OK, time for a round of "Are You Smarter Than the ER Attending?"
A guy has right shoulder surgery and immediately afterward, he gets a right shoulder nerve block for post-op pain management. He presents to the ER 12 hours later (at 3AM) with complaints of continued decreased sensation in his right arm. He denies any shortness of breath/chest pain/headache. He is still able to move his right arm but it is weaker than his left. Do you:
A. Order a head CT
B. Order a neck CT
C. Consult the ortho resident to rule out compartment syndrome
D. Ask the ortho resident to admit the patient for observation
E. All of the above
If your answer was F--reassure the guy that this is what is supposed to happen when you get a nerve block--then congrats, you are smarter than the ER attending. You are also equally smart to my sister, who was able to get the answer even before she heard all the options. You are also equally smart to the patient, who correctly predicted that was what was going on but just wanted to make sure because he didn't realize it was going to last that long. I don't fault him for going to the ER, although I think he probably just could have called the surgeon or the anesthesiologist and gotten an answer as well as decreased radiation exposure.
I would say the two hardest parts of that consult were dragging my butt out of bed and down to the hospital at 3AM and trying to explain to the ER doc that this was totally normal and I didn't need to bring the guy back to the OR for some sort of nerve exploration. Finally I said to him, "you know, we see this every now and then. Patients have nerve blocks and then they come back to the ER because they're surprised it lasted as long as it did."
My ortho attending thought it was kind of funny, but he wasn't the one who had to deal with it at an unG-dly hour of the morning.
Go go modern medicine.
In the ER doc's defense, he has to CYA. Suing someone to fund your retirement is a way of life here. It's his ass on the line, and if he missed something there are plenty of docs who'd testify against him (for cash) that he'd been negligent in not working the patient up further. No matter how obvious the real answer might be.ReplyDelete
Could the guy really have called his surgeon / anesthesiologist at 3 in the morning? Yes, he could have waited another couple of hours but it's totally understandable that he's freaking out and wants some attention stat.ReplyDelete
I understand Grumpy Doc's point, though I think it's a stretch in this case. Anonymous makes a very good point about your options at 3 a.m. ... I would like to point out another villain - the doctor/nurses involved in giving the nerve block to begin with. As a newbie to this whole medical profession it still floors me that we don't give clear written and verbal explanations of what to expect over time and when to go to the ER for an unlikely side effect. I realize sometimes some of us do. But most really don't. Verbal instructions are given quickly with a lot of shorthand. When written instructions are given they are long, wordy and full of jargon - and mostly written instructions are NOT given. And when people are under stress - like about to get a needle put into their body because they are already in great pain - they can't focus/retain information very well anyway. I have left appointments/procedures pretty confused about my instructions - and that is with years of medical education. So I'd just like to raise the possibility that it was the duty of the medical team giving the nerve block to give this patient realistic expectations about what he would experience.ReplyDelete
Once you've been sued - even if you won - it changes your entire view of this job. You've been threatened with the loss of everything you've ever worked for and your livelihood. After that you'll order whatever tests are needed to cover yourself, regardless of how silly they seem. When I was in training we used to make fun of the ER docs for similar shit. Now that I've been sued I understand, and do the same.ReplyDelete
Don't blame the ER doc. What's stupid is a system that makes us practice defensive medicine to this extreme, and a culture where patients often see the slightest medical error as the Golden Ticket.
Well said doctor G!Delete
Had a similar situation but with an 85 yo who had vertebroplasty. Still high from the surgery, the pt was going on and on about how the pain just disappeared, how much better he felt, blah blah. Of course we thought "oh crap, he thinks all his suffering is over". Naturally about 2 hours later when some of the anesthetic effects wore off, his tune changed to "I never should have had this done, you made this worse, I hate this hospital" etc. um...you just had major surgery! Did you really expect it to be pain-free?ReplyDelete
On another note, when are you getting your own blog? :)
Now this is pretty unfair to the ER doc. As an ER doc of 10 years, who has never seen a patient 12 hours after regional nerve block, I would have no idea whether it was normal or not. I absolutely would have woken up his surgeon/anesthesiologist/whoever is on call to weigh in. Even if I google the longest acting local anesthetics I can think of and reassure my self that yes it probably is OK, no way I am letting him go without the ortho consult. And I fall on far on the "minimal testing, high risk acceptance" end of the EM practice spectrum.ReplyDelete
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It's also worth pointing out that while an extended nerve block is probably what's going on here, that is certainly not the only possibility. I don't know whether the ERP in this case was thinking about nerve injury secondary to mal-positioning in the OR. As you know, shoulder surgeries are often done in the "beach-chair" position, but then they might be done in lateral decubitus position too. All of these predispose toward peripheral nerve injury, from cervical radiculopathy to brachial plexopathy.ReplyDelete
I wouldn't have done a head CT or considered compartment syndrome very likely, but neck imaging wasn't necessarily unwarranted.
I can count on one hand the number of times the ED doc calls and the Ortho or anaesthesia doc answers with "sure, I'll be right over." What I normally get (esp. from the ortho docs) is 'what did the films show' and 'just send them to my clinic tomorrow' - neither of which are appropriate in this case.ReplyDelete
And extended anaesthesia DOES happen... but it isn't common and the standard of care the ED doc is held to is quite different that that of the surgeon who just saw the patient: every patient is new, every patient is assumed to have really bad disease until proven otherwise.
I'd say I'm sorry you had to be out of bed at 0300... but I'm not. Part of residency is learning to make good decisions when you're dog-tired and when there is good backup to help you make those decision - cause it certainly isn't there when you graduate. This patient was a learning experience for you: you certainly learned something... and you certainly have a good deal more to learn.
Perhaps if you'd considered the possibility of explaining the procedure and its possible (probable?) late effect, you wouldn't have been woken up at 3 am. I'm terribly sorry, but I'd very much indeed do the same thing as the ER doc in question. I neither do regular shoulder nerve blocks post-op, nor do I provide followup for surgical patients - simply not what I was trained to do. I also haven't the slightest of what the usual, let alone unusual complications of shoulder surgery might present as. And, yes - I can look it up, but it doesn't exclude the uncertainty of a diagnosis, so why would you expect a d/c+reassurance when even I can't rest assured?ReplyDelete
For the record, I have known Dr. Orthochick a long time, and she is just about the most kind, caring orthopedic surgeon you'll ever meet. She works her ass off and really does her best for patients. I'm lucky enough to be privy to her private journal and I know in detail what she goes through. She's going to be an amazing doctor.ReplyDelete
I feel a need to clarify her response, which was not that she should not have been called at all, I think, but that ordering head and neck CTs and being pressured to admit the patient was not the right thing to do. I don't think she minded having to explain the situation to the patient or ER doc (she said that the patient could've called the surgeon instead). Just that too much work up was done.
But if you don't mind paying $3000 every time a patient anesthesia lasts as long as it's supposed to, hey, fine by me.
I agree that too much workup was probably done, but I don't think that invalidates the consult itself. As a resident from a service which does only in-house call, I'm not unfamiliar with getting a simple but annoying 3am call. But it certainly could have been something other than a long-acting nerve block, as I mentioned above, and no matter how much residents end up complaining about "bad" or "stupid" emerg docs, they don't have the luxury of being able to assume the most benign process.ReplyDelete
Exactly as JG said. In Emergency Medicine, you're trained to assume the worst and work backwards - that's how we catch atypical presentations of deadly diseases, which we do quite often. It's easy to assume the most common or benign diagnosis -- and it's of course easy to know more than the ER doc about your OWN specialty-- but very tough to blow off a presentation as benign when you have no personal experience to draw from (e.g never having seen a post-op patient with a shoulder nerve block 12 hours after surgery).ReplyDelete
An ER attending
Doesn't it make sense though to call the orthopedic surgery consult before doing a million-dollar workup?Delete
Sure, but that does not make me smart. This, apparently, does - ''F--reassure the guy that this is what is supposed to happen when you get a nerve block'' Then congrats - ''you are [a] smart[er than the] ER attending''.Delete
Another ER attending.
You're right. Calling ortho is definitely warranted. But the million-dollar workup wasn't.Delete
So if you actually think it's something bad (stroke, etc) then why call an ortho consult first? It's not like ortho knows how to treat strokes.Delete
If you truly believe that based on other evidence, fine. But if the orthopedic surgery resident tells you that the anesthesia is lasting exactly as long as it supposed to and this is expected, why get further work up? Anyway, since you would have no idea when the stroke started, you wouldn't be able to treat the stroke with tpa anyway, so a watch and wait approach is appropriate if you're pretty sure that this is just an effect from anesthesia.Delete
If the ortho resident is willing to put their signature on it - by all means no further workup.Delete
Name 5 ortho docs in the country who will see an ortho patient without films being done.Delete
Well, presumably if it's a patient they just saw earlier that day and know well, I doubt they would ask for films. I mean, if a patient on the Ortho service is having a fever, they don't make the nurse get an x-ray before they go see the patient. I think it's understandable if it's a new consult though.Delete
Right, they wouldn't ask for an x-ray if there was a fever. They would ask for a FP/IM/ID consult.Delete
Agree with Grumpy it's very easy to play monday morning quarter back. I'm ER doctor for 4 yrs now and from my experience in academic medicine if you don't have a shoulder film / ESR / CRP plus excluding everything else I've had to fight ortho residents in middle of the night who refuse to negotiate or see the pt until those are done. But either way in the ER you are damned if you do as the over tester and if you don't ie the stupid ER doc who didn't get the one test i care about as a subspecialist. At the end of the day you have to protect yourself and your patients. The other possibility is consulting the orthopod who has to see the pt and have formal consult note describing they think nothing further is required and have it staffed with their attending and that is the third ideal option which rarely happens for aforementioned reasons Dr. DReplyDelete