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To the ER you go...

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What are some common conditions that you all end up shipping to the ER vs working up as an outpatient? 

 

I hate burdening our local ER system, but getting a stat CT approved always seems to be hours of my nurse on the phone.. STAT labs are back in the AM, etc... So for these reasons obviously, some folks just have to go..

 

What do you ship out? 

 

 

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worrisome presentations of the following: chest pain, abd pain, tia/cva like sx, serious infections, moderate+ chf/asthma/copd exacerbations, head injuries, overdoses, serious psych stuff, trauma requiring adv imaging, aloc of new onset, new seizures, hypotension, htn crisis, bad eye/ent issues, airway issues, etc...basically if they should have called 911 instead of being in your clinic you should ship them...

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Progressive swollen eyelids occluding half of iris or more with altered vision and eye "pain". Can't measure IOPs and don't have a slit lamp so I'm taking no chances with peepers. You do NOT want to miss a periorbital cellulitis. Report back->bad conjunctivitis per ophthalmology. A lot easier to apologize for their time than for the loss of an eye. Agree with E, refractory RAD not improving after three consecutive neb tx's (in an OP setting). Not much sympathy however when I can smell the nicotine on them like today.

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I send things that need an answer now - as you mentioned - stat labs aren't stat and CTs from your office need a pre auth which doesn't make for stat either.

 

Babies less than 6-9 months with high fever and no obvious source or appear toxic, dehydrated. ER now.

 

I am in a private FP office and across the street from a mediocre ER that doesn't listen to me. I often have to shuffle folks downtown to the better ER to get them what they need.

 

I agree that erring on the side of ER/specialty eval than take chances if the hair on the back of my neck itches or it is the typical Friday afternoon on a holiday weekend at 4 pm with fever, abd pain and vomiting.......

 

If it needs an answer and disposition before the end of the day then the ER is sometimes the only place with results available in a timely fashion.

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My rule.. If my DDx shows it can kill, paralyze, or permanently affect their senses acutely then I send them to the ER. Or I'll send them if they just need a higher level of care. Otherwise out patient imaging / labs. If I'm ever unsure, I'll ask the ER clinician on duty to where the patient wants to go for a consult before I send them if I'm ever unsure. Most the time they're friendly and helpful and will accept the patient as I feel I've had some good judgement about when to send vs not send them, but I'm a newer grad and ask questions and not to afraid to admit when I don't know something and will ask for help. As are the physicians, NPs and PAs I work with as we collaborate well as a team.

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