GOMERS

[RustedFox]

GOMERS
GOMERS
GOMERS
GOMERS
GOMERS
GOMERS
GOMERS
GOMERS
GOMERED.

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[RustedFox]

All damn shift long. Get me out of heeeere.

 

[Tenk]

I feel like you should be at peace with them by now.

 

[RustedFox]

I feel like you should be at peace with them by now.

It wasn't this bad last month.
90% of my patients are just seniors who are "having a bad day" and don't know what else to do besides come here because they have no coping skills and nothing else to do. It helps that they all have some chronic disease process.

Lets run the board. Here are the ages.

91.
22 (kidney stone, now discharged)
72
73
63
58
62
77
87
89
82

 

[RustedFox]

Just checked in: "My foley might not be working, but its working; I don't know."

EDIT: It was working just fine.

Seriously seniors... the ER is not the place to come just to check and see how your chronic disease process is doing. Knock it off.
Go get a cat.

 

[DocEspana]

I'm doing a lot of urgent care shifts because my CMG just purchased a chain of them and a lot of the previous staff quit (which I get. Old owners offered retirement benefits and it was mostly staffed by older docs pulling off a retirement move). So now I'm essentially 33% UC shifts since its basically free money for me to cover their gaps in staffing.

Anyway - I never knew people in their 20s and 30s could be GOMERs. GOMUCs? Whatever. I get the "my throat is sore" or "is it covid" is the bread and butter. I accepted that. But so many people show up for 6-8 months of "I just don't feel like myself lately. Do you know what I mean?" I don't.

"Can you review all of my medications and confirm that my primary doctor is treating my lipodiabetension correctly?" I think it would work better without the sleeve of girl scout cookies you brought with you into the exam room.

"I know you will be the person to correctly diagnose why it always burns when I pee and I swear I have pus coming from my pee hole even though you can't see it - despite the fact that my urine is always sterile, my STD panel is always negative, and I have been through first, second, and third line STD therapies for all crotch rot varietals already. I have faith in you - eighth doctor in 3 months." I appreciate your respect for my penis expertise, but it may be misplaced.

Get out of my urgent care so I can get back to ordering POC covid and flu (+/- strep) from my seat while I slowly develop a gluteal pressure ulcer.

 

[Brigade4Radiant]

Since I’m RVU I just look at these patients as job security

 

[Saddleshoes]

Hour Of God Rule #1: Gomers don't die.

 

[s/p epilepticus]

90% of my patients are just seniors who are "having a bad day" and don't know what else to do besides come here because they have no coping skills and nothing else to do

ICD-10-CM Diagnosis Code Z73.89 - Other problems related to life management difficulty

Z73.89 is a billable diagnosis code used to specify other problems related to life management difficulty. Synonyms: able to perform food and/or nutrition skill with

icdlist.com

 

[BoardingDoc]

"Can you review all of my medications and confirm that my primary doctor is treating my lipodiabetension correctly?" I think it would work better without the sleeve of girl scout cookies you brought with you into the exam room.

One of my last UC shifts ever was where I had to go back into a room like 5 times because I aggroed some Karen and on one return visit she said she couldn't understand why I didn't take the time to "go over all of her individual medications and confirm how she was doing with them." I said that I had literally never done that with a patient in my life and that we don't do that in urgent care. I haven't worked urgent care in over 2 years now and my sanity has improved considerably.

UC: So you have insurance and some sort of neurosis? C'mon in!

 

[Tenk]

One of my last UC shifts ever was where I had to go back into a room like 5 times because I aggroed some Karen and on one return visit she said she couldn't understand why I didn't take the time to "go over all of her individual medications and confirm how she was doing with them." I said that I had literally never done that with a patient in my life and that we don't do that in urgent care. I haven't worked urgent care in over 2 years now and my sanity has improved considerably.

UC: So you have insurance and some sort of neurosis? C'mon in!

That would have been a perfect moment for my favorite one liner: “We don’t do that here.”

 

[Tipsy McStagger]

You guys need to legalize recreational marijuana and hand it out to them during the dc process. "When you're thinking of coming in, smoke this instead."

"hungry, happy, sleepy" - Kat Williams

 

[wareagle726]

"hungry, happy, sleepy" - Kat Williams

Excellent reference.

 

[JacobMcCandles]

Just wait until Millennials and Gen Z are old. You think the elderly come to the ER a lot now...

 

[CajunMedic]

Just wait until Millennials and Gen Z are old. You think the elderly come to the ER a lot now...

Old? Heck, I'm seeing a ridiculous amount of them now. Every cough, cold, runny nose, sore throat, bump, nick, manscaping accident, muscle cramp, chest wall pain; ad infinitum ad nauseam. Apparently the concept of over-the-counter medications, band aids, and ice packs are completely foreign.

 

[thegenius]

"Can you review all of my medications and confirm that my primary doctor is treating my lipodiabetension correctly?" I think it would work better without the sleeve of girl scout cookies you brought with you into the exam room.

"No. That is not a service offered at any Urgent Care / Emergency Department."

I say that at least 1-2x / shift.

 

[RuralEDDoc]

One of my last UC shifts ever was where I had to go back into a room like 5 times because I aggroed some Karen and on one return visit she said she couldn't understand why I didn't take the time to "go over all of her individual medications and confirm how she was doing with them." I said that I had literally never done that with a patient in my life and that we don't do that in urgent care. I haven't worked urgent care in over 2 years now and my sanity has improved considerably.

UC: So you have insurance and some sort of neurosis? C'mon in!

“Sir or madam, I went to a powerhouse residency that literally trained me to not care about that nonsense. Good day”

 

[Boatswain2PA]

ICD-10-CM Diagnosis Code Z73.89 - Other problems related to life management difficulty

Z73.89 is a billable diagnosis code used to specify other problems related to life management difficulty. Synonyms: able to perform food and/or nutrition skill with

icdlist.com

Unfortunately...Unacceptable as principle diagnosis

 

[medninja]

Let’s not gove the young and relatively healthy a free pass here. Sure, elderly, week and dizzy is a daily nightmare, but I constantly have to bite my tongue when seeing a young, healthy pt who’s had more ED visits in the last two weeks than most responsible adults make in their lives. “Why does my vagina smell?” That BV is between you and your God. You need an exorcism more than another round of Flagyl. Moreover, you need to get out of the ED and never come back.

 

[Alvarez13]

You guys need to legalize recreational marijuana and hand it out to them during the dc process. "When you're thinking of coming in, smoke this instead."

"hungry, happy, sleepy" - Kat Williams

Marijuana hyperemesis in a gomer, brilliant...

 

[Fox800]

Dude, you live in GOMERland, USA. Idk what you expect?

I don't think I could work and live in a medicolegal hellhole where the average patient age is "The Cryptkeeper from Tales from the Crypt".

I love that the cartoon sun is basically Carl from Aqua Teen Hunger Force.

 

[Apollyon]

Unfortunately...Unacceptable as principle diagnosis

Right. I used to use another Z code, which was "unspecified psychosocial circumstance". I was later told by a coder that using that Z code would, on a solid level 5 chart (like pedestrian struck), downcode it by one. So your solid 5 became a 4.

 

[HemorrhagicShock]

Right. I used to use another Z code, which was "unspecified psychosocial circumstance". I was later told by a coder that using that Z code would, on a solid level 5 chart (like pedestrian struck), downcode it by one. So your solid 5 became a 4.

This makes no sense to me. Why would an otherwise great level 5 chart (with appropriate and supporting documentation) be reduced by ADDING to it? I assume for the CPT 2023 changes this doesn't really matter anymore, but I am nowhere close to an expert on the subject

 

[RustedFox]

ALL of those cartoons are 100% accurate.
Florida is absolutely pants-on-head crazy.
That cat.... DJ Kitty is an official Rays mascot.

 

[RustedFox]

That mini-mall sign especially.
The haphazard amalgamation of storefronts that make limited at best sense when put together.
Yep. You... you got it right.

 

[TooMuchResearch]

Just wait until Millennials and Gen Z are old. You think the elderly come to the ER a lot now...

Insert "I can't even" meme.

 

[CajunMedic]

Let’s not gove the young and relatively healthy a free pass here. Sure, elderly, week and dizzy is a daily nightmare, but I constantly have to bite my tongue when seeing a young, healthy pt who’s had more ED visits in the last two weeks than most responsible adults make in their lives. “Why does my vagina smell?” That BV is between you and your God. You need an exorcism more than another round of Flagyl. Moreover, you need to get out of the ED and never come back.

Best door to dispo time I ever had as an attending was one of these, 23 y/o male, 8th visit in 6 days with multiple negative workups for chest and belly pain, 41 total visits in roughly 5 weeks. Always came to my shop at night via EMS, and goes across the state line by EMS during the day. What really pissed me off was, he had literally been in the department with his wife all day and did this not even 3 hours after she had been discharged.

I went out to triage and asked “How is this any different than any of your previous 8 visits?” “It’s not.” “Have you contacted any of the referrals for follow up?”, “no”, “Well, you’ve had multiple negative workups for emergent medical conditions this week, there’s been no change, and your vital signs are better than mine…Call your ride, you’re discharged” and I went back and put in the D/C. Total time: 17 minutes. He had the nerve to ask the triage nurse, referring to me: “can’t he get into trouble for doing this?” Who replied: “nope, all you have to get is a screening exam, which you just got and you don’t have an emergent condition, so you can be discharged”

 

[DocEspana]

Dude, you live in GOMERland, USA. Idk what you expect?

I don't think I could work and live in a medicolegal hellhole where the average patient age is "The Cryptkeeper from Tales from the Crypt".

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I love that the cartoon sun is basically Carl from Aqua Teen Hunger Force.

That shopping center is 18 minutes away from me. But that billboard is NOT there. Literally everything else, including the murderous muscovy duck, is exactly as pictured.

 

[Apollyon]

This makes no sense to me. Why would an otherwise great level 5 chart (with appropriate and supporting documentation) be reduced by ADDING to it? I assume for the CPT 2023 changes this doesn't really matter anymore, but I am nowhere close to an expert on the subject

I don't know. ICD? Gubmint?

 

[door_to_balloon_knot]

Since I’m RVU I just look at these patients as job security

I like the cut of your jib mate.

 

[allantois]

Follow rule #13

 

[thegenius]

Best door to dispo time I ever had as an attending was one of these, 23 y/o male, 8th visit in 6 days with multiple negative workups for chest and belly pain, 41 total visits in roughly 5 weeks. Always came to my shop at night via EMS, and goes across the state line by EMS during the day. What really pissed me off was, he had literally been in the department with his wife all day and did this not even 3 hours after she had been discharged.

I went out to triage and asked “How is this any different than any of your previous 8 visits?” “It’s not.” “Have you contacted any of the referrals for follow up?”, “no”, “Well, you’ve had multiple negative workups for emergent medical conditions this week, there’s been no change, and your vital signs are better than mine…Call your ride, you’re discharged” and I went back and put in the D/C. Total time: 17 minutes. He had the nerve to ask the triage nurse, referring to me: “can’t he get into trouble for doing this?” Who replied: “nope, all you have to get is a screening exam, which you just got and you don’t have an emergent condition, so you can be discharged”

I do this too it is so nice. I don't even ask how are your symptoms different from before. I just see the chief complaint on the board and if it's the same as priors, I just say "I'm sorry we can't help you anymore."

 

[dchristismi]

The Billboard is one of many dotting I-4, I-75, I-95... and practically every other highway. The murderous muscovies are everywhere, although I could have sworn the sinkhole Publix was the one here (it took over 6 months to fill the gigantic hole in the parking lot, although that was some time ago.)

And the Publix always anchors the mini mall. But yeah, the photo is spot on. Sigh.

 

[Interpolfanclub]

Dude, you live in GOMERland, USA. Idk what you expect?

I don't think I could work and live in a medicolegal hellhole where the average patient age is "The Cryptkeeper from Tales from the Crypt".

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I love that the cartoon sun is basically Carl from Aqua Teen Hunger Force.

Can confirm, I trained in FL. All of this is true. The whole state is just insane, old people, young people, everyone.

 

[Interpolfanclub]

I do this too it is so nice. I don't even ask how are your symptoms different from before. I just see the chief complaint on the board and if it's the same as priors, I just say "I'm sorry we can't help you anymore."

Me too. 19 years old and 11 visits for chest pain in two months? No tests, discharge. And I look at a recent note from another hospital and people are still working them up with trops xrays etc. What are you looking for, they've had it all. I'm risk averse but not that risk averse, just DC them.

 

[bravotwozero]

Some of those young characters need to get tossed out of the ED like Jazz from uncle Phil’s mansion on the fresh Prince - enforced by federal mandate.

 

[CoolDoc1729]

Me too. 19 years old and 11 visits for chest pain in two months? No tests, discharge. And I look at a recent note from another hospital and people are still working them up with trops xrays etc. What are you looking for, they've had it all. I'm risk averse but not that risk averse, just DC them.

I present it to people in a collaborative way and they rarely argue. If they do. I don’t care. I order the tests and move on with my life. But I’d say legit 95% of the time they happily leave with no testing.

“You know, it looks like your evaluation was pretty thorough the other x times you’ve come in for this. Every time you come in we have the same tests available for y complaint. You’ve had all of them. If you want to have them again I don’t mind, but the results are probably going to be the same. What you really need is follow up for abc tests with your doctor. I don’t have those here. So what would you like to do?”

 

[thegenius]

I present it to people in a collaborative way and they rarely argue. If they do. I don’t care. I order the tests and move on with my life. But I’d say legit 95% of the time they happily leave with no testing.

“You know, it looks like your evaluation was pretty thorough the other x times you’ve come in for this. Every time you come in we have the same tests available for y complaint. You’ve had all of them. If you want to have them again I don’t mind, but the results are probably going to be the same. What you really need is follow up for abc tests with your doctor. I don’t have those here. So what would you like to do?”

I don't even bother. If you have come to the ER 10 times in 2 months for the same problem, there is nothing to collaborate on. It is better to tell them the truth which is "This Emergency Department, and the ER system in general, can no longer help you for your medical complaint. If you want help, you have to find other doctors."

And just leave.
Don't let them ask questions.
If they bitch and complain, I would immediately call security to have them escorted out.

Every single time these people are heard, or have a test run, or are given a medicine, they will come right back.

 

[RuralEDDoc]

“You know, it looks like your evaluation was pretty thorough the other x times you’ve come in for this. Every time you come in we have the same tests available for y complaint. You’ve had all of them. If you want to have them again I don’t mind, but the results are probably going to be the same. What you really need is follow up for abc tests with your doctor. I don’t have those here. So what would you like to do?”

That’s a very respectful approach and a way I used to do it. Now I take the same approach as Genius. These patients will bog you down in questions and work any way they can to get something from you, whether that’s a duplicate test, an unnecessary prescription, or even just a social visit. We’re in a zero sum game these day and spending even 30 seconds with these patients takes 30 seconds away from another patient or makes me home 30 seconds later, both of which is unacceptable these days.

 

[BoardingDoc]

I don't even bother. If you have come to the ER 10 times in 2 months for the same problem, there is nothing to collaborate on. It is better to tell them the truth which is "This Emergency Department, and the ER system in general, can no longer help you for your medical complaint. If you want help, you have to find other doctors."

And just leave.
Don't let them ask questions.
If they bitch and complain, I would immediately call security to have them escorted out.

Every single time these people are heard, or have a test run, or are given a medicine, they will come right back.

Yep. Punt em. I had a gastroparesis / vague and pain lady. Early 40s. Averaged 4-6 visits a month. Workup always benign. I was fortunate ate enough to get her two times in a row a while back. Both times I said "this is a chronic issue that we have proved we won't diagnose in the ER with any testing and coming back here routinely for IV meds of questionable benefit is not good for your long term health. We will no longer be providing any medication or doing any testing for this issue." Discharged her. She came back a week later and got me again and did the same. Now she's a regular at the ER a couple towns over.

 

[RoyBasch]

That’s a very respectful approach and a way I used to do it. Now I take the same approach as Genius. These patients will bog you down in questions and work any way they can to get something from you, whether that’s a duplicate test, an unnecessary prescription, or even just a social visit. We’re in a zero sum game these day and spending even 30 seconds with these patients takes 30 seconds away from another patient or makes me home 30 seconds later, both of which is unacceptable these days.

This is the way.

 

[thegenius]

Yep. Punt em. I had a gastroparesis / vague and pain lady. Early 40s. Averaged 4-6 visits a month. Workup always benign. I was fortunate ate enough to get her two times in a row a while back. Both times I said "this is a chronic issue that we have proved we won't diagnose in the ER with any testing and coming back here routinely for IV meds of questionable benefit is not good for your long term health. We will no longer be providing any medication or doing any testing for this issue." Discharged her. She came back a week later and got me again and did the same. Now she's a regular at the ER a couple towns over.

This is the way. All ERs need to do this.

 

[thegenius]

That’s a very respectful approach and a way I used to do it. Now I take the same approach as Genius. These patients will bog you down in questions and work any way they can to get something from you, whether that’s a duplicate test, an unnecessary prescription, or even just a social visit. We’re in a zero sum game these day and spending even 30 seconds with these patients takes 30 seconds away from another patient or makes me home 30 seconds later, both of which is unacceptable these days.

I used to do what @CoolDoc1729 said for a few years after residency. I thought you could talk to most of these people and change their expectations and reason with them. Oh how I was wrong. While most of these patients are not a-holes (although a few are), they do come in because they are unwilling to change their chronic bad habits and they get to feel better for free, 24-7 -365.

If I'm feeling particularly feisty sometimes I ask or say
- do you expect a different outcome today vs your prior [x] visits?
- do you think we withhold tests or treatment from patients?
- you've come in with pain, you will be leaving with pain
- you need to develop new coping mechanisms for your pain
- maybe you've been dealt a bad hand in life, I don't know. but we can't help you anymore
- you don't have an emergency, if you had one we would have fixed you.

 

[Dantrolene FC]

Best door to dispo time I ever had as an attending was one of these, 23 y/o male, 8th visit in 6 days with multiple negative workups for chest and belly pain, 41 total visits in roughly 5 weeks. Always came to my shop at night via EMS, and goes across the state line by EMS during the day. What really pissed me off was, he had literally been in the department with his wife all day and did this not even 3 hours after she had been discharged.

I went out to triage and asked “How is this any different than any of your previous 8 visits?” “It’s not.” “Have you contacted any of the referrals for follow up?”, “no”, “Well, you’ve had multiple negative workups for emergent medical conditions this week, there’s been no change, and your vital signs are better than mine…Call your ride, you’re discharged” and I went back and put in the D/C. Total time: 17 minutes. He had the nerve to ask the triage nurse, referring to me: “can’t he get into trouble for doing this?” Who replied: “nope, all you have to get is a screening exam, which you just got and you don’t have an emergent condition, so you can be discharged”

As an intern, a patient was discharged after a negative chest pain workup. He presented again 30 minutes later, to the same hospital and same attending, by ambulance. Before the nurse even sees the patient, the attending goes into his room, removes his IV, and tells him to leave.

 

[dozitgetchahi]

Can confirm, I trained in FL. All of this is true. The whole state is just insane, old people, young people, everyone.

I have in-laws in the FL panhandle. Can also confirm.

Example: last time we visited we pulled into town near midnight. As we stopped at a stoplight on a busy 4 lane divided highway, we suddenly got passed by half a dozen drunk looking dudes on horseback, riding up the median. My wife looks at me and goes “where the hell did these horses come from? And where are these guys going?”

The next day, one neighbor decided to burn a refrigerator in their back yard.

 

[The Knife & Gun Club]

Dude, you live in GOMERland, USA. Idk what you expect?

I don't think I could work and live in a medicolegal hellhole where the average patient age is "The Cryptkeeper from Tales from the Crypt".

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I love that the cartoon sun is basically Carl from Aqua Teen Hunger Force.

I concur but I love my life in Florida. Old people central but man if the chaos isn’t fun.

I was so bored when I lived in Atlanta. I need a surprise catastrophic thunderstorm to make the day fun. Or any drug dealer related complaint in the ED. My last drug dealer got bit by a Gila Monster. We are >2000 miles from where Gila monsters are are supposed to live

 

[CajunMedic]

Example: last time we visited we pulled into town near midnight. As we stopped at a stoplight on a busy 4 lane divided highway, we suddenly got passed by half a dozen drunk looking dudes on horseback, riding up the median. My wife looks at me and goes “where the hell did these horses come from? And where are these guys going?”

Sounds a lot like St. Landry Parish, Louisiana. My first weekend there working EMS, there was a horseback police chase. 2 guys came riding through our parking lot at full gallop with a PD cruiser chasing them.