Low utility tests you (usually) shouldn't order in the ER

[southerndoc]

I agree with the Tamiflu. I tell them: "I will prescribe Tamiflu if you want it, but it won't make you better much faster, won't reduce severity of symptoms, will be expensive, and could cause side effects. Do you still want me to prescribe it?"

I say something similar for the swabs: "We can do the swabs if you want, but you will wait 2 hours for the results, won't change anything I prescribe, and you will still be going home. Would you rather I just discharge you now?"

I searched for Tamiflu and found this page. Tamiflu shortens duration by about 24 hours and will stop the virus from shedding in nasal secretions after 72 hours of treatment. As some of you know, I do consulting work for a hedge fund for products/drugs going before the FDA for approval. One recent application caught my attention as it relates to emergency medicine. Although I can't mention many specifics (cost, financial forecasts, etc. due to a non-disclosure agreement), the basis of the story is public and I can comment on it.

On Monday, the FDA granted priority review to Genentech's novel baloxavir marboxil. It's a inhibitor of cap-dependent endonuclease protein within the flu virus. This is responsible for viral replication. This means that strains resistant to Tamiflu will be treatable with baloxavir marboxil. It's a single dose that also reduces severity by 24 hours (average duration of symptoms was 54 hours instead of 80), but more importantly, it reduced shedding of the virus significantly at 24 hours post-administration. That means people are much less infectious. This has a great deal of implication in preventing flu outbreaks by treating patients promptly since most are infectious up to 96 hours after onset of symptoms. One pill in the ER or urgent care can treat them.

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[GeneralVeers]

On Monday, the FDA granted priority review to Genentech's novel baloxavir marboxil. It's a inhibitor of cap-dependent endonuclease protein within the flu virus. This is responsible for viral replication. This means that strains resistant to Tamiflu will be treatable with baloxavir marboxil. It's a single dose that also reduces severity by 24 hours (average duration of symptoms was 54 hours instead of 80), but more importantly, it reduced shedding of the virus significantly at 24 hours post-administration. That means people are much less infectious. This has a great deal of implication in preventing flu outbreaks by treating patients promptly since most are infectious up to 96 hours after onset of symptoms. One pill in the ER or urgent care can treat them.

Is this another drug with efficacy supported by a drug-company sponsored study that will later be repudiated with more research? Call me skeptical. We heard these same wild claims about Tamiflu when it was first introduced. Just what we need, another "wonder drug" that desperate, low-information patients will be clamoring to the ED to get.

 

[southerndoc]

Is this another drug with efficacy supported by a drug-company sponsored study that will later be repudiated with more research? Call me skeptical. We heard these same wild claims about Tamiflu when it was first introduced. Just what we need, another "wonder drug" that desperate, low-information patients will be clamoring to the ED to get.

Of course it is. It's a new drug, and nearly all new drugs are funded by the pharmaceutical industry. The study (CAPSTONE-1) was funded by Shionogi, which is working with Roche to market the drug. It's being marketed by Genentech (owned by Roche). It's already marketed in Japan as Xofluza.

 

[VA Hopeful Dr]

I searched for Tamiflu and found this page. Tamiflu shortens duration by about 24 hours and will stop the virus from shedding in nasal secretions after 72 hours of treatment. As some of you know, I do consulting work for a hedge fund for products/drugs going before the FDA for approval. One recent application caught my attention as it relates to emergency medicine. Although I can't mention many specifics (cost, financial forecasts, etc. due to a non-disclosure agreement), the basis of the story is public and I can comment on it.

On Monday, the FDA granted priority review to Genentech's novel baloxavir marboxil. It's a inhibitor of cap-dependent endonuclease protein within the flu virus. This is responsible for viral replication. This means that strains resistant to Tamiflu will be treatable with baloxavir marboxil. It's a single dose that also reduces severity by 24 hours (average duration of symptoms was 54 hours instead of 80), but more importantly, it reduced shedding of the virus significantly at 24 hours post-administration. That means people are much less infectious. This has a great deal of implication in preventing flu outbreaks by treating patients promptly since most are infectious up to 96 hours after onset of symptoms. One pill in the ER or urgent care can treat them.

I thought that was called into question a few years back by the Cochrane folks, and didn't a group of UK doctors sue trying to obtain trial data that Roche was refusing to release?

 

[deleted109597]

I searched for Tamiflu and found this page. Tamiflu shortens duration by about 24 hours and will stop the virus from shedding in nasal secretions after 72 hours of treatment. As some of you know, I do consulting work for a hedge fund for products/drugs going before the FDA for approval. One recent application caught my attention as it relates to emergency medicine. Although I can't mention many specifics (cost, financial forecasts, etc. due to a non-disclosure agreement), the basis of the story is public and I can comment on it.

On Monday, the FDA granted priority review to Genentech's novel baloxavir marboxil. It's a inhibitor of cap-dependent endonuclease protein within the flu virus. This is responsible for viral replication. This means that strains resistant to Tamiflu will be treatable with baloxavir marboxil. It's a single dose that also reduces severity by 24 hours (average duration of symptoms was 54 hours instead of 80), but more importantly, it reduced shedding of the virus significantly at 24 hours post-administration. That means people are much less infectious. This has a great deal of implication in preventing flu outbreaks by treating patients promptly since most are infectious up to 96 hours after onset of symptoms. One pill in the ER or urgent care can treat them.

I'm going to have to ask you to show me the 24 hour data for Tamiflu. It's 16 hours at best based on Cochrane.

 

[Brigade4Radiant]

If you want to prevent the flu you give someone a vaccine. Also influenza is most contagious before symptoms start.

 

[Rendar5]

I searched for Tamiflu and found this page. Tamiflu shortens duration by about 24 hours and will stop the virus from shedding in nasal secretions after 72 hours of treatment. As some of you know, I do consulting work for a hedge fund for products/drugs going before the FDA for approval. One recent application caught my attention as it relates to emergency medicine. Although I can't mention many specifics (cost, financial forecasts, etc. due to a non-disclosure agreement), the basis of the story is public and I can comment on it.

On Monday, the FDA granted priority review to Genentech's novel baloxavir marboxil. It's a inhibitor of cap-dependent endonuclease protein within the flu virus. This is responsible for viral replication. This means that strains resistant to Tamiflu will be treatable with baloxavir marboxil. It's a single dose that also reduces severity by 24 hours (average duration of symptoms was 54 hours instead of 80), but more importantly, it reduced shedding of the virus significantly at 24 hours post-administration. That means people are much less infectious. This has a great deal of implication in preventing flu outbreaks by treating patients promptly since most are infectious up to 96 hours after onset of symptoms. One pill in the ER or urgent care can treat them.

I’m sorry did you say the control patients with influenza were sick for 3.3 days? That smells like a bs study to begin with since I don’t know a single flu patient who is all better by the end of the 4th day of illness

 

[UKEMdoc]

Agree, if you’re better after four days then you didn’t have flu, you had a case of the sniffles.

 

[s109442]

I decided to not care about the bull**** anymore about 2 years ago, bought a house on Lake Michigan and I feel great now. You can’t fix stupid people, move on your shift will end, when it does take your Samoyed for a run.

 

[deleted859535]

I decided to not care about the bull**** anymore about 2 years ago, bought a house on Lake Michigan and I feel great now. You can’t fix stupid people, move on your shift will end, when it does take your Samoyed for a run.

Amen. I'm a younger attending but increasingly tell myself I'm not here for the bull**** and just make that part of my job as painless as it can be.

 

[RustedFox]

I decided to not care about the bull**** anymore about 2 years ago, bought a house on Lake Michigan and I feel great now. You can’t fix stupid people, move on your shift will end, when it does take your Samoyed for a run.

Amen. I'm a younger attending but increasingly tell myself I'm not here for the bull**** and just make that part of my job as painless as it can be.

I need to hear this being said by other people to remind me of this attitude. It helps me. A lot.

 

[anthony78001]

If your hypokalemic then you are low on magnesium. Mag levels don't even really tell you about the body's Mg levels.

ive had a hospitalist give me a hard time when i didnt get a mag level on a hypokalemic pt without ekg changes. i think with some it makes the feel better to have the number for mag

 

[deleted859535]

ive had a hospitalist give me a hard time when i didnt get a mag level on a hypokalemic pt without ekg changes. i think with some it makes the feel better to have the number for mag

Well, in all fairness, it's not entirely useless if the K was low enough to be worth mentioning EKG changes or not. Hypomagnesemia physiologically limits the ability to replete hypokalemia.

 

[Zebra Hunter]

Well, in all fairness, it's not entirely useless if the K was low enough to be worth mentioning EKG changes or not. Hypomagnesemia physiologically limits the ability to replete hypokalemia.

I think the point was that you should always replete them together regardless of the mag level, so what’s point of even getting one when it doesn’t change management?

 

[deleted859535]

I think the point was that you should always replete them together regardless of the mag level, so what’s point of even getting one when it doesn’t change management?

I don't do this as an absolute nor do any of my partners as far as I'm aware. I replete mag if it's low, but if it's normal, I don't. A cursory search of UpToDate regarding concurrent hypomagnesemia with hypokalemia suggests that it's still a "treat if it's low" type situation.

 

[southerndoc]

Corey Slovis teaches hyperK=EKG, hypoK=hypomag.

I send mag levels on all hypokalemic patients low enough to warrant repletion with IV meds (<3). If it's 3.2 and they're just getting PO, I don't order it. If it's 2.8 and they're getting 10 IV + 40 PO, then yea, I order it. If the mag is >1.8 I don't give them any.

I've found some very suprisingly low mag levels with this approach. Many required admission (one was 0.5 after a syncopal episode with a K of 2.7 -- I'm pretty sure he had an arrhythmia that caused his syncope).

 

[Zebra Hunter]

I don't do this as an absolute nor do any of my partners as far as I'm aware. I replete mag if it's low, but if it's normal, I don't. A cursory search of UpToDate regarding concurrent hypomagnesemia with hypokalemia suggests that it's still a "treat if it's low" type situation.

The problem with this practice pattern is that serum levels of mag don’t reflect actual total body mag. I don’t give it for the potassium of 3.3 that is getting discharged, but if it is severe enough for admission, they are getting mag regardless of what the mag level is.

 

[thegenius]

Can't CT or MR everyone. Strikes me as a due diligence thing. Middle-aged folks with back pain get an XR for me. Would rather at least look for badness understanding the potential remains and tell them there may be more to do than to not look at all. But as usual, more than one way about things.

The one nice thing about ordering X-rays, like lumbar xrays, is the chance of uncovering an incidental finding that you don’t want to deal with is extremely low. So it’s kind of a pointless test in most cases but at least it’s a test that won’t require you to make them follow-up with a doctor or cause the patient undue angst.

 

[SamtheWise]

The one nice thing about ordering X-rays, like lumbar xrays, is the chance of uncovering an incidental finding that you don’t want to deal with is extremely low. So it’s kind of a pointless test in most cases but at least it’s a test that won’t require you to make them follow-up with a doctor or cause the patient undue angst.

Lumbar XRs cause me a significant amount of angst, the ACR back pain imaging appropriateness criteria is very illuminating, I feel like it's only useful (maybe) in old people or people on steroids with a low concern for trauma. But man patients love it, they feel like you did something for them even though all you did is irradiate the portions of their body most likely to develop cancer.

 

[thegenius]

Lumbar XRs cause me a significant amount of angst, the ACR back pain imaging appropriateness criteria is very illuminating, I feel like it's only useful (maybe) in old people or people on steroids with a low concern for trauma. But man patients love it, they feel like you did something for them even though all you did is irradiate the portions of their body most likely to develop cancer.

Lumbar xrays don't cause me angst although I agree they are pretty much pointless unless you are very old or have direct trauma to that area. They are even lousy for seeing metastatic disease as well.

The reason why I like them is patients like them, they are cheap, and they don't have incidental findings that I have to deal with.

With all the largesse in health care spending, the 100,000's we spend a week on old people who have no life in front of them, keeping people trached and PEGed alive for countless years in a vegetative state, why are we making a big fuss over a simple, cheap $20 lumbar xray? Let's save money elsewhere.

If we prevent 50,000 lumbar xrays a year, that doesn't even pay the salary of one insurance executive.

 

[Porfirio]

I find I get into trouble (patient complaint, additional dispo time in ED, complaint from hospitalist, complaint from management, having to take extra time to explain “why not” to patients, miss potentially important things that later matter - once in the hospital) when I focus on not doing the useless instead of doing what is on my laundry list of potential problems for the patient.

 

[jw3600]

I skipped the middle of the thread. Did no one say hemoccult?!?

 

[TooMuchResearch]

This is what I do.

I do add on the mag later if I remember. Or the hospitalist does it later.

HypoK, hypo mag, Slovis ftw

The problem with this practice pattern is that serum levels of mag don’t reflect actual total body mag. I don’t give it for the potassium of 3.3 that is getting discharged, but if it is severe enough for admission, they are getting mag regardless of what the mag level is.

 

[Siggy]

I skipped the middle of the thread. Did no one say hemoccult?!?

The bane of my ICU existence.

"The patient needs to come to the ICU... they're hemodynamically stable, but their stool occult blood is positive."

Me: "Why does colon cancer need to come to the unit?"

 

[GeneralVeers]

Uric acid level. I just objectively treat their gout and D/C home.

 

[southerndoc]

Uric acid level. I just objectively treat their gout and D/C home.

Plenty of people with gout have normal uric acid levels and still have a gout flare. I agree that uric acid levels are worthless.

Colchicine 0.6 mg x2 plus another one hour later, 10 mg dexamethasone, 30 mg ketorolac (if they're kidneys aren't toast), and discharge with diclofenac, Medrol dosepack, and instructions to drink tart cherry juice like crazy. Works like a charm.

 

[Apollyon]

I agree that uric acid levels are worthless.

I wouldn't say "worthless". If it is, say, 3.5, that might tip me towards cellulitis, or to consider pseudogout.

 

[thegenius]

I wouldn't say "worthless". If it is, say, 3.5, that might tip me towards cellulitis, or to consider pseudogout.

Sometimes it's hard to tell...first time someone has pain and tenderness around their first MTP. Its a little red, very painful
maybe the pain goes into the big toe or is a little spread around the top of the foot
so I get labs including a Uric Acid level, foot xray
give colchicine x2 like said above

labs, uric acid and XR are normal
and I'm back at square one

don't quite know what it is.

so I treat for both


My guess is in these situations it's probably an inflammatory arthropathy and not cellulitis.
I really don't want these people to come back to the ED so I treat them for both and say "see another doctor if you are not better in 7 days"

I don't think a Uric Acid level is worthless, but it's not worth a lot that's for sure.

It's good for tumor lysis syndrome, but that is pretty darn rare. I also send it if I'm concerned for lymphoma

 

[GeneralVeers]

The hallmark of gout is exquisitely tender skin over the painful area. If they wince at even light touch on exam, then it's gout.

 

[southerndoc]

The hallmark of gout is exquisitely tender skin over the painful area. If they wince at even light touch on exam, then it's gout.

I have gout. Hurts like heck, and you're correct, light touch makes it worse. Even a sheet will cause excruciating pain. Always my right ankle that has an attack (once my great toe). Stopped drinking alcohol because of it. Luckily meat doesn't seem to bother me.

 

[aafisahar]

I wouldn't say "worthless". If it is, say, 3.5, that might tip me towards cellulitis, or to consider pseudogout.

err gout levels can be normal or even low in an acute gout flare as all the crystalized uric acid decreases serum concentration. a uric acid level doesn't tell you anything in an acute flare, you would need a tap to demonstrate gout crystals vs CPPD.

 

[KGflyboy]

I tend to tap a fair amount of these joints. I would rather know for sure than sent a septic joint home.

 

[Groove]

I don't tap nearly as many joints as I used to. True septic arthritis is fairly uncommon. Most that I've tapped in the past with low and even moderate PTP turned out to be reactive arthritis or synovitis from a myriad of other arthropathies. If they have high risk features or more than one or two risk factors, I tend to tap. Most that are positive...I knew were going to be positive before I tapped them.

I'm not sure if this one has been listed yet or not:

Keppra and Dilantin levels in seizure patients. I just find these to be useless tests if they aren't showing signs of toxicity. I once had a neurologist call me up and ask why I hadn't checked a dilantin level in his seizure patient and I told him the same thing.

 

[Dr Mantis Toboggan]

I tend to tap a fair amount of these joined. I would rather know for sure than sent a septic joint home.

Mantis’ ease of joint taps scale (1-10):

Knee without U/S - 4
Knee with U/S - 1
Wrist, elbow, ankle, shoulder without U/S - 8
Wrist, elbow, ankle, shoulder with U/S - 6
MTP joint - no

 

[TheSingularity]

Mantis’ ease of joint taps scale (1-10):

Knee without U/S - 4
Knee with U/S - 1
Wrist, elbow, ankle, shoulder without U/S - 8
Wrist, elbow, ankle, shoulder with U/S - 6
MTP joint - no

Love using US for knees. So easy!

Sent from my Pixel 3 using SDN mobile

 

[coachB]

I don't tap nearly as many joints as I used to. True septic arthritis is fairly uncommon. Most that I've tapped in the past with low and even moderate PTP turned out to be reactive arthritis or synovitis from a myriad of other arthropathies. If they have high risk features or more than one or two risk factors, I tend to tap. Most that are positive...I knew were going to be positive before I tapped them.

I'm not sure if this one has been listed yet or not:

Keppra and Dilantin levels in seizure patients. I just find these to be useless tests if they aren't showing signs of toxicity. I once had a neurologist call me up and ask why I hadn't checked a dilantin level in his seizure patient and I told him the same thing.

Well perhaps sub therapeutic dilantin level would explain the seizure? Or perhaps if therapeutic, an alternate anti-epileptic should be considered?

On the other hand, zero reason I can think of to ever check a Keppra level. It's dosed to effect, not level.

 

[Raryn]

Well perhaps sub therapeutic dilantin level would explain the seizure? Or perhaps if therapeutic, an alternate anti-epileptic should be considered?

On the other hand, zero reason I can think of to ever check a Keppra level. It's dosed to effect, not level.

One reason I can think of - to assess for adherence. If the keppra level is zero...

 

[bravotwozero]

If I order a keppra level, it's a send out to another state for me! Hard pass on that...

 

[Groove]

The dilantin and keppra level never changes my management. I can totally see why an internist or neurologist would be curious and why it might seem common sense to obtain one, but it makes zero difference for me in the ED, hence why I never get them.

 

[Siggy]

The problem is that the Keppra level becomes quickly useless after they get 4.5 grams of Keppra (or really Keppra).

It's like anemia workups post transfusion. No one is saying "wait to get the results back," just "get the lab started so that we can provide the patient with better care."

Heck... ordering the lab won't even increase your door to dispo time. No single critical care patient had less ICU days because of a lack of a PT/OT order... but it helps the patient get out of the hospital quicker.

 

[KGflyboy]

I'll add extremity MRI to the list. Our NPs order knee and ankle MRIs for sprains all the time.

 

[bravotwozero]

I'll add extremity MRI to the list. Our NPs order knee and ankle MRIs for sprains all the time.

LOL WUT? It'd be one thing if I was admitting and ordering a routine MRI for something like osteomyelitis/internal derangement, but STAT, in the ED? I'd throw a fit if one of our MLPs was doing that.

 

[KGflyboy]

LOL WUT? It'd be one thing if I was admitting and ordering a routine MRI for something like osteomyelitis/internal derangement, but STAT, in the ED? I'd throw a fit if one of our MLPs was doing that.

Yeah, I think this was addressed at some point and the frequency deceased. It still happens though. Things are better now though. We are working toward a model where every patient is seen by a physician even if managed primarily by the MLP. It cuts down on this inappropriate testing quite a bit.

 

[GeneralVeers]

Yeah, I think this was addressed at some point and the frequency deceased. It still happens though. Things are better now though. We are working toward a model where every patient is seen by a physician even if managed primarily by the MLP. It cuts down on this inappropriate testing quite a bit.

We've tried that system. It doesn't work. I'd rather just cut the MLP out altogether at that point. Give me 2 scribes, and the extra $60/hr for not employing an MLP and I could see everyone. My workups would be better, and the LOS shorter. If I can't trust MLPs with low acuity garbage and have to see all the patients, I just don't need them.

 

[thegenius]

I'll add extremity MRI to the list. Our NPs order knee and ankle MRIs for sprains all the time.

Huh?

In the ER?

Your NP's in the ER order MRI's on ankles and knees all the time?

 

[KGflyboy]

Huh?

In the ER?

Your NP's in the ER order MRI's on ankles and knees all the time?

Yes.

There are rumors of going to an all physician staffing model here, but I'll believe it when I see it.

 

[Food]

If you have cap, cellulitis, uncomplicated pyelo you have a source by definition. But there are plenty of times when the ED just starts antibiotics which really screws the admitting doc in fuo.



Why do you need a ptt before starting a heparin drip? It's dosed by weight.

I would get a ptt if they were on heparin, lovenox or some other anticoagulant recently and I am starting them on heparin.

 

[TooMuchResearch]

What the fork?

I'll add extremity MRI to the list. Our NPs order knee and ankle MRIs for sprains all the time.