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In The ER With Abdominal Pain? Lower Your Diagnosis Expectations

Abdominal pain is the bane of many emergency physicians. Recently, I wrote how CT scans are on the rise in the ER. Much of those scans look for potential causes of abdominal pain.

In an essay from Time, Dr. Zachary Meisel discusses why abdominal pain, in his words, is the doctor’s “booby prize.” And when you consider that there are 7 million visits annually by people who report abdominal pain, that’s a lot of proverbial prizes.

One reason is the myriad of causes that lead bring a patient to the hospital clutching his abdomen. It can range from something as relatively benign as viral gastroenteritis where a patient be safely discharged home, to any number of “acute” abdominal problems necessitating surgery.

But more importantly, we need to consider how limited doctors actually are in the ER. Consider the ubiquitous CT scan, which is being ordered with increasing regularity:

The pros: CT scans are readily available, able to look at every organ in the abdomen and pelvis, and very good for ruling out many of the immediately life-threatening causes of belly pain. CT scans can also reduce the need for exploratory surgery. The cons: Often, CTs can’t diagnose the actual cause of ER patients’ abdominal pain. Worse, CTs deliver significant doses of radiation to a patient’s abdomen and pelvis (equivalent to between 100 and 250 chest X-rays). Over a lifetime, patients who receive two or three abdominal CT scans are exposed to more radiation than many Hiroshima survivors.

Add that to the fact that patients expect a definitive diagnosis when visiting the hospital — one that doctors can’t always give when it comes to abdominal pain. Read more »

*This blog post was originally published at KevinMD.com*

Is The ER Really The Best Place to Get Primary Care Quicker?

In 1986, when Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals and ambulance services were mandated by law to stabilize anyone needing emergency healthcare services regardless of citizenship, legal status, and/or insurance status.

This was instituted at the time to prevent the prevalent practice of “dumping” — refusing to treat patients because of insufficient insurance or transferring or discharging patients on the basis of anticipating high diagnosis and treatment costs. While the implications of this law are indeed very noble in providing undifferentiated care to all patients based solely on healthcare needs and not financial status, it has unfortunately led to many patients presenting to the emergency department (ED) for primary care issues.

The misconception is that the care in the ED is similar if not better (because of increased access to consult services and imaging) and quicker than waiting to see your primary care physician (PCP). A 2010 study published in Health Affairs found that 14 percent to 27 percent of visits to hospital EDs are nonemergent, such as minor infections, strains, fractures, and lacerations. The study found that all of these cases could have been appropriately triaged in urgent care centers or retails clinics.

England has a model that may be a potential solution. The healthcare goal of the National Health Services (NHS) is to “treat the right patients in the right place at the right time.” The NHS employs nurses and paramedics to handle 999 (their equivalent of our 911) triage calls with more appropriate triaging of patients based on acuity. Read more »

When Cancer Hits A Doctor’s Home

This year has been a weird one for me and cancer. In the ER, we see cancer patients pretty infrequently. The occasional chemotherapy with fever, but that’s about it. I think the oncologists try hard to keep the patients out of the ER — to everybody’s benefit.

But this year, I’ve had a weird rash of cases where I’ve made primary diagnoses of cancer in the ER — several times over and over and over again. In ten years I don’t think I’ve made as many cancer diagnoses as I have this year alone. Just very strange.

Unfortunately, it came home to roost. My wife was diagnosed with breast cancer last week. Read more »

*This blog post was originally published at Movin' Meat*

The “Street” Economics Of Drug Abuse

I’ve discovered over the years that I really like economics. I never took an econ class in my entire life, since I was pretty focused on the life sciences, but I’ve picked up a fair amount informally over the years. Fortunately I have a strong background in statistics and math, and I’ve done a lot of reading on economics. I wouldn’t say that I have any special level of understanding or credibility on the topic. Perhaps it should be noted that my wife took away the checkbook for good reason. But I enjoy it as a topic, as something to read about and a powerful tool for understanding how the world works.

One consequence of being an ER doc is that you are pretty close to “the street,” and I don’t mean Wall Street. I mean the folks living and scrounging on the streets. As a matter of functioning in the job, you learn the street jargon, you learn what drugs people are using and why, and what the effects of those drugs look like.

The other day I saw a middle-aged guy brought in for acting really weird. Though everything in his social history argued against it, he just looked like he was on meth. I checked a tox, and sure enough, it came back positive. He strenuously denied any drugs, but eventually gave in and admitted the meth use.

I remember in residency walking through downtown Baltimore with a fellow resident and our spouses, and we amazed them by serially identifying the likely drug of choice of the various street people we passed, based on casual observation of their behavior. It’s just what we do. Baltimore was a heroin town. Read more »

*This blog post was originally published at Movin' Meat*

Drug Seekers And A New Threat

I wish I could say that every patient encounter worked out well, that all my patients went home happy and satisfied. It would be nice, but unfortunately that is not true at all.

There are many patients who present with unrealistic expectations or an agenda which is non-therapeutic, and I am relatively straightforward and unapologetic about correcting patient’s misconceptions about the care that is or is not appropriate in the ED. Unsurprisingly, this often though not always involves narcotic medications.

Which is not to say that I am a jerk. I try to be compassionate, and I try to find alternative solutions, and I have been told that I can turn away a drug seeker more nicely than any other doctor in the department. But when it is time to say “no,” I say “no” firmly and without evasions or excuses. People don’t like to hear that, and all the more so in this “the consumer is king” environment of customer-service culture we foster in the medical industry these days.

So when I do say “no,” as nice as I try to be, some people get upset. Sometimes they escalate. They hurl insults, spit, throw themselves on the floor and throw a fit or feign unconsciousness. Read more »

*This blog post was originally published at Movin' Meat*

Latest Interviews

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Latest Book Reviews

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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