Questioning the Utility of the ER Pelvic Exam

I hate doing pelvic exams because in the ER setting, they are:

1) time consuming
2) labor-intensive (requiring an assistant)
3) low yield

Women commonly require pelvic examinations in the ER for three reasons: bleeding, discharge, and pelvic pain. It's rare that the pelvic exam findings change my management. Occasionally the woman with vaginal discharge will have an unsuspected retained tampon. Usually, they know.

Every woman who complains of heavy periods comes in saying she's bleeding A LOT; maybe one in 20 really are. The sensitivity and specificity of diagnosing anything from a bimanual exam are not much better than flipping a coin.

If we think she has ovarian torsion or if she is pregnant with bleeding/pain, she gets an ultrasound automatically. If we think she might have appendicitis, we're going to order a CT scan anyway. If we think she has PID, we're going to empirically treat with antibiotics. Endometriosis? Who cares.

We don't get the STD panel back before the patient leaves the department; it takes a couple of days. The wet prep could be made obsolete by just adding Flagyl and Diflucan to the standard STD cocktail. Probably some of us do that already.

With vaginal bleeding all we really need are the CBC, urine pregnancy test, and maybe orthostatic vital signs. If the patient isn't going to be transfused, the ER treatment is the same: it's megahormones or nothing.

For such a useless procedure, there is an unreasonable amount of emphasis placed on its performance by our consultants, probably a vestigial remnant from the olden days when CT scans, ultrasounds, and antibiotics were not as powerful or widely available. Don't get me wrong, I still do pelvic exams as often as historically indicated. But it's sort of like checking the control on a hemoccult slide. Yeah, we're supposed to do it and document it thoroughly. But how often does it really matter?

Medical Student Tips - Using the Speculum

This started out as as reply to Graham's post, but as I got into it, I decided to make it a post of my own, and perhaps a series.

My most important tips for using the vaginal speculum:

• The patient's buttocks need to be extending a couple of inches beyond the end of the stretcher (particularly if the uterus is anteverted), otherwise you might not be able to maneuver the speculum into the proper angle to see the cervix. If it looks like they might not be scooted down far enough, then they aren't scooted down far enough. You can always have them scoot down more after you realize your mistake, but it's better to just position them properly before you begin.

• The patient has to be relaxed. If she's all tensed up and adducting her thighs, you shouldn't just try to force your way in. You've got to make her relax first. Act relaxed yourself, using gentle tones. Tell her to take a deep breath or two and let it out slowly. Take your time. Reassure her. If you can't gently separate her knees, she's not relaxed enough.

• Touch the inner thigh with your non-speculum hand before you touch the genital area, and tell her your intentions before you proceed. Don't just dive right in. A female instructor once asked me many years ago, "how would you like it if you were in that position and I just came up and grabbed your balls?" Hmmmm.

• You can push downward on the speculum with considerable force without causing unreasonable discomfort, but stay the heck away from the urethra. All the pressure should be directed inferiorly as you insert the speculum. I use my index finger to press down firmly on the inferior blade as I slide the speculum in. Torquing on the urethra with the speculum is as much of a no-no as using the upper incisors as a fulcrum for the laryngoscope. Just don't do it.

• You must find the cervix. If you don't, you're a failure.
  Just kidding....sometimes it's not so easy. But don't give up, practice makes perfect.

EMT Snark

If my patients or colleagues knew what I was like when I was 18, they would run away in horror. Emily's off to a better start.

Ways to suck the life out of your EMT.

My favorites:

"If you’re a patient...

Call the ambulance. Meet us at the curb. Ask to ride in the front seat.

If you’re a nurse...

Ignore us when we bring you a patient. Especially if we’re EXTREMELY busy... Especially if you’re just sitting there having a cup of coffee…I know we all need coffee breaks, but A) you’ve only been on shift since 0700, it’s only 0830…I’ve been on since 1500 yesterday, haven’t slept since who knows when and I have puke on my pants from a toddler…a toddler who arrested in my rig…yea, quit your bitching, get your ass out of the chair and come get this patient report so we can go back on the streets."

Lizard of the Day

Where Did It Go?

Like a lost sock in the washing machine, some objects seem to defy the laws of physics as we understand them.

Some examples are the retained tampon or sex toy, the persistently perceived contact lens or corneal foreign body, the dreaded fish bone in the throat, and the mystery pebble or insect in the ear or nose. Something unnatural is in one of their orifices and they want it out. And yet occasionally the object is nowhere to be found.

How long do you look? Is it worth a referral, and if so, how urgently? Perhaps I didn't look closely enough, so I'll have another look. Nope, it's still not there.

"How can that be?" the agitated patient may ask. "Where did it go?"

Some mysteries are simply unexplainable by the laws of nature. That's when I turn to the cartoon laws of physics.

Or perhaps we should review some of the ER Laws of Physics:

1) Following equivalent applications of force, the more intoxicated patient will suffer fewer injuries.

2) Given two patients with a headache, the nicer one will always have the brain tumor.

3) A disheveled patient can easily walk 5 miles to the Emergency Department for a dressing change and a refill on his vicodin, but he will need a cab voucher to get home.

4) One dood is never sufficient to overpower a given intoxicated male, but two doods are more than enough.

5) The mere act of bringing a feverish, fussy, vomiting toddler to the ER is often enough to transform them into a smiling, happy, juice-guzzling, cookie-eating cutie-pie. Want a sticker?

6) The time it takes to be seen in the ER is inversely proportional to the actual severity of illness. But the perceived time is exponentially so.

7) The likelihood of finding a foreign body is completely unrelated to the certainty of the patient regarding its presence.

Got any more?

Sebaceous Cyst

This one was a whopper.

What the heck is a sebaceous cyst?

The procedure.

Dr. September

Hey, I'm 20 again! Thanks for including me in your fun series, MedBlog Addict.

Andrew Meyer Should Have Watched This

Language Warning.



Come to think of it, he probably should have watched this too.

The Black Knight Lives

Totally freaking amazing.

"Come on, you pansy!"

Mystery Illness From Outer Space

September 17, 2007:

Villagers in southern Peru were struck by a mysterious illness after a meteorite made a fiery crash to Earth in their area, regional authorities said Monday.

Residents complained of headaches and vomiting brought on by a "strange odor," local health department official Jorge Lopez told Peruvian radio RPP.

Seven policemen who went to check on the reports also became ill and had to be given oxygen before being hospitalized, Lopez said.

Rescue teams and experts were dispatched to the scene, where the meteorite left a 100-foot-wide (30-meter-wide) and 20-foot-deep (six-meter-deep) crater, said local official Marco Limache.

"Boiling water started coming out of the crater and particles of rock and cinders were found nearby. Residents are very concerned," he said.
____________________________________________________

So are these symptoms due to radiation sickness, noxious fumes, hysteria, or something far far worse?

DEVELOPING

Most Blatant Drug-Seeker Ever

Our award-winner presented with a chronic condition that admittedly had the potential to be painful. With the right story, he might have scored some decent narcs. Unfortunately, he lacked that certain finesse that his more expert colleagues have polished to a glistened luster.

So after we had ruled out the potentially life-threatening conditions that his presentation mimicked, it was time for the all-important disposition. Since I'm the friendly sort of ER doc that typically makes my patients as comfortable as a kitten curled up on the end of the bed on a quiet sunny morning, I suppose I gave him the wrong impression. After I wheeled him to the bathroom myself, he eagerly pushed his entire stack of chips forward and went all-in. He whispered:

"Say, doc...can you write me for 90 Somas and some Xanax? And what's the name of those little white pills, I forget their street name. Damn. Oh, well...how about some of that cough syrup too. Phenergan with codeine."

Sorry dude. You busted.

Baby Face, MD

Ten out of Ten has a great post about the drawbacks of being a young physician (or at least looking like one). I used to get irritated with those sorts of patient comments too, but after about the thousandth time I guess I got used to it.

"How long have you been a doctor?"
- "Hmmmm.... about 6 weeks now."

"You don't look old enough to be a doctor."
- "It's just good clean living, ma'am."

"Have you done this before?"
- "Well, I've seen it done a couple of times. Just bear with me."

"Where did you go to medical school?"
- "Aruba. Those American schools are WAY too competitive."

"What's your specialty going to be?"
- "This is my specialty. Fixing people."

Where's Platy?

March of the Platypi, one of my favorite ER nursing blogs, seems to have disappeared. I hope we haven't lost another blogger.

Do You Ever Admit Migraine Patients?

In which Scalpel again pokes the anthill.
(and borrows Panda Bear's A.A. Milne literary device)



After perusing the migraine forums and considering my recollection of previous discussions with former blogger and migraineur Carrie (NeoNurseChic), I have come across several reports that one of the currently-utilized treatments for migraine is to admit such a patient to the hospital for several days to administer various IV therapies.

Now I'm aware that some of the Major Headache Centers do this, probably with the assistance of some sort of government or pharmaceutical company funded research protocols. But looking back on my career, I can only recall ever admitting one migraineur to the hospital. And I remember that at the time, I was quite surprised that the Neurologist wanted to pursue that option. Furthermore, that case was about 8 years ago.

Now I'm going to exclude anyone with intractable vomiting or neurologic deficit, because those are indications for admission on their own merits. And I understand that the migraine literature states that "status migrainus" or unrelieved headache is an indication to admit.

I just have never failed to relieve the headache of such a patient in the ER. It might take two (or rarely three) rounds of medication, but they always leave satisfied and pain free. As long as they agreed to my terms, that is. Maybe I'll talk more about that later.

I suspect that at least some of the Headache Specialists (to whom altars are likely constructed in darkened bedrooms all over the world) typically practice in spa-like facilities with plush bathrobes, soothing background music, and scent-free candles. And I also suspect that some of them are only too happy to swipe the credit cards of desperate migraineurs but decline insurance reimbursement.

I wonder if insurance would even pay for a 7-30 day migraine hospitalization, as I have read often occurs at these sorts of specialized facilities. Heck, most hospitals discharge patients the day after giving birth and a few days after a heart bypass nowadays. I can't even imagine keeping a patient with a headache in the hospital for a month. Even if it was the sort of REALLY BAD headache that MIGRAINE SUFFERERS get.

Now, judging by my recent experience, I'm certain that the angry mob of hand-wringing migraineurs will wave these comments around like a burning effigy of George W. Bush at a Code Pink rally as evidence of my incompetence and obvious need to "educate myself about migraines." Well, I'm trying. Give me credit for that.

So I humbly ask my fellow physicians and nurses....how often do you admit patients with migraines who can tolerate water by mouth and have no neurologic deficits? To a regular hospital, that is.

Speaking for myself, my N=1.

Multitasking (and why migraine patients wait)

At any given moment during the typical shift in the ER, here is what is happening:

• There are 10-20 patients in the waiting room. Some have been waiting 6 hours. A couple of them have ankle sprains and were already X-rayed, and their X-rays were already read by the Radiologist as "no bony abnormality, soft tissue swelling." They would like to leave without being seen. We don't argue too much.


• I'm waiting on a callback from a specialist, and I have two more calls to make after that one. If I paged them all at once, they would all call back at the same time, then two of them would hang up before I was finished talking with the first one. They would be understandably angry when they were repaged, and they would take an hour to call back the second time. So I page them one at a time. As soon as I introduce myself to the next patient I see, the first one will call back.
  


• I have one patient in the CT scanner and two more patients drinking contrast waiting their turn to get scanned. One of them just vomited, and will need some more antiemetic (and some more contrast). The other one wants more pain medication. One of these will need to be admitted for surgery, another will need to be admitted for IV antibiotics, and the other can be discharged after several hours of medical management and serial evaluations in the ER.
  


• I'm waiting on the Radiologist to interpret the head CT scan and X-rays of the lady that passed out and fell down the stairs. I need to see her blood tests too, but the lab is taking longer than normal. I still need to suture her lacerated lip and eyebrow.
  


• I have a dialysis patient who has missed his last couple of dialysis treatments, preferring to go to the crack house instead. His blood pressure is dangerously elevated, he has chest pain, his lungs are full of fluid, and his potassium is dangerously high. It initially appeared that he might need to be intubated, but after 20 minutes of aggressive medical management he is starting to breathe a bit easier. There are no ICU beds available, so he requires a nurse to give one-on-one care until he is stabilized.
  


• There is a homeless patient who is "suicidal" after running out of money to buy crack who is taking up an ER room (and a tech to act as a sitter) while waiting for his transfer to the first Psychiatric facility that will take him. No facility will accept him during my shift, and he will be turned over to the next doctor in the morning.


• One elderly patient with chest pain and known coronary disease is waiting to be admitted to a telemetry bed, and a nurse is standing behind me (as I am charting on someone else) asking me for a Tylenol order because he has a nitro headache, and by the way, his blood pressure is still high. Two other new patients with chest pain are still waiting to be seen. I need to look at their medical records to see what their last cardiac admissions revealed, and to see who admitted them the last time. The tech is standing next to me waiting to show me their ECGs.
  


• I can hear a toddler screaming with a fever of 103 and (hopefully) an ear infection. I would love to see him quickly and get him out of the ER ASAP, but I have to pop in to see the new chest painers first. His nurse is taking care of the dialysis patient, so the kid still hasn't gotten the Motrin I ordered half an hour ago. His father is standing angrily at the door with arms crossed, glaring at all who pass by.
  


• EMS just brought in a drunk guy on a backboard who is now in the hallway because there are no rooms to put him in. He's cursing and trying to take off his cervical collar. I'm going to have to quickly look him over before I see the two chest painers. But he will have to wait a minute, because...
  


• EMS is transferring a frail nursing home resident with fever and mental status changes onto our stretcher. Her mouth is open, her tongue is as dry as the Sahara, dried feces is caked on her legs and fingernails, and she smells strongly of urine. She doesn't speak, staring blankly at the ceiling. Her blood pressure is low, and she is pale. No family is present, and she has never been to our facility before. She usually goes to Big City Hospital, but they are on drive-by. I wonder for a second why we aren't, then I remember that we are. It doesn't matter. She's our patient now.
  


• A patient who was admitted by the doctor I replaced is waiting on an inpatient bed, and her family keeps coming up to the nurses' station to ask for an extra pillow, a cup of ice, somebody to come help them lower the head of the bed, and the all-important "how much longer?" Oh, and the IV machine is beeping again. All the nurses are taking care of other patients, and since I am stuck at the desk charting, I am the default question-answerer. I tell them I'll ask their nurse to come in as soon as I can, but I am quickly sidetracked with other concerns and never do so.


• A migraine patient was brought into her darkened room 30 minutes ago, not because she was necessarily the most acute patient in the waiting room, but because she had already been waiting for 6 hours. Her concerned mother had been pestering the triage nurse relentlessly. Mom is standing in line behind the other people who are asking me questions, ready to ask me "How much longer? She's really hurting." This is her tenth ER visit this year for the same complaint.
  

All this chaos, and I'm just sitting at the desk, playing on the computer.

Migraine Rantings

ERnursey was kind enough to allow me to hijack the comments to her excellent post about patient satisfaction scores (which evolved into a raucous discussion about the treatment of migraine patients in the ER), and then she came up with another brilliant post which explains how to tell the difference between a "migraine" patient and a patient with a migraine.

Good stuff.

Thank you ma'am. Sorry for the detour.

Angel Dust

So it was a busy weekend night at 5 am, and our Generation Y patient was concerned. Muscle aches, numbness, incoordination, difficulty speaking properly.

"Did you hear that? I don't usually talk like that."

MmmmK.

Although these problems had been going on for over a month, word on the street was that Dr. Scalpel was working that night, and my shift was almost over. Good thing you came in when you did, my wild-eyed friend. You almost missed me.

The first and perhaps most important part of the physical examination is simple observation, and I couldn't help but notice that your affect fluctuated rapidly between fearful, agitated, overfriendly, and inappropriate laughter. And the rest of your exam was really pretty normal.

Your drug screen, of course, was not. But you knew that already.

"Dude, it ain't that. I think there is something really wrong with me."

Yes there is. Now go fix it.

Animals in the ER

I've been around the block a few times, and I thought I'd seen it all.

Until the patient walked into the ER carrying both a small dog and a parrot, that is.

Service dogs are nothing new, yet they are still uncommon enough to raise an eyebrow (and a smile).

But a service parrot? Interestingly, there is such a thing.

Attention 911 doc.....king me!

The Best New ER Blog

That I have seen in quite a while is over at White Coat Rants.

Great stories and storytelling, side-splitting humor, and just the right amount of snark. My favorite examples are the Chinese pager torture and the anxiety disorder of Mr. Wayne.

Welcome to the medblogosphere, and keep up the good work!

h/t ERNursey

Karma is Painful (but funny)

Reporter who mocked President Bush for falling off a Segway tests the karmic waters, and breaks three ribs in the process.

May he heal quickly.

via Ace.

Socialism or Fascism?

John Edwards' universal health care proposal would require that Americans go to the doctor for preventive care.

"If you are going to be in the system, you can't choose not to go to the doctor for 20 years. You have to go in and be checked and make sure that you are OK."

He noted, for example, that women would be required to have regular mammograms in an effort to find and treat "the first trace of problem."

Sieg Heil!