The life of an Emergency Medicine (EM) doc is filled with moments like this one – when a consult tells you to do the wrong thing. With virtually no exception whatsoever, an EM doc should never rely on a consult. In a teaching hospital, the consult is usually someone with less experience and less knowledge. The teaching point for EM residents is knowing how to respond.
(1) When a consult tells you what you don’t want, do not say “yes”, do not let the consult walk away. You have to explain yourself and battle it out right then and there.
(2) EM is a game of chess. Be two moves ahead. Have a speech prepared. I posit my residents with “what is your answer when the consult wants to discharge this patient (inappropriately)?” A simple response here would be – “I’m really worried the patient has a ruptured ectopic. She has so much pain.”
(3) Know what your backup plans are. Simply, do not discharge the patient. Keep the patient in the ED indefinitely if you have to. The first step is usually “Have your attending call me.” The nuclear button is to transfer the patient out to another hospital. If your general surgeon refuses to operate on an appendix that is about to explode, transfer the patient to another hospital. That will get the attention of your hospital admin. There are many moves in between.
The medicine part of this case is straightforward. Patients bleed to death with ruptured ectopics and hcg < 100, so the hcg quant is meaningless in this regard. If you are confident with your sono and clinical skills, everything about this patient screams ruptured ectopic. Ectopics can go home (we often send them home intentionally). Ruptured ectopics canNOT go home.
In cases of pregnancies of unknown location, patients without pain can go home; patients with pain should not go home. There are other factors that come into play, such as whether the pregnancy is desired (undesired pregnancies may be treated as a presumed ectopic, get a shot of methotrexate, and go home), so these decisions are more complex than stated.
In this case, we didn’t need to go nuclear. We explained our concerns, and the resident said she would get her attending. Unlike the consult who was “not impressed” by the patient, the attending took the patient to the OR. The patient had a ruptured ectopic. The patient did fine. The case is a teaching moment for the consult resident, who hopefully will not make the same mistake again.
“EM doc should never rely on a consult.”
– Siuf 3:16