April 19, 2014

Medical clearance, Locum Tenens, and Patient Satisfaction: Rant off 2013

The gloves are off and the vitriol is bubbling hot. This is the episode where you get the mic and tell the world what really gets your goat.

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Rant off 2013 players

Gerry O’Malley is no fan of patient satisfaction surveys

Ken Grauer say we shouldn’t throw away the atropine for some cases of asystole

Graham Walker is hot under the collar about medical workups for psych patients

Matt Dawson and Mike Mallin think we should hold the narcotics and  and place femoral nerve block patients with hip fractures

Ryan Radecki on headaches and hypertension

Michelle Lin gives a pearl on keeping central line guidewires going in the right direction

Rob Bryant tells us how to throw the guidewire away

Graeme Pickford gives advice to would-be locums physicians  traveling to Australia

Seth Trueger Emergency physician and Health Policy fellow in Washington, DC

Gabe Rose is not a fan of pelvic exams

Andy Sloas rants about, well, I’m not really sure, but he seems quite upset

Jim Miller from Montana thinks we make much ado about nothing when it comes to fecal disimpaction

 Matt Freeman thinks the terms ‘midlevel’ and ‘physician extender’ are out of touch

Rob Bryant’s Brass Knuckles Technique for Guidewire Disposal

 

 

 

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Comments

  1. Great series of Rants, with a capital “R”! Listening to Andy Sloas talk about his experience with the trauma surgeon, we’ve all been there, and when you’re sure you’re right, making the call yourself is absolutely the right thing to do. I’m really trying to address these issues head-on in my new blog, Resus Room Management (RRM, which is CRM for the resus room) http://www.resusroom.mx We’ll be teaching RRM on our new ED focused trauma course as well (http://www.etmcourse.com), due to launch in late 2013, in Melbourne, Australia (shameless plugs I know). RRM is a new, dynamic concept that I want to evolve with input from as many experienced ED/ER clinicians as possible, if any of your readers/listeners have cool, calm, collected, objective strategies for dealing with guests who behave badly, I’d love to hear from them. Great show as usual Rob.

  2. ekgpress says:

    I feel honored to be included in the 2013 “Rant Off”! This is not only FUN to listen to -- but highly educational. Wonder if Rob Bryant will become rich for patenting his “Brass Knuckles Technique” for Guidewire Disposal. THANK YOU Rob Orman for putting this together! -- : )

  3. Rob, awesome show. I am a long time listener and you show has made me better at what I do. As an emergency nurse practitioner it was good to hear from Matt as the last rant (don’t you think you should add him in the list of rant off players?). I fully agree with his points and think that we do need to change the vernacular we use in the description of NPs and PAs. For now I think it’s best that we use the terms of our conferred degrees.

    On a different note It would be awesome to hear more from other NPs and PAs.

    Thanks again for your awesome podcast.

    • Rob Orman says:

      Thanks Gabe. Matt has been added to the list. If you know of PAs or NPs with a particular area of expertise that you think would like to contribute to the show, send them my way!

  4. Jim Miller says:

    Full disclosure -- about a week after leaving my disimpaction rant on Rob’s rant phone I was having dinner with my family when I smelled something bad. I looked down and there was a small piece of stool on my watch from a disimpaction I did earlier that day. Karma, needless to say I am rethinking the disimpaction suit.

  5. For those of us who are cyclists, we are aware of the vehicle approaching from the side street who appears to have the default guideline: “I will run the stop sign, …….unless there’s an 18 wheeler coming.” Compared to the car slowing in such a way that the appearance is “I will stop at this stop sign, but if I get a good view and no one is coming, I might roll through.” The difference in threat to me as a cyclist is apparent.

    When the default is “I will do whatever I can to avoid doing a pelvic (or rectal) exam……” there is an implied threat to the patient of missing important and clinically relevant information. When the default is: “The pelvic exam is a part of the physical exam, and I will do it unless it is clearly irrelevant to the task at hand -- much like we often skip the heart and lung exam when the complaint is a thumb in the eye, but not when the complaint is a sore throat -- then, the pelvic exam may provide a wealth of clinical information that may focus our search for the source of symptoms, modify our use or misuse of diagnostic technology, or even (God help us) make a clinical diagnosis. Or it might turn out to be, like the heart and lung exam, in retrospect, uninformative. So be it.

    The ranter’s misogynist implied attitude of evil in female genitalia, and the need to therefore approach them cautiously, is calamitous to professionalism and good clinical care.

    There may be a slippery slope that leads from the pelvic exam is completely irrlevant and need not be done, to borderline so I’ll skip it, to might be helpful but the ultrasound is as good or better, to -- the pelvic is the important test, but I hate doing them, so I’ll gust get a PCR and an ultrasound. What could be wrong with that plan?

    Perhaps we should consider our default approaches to life: Don’t run stop signs, but do do pelvic exams -- unless there is a clear alternative path ahead. The cyclists and women of the world will be better for it. And, no good doctors will be harmed in the making of such a movie.

  6. David Levy says:

    Regarding the rant by my Asutralian colleague, Graeme Pickford, I have heard that if you have a criminal record this is a bonus in OZ for obtaining locum status…from an American ex-pat who is now a FACEM in NZ!

  7. Dear Rob,
    First, thank you for including me on your rant-off. It’s been quite an honor for this social media newbie.

    I think Dr Abbot makes some great points in his rebuttal on the utility of pelvic exams in the ED (not to mention a splendid analogy to cycling). I’ve never met Dr Abbot but he certainly sounds like a sharp, experienced clinician and is an quite the adroit writer. I’d like to contribute further by clarifying a few of my points if I may:
    1. ED pelvic exams are not futile but rather are low in accuracy and yield. This is evidenced by the articles cited in my blog post, including the eloquent review article written by the great Dr. Mel Herbert.
    2. That is not to say that when female patients present with lower abdominal pain a pelvic exam adds no value. To draw a parallel consider the worth of a good cardiac evaluation in patients presenting with epigastric pain.
    3. Regarding the unpleasantness of doing a pelvic exam- like a rectal or manual disimpaction — I have yet to find an EP who would gleefully jump to the occasion such as one would for an intubation, chest tube, thoracotomy or pretty much any other ED-based procedure. Pelvic and rectal exams are unfortunately sometimes a necessary component of a thorough workup but -- at least in my opinion -- not particularly exciting, fun, or rewarding. Female physician colleagues of mine seem to agree and are just as irked when having to perform vaginal and rectal exams, as well as male gentile exams. This leads me to my final point…
    4. While we here at EM Broad Spectrum enjoy putting a comical spin to topics in evidence based practice, misogyny or any other form of hatred is neither endorsed nor tolerated. If my ideas or tone were somehow misconstrued as such then I sincerely apologize and will strive to be more careful in future posts.
    Thanks again. -Gabe Rose

  8. I would like to come to the defense of Dr. Rose and say that his objective thoughts are right on. However, any time a male physician vocalizes dread in doing a pelvic exam it will not be taken kindly by some no matter how they say it- and I have nothing wrong with his tone during the rant.

    That being said- be honest- there isn’t an EM physician alive (male or female) who doesn’t have at least some sort of mild groan when they pick up a chart that says “vaginal discharge.”

    But let’s take all of that out of the equation and look at objective evidence for the pelvic exam with some references. Here are the 3 clinical situations where pelvic exams come into play the most and why it doesn’t help us a lot

    1) Vaginal discharge with no abdominal pain/tenderness and non-toxic -- Dr. Rose is right- there isn’t any vaginal discharge that can’t be treated with ceftriaxone and azithro (+/- flagyl or fluconazole if very suspicious). If you want to be cautious then treat for PID and substitute doxycycline for azithro. The CDC guidelines recommend that even the mildest cervical or tuterine tenderness should be treated as PID. (1) In all these situations, a urine HCG, UA, Urine GC/Chlamydia and that is all that is needed. A lot of EDs don’t get back GC/Chlamydia on a STAT basis so we are left to treat most of these empirically anyway. There is good evidence to suggest that the type, quantity, or quality of discharge can’t help you diagnose it so why even bother? (2) Diagnose the STDs via urine GC/CHlamydia for patient knowledge and public health purposes but a pelvic exam isn’t going to add any additional information that will alter your management of any emergent conditions. (We’ll get to torsion/masses in a second)

    2) Vaginal bleeding- if stable and not pregnant what is the pelvic exam going to tell you that will alter management? The sensitivity of adnexal masses on anesthetized patients is poor (15-30% in one study) (3) while another study showed very poor inter-rater reliability (0.2-0.3) in an ED setting for the bimanual exam (4). While I realize that we are now expected to perform more primary care in the ED more than every before- shouldn’t we draw the line somewhere? In first trimester vaginal bleeding without continued bleeding or passage of tissue- do we even need a full pelvic? Why not just do a bimanual for cervical opening along with the UA, urine GC/chlamydia, and transvaginal ultrasound? Is the full pelvic really necessary in that case? Per ACOG and the CDC, (5,6) if the patient is asymptomatic, treatment for asymptomatic bacterial vaginosis in pregnancy is not recommended and candiadiasis will be obvious from the history. As all of my attendings have asked me multiple times- “How will it change your management?”

    3) Female lower abdominal pain- in this population I agree you will be doing pelvic exams the most often. However, I think we can make a case for selective pelvic exams. If the patient has classic appendicitis- you know it, the patient knows it and the janitor knows it- and the CT/US is positive- is the surgeon really going to say “we can’t take the patient to the OR without a pelvic exam”? Once again- UA, Urine HCG, and urine GC/Chlamydia is all you need here. I realize that sometimes you will get fooled and the CT will come back negative but will it really change your management or ED flow to do the pelvic exam later if you save 10 of them from being done in the first place? Even in cases of ovarian torsion- given the lack of sensitivity of the exam for adnexal masses in ANESTHETIZED patients- what do you think the same sensitivity is in a busy ED? I recently diagnosed an ovarian torsion without having done a pelvic exam because the patient went for the ultrasound before I could do one. In that case- a pelvic exam would have added an unnecessary delay in a time sensitive diagnosis.

    Every day and with every patient we make clinical decisions about what needs to be done for each patient and this includes the physical exam. You wouldn’t dream of doing a rectal exam on a patient with a sore throat and no other complaints. You wouldn’t do a breast exam on a patient with a headache. Why should the pelvic exam be any different? You can use the same logic that is used for the routine pelvic exam to say that we should do rectals and other invasive exams on every patient. It used to be hardcore dogma that a rectal be done in every trauma patient- we now know that exam to be of little clinical utility in adults (7 and many more) and kids (8). If you would have suggested this years ago you would have been chased out of a conference by an angry mob holding torches. I see avoiding unnecessary pelvic exams as a service to our patients similar to avoiding unnecessary rectal exams.

    All that being said- I teach the basics and I would be remiss to say that I think all of this comes with time and clinical experience. The safest thing to say is that at the medical student and resident level, you have to see a lot of negatives to catch that one positive so you know what positive looks like. My suggestions here should probably only be done by a senior resident/attending level once you have the experience to know the pitfalls of these chief complaints.

    I know that I will probably get at least one reply back saying “there was this one time…” and that will always be the case in emergency medicine. I have never really heard anyone argue the way I just have against the routine pelvic exam so I welcome any comments on this line of thought. Am I completely off base? If you’re an attending in the community- please comment (annonymously if you have to) and let me know what your practice is away from the academic meccas.

    Steve

    References

    (1) CDC guidelines for the treatment of Pelvic Inflammatory Disease http://www.cdc.gov/std/treatment/2010/pid.htm

    (2) Anderson MR, Klink K, Cohrssen A, Evaluation of vaginal complaints. JAMA. 2004;291(11):1368.

    (3) Padilla LA, Radosevich DM, Milad MP. Accuracy of the pelvic examination in detecting adnexal masses. Obstet Gynecol. 2000 Oct;96(4):593-8.

    (4) Close RJ, Sachs CJ, Dyne PL. Reliability of bimanual pelvic examinations performed in emergency departments. West J Med. 2001 Oct;175(4):240-4

    (5) Committee on Practice Bulletins—Obstetrics, The American College of Obstetricians and Gynecologists Practice bulletin no. 130: prediction and prevention of preterm birth.
    Obstet Gynecol. 2012;120(4):964.

    (6) Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines, 2010.
    MMWR Recomm Rep. 2010;59(RR-12):1.

    (7) Shlamovitz GZ, et al. Poor Test Characteristics for the Digital Rectal Examination in Trauma Patients. Annals of Emergency Medicine Volume 50, Issue 1 , Pages 25-33.e1, July 2007

    (8) Shlamovitz GZ, et al. Lack of evidence to support routine digital rectal examination in pediatric trauma patients. Pediatr Emerg Care. 2007 Aug;23(8):537-43. Available- http://www.ncbi.nlm.nih.gov/pubmed/17726412

    • Excellent review Steve -- well done. Also, ranting to me is often water cooler talk--venting. But sometimes just because we do not always agree with or enjoy doing what needs to be done does not mean we will neglect to do it.

  9. Great episode! As and ER Physician Assistant I would have to say I fall more on the side of your local hospitalist Nurse Practitioner. I can’t come up with a better term than mid-level provider if not called a PA (or NP in Matt and Gabes case), and frankly it doesn’t bother me. I spent 18 months in an ER residency for PAs and never once did I feel inferior to the MD residents of a similar vintage (many of whom I took classes with during PA school as our programs are combined in many facets). I had the same initial reaction as Matt to the comments regarding the shoulder exam, however after listening to it again the teaching points come out and the “slam” on mid-levels fades.
    Thanks for putting out this great podcast, I’ve used it more than once as a resource to start discussions that have on more than one occasion changed practice patterns in my shop.

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  1. [...] that could result in this presentation that may also kill them. Graham Walker went on a rant about medical clearance for psychiatric patients on ERCast Rant-off 2013 recently that fires a few shots in the other [...]

  2. […] Rob also gave my site (A Lesser Known Indication for Tranexemic Acid post) some free promo on his Rant-off 2013 episode, and then owned up to erroneously calling me a “she” on the very next ERCast show (FYI, I am a […]

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