call on our answering machine from him to call his office ASAP. This scared me to death so of course I call immediately and he is still there. He comes on and tells me he is very concerned becuse my potassium was to low.

It is Friday afternoon (late afternoon) so I know my local PCP is gone for the weekend. This CCF Doc. says it is way to dangerous to wait until Monday and he wants the name and number of my pharmacy so he can call in a prescripion for Potassium and does so pronto. My number was....3.3!

scalpel said...

Err, yeah. Dangerous enough to call in a script maybe. Not dangerous enough to make you spend the night in the ER.

Richard A Schoor MD FACS said...

I agree with you in theory, but in actuality you just can't send every patient who calls to the ER. You'll anger the patients. Best way, in my view, is to try to take a good history on the phone and go from there.

Mike said...

scalpel... the whole idea is at least they are IN the ER. If they collapse in the waiting room, then I made a good call. If they don't, then I erred on the side of caution. Everyone knows you wait forever in the ER.

Independent urologist... in all the scenarios I posited, no amount of phone history would change my decision, but I agree it is impractical to send EVERYONE to the ER. That's not reality anyway. Most ER bullcrap is homeless, uninsured, drug/alcohol users or people looking for free care (i.e. free pregnancy test, read CharityDoc's blog for that)

scalpel said...

I don't think anyone in the history of mankind has ever collapsed because of a potassium of 3.3, whether they are in the ER or not.

I linked to this on my site, btw, because I think this is an interesting discussion. Thanks for initiating it.

Mike said...

scalpel... its not the K of 3,3. Its the REPEAT K. I cant make it any clearer except by example. A patient in my hospital had a K of 3.3, and then it drifted down, and no one followed it up.

And you were right, she was totally asymptomatic.. until she coded and died of hypokalemia. It always STARTS at 3.3. It just may not end there.

And the magnesium may also be low at this point. To wait seems unwise.

scalpel said...

Umm...yeah. That's why you should call in a prescription of K-Dur. So it doesn't drift down to a dangerous level. Of course such a drift would not likely happen overnight, unless the patient had a severe gastroenteritis or was on high dose lasix.

So you call in a prescription, and then you see her back in a couple of days to follow it up. That's good medicine, right there.

Anything less is laziness, and your patients will eventually figure that out.

High potassium is what you should be worried about. Much more dangerous than low potassium.

Anonymous said...

Scalpel, thanks for doing your best to educate these two. Surely they sleep well at night knowing that they sent their hypokalemic (3.3) patient to get a repeat K. Unfortunately, the patient (and family) didn't sleep well. Now, that may seem like good medicine, and by that same token, sending all patients with a question or concern, or a symptom to the ER is probably good medicine to in the Harrison's guides for Happyman and Mike, but for the rest of us, we tend to think through the issue and decide if emergency exists or not. Rest assured, the patient will find out if an emergency existed or not. Particularly if they were told to expect to be admitted and ended up going home.

Anonymous said...

Now 10 years into my career in Emergency Medicine and seeing the increasing frequency of PCPs dumping their overflow patients into my overswelling ED, this issue of the abnormal lab value espcially strikes home. An elevated K level? Absolutely...send them in, I am worried. But I have to agree with the previous posts that I can not justify the K of 3.3 being sent in for an evaluation. Over 90% of what you need to know can come from a thorough history...over the phone or in person. What has happened to the art of medicine? We are overreliant on tests (and more tests) rather than listening, evaluating, assesing the complaint, what meds the patient is taking and any recent med changes. I am continually frustrated that our local (and overworked) PCPs don't have adequate room in their schedules for urgent complaints and even ED follow-ups. On the other side of the coin I recently cared for an 85 year old woman who went to sleep with bilateral arm aching and diaphoresis, awoke felling okay but tired, sees her MD who orders labs (no ECG), is sent home only to be called later (and said MD also called 911 to go to her house) for the troponin of 21. Yes 21.0. The system is broken and I don't know how to fix it when the specialists make buckets of money and the grunts make a relative pittance...and don't get me started on the radiologists with NPC (no-patient contact) and Night Hawk to read their overnight films while they rest soundly with no overnight work. Bitter and moderately disgruntled, but calling the spade a spade.
PS--the INR of 5 who isn't bleeding or symptomatic (ask the questions) can also wait for followup and instructed to hold their coumadin dosing.

Anonymous said...

Left this comment at scalpel's blog; guess what his response was?

"With you Mike!

Like scalpel, am a BC internist; unlike scalpel, I have not totally disengaged myself from managing CHRONIC illnesses in the comfort of an ER where you get labs -repeat or not- fast enough to truly make meaningful decisions, i.e. w/o worries whether the value stabilizes where its ought to be, or it has gone exactly opposite and the patient is on the way to the ER via 911.

Internists and FPs in the trenches follow chronic patients with globally complicated and chronic problems. Yes, GLOBALLY COMPLICATED AND CHRONIC PROBLEMS! ISOLATED K 3.3 on relatively stable HTNsive diuretic regimen - like scalpel said, let them eat bananas. BUT how many IM/FP patients have that isolated condition? If they are getting INRs too, chances are they must be at least cardiomyopathic, fibrillating geriatrics! I wont dare play with hypoK and dig...if they have COPD, yes - Mg to boot!

To nurse K,etc. - again you are way out of turf in your critique. Take MCAT and be on your way to your missed calling. If you cannot pass the MCAT, it should tell you how little you know about simple reading and comprehension. Whatever indicated to you the labs were drawn without exam of the patient?
And if I can "see" hypoK or INR elevation by physical exam...that patient needs to be in the ER pronto!
Do you have a slightest clue how outpatient medicine workflow goes? Or has your [hated] long hours in the ER made you think that outpatient offices have capabilities just like an ER, except office hours are 8-5? Where are you coming from? "

-POed at nurses and midlevels who think they're bigger than the elephants they're perched upon

Anonymous said...

To answer the question in the title:

1) Normal country: Next day in the office. No ER. US: Go to the ER. Do not pass Go.
2) Normal country: Go to the ER. US: Call 911 to take patient to the ER.
3) Normal country: Call patient. Tell him to take KCl, eat bananas, whatever, and come to the office on Monday. US: Tell him to go to the ER. NOW!!!
4) Normal country: Call patient, ask about bleeding symptoms and signs, tell him to stop warfarin, counsel about bleeding risk and signs. US: Call patient, tell him to stop warfarin, and to go to the ER in case of the smallest bleeding, like the one after a razor nick. Better, just go to the ER to rule out acute bleeding.

Normal country: you do the best job you can, and you don't have to care about losing your life's earnings because of one mistake (or because of a sleazy scumbag attorney who is better than yours).

US: you waste a lot of time and resources covering your a**. You try to be as pessimistic and paranoid as possible, focusing on "how would this look if I were sued", not common medical sense.

Mike said...

anon above... cannot argue. But, as you say, I do live in the US...

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Anonymous said...

This was posted in Scalpel's blog as comment to continuing "dialogue" regarding issues wonderfully manageable by retrospectoscopes...

EX. Mgt of Elevated INR > 4

POed at pompous ER workers said...

Interesting... nurse k's own admission: anyone who can plug in terms [even if mis-spelled] can search Google. Agree 1000% - no need for MCAT nor residency for that!

...wonder how this information will help any liable prescriber, when he/she sits in deposition for a mishap that the article itself, written by an ER physician cites:

"Warfarin has been implicated as the one medication associated with the highest incidence of outpatient morbidity, and up to 10 percent of patients will experience a bleeding episode on this drug. Most emergency physicians have a limited knowledge of warfarin, and primarily understand bleeding complications.

"Summary: Patients treated with warfarin can become excessively anticoagulated in a rather surreptitious and clandestine fashion. Even if the INR has been stable for many months, there are just too many variables in maintaining a proper INR to allow patients and clinicians to eschew INR testing on a regular basis. This is especially true in ED patients. My advice has always been to do an INR on almost any patient taking warfarin who presents to the ED with almost any complaint or issue. If nothing else, you give them a free coagulation update. Particularly at risk for erratic INR evaluations are elderly, noncompliant patients and those with excessive comorbidity (and that probably defines almost anyone on warfarin). Even minor changes in diet can wreak havoc with a previously stable INR. Those otherwise healthy leafy green vegetables contain vitamin K that can negate warfarin effect. Of course, almost any drug you prescribe, even antibiotics, will bump the INR one way or another, usually to the upside."

...2 quotes above make the points of the article, written by an ER physician, ironically for his ER colleagues who maybe lost at how to manage elevated INRs

...after ruling out bleeds not discernible by history alone [or even physical exam unless, bleeding is already overt], the ER docs problem goes back to the admitting colleague if he/she, despite additional information gathered from the protected STAT capabilities of the ER, insists on admitting just to feed the arrogance and irritation started before he/she put on his "RETROSPECTOSCOPE"

...funny but not, perhaps the Internist who has escaped into the protected box of the ER, will never have to deal with the liabilities and risk numbers cited in the article, and can continue to be arrogant and pompous

'nuff said

POed at pompous providers carrying 20/20 retrospectoscopes

Dr. David said...

Telephone triage? What's that?

Anonymous said...

I am an ER doc practicing in California in a county hospital (and a private hospital to fund the kid's college funds ;) and certainly appreciate the discussion going on here.
The only comment I have is on the K+ of 3.3. If the patient came to MY ER with a note from the PMD of "Pt's K+ is low, 3.3", I would indeed intervene. By re-checking the K+. Still low? Likely an Rx for bananas. Or K-Dur.
The point is that when they are sent in for seemingly obnoxious reasons, I do not have the "cajones" to just say, you will be fine and followup with your doctor tomorrow. Nope. I will recheck the lab. And I think this is an important consideration that we, as ED docs, need to think about. If the PMD's could get stat electrolytes they would probably, hopefully, not "dump" these patients onto our ERs. However, the truth is that they cannot and in this day and age of ambulance chasers following our every (mis)steps, we do tend to be overly cautious.
Let's have some perspective. When I see the patient sent in for a K+ of 3.3, I feel relieved that, 1) they will likely not be spitting at me, 2) I do not have to do a rectal/pelvic exam, 3) they will have appropriate followup and 4) they have a chief complaint that is easily addressed and managed! These patients are rarities now adays and I find it as a mini-break when I get to talk to a 'normal' patient with a simple problem.

Please don't think I am siding with the PMDs. I'm not. But I understand why they would send their patients in for a stat recheck. If we (ie ER docs) would NOT send the patient in under that circumstance then feel free to just re-assure the patient and have them followup with their PMD WITHOUT rechecking the K+ level. Because as soon as you decide that you are going to get a STAT Chem-7 (or better yet, Chem 10 to check the Mg) then you cannot reasonably argue that the PMD should not have sent the patient into the ER.

Mike said...

anon 4:25...

Thank you for at least agreeing that ER docs are just as guilty as the PCp's for doing what we wish we didn't have to. (send pt for K of 3.3)

I don't think scalpel or any of the ER guys should have any beef with that.

But they do.

Anonymous said...

Very interesting to hear the point of views. Especially about the K+. I had a K+ of 3.3, might still have for all i know.It was found out because i presented to my GP with giddy, pre-synocpial episodes, getting worse but hadnt fainted. Was in sinus rhythm when pulse taken. I went for a follow-up on blood results was told low K+ (and urea). Told to eat a more balanced diet and not to worry. being a medical student i knew what had K+ in so made myself eat the occasional banana. This hasnt even been followed up or asked about.I'm still here and still get giddy. that all happened 15-18 months ago.

That is a complete contrast to what AngryDoc is saying he would do. I live in the UK and wonder if this makes a difference.

Anonymous said...


Anonymous said...

How bad is a level of 2.8 considered? I know it's considered to be a deficiency but HOW bad is that esp w/ someone that has COPD.

Thank You, JMT

Spanco said...

I am really very impressed from this article. I agree with all. But i think the main duty of the doctor is to save the life of a person without commenting anything.

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