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The ER work up


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New to the ER as of 6 weeks ago after spending 6.5 years in urgent care.  Before PA school spent 14 years as a volunteer medic (full time job was not medical).  This transition to the ER has been a lot harder than I expected (and my "training" was shadowing another PA for 16 hours).  The amount of resources I now have at my disposal is at times overwhelming (when do I really need to order all these tests?  What the heck are some of these anyway?!!!).  The "burden of proof" the ER has is at times also overwhelming.  I have plenty of book resources.  I am trying to follow the workups being done on other patients by other providers when I am working to get a sense of how things are done by other folks.  But any tips on adjusting to that ER mind set?  I have seen patients I feel I would of sent home in UC but here in the ER I'm doing CXR, fluids, blood work,  blood cultures, etc.  

And the schedule.  Holy crap, I'm exhausted.  My shifts are either 0800-1800 or 1600-0200 but I have almost an hour commute on either end.  And I may or may not get out on time.  Tips for coping with a crazy schedule?  

Overall, my attendings are helpful.  The nurses are generally good and helpful.  I have a scribe (how did I ever live without them?).  But the transition has been tough.  Some shifts feel smooth.  Other shifts, I'm convinced I killed everyone I ever saw in UC and I'm up all night questioning my work up.  Maybe this is just a normal part of transition?  I am trying to remember how I felt when I first started at UC.  Probably similar.  It also hasn't helped that a couple zebras have trotted through the doors recently (my last shift I had a 5 yo male with a possible renal abscess? Yeah, I can say that wasn't on my differential.  And radiology called it pyelo, it was only when my attending stopped me after looking at the images herself that that the possibility of abscess entered).  

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As a general rule of thumb chance of badness is related to age.

10 yr old at the ED looking vague? 10% chance of a real dx

90 yr old, 90%....

Old people with belly pain ALL get CTs, young folks only if you really suspect badness. 

all women of childbearing age get pregnancy tests

order a lipase for abd pain. it's a great test. get UAs on anyone confused, especially the elderly

MRIs are Over-utilized in the ED. Get them only on the advice of a consultant or if you really suspect an epidural abscess. 

Order a magnesium every time you order a cmp. low mag levels contribute to fatigue, myalgias, arrhythmias, etc. If you are worried about the K , you should worry about the Mg.  

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2 hours ago, EMEDPA said:

As a general rule of thumb chance of badness is related to age.

order a lipase for abd pain. it's a great test. get UAs on anyone confused, especially the elderly

In elderly, where you suspect a pulmonary process such as pneumonia in a febrile elderly patient, don't trust a negative chest x-ray.  A lot are dehydrated, you hydrate them, and there's your pneumonia on the CXR.

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2 hours ago, DogLovingPA said:

Thanks for the tips.

For old folks, are you getting CTA of abdomen to include mesentaric ischemia dx?

Good to know about the mag, will add to my ever growing arsenal.  

If the clinical history and exam dictate it, but not always. The key early is pain out of proportion with exam. Remember that rebound comes from stretch pain receptors in the viscera, so early there won’t be these signs. One pneumatosis develops, these people are going to be sick sick looking. Once they have rebound, you aren’t going to typically be discharging these patients and even a noncon ct catches these, but you won’t make the diagnosis necessarily as pneumatosis can occur for other reasons. A dimer can help lower suspicion, but remember to think of your pretest probability and Bayesian statistics. Have a higher suspicion in people with peripheral arterial disease, cancer, afib, especially if new or not anticoagulated. 

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3 hours ago, DogLovingPA said:

Thanks for the tips.

For old folks, are you getting CTA of abdomen to include mesentaric ischemia dx?

Good to know about the mag, will add to my ever growing arsenal.  

the key to mesenteric ischemia is pain out of proportion to exam. those folks get a CTA.  also check a lactate. generally it will be elevated in the setting of ischemic bowel.

also make the MDCalc site your friend. Geneva for PE, pecarn for head injury, heart scores, curb-65, abcd2, etc

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Amen to what everyone says.  6 weeks into EM, even with UC experience, you SHOULD be SCARED as well as overwhelmed.  It shows you know enough to know what you don't know.  Don't let the fact that you had some zebras spook you.  They're only there to teach you that weird stuff exists.  You shouldn't grade yourself on having a large "zebras to exclude list".  It will probably be at least 3 years before you really feel comfortable.  Give yourself time.

Some suggestions:

  • PA colleagues and nurses are great sources of mentoring.  They both know the usual workups for various undifferentiated complaints.  It's usually much less intimidating to ask them than the docs.
  • Become a procedure expert: repair of complex lacs, gnarly I&D's, fracture & joint reduction.
  • Consider PE in the differential for every dyspnea and chest pain complaint.  D-dimer only if you think it's unlikely that they have a PE.  If you think PE is likely, just get the scan.  It will get you that answer and also tell you more about pneumonia, etc.
  • Get a free subscription to Medscape: very well organized into presentation, workup, treatment, etc.
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I have MD calc on my phone with my favorite "rules" marked.  Love Medscape, I find this much easier to navigate than up to date. 

GMOTM and Lt, thanks for the additional tips, I appreciate your knowledg and experience.  

Ohio - thanks for the reassurance.  Every day I am astounded by how much I realize I don't know.  Which is ironic, because the main reason I moved to the ER was to take care of actual sick people (in UC I was at the point that if one more "sinus infection" checked in I was going to poke my eye out) and expand my knowledge and pt care abilities.  Now that I'm here, I'm like "FARK!  These people are sick".  Lol.

EmedPA - Appreciate the support!  I found Iraq to be much more like EMS, which I find to be the easiest of all my jobs.  Stop the bleeding, make sure they are breathing and get them on an ambulance.  Lol.    

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28 minutes ago, DogLovingPA said:

I have MD calc on my phone with my favorite "rules" marked.  Love Medscape, I find this much easier to navigate than up to date. 

GMOTM and Lt, thanks for the additional tips, I appreciate your knowledg and experience.  

Ohio - thanks for the reassurance.  Every day I am astounded by how much I realize I don't know.  Which is ironic, because the main reason I moved to the ER was to take care of actual sick people (in UC I was at the point that if one more "sinus infection" checked in I was going to poke my eye out) and expand my knowledge and pt care abilities.  Now that I'm here, I'm like "FARK!  These people are sick".  Lol.

EmedPA - Appreciate the support!  I found Iraq to be much more like EMS, which I find to be the easiest of all my jobs.  Stop the bleeding, make sure they are breathing and get them on an ambulance.  Lol.    

Now that I'm out of the game, I'd like to comment on a matter having to do with people applying to all these programs.  Give me someone any day of the week with a lower GPA but who has actually been in life/death situations and responded appropriately under the stress of it by being able to think on their feet.  An average student who can function under stress beats a bookworm that doesn't know their left hand from their right hand because they haven't been there, or in other words, they're an unknown commodity.  It's easier to learn/pick up things than learn how to think on your feet and deal with stress IMO.

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You order more because you probably feel the need to cya more. The ED can be a cluster f***. The only way to become more comfortable is time. You'll find people that are, what I like to call, review of systems positive - meaning every question/symptom you ask will be an affirmative. Takes some practice weeding through those. 

Check out the book Chief Complaint. Won't help you with the hundreds of disease processes that could be going on, but will help you consider the ones you cant miss.

But agree with some of the above: old people get CTs of their belly; lipase is great (even chest pains get this test); risk stratification tools can be helpful with dispo home v admission - but be careful because even these have limitations such as not being validated for ED use (eg. ABCD2) and not being validated with certain assays (eg. HEART score with the newer high-sensitivity troponins).

PERC criteria is your best friend when evaling young people for PE.

Aortic dissection risk stratification score is as good as it gets when considering the ominous and otherwise hard to rule out aortic dissection (unless you just CTA everyone).

Try to really learn ECGs - there's more to them than just STEMIs. If you order one and the doc signs off on it there is a decent chance that's all he/she is looking for so you need to know what you're looking for when you get it (lifeinthefastlane is a site I reference often).

As much as youd like to call out people on their bullsh*t that's how you miss stuff and get sued. So if an otherwise healthy 20 year old says they have chest pain I'm getting an ECG and probably at least one trop (people like to lie about doing cocaine and meth, and some people just were dealt a sh*tty family history and have bad genes).

Dont spend too much time mentally masturbating about something. If you're on the fence about a lab test, CT, etc then just get it. Your nurses may hate it but you'll sleep better, you'll catch some weird and potentially important findings, and quite frankly your patients will probably appreciate it when you sit down with them at discharge and say, "I dont know exactly what is going on, but I was worries about x, y, and z so we did these tests and thankfully they were negative."

If in doubt present the patient to your doc and ask what you could be missing. Up to date has some good overviews of evaluating certain complaints in the ED which are very worthwhile.

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Another thing to think about is as you are developing your work-up, step 1 is immediate symptom management:

  • anti-emetics
  • fluids
  • pain control
  • respiratory interventions: nebs, steroids, O2, BiPap if needed
  • chest pain: ASA, nitro (after IV access)

tell the patient how you are going to help them feel less bad while you're figuring out what's going on - also tell them what your plan is for that: urine, blood, imaging, EKG, etc.

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