04 January 2010

Algorithms

ER medicine is all about algorithms -- pre-established decision-making rules that determine the management of most any problem. You have your chest pain algorithm, the rule-out PE algorithm, the febrile child algorithm, and so on.  ERP provides a wonderful algorithm for the ER management of vaginal bleeding:

Vaginal Bleeding, Simplified for the ER Doctor
vag-bleeding.jpg
I wonder if we went to the same training program, since I learned the exact same algorithm.

Funny thing: you note that the decision tree does not necessarily include a pelvic exam.  Like Scalpel, I too have long questioned the value of the routine pelvic exams in the ER, and in many many cases it can be omitted.  Non-pregnant with unimpressive bleeding, stable HCT and vitals?  Don't care -- it's not an emergency.  Follow up with your PCP or GYN if it doesn't go away.  That description, by the way, accounts for something like 70% of ER presentations of non-pregnancy-related vaginal bleeding.  No pelvic required.  And if you are pregnant and bleeding, I'll get way more information from my bedside ultrasound than from the pelvic exam.

I think that at this point in my career I do about 25% of the pelvics that I did immediately after graduation form residency.  The funny thing is that I used to feel guilty about omitting it, as if I was breaking a commandment, but patients, when I tell them that I do not think they need a pelvic exam, are usually downright grateful.   Hmm.  Could it be that women don't enjoy pelvic exams?  What an odd thought.

6 comments:

ERP said...

I only do a cursory exam in these stable preg bleeders to see if the os is open. It almost never is! And even if it is, the GYN wants an U/S before they will D and C her.

alexandralynch said...

I'd love to know some of the algorithms, so that as a member of the public, I don't come into the ER and bother people when it's something they're going to tell me is not as much of an emergency as I think it is.

Kipper said...

I loved this chart when ERP posted it. Trouble-shooting skills are essentially the reason I've ever been employed, and it's neat to see the same kind of thing taught in another field.

The Patient Patient said...

Your chart on vaginal bleeding makes me shiver because I had unstable bleeding with my third pregnancy. I was rushed to the emergency room several times due to heavy bleeding, I was over 20 weeks pregnant.
They were unable to stop the bleeding and were getting me prepped for a D & C. The doctor said he wanted to take one last listen "just in case." His face turned white, he said that was the strongest fetal heartbeat he ever heard.
I discovered years later that I have Ehlers Danlos which can cause heavy bleeding during pregnancy. I'm grateful that doctor took "one last listen."

Hey, You said...

Stop, Dr. Shadowfax, you're cracking me up:

Hmm. Could it be that women don't enjoy pelvic exams? What an odd thought.

I can't catch my breath! What is the treatment for uncontrollable laughter?

Seriously, on behalf of women everywhere, let me just thank you for omitting unnecessary pelvic exams.

Now, if we could just get you to stop making us change into gowns for a laceration to the hand.....

Anonymous said...

The number of pelvic exams we perform in the ED is embarrassing. What is this absolute compulsion to require a woman to endure this type of exposure for anything involving abnormalities below the chest? I have seen non-pregnant abdominal pains dismissed AMA because they would not subject themselves to one. Awful.