Payal Shah, PA-C
While studying for my CAQ, I learned many different things. Some while sitting down and answering review questions, others while actually on shift from my peers, attendings and consultants. I can discuss a plethora of information about everything I have learned, but I think the three most relevant things are:
1) Treat the patient, not the number
2) The proper location to incise a bartholin cyst/abscess
3) How to effectively use certain screening tools.
Treat the patient not the number
Patients with a leukocytosis need antibiotics ASAP. A patient coming in with a BP 220/110 with a shoulder dislocation needs blood pressure medicines STAT. A patient with a blood pressure of 60/40 but mentating appropriately needs pressors IMMEDIATELY. I have seen many different patients with these scenarios. Before jumping the gun and ordering all those medicines – see the patient! Get the history and then base your assessment and plan from there.
The patient with leukocytosis may have just gotten a steroid injection into their arm and be without any systemic symptoms. The leukocytosis could be reactive from the cortisone. The patient who has an elevated BP and has a shoulder dislocation. The blood pressure likely could be from pain. Treat the pain and the dislocation and see if that changes the BP. Consider a bigger workup only IF IT IS INDICATED.
The patient with hypotension but appropriately mentating, get that history to see if this is their normal, REPEAT THE VITALS and then decide if we need to push fluids, do a sepsis work up before jumping to pressors to increase the BP. I cannot stress enough that numbers by themselves should not be an indication of medications before evaluating the patient, and even then, use your clinical judgment to decide to start the antibiotics, start the anti-hypertensives, or the pressors.
Where to incise to drain a bartholin cyst
I know how it sounds, it is an abscess- just on the bartholin gland – how much different could it be? PA school did not teach how to properly drain a bartholin cyst. I did not really see much of them while on rotations, and the 1-2 that I had at my first job – I barely got drainage from – and I did not why. I started studying for my CAQ and at my current job, we have a population where we saw a bartholin cyst abscesses AT LEAST once a shift. Studying for the CAQ narrowed by focus and showed me what I was doing wrong.
I realized the technique I thought I was doing correctly was completely wrong. The location of the incision does matter in this case of an incision and drainage. Below, you can see the bartholin cyst. The first few I had to drain, I was cutting into the outer skin area of the cyst, instead of the mucosa you should incise on the inner aspect of the cyst (the second image). Once I learned that, my incision and drainages were successful every time.
Screening tests are screening tests
In a perfect world, we would be able to scan every patient without the risks of radiation and without any delay or space issues in the ED. However, we do not live in a perfect world. Radiology studies can take hours to be resulted. This delays care in an environment that is meant to be fast paced and quick. Many evidence-based clinical decision rules have been published. You should use them to reduce unnecessary testing. There are many out there, and I’ll cover a few that I use most often in the Emergency Department. These translate well to primary care and urgent care settings as well. They are very quick to use with a high sensitivity. Examples of these screening tests are: Canadian Head CT, NEXUS criteria for Cspine injuries, Ottawa Ankle Rules, Well’s Criteria, Centor Criteria, and PERC rule for PE risk stratification.
While all of these are great screening tests, at the end of the day, they are still screenings. If there is a high pre test probability or your gestalt is telling you to move forward with imaging or testing, DO IT.
Canadian CT head rules
This rule has 70% sensitivity in ruling out intracranial injuries that may require neurosurgical intervention without doing a CT scan. It applies to patients coming in with minor head injuries and a Glasgow coma scale between 13-15 with disorientation, loss of consciousness OR amnesia about the event. We cannot apply this rule if the patient is less than 16 years old, is on any blood thinners, or had a seizure after the injury. If patient does not have any of these criteria, then we can move forward with using the Canadian Head CT rules.
Nexus Criteria for C-spine Injuries
The Nexus criteria is used for stable trauma patients to rule out spinal injury without radiology. It is a great screening tool that detects 99% of spinal injuries.
Ottawa Ankle Rules
I’m more of a visual learner, so this image below helps me whenever I need a refresher on the ankle rules. Correctly applying these rules can reduce unnecessary imaging by almost 30%.
Centor Criteria for Strep Pharyngiits
This is used for patients with <3 days of pharyngitis symptoms. Patient testing criteria is based on the number of points they score. This also allows for clinical management without testing.
Well’s Criteria for Pulmonary Embolism
Similar to the Centor criteria, the Well’s criteria for PE is a points based system. When applied correctly it can help determine if patient can be safely cleared from having a PA, needs a d-dimer, or needs a formal study.
PERC Rule for PE risk stratification
The PERC rule can be applied after a pre test probability is less than 15% using the simplified Well’s score. If any positive, then move to the PERC rules. Answering “no” to all 8 PERC criteria allows your patient to be cleared from having a PE without imaging or testing. Any yes answer on the PERC criteria will require that you order a study. There are some other criteria that will exclude this decision rule, so make sure you know these!
While studying for an exam such as the CAQ, everyone will take away different things from it. Based on their own personal experiences, clinical and otherwise, we will all remember various topics better than others. These are the three biggest things I have learned, and apply to my ER work daily. Remember what you learned, but trust your gut. If something seems off, run the tests and do the imaging. Every patient is an opportunity to learn!
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