SERENITY NOW

I wonder if there are PAs who ever work with the coroner haha

I'm frequently on interviews for PA/NP candidates in our group. We look for a few key things... 1) experience related to the job (even if before PA school) and dedication to the field 2) personality and how well spoken they are. Do we think they'll fit in with local culture of group. 3) likelihood to stay. What ties you to the group / the area? We want longevity, so convince us of that. 4) some questions we ask: what are your weaknesses you've noticed so far in practice? What do you want in a group? What's your 5 year plan?

Students, beware of a few cognitive biases / traps that are super common and easy to fall into: anchoring bias and diagnosis momentum. It happens all the time and results in many misses / lawsuits. This case is a perfect example. If we hear, "sent with shortness of breath from likely GI bleed and concern for anemia", many people anchor on that and go down that one pathway of "GIB". Look at all factors in the case and see if any don't fit.... does GIB and anemia cause hypoxia? Would you expect hypotension from a GIB have a normal HR? Don't let yourself be pigeonholed! This patient is significantly hypoxic, and is in shock... expand your differential to address both. Great case so far, E... excited to see where this goes.

Wanted to resurrect this old thread to share another VERY useful exam finding that has changed my practice... I now look for this every shift in the ED: Spontaneous Venous Pulsations ("SVP", as part of the fundoscopic exam). I use it as part of my assessment for every patient presenting with headache, neurological complaints, severely elevated blood pressure, etc. I started doing this a couple of years ago after hearing Greg Henry, a legendary EM lecturer and expert on everything medicolegal and neurology. One of his main take home points was that you haven't completed a thorough neuro exam until you've looked in their eyes and watched them walk. People will say the fundoscopic exam is too hard to do on a nondilated pupil, but let me tell you that after practicing this for 1 week, you'll have it down, and after a few months you'll be able to get it done in about 30 seconds. How does the exam technique work? Dim the lights, have the patient focus on a specific point across the room (use accommodation to dilate the pupils as much as you can), start by looking nasally, find any eye vessel and follow it both ways until you find the optic disc, and look for the pulsing vein. Done; its really quick and simple. Its easier to find this than papilledema in my opinion, and its present in the vast majority of patients... Why is it important? The presence of SVP essentially rules out elevated intracranial pressure, which can be seen in a TON of conditions. Conditions like space occupying lesions (tumor, abscess, bleed with mass effect), increase intracranial fluid production (pseudo tumor cerebri, meningitis), outflow decreases (hydrocephalus, cerebral venous thrombosis).... So, by confirming normal ICP, the likelihood of all of these things decreases substantially. The majority of headache patients need no emergent workup in the ER, but you need to do a thorough clinical evaluation. If there are no red flags on Hx, exam is normal including neuro exam, patient has a normal gait, and spontaneous venous pulsations are present, the likelihood of an emergency is quite low and I can focus on just treating symptoms. This saves a lot of unnecessary spending and wasted ED bed space! Give it a try! https://jnnp.bmj.com/content/74/1/7

Totally agree and thank you for the post. I didn't want to suggest that people simply order tests for these possibilities, but to avoid anchoring and at least keep it on the ddx and ask those questions like you mentioned.

Another trap came to my mind today that is along similar line of thinking as "oh there are sick contacts so its probably benign" is the trap of "spontaneously improving symptoms, so it must be benign". This happens all the time; the triage team will come up to me and ask if I can go discharge this patient from the waiting room "because their symptoms have resolved while they were waiting and they're asking if they can go!" It would be very easy to turn the brain off and do it, but beware! Spontaneous improvement still happens in bad disease: -SAH -TIA -CO poisoning -Intussusception -intermittent torsion -I'm sure there are many more.....

True, but that would be easy to defend since the test would still have been clearly indicated. With a high pretest suspicion for dissection and you get an elevated creatinine back, CT is still indicated / recommended by experts. The risk of dissection is huge, and risk of CIN progressing to ESRD is extremely unlikely.

Love these cases! Keep them coming. My basic thoughts on case 2 would be to transfer, but if for the purposes of discussion that weren't an option or if it came back indeterminate, next step would be bedside echo for all of the fancy things they're now looking for suggesting PE / right heart strain. Lets say its another patient like in case 1 who is a high risk for starting anticoagulant and you want to be absolutely sure before you anticoagulate, would it be crazy to just do the CTA? If the risks of starting anticoagulation / bleeding outweigh the probably overstated risk of contrast induced permanent ESRD (the only real outcome we care about), then we take the less riskier option of the two and scan them. Could maybe get nephrology input, or do shared decision making with the patient. In an episode of emrap, I think, they had a similar discussion, stemming from the question "if you have a high suspicion for dissection, why the heck are you waiting for the creatinine to come back? Get them to CTA now!" There are two possibilities: the creatinine comes back normal and you can get the CT without issues, or the creatinine comes back very elevated suggesting even higher pretest suspicion for dissection because it is now knocking out the kidneys meaning you need the CT all the more. In both situations you need the CT, so just forget the creatinine and send them asap.

Thats the second one! One of the risk factors for meningitis is close quarters with others who might have some part of the spectrum of illness. Now, whenever I hear about positive sick contacts, I make sure to consider, and document, why I don't think its meningococcus or CO poisoning before labelling them as URI. I've been thinking about this a lot lately... so much of our job is pattern recognition, and exercises like in this thread is all about recognizing those triggers that should make you stop and take a second to think, "I remember this could represent something easily missed". If anybody else has cases / examples to share, please post them!

FWIW, the UCC associated with our ED is in the same hospital system and they only send the patient one bill for the ED if the patient is sent. I'd imagine if you're not in same billing system you wouldn't be held to that.

Bingo! CO poisoning is one of two emergency ddx that comes to mind if someone else at home has it as well. Anybody care to guess the other one? Our standard blood work and viral testing would miss this other dx, so you have to know to look for it and its largely a clinical suspicion thing. I'll give a clue... the nurse comes to you and gives you an update while waiting for tests to come back, "hey FYI that guy in room 8 seems like he is getting one of those "viral exanthems" - small spots of pink / red popping up throughout body. You press on it and it doesn't blanch. Thoughts?

Another theme I've noticed during my first years out was anchoring on sick contacts as a definitely benign sign... of course it most often is, but are there things you should consider and ask about in HnP before anchoring on a benign infectious process? case 16. 21 year old male living in a fraternity comes in for malaise, sore throat, feeling feverish, headache, body aches. His roommate is sick with similar syndrome --> strep test is negative --> do you discharge him? What else is on your ddx?

My dream early retirement job would be something along these same lines... telemedicine from home (hate the general idea but would be easy work)... low enough call volume that would let me work a side job online at the same time like EMEDPA... while earning USD... while living in whatever part of the world has the strongest conversion for the USD. You could probably make enough to be considered "rich" for about 10 hours a week haha. Someday!

I'll repost something because I think its important for people to know the details. Don't just know that you are billing 85% of a physician; calculate out how much you are collecting (since many places won't let us be privy to the actual books unfortunately). Know what your productivity metrics are: patients per hour, RVUs per hour, etc. Know what the averages are for the group. Its huge bargaining power and leverage for increasing pay if you can tell employers, "I bring in 30% more than the group average here, to the tune of hundreds of thousands of dollars more in your pocket." They might say the offer is nonnegotiable when in fact there is often room to budge somewhere in the offer, especially if you have leverage. Don't feel bad for negotiating... for the company to secure experienced, high producing PAs will cost them more but they'll collect much more so its a win-win. Updated repost: "Numbers to know in EM - 35$ collected per RVU for medicaid, up to 100+$ collected per RVU for private insurances. 150$ collected on average per ER patient. You work 150 hours per month X 12 months per year X 2 patients per hour X 150$ collected per patient = 540,000$ per year collected in your name. This is for the provider fee alone, so it doesn't even include the facility fee going to the hospital. I'm all for the PA-MD team and clearly the docs earn what they make as well, but it doesn't seem so outrageous that we have some experienced, high producing PAs making 200k per year...... Know the numbers." Medicine has become a business, folks, and the sooner we accept that and learn how to play the game, the better off we will be as a profession. If you're interested in a longer read giving some insight into the business side of things in EM, read this thread from SDN... well worth the read. https://forums.studentdoctor.net/threads/how-much-are-you-actually-worth.1236817/

Surge season is hitting us hard, and I've been trying to be more efficient with our limited bed space. Here is my goal: dial back as much unnecessary workups as possible, and optimize / expedite the "unavoidable workups". I've been brainstorming about common scenarios and come up with quite a few. I'm thinking this could be a beneficial forum exercise as well where we could likely learn from each other.... so please share additions if you have time. "Situations commonly worked up that could likely be deferred"... -with flu season, everyone has chest pain with their viral illness. Many order blood work like troponin which equals an automatic 2-3 hour discharge length of stay (dLOS). My thoughts are this; EKG and CXR are quick and easy, and if you can explain away sepsis, ACS, PE, CHF / myocarditis clinically, that is enough for me to dc. Infectious chest pain patients went from dLOS of 2-3 hours to out of dept in 30-40ish minutes. Is this your practice pattern? Are you doing blood work on all of these? Or no workup including no ekg / cxr? -"Patient sent in from primary doctor for BP 200/110, but he is completely asymptomatic" with no s/s to suggest end organ damage... he needs NO workup at all. Lots of literature to support you on this. Check out acep policy on asymptomatic htn. Discharge length of stay win 2.5 hours --> 15 minutes. -first trimester pregnant vaginal bleeding with prior US establishing IUP and known Rh positive who are well appearing. Most of these get labs and US every time they come in but why?! How does that change ED management? I'm thinking FHT and dc to OB. What is all of your practice here? dLOS 3.5 hours --> 20 minutes -epigastric pain in healthy patient with nontender abdomen, no risk for acs, can often completely forgo workup and give rx PPIs with PCP / GI follow up. dLOS 3.5 hours --> 20 minutes -vast majority of pediatrics haha.... -what would you add to the list? "situations with unavoidable longer LOS / workup, but we can still at least expedite it or optimize it" -see cam berg's ADPs / accelerated diagnostic pathways -vague nonspecific neuro complaints. What often happens is workup piece by piece starting with CT head, maybe other imaging later, lots of labs, consults for recommendations, reevals ,etc. Now we just go straight to CTA head neck from beginning, document why we don't think active stroke or other emergent ddx, dispo in 1/2 the time. -young healthy patient, or recently normal creat documented, then no need to wait the 1-2 hours for your creatinine to result, just send them to the CT scanner right away. Very low risk for contrast induced nephropathy. -CHF pathways can be really helpful. Majority of time its med noncompliance volume overload... give IV lasix immediately, order whole workup, tell nursing staff right away to road test by hour 2 and report back should be ready for dispo. Know admission criteria for this well so that hospitalist doesn't jerk us around. -cyclic vomiters (and similarly, migrainers)- most important thing is hit it hard up front - big cocktail with multiple liters of dextrose infused saline, reglan benadryl bentyl haldol capsacin (if marijuana on board) etc. repeat PRN orders are preloaded so your interruptions are lessened. -others? If everyone shares some of their favorite hacks for increasing efficiency, we could learn some great stuff from each other and I think it would be really helpful. Please share! (*mandatory disclaimer especially for new grads: this is informal idea sharing and not 'standard of care'. Realize that these are simplified discussions excluding a lot of implied information. please don't substitute standard textbook / medical learning. Reference your textbooks, uptodate, colleagues and doctors before implementing anything like these into your practice pattern. )