sas5814 Posted September 25, 2018 Share Posted September 25, 2018 1st patient of the day. Healthy 36 YO male with no history or co-morbidities sees an NP in FP with acute low back pain after handling some farm animals 10 days ago. Imaging? Nope.... Ok not really a problem. I might not have either. Meds? Nope. PT Nope. Referral to neurosurgery. These are the things that make life hard for all of us. Link to comment Share on other sites More sharing options...
KMD16 Posted September 25, 2018 Share Posted September 25, 2018 Careful here. Not sure if this is the whole story. It’s easier to pint finger. Have you worked in primary care? Was there anything on exam that could have warranted imaging or a referral to neurosurgery? The patients insurance carrier that could have made it difficult for quick access to a specialist? Just thinking out loud here. Link to comment Share on other sites More sharing options...
sas5814 Posted September 25, 2018 Author Share Posted September 25, 2018 I worked in FP for 20 years. The patient is on Medicaid which makes referrals difficult on a good day but we have PT and Physical Medicine available for Medicaid patients. This was a turf and a lazy one at that. Neurosurg is going to refuse to see the patient if they haven't already. Link to comment Share on other sites More sharing options...
thinkertdm Posted September 25, 2018 Share Posted September 25, 2018 Yeah, neurosurgery without a workup? While it's possible that "OMG, your left leg is totally flaccid, and you've been pissing all over yourself" maybe neurosurgery wouldn't be the first choice. Before everyone jumps on the np bashing bandwagon, this does not seem like an np post, just a "hey, let's use some evidence and common sense" post. Most people have disk herniation without neuro findings or even pain. Many with significant pain and neuro findings have minimal MRI findings. Many fall in between. Most herniations respond to conservative measures. X-ray shows bone, so unless there is a trauma or other good rationale, dont, even if their uncle's best friends room-mate had x, y, or z. Also, neurosurgery? Personally, I would have turned to the ED. Sounds emergent. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted September 25, 2018 Share Posted September 25, 2018 So let’s learn from this. What are the indications to obtain plain films for non-traumatic back pain, i.e.-fall? Students?Uh oh. Is this considered student pimping? Link to comment Share on other sites More sharing options...
sas5814 Posted September 25, 2018 Author Share Posted September 25, 2018 It just happened to be an NP. This was a guy with a backache from bending and lifting. Young, healthy, trim. No back history. No risk factors. No significant findings on exam. Neurosurgery referral without any workup or attempts at treatment? No no no.... I don't know if I am sensitized today or if I'm just watching for these things because the profession has so much going on that I am looking for things that can and will be turned against us. This morning I saw a 3 year old with a 2 day old cold whose PNP gave steroids and antibiotics to. The kid was happy as a clam and basically had a runny nose. Another who documented "erythematous pharynx" and "swollen pharynx" and "normal pharynx" in the same sentence. I'm not the greatest PA that ever lived and heaven knows there are oceans of things I don't know but these things are basic and reflect...I dunno....laziness. I know some of it is the dreaded Press Gainey survey and patient satisfactions scores but cumon people.... Link to comment Share on other sites More sharing options...
cbrsmurf Posted September 25, 2018 Share Posted September 25, 2018 1 minute ago, GetMeOuttaThisMess said: So let’s learn from this. What are the indications to obtain plain films for non-traumatic back pain, i.e.-fall? Students? Uh oh. Is this considered student pimping? Patient expectations! Next question Link to comment Share on other sites More sharing options...
sas5814 Posted September 25, 2018 Author Share Posted September 25, 2018 1 minute ago, GetMeOuttaThisMess said: So let’s learn from this. What are the indications to obtain plain films for non-traumatic back pain, i.e.-fall? Students? Without looking anything up.... I almost never do plain films on first visit of atraumatic low back pain without concerning findings. Second visit unimproved or if things worsen? Maybe...depending on the findings and how the story might have changed as things evolved. Always before a referral even if I am sending them to PT. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted September 25, 2018 Share Posted September 25, 2018 Patient expectations! Next questionLOLOL. I almost fell off my chair, that caused me to have LBP when I stood up off it yesterday. No neuro sx. I’m leaving later to go to my neurosurg visit. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 25, 2018 Moderator Share Posted September 25, 2018 12 minutes ago, sas5814 said: Without looking anything up.... I almost never do plain films on first visit of atraumatic low back pain without concerning findings. Second visit unimproved or if things worsen? Maybe...depending on the findings and how the story might have changed as things evolved. Scott knows this, but the exception being old folks. some of them cough and get fxs or have metastatic dz, etc Of course my bar for "old folks" keeps getting older as I do. In school we learned to consider films over age 55. Now I don't think of 55 year olds as being "old". Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted September 25, 2018 Share Posted September 25, 2018 Back pain with fever, Hx of CA (Mets), recent spinal injection w/ development of fever/painful movement (discitis), Hx of active TB, and E’s recommendation of non-traumatic, new onset back pain in elderly (compression fx). Link to comment Share on other sites More sharing options...
sas5814 Posted September 25, 2018 Author Share Posted September 25, 2018 Yea old folks are a different issue...and by old I mean older than me....Ok maybe as old as me. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 25, 2018 Moderator Share Posted September 25, 2018 especially fever in folks who are "sketchy". (I'm thinking epidural abscess in the IV drug users). OF course then we are talking MRI, not plain film. One of my partners had a great catch awhile ago. Sketchy pt with a URI, myalgias, and back pain with fever. he started with blood work and found a 30k white count and + lactate. MRI showed huge epidural abscess, later drained by nsg and > 1000 cc of pus. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted September 25, 2018 Share Posted September 25, 2018 30 minutes ago, EMEDPA said: especially fever in folks who are "sketchy". (I'm thinking epidural abscess in the IV drug users). OF course then we are talking MRI, not plain film. One of my partners had a great catch awhile ago. Sketchy pt with a URI, myalgias, and back pain with fever. he started with blood work and found a 30k white count and + lactate. MRI showed huge epidural abscess, later drained by nsg and > 1000 cc of pus. This guy was "sick", the pt in the OP clearly was not! ' Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 25, 2018 Moderator Share Posted September 25, 2018 6 minutes ago, CAdamsPAC said: This guy was "sick", the pt in the OP clearly was not! ' would have been easy in this setting to blow this guy off as a "junkie with a cold". I think his temp was only like 99.5 too. this was in a high volume dept that saw > 100k pts/year and we were expected to move the meat and avg 3/hr. I don't work there anymore. Link to comment Share on other sites More sharing options...
Guest JMPA Posted September 25, 2018 Share Posted September 25, 2018 try explaining to a jury why you failed to do an x-ray (minimal radiation exposure) and missed lithesis, cancer, fracture ect. Link to comment Share on other sites More sharing options...
sas5814 Posted September 25, 2018 Author Share Posted September 25, 2018 The "try explaining it to a jury" argument is a bit of cognitive dissonance that gets trotted out all too frequently. That argument holds for any and every patient you see for any and every problem. Any visit can have some zebra hiding out that has bad implications and "why didn't it get caught at the first visit." Why not do every test imaginable for every possible diagnosis at every visit so you don't have to explain anything to a jury? Because we have standards and recommendations based on good science. I am very cautious but never fearful. Link to comment Share on other sites More sharing options...
NicoleTNY Posted September 25, 2018 Share Posted September 25, 2018 I wouldn’t pinpoint it exactly to NPs or PAs only. I would attribute it to just poor clinical decision making and incompetent providers as a whole. I have seen many young and old physicians that do things that are questionable as well. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted September 25, 2018 Share Posted September 25, 2018 1 hour ago, EMEDPA said: would have been easy in this setting to blow this guy off as a "junkie with a cold". I think his temp was only like 99.5 too. this was in a high volume dept that saw > 100k pts/year and we were expected to move the meat and avg 3/hr. I don't work there anymore. Why a proper H&P even in Fast Track is important. My old boss told me even crocks get sick. Add in experience and a good clinical gut feeling you won't miss a guy like this. Link to comment Share on other sites More sharing options...
Moderator ventana Posted September 25, 2018 Moderator Share Posted September 25, 2018 don't forget IVDA and discitis.... Link to comment Share on other sites More sharing options...
HMtoPA Posted September 26, 2018 Share Posted September 26, 2018 10 hours ago, EMEDPA said: Scott knows this, but the exception being old folks. some of them cough and get fxs or have metastatic dz, etc Of course my bar for "old folks" keeps getting older as I do. In school we learned to consider films over age 55. Now I don't think of 55 year olds as being "old". +1 I saw an older guy a few weeks ago, a bounce back who had seen a colleague a few days before. LBP after moving a large appliance - an oven, or something like that. Relatively benign mechanism. I probably wouldn’t have gotten films the first time - hell, almost didn’t do so the second time. But I did, and found a compression fracture. In some ways, it would’ve been no harm, no foul if I’d missed it - it was non-op - but I felt a little sheepish and stupid for not just getting the films without hesitation. I think I have a pretty good gestalt, but I sometimes have to remind myself that there are simple diagnostic tests that can quickly eliminate the low-hanging fruit, and there’s no shame in being careful. Better than being cavalier and having a bad outcome. Not that you should just shotgun tests, but you’ve gotta consider your differential. It’s definitely hard sometimes, especially with the emphasis on volume. Link to comment Share on other sites More sharing options...
sk732 Posted September 26, 2018 Share Posted September 26, 2018 Did anyone ask the NP if this neurosurgeon was a buddy of their's and maybe getting a little something in return for even BS consults? I knew doc many moons ago I swear was getting kickbacks from a surgeon because he would refer to them and them only, even for things that were really minor and in his scope of practice. Just kicking that out there as well to stir the pot SK Link to comment Share on other sites More sharing options...
BruceBanner Posted September 26, 2018 Share Posted September 26, 2018 On 9/25/2018 at 9:22 AM, sas5814 said: 1st patient of the day. Healthy 36 YO male with no history or co-morbidities sees an NP in FP with acute low back pain after handling some farm animals 10 days ago. Imaging? Nope.... Ok not really a problem. I might not have either. Meds? Nope. PT Nope. Referral to neurosurgery. These are the things that make life hard for all of us. Bad form. I relish my ability to refer a great number of patients in FP but I dont abuse it. I always ask myself if I have done my (reasonable) due diligence before I refer. Link to comment Share on other sites More sharing options...
ravenspac Posted September 26, 2018 Share Posted September 26, 2018 On 9/25/2018 at 9:22 AM, sas5814 said: 1st patient of the day. Healthy 36 YO male with no history or co-morbidities sees an NP in FP with acute low back pain after handling some farm animals 10 days ago. Imaging? Nope.... Ok not really a problem. I might not have either. Meds? Nope. PT Nope. Referral to neurosurgery. These are the things that make life hard for all of us. Im not sure why you would refer for surgery without acute weakness or neuro defecits... always a fan of the Pred taper, plus PT, plus Chiro, and single Rx for anti inflammatory if no heart disease for lumbago Link to comment Share on other sites More sharing options...
cbrsmurf Posted September 26, 2018 Share Posted September 26, 2018 4 hours ago, ravenspac said: Im not sure why you would refer for surgery without acute weakness or neuro defecits... always a fan of the Pred taper, plus PT, plus Chiro, and single Rx for anti inflammatory if no heart disease for lumbago Why chiro? Why prednisone? Link to comment Share on other sites More sharing options...
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