Two Chief Complaints that drive me nuts.

[southerndoc]

This conversation about dizziness with no neuro symptoms is akin to unstable angina - discharging a 65 yo person with acute chest pain and negative EKG's and Troponins, yet they continue to have chest pain in the ED (that isn't a PE, dissection, PNX, etc.). I doubt many of these are going home.

So you're admitting with normal neuro exams all elderly dizzy patients?

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[thegenius]

So you're admitting with normal neuro exams all elderly dizzy patients?

All? No. But I have admitted, and will continue to admit elderly dizzy patients if I think there might be something pernicious going on.

And I bet any reasonable ER doctor would as well.

The problem with these kinds of discussions over a forum is that we tend to speak in hyperbole, talk about extremes, never acknowledge the nuanced complaint or the patients we just can't get a good neuro exam on, or those who say this what I felt last time I had a confirmed stroke (and they have a normal neuro exam). We envision doctors admitting patients who are walking around with alacrity without nary a neurologic sign at all. The extremes of any spectrum of disease or symptomology are easy. It's those in the middle where there is a significant practice variation.

 

[southerndoc]

I bet if you were to follow-up on those that you admit with dizzy complaints with a normal neurologic exam rarely are found to have had a stroke.

I admit elderly dizzy patients who can't walk, who have abnormal neuro exams, or who have extreme symptoms unrelieved with medication.

However, the vast majority of them go home without an abnormal neuro exam or other reasons to admit.

I do send home elderly chest pain patients if by chance their HEART score is <4. It's rare, but it does occur sometimes.

 

[deleted836128]

Rare presentation. I've had one lady come in with an EARACHE (swear it was her only complaint) who was having an INFERIOR STEMI at the ripe age of 45. Only reason it was found is because a tech did the EKG in the wrong room. She thought it was ordered on the patient when it wasn't. Does that mean I obtain an EKG for every earache? Nope. It's a zebra, much like your grandmother's. The yield of doing an MRI on every dizzy patient is very low. In your mother's case, there was no emergent intervention available.

that’s freaking nuts. I bet you wanted to hug the EKG who accidentally did an EKG! Gosh - that’s scary. I try not to forget about cardiac ischemia masquerading as something stupid but I wonder how many times I missed it. A few months ago I ordered an EKG on a guy with tooth pain because his exam was normal and the pain was just poorly localized... I got so much **** from nursing for that. Of course EKG was normal.

 

[Groove]

Interesting spread of practice patterns.

I usually don't get MRIs on my patients who are going to be admitted once I've obtained CTH/CTA (usually the "code strokes"). The time sensitive question is whether there is a stroke/mass/blood, tPA, etc.. and whether there is an endovascular lesion that is amenable to rescue therapy. After that, the results of the MRI don't change my management at all and it takes up excessive time in the ED and is probably an inefficient use of resources unless a neurologist is asking for it STAT at 2a.m. Most of my neurologists are on board with getting MRI/MRAs in the a.m. as a routine study. The only people I MRI in the ED are the quasi dizzy/stroke like symptom presentations where I have a really low pre-test probability of stroke or intracranial process and with a negative MRI am comfortable discharging them home. For those people, I'll get a stat MRI.

I rarely send home elderly dizzy patients with subjective difficulty with ambulation, even if I can't reproduce it and even if they are otherwise afocal. As I posted earlier, symptom based approaches are worthless. If it makes you feel better that the pt isn't describing "vertigo", then sure, add it to your chart as long as you realize I could walk in there and they have a 50% chance of describing vertigo to me before I walk out of the room. It's not that I don't feel we can adequately work up and rule out vertebrobasillary insufficiency in the ED, but it's very time consuming and luckily I'm in a shop where neuro is 100% on board with admitting people that are anything other than low risk. These are easy admissions and I don't have to waste time on time intensive testing other than a CT +/- CTA depending on time frame. If I have a soft admission, all it takes is one call to my neurologist who wants to admit everybody and it seals the admission.

 

[Groove]

It's not the dizzy admissions that get me frustrated, it's the syncope or near syncope admissions where medicine asks for EVERYONE to get a head CT. Ugh.

 

[GeneralVeers]

It's not the dizzy admissions that get me frustrated, it's the syncope or near syncope admissions where medicine asks for EVERYONE to get a head CT. Ugh.

It's a MIPS quality measure to NOT get the head CT on syncope and I tell the hospitalists this. We actually get dinged by CMS if we order these.

A way around it is to put the order in as a verbal order from the hospitalist. That way it goes against them and not us.

 

[Groove]

It's a MIPS quality measure to NOT get the head CT on syncope and I tell the hospitalists this. We actually get dinged by CMS if we order these.

A way around it is to put the order in as a verbal order from the hospitalist. That way it goes against them and not us.

Which quality measure is that? We only use the following:

116 - Abx for Bronchitis
254 - Pregnancy U/S
40 - Sepsis bundle
415 - CT Head for Trauma
65 - Peds URI
76 - Catheter insertion prot
91 - AOE: Topical Abx
93 - AOE Antimicrobial Therapy
76 - CVL
416 - Minor blunt head injury Peds
255 - Rhogam
EMIQ #1 - TPA and endovascular considered for the CVAs, etc..

 

[southerndoc]

It's a MIPS quality measure to NOT get the head CT on syncope and I tell the hospitalists this. We actually get dinged by CMS if we order these.

A way around it is to put the order in as a verbal order from the hospitalist. That way it goes against them and not us.

That's been retired a few years now.

 

[GeneralVeers]

That's been retired a few years now.

Oh nice! I'm still going to use it on my hospitalists though.

 

[RoyBasch]

Interesting spread of practice patterns.

I usually don't get MRIs on my patients who are going to be admitted once I've obtained CTH/CTA (usually the "code strokes"). The time sensitive question is whether there is a stroke/mass/blood, tPA, etc.. and whether there is an endovascular lesion that is amenable to rescue therapy. After that, the results of the MRI don't change my management at all and it takes up excessive time in the ED and is probably an inefficient use of resources unless a neurologist is asking for it STAT at 2a.m. Most of my neurologists are on board with getting MRI/MRAs in the a.m. as a routine study. The only people I MRI in the ED are the quasi dizzy/stroke like symptom presentations where I have a really low pre-test probability of stroke or intracranial process and with a negative MRI am comfortable discharging them home. For those people, I'll get a stat MRI.

I rarely send home elderly dizzy patients with subjective difficulty with ambulation, even if I can't reproduce it and even if they are otherwise afocal. As I posted earlier, symptom based approaches are worthless. If it makes you feel better that the pt isn't describing "vertigo", then sure, add it to your chart as long as you realize I could walk in there and they have a 50% chance of describing vertigo to me before I walk out of the room. It's not that I don't feel we can adequately work up and rule out vertebrobasillary insufficiency in the ED, but it's very time consuming and luckily I'm in a shop where neuro is 100% on board with admitting people that are anything other than low risk. These are easy admissions and I don't have to waste time on time intensive testing other than a CT +/- CTA depending on time frame. If I have a soft admission, all it takes is one call to my neurologist who wants to admit everybody and it seals the admission.

This is pretty much my practice pattern. I rarely get an MRI in the ER as I feel the HCT, CTA H/N are more important for determining immediate steps (tPA, endovascular therapy, etc.) I only get the MRI if negative pt can be dc'd.

I also have a pretty low threshold to admit dizzy patients (even if symptoms only subjective) if they are sufficiently old and co-morbid.

 

[Hamhock]

Had another pseudo-seizure lady who wake up just as we were pushing the rocuronium. Oops...sorry too late. You get the tube.

Been there done that. Always a weird moment when their eyes suddenly slam open in terror when they feel the paralytic setting in. I don't feel too bad tho,

Wait, you guys are intubating presumed status without benzos or propofol? Just roc?

HH

 

[RoyBasch]

Wait, you guys are intubating presumed status without benzos or propofol? Just roc?

HH

No typical sedative/paralytic combination (usually etomidate). However, for these patient's there can be a short moment of realization when they feel the effect of the medications before becoming deeply sedated.

 

[GeneralVeers]

Wait, you guys are intubating presumed status without benzos or propofol? Just roc?

HH

Usually they've had 1 round of ativan. The actual, real status epilepticus patient won't care if etomidate is on board or not. The fakers will get an unpleasant experience.....

 

[RuralEDDoc]

Usually they've had 1 round of benadryl. The actual, real status epilepticus patient won't care if etomidate is on board or not. The fakers will get an unpleasant experience.....

OMFG

 

[TooMuchResearch]

My primary care doc referred me to a specialist. When I scheduled, I confirmed I'd be seeing a doctor. Not surprisingly, I saw a PA who recommended I try the things I already tried before I asked for a referral, then was out of ideas... Thanks for the high quality medical care!

Pretty crazy if you think about it. Primary care doc refers out to someone... who knows less than them. Defeats the entire purpose when a first consult is seen by a midlevel.

 

[TooMuchResearch]

Wtf? Is it abnormal that most of our community docs seem to trust our judgement? Not always, but often.

You're lucky I've had some patients call their PCP who then screams at me over the phone to demand I give them IV antihypertensives.

 

[Brigade4Radiant]

Even for posterior circulation stroke of long onset does it even matter you reduce risk factors aspirin if you are really concerned about someone’s vertigo admit and be done with it.

 

[TooMuchResearch]

I also work in a comprehensive stroke center, and our neurologists love some MRI action on room spinning dizziness without other symptoms.

I'm still in disbelief that you guys MRI/CT "dizziness" without focal neurologic findings. The only way I'm imaging a "dizziness" complaint is if they have a neurologic finding (including gait ataxia -- I actually witness them walk).

I don't think I've ever MRI'd a dizzy patient without focal findings and I work in a comprehensive stroke center who sees posterior strokes all the time.

Many of the patients who complain of dizziness actually mean lightheadedness. When you ask them if they feel like they're on a merry go round or the room is spinning, most will say no. If you ask if they feel woozy when they change positions, most will say yes: lightheadedness instead of dizziness.

 

[southerndoc]

Of course the neurologists love MRI's. What neurologist doesn't? The question is does the patient actually need it.

 

[TooMuchResearch]

As our neurologists will tell you, it can be very difficult to know without the MRI...

Of course the neurologists love MRI's. What neurologist doesn't? The question is does the patient actually need it.

 

[RuralEDDoc]

The challenge we all face is that essentially all consults are phone consults. With in person consults, real advice with real specialty specific insights can occur. With phone consults, the consultant has no incentive, at all, to give cost effective advice - the only incentive is to minimize personal risk. So for Neuro phone consults, the answer is MRI. Cardiology questions, answer is rule out and stress or cath. It’s entirely predictable. The role of the Emergency Physician is to know when to call and when to discharge without calling a consult.

 

[thegenius]

The challenge we all face is that essentially all consults are phone consults. With in person consults, real advice with real specialty specific insights can occur. With phone consults, the consultant has no incentive, at all, to give cost effective advice - the only incentive is to minimize personal risk. So for Neuro phone consults, the answer is MRI. Cardiology questions, answer is rule out and stress or cath. It’s entirely predictable. The role of the Emergency Physician is to know when to call and when to discharge without calling a consult.

What I find is that Neurologists ask for MRI's even when they see the patient. It's really shocking how often they want one, for any neurologic condition. What did Neurologists do when MRI wasn't around?

 

[deleted109597]

What I find is that Neurologists ask for MRI's even when they see the patient. It's really shocking how often they want one, for any neurologic condition. What did Neurologists do when MRI wasn't around?

Even less than they do now*. But they had a much bigger bag of tools.
They also used to do their own LPs and whatnot.








*Neurologists are definitely needed for a specific skill set, and the fact that we may say they don't do much is no different than any other specialty ragging on another. Neurologists do a ton for headaches, many bizarre conditions (Guillain Barre etc) and the fact that they can't cure strokes isn't their fault.

 

[CajunMedic]

They also used to do their own LPs

On Peds EM this month, had one sent from the neurologist office literally for an LP: “encephalitis vs. partially treated meningitis”

Mind you, I’ve seen this patient 3 times for vague headache, Otitis Media, and toe pain, all within a 3 week stretch. Plus ENT, PCP, and Neuro. Multiple negative workups to include CT, MRI, labs, vitals, etc. Amazingly, they get better with the migraine cocktail and they’re so ill, they just can’t stop watching YouTube and taking hospital selfies

The best part? Mom has gotten totally neurotic/more overbearing than she already was. Carries a notebook and date/times every interaction, and refuses to let us do it. Wants the Peds hospitalist to do it. Peds comes down, takes one look at the crazy, and says “nope”. Anesthesia comes to the ED and does the LP:

Lo and behold, negative....



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[DrGasPasser]

What I find is that Neurologists ask for MRI's even when they see the patient. It's really shocking how often they want one, for any neurologic condition. What did Neurologists do when MRI wasn't around?

Are you referring to patients in the ED? If so, I’m curious to know how your neurologist think that an MRI helps with the emergent management of dizzy patients. If an MRI is positive for posterior circulation stroke, then the patient still needs to be admitted. If it’s negative, you still have not ruled out posterior circulation stroke in the first 24 hours since MRI is only 80% sensitive.

In the ED, it really comes down to 2 questions for dizzy patients where metabolic causes have been ruled-out:

1) Do they have a focal deficit?
2) Do they have a disturbance in their baseline gait?

If either is positive, then the patient needs to be admitted no matter what, and the MRI can be obtained on the floor. If both questions are negative, then I’m unclear why stroke or large mass is in the emergent differential.

 

[DrGasPasser]

On Peds EM this month, had one sent from the neurologist office literally for an LP: “encephalitis vs. partially treated meningitis”

Mind you, I’ve seen this patient 3 times for vague headache, Otitis Media, and toe pain, all within a 3 week stretch. Plus ENT, PCP, and Neuro. Multiple negative workups to include CT, MRI, labs, vitals, etc. Amazingly, they get better with the migraine cocktail and they’re so ill, they just can’t stop watching YouTube and taking hospital selfies

The best part? Mom has gotten totally neurotic/more overbearing than she already was. Carries a notebook and date/times every interaction, and refuses to let us do it. Wants the Peds hospitalist to do it. Peds comes down, takes one look at the crazy, and says “nope”. Anesthesia comes to the ED and does the LP:

Lo and behold, negative....



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As long as their are no abnormalities in vitals and a normal exam, you probably won’t miss much. Just be careful with bounce backs for acute complaints - even in high-utilizers of the ED. They can bite you in the ass.


Now, I’m not saying that you should spin every recidivist patient or go crazy with LPs. But, be careful with bounce backs; especially those with language or psych barriers. Be very careful with bounce backs that have or report worsening vitals like fevers.

Sometime, your better off spending the political capital and admitting those patients on that 3rd ED visit.

 

[thegenius]

On Peds EM this month, had one sent from the neurologist office literally for an LP: “encephalitis vs. partially treated meningitis”

Mind you, I’ve seen this patient 3 times for vague headache, Otitis Media, and toe pain, all within a 3 week stretch. Plus ENT, PCP, and Neuro. Multiple negative workups to include CT, MRI, labs, vitals, etc. Amazingly, they get better with the migraine cocktail and they’re so ill, they just can’t stop watching YouTube and taking hospital selfies

The best part? Mom has gotten totally neurotic/more overbearing than she already was. Carries a notebook and date/times every interaction, and refuses to let us do it. Wants the Peds hospitalist to do it. Peds comes down, takes one look at the crazy, and says “nope”. Anesthesia comes to the ED and does the LP:

Lo and behold, negative....



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What an absolute blessing that you didn’t have to suffer being in that room any longer than you had to be.

 

[thegenius]

Of course the neurologists love MRI's. What neurologist doesn't? The question is does the patient actually need it.

So the problem is in court, when they call the expert witness, the answer is yes they needed it. Because the expert witness will be a neurologist and not an ER doctor

 

[southerndoc]

So the problem is in court, when they call the expert witness, the answer is yes they needed it. Because the expert witness will be a neurologist and not an ER doctor

Not in Georgia. Expert witnesses are required to be in the same specialty. Neurologist can testify against a neurologist, but never against an emergency physician. His testimony will be excluded from anything other than neurology. The case must be reviewed by an emergency physician and an affadavit by that emergency physician must be notarized stating that the emergency physician was grossly negligent in his or her care before the litigation can even be filed.

 

[Zebra Hunter]

On Peds EM this month, had one sent from the neurologist office literally for an LP: “encephalitis vs. partially treated meningitis”

Mind you, I’ve seen this patient 3 times for vague headache, Otitis Media, and toe pain, all within a 3 week stretch. Plus ENT, PCP, and Neuro. Multiple negative workups to include CT, MRI, labs, vitals, etc. Amazingly, they get better with the migraine cocktail and they’re so ill, they just can’t stop watching YouTube and taking hospital selfies

The best part? Mom has gotten totally neurotic/more overbearing than she already was. Carries a notebook and date/times every interaction, and refuses to let us do it. Wants the Peds hospitalist to do it. Peds comes down, takes one look at the crazy, and says “nope”. Anesthesia comes to the ED and does the LP:

Lo and behold, negative....



Sent from my iPhone using SDN

I am happy to appease outpatient docs, like admitting their patients or performing a test when it is within reason; however, when it is this scenario, and the outpatient doc is not the one admitting, not the one who is going to see them in the hospital, and there is no indication whatsoever for the test they are recommending, I have no qualms telling these patients and their families “no”. We are essentially just passing the buck to our IM colleagues when we appease ridiculous requests like this.

Can you imagine how much more “fun” this patient and family will be when they bounce back for the pt’s post LP headache? Sometimes we have to save pts from themselves.

 

[RustedFox]

I am happy to appease outpatient docs, like admitting their patients or performing a test when it is within reason; however, when it is this scenario, and the outpatient doc is not the one admitting, not the one who is going to see them in the hospital, and there is no indication whatsoever for the test they are recommending, I have no qualms telling these patients and their families “no”. We are essentially just passing the buck to our IM colleagues when we appease ridiculous requests like this.

Can you imagine how much more “fun” this patient and family will be when they bounce back for the pt’s post LP headache? Sometimes we have to save pts from themselves.

This, plus this nonsense stems from the fact that this patient (if it should be admitted), should be DIRECTLY ADMITTED.
Then, it becomes a discussion between IM and FP, without an unnecessary EM visit/expense.

I swear to FoxGod that if some ******* sends my spouse or dad to the ER for "admission", that I will call them and personally berate them.

Now, not to complain without presenting a solution, I submit this:

If a chart audit (and yes, we EPs need to document this) reveals a clear trend of "just go to the ER" from community doc (be it IM/FM/EM, whatever), then the fees incurred by the insurer for their bull**** admission-runaround willl be paid for by the referring physician. Yes, Nancy McDonaldHadaFarm NP; E-I-E-I-Oh - when you say "just go to the ER"; it will cost you a few thousand. Get used to it. Which is better? A few thousand out of your practice, or a brief conversation with the insurer that requires you to do your job at 4:45PM? Gee. I thought so, too.

Watch as this nonsense [ideally] disappears, and watch as a whole industry pops up to accommodate lazy community docs who no longer have their "RN on call" [i.e. - "just go the the ER" machine] available to them, as they've been fired because a box of bonbons and an hourly LPN to answer the phone doesn't cut the mustard anymore. ...... BONUS! - These new "admission centers" (perhaps run by hospitals) will also branch out to include a new troupe of "my widget is broken" experts who can do things like determine when a widget is working as intended, and the patient/family is simply stupid. Perhaps the widget expert can also provide education to the folks who can't work a widget. At the very least, the widget fellow (ooh, I didn't mean that; I meant 'expert' --- look out for that degree creep*; that's the NEXT hotword that they'll latch on to to imply a degree of expertise... I shouldn't have typed that) would be able to be on the phone to say things like: "Your PEG tube won't flush? Okay. Go back to bed. Come to us tomorrow morning. No biggie, homey." It would be similar to the LPN who only says: "Go to the ER", expect they'll say: "Go back to sleep and see me, the WidgetWizard in the morning, and you'll save everyone money, hassle, and frustration."


This post made me MORE mad now than I was when I started it.

So much for SDN being a spring of catharsis.

*I can hear them, now.

I did a "residency" in EM as a PA.
I did a "fellowhship" in widgetry as an NP.

Might as well be: "I did a study abroad in Spain.... where everyone spoke English. It was fun and I drank a LOT of SANGRIA and the guys were like, sooo cuuuute. Lolz. KAPPER DELTER GAMMER! WHOO!"

Remember when you were a kid, and you used a word that you didn't understand in front of adults; and you realized; "WHOOPS!, I didn't know what that word meant?!" If your dad was a good dad, he hit you across the cheeks when that word was inappropriate (and it was). If you were a good son, you stood up afterwards and said; "Yep. I kind of knew what that word meant - but now I'm sure that I shouldn't say it. At least until I'm WAAY older and I can really understand what that word means." [FREQUENT POSTERS: REMIND ME TO EXPOUND UPON THIS LATER, AS THE COROLLARY IS TOO SENSITIVE FOR TEH (sic) SNOWFLAKE CROWD... psst...I wrote what a "bad dad" would do, but I deleted it.]

That's MLPs for yah.

Knock it off, physicians. You gonna be a good dad, or a bad dad? Pick a side.

Knock it off, pledges. The buck stops here. Get real, or get in line. Your daddy ain't gonna be here forever; as you so desire. If you're happy with your existence (and I'm sure that many, many of you are and should be)... then be quiet when daddy needs to talk. After all, its his bacon on the table.

Yes, I understand that I also don't remember every frame of S2E5 of Game.Of.Thrones.Of.Immunology; but I learned it, and its in my brain to make the necessary connection (singular) happen. And I've seen that episode enough that I can act on it. You remember that line that DragonGirl said and I didn't? Great; doesn't mean dragon$hit.

Yes, I understand that some of you are smarter than some of the MD/DO crowd out there; but you know what ? They can answer for themselves. Think VERY carefully before you ask for the same privilege.

 

[DocEspana]

I usually don't get bent out of shape over hypertension. Simply telling them that asymptomatic hypertension just needs adjustments to medication and not emergently treated usually will do the trick after I go through the spill that their hypertension may be temporary from increased salt, stress, caffeine, etc.

I've had to have security escort some people out, but I can't say that I've ever had a hypertensive patient need that level of discharge. Usually it's the people demanding narcotics.

As zebra Hunter later said... I only ever had to go half way or a third of the way down that script with my inner city patients. Once I started working in a rich white suburb? Disturbing frequency of needing to go all the way down including filing a complaint and having security escort them out. All over a 185/88 bp (it's always isolated systolic. Which makes it even more annoying)

 

[DocEspana]

I wonder if we trained at the same place.

Hispanic dizziness (and Hispanic like Mexican, central America, not Spanish) is a catch all phrase that means they just don't feel good. It doesn't mean fainting, it doesn't mean vertigo, it doesn't mean anything besides what a bowl of cooked black beans means......nothing. It took me 4 years, about 50 consecutively negative MRI's, about 10 admissions as such, Neurology consults, and lord knows how many labs and neuro exams to realize that MAREO means ****ing NOTHING. I don't care how old you are....if you say you are MAREO you get a neuro exam, EKG, labs maybe a CT Head and if all is negative AN ABSOLUTE FUUUUCCCCCKKKIINNG discharge. God I wracked up 5M in useless tests just based on that one word that isn't even English.

Hispanic panic is real, extraordinarily real, and an enormous burden on our health care system

Oh yeah. As a native Spanish speaker I don't understand why medical translators decide to use the word dizzy for mareo. The word used for dizziness the way English speakers understand it (vertigo, possibly disequilibrium) is mareado.

Mareo is a related word (in it's etymology, it would appear one is the adjective and one is he noun form of the same idea, but it's not how it's used) but you wouldn't say you have mareo if you meant dizziness. You say mareo more for a nauseated or unwell feeling. It doesn't have a direct English translation but "dizziness" is not at all how it should be translated to someone familiar with it's common use with Spanish speakers and with medical terms in english.

This leads to the amusing phenomenon where most patients who say that they have mareo will then go on to deny being mareado.

 

[GonnaBeADoc2222]

Oh yeah. As a native Spanish speaker I don't understand why medical translators decide to use the word dizzy for mareo. The word used for dizziness the way English speakers understand it (vertigo, possibly disequilibrium) is mareado.

Mareo is a related word (in it's etymology, it would appear one is the adjective and one is he noun form of the same idea, but it's not how it's used) but you wouldn't say you have mareo if you meant dizziness. You say mareo more for a nauseated or unwell feeling. It doesn't have a direct English translation but "dizziness" is not at all how it should be translated to someone familiar with it's common use with Spanish speakers and with medical terms in english.

This leads to the amusing phenomenon where most patients who say that they have mareo will then go on to deny being mareado.

Omg this is really good to know. Will try asking the patient to clarify in the future

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[Gastrapathy]

I put in one of those annoying widgets so I’ll clarify a couple things:
1. Clogged PEG is not an emergency
2. Pulled out PEG is a potential free perf for the first 6 weeks or so after placement (and since so many patients get PEGs in their last few weeks of life, this is an embarrassingly high portion of the total PEG population.
3. Pulled out PEG >6 weeks is not an emergency...except that the tract can close in hours and take a 5 min PEG exchange and turn it into another endoscopic or IR placement. I’ve seen these sent out of the ED with nothing done when the tract could have been saved and now the patient needs another procedure. You don’t have to have a replacement PEG on hand (although popping them in is super easy if you do), just put a foley through the tract so it will stay open.

One of our nurses exchanges PEGs in our clinic on a walk in basis. Pull then push. I like the MIC-KEY low profile replacement PEG. It’s easier than a foley and if you kept a couple around, you’d save those repeat procedures.

 

[thegenius]

I put in one of those annoying widgets so I’ll clarify a couple things:
1. Clogged PEG is not an emergency
2. Pulled out PEG is a potential free perf for the first 6 weeks or so after placement (and since so many patients get PEGs in their last few weeks of life, this is an embarrassingly high portion of the total PEG population.
3. Pulled out PEG >6 weeks is not an emergency...except that the tract can close in hours and take a 5 min PEG exchange and turn it into another endoscopic or IR placement. I’ve seen these sent out of the ED with nothing done when the tract could have been saved and now the patient needs another procedure. You don’t have to have a replacement PEG on hand (although popping them in is super easy if you do), just put a foley through the tract so it will stay open.

One of our nurses exchanges PEGs in our clinic on a walk in basis. Pull then push.

can you further explain #2?

 

[GonnaBeADoc2222]

I put in one of those annoying widgets so I’ll clarify a couple things:
1. Clogged PEG is not an emergency
2. Pulled out PEG is a potential free perf for the first 6 weeks or so after placement (and since so many patients get PEGs in their last few weeks of life, this is an embarrassingly high portion of the total PEG population.
3. Pulled out PEG >6 weeks is not an emergency...except that the tract can close in hours and take a 5 min PEG exchange and turn it into another endoscopic or IR placement. I’ve seen these sent out of the ED with nothing done when the tract could have been saved and now the patient needs another procedure. You don’t have to have a replacement PEG on hand (although popping them in is super easy if you do), just put a foley through the tract so it will stay open.

One of our nurses exchanges PEGs in our clinic on a walk in basis. Pull then push. I like the MIC-KEY low profile replacement PEG. It’s easier than a foley and if you kept a couple around, you’d save those repeat procedures.

Regarding 1, please tell this to the nursing homes that send these people in at 11pm.

Regarding 3, yes, we all know this we learned it in dumb er doctor school.

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[Gastrapathy]

@thegenius Sure...there is a hole in the stomach and the bumper holds it against the abdominal wall until scarring creates a mature tract. That usually happens by 3-4 weeks but can theoretically take longer. Before that, the stomach and hole can fall away.

 

[Gastrapathy]

@GonnaBeADoc2222 ok, maybe the ones who’ve sent these out over the years knew better and just couldn’t be bothered.

I guess I was just surprised that this 5 min dispo was something that would bother an EM physician considering all the BS you see. Was trying to make it easier. Teach a nurse to exchange them “per protocol” and done

 

[Dr Mantis Toboggan]

I’m aware of a case where that was done to an infant with cleft palate. No injection study was done on a fresh tube replacement. The replacement just poured feeds into the peritoneum. Tragic ending.

can you further explain #2?

 

[RoyBasch]

I’m aware of a case where that was done to an infant with cleft palate. No injection study was done on a fresh tube replacement. The replacement just poured feeds into the peritoneum. Tragic ending.

This is why no matter how easy these seem (theoretically a 5 second dispo) I always do confirmation with injection of contrast into the new G tube and confirmatory XR showing good opacification of the stomach. One of my mentors when I was a resident impressed the importance of this on me as he was familiar with a similar case in our area with similarly bad outcome.

Although I think what gastrapathy is getting at is that with a relatively new PEG, the fistulous tract isn't mature yet and if the tube completely falls out, the stomach can fall away from the abdominal wall and you basically have the equivalent of perforated stomach ulcer that can pour stomach contents into the peritoneum leading to rapid peritonitis.

Either way I agree it seems the likelyhood of a false passage with the replacement tube is higher the less mature the tract is. Similar to how fresh trach's can be more problematic and dangerous to mess with/instrument.

 

[GonnaBeADoc2222]

Ya so...nurses won't even push the gastrograffin after placement....good luck getting nurses to place a peg LOL good one

@GonnaBeADoc2222 ok, maybe the ones who’ve sent these out over the years knew better and just couldn’t be bothered.

I guess I was just surprised that this 5 min dispo was something that would bother an EM physician considering all the BS you see. Was trying to make it easier. Teach a nurse to exchange them “per protocol” and done

Sent from my Pixel 3 using SDN mobile

 

[TooMuchResearch]

They're easy to replace (if I'm in a place that can get me the right size), so unless they're new, I just replace them, confirm w x-ray, and move on with my day.

@GonnaBeADoc2222 ok, maybe the ones who’ve sent these out over the years knew better and just couldn’t be bothered.

I guess I was just surprised that this 5 min dispo was something that would bother an EM physician considering all the BS you see. Was trying to make it easier. Teach a nurse to exchange them “per protocol” and done

 

[RustedFox]

@GonnaBeADoc2222 ok, maybe the ones who’ve sent these out over the years knew better and just couldn’t be bothered.

I guess I was just surprised that this 5 min dispo was something that would bother an EM physician considering all the BS you see. Was trying to make it easier. Teach a nurse to exchange them “per protocol” and done

A few things:

1. I dig you, man. Thanks for being an awesome GI and hanging with us.
2. A "five minute dispo" is not so in real life. It takes our crew an hour or so to find "a" tube from "central supply", and then I tell them its not the right size, and then they argue with me over whether it will "work" or not, and then other shenanigans generally occur. Sometimes, they bring, like, a "rectal airwary tube" and I say: "This is the entirely wrong thing. How high are you right now?"
3. Nevermind #2. There is NOTHING emergent about this. It does not require an ambulance ride from DeathAcres Nursing Home at 2 AM. It can be done easily.... in the same facility... at 9 AM. All it takes is the facility doc to learn to NOT breathe thru his mouth for a second.

 

[Gastrapathy]

@RustedFox I get it. I know it was dismissed earlier but we have a nursing protocol for this. Replacing tubes in old tracts in adults (I know ****-all about kids) doesn’t require a contrast study. Our nurse does it all the damn time. Once in a while, we get asked to look at it. The facilities know that they can call our recovery, arrange transport (we don’t let them leave and do the exchange on the EMS gurney) and send them away. It really is 5 min for us.

 

[TooMuchResearch]

We did them in kids all the time in the Peds ED in residency. Wasn't any more complicated than adults.

@RustedFox I get it. I know it was dismissed earlier but we have a nursing protocol for this. Replacing tubes in old tracts in adults (I know ****-all about kids) doesn’t require a contrast study. Our nurse does it all the damn time. Once in a while, we get asked to look at it. The facilities know that they can call our recovery, arrange transport (we don’t let them leave and do the exchange on the EMS gurney) and send them away. It really is 5 min for us.

 

[Zebra Hunter]

Ya so...nurses won't even push the gastrograffin after placement....good luck getting nurses to place a peg LOL good one

Sent from my Pixel 3 using SDN mobile

I have a couple nurses I’m friends with who will put these in for me if I’m busy with a resuscitation.

 

[RuralEDDoc]

@RustedFox I get it. I know it was dismissed earlier but we have a nursing protocol for this. Replacing tubes in old tracts in adults (I know ****-all about kids) doesn’t require a contrast study. Our nurse does it all the damn time. Once in a while, we get asked to look at it. The facilities know that they can call our recovery, arrange transport (we don’t let them leave and do the exchange on the EMS gurney) and send them away. It really is 5 min for us.

This is likely due to the difference between a GI clinic and the ER.
GI clinic: Your patient who you know (you probably placed the tube) shows up and can tell you (or their caregiver can) how and when the tube fell out. Tube replaced, goodbye.
ER: Patient shows up, nobody knows when or why the tube was placed, and nobody knows when the tube fell out. But the tube is out. So you call around to family and SNF staff and no one can help you. So you search for the right tub, but no one can find the exact replacement. You eventually get the wrong replacement tube and try to replace. Some bleeding occurs, patient grimaces, so you take an XR and praise Jesus, it worked. Now, your patient waits three hours for a return ambulance ride.
I wish I was joking or exaggerating about any of this but this is a common reality.

 

[Groove]

I had a perfect track record until I got this old NH patient with little documentation with a report that the PEG tube was out and needed replacing. EMS assured me that the nurses told him the PEG was old and I didn't feel the need for verifying. Stoma didn't look fresh. Pt was too demented to tell me anything and the PEG procedure was done at another hospital. I changed it out, squirted the gastrografin and voila...contrast everywhere, except the stomach. I felt like the "SHAME!" lady from GOT was following me around the rest of my shift. Luckily, it wasn't a big deal. They replaced it endoscopically the next day and there was no peritonitis or clinically significant gastric leak. I squirt these to verify placement 100% of the time.

@Gastrapathy I realize you're trying to be helpful but you really have no idea what it's like for us replacing these in the ED. We have ZERO information on the PEG most of the time. It's done somewhere else, nobody knows WHO did it, or what hospital it was done at, or even WHEN it was done. Sometimes, these things have been out for hours before any nurse noticed at the NH which prompted a delayed transfer to the ER. The stoma is half closed and it's a work out getting it re-inserted, praying to God that I didn't just create a new tract or that this isn't a fresh tract after talking to a NH nurse at 2a.m. who just met the pt that day and has no idea how old it is and after asking a next of kin on telephone who again....has no idea when it was placed. It's a classic hail Mary PEG replacement. And you want us to send them back out without contrast verification that it's in the gut? No thanks. Plus, how hard is it to put in 20ccs of gastrografin and shoot an abdominal XR? It takes like 2 minutes.