Pelvic exams and cancer

[Brigade4Radiant]

So on the big Physcian community Facebook group there was a thread topic saying that ED/PCPs do not do as many pelvics as one OBGYN would like. They all list cancer as why pelvics should be done. There were a few posts saying it was malpractice for missing cancer. But when I do my pelvics and the cervix looks nonuniform I just tell them to go to OBGYN.

Even if it is a necrotic mass Gyn says they should still follow up in the office.

I see for foriegn body removal or lac repair (calling Gyn for it) A lot of pelvics don't change my management and with obese patients its hard to locate the cervix. For most vaginal bleeding after swabbing I'm only really able to tell if the cervix is closed or open. Similiar for vaginal discharge.

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[EctopicFetus]

Pelvic problem = follow up with your gynecologist

 

[RustedFox]

Obesity.

 

[NYEMMED]

Most pelvic exams are not necessary in the ED

 

[Brigade4Radiant]

Most pelvic exams are not necessary in the ED

This is true all that post in EM docs and physician community will say always do a pelvic exam. However, it doesn’t change the management. If you have vaginal discharge do you get treated for PID.

Vaginal bleeding to do a transvaginal ultrasound. Even setting up a pelvic you need to get a female shop around and went to nursing shortage and room shortage. It will be painful and it wouldn’t really tell you much anyway.

 

[DrDrummer]

However, it doesn’t change the management. If you have vaginal discharge do you get treated for PID.

I am confused by this. You treat all vaginal discharge as PID?

 

[cyanide12345678]

follow up in gynecology, if there’s a mass, it will be found in a week when gynecology sees the patient and does biopsy.

This is not an ER issue. I have patients do self swabs for vaginal discharge now. If it’s a pregnant person bleeding with a known iup, i just do a bedside ultrasound, used to check to see if cervix was open or closed, but in the grand scheme, it really doesn’t matter as far as management goes and have since then stopped doing so.

 

[emergentmd]

I do pelvic exams on all females that are reproductive age looking for cancer. I do biopsies and have them come back for results in a week.

I also manage HTN, DM, lipids.

All pts get rectal exams looking for tumors. Scoliosis evals in kids. We have a dedicated room for vision and hearing tests for pediatric pts.

Wtf. Tell these on docs to do their job. Or I can send them emergencies so they can manage those too


My pelvic exams over 20 yrs have essentially come down to looking at lesions and discharge complaints. That’s pretty much it. Rectal exams only for bleeds or abscesses.

I have figured out exams in places typically covered are quite useless in most pts.

 

[Brigade4Radiant]

I am confused by this. You treat all vaginal discharge as PID?

Not all but with my pelvics with the consideration of cervicitis vs PID if there is no cervicales motion tenderness I tend to be more aggressive with treatment

 

[bearstanley]

i don't think (diagnostic) pelvic exams are essentially ever indicated in stable patients in the emergency room, assuming you have OBGYN and an ultrasonographer in house (which i do at 1/2 of my sites).

stable vaginal bleeding, pregnant or not-- TVUS if needed
discharge-- self swab
pain with concern for PID/TOA-- TVUS / bimanual exam, but this is categorically different from a full speculum pelvic exam, and not useful when TVUS is diagnostic

vaginal FB, vaginal lac-- these need a therapeutic intervention via pelvic


but, like the LP, i think the diagnostic utility of the ED pelvic has evaporated thanks to improvement in other diagnostic modalities.

 

[RoyBasch]

So on the big Physcian community Facebook group there was a thread topic saying that ED/PCPs do not do as many pelvics as one OBGYN would like. They all list cancer as why pelvics should be done. There were a few posts saying it was malpractice for missing cancer. But when I do my pelvics and the cervix looks nonuniform I just tell them to go to OBGYN.

Even if it is a necrotic mass Gyn says they should still follow up in the office.

I see for foriegn body removal or lac repair (calling Gyn for it) A lot of pelvics don't change my management and with obese patients it’s hard to locate the cervix. For most vaginal bleeding after swabbing I'm only really able to tell if the cervix is closed or open. Similiar for vaginal discharge.

Cancer is by definition a slow developing and chronic illness. In an of itself it is not an emergency. Therefore I am unsure of the role of EMERGENCY physicians in screening and diagnosis of asymptomatic tumors.

The amount of **** other physicians try to push off onto us is mind boggling.

They need to shut the **** up and do their jobs. The gynecologist want someone else to do their pelvics and screen/diagnose gyn malignancies? What?!

…I’m having an office space moment here: “so what would ya say you (gynecologists) do here?”

Complications of cancer (obstruction, bleeding, intractable pain, etc.) are emergencies but typically late findings.

I find pelvic exams fairly worthless in the ER but diagnosis cancers has to be the WORST reason I can think of to argue for doing more.

 

[RustedFox]

Yeah, this reminds me of a frequent complaint/pet peeve of mine; the visit for "my widget (PEG tube, catheter, whatever) is broken; fix my widget". This can easily be done by the facility physician or PA in a timely fashion; but they absolutely must be sent to the ER for me to do it instead.

 

[bearstanley]

Yeah, this reminds me of a frequent complaint/pet peeve of mine; the visit for "my widget (PEG tube, catheter, whatever) is broken; fix my widget". This can easily be done by the facility physician or PA in a timely fashion; but they absolutely must be sent to the ER for me to do it instead.

"i am not the 'tube guy,' and this is not the 'tube problem room.' please send this patient to see their tube doctor when the sun is up."

 

[RustedFox]

"i am not the 'tube guy,' and this is not the 'tube problem room.' please send this patient to see their tube doctor when the sun is up."

Seriously. Drives me nuts. We're not a Jiffy Lube for devices.

 

[turkeyjerky]

What's with all the posts above saying US is needed in vaginal bleeding? I get doing it in pregnant patients (although if an IUP has already been confirmed this gestation, I'd actually argue that it's not actually an emergent issue). But I've never had an US alter ED management of non-pregnant patients with vaginal bleeding. (what's next, stat endometrial biopsies too?)

I'm sorry but some of these people are so ridiculous. I had a patient come in the other day come in for a heavier than expected period that started earlier in the evening. I think she had to change out a tampon twice in an hour or something. Hgb 14.7. Slight trickle, if that, on the pelvic. I told her that I didn't see anything that would merit an emergent hysterectomy and her friend flashed me a surprised pikachu face.

 

[Jabbed]

What's with all the posts above saying US is needed in vaginal bleeding? I get doing it in pregnant patients (although if an IUP has already been confirmed this gestation, I'd actually argue that it's not actually an emergent issue). But I've never had an US alter ED management of non-pregnant patients with vaginal bleeding. (what's next, stat endometrial biopsies too?)

I'm sorry but some of these people are so ridiculous. I had a patient come in the other day come in for a heavier than expected period that started earlier in the evening. I think she had to change out a tampon twice in an hour or something. Hgb 14.7. Slight trickle, if that, on the pelvic. I told her that I didn't see anything that would merit an emergent hysterectomy and her friend flashed me a surprised pikachu face.

I had a 49 year old that was convinced that she was pregnant but HCG was negative (including the 5 home pregnancy tests). Obviously perimenopausal DUB but neither she nor her daughter believed me (“she had 5 kids, I think that she would know if she’s pregnant”). Whatever. I’d normally just eat the Press Ganey and move on to the next one, but instead I ordered the TVUS and was rewarded with a surprised Pikachu face by the family member when I showed them photos of empty uterus.

 

[Rendar5]

Seriously. Drives me nuts. We're not a Jiffy Lube for devices.

I actually love these cases. I get paid in RVU's, I spend 30seconds on some cases for a level 3 with the patient. Maybe another 60 seconds in charting. Or I spend more time, do the fix myself (I'll swab a PEG tube any day) and then get a procedure out of it.

 

[JacobMcCandles]

Doctor: We can do a pelvic exam but, as you know, they're uncomfortable, won't change your current management, and your OB/Gyn will need to do another one when you see them.
Patient: Then I don't want a pelvic.

GU exam: deferred by patient

 

[thegenius]

What's with all the posts above saying US is needed in vaginal bleeding? I get doing it in pregnant patients (although if an IUP has already been confirmed this gestation, I'd actually argue that it's not actually an emergent issue). But I've never had an US alter ED management of non-pregnant patients with vaginal bleeding. (what's next, stat endometrial biopsies too?)

I'm sorry but some of these people are so ridiculous. I had a patient come in the other day come in for a heavier than expected period that started earlier in the evening. I think she had to change out a tampon twice in an hour or something. Hgb 14.7. Slight trickle, if that, on the pelvic. I told her that I didn't see anything that would merit an emergent hysterectomy and her friend flashed me a surprised pikachu face.

100% agree. Looking in the ER vagina is something I avoid as hard as avoiding genital herpes.

 

[HemorrhagicShock]

The whole "ER docs don't do enough pelvic exams" back-and-forth that you see in EM (and other medical) social media is 99% mired in gender politics. It's effectively impossible to discuss it reasonably in any kind of non-anonymous public forum.

 

[Brigade4Radiant]

I will never forget when I was doing my OBGYN rotation they had a M&M conference about some lady in ohio who had HSV2 genital infection she had vaginal pain and went to the ER for two years getting refils she ended up having cervical cancer with mets and they sued the ER.

The OBYGNs in conference where all criticizing the ER. "Saying they deserved to pay up!!"

 

[Kryptocoin]

I will never forget when I was doing my OBGYN rotation they had a M&M conference about some lady in ohio who had HSV2 genital infection she had vaginal pain and went to the ER for two years getting refils she ended up having cervical cancer with mets and they sued the ER.

The OBYGNs in conference where all criticizing the ER. "Saying they deserved to pay up!!"

So she finally went to see her OB after 2 years of coming to the ER?

 

[BoardingDoc]

So she finally went to see her OB after 2 years of coming to the ER?

You kidding? I'm assuming she came to the ED again, but with abd pain from mets or something, got a CT AP and diagnosed that way.

 

[pkwraith]

Definitely high up on my annoyance list is the patient that is in the ED multiple times a year for vaginal discharge or STD check and has never seen an ob gyn because they're too busy.

 

[Dr Mantis Toboggan]

Definitely high up on my annoyance list is the patient that is in the ED multiple times a year for vaginal discharge or STD check and has never seen an ob gyn because they're too busy.

My buddy was working in the Bronx in 2020 and told me that covid cured vaginal bleeding in NYC… at least for a little while anyway.

 

[WilcoWorld]

I will never forget when I was doing my OBGYN rotation they had a M&M conference about some lady in ohio who had HSV2 genital infection she had vaginal pain and went to the ER for two years getting refils she ended up having cervical cancer with mets and they sued the ER.

The OBYGNs in conference where all criticizing the ER. "Saying they deserved to pay up!!"

Interesting, since cervical cancer doesn't cause vaginal pain. So, the ED's were actually correctly treating her chief complaint (HSV)...they just failed to diagnose an anatomically adjacent (but unrelated) pathology.

Maybe they should've sued the GYN clinic scheduler who never got her in, in spite of her likely being referred to their clinic for follow up after each visit.

 

[alpinism]

The summer of 2020 magically cured a lot of things in New York.

I was at a 100K+ visit ED that went down to 1 PPH on shifts.

 

[BoardingDoc]

The summer of 2020 magically cured a lot of things in New York.

I was at a 100K+ visit ED that went down to 1 PPH on shifts.

I'm not sure what that's supposed to indicate. What was your pph to start with? If you mean that you went from 100k visits to 8.7k visits (1pph all day every day) then yeah, that's crazy.

I assume you mean that your personal volume went down to 1 pph. That drop could be a lot, or not so much.

 

[dpmd]

…I’m having an office space moment here: “so what would ya say you (gynecologists) do here?”

From my experience as a general surgeon they insist it must be a general surgical problem until I take the patient to the OR and send them pictures of the TOA or other gyn issue they were sure was an appendicitis.

 

[alpinism]

I'm not sure what that's supposed to indicate. What was your pph to start with? If you mean that you went from 100k visits to 8.7k visits (1pph all day every day) then yeah, that's crazy.

I assume you mean that your personal volume went down to 1 pph. That drop could be a lot, or not so much.

We had shifts with 1PPH in the ED with 4 docs and 6 residents.

Personally had multiple shifts where I saw 2 in 10 hrs.