Cute small list to aid triage.

[surgblumm]

[SHU-CH]

I once had an ER patient that arrived at 2am and waited ~3 hours to be seen for athlete's foot. 

In my childhood there were a fair number of TV commercials related to treating athlete's foot. You don't really see them any more. I guess we are no longer athletic, yet people still get dermatophytes. Maybe we will have to rename it "couch potato foot."

[Cideous]

Strange that abdominal pain in not on that list.  That is the number one reason I turf UC patients to the ED.  People have no concept that unless it's a straight forward UTI or GE that there is nothing I can do in UC for abdominal pain.  No US and no CT.

[surgblumm]

The problem with UC is that if you constantly are seeing level l-ll patients you can be lulled to sleet and become anesthetized to the potential of thinking like an EM PA and begin to become sloppy. I wished that all my UC patients were tones of any sort or the average UTI or Otitis Media or Externa or URI, Strep throat or influenza but we still need to be alert for other presentations. I noticed the abdominal pain patient by Cideous and I have seen hundreds of these presentations but as a surgical PA primarily, I did a full abdominal exam with a mixed pulmonary and cardiac an listened carefully to the complaint and presentation and occasionally ordered a CXR along with my labs and to my retirement, did not miss a surgical abdomen. I did send patients to the ER with acute appendicitis as well as a feebAAA’s and pneumonia’s and an atypical MI. It’s nice to have all the diagnostic tools but not always grasp. Cope Examination of the Abdomen was my go to book that I read every six Monty. The endgame message is; Stay Alert .

[ventana]

Where is PA listed?

 

A "Doctor" sees all the simple stuff then punt to UC or ER where they see a PA????

 

[surgblumm]

In response to you Ventana, I think when they write doctor they are making a generality of a physician PCP. Itygive the PCP the low hanging fruit that is appropriate for making money and turf the remainder.

[thinkertdm]

This is true in all specialties, and the aphorism of the hooves and zebra baloney doesn't really hold true, and should not necessarily be used to guide your thought process.  In a primary care setting, chest pain can be anything, but if one gets tied down in a "jeez, another overweight forty something with heart burn" they are going to be the ones getting burned if they are not careful.  Same with UC.  In the ED, there are a number of possible fallacies; if they aren't about to die, it's not important; if it's not chest pain that meets such and such, its not an MI and I'm not going to rule it out; dizziness is "labyrinthitis" and away they go.  

While nine out of ten of each of these you will be right, one will be wrong, and you could have caught that one by...being human and thinking.  Not letting the administrators guide your thought process.  Be efficient, not fast.

Here's an example.  Someone went to an UC for some dyspnea for the past few months, some chest tightness.  The provider on duty asked a few rote questions, stated that she didn't hear any wheezes but prescribed some steroids and an albuterol inhaler.  Boom.  Level four, out the door.  She didn't ask about recent travel, recent bed rest, recent surgery, check legs for edema.  

That provider must have seen a bazillion asthma and COPD flare ups in the past week.  She heard hooves, and didn't stop to think, she went with horses.  In fact, don't even bother with hooves and horses and other bullshit.  Do this:

1. talk to the patient.  That the basis of a "full history".  Who, what, where, when, how.  We all learned how to do it.  Keep asking questions.  

2. Come up with a preliminary differential.  We all walk into the room with a list based on what is listed on the schedule.  This is helpful, but we should know it may change.  This differential shouldn't specifically include every damn thing, because, honestly, brain tumor for headache is unlikely.  This isn't hooves/zebra baloney; this is elicited by that history you just did.  Length of time, intensity, etc.

3. at some point, look at what has been done.  If you have a chart bursting with info, great!  use it.  If you can get it, get it.  

4. physical exam we've been told is tailored to the differential.  That's true.  On the other hand, sometimes the physical exam is so unhelpful...but look anyways.  If you don't hear a wheeze and you expect to find one, don't make the patient fit your differential.  

5. go back to the ol' differential.  By now something should be coming out.  How can you tease it out?  If nothing, go back to square one.  

I went to a museum.  Like many people, I rushed through, to say, "I went to that museum!"  I felt each exhibit was the same, telling me something, but there was always one ahead of it.  Gotta keep moving.  "Oh that's nice".  Shuffle, shuffle, shuffle.

This is not the way to approach your schedule.  Each patient is a unique display, full of mysteries that's right there in front of you.  Do not let the previous display or the next waiting to bias or color the current one.  

Ehh.  It's been a long day already.  

[surgblumm]

What an excellent and extraordinary response. You demonstrated your education and experience and set the bar or standard for all PAs. Bravo!

[LT_Oneal_PAC]

56 minutes ago, thinkertdm said:

This is true in all specialties, and the aphorism of the hooves and zebra baloney doesn't really hold true, and should not necessarily be used to guide your thought process.  In a primary care setting, chest pain can be anything, but if one gets tied down in a "jeez, another overweight forty something with heart burn" they are going to be the ones getting burned if they are not careful.  Same with UC.  In the ED, there are a number of possible fallacies; if they aren't about to die, it's not important; if it's not chest pain that meets such and such, its not an MI and I'm not going to rule it out; dizziness is "labyrinthitis" and away they go.  

While nine out of ten of each of these you will be right, one will be wrong, and you could have caught that one by...being human and thinking.  Not letting the administrators guide your thought process.  Be efficient, not fast.

Here's an example.  Someone went to an UC for some dyspnea for the past few months, some chest tightness.  The provider on duty asked a few rote questions, stated that she didn't hear any wheezes but prescribed some steroids and an albuterol inhaler.  Boom.  Level four, out the door.  She didn't ask about recent travel, recent bed rest, recent surgery, check legs for edema.  

That provider must have seen a bazillion asthma and COPD flare ups in the past week.  She heard hooves, and didn't stop to think, she went with horses.  In fact, don't even bother with hooves and horses and other bullshit.  Do this:

1. talk to the patient.  That the basis of a "full history".  Who, what, where, when, how.  We all learned how to do it.  Keep asking questions.  

2. Come up with a preliminary differential.  We all walk into the room with a list based on what is listed on the schedule.  This is helpful, but we should know it may change.  This differential shouldn't specifically include every damn thing, because, honestly, brain tumor for headache is unlikely.  This isn't hooves/zebra baloney; this is elicited by that history you just did.  Length of time, intensity, etc.

3. at some point, look at what has been done.  If you have a chart bursting with info, great!  use it.  If you can get it, get it.  

4. physical exam we've been told is tailored to the differential.  That's true.  On the other hand, sometimes the physical exam is so unhelpful...but look anyways.  If you don't hear a wheeze and you expect to find one, don't make the patient fit your differential.  

5. go back to the ol' differential.  By now something should be coming out.  How can you tease it out?  If nothing, go back to square one.  

I went to a museum.  Like many people, I rushed through, to say, "I went to that museum!"  I felt each exhibit was the same, telling me something, but there was always one ahead of it.  Gotta keep moving.  "Oh that's nice".  Shuffle, shuffle, shuffle.

This is not the way to approach your schedule.  Each patient is a unique display, full of mysteries that's right there in front of you.  Do not let the previous display or the next waiting to bias or color the current one.  

Ehh.  It's been a long day already.  

I don't think when people say hoof beats think horses, not zebras, they aren't talking about think benign conditions. MI is a horse. I believe they mean, don't look at hypertension and think pheochromocytoma or syncope and think insulinoma, things that likely won't kill you immediately and providers may say one, if that, in their lifetime. So I think it's still pretty valid. In the scenario you provided, I would call those questions looking for horses. Checking an alpha 1 antitrypsin on a first visit for dyspnea may be looking for a zebra.

What I believe your referring to is anchor bias, relying on only a small amount of information or preconceived ideas to guide decision making, which is something we all definitely need to watch out for. You hear someone is a drug addict and you walk in thinking they are malingering, see they are a BMI of 40 and they have deconditioning, ect. Definitely agree with you that this can be a real trap that anyone can fall into and must be vigilant to check your bias at the door. I usually catch myself falling into it after the nurse says something like "oh he's just whiny" or something other blow off statement and need to realign myself.

[ventana]

I like to call it premature closure......

 

get ALL the facts first,  Ddx of ATLEAST 5 things, then start to decide.....