Am I the dingus?

[Throwaway20205]

60 y/o F pops on the board with cc of "possible stroke".

I go to the room, the patient is in CT, I speak with the husband. She just received a call from her sister and daughter who hate her, and as of 3.75hrs ago she has been having "memory problems" but he denies any other neuro symptoms. I explain his wife will be back from CT soon.

Wife comes back. I do a quick exam. I cannot identify a single subjective or objective focal deficit. I explain that the neurologist will speak with her shortly because there was concern for stroke but it seems exceptionally unlikely. She asks me why there was concern for stroke. I tell her I don't know. I ask her if she used the word stroke in triage. She says yes. I explain that is probably why.

I go and speak with the PA, i'm very nice about it. The PA also thinks this is bull****. The PA went and asked a physician because the patient was so anxious and the attending told her to just call the stroke code and didn't evaluate the patient.

Neurologist does their robot eval and calls me back at 4.5hrs. I can't help but wonder what if this was a real stroke since we've screwed around for an hour and she would now be out of the window. Seems like a pretty bad response time. Then again idk if I believe in TPA. Anyway, neurology tells me they have some concerns about her memory but don't think its a stroke. They're still recommending an MRI and A1C and stuff. Shocker.

I go to the patients room and explain to her she is being admitted. She asks me who I am and why she is being admitted. I tell her we've meet 3 times now and thats why she is being admitted. I still don't believe her at all.

The internist comes down and thinks the admit is silly but is nice enough. She cannot have walked away from my desk for more than 60 seconds before she comes back and tells me the patient and husband do not want to be admitted. Fine with me. But she did make an agreement with them that I would get their MRI Brain before they get discharged from the ED. I fume internally but just say sure.

I call down and make the MRI techs come and get this woman for her emergent MRI. The MRI is done, and read, and its normal. This woman has now been in my ED for 6hrs. I inform her the MRI is normal and we will get her leaving. As they had all these nonspecific neuro recs like the A1C and statin based on LDL that are not being done, I have my nurse sign them out AMA. The AMA form terrifies the husband and patient, and now they demand admission claiming the patient is not at her neurocognitive baseline.

I have a somewhat terse conversation where I explain indications for urgent v. emergent studies, MRI wait times in the community, and how resource mishandling like this is why it takes 6 months for Jimmy to get his outpatient MRI to find out he has brain cancer. The patient makes a literal pouty face like a 6 year old girl and says she feels like she s "getting in trouble". I stare at her for 25 seconds in profound disbelief that this is what society has come to, and tell them I will admit them as was the initial plan.

I page the internist for admission a second time. The internist has reviewed her labs and her UDS is positive for marijuana so thats the diagnosis and now that the MRI has been done there is no reason to admit as there are no further tests that exist for encephalopathy (a complete ****ing lie). She recommends maybe I get a U/A before discharge. I go tell the patient they have to leave and they don't have to sign the form and to followup with PCP. I write a somewhat scathing note passive aggressively damning all involved and how the MRI was inappropriately timed and a waste of ED resources. The internist reads the note then comes down and almost-apologizes-but-not. She states she wants to work as a team and that if I had just pushed harder, she would have admitted. She admits for observation all the time to just "cover for the ED attendings". I rewrite my note to be less of a dick.

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[goodoldalky]

This is just the **** that sometimes happens that infuriates you, try and forget it.

Sounds like transient global amnesia and a good reason to admit, even though the MR is often negative in such cases.

My principles to try and avoid getting in such messes:
1. Never call a consultant without having a plan in my mind that I want them to do. Very rarely I do not have any idea what to do, and in those cases maybe it's a general wide open question. But in 99.9% of cases its "I have a consult in 32, needs admit to medicine for XYZ, etc. etc"
2. Never **** up a good disposition.
3. Never let a consultant **** up a good disposition.

As for point 2 and 3 here, when the IM doc went in to reevaluate the amnestic lady and came back out to inform you they didn't want to be admitted, I would have said, "Oh, well that's too bad, the lady is clearly amnestic and wouldn't be able to provide an informed refusal of care, so she can't sign out AMA - let's go into the room together now and talk to them."

 

[CoolDoc1729]

60 y/o F pops on the board with cc of "possible stroke".

I go to the room, the patient is in CT, I speak with the husband. She just received a call from her sister and daughter who hate her, and as of 3.75hrs ago she has been having "memory problems" but he denies any other neuro symptoms. I explain his wife will be back from CT soon.

Wife comes back. I do a quick exam. I cannot identify a single subjective or objective focal deficit. I explain that the neurologist will speak with her shortly because there was concern for stroke but it seems exceptionally unlikely. She asks me why there was concern for stroke. I tell her I don't know. I ask her if she used the word stroke in triage. She says yes. I explain that is probably why.

I go and speak with the PA, i'm very nice about it. The PA also thinks this is bull****. The PA went and asked a physician because the patient was so anxious and the attending told her to just call the stroke code and didn't evaluate the patient.

Neurologist does their robot eval and calls me back at 4.5hrs. I can't help but wonder what if this was a real stroke since we've screwed around for an hour and she would now be out of the window. Seems like a pretty bad response time. Then again idk if I believe in TPA. Anyway, neurology tells me they have some concerns about her memory but don't think its a stroke. They're still recommending an MRI and A1C and stuff. Shocker.

I go to the patients room and explain to her she is being admitted. She asks me who I am and why she is being admitted. I tell her we've meet 3 times now and thats why she is being admitted. I still don't believe her at all.

The internist comes down and thinks the admit is silly but is nice enough. She cannot have walked away from my desk for more than 60 seconds before she comes back and tells me the patient and husband do not want to be admitted. Fine with me. But she did make an agreement with them that I would get their MRI Brain before they get discharged from the ED. I fume internally but just say sure.

I call down and make the MRI techs come and get this woman for her emergent MRI. The MRI is done, and read, and its normal. This woman has now been in my ED for 6hrs. I inform her the MRI is normal and we will get her leaving. As they had all these nonspecific neuro recs like the A1C and statin based on LDL that are not being done, I have my nurse sign them out AMA. The AMA form terrifies the husband and patient, and now they demand admission claiming the patient is not at her neurocognitive baseline.

I have a somewhat terse conversation where I explain indications for urgent v. emergent studies, MRI wait times in the community, and how resource mishandling like this is why it takes 6 months for Jimmy to get his outpatient MRI to find out he has brain cancer. The patient makes a literal pouty face like a 6 year old girl and says she feels like she s "getting in trouble". I stare at her for 25 seconds in profound disbelief that this is what society has come to, and tell them I will admit them as was the initial plan.

I page the internist for admission a second time. The internist has reviewed her labs and her UDS is positive for marijuana so thats the diagnosis and now that the MRI has been done there is no reason to admit as there are no further tests that exist for encephalopathy (a complete ****ing lie). She recommends maybe I get a U/A before discharge. I go tell the patient they have to leave and they don't have to sign the form and to followup with PCP. I write a somewhat scathing note passive aggressively damning all involved and how the MRI was inappropriately timed and a waste of ED resources. The internist reads the note then comes down and almost-apologizes-but-not. She states she wants to work as a team and that if I had just pushed harder, she would have admitted. She admits for observation all the time to just "cover for the ED attendings". I rewrite my note to be less of a dick.

Sounds like you’re a kind person genuinely trying to do the right thing, against strong headwinds from all directions. I sympathize.

Last night my hospitalist was complaining about soft admissions from our freestanding.

Well, why don’t you discharge them then?

“Why should I take that liability when I don’t have to?”

Why should we !?

It’s not always possible to please the patient, the admitting team and your own conscience … important to be able to sleep at night, or whenever you sleep.

 

[Mount Asclepius]

Maybe just a little crispy and found yourself in a couple of probably needlessly argumentative interactions. If someone else activated a stroke alert without evaluating the patient and you don't feel is necessary, then deactivate. I wouldn't have made the patient leave AMA over checking an A1c and lipid panel. Not worth explaining resource utilization to patients. Don't chart joust. Just don't.

I'll readily admit that your hospitalist continuing to request testing despite declining admission is understandably frustrating. If continued testing necessary then they can admit.

 

[pkwraith]

If the hospitalist wants a MRI that can admit the patient for the MRI

 

[thegenius]

60 y/o F pops on the board with cc of "possible stroke".

I go to the room, the patient is in CT, I speak with the husband. She just received a call from her sister and daughter who hate her, and as of 3.75hrs ago she has been having "memory problems" but he denies any other neuro symptoms. I explain his wife will be back from CT soon.

Wife comes back. I do a quick exam. I cannot identify a single subjective or objective focal deficit. I explain that the neurologist will speak with her shortly because there was concern for stroke but it seems exceptionally unlikely. She asks me why there was concern for stroke. I tell her I don't know. I ask her if she used the word stroke in triage. She says yes. I explain that is probably why.

I go and speak with the PA, i'm very nice about it. The PA also thinks this is bull****. The PA went and asked a physician because the patient was so anxious and the attending told her to just call the stroke code and didn't evaluate the patient.

Neurologist does their robot eval and calls me back at 4.5hrs. I can't help but wonder what if this was a real stroke since we've screwed around for an hour and she would now be out of the window. Seems like a pretty bad response time. Then again idk if I believe in TPA. Anyway, neurology tells me they have some concerns about her memory but don't think its a stroke. They're still recommending an MRI and A1C and stuff. Shocker.

I go to the patients room and explain to her she is being admitted. She asks me who I am and why she is being admitted. I tell her we've meet 3 times now and thats why she is being admitted. I still don't believe her at all.

The internist comes down and thinks the admit is silly but is nice enough. She cannot have walked away from my desk for more than 60 seconds before she comes back and tells me the patient and husband do not want to be admitted. Fine with me. But she did make an agreement with them that I would get their MRI Brain before they get discharged from the ED. I fume internally but just say sure.

I call down and make the MRI techs come and get this woman for her emergent MRI. The MRI is done, and read, and its normal. This woman has now been in my ED for 6hrs. I inform her the MRI is normal and we will get her leaving. As they had all these nonspecific neuro recs like the A1C and statin based on LDL that are not being done, I have my nurse sign them out AMA. The AMA form terrifies the husband and patient, and now they demand admission claiming the patient is not at her neurocognitive baseline.

I have a somewhat terse conversation where I explain indications for urgent v. emergent studies, MRI wait times in the community, and how resource mishandling like this is why it takes 6 months for Jimmy to get his outpatient MRI to find out he has brain cancer. The patient makes a literal pouty face like a 6 year old girl and says she feels like she s "getting in trouble". I stare at her for 25 seconds in profound disbelief that this is what society has come to, and tell them I will admit them as was the initial plan.

I page the internist for admission a second time. The internist has reviewed her labs and her UDS is positive for marijuana so thats the diagnosis and now that the MRI has been done there is no reason to admit as there are no further tests that exist for encephalopathy (a complete ****ing lie). She recommends maybe I get a U/A before discharge. I go tell the patient they have to leave and they don't have to sign the form and to followup with PCP. I write a somewhat scathing note passive aggressively damning all involved and how the MRI was inappropriately timed and a waste of ED resources. The internist reads the note then comes down and almost-apologizes-but-not. She states she wants to work as a team and that if I had just pushed harder, she would have admitted. She admits for observation all the time to just "cover for the ED attendings". I rewrite my note to be less of a dick.

Sorry man. Schit happens sometimes. You didn't do anything wrong. we all get these encounters every now and then.

 

[JacobMcCandles]

Sounds like it was just one thing after another with this patient. Everyone practices differently and it’s easy to say after the fact on what you’d do. Going along with the case, tPA would have never even entered my mind as an option for this patient (I’m with you on the hesitations with the tPA anyway). I probably wouldn’t have spoken with the Neurologist on this case as I already know what they’re likely going to say. It wouldn’t be unreasonable to get the MRI to cover your bases. Signing them out AMA over an A1C and lipid panel wouldn’t have crossed my mind. That’s outpatient stuff all day every day. If you’re calling for admission then you need to be firm. It sounds like she sensed some softness and took advantage. Next time tell her why they’re being admitted and then the conversation is done. If she wants further tests then she can order them.

 

[lymphocyte]

I fume internally but just say sure.

I stare at her for 25 seconds in profound disbelief that this is what society has come to, and tell them I will admit them as was the initial plan.

I write a somewhat scathing note passive aggressively damning all involved and how the MRI was inappropriately timed and a waste of ED resources.

Don't do this. Don't silently fume at consultants and lecture scared patients.

The patient doesn't know any better; the consultant does. Tell the consultant up front that you don't agree with the decision, and then you can have the fight with someone who can actually fight back.

Also don't say yes to everyone and get upset about the outcome. Yes to the neurologist's emergent MRI request. Yes to the patient's request to get readmitted. The moment you agree to something you know is idiotic, you are part of the idiotic decision. Just accept the consequences gladly. You'll feel stronger and more powerful the more agency you embrace.

Otherwise, I completely agree with you and your frustration.

 

[Throwaway20205]

I think a lot of what is being said above is fair. There are some things I would like to address.

1) While I don't believe the patient, and suspect this is psychologic, I generally don't discharge any kind of acute cognitive dysfunction I cannot easily explain away and returns to baseline. Its one thing if they do drugs, or have a profound psychiatric history, or had a first-time seizure. But this woman continued to express intermittent episodes of amnesia. The neurologist was concerned for transient global amnesia, a fact expressed both in his note and to the internist (someone mentioned it above). It was largely for that reason that I had them sign out AMA initially, which admittedly was not what I expressed above. I'm no neurologist so I don't know how complete the work needs to be to rule out some stupid **** that will never be diagnosed in the ED like isolated hippocampal seizure or some profoundly irregular presentation of Wernicke Korsakoff. I guess at some point you accept your life is like a boring version of 50 First Dates. But regardless, thats not my wheelhouse. This 60 year old woman and her husband were very waspy looking, and my dad was still flying planes at 60, so I have no idea what she's going to try to do at home.

2) In general I don't deactivate stroke alerts unless its something really obvious Bell's Palsy. In this circumstance, I was glad the neurologist was involved earlier. What if the internist had pushed back against even needing an MRI when I tried to admit without a neuro consult? (I don't feel an emergent neuro consult was indicated, but I was glad to have one). Maybe this is a little hypocritical, since I went on a small tirade about resource utilization earlier. Also, the neurologist did not push for the MRI in the ED, it was the internist who pressured me into getting it since the patient did not want to stay to wait for it inpatient.

3) I really strongly disagree with the attitude that the patient was blameless in this whole scenario. Coming to the ED for something you're obviously very concerned about, enough to freak out the triage PA, and then turning around and getting bored after your stroke consult and wanting to go home is absurd. Why did you even come in? You should feel bad. Maybe the wife who maybe wasnt all there, but especially the husband who kept enabling her behavior. To say "we wanted to know what the MRI would show before we made a decision" and then readily acknowledge that it didn't effect your decision at all? Its absurd. While maybe I was ruder than I should have been, people should absolutely be aware how wildly inappropriate that behavior is.

 

[throway134]

I think a lot of what is being said above is fair. There are some things I would like to address.

1) While I don't believe the patient, and suspect this is psychologic, I generally don't discharge any kind of acute cognitive dysfunction I cannot easily explain away and returns to baseline. Its one thing if they do drugs, or have a profound psychiatric history, or had a first-time seizure. But this woman continued to express intermittent episodes of amnesia. The neurologist was concerned for transient global amnesia, a fact expressed both in his note and to the internist (someone mentioned it above). It was largely for that reason that I had them sign out AMA initially, which admittedly was not what I expressed above. I'm no neurologist so I don't know how complete the work needs to be to rule out some stupid **** that will never be diagnosed in the ED like isolated hippocampal seizure or some profoundly irregular presentation of Wernicke Korsakoff. I guess at some point you accept your life is like a boring version of 50 First Dates. But regardless, thats not my wheelhouse. This 60 year old woman and her husband were very waspy looking, and my dad was still flying planes at 60, so I have no idea what she's going to try to do at home.

2) In general I don't deactivate stroke alerts unless its something really obvious Bell's Palsy. In this circumstance, I was glad the neurologist was involved earlier. What if the internist had pushed back against even needing an MRI when I tried to admit without a neuro consult? (I don't feel an emergent neuro consult was indicated, but I was glad to have one). Maybe this is a little hypocritical, since I went on a small tirade about resource utilization earlier. Also, the neurologist did not push for the MRI in the ED, it was the internist who pressured me into getting it since the patient did not want to stay to wait for it inpatient.

3) I really strongly disagree with the attitude that the patient was blameless in this whole scenario. Coming to the ED for something you're obviously very concerned about, enough to freak out the triage PA, and then turning around and getting bored after your stroke consult and wanting to go home is absurd. Why did you even come in? You should feel bad. Maybe the wife who maybe wasnt all there, but especially the husband who kept enabling her behavior. To say "we wanted to know what the MRI would show before we made a decision" and then readily acknowledge that it didn't effect your decision at all? Its absurd. While maybe I was ruder than I should have been, people should absolutely be aware how wildly inappropriate that behavior is.

I suppose the sand castle is allowed to be mad at the tide but I don’t think it’s going to change the outcome.

Or what happens the next day.

There are always more dumb, irresponsible people. If you spend your time being mad about it, that’s what your life will be.

I’ve done the stupid workup many times. I’ve also bent over backwards for specialists who spat at me after, especially in my first year out.

Having said that, my response to the internist would be “that’s unfortunate because I have no way to make that happen.” If they want the study made emergent, they can do that themselves.

They basically demanded that a routine study be made emergent (and messed up the night of several mri techs) for no reason. I have no problem messing up the techs night for things they are actually supposed to be there for. This ain’t it.

This is how studies get put behind specialist walls.

 

[ScepticSkeksis]

No reason to get "emergent MRI" in this patient. We all know when a study will be negative as in this case, and the MRI won't change your disposition.

 

[Mount Asclepius]

I think some are overthinking transient amnesia episodes. High likelihood of psychogenic etiology. If transient or you have a negative MRI, send them home. Especially if an emotional stressor. You can’t work up or admit everyone. Neurological complaints are high risk. These aren’t the ones though.

 

[Tiger26]

I rarely see a reason to admit TGA. Obviously easier with a normal MRI, but that's not a stroke. Sounds like it was a soul-sucking case all the way around. Also, I'd rather document a good discussion in my note about patient preferences (including AMA) rather than force them to sign the papers.

 

[NYEMMED]

You are only a dingus for changing the note. I would have left it

 

[Interpolfanclub]

I think some are overthinking transient amnesia episodes. High likelihood of psychogenic etiology. If transient or you have a negative MRI, send them home. Especially if an emotional stressor. You can’t work up or admit everyone. Neurological complaints are high risk. These aren’t the ones though.

I used to send basically all of these home until I had a younger guy bounce back with a bad stroke. And a partner of mine who is a good doc is getting sued on one of these now, we both admit all of these for Tia work ups now. I hate it but in this county I think you’re taking a risk by sending these home. If they’re young with psych history I still do it but for normal people they come in.

 

[TooMuchResearch]

60 y/o F pops on the board with cc of "possible stroke".

I go to the room, the patient is in CT, I speak with the husband. She just received a call from her sister and daughter who hate her, and as of 3.75hrs ago she has been having "memory problems" but he denies any other neuro symptoms. I explain his wife will be back from CT soon.

Wife comes back. I do a quick exam. I cannot identify a single subjective or objective focal deficit. I explain that the neurologist will speak with her shortly because there was concern for stroke but it seems exceptionally unlikely. She asks me why there was concern for stroke. I tell her I don't know. I ask her if she used the word stroke in triage. She says yes. I explain that is probably why.

I go and speak with the PA, i'm very nice about it. The PA also thinks this is bull****. The PA went and asked a physician because the patient was so anxious and the attending told her to just call the stroke code and didn't evaluate the patient.

Neurologist does their robot eval and calls me back at 4.5hrs. I can't help but wonder what if this was a real stroke since we've screwed around for an hour and she would now be out of the window. Seems like a pretty bad response time. Then again idk if I believe in TPA. Anyway, neurology tells me they have some concerns about her memory but don't think its a stroke. They're still recommending an MRI and A1C and stuff. Shocker.

I go to the patients room and explain to her she is being admitted. She asks me who I am and why she is being admitted. I tell her we've meet 3 times now and thats why she is being admitted. I still don't believe her at all.

The internist comes down and thinks the admit is silly but is nice enough. She cannot have walked away from my desk for more than 60 seconds before she comes back and tells me the patient and husband do not want to be admitted. Fine with me. But she did make an agreement with them that I would get their MRI Brain before they get discharged from the ED. I fume internally but just say sure.

I call down and make the MRI techs come and get this woman for her emergent MRI. The MRI is done, and read, and its normal. This woman has now been in my ED for 6hrs. I inform her the MRI is normal and we will get her leaving. As they had all these nonspecific neuro recs like the A1C and statin based on LDL that are not being done, I have my nurse sign them out AMA. The AMA form terrifies the husband and patient, and now they demand admission claiming the patient is not at her neurocognitive baseline.

I have a somewhat terse conversation where I explain indications for urgent v. emergent studies, MRI wait times in the community, and how resource mishandling like this is why it takes 6 months for Jimmy to get his outpatient MRI to find out he has brain cancer. The patient makes a literal pouty face like a 6 year old girl and says she feels like she s "getting in trouble". I stare at her for 25 seconds in profound disbelief that this is what society has come to, and tell them I will admit them as was the initial plan.

I page the internist for admission a second time. The internist has reviewed her labs and her UDS is positive for marijuana so thats the diagnosis and now that the MRI has been done there is no reason to admit as there are no further tests that exist for encephalopathy (a complete ****ing lie). She recommends maybe I get a U/A before discharge. I go tell the patient they have to leave and they don't have to sign the form and to followup with PCP. I write a somewhat scathing note passive aggressively damning all involved and how the MRI was inappropriately timed and a waste of ED resources. The internist reads the note then comes down and almost-apologizes-but-not. She states she wants to work as a team and that if I had just pushed harder, she would have admitted. She admits for observation all the time to just "cover for the ED attendings". I rewrite my note to be less of a dick.

You are not the dingus. However, never again let an admitting service trick you into getting their study done. That patient still wants the MRI because of the hospitalist? Hospitalist can write an admission H&P and follow up on results and discharge the patient in 6 hours if MRI is negative.

 

[TooMuchResearch]

This is just the **** that sometimes happens that infuriates you, try and forget it.

Sounds like transient global amnesia and a good reason to admit, even though the MR is often negative in such cases.

My principles to try and avoid getting in such messes:
1. Never call a consultant without having a plan in my mind that I want them to do. Very rarely I do not have any idea what to do, and in those cases maybe it's a general wide open question. But in 99.9% of cases its "I have a consult in 32, needs admit to medicine for XYZ, etc. etc"
2. Never **** up a good disposition.
3. Never let a consultant **** up a good disposition.

As for point 2 and 3 here, when the IM doc went in to reevaluate the amnestic lady and came back out to inform you they didn't want to be admitted, I would have said, "Oh, well that's too bad, the lady is clearly amnestic and wouldn't be able to provide an informed refusal of care, so she can't sign out AMA - let's go into the room together now and talk to them."

What? The only times I've evaluated a patient with the hospitalist is when there has been an acute change between me seeing the patient and them seeing the patient and they just want me to double check and confirm if there has been a change. Like one time I was admitting someone for some non-specific confusion or something and while waiting for the hospitalist, the patient developed hemiplegia from their massive stroke that I guess hadn't totally occurred when they were initially evaluated.

 

[ScepticSkeksis]

You are not the dingus. However, never again let an admitting service trick you into getting their study done. That patient still wants the MRI because of the hospitalist? Hospitalist can write an admission H&P and follow up on results and discharge the patient in 6 hours if MRI is negative.

The only time the MRI is really needed before admission would be if there's any concern for neurosurgical issue and you don't have neurosurgical coverage. Otherwise just admit and let the hospitalist sort out the MRI in the AM.

 

[goodoldalky]

What? The only times I've evaluated a patient with the hospitalist is when there has been an acute change between me seeing the patient and them seeing the patient and they just want me to double check and confirm if there has been a change. Like one time I was admitting someone for some non-specific confusion or something and while waiting for the hospitalist, the patient developed hemiplegia from their massive stroke that I guess hadn't totally occurred when they were initially evaluated.

This is not about the reevaluation, it’s about getting on the same page with the disposition.

 

[JacobMcCandles]

Too bad you don’t have transient global amnesia about this case.

 

[Clean7795]

I have a somewhat terse conversation where I explain indications for urgent v. emergent studies, MRI wait times in the community, and how resource mishandling like this is why it takes 6 months for Jimmy to get his outpatient MRI to find out he has brain cancer. The patient makes a literal pouty face like a 6 year old girl and says she feels like she s "getting in trouble". I stare at her for 25 seconds in profound disbelief that this is what society has come to, and tell them I will admit them as was the initial plan.

Talk to these sort of patients less, you'll be happier for it. The more you try and explain/reason with them on the job, the younger you're going to have a MI.

I page the internist for admission a second time. The internist has reviewed her labs and her UDS is positive for marijuana so thats the diagnosis and now that the MRI has been done there is no reason to admit as there are no further tests that exist for encephalopathy (a complete ****ing lie). She recommends maybe I get a U/A before discharge.

The internist got you to do the main work-up for them. Afterward there was really no indication for admission.

Also don't get into chart wars. It just raises your own medmal liability.

 

[thegenius]

Talk to these sort of patients less, you'll be happier for it. The more you try and explain/reason with them on the job, the younger you're going to have a MI.



The internist got you to do the main work-up for them. Afterward there was really no indication for admission.

Also don't get into chart wars. It just raises your own medmal liability.

Why? According to who?

Example: You have a patient who has a surgical emergency.

0110: Called surgeon, left VM
0120: Called surgeon again, left VM
0135: Pt deteriorating, giving more interventions
0145: Called surgeon again, discussed case. Surgeon doesn't believe it's a surgical emergency. Asking for <insert unindicated test>. I reviewed again that pt's vital signs, physical exam, and labs all support a surgical emergency. Again surgeon asks for <unindicated test> and will evaluate patient after test is performed. I asked surgeon for a consult in the ED and surgeon again wanted the <unindicated test> before coming in.
0200: Pt deteriorating more, inserted central line and started vasopressors.
0400: <Unindicated test> performed. Called surgeon back. Pt still has a surgical emergency. Surgeon said will evaluate pt in ED.
0530: Surgeon evaluated pt in ED.
0700: Surgeon takes pt to the OR.

Pt dies that night in the ICU.

I'm certainly not writing one consult in the note indicating all of this. Covering up egregious problems like this increases your own medmal risk.

 

[Mount Asclepius]

I write a somewhat scathing note passive aggressively damning all involved and how the MRI was inappropriately timed and a waste of ED resources.

Also don't get into chart wars. It just raises your own medmal liability.

Why? According to who?

Example: You have a patient who has a surgical emergency.

0110: Called surgeon, left VM
0120: Called surgeon again, left VM
0135: Pt deteriorating, giving more interventions
0145: Called surgeon again, discussed case. Surgeon doesn't believe it's a surgical emergency. Asking for <insert unindicated test>. I reviewed again that pt's vital signs, physical exam, and labs all support a surgical emergency. Again surgeon asks for <unindicated test> and will evaluate patient after test is performed. I asked surgeon for a consult in the ED and surgeon again wanted the <unindicated test> before coming in.
0200: Pt deteriorating more, inserted central line and started vasopressors.
0400: <Unindicated test> performed. Called surgeon back. Pt still has a surgical emergency. Surgeon said will evaluate pt in ED.
0530: Surgeon evaluated pt in ED.
0700: Surgeon takes pt to the OR.

Pt dies that night in the ICU.

I'm certainly not writing one consult in the note indicating all of this. Covering up egregious problems like this increases your own medmal risk.

This isn’t the same thing. I would have phrased your example slightly differently, but it’s still not quite the same thing as what was implied by the OP.

Chart jousting raises everyone’s liability. As soon as lawyers have an example of doctors pointing fingers at each other, they have an indication something was done wrongly and pseudo free expert witness testimony. A jury of not our peers often can’t discriminate accurately which physician was in the wrong. The wrong physician could be held liable, or even both liable.

Don’t chart joust. Keep it accurate and objective, which I know is what you were trying to do with your example. It’s a better example than what the OP implied.

Also remember it’s primarily the patient’s record and not primarily a venue for conveying side party frustrations.

 

[RoyBasch]

Why? According to who?

Example: You have a patient who has a surgical emergency.

0110: Called surgeon, left VM
0120: Called surgeon again, left VM
0135: Pt deteriorating, giving more interventions
0145: Called surgeon again, discussed case. Surgeon doesn't believe it's a surgical emergency. Asking for <insert unindicated test>. I reviewed again that pt's vital signs, physical exam, and labs all support a surgical emergency. Again surgeon asks for <unindicated test> and will evaluate patient after test is performed. I asked surgeon for a consult in the ED and surgeon again wanted the <unindicated test> before coming in.
0200: Pt deteriorating more, inserted central line and started vasopressors.
0400: <Unindicated test> performed. Called surgeon back. Pt still has a surgical emergency. Surgeon said will evaluate pt in ED.
0530: Surgeon evaluated pt in ED.
0700: Surgeon takes pt to the OR.

Pt dies that night in the ICU.

I'm certainly not writing one consult in the note indicating all of this. Covering up egregious problems like this increases your own medmal risk.

Don't worry, regardless of what you chart, peer review will determine the emergency physician's "failure" to recognize the severity of the condition and appropriately express the gravity of the problem to the specialist is the prime error.

 

[thegenius]

This isn’t the same thing. I would have phrased your example slightly differently, but it’s still not quite the same thing as what was implied by the OP.

Chart jousting raises everyone’s liability. As soon as lawyers have an example of doctors pointing fingers at each other, they have an indication something was done wrongly and pseudo free expert witness testimony. A jury of not our peers often can’t discriminate accurately which physician was in the wrong. The wrong physician could be held liable, or even both liable.

Don’t chart joust. Keep it accurate and objective, which I know is what you were trying to do with your example. It’s a better example than what the OP implied.

Also remember it’s primarily the patient’s record and not primarily a venue for conveying side party frustrations.

I agree with that. I don't chart arguments and greviances, but I do chart things like what happened above. 100%. At the end of the day I need to preserve my license and I will tell the truth the way I see it, and will defend myself in court if it ever gets to that point.

I also chart stuff about patients yelling at me, swearing at me, making threatening remarks about me, etc.

 

[thegenius]

Don't worry, regardless of what you chart, peer review will determine the emergency physician's "failure" to recognize the severity of the condition and appropriately express the gravity of the problem to the specialist is the prime error.

Right...the defense of "oh if the ER doctor had just said 'peritonitis' or BP of 80/40, then I would have come in immediately."

LULZ.

that's why I put that **** in the chart, because I do tell them that stuff.

 

[RoyBasch]

Right...the defense of "oh if the ER doctor had just said 'peritonitis' or BP of 80/40, then I would have come in immediately."

LULZ.

that's why I put that **** in the chart, because I do tell them that stuff.

I've just accepted at this point we get blamed for everything.

To the kids reading at home, if you want/need respect and accolades from other physicians and powers that be in the house of medicine: Emergency medicine is not the specialty for you.

You have to be honest with yourself if you managed a case well or not. You certainly wont get accurate validation from the rest of the medical society which doesn't fundamentally understand what we do.

The rest of the hospital administration views us as more expendable meat shields they would throw away in a second to protect the integrity of a more lucrative service line such outpatient surgery, cardiac catheterization, endoscopy, chronic infusion therapy, etc.

or more succinctly put by Upton Sinclair: "

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”​

 

[Splenda88]

The leaving AMA was unnecessary IMO. IM should have admitted the patient or you could have discharged her.

I am happy to admit these kind of patients as a hospitalist instead of a 90 y/o with dementai/AMS, respiratory failure, septic shock on 20 meds.

I don't know if it's a good idea to write passive aggressive notes in a legal document.

I think the patient/husband were mainly the issue here but I believe you could have handled the situation better.

 

[ScepticSkeksis]

The leaving AMA was unnecessary IMO. IM should have admitted the patient or you could have discharged her.

I am happy to admit these kind of patients as a hospitalist instead of a 90 y/o with dementai/AMS, respiratory failure, septic shock on 20 meds.

I don't know if it's a good idea to write passive aggressive notes in a legal document.

I think the patient/husband were mainly the issue here but I believe you could have handled the situation better.

I've never understood the pushback. These are low-complexity, easy admits for you guys. They neuro consult + MRI in the AM then usually discharge on Aspirin and Plavix.

 

[throway134]

I've never understood the pushback. These are low-complexity, easy admits for you guys. They neuro consult + MRI in the AM then usually discharge on Aspirin and Plavix.

To some extent you could apply this answer to the op.

Why give a **** about the tga weak neuro story someone started a neuro workup on?

Just admit for mri and be done, the momentum on this is already outside your control unless you want to waste two hours and piss everyone involved off. As above, I would leave decisions on emergent imaging (and the work of getting it done) to the admitting team, but if you did do it and it’s negative just dc. Unless you totally missed the boat there’s no liability on this case because there isn’t anything wrong, and it’s ms. Pouty faces bankruptcy not yours.

If you feel super skittish about dc, call mr./mrs Neuro back and do whatever she/he says (probably outpt follow up with pmd is fine, vs maybe a one off with a neuro person).

Better yet, make the pa who started all this crap do all the phone calls.

 

[Splenda88]

I've never understood the pushback. These are low-complexity, easy admits for you guys. They neuro consult + MRI in the AM then usually discharge on Aspirin and Plavix.

I don't understand it either. I have argued to the ones that I am friends with and they haven't change their attitude on these easy admits. I always welcome these easy admits.

 

[ScepticSkeksis]

I don't understand it either. I have argued to the ones that I am friends with and they haven't change their attitude on these easy admits. I always welcome these easy admits.

Typically don't most of you get extra $$$ if you do more admits? I get there's a point where the extra work causes burnout, but these are way simpler than the quasi-septic 90 year old confused patient who needs Intermediate care unit due to soft pressures.

 

[Splenda88]

Typically don't most of you get extra $$$ if you do more admits? I get there's a point where the extra work causes burnout, but these are way simpler than the quasi-septic 90 year old confused patient who needs Intermediate care unit due to soft pressures.

My place is straight salary. We have no incentives or RVUs structure.

 

[ScepticSkeksis]

My place is straight salary. We have no incentives or RVUs structure.

Oh that makes sense then. The socialist plan encourages work avoidance in some people....

 

[CoolDoc1729]

Better yet, make the pa who started all this crap do all the phone calls.

Our midlevels would call my chair saying we were being “mean” - it wouldn’t even be worth trying lol. This whole mess sucks.

 

[throway134]

Our midlevels would call my chair saying we were being “mean” - it wouldn’t even be worth trying lol. This whole mess sucks.

That’s absurd, but I understand culture can be really variable. I’m not a jerk about it but my general expectation has always been that if you can order the consult you can talk to the consultant.

Last place I worked banished midlevels from speaking to icu, based on the somewhat reasonable expectation of a doc to doc discussion if someone is critically Ill, but even that was silly for the whiff of dka who “can’t go to floor” because a floor nurse did a bad boo-boo 40 years ago with an insulin drip.

 

[RustedFox]

Our midlevels would call my chair saying we were being “mean” - it wouldn’t even be worth trying lol. This whole mess sucks.

*Memories of my last gig.*

"We want to be treated as equals! Blah blah SKILL SET blah blah TOP of my LICENSE blah blah."

Okay. Do the thing.

"Waaahhhh! MeAnIE! *Cries in PLP*."

 

[CoolDoc1729]

*Memories of my last gig.*

"We want to be treated as equals! Blah blah SKILL SET blah blah TOP of my LICENSE blah blah."

Okay. Do the thing.

"Waaahhhh! MeAnIE! *Cries in PLP*."

Yeah it’s the equal equal equal then WeLl iM nOt ThE dOcToR when something goes wrong that irritates me the most - if they just did appropriate things and ask when they don’t know what to do that would be wonderful. We have one that is excellent, two that are decent and then like 6 bad ones. Two lazy and four that just randomly go rogue 🤦🏻‍♀️

 

[EctopicFetus]

Yeah it’s the equal equal equal then WeLl iM nOt ThE dOcToR when something goes wrong that irritates me the most - if they just did appropriate things and ask when they don’t know what to do that would be wonderful. We have one that is excellent, two that are decent and then like 6 bad ones. Two lazy and four that just randomly go rogue 🤦🏻‍♀️

Things change when you are their boss. The 4 crappy ones would be fired. Especially in hard to staff places with high physician turnover they think they are the kings.

 

[BoardingDoc]

Things change when you are their boss. The 4 crappy ones would be fired. Especially in hard to staff places with high physician turnover they think they are the kings.

Agreed. I really like our PAs. They're all quite clever and more importantly they know what they don't know and seek out help whenever needed but don't bug me for the small stuff. Not all of them have been that way. The ones that weren't no longer work here.

 

[thegenius]

Everytime I see the title of this thread on the EM forum homepage, I read it as "Am I Evil?" from Metallica