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Would you head CT this?


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20 y/o obese female, no PMH, in NAD, presents w/ HA x "1-2 weeks", much worse than any HA she has ever had, but gradual onset.  Pain is pulsatile, unilateral, 8 or 9/10 (but pt appears comfortable).  HA a/w nausea w/o emesis.  Mom had migraines that began in 30s.  Has tried no meds.  Better with lights off and no noise.  Was a/w blurry vision at onset, now resolved.  No fever/chills, neck pain or rigidity, or other neuro complaints.

 

Vitals totally normal.  CBC, BMP , UA normal and U preg (-).  Thorough neuro and all other exams totally normal.  Zofran, compazine and benadryl and the pt is feeling much better and stating she is ready to go home. 

 

Would like the input from ED PAs and jmj if he has the time.  Would you personally CT this pt?  There is data to support that all new HA get a CT, and data to support that HA resolving w/ migraine med does not r/o more serious etiology.  But my question is if this were your pt, would you order the heat CT or not?  If this was day 1 of presentation, would your decision change?

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The American Headache Society has stated that there is no place for a CT brain in headache except for the suspicion of hemorrhage such as thunderclap headache. I would not in this case. I may end up doing a non-emergent MRI brain depending on lack of resolution or any other concerning neurological symptoms. Certainly I would do a good fundoscopic eye exam (aka poor man's mri)

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problem is

 

1) you get sued for missing the one zebra out a million - or they complain to admin you "did nothing, not even a CT"

2) you don't get in trouble for ordering the CT

3) you don't have to deal with the Brain CA Dx in 30 years - that is some else problem

 

 

honestly I can see both sides, the Er doc's don't want to get sued, and want to not raise feathers, and at the same time we all should strive for doing what is right. 

 

Good documentation is key - great neuro exam, no red flags, and solid follow up care defend against annoying complaints and lawsuits...

 

 

If it were day 1 and was the worst HA of her life, and she appeared to be in pain (yeah not the 12/10 pain where they are still talking on the cell phone and acting normally, but instead real pain)  humm that is a good one....

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Can someone explain to me why a migraine in the office is a migraine until proven otherwise, but a migraine in an ER is a life threatening hematoma until proven otherwise?

 

KevinMD to keep you angry:

http://www.kevinmd.com/blog/2015/01/physician-assistants-nurse-practitioners-really-save-money.html

the fp doc can miss it and say "go to the er if it gets worse". we can't. we are the last check against badness. the entire idea of emergency medicine is the ROWS criteria:

R/O Worst-case Scenario.

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Yeah, that is exactly what we say in FP, go to the ER if worse.   I would have treated this like a migraine in FP altho there are a few times I have CT'd headaches that come in to see me.  

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there is a level of care that is created by merely showing up in the ER

 

It is a different 

 

Can someone explain to me why a migraine in the office is a migraine until proven otherwise, but a migraine in an ER is a life threatening hematoma until proven otherwise?

 

KevinMD to keep you angry:

http://www.kevinmd.com/blog/2015/01/physician-assistants-nurse-practitioners-really-save-money.html

 

 

the fp doc can miss it and say "go to the er if it gets worse". we can't. we are the last check against badness. the entire idea of emergency medicine is the ROWS criteria:

R/O Worst-case Scenario.

 

 

there is an level of care and standard that is created by going to the ER

 

kid with a flu gets sent home from the office, kid with a flu in the ER get full work up

 

neck pain in the office almost never gets imaging, neck pain in ER with any type or trauma may well get imaging

 

 

 

This is self triage, that in the perfect world works, and due to the emergent nature of the ER the Insurance companies can't force prior auth's on them...... but the system is broken by a lack of PCP and an apathetic attitude of the patients towards trying to fit with in the system.  They would rather seemingly go to the ER and get all their testing done right then and there (even if it exposes them to more tests and high dose radiation) then follow the advice of a PCP.  

 

 

 

This is certainly not the bulk of patients, but certain some.  I really think one idea encourages this - no financial skin in the game - for medicare patients there is no cost to the ER and if you are so broke and don't have an insurance, and no PCP you have no choice but the ER.  This is where the system has to change.....  We should charge EVERY person an ER copay - can be on a sliding scale, but the fact so many people on medicare can get ER care for FREE works against the entire system.  Course the ER department heads, bean counters, and hospitals actually want this flow of business as it makes a fair amount of $$$ for the dept and company.

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the fp doc can miss it and say "go to the er if it gets worse". we can't. we are the last check against badness. the entire idea of emergency medicine is the ROWS criteria:

R/O Worst-case Scenario.

 

Ok, ER is ROWS and FP is not.  However, why is the ER ROWS?  It doesn't actually strike me as the last check because patients are still discharged with orders to follow up for diagnosis with the FP or with orders to return if things get worse.  Isn't every migraine naturally dc'd with orders to return if it "gets worse" whether they had a head CT or not?  Isn't every PT dc'd with similar instructions?

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Ok, ER is ROWS and FP is not.  However, why is the ER ROWS?  It doesn't actually strike me as the last check because patients are still discharged with orders to follow up for diagnosis with the FP or with orders to return if things get worse.  Isn't every migraine naturally dc'd with orders to return if it "gets worse" whether they had a head CT or not?  Isn't every PT dc'd with similar instructions?

it's ROWS because of lawyers...."so mr PA (it is Mr, right because you didn't go to medical school.....) when mr smith said his pain was 10 out of 10 and he had never had back pain like that before did you consider any other diagnosis than back strain? have you even heard of an epidural abscess. do they teach that in PA school? our witness DR (and he is a dr because he went to medical school) caruthers said he would never have sent that pt home without an MRI. well, now mr smith got septic and spent 3 weeks in your hospital and is seeking damages of 2 million dollars....."

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No focal neuro findings, looks comfortable, nontoxic....I usually rub traps/neck muscles looking for the tight muscle there and when I find it I ask them "Does this make your HA worse?"  They usually say yes, so then I explain to them that it's likely a tension headache.

ANY focal neuro findings (like the "double vision" post), or they look uncomfortable/toxic and it's their first HA, then I might CT them.  I did that once and found the shunt that had been placed a few years before....that was NOT disclosed by the patient.  ("Oh yeah, they said my brain produced too much water so they fixed that").

Sudden onset = CT +/- bp control.

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it's ROWS because of lawyers...."so mr PA (it is Mr, right because you didn't go to medical school.....) when mr smith said his pain was 10 out of 10 and he had never had back pain like that before did you consider any other diagnosis than back strain? have you even heard of an epidural abscess. do they teach that in PA school? our witness DR (and he is a dr because he went to medical school) caruthers said he would never have sent that pt home without an MRI. well, now mr smith got septic and spent 3 weeks in your hospital and is seeking damages of 2 million dollars....."

 

Don't you mean "Dr Rosen", the author of one of the emergency medicine bibles, who has sold out emergency docs and is now prostituting himself as an expert witness for plaintiffs?

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I hear ya.  I have another question, though.  Why is the lawyer more dangerous if the PT was seen in an ER rather than a clinic?  It sounds like if the ER doc skips the CT and misses the 1 in 10,000 zebra - he is liable, but if the FP doc starts with the presumption it is a migraine and misses the 1 in 10,000 zebra, he is not liable?  Is that the suggestion?

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the FP doc can say " I told him to go to the ER if it got worse. he didn't and he died. not my fault". once again, the ER is the end of the road.

"f/u with pcp" from the ER basically means " you are not sick enough to be here and you are wasting my time". If a pt has anything real you don't send them back to the pcp, you work it up and admit or transfer them.

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If a doc sends a PT home from a clinic and says to go to the ER if it gets worse, he is not liable.

 

If a doc sends a PT home from an E.R and says to go to the ER if it gets worse, he is liable.

 

Why are the results different for the same action?

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the pt in #2 was already at the ER. there was a CT scanner/insert other technology or consult available there at the first visit. if the person comes back to the er it is because they missed something. if someone goes from fp to er it is because the fp lacks resources and training and needs to send the pt to a place with more resources.

trust me. outpt clinics are held to a much softer standard than er/hospital based clinicians.

acceptable miss % in the ER = zero. how many heart attacks or head bleeds is it ok to send home without a workup?

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I think the statement you've made which strikes me as most compelling is when you say that outpatient clinics are held to a much softer standard.  I feel this sounds true, but it's hard to fully grasp.

 

You say an acceptable miss % in the ER = zero.  What is the acceptable miss % in clinic?  I would think zero...

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nope. an FP clinic can miss anything they can't work up. they can't do cardiac enzymes or CT a head. that's why they say "go to the ER".

you hear stories all the time about pts who saw their doc in clinic the prior day and died and nothing happens. when EM clinicians send folks home and they die and they really should have known better they generally get canned and/or sued. you can get it right 4999 times/yr, but miss it once and you are careless....also, PAs are held to a much higher standard than docs in every setting. "A doc never would have missed this" is how every PA case gone bad starts....

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emergency medicine was still very much in its infancy in 86. remember the first EM residency had only started 16 years earlier in ohio. lots of ER docs were actually still fp, im, and surgery boarded then (or GPs who did an internship only and were not boarded in anything). in 86 emts couldn't use aeds yet. I was in one of the first EMT-D upgrade courses in 88 because I happened to know some folks on a rural ems squad who were getting the training and invited me to join them. The director of the ER I worked in then as an er tech was a cardiologist. one of the other regular docs there was a moonlighting nephrology fellow. The 90s is when emergency medicine really took off as a specialty as grads of the programs started infiltrating urban departments all over the country. now most non-rural depts. are staffed almost entirely by EM residency grads.

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