Espresso: The Emergency Department Consult
/Why do patients come to the ER with GYN complaints?
A whole host of reasons! But some of the most common:
Bleeding irregularities – heavy bleeds, mistimed bleeds, unusual bleeding
Pain – PID, ovarian cysts, ectopic pregnancy, ovarian torsion, endo, non GYN pain issues
Infections – Bartholin’s and other cysts, UTIs, PID
Urinary complaints – most often retention or incomplete voiding
OB - patients who haven’t established prenatal care, or otherwise sick OB patients (trauma, medical issues) may be first evaluated in the ED
Sexual assault and injuries, such as lacerations
Before the Consult: What the EM Clinician Should Do
Normal EM things – obtaining your acute history and HPI, vital signs, physical exam, and getting the “sick vs not sick” intuition.
Consider pregnancy test and pelvic exam as part of your basics.
Pregnancy tests should mostly be protocolized for appropriate patients in EDs, but also frequently missed in the evaluation of reproductive-aged patients.
If positive – be sure that your labs include a type-and-screen for Rh status, and likely plan on an ultrasound (especially if the diagnosis of pregnancy is new).
Pelvic exams are controversial, and we see the argument:
OBs are specialized in performing the exam, and we’re likely to repeat it.
However, particularly with bleeding – having a sense of whether the bleeding is light, moderate, or heavy/rapid helps us triage the consult urgency and a differential!
Contraindications to digital pelvic exam –
Suspected rupture of membranes at 34 weeks or less (unless laboring);
Bleeding in pregnancy without confirmation of placental location.
OB residents – this is a long-standing controversial issue and training / advice will differ based on region and one’s own biases.
If it hasn’t been done and you can’t go to evaluate immediately, ask kindly for it to be performed and for a call back if the bleeding is concerning.
EMs, consider bouncing back with your OB/GYN colleagues when they do a pelvic exam!
Getting to do these exams and then comparing your findings will help you to gain comfort with making calls when you’re in the community on your own!
What constitutes an emergency consult?
Sometimes, things can’t wait!
If you have clinical suspicion of ovarian torsion or ruptured ectopic pregnancy, those are surgical emergencies and so merit a rapid response from your GYN colleagues.
Heavy vaginal bleeding (>1 maxipad per hour) and/or hemodynamically unstable patient – can range from ectopic pregnancies to gynecologic cancers - need an expert in exam present to help triage.
Major OB traumas – ideally, this should prompt OB to be present at the time of patient arrival or rapidly.
The “sick” OB patient – this should also prompt OB to be present rapidly, especially if the patient is “viable” or the uterus is at/above umbilicus. Considerations for delivery might need to be made.
Common reasons for this could be DKA in pregnancy, sepsis in pregnancy or septic abortion, or other decompensated illness.
Framing the ED Consult
For our EM colleagues, we love the mnemonic BLUF: bottom line, up front.
“This is a consult for possible ectopic and hemodynamic instability” immediately grabs our attention.
Follow with that history though so we can help:
Gs and Ps – even we mess these up, so just sharing some important pregnancy history can be more helpful (i.e., G3P0020 is less helpful than “two prior ectopics.”)
Nature of presenting complaint: as you normally would
Vitals / hemodynamic status
Laboratory and imaging evaluation done or ongoing
In the less-emergent patient, lead off with your BLUF by starting with the specific question or ask:
I.e., “This is a consult for a pregnancy of unknown location, and we need your assistance in confirming the findings and coordinating follow up.”
For our OB colleagues, help facilitate this conversation:
Ask for the BLUF – “before we get to her history, can you tell me what your primary clinical concern or question is? That just helps me to triage more appropriately.”
Recognize you’re not going to always get a history or question on a silver platter.
Formulate your differential even if it seems like a slam dunk – and make sure you’re asking the right questions to get there
For instance, common misses include pregnancy tests, Rh status.
When in doubt, go see the patient faster! You’re the expert here and your expertise is being requested.
Follow up with colleagues after you see the patient, or even better as you are getting ready to see them – particularly at training facilities, your EM resident colleagues may want to go see the patient again with you to get confirmatory findings, pearls of wisdom for their independent practice, and help with counseling.