So I just left the Emergency Room

[shortylickens]

I've been to the Emergency Room and Urgent Care too.

I shouldnt crap on someone with a lot more college than me, but realistically if those doctors were more experienced or much smarter they would be working a regular 9-5 job in an office and reaming people for money.

It seems like most of the doctors who end up in ER or UC are either mediocre or really inexperienced.

And when the smart ones get some experience they go to a private practice and charge ass-loads of money.

 

[episodic]

Originally posted by: shortylickens
I've been to the Emergency Room and Urgent Care too.

I shouldnt crap on someone with a lot more college than me, but realistically if those doctors were more experienced or much smarter they would be working a regular 9-5 job in an office and reaming people for money.

It seems like most of the doctors who end up in ER or UC are either mediocre or really inexperienced.

And when the smart ones get some experience they go to a private practice and charge ass-loads of money.

Actually, I knew an emergency room doc that just goes around and staffs understaffed ER's for a company. Makes over 1000 dollars for a 12 hours shift.

He works 3 shifts a week. You do the math. He has no other worries and doesn't have to do rounds at the hospital, etc.

 

[preCRT]

Originally posted by: shortylickens
I've been to the Emergency Room and Urgent Care too.

I shouldnt crap on someone with a lot more college than me, but realistically if those doctors were more experienced or much smarter they would be working a regular 9-5 job in an office and reaming people for money.

It seems like most of the doctors who end up in ER or UC are either mediocre or really inexperienced.

And when the smart ones get some experience they go to a private practice and charge ass-loads of money.

That is the stupidest thing I've read in this entire thread.

 

[dethman]

Originally posted by: Mark R

Originally posted by: 911paramedic
It detects the breakdown of a clot, FDP's. So if he was in the middle of a thrown clot, I doubt it would show up. Perhaps after, but that is only if his clotting cycles were working correctly. Otherwise they would need to give him something like t-PA or Streptokinase (sp?) to break it up.

There is a significant difference in the mechanism between coronary thrombosis and pulmonary embolus.

In MI, the pathology is in-situ thrombosis due to atherosclerotic plaque rupture, or in the case of unstable angina, platelet aggregation on an unstable plaque. In these cases, you are quite right, there isn't time for detection of thrombosis degradation products. The diagnosis has to be made and treatment instituted on the history, examination and ECG alone, and then confirmed by enzymes after the event has passed.

In the case of pulmonary embolus, the thromosis is from the veins, which do not develop atherosclerotic plaques. It's not unreasonable to say that essentially all PEs come from established DVTs (either in the legs or the iliac veins). As such, the clots aren't acute, and hence there will virtually always be detectable degradation products at the time of presentation.

There are 2 catches: 1.warfarin/coumadin treatment disrupts normal clotting pathways and degradation products are produced in reduced amounts, and the d-dimer test may be negative, if someone has been taking warfarin for another condition.
2. Any intercurrent illness will cause d-dimer levels to be elevated, as it partly plays a role in the inflammatory process. As a result a positive d-dimer test is meaningless, except to say that thrombosis cannot be excluded.

an educated post on anandtech. who'd have thunk it? well written, sir.

 

[shortylickens]

Originally posted by: preCRT

Originally posted by: shortylickens
I've been to the Emergency Room and Urgent Care too.

I shouldnt crap on someone with a lot more college than me, but realistically if those doctors were more experienced or much smarter they would be working a regular 9-5 job in an office and reaming people for money.

It seems like most of the doctors who end up in ER or UC are either mediocre or really inexperienced.

And when the smart ones get some experience they go to a private practice and charge ass-loads of money.

That is the stupidest thing I've read in this entire thread.

Well, given that you think its constructive to say absolutely nothing I honestly cant be too concerned with your position on intelligence.

Had you made a useful comment LIKE THE PERSON WHO HAD ALREADY POSTED BEFORE YOU then your opinion might be of value.

I based my statement on what I've personally experienced in an emergency room and urgent care many times in different parts of the country. I always got much better care in a private doctors office the next day.

 

[imported_Baloo]

It's called hypochondria, it won't go away until you die.

 

[Engineer]

Originally posted by: Brainonska511
Gallbladder?

Absolutely a possibility!!!

I had the same type of pain and it was later diagnosed as Galbladder. Since I've had it removed, no problems.

 

[dud]

You have an alien growing inside you ..

 

[mattpegher]

Originally posted by: 911paramedic
I love the post about a pulmonary embolism and D-dimer, as well as Illusion88's post. Sorry, but they were funny.

D-dimer is for disseminated intravascular clotting, not a single embolism. A single embolism is usually from some plaque breaking loose. (Or a clot from an injury/blockage somewhere.) This too would show elevated enzymes.
Unstable angina will still show elevated CK levels due to the ischemia Illusion88.

Doesn't sound cardiac related to me, but worth the time to figure out what it is.

(This is from my paramedic and clinical lab technicians point of view, not a cardiologists.)

D-dimer is the primary tool for ruling out DVT and PE in the clinical setting in patients with low risk presentations. Unfortunately it can be wrong, so in patients that have a high risk presentation CT for PE and Doppler for DVT are still suggested.

(this is from my 12 years as an emergency physician and the recent literature regarding the screening for thromboembolic disease. Forgive me if I don't wish to quote articles at this time.)

 

[mattpegher]

Originally posted by: Mark R

Originally posted by: 911paramedic
I love the post about a pulmonary embolism and D-dimer, as well as Illusion88's post. Sorry, but they were funny.

D-dimer is for disseminated intravascular clotting, not a single embolism. A single embolism is usually from some plaque breaking loose. (Or a clot from an injury/blockage somewhere.) This too would show elevated enzymes.
)

Modern high-sensitivity d-dimer tests are sensitive enough to detect a single small embolus.

In fact, they are so sensitive that a negative 'high sensitivity' d-dimer test is the single most powerful negative predictor of PE - the negative predictive value is better than 99%, verified in muti-center trials.

Current international guidance is that if a suitable d-dimer test is negative, the diagnosis of DVT or PE is excluded and no further investigation is appropriate, unless there is very high pre-test probability (e.g. combination of previous history, documented hypoxia, ECG changes, tachycardia and hemoptysis).

Exactly but a recent retrospective of patients with high probability presentations as you listed above showed as many as 40% of these patients with positive pe on angiography had D-dimers within normal limits.

That is until the next study changes everything. LOL

 

[Mark R]

Originally posted by: mattpegher
Exactly but a recent retrospective of patients with high probability presentations as you listed above showed as many as 40% of these patients with positive pe on angiography had D-dimers within normal limits.

That is until the next study changes everything. LOL

Ah. Yes. I hadn't realised that I'd forgotten that important qualification in the 2nd paragraph. The 99% NPV only applies in the 'low and medium' pre-test probablility groups. In high risk groups, the d-dimer cannot be adequately relied on.

But aye, this is a rapidly changing field. Big controversy at the moment is whether all PEs found on modern CT angiography are relevant. Modern CT is so sensitive that the prevalence of unsuspected minor PE found incidentally on thoracic CT performed for another reason is surprisingly high (up to 16% in some groups).

 

[mattpegher]

Originally posted by: shortylickens
I've been to the Emergency Room and Urgent Care too.

I shouldnt crap on someone with a lot more college than me, but realistically if those doctors were more experienced or much smarter they would be working a regular 9-5 job in an office and reaming people for money.

It seems like most of the doctors who end up in ER or UC are either mediocre or really inexperienced.

And when the smart ones get some experience they go to a private practice and charge ass-loads of money.

Medicine doesn't work that way. I am boarded in internal medicine and emergency medicine. The pay per hour is often much better in the ER than office. The trade off is actually pay and set hours versus being your own boss. Sure specialists can make more. I for one often kick myself for not accepting the fellowship and doing a few more years of training. But when your 30 and havent yet been paid what your worth you are eager to get out of training.

The problem with staffing Emergency rooms is a "warm body" mentality of many hospitals about who staffs the ER. Often the group of physicians is not private but a mega-group that staffs many hospitals and contracts with the hospitals.

How can you improve the care you recieve in the ER? Most hospitals utilize some form of patient opinion polls. Be sure to respond and please list, by name if you know it, the physician you saw. Also please try to be as quick to praise as you are to criticize. Most people only take the time if they are unhappy with their care, but negative reinforcement tends to be less productive than positive.

 

[mattpegher]

Originally posted by: Mark R

Originally posted by: mattpegher
Exactly but a recent retrospective of patients with high probability presentations as you listed above showed as many as 40% of these patients with positive pe on angiography had D-dimers within normal limits.

That is until the next study changes everything. LOL

Ah. Yes. I hadn't realised that I'd forgotten that important qualification in the 2nd paragraph. The 99% NPV only applies in the 'low and medium' pre-test probablility groups. In high risk groups, the d-dimer cannot be adequately relied on.

But aye, this is a rapidly changing field. Big controversy at the moment is whether all PEs found on modern CT angiography are relevant. Modern CT is so sensitive that the prevalence of unsuspected minor PE found incidentally on thoracic CT performed for another reason is surprisingly high (up to 16% in some groups).

Good point