Another Poor Use of the ER . . . Which I had to Participate in

[jmj11]

I don't see many acute new onset headache problems, because most are referred by PCPs.  However, this week I saw a 29 year old with a new onset of thunderclap headache (clearly the worse in her life) that came with orgasm.  The odds will be 99% this will be a benign headache type, which call orgasmic headache or a more fancy term, "Paroxysmal Situational Headache-Sexual Headache Type II."  But there is the 1% that it could represent a sentinel bleed.

 

I ordered a CT, which was normal. Then I ordered a LP . . . and that's when things got dicey. We attempted to order it at all three local hospitals and the orders were rejected.  I had ordered the same at each one in the past. But now it was rejected because I do not have privileges at any of those hospitals and it is impossible for me to get them.

 

It is a long story but we beat our heads against the wall for a year trying to get privileges and with each hospital we found ourselves in a labyrinth that would do Pan proud.  One hospital required proof that we had admitted a patient at another hospital in the previous 12 months and we had to have a physician give reference that we had cared well for those patients. We (my SP nor I) have admitted a patient anywhere in years.  The next hospital required us to admit one patient per month and if we didn't we would be held accountable in a negative way. Because we do good work, there is never, ever a place for us to admit a headache patient.  The last hospital also required a quota of admissions plus they required us to have a sponsoring physician who presently has privileges. No physician would sponsor us because our clinic is PA-owned and they sensed (falsely) that it would expose them to suits. 

 

So, when things are said and done, I had no choice but advise the patient to go to the local ER to report a severe headache that came last week and now is minimal. 

 

The patient, like many of ours, is from outside this region and didn't have a local PCP.  I wish this were the days when I did LPs in my office and we could do blood patches too. But now, I don't know of any small practice that does routine LPs in their office due to liability. 

 

[nebero]

At least your pt needs that LP. Given the amount of unnecessary tests done in the ER, this is nothing. Don't feel bad. You tried your best but most importantly, your pt needs that LP

 

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[jdenning]

We refer most of our LPs to our local pain management practice. Then their office takes over and does the procedure. We get a procedure note - we always ask for opening pressure- and then cytology. Works well. Would this be an option?

[True Anomaly]

I'm curious, jmj, if when your patient went to the ED, did they get an LP?

[jmj11]

We refer most of our LPs to our local pain management practice. Then their office takes over and does the procedure. We get a procedure note - we always ask for opening pressure- and then cytology. Works well. Would this be an option?  I don't know. I work pretty close with a couple of intervention pain clinics but I've never asked them to our LPs.  I could run it by them.

[jmj11]

I'm curious, jmj, if when your patient went to the ED, did they get an LP?

This is another way the system is messed up.  I strongly encouraged them to go (I still think a bleed is highly unlikely . . . but if was could be catastrophic).  They have not met their deductible this year and wanted to "think about it" before they go to the ER.  I'm waiting to hear back. They know that timing is essential.

[jdenning]

So while contemplating the "deductible issue" (really???) they went home to have sex and see if it happens again???