Fever and undifferentiated abdominal pain - WWYD?

[deleted836128]

What would you do in this situation?

60 year old obese female with hypertension and hyperlipidemia comes in with a week of upper abdominal pain radiating into the chest and back, with lightheadedness, and today she developed a fever. No rash, cough, vomiting, diarrhea, blood in the stool or urinary symptoms. No recent travel or exposure to ill contacts with similar symptoms. History of a cholecystectomy and appendectomy years ago. No other surgeries. Initial vitals include a temperature of 101.6F, heart rate in the 110s, normal blood pressure. She is very tender to the right upper abdomen and epigastrium without guarding. Labs reveal a mild leukocytosis of 12.5K with left shift. AST, ALT, alk phos, bilirubin, lipase, troponin, urine, and lactic acid are normal and heck, even a flu test is negative. Of course the pregnancy test is negative because you never know. Chest x-ray looks good. EKG looks good. CT of the abdomen and pelvis with IV contrast is sure to reveal the cause of the fever, right? No... it’s totally negative. Evidence of prior cholecystectomy. No biliary duct dilation. All looks great. The patient doesn’t feel better and looks even more fatigued and nauseated despite morphine, GI cocktail, Tylenol, Zofran and fluids but the tachycardia and fever declined.

So I admitted her for observation. I didn’t like sending home undifferentiated abdominal pain with a high fever meeting sepsis criteria technically. I got SO MUCH push back from the hospitalist this week for admitting this patient. “This could be a viral syndrome... come on, ERCAT, you know this is a terrible admission! I don’t even need to tell you!”

I can’t think of many times where I’ve had a patient with belly pain and a fever without a clear source and would be interested to know what you all think and what you’d do in this situation.

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[thegenius]

A lot of this, in my opinion, comes down to "how the patient looks", what kind of follow-up they have. It sounds like with normal vital signs, or normal vital signs after you treated her, and labs that are basically normal, and everything else is normal....she probably isn't "sick" like the way ER doctors think patients are sick. She probably has some intestinal virus or something else that is not serious.

Sometimes with these patients, I will redo labs. Although in this case it may not have helped because she is s/p chole. I had a woman with RUQ / epigastric pain with normal abd labs and just cholelithiasis. Her pain almost went away but still had a little...and my signout was "if she passes PO AND her repeat abd labs are OK, then she can go." Low and behold, her repeat AST/ALT were 350 each, TBili was 2.5 and she was admitted for symptomatic biliary colic / cholecystitis / choledocho.

I think we all see these kinds of patients on a regular basis...they have a fever and are older but actually look pretty good. Sometimes I send them home and say "come back tomorrow if you still feel crummy" and sometimes they do and sometimes they don't. Sometimes I admit them and they rarely have acute pathology that was just in the brewing stage while in the ED. Or sometimes they declare themselves the next day with several bouts of diarrhea. I'd say > 95% of the time they end up just getting better whether they are sent home or admitted.

Sometimes I scan the chest as well as the abd, and they end up having streaky, non-lobar pneumonia on the right.

Overall it's very hard to say and I bet on this forum you will get a multitude of answers and probably a very lively conversation about docs being too risky or too conservative that will sure to rile us all up.

 

[gro2001]

What would you do in this situation?

60 year old obese female with hypertension and hyperlipidemia comes in with a week of upper abdominal pain radiating into the chest and back, with lightheadedness, and today she developed a fever. No rash, cough, vomiting, diarrhea, blood in the stool or urinary symptoms. No recent travel or exposure to ill contacts with similar symptoms. History of a cholecystectomy and appendectomy years ago. No other surgeries. Initial vitals include a temperature of 101.6F, heart rate in the 110s, normal blood pressure. She is very tender to the right upper abdomen and epigastrium without guarding. Labs reveal a mild leukocytosis of 12.5K with left shift. AST, ALT, alk phos, bilirubin, lipase, troponin, urine, and lactic acid are normal and heck, even a flu test is negative. Of course the pregnancy test is negative because you never know. Chest x-ray looks good. EKG looks good. CT of the abdomen and pelvis with IV contrast is sure to reveal the cause of the fever, right? No... it’s totally negative. Evidence of prior cholecystectomy. No biliary duct dilation. All looks great. The patient doesn’t feel better and looks even more fatigued and nauseated despite morphine, GI cocktail, Tylenol, Zofran and fluids but the tachycardia and fever declined.

So I admitted her for observation. I didn’t like sending home undifferentiated abdominal pain with a high fever meeting sepsis criteria technically. I got SO MUCH push back from the hospitalist this week for admitting this patient. “This could be a viral syndrome... come on, ERCAT, you know this is a terrible admission! I don’t even need to tell you!”

I can’t think of many times where I’ve had a patient with belly pain and a fever without a clear source and would be interested to know what you all think and what you’d do in this situation.

I think admitting for observation is reasonable. There is probably less than a 1 in 20 chance of her having any discoverable, let alone life threatening, pathology. However, we've all had similar cases where something isn't right, there is no identifiable pathology based on the testing available in the ED, and the patient ends up having either an uncommon disease or an uncommon presentation of a common disease. Even so, the hospitalist is also not exactly wrong. Although none of the tests we have available are 100% sensitive for anything, basically all of them being normal (mild leukocytosis be damned) leaves the probability of something really bad pretty low. Not zero, but low.

I think the strategy I would take with talking to the hospitalist would depend on my opinion of the hospitalist and prior relationship with them. If I thought they were generally a reasonable person with some experience under their belt, I would probably say almost exactly what you said and just acknowledge their counterarguments as valid, and repeat "even so, I am concerned that there could be something dangerous brewing" and "haven't you ever had a case where everything was negative, yet you suspected something was wrong and turned out to be right?" (even if they haven't, no one likes admitting to never having seen something). If I had a lower opinion of them as a colleague I would counter with non falsifiable question. "How do you know this isn't lymphoma? With B symptoms? Above AND below the diaphragm!" and things like that which might not necessarily stand up to close scrutiny but work in a pinch.

 

[thegenius]

I think the strategy I would take with talking to the hospitalist would depend on my opinion of the hospitalist and prior relationship with them. If I thought they were generally a reasonable person with some experience under their belt, I would probably say almost exactly what you said and just acknowledge their counterarguments as valid, and repeat "even so, I am concerned that there could be something dangerous brewing" and "haven't you ever had a case where everything was negative, yet you suspected something was wrong and turned out to be right?" (even if they haven't, no one likes admitting to never having seen something). If I had a lower opinion of them as a colleague I would counter with non falsifiable question. "How do you know this isn't lymphoma? With B symptoms? Above AND below the diaphragm!" and things like that which might not necessarily stand up to close scrutiny but work in a pinch.

LOL

 

[USCDiver]

“Well, after you’ve seen and examined the patient, come and find me and we can discuss disposition”

 

[Fox800]

I get this scenario fairly often as we see a high population of retirees. Unless it's a clear-cut URI, I admit them, at least to observation. I've had a few grow bacteria in their blood. Old folks with sepsis without a source don't go home. Ask the hospitalist to come down and see the patient. I had one cowboy hospitalist who gave pushback on these with some near-misses so I don't discharge them any more.

 

[BoardingDoc]

As said above I think it depends on what the patient looks like. If this patient looks clinically well, these symptoms have been going on for a week, has had an entirely unremarkable workup except a slight leukocytosis and the fever and tachycardia have resolved as noted above... I'd discharge them.

If they look sick, yeah, admit them.

 

[Zebra Hunter]

Old person w/ fever, tachycardia, abd pain, and no source almost never goes home unless they are demanding it. This is a significantly higher risk pt than the BS chest pain pt we are admitting every single shift.

 

[alpinism]

Discharge home.

Based on the above scenario there's less than a 1% chance of any life threatening pathology.

Remember this is a healthy 60 year old which is entirely different from an unhealthy 80 year old.

 

[Zebra Hunter]

Discharge home.

Based on the above scenario there's less than a 1% chance of any life threatening pathology.

Remember this is a healthy 60 year old which is entirely different from an unhealthy 80 year old.

Remember this is a fatigued, nauseated, febrile, tachycardic obese, HTN 60 yr old. I'd put mortality rate for all comers w/ all the above symptoms higher than 1%, of course there is no literature on this specific scenario, so we are in an evidence free zone here. Abdominal pain and fever are independent predictors of mortality in the elderly (age >65) w/ mortality rates in ER pts of 5% and 7-10%, respectively. She might not be >65, but given objective evidence of pathology (fever) along w/ worsening clinical status, continued pain, I don't think anyone is going to pat you on the back giving you a "job well done" for discharging this patient.

 

[TheSingularity]

We should make all hospitalists 100% RVU.

Would solve all admit push back problems.

 

[Porfirio]

Crystal balls are cloudy for a reason. Do what you think is right, and forget about what the hospitalist thinks.

 

[thegenius]

Overall it's very hard to say and I bet on this forum you will get a multitude of answers and probably a very lively conversation about docs being too risky or too conservative that will sure to rile us all up.

LOL

 

[thegenius]

I probably would have CT'ed the chest as well, and if that was negative I'm not really sure what the advantage of admitting them so they sit in a hospital bed for 24 hours looking at the wall picking her nose, getting her vitals checked every 8-12 hours.

All comes down to "how they look". If they look ill then admit them. If not they can go home. You have urine and blood cultures growing and if they are positive have them come back. Or have them come back in 24 hours. People think the chance of death or serious, irreversible morbidity is > 5-10% over 24 hours?

Also, just talk to the patient. Ask them they can go home or be admitted and see what they want. Then call the hospitalist. If the hospitalist refuses to admit they HAVE to put in a consult note, and have the patient come back in 24 hours for a re-eval. This entire scenario does not sound high risk to me whether they are admitted or discharged.

 

[thegenius]

Crystal balls are cloudy for a reason. Do what you think is right, and forget about what the hospitalist thinks.

Huh? I thought crystal was clear

 

[TheSingularity]

I'm so goddamn over hospitalists and consultants trying to d*** me over in the ED.

Hospitalist, do not say anything whatsoever about refusing an admission until you've seen the patient. If you are that adamant about not accepting the patient, discharge them yourself. If you didn't want to eat the s*** sandwich you should have studied harder and not been a hospitalist. I appreciate the hospitalists that actually see the patient, disagree with my admission decision, come to me face to face to discuss it, and present an alternative plan. Very often I say "wow you're right. good idea. let's do that instead."

Consultant, you are on call. I am not sorry about this fact. You knew that when you became an ENT, maybe I would wake you up like twice in a year about an issue that I need help with. I didn't call you the 17 billion other times, so when I call please do the right f****** thing.

 

[TooMuchResearch]

I got pushback on a "sepsis cellulitis" I admitted a while back. Unhealthy person. Labs looked mild sepsis, CT without abscess or anything to suggest necrotizing infection, I didn't have major concern for a necrotizing infection.

Hospitalist didn't want to admit but did it. Consulted surgery for concern for abscess (which wasn't there on CT). Surgery didn't want to do anything. Patient gets worse 2 days later, CT is repeated now shows deeper inflammatory changes, goes to the OR, has a necrotizing infection.

Hospitalist sends me to peer review (and not just by normal means, also sends it to my medical director by email) for not acting quickly on a sick patient. WTF.

I'm so goddamn over hospitalists and consultants trying to d*** me over in the ED.

Hospitalist, do not say anything whatsoever about refusing an admission until you've seen the patient. If you are that adamant about not accepting the patient, discharge them yourself. If you didn't want to eat the s*** sandwich you should have studied harder and not been a hospitalist. I appreciate the hospitalists that actually see the patient, disagree with my admission decision, come to me face to face to discuss it, and present an alternative plan. Very often I say "wow you're right. good idea. let's do that instead."

Consultant, you are on call. I am not sorry about this fact. You knew that when you became an ENT, maybe I would wake you up like twice in a year about an issue that I need help with. I didn't call you the 17 billion other times, so when I call please do the right f****** thing.

 

[deleted836128]

UPDATE ON MY PATIENT! (It’s crazy)

First off, before I get into the update, thank you guys for all your responses. It is literally crazy how different everyone would approach this case. I am in the more cautious camp. Undifferentiated belly pain doesn’t scare me much if the patient feels better and doesn’t have an impressive exam. Patients with continued pain without any answer make me nervous. Then throw in a fever and I am pretty bothered. Sometimes when I am trying to make a decision I think about how my chart would look to one of my supervising MDs or one of the docs I really respect if they were to review it. I think about how the case would look if the patient came back in 24 hours and then died. This usually gives me a pause. In this case sending home a 60 year old with belly pain of unknown source, fever, and tachycardia home wasn’t right to me. I argued with the hospitalist quite a bit - it’s very awkward doing that as a PA of four years when the hospitalist has been practicing for twenty years. My attending even said I could send her home if she looked okay. Couldn’t do it... I basically planted the idea in her head that she needed to be admitted and she went with it... your ideas are awesome. I like the idea of repeating labs in this kind of circumstance. I also did consider scanning her chest... hmm hmm... it’s all I thought about when I got home but at least I could sleep because I knew she was in the hospital. I also did order antibiotics. Hospitalist got pissed about that and immediately cancelled them. Awkward...

K, you’re never gonna believe what the patient had. Apparently she continued to complain of abdominal pain and had fevers the next day. Got scoped, nothing showed up. Infectious disease got involved and apparently she said she had a sore throat (not mentioned to me or any of the hospitalists before - I even specifically asked her about that). They ordered a CT and GUYS - retropharyngeal abscess! Straight to the ICU!!! INSANE!

 

[deleted109597]

Oh, I'll believe it.
Fevers in healthy people older than 2 and under 40 or so? Yeah, they can go home. Not a big deal.
Fevers in older people without obvious source, or any drug user, or any chronic medical patient (ie bad diabetics). They all have badness somewhere.
Mine field in clown shoes.

 

[thegenius]

K, you’re never gonna believe what the patient had. Apparently she continued to complain of abdominal pain and had fevers the next day. Got scoped, nothing showed up. Infectious disease got involved and apparently she said she had a sore throat (not mentioned to me or any of the hospitalists before - I even specifically asked her about that). They ordered a CT and GUYS - retropharyngeal abscess! Straight to the ICU!!! INSANE!

Would love to see the imaging on that.

She would have declared herself eventually. Either in the hospital or at home. Or she would have answered the question "do you have neck pain or a sore throat?" more accurately and somebody would have picked it up.

I was gonna say good case, but it's too weird!

 

[NITRAS]

Don’t forget to document. Called and discussed with SDN. 70% recommended admission.

 

[WilcoWorld]

I got pushback on a "sepsis cellulitis" I admitted a while back. Unhealthy person. Labs looked mild sepsis, CT without abscess or anything to suggest necrotizing infection, I didn't have major concern for a necrotizing infection.

Hospitalist didn't want to admit but did it. Consulted surgery for concern for abscess (which wasn't there on CT). Surgery didn't want to do anything. Patient gets worse 2 days later, CT is repeated now shows deeper inflammatory changes, goes to the OR, has a necrotizing infection.

Hospitalist sends me to peer review (and not just by normal means, also sends it to my medical director by email) for not acting quickly on a sick patient. WTF.

What came of the peer review?

 

[Zebra Hunter]

Would love to see the imaging on that.

She would have declared herself eventually. Either in the hospital or at home. Or she would have answered the question "do you have neck pain or a sore throat?" more accurately and somebody would have picked it up.

I was gonna say good case, but it's too weird!

Give credit where credit is due. RPA pts can crump quickly. The third option to your scenario is she doesn't declare herself and dies in her sleep, especially given the pt is obese. This is a great case and an excellent job of advocating for their pt by ERCAT. Its a great reminder to have a low threshold for the shotgun approach on the febrile, unwell appearing elderly w/o a clear source, and to have a low threshold to admit them even if that work up comes back unremarkable, or at least have a clear plan for very close f/u and maybe even a scheduled return to the ER. I follow up on every single pt I see via chart review. You would be shocked at how frequently a similar scenario plays out with the pts you see despite very thorough work ups. Happens at least once every 1 or 2 months where I see the pt's hospital course and I say to myself "wow, I did not expect that".

 

[VA Hopeful Dr]

I'm so goddamn over hospitalists and consultants trying to d*** me over in the ED.

Hospitalist, do not say anything whatsoever about refusing an admission until you've seen the patient. If you are that adamant about not accepting the patient, discharge them yourself. If you didn't want to eat the s*** sandwich you should have studied harder and not been a hospitalist. I appreciate the hospitalists that actually see the patient, disagree with my admission decision, come to me face to face to discuss it, and present an alternative plan. Very often I say "wow you're right. good idea. let's do that instead."

Consultant, you are on call. I am not sorry about this fact. You knew that when you became an ENT, maybe I would wake you up like twice in a year about an issue that I need help with. I didn't call you the 17 billion other times, so when I call please do the right f****** thing.

That seems a bit much

 

[deleted109597]

That seems a bit much

Some places it's just like residency all over again. They'll spend twice as long to avoid admission. It's not like I found the patient and made them come in.

 

[VA Hopeful Dr]

Some places it's just like residency all over again. They'll spend twice as long to avoid admission. It's not like I found the patient and made them come in.

Not defending bad hospitalist behavior in the slightest, but just because they can be a pain to deal with doesn't mean we should make nasty comments about their educational achievements (or lack thereof).

Medicine has enough problems without us being jackasses to/about each other.

 

[alpinism]

Remember this is a fatigued, nauseated, febrile, tachycardic obese, HTN 60 yr old. I'd put mortality rate for all comers w/ all the above symptoms higher than 1%, of course there is no literature on this specific scenario, so we are in an evidence free zone here. Abdominal pain and fever are independent predictors of mortality in the elderly (age >65) w/ mortality rates in ER pts of 5% and 7-10%, respectively. She might not be >65, but given objective evidence of pathology (fever) along w/ worsening clinical status, continued pain, I don't think anyone is going to pat you on the back giving you a "job well done" for discharging this patient.

Nearly everyone nowadays has some degree of obesity and hypertension. Sure they were also mildly febrile and tachycardic but that happens to millions of people every year with viral infections who all do just fine never visiting the emergency room.

And of course no one will pat you on the back for discharging this patient home with appropriate return precautions.

I’m fully aware we live in a 0% miss culture but that doesn’t mean it’s always the right thing to do for patients.

 

[alpinism]

Would love to see the imaging on that.

She would have declared herself eventually. Either in the hospital or at home. Or she would have answered the question "do you have neck pain or a sore throat?" more accurately and somebody would have picked it up.

I was gonna say good case, but it's too weird!

I’d also love to see the images.

Considering the patient didn’t even mention a sore throat or neck pain and had a completely normal HEENT exam along with EGD study I’d be honestly surprised if this patient had anything other than an early developing abscess.

Regardless she would have declared herself eventually and had the same outcome if she had been discharged home with strict return precautions.

 

[TooMuchResearch]

I've been seeing more and more old sick people with supplemental Medicare plans tell them they've taken too many ambulances and have to pay out of pocket, so they stay home until they're nearly dead and a family member checks on them and brings them in.

Not saying this would have been the case with the particular patient, but something to consider: Some patients can't come back. I don't know if I would have admitted the patient or not or at least given them the option. Hard to know without being there.

I’d also love to see the images.

Considering the patient didn’t even mention a sore throat or neck pain and had a completely normal HEENT exam along with EGD study I’d be honestly surprised if this patient had anything other than an early developing abscess.

Regardless she would have declared herself eventually and had the same outcome if she had been discharged home with strict return precautions.

 

[TooMuchResearch]

Most likely nothing other than they tally them and let us know we have too many peer reviews (regardless of patient outcome...) at our reviews with the medical director.

What came of the peer review?

 

[WilcoWorld]

Most likely nothing other than they tally them and let us know we have too many peer reviews (regardless of patient outcome...) at our reviews with the medical director.

That sounds like a less than optimal system.

 

[deleted109597]

Not defending bad hospitalist behavior in the slightest, but just because they can be a pain to deal with doesn't mean we should make nasty comments about their educational achievements (or lack thereof).

Medicine has enough problems without us being jackasses to/about each other.

True.

 

[TheSingularity]

Not defending bad hospitalist behavior in the slightest, but just because they can be a pain to deal with doesn't mean we should make nasty comments about their educational achievements (or lack thereof).

Medicine has enough problems without us being jackasses to/about each other.

I love ya VA Hopeful, but sorry, not gonna let some FMG hospitalist tell me, an ABEM boarded doc, that a patient with a high risk diagnosis shouldn't be admitted to the hospital.

It has nothing to do with not being collegial, and has everything to do with doing the right thing for the patient. Not gonna endanger the patient or myself because some overwhelmed hospitalist might get butthurt.

 

[VA Hopeful Dr]

I love ya VA Hopeful, but sorry, not gonna let some FMG hospitalist tell me, an ABEM boarded doc, that a patient with a high risk diagnosis shouldn't be admitted to the hospital.

It has nothing to do with not being collegial, and has everything to do with doing the right thing for the patient. Not gonna endanger the patient or myself because some overwhelmed hospitalist might get butthurt.

You seem to be misunderstanding me. You should absolutely advocate for your patients - that's kind of our job. But you can do that without being an dingus (which is what you were with that part I bolded up above, your insinuation that people are only hospitalists because they didn't have the grades to do anything else).

You even did it again just now - FMGs can be good doctors, and being ABEM boarded doesn't guarantee that one isn't a bad doctor.

 

[AMEHigh]

You seem to be misunderstanding me. You should absolutely advocate for your patients - that's kind of our job. But you can do that without being an dingus (which is what you were with that part I bolded up above, your insinuation that people are only hospitalists because they didn't have the grades to do anything else).

You even did it again just now - FMGs can be good doctors, and being ABEM boarded doesn't guarantee that one isn't a bad doctor.

Exactly!
I shouldn’t be surprised, but does everyone think that every doctor that is FM or IM is an idiot who didn’t study and wishes they really matched in to some other specialty?! It’s crazy how prevalent that thinking is.

Spoiler alert: some doctors actually chose and enjoy IM and FM...gasp.

 

[Boatswain2PA]

I would admit that patient every time. Observation is there for a reason.

 

[gro2001]

I love ya VA Hopeful, but sorry, not gonna let some FMG hospitalist tell me, an ABEM boarded doc, that a patient with a high risk diagnosis shouldn't be admitted to the hospital.

It has nothing to do with not being collegial, and has everything to do with doing the right thing for the patient. Not gonna endanger the patient or myself because some overwhelmed hospitalist might get butthurt.

You know the FMG hospitalist is also boarded, right? I am an FMG but am ABEM boarded. FMGs have to have 2-3 years (depending on the state, but mostly 3 years) of post graduate training in the US to be licensed, unlike the typical 1 year for US grads. So most FMG attendings have completed residency in the US. Some went through a different path, like doing all their required years in fellowship after having done residency in their home country, but they are a minority and are probably not the hospitalist you refer to.

 

[Birdstrike]

What would you do in this situation?

60 year old obese female with hypertension and hyperlipidemia comes in with a week of upper abdominal pain radiating into the chest and back, with lightheadedness, and today she developed a fever. No rash, cough, vomiting, diarrhea, blood in the stool or urinary symptoms. No recent travel or exposure to ill contacts with similar symptoms. History of a cholecystectomy and appendectomy years ago. No other surgeries. Initial vitals include a temperature of 101.6F, heart rate in the 110s, normal blood pressure. She is very tender to the right upper abdomen and epigastrium without guarding. Labs reveal a mild leukocytosis of 12.5K with left shift. AST, ALT, alk phos, bilirubin, lipase, troponin, urine, and lactic acid are normal and heck, even a flu test is negative. Of course the pregnancy test is negative because you never know. Chest x-ray looks good. EKG looks good. CT of the abdomen and pelvis with IV contrast is sure to reveal the cause of the fever, right? No... it’s totally negative. Evidence of prior cholecystectomy. No biliary duct dilation. All looks great. The patient doesn’t feel better and looks even more fatigued and nauseated despite morphine, GI cocktail, Tylenol, Zofran and fluids but the tachycardia and fever declined.

So I admitted her for observation. I didn’t like sending home undifferentiated abdominal pain with a high fever meeting sepsis criteria technically. I got SO MUCH push back from the hospitalist this week for admitting this patient. “This could be a viral syndrome... come on, ERCAT, you know this is a terrible admission! I don’t even need to tell you!”

I can’t think of many times where I’ve had a patient with belly pain and a fever without a clear source and would be interested to know what you all think and what you’d do in this situation.

That's a case where it's completely reasonable to consult a hospitalist to further evaluate the patient. If they think the patient's not sick, after evaluating them, then the hospitalist can discharge them from the ER. Hell, they're supposed to be the "expert," right? And if so, that "expert" needs to evaluate the patient before they make any diagnosis or assessment. And don't let them suck you into the trap of thinking, "You're making a weak admission." Bull crap. You don't admit anyone, ever. You consult. They admit. You don't admit. Ever. So, if it's a "weak admission" it's their weak admission. Don't let these whiny --- ----- get in your head. Do what you think is the right thing every time and move on. Period.

And by the way, none of what you or the hospitalist did in the ED, not a CT abdomen with iv contrast, nor a single lactate, rules out early bowel ischemia, in the ED (or an abscess hiding somewhere, like you found out, since this patient symptoms spanned nearly her whole body). Bowel ischemia patients often present like this, often are missed, and those patients die, and they die badly. Very badly.

Good work. Good instincts.

 

[WilcoWorld]

I love ya VA Hopeful, but sorry, not gonna let some FMG hospitalist tell me, an ABEM boarded doc, that a patient with a high risk diagnosis shouldn't be admitted to the hospital.

It has nothing to do with not being collegial, and has everything to do with doing the right thing for the patient. Not gonna endanger the patient or myself because some overwhelmed hospitalist might get butthurt.

I find your post to be quite troubling.

 

[TheSingularity]

I find your post to be quite troubling.

That was sort of off the cuff. My apologies. Just frustrating sometimes to try do your best for the patient and to be thwarted at every level yano?

Sent from my Pixel 3 using SDN mobile

 

[SamtheWise]

We should make all hospitalists 100% RVU.

Would solve all admit push back problems.

Or we can just put everyone who doesn't meet inpatient criteria in the obs unit and our groups can bill for the stay. They can block admissions and argue themselves into obsolescence.

 

[Marcus Brody]

Did draining the throat abscess fix her abdomen pain?

Funny that denying the sore throat might actually have kept her from being discharged home and a lawsuit from happening.

 

[DrGasPasser]

Couple of thoughts.

Acute undifferentiated abdominal pain can be pretty high-risk, especially in elderly patients. Granted, this patient was on the cusp of elderly at age 61, but factoring in co-morbid conditions and abnormal, unexplained vitals makes an observation admission my first choice.

When faced with a situation where the patient cannot be admitted for whatever reason, good time-specific follow-up is needed. I generally tell my discharged patients with acute, undifferentiated abdominal pain that they need a repeat abdominal exam in 8-12 hours, especially if imaging is being deferred. I invite them to return to the ED if they can’t be seen by a PCP. I would absolutely have this patient come back for a repeat exam in 8-12 hours if the hospitalist declined the admission after seeing the patient.

Finally, I’ve noticed a disturbing trend in medicine over the past 20 years - doctors demanding tests, making treatment recommendations, and deciding who needs admission by computer screen without ever having seen or examined the patient. The reasons are legion but I suspect the growing dominance of the EHR on our practice probably is a big factor. Granted, there are emergent, time-sensitive circumstances, but those are the extreme minority. I’m talking about doctors pushing-back on admissions and demanding expensive testing without ever having seen the patient. This is a growing poison in the house of Medicine that needs to be clipped.

 

[GeneralVeers]

I don't get much pushback on admissions. I tend to admit a far lower percentage of my patients than my colleagues, and the hospitalists acknowledge that if I call them the patient really needs admission.

 

[jw3600]

I get this scenario fairly often as we see a high population of retirees. Unless it's a clear-cut URI, I admit them, at least to observation. I've had a few grow bacteria in their blood. Old folks with sepsis without a source don't go home. Ask the hospitalist to come down and see the patient. I had one cowboy hospitalist who gave pushback on these with some near-misses so I don't discharge them any more.

With all due respect SIRS + vitals are not sepsis. Words matter. Don’t disagree with your disposition though.

 

[thegenius]

Did draining the throat abscess fix her abdomen pain?

Did they even drain the abscess?

Some RPAs are slivers of infection more along the deep fascial neck planes and not amenable to drainage, instead you give abx and just observe

 

[MedicineZ0Z]

I love ya VA Hopeful, but sorry, not gonna let some FMG hospitalist tell me, an ABEM boarded doc, that a patient with a high risk diagnosis shouldn't be admitted to the hospital.

It has nothing to do with not being collegial, and has everything to do with doing the right thing for the patient. Not gonna endanger the patient or myself because some overwhelmed hospitalist might get butthurt.

Nothing more I hate than inpatient folks/consultants who want to refuse admission without even assessing the patient themselves.

At the same time, why are you ripping on other docs? And it's always the ABEM folks who feel very insecure about themselves who have to bring up credentials, training and hate on others.

 

[TheSingularity]

They get ripped because they sit up in their call rooms and make decisions behind an EMR and don't come down to the pit to assess the patient.

Nothing more I hate than inpatient folks/consultants who want to refuse admission without even assessing the patient themselves.

At the same time, why are you ripping on other docs? And it's always the ABEM folks who feel very insecure about themselves who have to bring up credentials, training and hate on others.

Sent from my Pixel 3 using SDN mobile

 

[TheSingularity]

And I had amazing training, thx. So grateful to my program for what they gave me after seeing what's out there.

Like I said, some of my favorite moments during my career in medicine have been when a hospitalist and/or a specialist some to the ED and we co-manage a patient. It's pretty awesome to have their input because as EM we definitely don't have all the knowledge and expertise. I reserve the disdain for those who blow me off the second I call them or refuse to see the patient before saying "nah discharge them."

Nothing more I hate than inpatient folks/consultants who want to refuse admission without even assessing the patient themselves.

At the same time, why are you ripping on other docs? And it's always the ABEM folks who feel very insecure about themselves who have to bring up credentials, training and hate on others.

Sent from my Pixel 3 using SDN mobile

 

[thegenius]

And I had amazing training, thx. So grateful to my program for what they gave me after seeing what's out there.

Like I said, some of my favorite moments during my career in medicine have been when a hospitalist and/or a specialist some to the ED and we co-manage a patient. It's pretty awesome to have their input because as EM we definitely don't have all the knowledge and expertise. I reserve the disdain for those who blow me off the second I call them or refuse to see the patient before saying "nah discharge them."

Sent from my Pixel 3 using SDN mobile

Reminds me of a pt recently who came in for worsening testicular pain. He's had years of pain. Today was worse...the US showed decreased vascularity and possible torsion or intermittent torsion. We called Urology and he said "it's not torsion this is stupid. if I come in I am taking that testicle out no matter what"

we are like …. "uh.....why are you getting so pissed off. you're on call and you're the Urologist."

It was almost like he (Urology) was trying to pick a fight.


I like the notion of recording all conversations with consult services. Then use an anonymous reporting system at work for those truly egregious phone calls with bad manners and who are just jerks overall, or refuse to examine a patient in the ED.