EM case

[LT_Oneal_PAC]

Let me phrase it another way. What is he going to get inpatient for elevated LFTs that he wouldn’t get outpatient? 

[EMEDPA]

1 hour ago, LT_Oneal_PAC said:

Let me phrase it another way. What is he going to get inpatient for elevated LFTs that he wouldn’t get outpatient? 

A bigger bill, duh

[ventana]

1 hour ago, LT_Oneal_PAC said:

 

now the NP who said it was mycoplasma, can’t defend that.

Yeah. That’s a WTH moment. 

[MediMike]

1 hour ago, LT_Oneal_PAC said:

Let me phrase it another way. What is he going to get inpatient for elevated LFTs that he wouldn’t get outpatient? 

This is something it took me a while to wrap my head around. My wife worked ED before joining me in the ICU and she'd come home with these stories about sending folks home and I'd be like OMG BUT WHAT ABOUT...then she'd just stare at me and I'd remember how badass y'all are in the ED. 

[MedicinePower]

I'm not sure if the posters who suggest discharging someone with severe unexplained transaminitis is being serious or not. In my major academic institution discharging that person would most certainly end you up at M&M.

[LT_Oneal_PAC]

46 minutes ago, MedicinePower said:

I'm not sure if the posters who suggest discharging someone with severe unexplained transaminitis is being serious or not. In my major academic institution discharging that person would most certainly end you up at M&M.

They aren’t kidding because they don’t practice reflexively. They understand each situation is nuanced. Treat the patient, not the number. I won’t deny that further work up is needed and I probably would have done it very differently on the second visit, but he is obviously not in acute condition and of the list of life threatening liver diseases, he is low for all of them. 
 

im going to help you out and show you the literature of what you are looking for, and you tell me if he really is at risk for any of these or you really think he needed any of these treatments.
 

 

[MedicinePower]

We will have to agree to disagree. Such a serious transaminitis without explanation is reflexive admission to the GI service.

[polarbebe]

33 minutes ago, MedicinePower said:

We will have to agree to disagree. Such a serious transaminitis without explanation is reflexive admission to the GI service.

I agree.  

AST 16000 of unknown acuity in an otherwise healthy 23 year old male, no known history of severe transaminitis, no history of liver failure and also of unknown etiology would be admitted to medicine for an inpatient work up.  
 

In my experience very likely would include a GI consult to make sure all the bases were covered (autoimmune, over the counter supplements, etc.). 

As a side note I have picked up rhabdo in a similar fashion after someone having a seizure with an elevated AST.  Initial CK was in the hundreds then I noticed AST was close to a thousand, after inheriting the patient rechecked a CK a couple days after the initial and it was close to 20K.  
 

Take home point CK can peak at three days and bounce back up… and make sure all your compartments are soft. 
 

Btw thank you for sharing this case

Edited May 18, 2022 by polarbebe

[ohiovolffemtp]

Without speaking to the specifics of this case. you very much have to practice differently in a rural setting where you have limited specialist resources vs a major urban setting, much less an academic setting, where a huge variety of specialist resources are available.  I don't know what the LT's specialist pool is, but I've practiced in rural CAH's where GI came once a week and in others where there was no GI.

So, the decision becomes:

• admission for whatever a hospitalist, who might be the town's outpatient IM doc, can do
  • this implies that there's something that can be done locally that will improve the patient's condition
• transfer to larger center, where the specialist resources are available.  However this requires:
  • agreement on the part of the patient to go
  • agreement from a receiving hospitalist to accept the patient because those specialists don't admit
  • availability of a transport unit. (some places where I work there is often a 12+ hour wait)
• arrangements for outpatient follow-up with the specialist - again which requires getting the patient to agree to go, likely to a distant bigger city

So, in the rural resource limited ED, you do have to make decisions on the patient's clinical condition, how long the condition has been going on, what the trend has been, etc, and then match this with what you can make happen, including the patient's willingness to comply.

[MediMike]

I think @ohiovolffemtp has hit the nail on the head here.  I previously worked at a "major academic institution", but maybe not as major as yours because we sure as hell didn't have a GI service that admitted patients.  But we would admit things like pericarditis which was clearly viral and put the patient through a wide variety of tests simply because we could and it may be a good learning case. 

If you've ruled out life threatening or progressive dz processes what good is admitting the patient to a 10 bed hospital going to do? If you've arranged imaging, done the necessary labs and obtained a thorough history?  I think the idea that everything needs to be an inpatient workup is a little over the top and also contributes to a decrease in the appropriate utilization of OP providers. I guess a question would be what is your threshold level of AST to reflexively admit someone to the hospital? If 16000 is appropriate is 200? What about 80?

I would agree that there was a pretty big miss on the 2nd visit and I likely would have called someone...but I've got resources.  I also probably wouldn't have written for the Z-Pack

[polarbebe]

1 hour ago, MediMike said:

 

If you've ruled out life threatening or progressive dz processes what good is admitting the patient to a 10 bed hospital going to do? If you've arranged imaging, done the necessary labs and obtained a thorough history?  I think the idea that everything needs to be an inpatient workup is a little over the top and also contributes to a decrease in the appropriate utilization of OP providers. I guess a question would be what is your threshold level of AST to reflexively admit someone to the hospital? If 16000 is appropriate is 200? What about 80?

I would agree that there was a pretty big miss on the 2nd visit and I likely would have called someone...but I've got resources.  I also probably wouldn't have written for the Z-Pack

I have only worked in a metropolitan area with multiple specialties available on call or always with the ability to transfer to a facility with said service within 1 hour (usually 30 minutes or less).   I primarily work critical care and for a number of years ER part time   

In this case on day 3 seen by the NP finds AST 16000 with no prior labs to indicate acuity, unknown etiology and discharged which looks like close follow up (or anxious patient with hypochondria) since he was seen by PCP and back in the ED shortly thereafter.   There was no rule out of life threatening disease or progression at this point.  
 

Given what I knew at this point, wearing the shoes of the ED NP provider, in my medical opinion I would not discharge.  I would either admit for at least one day to at least trend the values (stable or declining, not skyrocketing), get more history and if a detailed history is unable to make a definitive diagnosis; more labs (all within the scope of internal medicine with an initial work up for autoimmune hepatitis? myositis? viral loads, serologies, etc), get a more detailed history (powders, illicits, etc) and get synthetic function as the transaminases can lag them by a bit.  
 

As far as I am aware there is no lab cutoff for transaminitis for admission. 
 

Your question what AST do I feel uncomfortable with?  You suggest 80? That is extremely cheap and may be actually WNL for certain labs/facilities.  200? Cheap as long as asymptomatic, follows up, etc. 

 

My main specialty is critical care, I will see AST >1000 (maybe a handful at that level of 16k in my entire career) perhaps several times a year and also having worked in ED part time for a number of years none at that level of 16000 thus my comfort level to discharge is zero.   
 

If as you said life threatening disease, progression has been ruled out and close follow up has been arranged, I do agree discharge may be appropriate.  That was not the case on day #3. 
 

We can agree to disagree.  We come from different training, backgrounds and resources available.  

Edited May 18, 2022 by polarbebe

[MediMike]

6 minutes ago, polarbebe said:

Given what I knew at this point

I can totally agree with the argument that if there was no plan to work any of this up besides an OP RUQUS then yes, they could have been admitted, simply so a different provider who may have been more aggressive in their workup could lay eyes and/or brain on them.  I think the argument that started here is whether someone needs to be reflexively admitted based on lab values in the absence of signs of end organ dysfunction. 

[LT_Oneal_PAC]

@polarbebe

@MedicinePower

@MediMike

what I didn’t realize until polarbebe’s post was there was a typographical error. The AST is 1,600 at the second ED visit not 16,000.

perhaps this makes you more comfortable?

let me make a few other points. First, this patient needed a much larger work up for an unknown etiology. Mycoplasma is just stupid. I would have worked him up in the ED with a bedside RUQ US, ceruloplasmin, hepatitis panel, acetaminophen level. I still would let him go with next day follow up and repeat labs and formal RUQ This because he needs no monitoring and there would be no transfer as the only center with hepatology is always full/near full since COVID. Would have been a level 3 transfer and waited inpatient at our facility with no GI for minimum 3 days before acceptance.

 

[ventana]

2 hours ago, LT_Oneal_PAC said:

@polarbebe

@MedicinePower

@MediMike

what I didn’t realize until polarbebe’s post was there was a typographical error. The AST is 1,600 at the second ED visit not 16,000.

perhaps this makes you more comfortable?

let me make a few other points. First, this patient needed a much larger work up for an unknown etiology. Mycoplasma is just stupid. I would have worked him up in the ED with a bedside RUQ US, ceruloplasmin, hepatitis panel, acetaminophen level. I still would let him go with next day follow up and repeat labs and formal RUQ This because he needs no monitoring and there would be no transfer as the only center with hepatology is always full/near full since COVID. Would have been a level 3 transfer and waited inpatient at our facility with no GI for minimum 3 days before acceptance.

 

Damn decimal point.   Why can’t HR make that mistake with my paycheck.  

[rev ronin]

45 minutes ago, ventana said:

Damn decimal point.   Why can’t HR make that mistake with my paycheck.  

Don't give them any ideas... they just might, but not in the direction you prefer.

[EMEDPA]

17 hours ago, MedicinePower said:

We will have to agree to disagree. Such a serious transaminitis without explanation is reflexive admission to the GI service.

None of the places many of us work have a GI service or even a GI physician on staff. With hospitals refusing legit trauma, stemi, and stroke patients due to bed(read Nurse staffing) availability, a vagueoma like this would not get transferred to the big city anywhere I work.

[SedRate]

16 hours ago, EMEDPA said:

None of the places many of us work have a GI service or even a GI physician on staff. With hospitals refusing legit trauma, stemi, and stroke patients due to bed(read Nurse staffing) availability, a vagueoma like this would not get transferred to the big city anywhere I work.

Unless you're talking about the Level 1 that I work at that will accept just about everything regardless of staffing issues, such as a chronic fx with a chrohns flare that was transferred for GI. When the pt arrived, it still took 4 days for GI to see the pt and recommend no need for further workup and outpt f/u with established GI doc.