WeBuyAndSellJunk Posted July 13, 2016 What do you all tend to do during these situations? My gut says simply defer to my SP, but my brain says that I should do right by the patient and not fall victim to the appeal to authority fallacy. For background: 30ish female presenting with acute on chronic chest pain, sharp in nature now, dyspnea, lowered threshold for exertional CP acutely, tachycardia (120ish), BP 90/70, orthostasis. The HR, BP, and orthostasis alone for me gets this patient to the ER for evaluation, but the SP elected that patient was stable due to physical appearance and for patient to have outpatient work-up. There is nuance here that the patient was young, had negative stress testing and CTA several months ago, and the EKG was tachy only. The patient was also already evaluated at the clinic earlier the same day and had returned after failing inhaler treatment for suspected asthma (which is also a big red flag for me). I don't know if this is just my ego taking a hit, if I am justified to question the SPs judgment, or how to address this type of situation in the future. Thoughts?
cinntsp Posted July 13, 2016 I had a doc that loved bicarb and seemed to want every patient with a CPK of 1000 on it. I disagreed and cited the lack of evidence for its use(aside from the fact that a CPK of 1000 is not impressive). They said a bunch of stuff about their license being on the line and I replied with the same thing. We agreed to disagree and the end result was the doc would put the actual order in if I felt strongly against something and I would document "Discussed X with Dr. Y and he/she ordered Z." The doc was still pissed that I wouldn't comply with what they told me to do but hey, I care about my patients and my license. Just keep in mind that you can be overruled as a PA and being seen as disruptive can get you fired.
MT2PA Posted July 13, 2016 ^^Yep. Whatever you do, document, document, document. There's a reason questions like this pop up in many program interviews...it happens and there is no good answer.
GetMeOuttaThisMess Posted July 13, 2016 Sure there's a good answer. Whenever this type of issue occurs defer to the ultimate and final authority...the insurance company authorization rep with the HS diploma.
Moderator ventana Posted July 13, 2016 Moderator doc always win, just document that it was at the direction of Dr ________ in the chart bring up your concerns with the doc, i.e. PE in this patient - is she on BCP? Vitals are called vital for a reason and I would hesitate to send someone home tachy at 120....
GreatChecko Posted July 13, 2016 doc always win, just document that it was at the direction of Dr ________ in the chart bring up your concerns with the doc, i.e. PE in this patient - is she on BCP? Vitals are called vital for a reason and I would hesitate to send someone home tachy at 120.... same thoughts here...add to that hypotensive and dyspneic acutely, I don't think that's the picture of "stable" to me. I would have said, "I really don't feel comfortable just sending her home. This really looks and sounds like a PE to me and I'd hate to see her have a bad outcome while she waits for a test that can be done relatively quickly in the ER right now." Add in any pertinent criteria like Wells (high risk group), PERC (unable to PERC out), in the discussion. Suggest just sending her for a stat, outpatient CT PE, with that BMP you ran in the lab, not ideal, but the doc might bite. Otherwise, yes, document as above, but don't document the disagreement, that's just lawyer bait, talk to the patient and give them very specific instructions on when to go to the ER, chart all that, and know you did your best.
Moderator ventana Posted July 13, 2016 Moderator same thoughts here...add to that hypotensive and dyspneic acutely, I don't think that's the picture of "stable" to me. I would have said, "I really don't feel comfortable just sending her home. This really looks and sounds like a PE to me and I'd hate to see her have a bad outcome while she waits for a test that can be done relatively quickly in the ER right now." Add in any pertinent criteria like Wells (high risk group), PERC (unable to PERC out), in the discussion. Suggest just sending her for a stat, outpatient CT PE, with that BMP you ran in the lab, not ideal, but the doc might bite. Otherwise, yes, document as above, but don't document the disagreement, that's just lawyer bait, talk to the patient and give them very specific instructions on when to go to the ER, chart all that, and know you did your best. Agree with 99%, but not sure I would purposefully chart that you did not disagree with the doc - CAUTION though as if you chart contrary to a doc, you are giving them ammunition to fire you for disagreeing with the doc..... So you have to very careful to paint the clinical picture, what your concerns are, the fact that you d/w the doc in it's entirety and that the doc decided that the plan would be to do XYZ........ FYI - I stood up to a crazy doc doing crazy things once.... I never let the patient in on the disagreement (saved my job) but then had to defend myself at about 4 different meetings with HR and Higher ups...... The worst part - it could have killed the patient, and I was proven right in the end - by the patients own actions..... I did not get so much as a write up, but I had to stand tall for a few months. Thankfully I was right, the doc was nuts, and the patients own outcome demonstrated I was right...... The doc was the department head, so I left soon there after. Then about 1 year later they were politely told they were no longer fit for duty, and returned to their old job (non-management) in a different deparmtent. Point is I placed my entire job and career at risk, and the only things that saved me was that I never contradicted the doc to the patient, and I was right...... Easily a misstep and I could have black balled for the insubordination....
marktheshark89 Posted July 13, 2016 Why was the doctor consulted in the first place? Is that just how your practice operates or were you on the fence about sending? Had this patient came to ours and I saw them I would have just sent to the ED myself without consulting, but thats kosher in our group.
UGoLong Posted July 14, 2016 When you say dyspneic, what was her resting resp rate? What was her spo2? Any changes in her ekg since the stress test, including pulm strain pattern? None of the answers to my questions would rule out a pe, but i'm curious. Sent from my iPad using Tapatalk HD
WeBuyAndSellJunk Posted July 15, 2016 Author Thanks for the thoughts. There is such a weird void when it comes to that pesky Hippocratic oath and deference to a physician. As for the remainder of the clinical picture, EKG was just tachy sinus rhythm without evidence of strain, pulse ox was normal to my memory. I cannot clearly recall respiratory rate. I can certainly see where the nuance comes from, but I agree that there are few exceptions to ignoring vital signs, which was my gripe. I will simply keep up appropriate documentation.
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