Saturday, October 31, 2009

Emergency only if it is Before 5 pm

Here in the US, one of the big things that we get cited for is too many scans. In our ER one of the major reasons we do CTs is to check for pulmonary embolism which essentially is a clot in your lungs that can kill you. This is a NHS protocol from Kings Hospital in the UK.

There, if you come in with the symptoms of this life threatening condition, they will do the scan as long as it is before 5pm. That is of course after you have survived 2 hours. They also might just discharge you early to save money and just have you follow up in a few days and put you on a medication that can cause you to bleed to death in the meantime.


Andrew_M_Garland said...

This fictional but true quote illustrates how politicians are deeply religious and caring:

"Money is evil. We can't have medical care provided for payment. Doctors say that they care, so we underpay them for public healthcare, to allow them to prove their goodwill. We can't let some people pay while we underpay, because this might influence the good will of the doctors."

"Instead of money, we rely on The Lord. If The Lord smiles upon you, rich or poor, He will deliver you to the ED in accord with the rules and regulations of the NHS. If He determines, in His wisdom, that your time is up, then why should we oppose Him."

"Meanwhile, we save a lot of money by sending the CT scan technicians home at 5:00 PM. They work for the government and need a home life. Really, we deny very few patients, although this survey is difficult to establish, because no one comes by after 5:00, and there is no one there anyway to take a survey after 5:00."

"Government is the ideal director of medicine. Politicians are thoughtful, caring, and altruistic. They devote their lives to helping others. Contrast this to physicians, who spend half their lives learning diagnosis and complex, delicate procedures, with the intent of charging sick people for these services."

Andrew_M_Garland - EasyOpinions

Jessica said...

Here's the thing though -is there an emergency treatment for PEs that I seem to be forgetting about? Last I was LMWH....and good luck too you (provided they are stable, and all that jazz)

I work in an ER (tertiary) in Ontario and we do much the same thing. We do CT PA until 10pm at night. If, after that, they present and require the scan, we give then a 1/2 dose of LMWH and have them return in the AM for the scan (or they are admitted, depending on their condition). So, they get a 1/2 dose of the prescribed treatment (because it is later at night, when most people will be getting future injections during the day), then get scanned. If + they continue treatment, if - then LMWH is d/c'd. Last I checked, the risk of ONE dose of LMWH was close to non-existant, and the pt will be put on it anyway, if they are positive. And, of course, pts have the right to refuse the med, pending results of the scan.

Oh, and the comment about "surviving" for 2 hrs really was not necessary -that is simply a guideline for nursing staff in terms of when their VS should be checked, NOT how long they must survive in order to be eligible for the scan.

And just because we don't do CTPA after 10pm doesn't mean we're working in some archaic system -CT is available 24 hrs a day (so is MRI), just with some reasoning behind it. Major trauma -done. Suspected CVA/TIA -done. Chest pain, r/o dissection -done. RLQ pain r/o appy -done.

Just because you CAN scan them doesn't mean you HAVE TO scan them.

Jessica said...

And I happen to find the hospital's Plan of Care (and flowchart) to be quite detailed and straightforward. It identifies which patients can be excluded from early discharge from hospital (yes, they are admitted with confirmed PEs) due to co-morbidities or more complicated risk factors. This takes the guess-work out of it for physicians and leads to a more standardized level of care (which has been shown to significantly improve patient outcomes)

Throckmorton said...


I actually think the protocol is very good. I posted it tongue in cheek to see who was reading. Here in the US you can be sued for delay in diagnosis. So, here if you do not get the ct until later, you can end up in court. Further, if you did not get the scan and started them on Lovenox and got a bleed or got a complication, you still end up in court. It is a D if you do and a D if you dont. The interesting thing is that the mortality and morbidity of both this protocol and the one we use are the same. The difference is that we get a lot more scans immediately and face lawsuits.

SeaSpray said...

I would think that if you know/it's been proven that there isn't any difference in outcomes ..that you shouldn't be sued.

I guess the argument could be made that ..what if ..this patient could've had a better outcome.. if only ...
I heard republicans came out with something for the health bill involving tort reform .. but just beginning to watch the news now and so don't know in detail.

It looks like there is political corruption going on in my state (NJ) with the gubernatorial race.

Just put a little post up venting my frustration. used an excerpt from this article:

So discouraging..I have to tell you.

Jessica said...

Thanks for the reply. Didn't realize it was tongue-in-cheek. I wish the courts realized that imaging doesn't always lead to better outcomes. In spite of all our advances in medicine, some conditions will still kill people. We're not designed to live forver. Unfortunately, it seems that lots of people still want to.

SeaSpray said...

Good night in NJ ..if voting for Christie! :)

Getting him elected clear demonstration of never give up, never assume .. and every vote does count. Definite political upset for this very blue state.

And if the independent weren't in the race and I still question the tactics of the acorn affiliates with their absentee ballots, etc I think he would've one by even more if not for that.

he seems determined, no nonsense and fair with good values.

I am optimistic that because he won all of his criminal cases... he will be effective with crime in this state and the determination in getting convictions will carry over into other areas.

Time will tell.

Jessica ..I'm opting for the live forever option. Sounds better than the alternative. ;)

Jessica said...


See if you still want to live forever when you're 95, you're peeing in a diaper and your family wants you to die, so they can stop wiping your ass.

Your comments are so random...and seem to be on every bloody blog I read. Methinks you might have a problem....

SeaSpray said...

Jessica - like Throckmorton ... I was being FACETIOUS... hence the *wink* at the end of my statement.

I knew *exactly* what you were talking about and suspected you might misunderstand.

I am all for advanced directives and I know a lot of money is wasted on people totally gorked that will never come off of respirators, tubes and all the things that modern medicine provides to keep them alive and that it is a drain on the system and families.

I know all to well what you are talking about since I recently lost my elderly mother who had to live as you stated:"you're peeing in a diaper and your family wants you to die, so they can stop wiping your ass. " in a nursing home the last 6 months of her life. She lost her ability to read, use a remote and couldn't do anything for herself but eat.. and I could see the ability to do that was also becoming compromised... and she was at the mercy of whatever staff was on.

Except... selfishly.. I did not want her to die... and was not prepared to lose her. I would not have kept her alive by extraordinary means and I worked that out with the hospitalist the night she was dying in the ED .. just in case she made it up to ICU.

You said "Your comments are so random...and seem to be on every bloody blog I read. Methinks you might have a problem...."

Yes you are right about my comments being around mostly the med blogosphere. I've been blogging 3 years... and my first written post was 11/13/2006 and have been encouraged by other bloggers blogrolling me or by their various comments and e-mails. You can check out some of the best comments by fellow bloggers on my sidebar.

I will however take your comment under advisement.

Oh ..I am pleased to say (no matter how much I was annoyed or disagreed)I have never felt the need to belittle or insult a fellow blogger with a personal attack.