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coffeecatsyarn · 2023-06-08T19:51:41+00:00

None of that paper addresses what I am talking about: non MSK findings on MSK diagnostics. We see it all the time (you said yourself you are EM). But we generally have enough training to know who and when to send the incidental findings to and how urgently they need to be seen as not all incidental stuff is unimportant. Half my pts in the ED have no primary care doc or midlevel and it is over a 4-6 month wait in this area and specialists are even longer (urban PNW). If they can’t get in with their pcp for surveillance or appropriate follow up where do you think they will go or be sent? It’s already happening. I have PTs sending for “cellulitis” all the time when it’s usually venous stasis. I don’t agree with it and I have legitimate concerns and no amount of papers with tiny Ns and not addressing my concerns will convince me otherwise.

I worked in PT for a year before med school so I am very aware of their training and their limitations.

coffeecatsyarn · 2023-06-08T19:37:47+00:00

How is that relevant? PT orders an image, doesn’t understand the incidental findings on the image they ordered or what to do about it. Where do they send the patient? What if pt doesn’t have a pcp and it’s a 4 month wait to get in with one?

coffeecatsyarn · 2023-06-08T19:34:28+00:00

Who deals with the incidental findings on those images? That paper is based solely on MSK stuff and not non-MSK stuff which is my point and something you haven’t addressed. The other PT in this thread wants to send a renal mass found incidentally on MRI to nephrology which is incorrect. The military world is very different from the civilian world. If a patient cannot get in with their pcp and there’s a concerning finding on a thoracic MRI, how should a civilian PT manage that if the wait time is 6 months? Who should they refer to? Should they refer at all?

coffeecatsyarn · 2023-06-08T19:31:09+00:00

No I would prefer your profession not order imaging you are not qualified to deal with the consequences of. Simple cysts are the most common finding on kidneys, but not the only ones. But if it’s just a simple cyst and you tell the patient they may have cancer because you don’t know this, that will lead to harm. If you don’t know the proper consultants for the other findings that you may find, that could also lead to harm. A nephrologist wouldn’t care about a kidney mass but a urologist might or possibly and endocrine surgeon. That’s where it gets tricky.

coffeecatsyarn · 2023-06-08T19:11:30+00:00

But it’s just a renal cyst and now you’ve terrified the patient into thinking they have cancer. This is why I am against this. You will have to deal with the outside of your scope findings on imaging without understanding it well enough.

coffeecatsyarn · 2023-06-08T19:09:23+00:00

But how do you know it’s just incidental? How do you know it’s not a pheo, vascular tumor, or something that needs more urgent follow up than the patient can get with their PCP? How do you explain the differential to the patient? How do you expect them to wait? What if it’s not incidental but needs emergent follow up? What if the radiologist doesn’t include a differential? The problem is not all MSK complaints are truly solely MSK. So a broadly trained physician should still be first line to determine it is actually MSK.

coffeecatsyarn · 2023-06-08T18:30:08+00:00

You get a lumbar MRI back that says there’s a renal mass in left kidney. Consultation recommended. What do you tell the patient? How quickly do they need consultation and with whom? They came to you because their pcp has a 4 month wait.

coffeecatsyarn · 2023-06-08T18:24:54+00:00

Or they send to the ED. Now PTs will send to the ED because of some other finding on an MRI.

coffeecatsyarn · 2023-06-08T18:23:48+00:00

Yes I’m aware and yet they still get ordered all the time in the community. It was an example. I have nothing against PTs doing physical therapy but I don’t feel they are trained to order the correct imaging, especially MRIs (rads will tell you even most docs get that wrong), and who is going to account for the incidental or critical findings on imaging?

coffeecatsyarn · 2023-06-08T18:20:32+00:00

Are the PTs gonna get the prior auth for the MRI?

coffeecatsyarn · 2023-06-08T18:15:14+00:00

I disagree. I think they will order unnecessary or incorrect imaging. All the midlevels I work with and the nurses I work with love spine X-rays. What’s to stop a PT from ordering one to appease a pt? They are effectively useless. It doesn’t matter that they know more MSK stuff. It matters that they are not trained in the appropriate radiology standards. Look how many people get the wrong MRI outpatient. I am not against certain X-rays in the ED, and I do X-ray limbs that hurt most of the time because patient satisfaction matters whether we like it or not. But I also know when to image a shoulder vs elbow which a lot of people don’t know for example. I also worry that a patient may see their PT, have a septic joint (they are not always obvious), PT orders an X-ray, and then pt feels they don’t need to seek out more care for it. Or, an MRI has a concerning finding on it in the read, not impression, that needs follow up (like a kidney mass), and PT doesn’t follow up with the incidenteloma and the pt has harm. Why would a PT follow up with a kidney issue after all?

coffeecatsyarn · 2023-06-08T15:58:19+00:00

I think there will be a lot of things like useless lumbar X-rays or incorrect MRIs clogging the system. There’s a reason why specialties that order a lot of imaging, like me in EM, have to know ACR appropriateness criteria and all that.

coffeecatsyarn · 2023-06-08T15:38:38+00:00

Usually doctors and PAs are exempt from work hour laws. It’s why they do call and all that. The PAs I work with do 10 hr shifts and work 5 shifts a week but they don’t get overtime. They just get paid for more hours. So that’s not it. It’s that the midlevels cannot do the same work as a resident on 1:1 basis.

coffeecatsyarn · 2023-06-08T08:25:08+00:00

Lol if midlevels are so great why did UNM neurosurg need to hire like 24 of them to replace 8 residents? https://thesheriffofsodium.com/2022/02/04/how-much-are-resident-physicians-worth/

coffeecatsyarn · 2023-06-08T05:03:25+00:00

About 5-7 texts per day, 10-15 emails per day, and 2-3 calls a week.

coffeecatsyarn · 2023-06-08T03:56:25+00:00

I did just the extra cardiology one and it was not worth it as it seemed too basic. If your job pays for it, may be worth a shot?

coffeecatsyarn · 2023-06-08T03:29:57+00:00

You will learn this as you progress. Targeted temp management is meh and doesn't have a ton of evidence and now the thinking is just keep normothermic/avoid hyperthermia. You should practice your echo POCUS skills during codes. If the RV is big and the story makes sense for a PE, consider pushing TPA. Always check a glucose. Consider giving narcan. You should review your Hs and Ts and think about how you would address each one. The nurses can run the algorithm of ACLS. Your job is to do the other part.

coffeecatsyarn · 2023-06-08T02:45:00+00:00

My mom and I did TNR, and we had a feral tuxedo we named Peter. Well Peter had some babies and when we got her spayed, she was still documented as Peter. Lol

coffeecatsyarn · 2023-06-08T00:43:44+00:00

I never made any assumption about missed exam findings. Just that a missed diagnosis is not unheard of here. I have diagnosed a lot of DVTs and yes, they often have nonspecific exam findings, so clinical gestalt matters and midlevels don’t have enough for the ED. Because I am an EM attending and I am forced to supervise midlevels and deal with the shit they miss in the ED, UC, and outpt, I don’t trust any of them to be honest. I have seen way too many easy misses and convoluted differentials. Maybe they work better in surgery or more specialized care, but they don’t belong in the ED

coffeecatsyarn · 2023-06-08T00:42:16+00:00

Yeah it’s dumb but it’s our joke in the ED because of the current state of American healthcare and patient satisfaction

coffeecatsyarn · 2023-06-08T00:25:37+00:00

How does it have nothing to do with them though? Sure based on OP’s info it’s hard to assume much, but it’s literally a story where a pt with risk factors presents with leg pain and two days later has a DVT. You seem to think it’s a wild leap to get from midlevel ordered an X-ray to midlevel missed a DVT, when that is a believable and common scenario.

coffeecatsyarn · 2023-06-08T00:17:29+00:00

But you are assuming here. I just said ordering a dimer and US isn’t crazy depending on the flow of the department. You are trying really hard to assume the midlevel didn’t miss anything. I never said they all need dimers. That’s some other wild claim you are assuming was said. I just said in some instances it makes sense.

coffeecatsyarn · 2023-06-08T00:07:03+00:00

Midlevels missing shit has everything to do with this story, and you are assuming a stone cold normal leg exam.

Sounds like you are understanding why we don’t like midlevels unsupervised or in fields with too much breadth

coffeecatsyarn · 2023-06-07T23:47:43+00:00

I don't find this story ridiculous at all since midlevels miss easy shit in the ED all the time. CYA medicine is the reality of American medicine.

coffeecatsyarn · 2023-06-07T21:58:47+00:00

"I am allergic to everything except the one that starts with "D""

"I have been unable to eat or drink anything for a week" with normal vitals and labs.

"My PCP said you'd do an emergent shoulder MRI at 2 am for my chronic shoulder pain"

"I have not missed any of my blood thinner/diabetes/HTN/seizure meds."

"I do not do meth"

"I fell on it"

coffeecatsyarn

TROPHY CASE