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Wednesday, July 18, 2018

​X-Rays for Pediatric Abdominal Pain
Endanger Vulnerable Patients for Dogma


The practice of emergency medicine always evolves with new data, reconsidered concepts, and the translation of medical evidence and shared experience to bedside decision-making. With a shrinking world and vibrant educational process, we continually see a narrowing of the gap between academic literature and clinical practice. Some stalwart holdouts persist against bevies of observations, trials, and guidelines, however. Few anachronisms better represent this than the pediatric pedagogy of abdominal radiography.

Despite near-eradication in adult emergency medicine (aside from narrow, niche applications), abdominal radiographs (AXRs) seemingly remain a staple of evaluating children presenting to the ED with abdominal pain. It is, frankly put, a bizarre practice—the use of ionizing radiation equating to 35 chest x-rays—to confirm a benign diagnosis, despite overwhelming evidence of the test's complete inability to do so. (Medicine [Baltimore] 2017;96[3]:e5907;

Perhaps you're as bamboozled as I am by this practice, and have yet to use your radiology suite to take a picture of pediatric poop. It would seem, unfortunately, that we're in the minority. A study published just last year found that 63 percent of children diagnosed with constipation in a pediatric emergency department received an AXR, echoing previous investigations consistently demonstrating rates of abdominal radiography between 50 percent and 75 percent. (Pediatrics 2017;140[1]; doi: 10.1542/peds.2016-2290.)

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Champions of this practice argue that the benefit of identifying a benign diagnosis is to avoid further evaluation and resource use in pursuit of more serious causes of abdominal pain. But AXRs are well-demonstrated to lack any validity or reliability when employed for pediatric constipation and abdominal pain. Studies have shown sensitivity and specificity as low as 60 percent and 43 percent, respectively, and inter-rater reliability little better than a coin flip. (J Pediatr 2012;161[1]:44;

What's more, the use of AXR likely causes outright harm. Putting aside the radiation exposure that should give anyone pause, there is little question that this test serves only as confirmation bias. Fifty percent of AXRs are interpreted as normal (which speaks independently toward poor test application), but obtaining abdominal radiography was associated with a higher rate of misdiagnosis (29%). The most commonly missed diagnoses were appendicitis (!), intussusception (!!), and bowel obstruction (!!!). (J Pediatr 2014;164[1]:83; Less concerning but nonetheless notable was that AXR independently predicted a higher likelihood of ED bounceback, even when the diagnosis of constipation was accurate. (J Pediatr Gastroenterol Nutr 2014;59[3]:32.)

​Ultrasound Instead
The United Kingdom's National Institute for Health and Care Excellence (NICE) workgroup released guidelines in 2010 recommending against AXRs for diagnosing pediatric constipation. (Clinical Guideline 99; updated July 2017; Some may attempt to argue that British baby bellies differ from American ones, but this condemnation of abdominal radiography was echoed in a 2014 clinical guideline from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Publications from the American Academy of Pediatrics and the American Academy of Family Physicians all offer similar sentiments. (JPGN 2014;58[2]:258; Abdominal radiography adds nothing beyond history and physical exam in evaluating for constipation, and is more likely to lead to misdiagnosis when utilized for serious underlying pathology.

Ultrasound's availability is growing and emergency physicians are increasingly comfortable with it, so either point-of-care at the bedside or performed by the radiology department offers a better alternative to poorly sensitive and nonspecific abdominal radiography, when imaging is needed at all. Ultrasound consistently demonstrates excellent sensitivity (nearing 100% in some studies) and specificity (nearly always 97% or greater) when evaluating serious abdominal etiologies of abdominal pain, such as appendicitis, bowel obstruction, intussusception, or volvulus, though, of course, it is limited by sonographer experience and skill. Even in the ridiculous and unnecessary application of imaging for constipation, US outperforms abdominal radiography without the harm of ionizing radiation. (
J Pediatr Surg 2010; 45[9]:1849;

Why, then, does this practice persist? Perhaps we've waited for more rigorous investigations or abundant data before changing ingrained practice in recognition of the unique considerations and fundamental differences of the pediatric population. Our desire to shield our most vulnerable has led us to ignore the harm borne from the dogma.

We emergency physicians stand at the forefront of knowledge translation to clinical practice, yet the persistence of AXRs in evaluating pediatric abdominal pain and constipation flies in stark contrast to the evidence-based practice and nonmaleficence we pioneer. The identification of benign poop causing a patient's complaint at first seems reasonable. In our search, though, we need not have ever looked beyond the test itself.

Dr. Pescatore is the director of emergency medicine research for the Crozer-Keystone Health System in Chester, PA. He is also the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine: Follow him on Twitter @Rick_Pescatore, and read his past columns at

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Wednesday, July 11, 2018

​The Myth of Midstream Clean-Catch Urine Samples


A 27-year-old woman is triaged with a complaint of suprapubic pain and provides a urine sample. The clinical picture does not suggest cystitis, but her urinalysis shows the presence of leukocyte esterase and nitrites. The patient tells you she urinated directly into the cup. How do you interpret this urinalysis? Should she receive antibiotics?

Inaccurate interpretation of urinalyses (UAs) can lead to overdiagnosis of infection, unnecessary treatment, and antibiotic resistance. (Clin Infect Dis 2017;65[7]:1199.) Accurate results are particularly important in special populations, including men, pregnant women, geriatric patients, and patients with diabetes mellitus. (Dtsch Arztebl Int 2010;107[21]:361.)

For an accurate interpretation of a UA, a physician must decide if the presence of leukocytes or nitrites represents a pathogenic bacterial infection of the urinary tract. Many clinicians rely on the presence or absence of squamous epithelial cells on UA to determine if a urine sample is contaminated. (Nephrol Dial Transplant 1999;14[11]:2746.) Evaluation for the presence of squamous epithelial cells requires microscopy, and is more time-consuming than the rapid bedside urine dipstick routinely used in many emergency departments.

A contaminated urine sample could be a urine culture with the growth of vaginal or skin contaminants such as Lactobacilli, Corynebacteria species, Gardnerella, and alpha-hemolytic Streptococcus. (Nephrol Dial Transplant 1999;14[11]:2746.) Polymicrobial urinary tract infections are rare, and samples demonstrating polymicrobial growth are considered contaminated unless the patient has an ileal conduit, neurogenic bladder, vesicocolic fistula, UTI with stones, chronic renal abscess, or indwelling urinary catheter. (Nephrol Dial Transplant 1999;14[11]:2746.)

Urine cultures can take up to three days for pathogen growth, so this method of distinguishing UTI from contamination is impractical for EPs, who must decide whether to treat with antibiotics before culture results are available. (Clin Infect Dis 2017;65[7]:1199; N Engl J Med 1993;328[4]:289.)

The best urine samples are those collected early in the morning or when a patient has not passed urine in the preceding four hours, providing a higher concentration and more time for bacteria to multiply. (Nephrol Dial Transplant 1999;14[11]:2746; Evidence-Based Diagnosis in Primary Care: Practical Solutions to Common Problems. Philadelphia: Elsevier Health Sciences; 2012.) The timing of collection, however, can rarely be controlled in the ED, so midstream catch or single catheterization has been recommended. (Nephrol Dial Transplant 1999;14[11]:2746.)

To decrease the risk of contaminated urine samples, women are instructed to spread their labia and vaginal opening, clean with water, and catch urine midstream, while uncircumcised men are instructed to pull back the foreskin prior to urination. Water is preferred over soaps and antiseptics, which can be bactericidal and lead to misleadingly low bacterial counts. (Nephrol Dial Transplant 1999;14[11]:2746.)

Beyond Collection Technique
Contrary to popular belief, multiple studies have shown no difference in bacterial contamination rates when comparing clean-catch samples against non-clean-catch samples. (N Engl J Med 1993;328[4]:289; J Emerg Med 2015;48[6]:706; J Hosp Infect 1991;18[1]:71; Arch Intern Med 2000;160[16]:2537.) The method by which patients were educated on how to provide a clean-catch sample like verbal instructions and posters in patient bathrooms failed to decrease contamination rates. (J Emerg Med 2017;52[5]:639; Am J Public Health 1977;67[7]:640.) One study found that 45 percent of patients who received verbal instruction on urine collection technique actually collected a midstream sample, and only 15 percent of women parted their labia during urine collection. (West J Emerg Med 2012;13[5]:401.)

Considering contamination is common and difficult to eliminate in ED samples, how can EPs interpret urinalyses? The presence of nitrites, a metabolic product of pathogens, increases the positive likelihood ratio of UTI by 2.6 to 10.6 times, but is an insensitive marker for infection. (Dtsch Arztebl Int 2010;107[21]:361.) The presence of leukocyte esterase alone is also a poor predictor, with a likelihood ratio between 1.0 and 2.6. (Dtsch Arztebl Int 2010;107[21]:361.) The presence of nitrites and moderate leukocytes increases the likelihood of infection more than sevenfold. (Fam Pract 2003;20[2]:103.) The combined presence of nitrites, leukocytes, and blood increases the likelihood by more than 15 times. (Eur J Emerg Med 2011;18[4]:221.)

These findings must be interpreted in the context of the patient's symptoms and the clinician's pre-test suspicion for infection. The clinician can ask about common symptoms of UTI: painful voiding, urgency, urinary frequency, and tenesmus (LR 1.16 to 1.31). (Fam Pract 2003;20[2]:103.) The characteristics of the urine, however, are more useful predictors of infection; cloudy urine has a positive likelihood ratio of 2.1 and specificity of 60%, while foul odor has a positive likelihood ratio of 5.1 and a specificity of 96% for infection. (Evidence-Based Diagnosis in Primary Care: Practical Solutions to Common Problems. Philadelphia: Elsevier Health Sciences; 2012.) A careful history and inspection of the urine specimen can greatly assist in diagnosing UTI when the UA is equivocal. Women with typical UTI symptoms may be treated empirically without a need for a UA.

Urine contamination commonly occurs in UAs, and we frequently treat based on the results of these contaminated tests. None of the efforts to decrease contamination rates in collection methods has been effective. A history from the patient and key indicators of infection in these imperfect urinalyses will help EPs make the right decisions regarding treatment.

Dr. Bae is a first-year EM resident at Temple University Hospital in Philadelphia, PA, and an elected AAEM/RSA board member for the upcoming year. Dr. del Portal is an associate professor of clinical emergency medicine at the Lewis Katz School of Medicine and an attending physician at Temple University Hospital in Philadelphia, PA.

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Thursday, July 5, 2018

Negotiation Gives Troubled Summa Residency a New Leader
as It Awaits ACGME Decision on Reaccreditation


​An agreement between Cleveland Clinic Akron General Hospital and U.S. Acute Care Solutions nimbly avoided a stumbling block that could have disrupted plans to reopen the emergency medicine residency at Summa General Health Care under the direction of Michael Beeson, MD. Dr. Beeson had led the Summa program (now operating under U.S. Acute Care Solutions [USACS]) for 27 years before going to Akron eight years ago.

Dr. Beeson gave a 90-day notice to Akron General on March 21, in preparation of moving back to Summa, but Akron terminated him without cause on May 23, according to a suit filed by Dr. Beeson, USACS, and its physician group, Emergency Medicine Physicians of Cuyahoga County, against Akron General Health System and its emergency physician organization, Partners Physician Group.

Dr. Beeson's contract contained a noncompete clause that forbade his working within a 10-mile radius of Akron General for a year after leaving the hospital. USACS, Dr. Beeson, and the Cuyahoga County Physician's group claimed in its complaint that "Dr. Beeson accepted this position [at Summa's Akron area campus] upon realizing that the noncompete provision of the agreement was unenforceable" in this situation. His Summa assignment would be to lead its residency program in the role of educator and to assist in its emergency department treating emergency patients, according to the pleading.

Akron General and other defendants wrote Dr. Beeson May 23, threatening to sue him for violating the noncompete clause. The hospital and the other plaintiffs noted in the pleading that the noncompete prevents Dr. Beeson from providing medical educational services to the Akron community, and asked the court to find the noncompete provision unenforceable under Ohio law.

Negotiations among lawyers for the plaintiffs and defendants resulted in a confidential settlement announced June 12. Akron and USACS noted in a joint statement that they had "agreed that Dr. Beeson may direct Summa's Emergency Medicine Residency Program, and that Dr. Beeson will honor his agreement with Akron General by not clinically practicing outside of that role for the next year. We jointly recognize the importance of education for the next generation of emergency medicine physicians."

The turmoil at Summa began Jan. 1, 2017, when its long-time emergency medicine group's contract was terminated and a new group under USACS took over. ("Summa Shaken by Change in ED Group," EMN 2017;39[3]:1; Questions about whether the new group could handle the residency program soon followed, and the Summa emergency medicine residency program subsequently lost its accreditation that July. ("Summa Residency Likely to Close in July," EMN 2017;39[4]:1; Summa reapplied for reaccreditation to the Accreditation Council for Graduate Medical Education, which conducted a site visit June 21, a Summa spokesman said, and the July 1 start of a new residency year passed without an emergency medicine class there.

Policy and Ethics
The issue of noncompete clauses in emergency medicine contracts arises frequently, mainly in contracts with management companies that work with community hospitals. This particularly visible one affected academic medicine and threatened the ability to train and retain emergency physicians in Akron, however.

Jeffrey C. Miller, an attorney for the plaintiffs in this matter, reiterated that he could not discuss details of the final settlement. An expert in noncompete clauses of all sorts, he said whether they are enforceable depends on the circumstances. "It always comes down to what I think is a business decision," he said.

Any employee—including emergency physicians—should have an attorney scan such contracts, particularly when they have a noncompete, Mr. Miller said. "What you want to do is to have the contract spell out the business purpose of the restrictive covenant so that at that point you can evaluate why there is the necessity for the inclusion of the restrictive language," he said. "That's how I draft mine."

He said he tends to write such covenants as stand-alone separate documents that emphasize the importance of the covenant and gives both sides a chance to review the information.

The American Academy of Emergency Medicine opposes restrictive covenants in regular practice, particularly in academic medicine, because such restrictions can affect a whole program, said Robert McNamara, MD, a former president of AAEM and the chair of emergency medicine at Temple University School of Medicine in Philadelphia.

Larry Weiss, MD, JD, a clinical professor of emergency medicine at the University of Maryland School of Medicine and also a former AAEM president, said in a discussion on the AAEM website that post-contractual restrictive covenants in physician contracts violate public policy and medical ethics. "Often, restrictive covenants violate the law," he said, "either because of state laws that ban restrictive covenants in physician contracts, or because the restrictive covenants serve an illegitimate business interest such as the restriction of competition. … AAEM condemns the use of post-contractual restrictive covenants in physician contracts." (AAEM White Paper on Restrictive Covenants;

Ms. SoRelle has been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.

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Thursday, June 28, 2018

A Better Approach for Pediatric Fever—Finally


The literature on pediatric fever is vast—a PubMed search yields more than 14,000 results—but that volume of evidence has still not yielded a unified clinical practice guideline or consensus addressing the clinical approach, appropriate workup, and disposition for febrile babies. Even so, the best evidence indicates that a fever in neonates and infants is no longer an automatic ticket to a hospital stay, and new studies permit risk-stratification that actually sends some babies home.

A lot of hype surrounds pediatric fever, but the amplitude of fever is not as important as the child's appearance and level of activity (playful vs. lethargic) in predicting bacteremia. (Pediatrics 1989;83[6]:1016.) Neonates (infants under 28 days old) and young infants (those 29-90 days old) have immature immune systems, and the risk of serious bacterial infections, such as urinary tract infection, bacterial meningitis, sepsis, and pneumonia, is significant (about 20%) and must be ruled out to prevent morbidity or mortality. (Pediatrics 1989;83[6]:1016.)

Body temperature should be measured rectally in children younger than 2 because it is the closest to core temperature. Oral temperatures are typically 1°C (1.8°F) lower than rectal ones, and axillary temperatures 2°C (3.6°F) lower, but these conversions should not be used as substitutes for rectal temperatures in the ED despite their convenience. (Barren JM, et al. Pediatric Emergency Medicine. Philadelphia: Saunders/Elsevier. 2008: 291-8.) A 2015 meta-analysis determined the accuracy of peripheral temperatures was unacceptable for making clinical decisions. Tympanic and temporal thermometry also have poor sensitivity for fever detection in pediatric patients. (Ann Intern Med 2015;163:[10]:768.)

We should definitely treat fever in the ED, not just because it makes patients more comfortable, but also because it allows the physician to re-evaluate a child's behavior when afebrile, risk-stratify for serious bacterial infections, and counsel parents accordingly. A serious bacterial infection should be suspected if the patient's vitals don't improve or his clinical picture worsens after correction of fever. Elevations in body temperature may alarm parents and caregivers, but fever is the body's way of fighting infection. Don't worry until the child's temperature reaches 41.5°C (106.7°F). (Pediatrics 2011;127[3]:580.) Heart rate increases by approximately 10 beats/minute and respiratory rate by five breaths/minute for every degree of Celsius over 38°C.

The absence of fever in the emergency department at the time of presentation, however, should not dissuade a physician from performing the appropriate workup in a child with a history of fever reported by the caregiver. Treatments for alleviating fever are not created equal. Despite confusion on this subject, data suggest that ibuprofen is superior to acetaminophen for treating fever and pain in children, probably because of its more potent anti-inflammatory mechanism of action. (Arch Pediatr Adolesc Med 2004;158[6]:521.) Using both drugs in an alternating pattern may be more effective, but is not recommended because the combination increases the potential for errors. (Paediatr Child Health 2007;12[2]:127.) Most fevers are caused by viruses, but Group B streptococci, Escherichia coli, and Listeria monocytogenes are the most common causes of serious bacterial infections in neonates. UTIs are the most common occult serious bacterial infection, especially in children. (Pediatrics 2003;111[5 Pt 1]:964.)

Traditional Management
Before the 1980s, neonates and young infants with fever would undergo a full sepsis workup, including studies for blood, urine, and cerebrospinal fluid, and be hospitalized for 48 hours pending bacterial culture results. A 1993 review-based clinical guideline emphasized that a full sepsis workup consisting of CBC, blood culture, urinalysis (noting that UTI may not present with pyuria), chest x-ray, HSV PCR if at risk, and CSF cultures for infants under 28 days old is recommended despite the low probability of a serious bacterial infection. (Pediatrics 1993;92[1]:140.)

This guideline was set forth to achieve a greater than 92% sensitivity in diagnosing a serious bacterial infection in a neonate, but it did not take into consideration the procedural complications and trauma involved in obtaining a lumbar puncture. This led clinicians to suggest the Rochester Criteria for risk-stratifying neonates in diagnosing serious bacterial infections.

​Modern Management
Two studies by Dagan, et al., demonstrated that an infant was at low risk for serious bacterial infection if he met certain criteria. (J Pediatr 1985;107[6]:855 and 1988;112[3]:355.) These became known as the Rochester criteria, which along with other criteria, became ways to identify febrile young infants at low risk for serious bacterial infection who may be eligible for discharge home without hospitalization. (Pediatrics 1994;94[3]:390.)

The Rochester criteria are the only ones that include neonates and young infants in risk-stratifying fever. A febrile infant with all of the Rochester criteria has a less than one percent risk of serious bacterial infection and a negative predictive value of 98.9% supporting discharge home with close follow-up and no empiric antibiotics. (Pediatrics 1994;94[3]:390.)

The Philadelphia criteria also may be used to risk-stratify patients between 29 and 59 days old presenting with fever. These criteria have a sensitivity of 98% and a higher NPV of 100%, but they mandate a lumbar puncture to classify the patient as low risk. A lumbar puncture is not taken into account in the Rochester criteria. (N Engl J Med 1993;329[20]:

The Boston criteria include infants up to age 89 days and also mandate a lumbar puncture. (J Pediatr 1992;120[1]:22.) They utilize a higher WBC threshold of 20,000 WBC/mm, but had the lowest NPV at 94.6%.

The Rochester and Philadelphia criteria permit infants at low risk to be discharged without antibiotics with reliable home observation and follow-up within 24 hours. (Pediatrics 1994;94[3]:390; N Engl J Med 1993;329[20]:1437.) The Boston criteria are the only of the three where the patient receives antibiotics at discharge. (J Pediatr 1992;120[1]:22.) (See a comparison of all three criteria: Table 1.)

SR table 1.JPG

​Step-by-Step Approach
Here's your best bet: A recent study by Borgia Gomez, et al., introduced a step-by-step algorithm to risk-stratify patients and compared the results to the Rochester criteria. (Pediatrics 2016;138[2]; Epub 2016 Jul 5.) The algorithm uses laboratory tests such as C-reactive protein and procalcitonin. Infants 90 days or younger with an objective temperature over 38°C at home or in the ED and a fever without a source were assigned 0-9 points. (Table 2.) 

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The study showed a sensitivity of 92% and a NPV of 99.9%, which surpasses the Rochester criteria. (Tables 3-5.) (Pediatrics 2016;138[2]; Epub 2016 Jul 5.) The availability of procalcitonin is not currently universal, however, limiting the applicability of the study.

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Low-risk neonates are discharged with close follow-up based on the Rochester criteria, and high-risk neonates get admitted with antibiotics to treat their potential septicemia after a full workup, according to all three criteria. (Pediatrics 1994;94[3]:390; N Engl J Med 1993;329[20]:1437; J Pediatr 1992;120[1]:22.)

The recommended antibiotic regimen includes an aminopenicillin (e.g., ampicillin 50 mg/kg IV) and an aminoglycoside (e.g., gentamicin 2.5 mg/kg) or a cephalosporin (e.g., cefotaxime). Data show that survival in neonatal sepsis may be increased with empiric use of gentamicin over cefotaxime. (Pediatrics 1994;94[3]:390.)

Ceftriaxone use in this age group is discouraged because neonates cannot metabolize or excrete it well, especially with preexisting hyperbilirubinemia. Acyclovir should also be given if the neonate is at risk for herpes infection. Well-appearing infants aged 29-59 days should undergo the full sepsis evaluation unless they are considered low risk per the Rochester criteria. A urinalysis with culture should always be performed (again noting that pyuria may not be present with UTI), as well as a CBC, blood culture, and chest x-ray. (Pediatrics 1994;94[3]:390.) Infants who meet the low-risk criteria and have reliable home observation and follow-up within 24 hours can be discharged without antibiotics, according to the Rochester and Philadelphia criteria.

Infants in this age group who meet high-risk criteria should be admitted pending culture results for antibiotics and a lumbar puncture for cell count and culture. The antibiotic of choice is ampicillin 50 mg/kg IV plus ceftriaxone 50 mg/kg IV (for normal CSF) or 100 mg/kg (for abnormal CSF). (Pediatrics 1994;94[3]:390; N Engl J Med 1993;329[20]:1437; J Pediatr 1992;120[1]:22.)  Most causes of infection in the 60-90-day-old group tend to be viral, especially if vaccinations are up to date. (N Engl J Med 1993;329[20]:1437.) All infants in this age group should receive a urinalysis and culture. Further septic workup may be tailored to the appearance of the child. (N Engl J Med 1993;329[20]:1437.) Routine CBC and blood cultures are not indicated in a vaccinated, well appearing child. (N Engl J Med 1993;329[20]:1437; J Pediatr 1992;120[1]:22.)

Chest x-rays may not be necessary in a child who is well-appearing and does not exhibit any respiratory symptoms such as tachypnea, tachycardia, wheezing, cough, or other focal symptoms. Lumbar puncture is only indicated in this age group if the infant looks toxic or is irritable. (N Engl J Med 1993;329[20]:1437; J Pediatr 1992;120[1]:22.)

Dr. Joseph is a fourth-year emergency medicine resident, Dr. Nguyen is a third-year emergency medicine resident, and Drs. Olsen and Ung, clockwise from top left, are emergency physicians, all at Nassau University Medical Center in East Meadow, NY.

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Wednesday, June 20, 2018

A Tale of a Transfer: One Patient, Six Hours


Few things make a shift seem longer or more painful than a complicated transfer. You know what I mean if you work in small-town or rural America. Our colleagues in large teaching centers have enormous stress and do heroic work—and they accept transfers night and day.

Those who work in large centers miss out, however, on the singular delight of making the call to transfer those patients. This isn't exactly the Great White Way, but the experience is rather like a Broadway show.

Setting: Dr. Leap is calling to transfer a critically ill young woman from Tiny Memorial Hospital to bright, shiny Massive Regional Hospital. Having no secretary and because all the nurses have important clinical duties, he picks up the phone, his cup of tea close at hand and his phone playing choral music to soothe his frazzled spirit.

Massive Regional Hospital: Hi, this is Brandi on the transfer line. Is this an emergency?

Dr. Leap: Well, it's complicated. It's an unresponsive 25-year-old woman with stroke-like symptoms. She was found at home and was intubated by EMS. No apparent trauma. She appears to have a small right frontal subarachnoid hemorrhage. She's also 28 weeks pregnant. I need a physician to accept her. She will most likely require several services. (Dr. Leap sighs, knowing what this portends.)

Brandi: So do you need neurology?

Dr. Leap: Probably neurosurgery.

Brandi: (Obtains demographics.) Just so you know, we're completely full except for stroke and STEMI, but I'll connect you with Dr. Evans of neurosurgery.

Dr. Leap tells story again (emphasizing things that make neurosurgeons care).

Dr. Evans: We aren't going to do anything with that tonight. She probably needs to go to the hospitalist service in the ICU.

Brandi: I'll get Dr. Cannon. He's the medicine resident.

Dr. Leap tells story, including all required numbers and porcelain levels for the internal medicine report.

Dr. Cannon: I'm internal medicine. I can't take that without an OB or neurology consult. I haven't delivered a baby in years.

Dr. Leap: She's not in labor.

Dr. Cannon: Still.

Brandi: I'll get OB.

Dr. Leap tells story.

Dr. Andrews-Guttman: That's terrible! She needs neurology. We can manage the baby part but not the neuro issues.

Brandi: I'll get the NP on call for neurology.

Dr. Leap tells story again. (He notes that NPs don't have last names).

Susan: I'll run it by my staff, but we don't accept transfers or do admits. It sounds neurosurgical. What did they say?

Dr. Leap: They said to call the hospitalist, who said to call OB, who said to call you.

Susan: That makes sense. OB didn't want to accept her?

Dr. Leap: (Snarky by now.) They only take care of baby brains.

Brandi: Shall I call critical care?

Dr. Leap: (Considers slitting wrists as patients pile up.) Yes, please.

Dr. Leap tells story again.

Dr. Morgan: I'm sorry to hear that! Of course, I'll manage the critical care side, but what did neurosurgery say?

Dr. Leap: They said she needs a hospitalist.

Dr. Morgan: They don't admit to the ICU.

Dr. Leap: Can I send her to you?

Dr. Morgan: Are neurology and OB planning to see her?

Dr. Leap: (Face on desk.) Yes, but they can't accept her in transfer.

Dr. Morgan: I have no ICU beds. Can you keep her there overnight? I'll call you when a bed's open. Just put her in your ICU, and have your neurologist see her.

Dr. Leap: I don't have any ICU beds, and I don't have a neurologist.

Brandi: We can call you in the morning when beds open up. Is that OK?

Dr. Leap: Sure.

Dr. Leap calls Southern Teaching Hospital, 75 miles in the opposite direction.

Rick: Hi, this is Rick, the transfer coordinator. Is this an emergency?

Dr. Leap repeats story again with similar cast of characters. Patient finally transferred six hours after the first call. He binge-eats King Don chocolate cake to clear his head.

​Have Mercy
Everybody is overwhelmed at big centers and small. I'm not trying to make anyone the villain. I hate sending things to busy centers because I've been there. It is almost comical, however, when you tell the same story six times and one more person needs to hear it from the top again.

There has to be a way we can streamline communication and patient acceptance (or rejection). Last time I checked, doctors can read summaries as surely as they can listen to them. In an age of constant texting, younger doctors may prefer it!

Hospitals need to consider these situations when staffing. Number of patients seen per shift isn't the only metric that matters. Transfers, sending and receiving, are complicated, dangerous, and extraordinarily time-consuming. This is especially so in small hospitals with little or no backup. When physicians and nurses are on the phone and at the desk completing the tomes needed for a transfer, they can't see sick people.

Dear administrators: Have mercy. We chart nonstop to document and bill. We need help so we can do all of this in the most thorough but efficient way possible.

Dr. Leap practices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available at, and Working Knights, Cats Don't Hike, and The Practice Test, all available at, and of a blog, Follow him on Twitter @edwinleap, and read his past columns at

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