Vaginal Bleeding Algorithm for the ED

Via ER Stories, a reminder of the flow chart every EM resident is taught…


Nicely done…

HT: MovinMeat


  1. Elegantly simple. It’s simplicity belies the complexity of interpreting patient history, vital signs, hematocrit, Beta HCG levels and ultrasound findings +/- a pelvic exam in cases that don’t neatly fit (like trauma and rape). May be a bit out of date for stable ectopics, who are more often than not managed medically than surgically these days.

    If a woman is stable but not clearly an intrauterine pregnancy and not yet in the discrimintory zone for ruling out an ectopic, just telling her to follow up with her gyn may not get her the follow up care in a timely enough fashion to diagnose the ectopic before it ruptured. Where I was trained, every single pregnant patient who presented to the ER was required to be seen by a gyn resident. (That would move the “not my problem right up to the top of your chart..) We kept what we called a “Beta log” to track these women from the ER whose pregnancy locations were not clear at ER discharge. In doing so, we prevented many a ruptured ectopic by following up with them till we knew the outcomes. I don’t know that this is possible in a community setting without residents, but it might be worth doing some follow up one of these days on the outcomes of your pregnant “I don’t cares” to see how many end up coming back to you or elsewhere with a ruptured ectopic that might have been prevented.

    Just a thought…


    It still means you don’t care, I know. But what you do with the I don’t cares is and important part of the flowchart.

  2. Apparently, some people a) don’t get humor and b) are simplistic enough to think Emergency Medicine is practiced by joke flowcharts.

    Step back, take a deep breath. If you don’t get the joke, that’s fine, but it’s still a joke.

  3. I get that it’s funny.

    But if you read Moving Meat and Er Stories posts about it, they actually discuss it’s value clinically as an algorithm. Moving Meat goes of into a discussion about the role of a pelvic exam in the evaluation of vaginal bleeding, and ER Stories talks about how the algorithm is useful to him when things get complicated. My comments were meant in that vein – to use the joke as a jumping off point to join the discussion of vaginal bleeding management. Maybe I should have posted my comment over on their sites instead. I didn’t mean to distract from your humor…