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I had a really poor experience calling a cardiologist from the ED the other day and wanted to get a gut check from cards PAs about whether I should have done something different.

 

Pt is 60 yo F, long history of a-fib.  Anticoagulated.  In past year she changed to a new cardiologist in tertiary center about 4 hours away (and in another state).  Had ablation 6 months ago which settled her down a lot.  Saw her cardiologist again just 2 weeks ago and he was going to send her for another ablation, but she didn't know why.  She's on Xarelto, metoprolol, lisinopril and a statin.

 

She comes to my (very rural) ED at 0300 with CP, palpitations, and dyspnea.  A-flutter with 2:1 conduction with a rate of 150.  Two squirts of diltiazem and she's down to 110 and feeling much better.  All labs are negative.  We put her on a diltiazem drip at 10 which drops her BP, so we give small bolus of NS and back off on the dilt.

This stabilized her well so I waited until 0800 to call her cardiologist, give him the picture, and ask if he has anything specific he would like us to do.  His response was "Well I'm not going to drive there and admit her myself."  I replied to him I didn't need him to do that, but since he was her cardiologist I wanted to touch base with him to see if he had a preference for anti-arrhythmic.  He just said double her metoprolol and hung up on me.

The only other time I've had physicians be douches like this to me were trauma docs when I am admittedly sending them soft cases (ie: patients I'm sure will be okay, but.....). 

Any suggestions on what I could have done different/better? 

 

End result - admitted the patient, convinced her she should follow up with a cardiologist at a closer town....no need to go to the big city hospital 4 hours away.  New cardiologist accepted her and we transferred her. 

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My, how things have changed, but not changed.  In my affluent suburb ED when I was there 10+ years ago, the biggest pains were the plastics guys, or IM on call (rare animal those hospitalists until near the end of my tenure there).  Ophthalmology call was almost non-existent since the staff were po'd at the hospital for not getting them new toys so no one took call.

 

Frankly, in my world, I'm surprised that cardiology would even speak to you, since you're only "an assistant".  Bottom line, you did right by the patient and you ultimately get the last laugh if the patient chooses to find a new cardiologist.

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Welcome to the ED, where someone somewhere feels they can be a dick to you on the phone when you are trying to do the right thing.

 

I know you wanted Cards PA opinions on this but I would suggest that this may cloud the issue for you in the ED. Your concern and action was correct. The ED provides transient care and we dont establish consistent relationships nor care other than episodically for our patients. You did the right thing with a phone call to her specialist. He did the unprofessional thing with his asinine behavior. Next time dont be courteous, call at 3 am.

 

These negative responses we get in the ED are driven by many factors, from outright personality disorders to a lack of understanding concerning local resources. I dont get bogged down with that. I dont care that someone is a dick on the phone, most of those people get what they deserve eventually. So I move forward through that chatter and focus on what I want to care for the patient. Which leads me to a primer on specialist interaction from the ED. Know why and what you are calling for. If this is her cardiologist you are speaking with then the conversation is: your patient was in rapid afib, I slowed her down, she is stable but I dont think she can go home, will you accept her in transfer?

 

The only thing I would point out is that it is unlikely that anyone would place this patient on antiarrythmics. The mantra should be rate control which you rightly provided. After that the rest is why is she SOB? why the chest pain? was there something that triggered this event? Labs and imaging will answer your question or reassure you that this was all rate driven. Then it rests on where the patient is dispositioned to.

 

Last, I would question the soft cases you send to trauma. Are they soft cases or do you have a legitimate concern you cant properly eval at your place? Most trauma services have a system in place to review and if you are an outlier, you will hear from them eventually. That can then make your life difficult when you really need them, making you jump through some hoops you dont have time for.

 

Good luck.

G Brothers PA-C

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As an addition, I did cardiology before emergency medicine, and frankly, I found our cardiologists to be some of the most accommodating physicians I have ever interacted with. Maybe it's the newer generation? At that point in time we truly were just "assistants". Histories and physicals, discharge summaries, daily rounds.

 

 

Sent from my iPad using Tapatalk

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I'm sure you did the write thing. Don't take it to heart. Learn to develop thick skin & be prepare before calling a specialist to discuss their patient.

 

Wondering why you did not run patient by your attending or at least have him call patient's card himself.

 

I won't sweat over it.

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G - Looks like all symptoms were indeed rate driven.  She was asymptomatic once we got her slowed down (a little toooo asymptomatic for a little while until we backed off on the dilt). 

 

The "soft case" I was referring to was a peds.  Special needs kid with low mechanism but soft finding of c-spine tenderness.  Couldn't CT without sedation and that shop won't let PAs use ketamine.  Called in anesthesia but they wouldn't sedate him because of his special needs, so I had to ship.  It was a soft finding, but he was special enough that I wasn't comfortable clearing his C-spine.  Trauma surgeon was grumpy, but he accepted which is all I cared about.  Turned out he didn't even CT him there, but that's his call, not mine.

KMD - I did call my attending, but most of my attendings just say "ok" when I call them.  Except for one guy I routinely work with whose english is so incredibly poor I can only understand 10% of what he says.  He usually rattles off a long list of stuff he wants me to which I don't understand at all, so I just return the favor and say "ok" to him.....and then do what I want.

For the record, I've got thick skin.  I don't care what this particular Doc thinks of me.  However I did want a gut-check to see if maybe I could do something better.

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How's your ED setup? Do you provide solo coverage? Are you provided backup when face with complicated/ crashing patient? Your response above prompted my question. I will be very concern if I can only understand 10% of what my SP is saying when discussing patient.

 

I wonder what other possible reasons may had cause the cardiologist to hung up. Is it because it's a common trend and behavior from that particular ED where you work. It's very likely he/she knew the patient well, heard you well and knew the patient was stable and a bump in their BB was all that was needed or the cardiologist just wanted to stay clear from crashing patient (seen by a PA) for medical legal reason.

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I would use a calm voice and tell the rude cardiologist at the end of the phone call that i would inform the patient and the patients family of his rude conversation and hang up.

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I'm guessing the guy was just a jerk; sounds like you presented a pretty reasonable course.  I don't know if you could generalize this to all cardiologists; we work with a lot of different cards guys, and most of them are pretty pleasant when you give them a coherent report.  Maybe the guy just isn't a morning person.

 

The only thing I could see him being agitated about was possibly using diltiazem when the patient was already on metoprolol.  A lot of us were taught not to mix calcium channel blockers and beta blockers, or the patient will spontaneously combust and the world will end (or at least develop significant hypotension).  I will typically stick with the same class of drugs that the patient is already on; if they are on PO metoprolol, I'll usually give a trial of IV metoprolol first.  Even if this was the case, it still doesn't justify him acting like an ass.

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I'm sorry about your experience. I'm a cards PA and our practice tries to be polite to providers of any persuasion who call. Or big gripe is when they don't call and automatically assign the patient to a different cardiologist! 

 

Your call was a great idea. The cardiologist knows the patient's history and their last ejection fraction, which figures in to which antiarrhythmic we would like used. I would have gone with the diltiazem myself, perhaps sprinkling in some digoxin as well. You can mix a CCB and a beta blocker (we do it all of the time), but you have to keep your eye on the patient too. 

 

Especially if the afib is paroxsymal (or of new onset), you should probably do a chem 7, Mg++. Replace K+ to be at least 4.0 (10 meq PO or IV) for each 0.1 below 4.0 (start with at most 80 meq and recheck. Don't forget to take the patient's renal status into account). If Mg++ is less than 2.0, give 1 gram IV (PO sucks for Mg++) for each 0.2 below 4.0 (no more than 4 grams to start and recheck).

 

Good luck and just accept the fact that some people are jerks, regardless of their degree or specialty. You did the right thing.

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How's your ED setup? Do you provide solo coverage? Are you provided backup when face with complicated/ crashing patient? Your response above prompted my question. I will be very concern if I can only understand 10% of what my SP is saying when discussing patient. I wonder what other possible reasons may had cause the cardiologist to hung up. Is it because it's a common trend and behavior from that particular ED where you work. It's very likely he/she knew the patient well, heard you well and knew the patient was stable and a bump in their BB was all that was needed or the cardiologist just wanted to stay clear from crashing patient (seen by a PA) for medical legal reason.

I work in several different rural (and very rural) shops, all of them single coverage.  This one is very rural, although there are five docs there who seem to be great.  I had already run this patient by the attending, mostly because I knew I was going to admit her (or ship her).  After briefing the attending, he told me to admit or ship, whatever I needed to do.  Nobody in the office had ever heard of this particular cards (again, he was 4 hours away at a tertiary center, but this shop usually sends to the tertiary center 4 hours the OTHER way). 

 

The SP I work with who I can't understand is at another shop.  While he's a great guy, and I'm sure a good doc....I just can't understand a thing he says.  I hate working with him because this is a really busy shop (probably going to break 9K ED visits a year) and we get a lot of really sick folks in there.  If I ever get to the point where I don't know what to do I usually call the EP at the closest tertiary center (only an hour from this shop) because I know I'm going to ship them there anyway. 

 

As for the physician back up - most of the places I work have an attending on call.  One place I work is, literally, a one doc (plus one PA and one NP) town.  I go take occasional weekends there when everyone wants the weekend off.  Last time I went the Doc was out of town for most of weekend.  He was still available by phone, but wouldn't be able to make it in.  The NP, who lives right across the street, was available to help if needed though. 

I'm sorry about your experience. I'm a cards PA and our practice tries to be polite to providers of any persuasion who call. Or big gripe is when they don't call and automatically assign the patient to a different cardiologist! 

 

Your call was a great idea. The cardiologist knows the patient's history and their last ejection fraction, which figures in to which antiarrhythmic we would like used. I would have gone with the diltiazem myself, perhaps sprinkling in some digoxin as well. You can mix a CCB and a beta blocker (we do it all of the time), but you have to keep your eye on the patient too. 

 

Especially if the afib is paroxsymal (or of new onset), you should probably do a chem 7, Mg++. Replace K+ to be at least 4.0 (10 meq PO or IV) for each 0.1 below 4.0 (start with at most 80 meq and recheck. Don't forget to take the patient's renal status into account). If Mg++ is less than 2.0, give 1 gram IV (PO sucks for Mg++) for each 0.2 below 4.0 (no more than 4 grams to start and recheck).

 

Good luck and just accept the fact that some people are jerks, regardless of their degree or specialty. You did the right thing.

No apologies necessary. 

 

Thanks for the additional info.  All labs were fine (including Mg, K, and Ca, and BUN and Cr were normal as well).  Never had any widening of QRS, just went from a beautiful 2:1 conduction to a variable conduction....and then got a bit hypotensive on a dilt drip of 10.  Backed her all the way to 2.5 and that worked for a while but we started having to turn it off, and back on again trying to balance hypotension vs tachycardia.  Started her on dig and shipped her after about 24 hours of playing with the dilt. 

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Guest Paula

^^^^^ this is an interesting thread.  It makes me so happy I got out of EM when I did.  I would not have been able to handle that patient and I started scaring myself when I saw some really sick pts. in the ED (I worked as a locums for 4 yrs or so) and the physicians were not very responsive to some of my questions and asking them to see the pt.  I always worked with a physician, too.  It was a bad environment and helped me to realize I was in the WRONG specialty!

 

Kudos to all of you EM PAs who love your jobs and know what you are doing.  I will continue in rural PC until I retire.  I love it and it fits me. 

 

The PA profession is beautiful. 

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Guest Paula

Well, the sun will come up tomorrow, betcha bottom dollar.

 

It's beautiful in that you can find the right specialty and aren't stuck if you pick the wrong one.  Thank goodness I was doing PC all along and filling in as a locums.  It paid for my kids college tuition and then I got out.  GetMeOuttaThere!!!!!

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I'll take ED over PC any day.  For example, I had a 50+ yo lady with persistent vaginitis in clinic the other day.  Exam and labs were completely normal, already on estrogen PO and vaginal.  In the ED it's easy....you're not gonna die, follow up with your PCM next week.  In clinic....crap, I AM acting like the PCM....what the he!! do I do now?!?

I'll take the ED

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I work in several different rural (and very rural) shops, all of them single coverage. This one is very rural, although there are five docs there who seem to be great. I had already run this patient by the attending, mostly because I knew I was going to admit her (or ship her). After briefing the attending, he told me to admit or ship, whatever I needed to do. Nobody in the office had ever heard of this particular cards (again, he was 4 hours away at a tertiary center, but this shop usually sends to the tertiary center 4 hours the OTHER way).

 

The SP I work with who I can't understand is at another shop. While he's a great guy, and I'm sure a good doc....I just can't understand a thing he says. I hate working with him because this is a really busy shop (probably going to break 9K ED visits a year) and we get a lot of really sick folks in there. If I ever get to the point where I don't know what to do I usually call the EP at the closest tertiary center (only an hour from this shop) because I know I'm going to ship them there anyway.

 

As for the physician back up - most of the places I work have an attending on call. One place I work is, literally, a one doc (plus one PA and one NP) town.

In that case. I would've admit or ship out. If you did already ran the pt by your SP. I would've documented that I d/w the pt's clinical presentations, my my exam finding, A/P/ treatment & pt's response to tx w/ the SP. Then, move on to next pt. No point calling the cardiologist, particularly, because the pt responded and wasn't crashing.

 

Working rural ED. You have it really good. Keep doing what you're doing. Not sure how far out you're post grad. If you stay the course, in 5+ years, you will be golden.

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sounds like you did the right thing. sometimes they don't need the drip after they are initially rate controlled because the causative issue was them missing an AM dose of their regular med  so I generally hold off a bit and see if their rate starts to creep back up before I start it. also, I think I get a better effect with minimal side effects by slowly titrating the cardizem 5 mg every 2 min or so. a lot of folks just slam 20 to start and then they get hypotensive. I often find 10-20 total does the trick.  I had a guy 2 weeks ago who took 25 total but that did it. 

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I'm just an RN and I have called many a specialist acting as a liaison between the hospitalist and whatever specialty the patient needed. I've had to clarify plans of care for emergent and routine situations and not once (well sometimes surgeons....) and usually they are pretty receptive and friendly as long as you are succinct and have a good idea what's going on. This guy sounded totally like ***hat....

 

Putting them on a 10-15 drip and monitoring BP changes depending on baseline (CHF? CAD?) seems like what we do a lot instead of boluses. Jumping to class 3/amio or something else right away would see a little too go-getterish with her rate being controlled and symptoms lessening? Am I wrong?

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You're not "just" a nurse. 

You're not wrong about going right to an anti-arrhythmic.  That's why I called her cards....to see if he wanted me to start something specific to help with his follow up therapy. 

A bolus of Dilt during rapid a-fib or flutter serves two purposes: to see if it will work AND rate control.  I push .25 mg/kg and watch carefully.  If that doesn't drop BP but doesn't slow down, then I push .35 mg/kg 15 minutes later.  If either of these bolus' slow them down then I convert to a drip.  If it doesn't, then I go on to other drugs for rate control. 

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I would have gone with the diltiazem myself, perhaps sprinkling in some digoxin as well. You can mix a CCB and a beta blocker (we do it all of the time), but you have to keep your eye on the patient too. 

I totally agree about the mixing, but I still hear this a fair amount from ED attendings (more than from cardiology).  I much prefer CCB to beta blocker for the rapid Af patient, so given the choice I'll always go with the diltiazem.  It's pretty rare for us to use the diltiazem drip after achieving rate control with the boluses though.  For the most part once we've got them to a good speed we orally load them with PO diltiazem, which seems to work well for most of our stable Af patients.

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  • 3 weeks later...

Cardizem is usually a better option for rate control in Afib than a beta blocker. We usually do the following:

 

1. 5 or 10 mg bolus. Can have significant pucker factor if SBP is low, but give it a shot.

2. Start drip at 5 mh/hr and titrate to hold heart rate less than about 110

3. Let that stabilize for a while, while you check and replace their lytes.

4. If in hospital for a while, wait a day and make sure the drip rate is stable.

5. Convert from the drip to oral:

   if 10 mg per hour, that would be 60 mg in 6 hours (for Cardizem 60 q6h) and 240 mg in 24 hours (for Cardizem CD 240 mg daily)

   (Would be nice if all drip to pill conversions were this easy!)

6. If in hospital for a while, we usually use the rapid Cardizem q6 for a day or two and then send them home on Cardizem CD.

 

We don't like to use Cardizem long term (i.e., out of hospital) for significant cardiomyopathy (EF< about 30%) and will try to control with digoxin alone if we can.

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