Subarachnoid bleed and hyperventilation

[FLdoc2011]

Why?

"I'm sorry, but until you diagnose the brain pathology I am afraid our neuro facility is not willing to help your suspected head injury patient."

That sounds sort of off kilter to me.

That would assume the facility has a working/available CT at all hours. I know of smaller hospitals in major US cities that shut down their CT at 9pm, with nobody on staff to run it in the building.

Not every ED is set up to dx and manage critical patients. I have seen multiple smaller hospitals in the US that do not even have CTs.

Well, knowing what the actual injury is can impact what type of care or even where the patient is transferred to. It may be something where after review our Neurosurgeons may decide that the pt needs to go to a different facility with a specific/specialized treatment available or the patient may need Neurointerventional radiology and our guy is off that night, etc...

But with EMTALA in order to transfer from one hospital to another it has be for a higher or different level of care not available at the first facility... so if you're going to transfer a patient for neurosurgical evaluation then you need to do if there's a neurosurgical problem.

If there's no CT available that's a different issue, but then again a transfer is warranted since you are transferring for a higher level of care in order to obtain a CT. In my example a facility is not going to transfer just to get a CT when they can do it there.

Forgive me, but from what I have seen, most outlying facilities and providers in any nation, even if they do have the equipment in the back room somewhere, would never consider such a procedure if they do not perform it regularly.

But I will put it to an informal poll to all of the EMs on my FB page just to get some more feedback on it.

Yea, I'm sure it's highly location/physician dependent on whether they are able to or have had the training. A good number of ED docs have done ED residency and most likely at a trauma center and may have some experience. Granted I'm sure it's a pretty rare thing for an ED doc to do, just like thoracotomy and emergent trach but certainly within their skill set if absolutely needed.

Do you think it is medically beneficial to a patient to receive a workup if they cannot be helped or is it just an administrative thing?

Stabilization is a rather tricky term. What does it mean to you?

I don't know about beneficial, but it's required. EMTALA mandates that a pt presenting to an ED has a screening medical exam to evaluate for any emergency conditions. Again, we don't do Peds or OB/Gyn but we still occassionally get really sick kids and preggos in the ED and we can't transfer them out without some idea of what's going on and some sort of workup while making sure they are stable enough for transport. When we call another facility and find an accepting doctor we have to have a reason to transfer them for additional care.

 

[Veneficus]

But with EMTALA in order to transfer from one hospital to another it has be for a higher or different level of care not available at the first facility... so if you're going to transfer a patient for neurosurgical evaluation then you need to do if there's a neurosurgical problem..

I think this can be accomplished with a good neuro exam, not specifically requiring a CT. Even if you have something like a subdural bleed, it doesn't mean it will require surgery. But that is a decision for neuro at whatever facility they are at.

If there's no CT available that's a different issue, but then again a transfer is warranted since you are transferring for a higher level of care in order to obtain a CT. In my example a facility is not going to transfer just to get a CT when they can do it there..

The last patient I referred to to a different facility for a CT presented with neuro deficits (and a very convincing story of mechanisms). Most patients I have seen, particularly in trauma centers present with neuro deficit.

In both my education and experience a CT is not what soley determines if there is a reason to refer to a facility for nero consult.

Yea, I'm sure it's highly location/physician dependent on whether they are able to or have had the training. A good number of ED docs have done ED residency and most likely at a trauma center and may have some experience. Granted I'm sure it's a pretty rare thing for an ED doc to do, just like thoracotomy and emergent trach but certainly within their skill set if absolutely needed...

As fate would have it, I know emergency physicians all over the world, both US residency trained as well as other specialties who work in emergency.

I posed the question: "If you were in a community hospital and suspected a patient had herniation from a TBI, would you be inclined to place a burr hole or other surgical intervention. It is being forwarded right now, but the first EM to answer stipulated he would only in the most grevious of circumstances. An ortho surgeon said yes he would.

I don't know about beneficial, but it's required. EMTALA mandates that a pt presenting to an ED has a screening medical exam to evaluate for any emergency conditions..

I do not dispute this, I just dispute if a CT at a facility that can do nothing with it but transfer the patient is required to do that as part of the screening exam.

Actually, I think I picked that up in my last ATLS class. Right along with "If you can't close a chest, don't open it."

Again, we don't do Peds or OB/Gyn but we still occassionally get really sick kids and preggos in the ED and we can't transfer them out without some idea of what's going on and some sort of workup while making sure they are stable enough for transport. When we call another facility and find an accepting doctor we have to have a reason to transfer them for additional care.

Cleveland Clinic?

 

[FLdoc2011]

I think this can be accomplished with a good neuro exam, not specifically requiring a CT. Even if you have something like a subdural bleed, it doesn't mean it will require surgery. But that is a decision for neuro at whatever facility they are at.

The last patient I referred to to a different facility for a CT presented with neuro deficits (and a very convincing story of mechanisms). Most patients I have seen, particularly in trauma centers present with neuro deficit.

In both my education and experience a CT is not what soley determines if there is a reason to refer to a facility for nero consult.

As fate would have it, I know emergency physicians all over the world, both US residency trained as well as other specialties who work in emergency.

I posed the question: "If you were in a community hospital and suspected a patient had herniation from a TBI, would you be inclined to place a burr hole or other surgical intervention. It is being forwarded right now, but the first EM to answer stipulated he would only in the most grevious of circumstances. An ortho surgeon said yes he would.

I do not dispute this, I just dispute if a CT at a facility that can do nothing with it but transfer the patient is required to do that as part of the screening exam.

Actually, I think I picked that up in my last ATLS class. Right along with "If you can't close a chest, don't open it."


Cleveland Clinic?

No, just a community hospital on Florida's west coast.

Can also ask your ED friends if they would or even could transfer a suspected head bleed for neurosurg eval (hypothetically if they didnt have the capability in house) without imaging/CT. Outside of blatant obvious trauma.

We get plenty that don't have any specific neuro defects.

Ultimately the reason to transfer to to another facility is to obtain a level of care not available at the current place. Outside of blatant obvious trauma how would you know it's a bleed that needs neurosurg vs say an ischemic stroke possibly requiring TPA that you could keep and treat in house? Or even a massive tumor that you may want to give steroids to.

I would be hung up on and/or laughed at if I called another doc/hospital asking to transfer a patient for neurosurg eval without actually knowing if there's a neurosurg issue even present. Not having CT capability is completed different.

There's also medical legal issue.... A lawyer would have a field day with this.
"So doctor, you suspected an intracranial hemorrhage based on clinical findings.
"Yes"
"What did you do to verify this before sending the pt out?"
"um... Nothing"
"so you don't actually know that's what was going on, how bad it was, if there was edema/shift/impending herniation/aneurysm/ischemic stroke/abscess/mass..... Which would require varying treatments that you have the ability to start at your facility."

If you really suspect a bleed then you have to follow standard of care or have your lawyer on speed dial.

 

[Veneficus]

Which would require varying treatments that you have the ability to start at your facility."

I think this is the key to the whole argument.

If you really suspect a bleed then you have to follow standard of care or have your lawyer on speed dial.

So if your CT delays a patient from definitive treatment, you would go to court with the defense:

"Lady's and gentlemen of the jury, despite my expert, professional, clinical judgement and a deteriorating patient, I sought to satisfy an interpretation on EMTLA and attempt a definitive diagnosis which I knew I might not be able to help, subsequently delaying the patient from a doctor that could have helped."?

I am sure a decent lawyer will follow that up with:

"So my client's mom might be alive if she would have arrived at a specialty center sooner?"

Really, if "follow this plan no matter what the patient presents with" is suppoosed to stop one from getting sued, I'll risk the court with:

"I judged the patient was beyond my capability and the capability of my facility and spared no effort or expense to give her every opportunity to get the help she desperately needed from an expert and a more capable center."

and my attorney could follow it up with:

"So you ignored a set of guidlines meant to protect you from a lawsuit in order to put the interest of your patient first?"

I also have no doubt both parties could present a chain of experts to back their position.

Ultimately if you are going to court you need to tell a really good story to 12 of the most ignorant people you can imagine, who may decide the merits of the case on the best story and the perception of the doctor's ego.

Perhaps we could consider this from a different angle?

If a patient presented with crushing substernal chest pain radiating to the arm and jaw, with EKG changes and elevated troponin and you didn't have a PCI lab but did have angio CT, would you perform the angio prior to transfer?

How is that any different from diagnosing a nonspecific brain injury on clinical symptoms of a neuro exam?

Because somebody suggested a picture?

 

[18G]

Not sure if I should comment in between you two guys but I agree that a head CT should be done. It is specific and tells a bigger picture of what resources or facility may be needed to handle the problem. If you don't do a head CT how is the receiving hospital to be prepared for what's coming in?

Isn't it kinda like having a patient with chest pain that is looking kinda bad and we want to quickly send them to the cath lab without doing a 12-lead and blood work? And the doc at the cath lab has no clue what he is getting or what's even causing the chest pain for sure? All he know's is he is getting a patient with chest pain that "could" require PCI.

It's great we get em out the door fast, but don't we also need to triage them to the appropriate facility and physician staff too?

 

[FLdoc2011]

So if your CT delays a patient from definitive treatment, you would go to court with the defense:

"Lady's and gentlemen of the jury, despite my expert, professional, clinical judgement and a deteriorating patient, I sought to satisfy an interpretation on EMTLA and attempt a definitive diagnosis which I knew I might not be able to help, subsequently delaying the patient from a doctor that could have helped."?

I am sure a decent lawyer will follow that up with:

"So my client's mom might be alive if she would have arrived at a specialty center sooner?"

Really, if "follow this plan no matter what the patient presents with" is suppoosed to stop one from getting sued, I'll risk the court with:

"I judged the patient was beyond my capability and the capability of my facility and spared no effort or expense to give her every opportunity to get the help she desperately needed from an expert and a more capable center."

Sounds good and all but not how it works. I'm not an ER doc, but it's not beyond the capability of an ER doc to diagnosis a brain bleed. He would be held to a certain standard of care, which would include a CT to look for bleed if clinically indicated.

Ultimately, they're going to be sued no matter what, so that's not really an argument. But they certainly WILL be sued if they rushed to get rid of the pt and missed something else on a CT, even if that mean the pt left a couple minutes sooner (the actual scan takes seconds).

It's a completely different story if it's beyond the capability of the facility. Totally different story and of course you have to transfer so that they can get the scan that is required.

If a patient presented with crushing substernal chest pain radiating to the arm and jaw, with EKG changes and elevated troponin and you didn't have a PCI lab but did have angio CT, would you perform the angio prior to transfer?

How is that any different from diagnosing a nonspecific brain injury on clinical symptoms of a neuro exam?

This is a little different. In the CP scenario you already have a diagnosis and diagnostic/test evidence confirming it. If it was clinically indicated then yes you may get the angio first (tearing sensation to the back, UE/LE BP discrepancies, widened mediastinum on Chest XR, etc....). But if you've already diagnosed STEMI then standard of care is PCI within 90min.

If you're diagnosing a nonspecific brain injury, then it's just that a "non-specific" brain injury. Sure, neuro exam is required and will probably give you the a pretty good idea but no one I know is going to stake their career/lives on just that. We're held to a different standard and in this day and age of technology exam alone is not standard of care.

What if in my good intentions of trying to get the pt out as soon as possible, I skip the scan and it turns out the pt actually has bacterial meningitis, and I've delayed them getting antibiotics in the goal time period and they die? There is no defense of that. I'm certainly NOT going to bet my license and career on having patients present with classic symptoms of whatever disease they have.

 

[FLdoc2011]

Isn't it kinda like having a patient with chest pain that is looking kinda bad and we want to quickly send them to the cath lab without doing a 12-lead and blood work? And the doc at the cath lab has no clue what he is getting or what's even causing the chest pain for sure? All he know's is he is getting a patient with chest pain that "could" require PCI.

Actually a good example I didn't think about.

As a physician part of my job is to diagnose and treat, and I'm held to the standard of care involved in diagnosing and using the modalities I have available to diagnose. In the case of suspected bleed I need the scan. I can't treat or transfer what I haven't diagnosed.

 

[Veneficus]

Sounds good and all but not how it works. I'm not an ER doc, but it's not beyond the capability of an ER doc to diagnosis a brain bleed. He would be held to a certain standard of care, which would include a CT to look for bleed if clinically indicated.

I attempted to find this standard of care.

In a quick google search, I found several different ones, mostly depending on the country and patient populations, adult, ped, GCS, clinical manifestations, etc.

All of the ones I found suggest that either:

A: neuro consult is available in house

or

B: There is deterioration or gross clinical signs. (including one that states transfer should be initiated even if the CT is clear but patient complains of persistent headache or vomiting)

As such, no universal guidline or standard of care exists, it is region dependant.

I even went as far as to look up the EMTLA law in regards to that section of the argument.

I could find nothing that states any specific part of an evaluation be performed, only that no part of the evaluation can be skipped because of the ability to pay.

Ultimately, they're going to be sued no matter what, so that's not really an argument. But they certainly WILL be sued if they rushed to get rid of the pt and missed something else on a CT, even if that mean the pt left a couple minutes sooner (the actual scan takes seconds)..

The scan takes seconds. If the table is open. After the patient has been transfered to it. After the appropriate scanning parameters are entered and the patient positioned. On average I have seen, 5-10 minutes.

Which doesn't sound like much. But if your initial exam and workup takes 15 minutes, you are now running into 20-30.

I have seen many patients code in a CT scan. I have read about many more. Particularly when surgical intervention was delayed for the scan.

If you're diagnosing a nonspecific brain injury, then it's just that a "non-specific" brain injury. Sure, neuro exam is required and will probably give you the a pretty good idea but no one I know is going to stake their career/lives on just that. We're held to a different standard and in this day and age of technology exam alone is not standard of care. .

Only in the US and I eagerly wait to see how many more years that is financially sustainable.

What if in my good intentions of trying to get the pt out as soon as possible, I skip the scan and it turns out the pt actually has bacterial meningitis, and I've delayed them getting antibiotics in the goal time period and they die? There is no defense of that. I'm certainly NOT going to bet my license and career on having patients present with classic symptoms of whatever disease they have.

All of the guidlines that I have found on antimicrobial therapy in meningitis suggest starting on clinical suspicion prior to CT. With a decline in prognosis after a delay of 3 hours(that is a rather long time), with a goal of 1 hour of arrival at the hospital.

 

[Veneficus]

Not sure if I should comment in between you two guys?

Why not?

This argument is really a difference of medical philosophy.

Technology dependence vs. clinical accumen.

It really could be about any pathology.

Being European trained, I advocate what I learned, which is more subjective than many US physicians. (physical exam and liberal use of ultrasound)

The US loves its expensive technology. And deemphasizes provider ability.

Neither of us doubt that a CT should be done. Neither think the patient shouldn't be treated by the place most capable. There is a argument about order of operation, that's all. No different that arguing ERC vs. AHA guidlines.

 

[FLdoc2011]

Not sure where you are looking but go to reputable source such as UpToDate or the specific practice guidelines for medical specialties.

CT head is the test of choice to diagnosis cerebral hemorrhage and important to distinguish between ischemic stroke and other stroke mimics.

When statements like that are made in peer reviewed medical publications then it's standard of care and it's going to get done.

I just now see the bit about Europe, and that plays a huge role. Honestly, the medical legal environment is completely different there and it may be feasible or accepted to transfer without the scan. At least in the US that's not the case.

And it's not really about clinical acumen. You're held to a different standard with your training and the diagnostic tools available. On one level it certainly is a philosophical argument and I don't disagree, there are a LOT clinical situations where I wish we could go back to relying on clinical judgement but that's not reality and there is standard of care that I must follow. And honestly, no matter how good of clinician I become stuff still gets by and I would be foolish to completely rely on it if I didn't have to.

 

[Veneficus]

Not sure where you are looking but go to reputable source such as UpToDate or the specific practice guidelines for medical specialties.

Went to various national position papers in UK, France, and Australia.

Did a google search for the US, but every site wanted money and I wasn't willing to pay.

CT head is the test of choice to diagnosis cerebral hemorrhage and important to distinguish between ischemic stroke and other stroke mimics.

Like I said, we do not disagree on this.

But when not in a specialty facility with one available, it is really just a question of when.

I just now see the bit about Europe, and that plays a huge role. Honestly, the medical legal environment is completely different there and it may be feasible or accepted to transfer without the scan. At least in the US that's not the case.

But I am willing to have an academic argument on it anyway.

And it's not really about clinical acumen.

I think if you got to see the clinical skills of European physicians, you would find them very impressive.

I grew up in the States andworked in EMS there, but when I saw a European physician dx SVT listening to heart tones and another dx not only an ischemic stroke vs hemorrhagic but the exact artery in the brain which was later verified by CT, I was sold.

More so when I was told I could not pass neuroscience if I could not do the same thing.

You're held to a different standard with your training and the diagnostic tools available. On one level it certainly is a philosophical argument and I don't disagree, there are a LOT clinical situations where I wish we could go back to relying on clinical judgement but that's not reality and there is standard of care that I must follow. And honestly, no matter how good of clinician I become stuff still gets by and I would be foolish to completely rely on it if I didn't have to.

Stuff always gets by. It is the nature of medicine. Whether you have technology or not.

 

[FLdoc2011]

At least in the US even when at a facility without neurosurg it's going to get done. They need the diagnosis before transfer and to rule out other intracranial pathology.

In UK it's probably different. EMTALA is a US thing and the legal environment here is different.

I have seen terrific clinicians, that's not the point. Even the best clinician isn't going to have near the sensitivity/specificity of a specific test like CT when it comes to something like hemorrhage. Anecdotal evidence of seeing great clinicans make great calls is not evidence based medicine and does not hold up in legal circles.

Found this: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_081059.pdf

Thats UK's national stroke strategy. On page 29 refers to urgent brain scan needed to differentiate between ischemic and hemorrhagic stroke and that scanning should be in next immediate scan slot or within 60mins if "out-of-hours" (?after hours I guess).

 

[Veneficus]

Neither of us doubt that a CT should be done

Not sure why you think there is an issue with that?

Next scan or within the hour if a CT is not immediately available is generally practiced everywhere except the US military. (been there seen that)

But I still doubt the utility of a scan in a facility that is not going to treat what it finds.

The "what if" game is not really impressive. "What if you have no changes on a scan but still symptoms?" Would you deny that patient a transfer for expert consultation?
(see I can play "what if" too )

But could I just inquire?

If you use CT as a replacement for physical exam instead of as an adjunct to it, what do you need a doctor for?

Everytime I try to debate the merits of a practice, particularly here, it always seems to degrade to the threat of legal action.

Adopting a "defensive medicine" strategy is not evidence based, good judgement, or good medicine. It is simply outrageously expensive and for the benefit of the provider not the patient.

I also am very entertained by the envoking of EBM. Especially since most often it is just a poor attempt to justify expense.

Could I ask you?

With all of the EBM "supporting" current US emergency practice, why are costs and extensive diagnositcs such a problem?

Why bother practicing in a place where medicine is based on fear?

With all the places around the globe looking for doctors, why not just skip the life of fear and take the show on the road?

I am sure if the US lost a significant percentage of its physician pool some serious effort would be made to control the legal problems?

Either that or it would train more mid-level providers at a lower cost and they could just follow the protocol anyway.

I get it, you will perform the scan before transfer because that is what you do. But your argument as to why it is a good practice comes down to fear of legal action.

Does that automatically make it good patient care?

Why bother having stroke centers if it is not the destination of choice prior to a CT scan?

 

[FLdoc2011]

Next scan or within the hour if a CT is not immediately available is generally practiced everywhere except the US military. (been there seen that)

But I still doubt the utility of a scan in a facility that is not going to treat what it finds.

Again, because even though they might not be able to surgically treat a bleed, they might be able start medical therapy (mannitol, 3%NS, hyperventilation, etc..) AND they need to know what they are treating. A doc is not to give one of those therapies without knowing what is actually going on or based purely on exam if they don't have to.

And again, another example is that we don't do OB, so a young female preggo walks in with pelvic pain she's getting that ultrasound even though we're may not be able to treat what we find. But the OB facility down the street is not going to take her unless there's a reason for them to.

The "what if" game is not really impressive. "What if you have no changes on a scan but still symptoms?" Would you deny that patient a transfer for expert consultation?
(see I can play "what if" too )

No changes on scan but still symptoms? Well then my differential and management change. See, I get the CT (early/immediate CT scan is recommended in the guidelines as above) because it changes my management of the patient. That's the general rule in medicine in regards to any test. If it made no difference then why get it. So a neg scan and still highly suspect a bleed then I would do an LP or change my differential to include some other mimics of stroke and change my workup accordingly.

If there's no neurosurgical issue then yes, I would not transfer. I mean you'd still probably get Neurology to see them and if I have neurology available in house then I can NOT transfer the pt just to receive the same level of care. And if I called another receiving facility asking to transfer they are going to ask why do you want neurosurg if your scan is negative and the LP is negative...... At that point I have ruled out a bleed.

But could I just inquire?

If you use CT as a replacement for physical exam instead of as an adjunct to it, what do you need a doctor for?

I never said a replacement for physical exam. When physical exam or a simpler test comes close to the sensitivity/specificity to CT for detecting a bleed then I'll reconsider and I'm sure recommendations will change at that point. In medicine we go by evidence and what test is going to give me the highest yield and change how I manage this patient. I'm certainly not forgetting about physical exam, it's just that I have a relatively cheap, quick, and relatively safe test that I can perform that will give me the answer.

Everytime I try to debate the merits of a practice, particularly here, it always seems to degrade to the threat of legal action.

Adopting a "defensive medicine" strategy is not evidence based, good judgement, or good medicine. It is simply outrageously expensive and for the benefit of the provider not the patient.

CT scan is not "outrageously" expensive, in fact I would argue it compares well if it take into account the money/time/use of resources involved in transferring someone who didn't need to be transferred, especially if you end of flying them somewhere.

You can't practice medicine without considering the legal aspect. In this case it isn't ordering a low yield test as a CYA defensive move (which happens a lot with other things), because this is the standard of care. If I DON'T get the scan I am not practicing standard care medicine and then I'm certainly open to legal issues.

This isn't defensive medicine, it's the standard of care as we've already pointed out in the guidelines (UK's own stroke initiative as well).

Could I ask you?

With all of the EBM "supporting" current US emergency practice, why are costs and extensive diagnositcs such a problem?

Well, some would argue a huge part again is the legal environment and EMTALA, which mandates that a pt needs to have a medical screen for emergent conditions. So someone comes in with Chest Pain they are going to be worked up and admitted if necessary because you bet that if they discharged saying it was just GERD, and have an MI when they get home they are going to sue.
So clinically you may not suspect an MI, but are you willing to bet your career/financial stability on that call and that it's not just an atypical presentation?
That's why we risk stratify pts and use that as a guide for certain workups.

In our case with the bleed if there's high suspicion or pt is at high risk of one then the CT is going to be the next step.

Why bother practicing in a place where medicine is based on fear?

With all the places around the globe looking for doctors, why not just skip the life of fear and take the show on the road?

I am sure if the US lost a significant percentage of its physician pool some serious effort would be made to control the legal problems?

Unfortunately that may happen. The US is still an attractive place to practice, not everyone wants to jump overseas quite yet.

I get it, you will perform the scan before transfer because that is what you do. But your argument as to why it is a good practice comes down to fear of legal action.

Does that automatically make it good patient care?

My argument again is not that it's due to fear in this specific instance, the argument is that it's the current standard of practice and the test of choice. So when I order the test of choice needed to potentially diagnosis a life threatening condition and decide on treatment/disposition THAT is good patient care.

Again, ask your EM colleagues which imaging test they immediately get if a pt presented with symptoms concerning for a head bleed.... AND also ask what their differential diagnosis is and what other conditions they are trying to rule out with that imaging test.

Why bother having stroke centers if it is not the destination of choice prior to a CT scan?[/QUOTE]

 

[Veneficus]

Again, because even though they might not be able to surgically treat a bleed, they might be able start medical therapy (mannitol, 3%NS, hyperventilation, etc..) AND they need to know what they are treating. A doc is not to give one of those therapies without knowing what is actually going on or based purely on exam if they don't have to.

Funny that, I have seen it during clinically apparent injuries. On both sides of the pond. In a level I trauma center. At the direction of a neurosurgeon. Prior to a CT so it would be working while in CT.

Perhaps he was not practicing to the standard of care?

And again, another example is that we don't do OB, so a young female preggo walks in with pelvic pain she's getting that ultrasound even though we're may not be able to treat what we find. But the OB facility down the street is not going to take her unless there's a reason for them to..

You mean being pregnant with pelvic pain and not at an OB center is not enough?

That sounds like you are just trying to gouge money from somebody.

CT scan is not "outrageously" expensive, in fact I would argue it compares well if it take into account the money/time/use of resources involved in transferring someone who didn't need to be transferred, especially if you end of flying them somewhere.

I think you should really reconsider what you call expensive.

I must say, you have an interesting arguing style, I have seen it here before. Do I know you?

You can't practice medicine without considering the legal aspect. In this case it isn't ordering a low yield test as a CYA defensive move (which happens a lot with other things), because this is the standard of care. If I DON'T get the scan I am not practicing standard care medicine and then I'm certainly open to legal issues.

This is another rather interesting statement. Most, if not all of the physicians I know generally work with doing the right thing and legal issues second.

You seem to have a preoccupation with this and EMTLA, with a rather interesting interpretation of it compared to what I have read.

This isn't defensive medicine, it's the standard of care as we've already pointed out in the guidelines (UK's own stroke initiative as well).

Nobody disputed that a CT was in order. If I recall correctly the original argument, we were talking about a patient with a suspected bleed? No wild zebra pathology.

Well, some would argue a huge part again is the legal environment and EMTALA, which mandates that a pt needs to have a medical screen for emergent conditions. So someone comes in with Chest Pain they are going to be worked up and admitted if necessary because you bet that if they discharged saying it was just GERD, and have an MI when they get home they are going to sue.
So clinically you may not suspect an MI, but are you willing to bet your career/financial stability on that call and that it's not just an atypical presentation?

Do we admit every person complaining of chest pain for OBS?

Do we not admit people to GI anymore?

This is a strange exampe and argument to me. Not everyone who complains of chest pain gets admitted.

Are you a medical doctor?

Unfortunately that may happen. The US is still an attractive place to practice, not everyone wants to jump overseas quite yet.

:rofl:

Yea, because everyone knows that the pay is not proportional to results or effectiveness.

Again, ask your EM colleagues which imaging test they immediately get if a pt presented with symptoms concerning for a head bleed.... AND also ask what their differential diagnosis is and what other conditions they are trying to rule out with that imaging test.

Why?

I have a fair idea of what they are myself. I have also many times that a CT was in order.

I again state, that in a suspected head bleed, like any other surgical emergency that was not potentially treatable where I was, I would start to move that patient prior to getting bogged down in diagnostics. Based soley on clinical findings and suspicion.

That is the whole point of escalating care. It is why people like ACS put out classes on not fooling around trying to treat something you are not capable of.

It is why a level III trauma center will send a patient to a level I. It is why a non cardiac facility will send a patient to a cardiac facility.

I have to ask. Exactly what kind of medicine do you practice where you must provide definitive and undisputed evidence the patient is over your head before you send them to somebody better capable?

"Yep the patient is dead now, maybe pathology will tell us if it was the bleed we suspected or not, we probably should have sent them out a bit earlier..."

Seems like a rather depressing conversation.

Rather than keep replying to this now nonsense, arguing about whether or not a CT is the standard of care in a patient with a suspected head bleed, without addressing the merits of early transfer except with zebras and legal interpretation, I am going to ask one more question...

Is this a reincarnation of ventmedic?

 

[18G]

So what happens when you suspect a head bleed (without a CT) and transfer the patient 2hrs down the road to a receiving facility that does a CT and comes to find out you were wrong and that it is not a head bleed? And the patient should have went to facility XYZ an hour closer or could have stayed where they were?

Is it possible to be 100% sure of a head bleed without a CT? A CT scan doesn't take that long and is more definitive than a physical exam is it not? So at the earliest suspicion of a head bleed, why not send the patient to CT?

If you're going to transfer a patient out shouldn't you be as sure as possible what the diagnosis is by using all the available tools at your disposal?

You don't get a prize for using physical exam alone do you? Or is it more of a "chest out, I'm that good" mentality that makes you argue against CT prior to transfer?

I can remember when I hurt my leg in elementary school and the doctor in the ED was dead set based on his exam that my leg wasn't broken. My mother was very insistent on an x-ray and the doc even got kinda smart with her. But he ordered the x-ray and guess what, I was in a cast for six weeks.

Technology is a great thing... why not use it and let it paint the picture of what the problem is?

 

[MS Medic]

You don't get a prize for using physical exam alone do you? Or is it more of a "chest out, I'm that good" mentality that makes you argue against CT prior to transfer?

This is a hit the nail on the head moment. Why would someone with MD training spend so much time on an EMS forum telling everyone why they are wrong rather than on a forum with peers where there can be higher level discussions.

 

[Pavehawk]

"Yep the patient is dead now, maybe pathology will tell us if it was the bleed we suspected or not, we probably should have sent them out a bit earlier..."

Seems like a rather depressing conversation.

Unless you're the pathologist... My cousin (a pathologist) likes to call it job security.

Remember, an internist knows everything and does nothing... A surgeon knows nothing and does everything... a pathologist knows it all and does it all... three days too late :rofl:

 

[Veneficus]

This is a hit the nail on the head moment. Why would someone with MD training spend so much time on an EMS forum telling everyone why they are wrong rather than on a forum with peers where there can be higher level discussions.

I don't see it as a chest out kind of thing, I see it as a "how much evidence do you need and how much fooling around are you planning on doing sort of thing."

As the "what if's" get more complex, individual judgement comes into play.

Would you withold a CT for a patient going far away? That depends on whether or not it would delay transport.

I see it as a similar situation as a abd bleed. Would you delay transport to confirm your suspicion with a ct, ultrasound, perform a DPL if you have clinical evidence of a bleed?

For some reason I don't think so.

Why would you treat any other surgical emergency any different?

If you have to wait 30 minutes for a transport, why not CT?

If you suspect herniation based on physical findings, would a ct really change anything?

Again I don't think so. At that point you probably need definitive action.

But at the same time, why would you sit on a patient when doagnositcs could take equal or longer than a transport and if you find something on your CT but can't help, what is the point of that?

Puff out your chest and say " I knew it now I can show the world?"

If you go way back to the original post, one of the questions I asked was, why go to a local facility to transport again.

I reiterated that position with several similar situations.

The answers I got was:

Because of an interpretation of a law

Because we CT everyone no matter what

What if X,Y,Z that had nothing to do with the scenario at hand.

Along with an almost OCD argument boardering on schitzophrenic features constantly going back to something I agreed with several times.

Why do I hang out here?

Stress relief mostly. I spend all day in high level discussion, usually involving patients where convential treatment is not working or has already failed.

When I am not doing that I am finding new solutions to rather old an complex problems.

It is nice to spend some time hanging out with EMS people.

I'd like to think I can give something back or offer a different perspective.

I am not without my passions though and do enjoy a spirited argument.

If it is that disruptive, I am sure I could go spend some time with a videogame just as easily.

 

[MS Medic]

The discussion between you FL Doc turned into something completely off topic from the OP. Seeing how we don't have CTs in the ambulance, I don't have any interest in that discussion but I'm still going to call it like I see it and you and I will have to agree to disagree.