Lopressor IV... how much I hate it.

[aussiegirl]

Or my favourite from...well, just about every ward where i work

Me: Hi, I'm one of the interns for Dr Whoever, someone just paged me?
Random nurse assistant answering phone: No, I didn't. Did anyone else?
....long long pause....
Random: No, nobody paged you...

Same situation repeats 2 or 3 times.
Later I read in patient's notes "Resident paged 3 times no answer"

Bottom line: just give them a shot in the head with your elbow and drop them to the ground if they try those games.

Damn good idea!

---

Members don't see this ad.

 

[Faebinder]

Or my favourite from...well, just about every ward where i work

Me: Hi, I'm one of the interns for Dr Whoever, someone just paged me?
Random nurse assistant answering phone: No, I didn't. Did anyone else?
....long long pause....
Random: No, nobody paged you...

Same situation repeats 2 or 3 times.
Later I read in patient's notes "Resident paged 3 times no answer"



Damn good idea!

Wow, Deja Vu. I get that all the time.. they page and expect the pager to beep instantaneously... It ain't a cell phone!

 

[telenurse]

My lopressor IV story of the night.
Post CABG pt.
BP 185/108 manual, P 88.
Has PRN lopressor 5-10 mg IV ordered
Is on scheduled lopressor 25 mg po BID
Had had a high BP on days, recieved lopressor. Pt is shallow breathing, rales to bilateral lung fields, had temp of 100.8. I convinced him to use spirometer, to cough and deep breath. Temp came down to 98.9.
Pt refusing lopressor, no matter how much teaching I and every other nurse and RT provides, insists the Lopressor caused the fever.
Resident: you paged.
I fill her in on the story of BP and P, and pt refusing IV lopressor.
Resident: I knew he was just pig ignorant, but this takes the cake. D/c all lopresser, start him on labetalol 300 mg po bid and increase his zestril to 20mg qday starting tonight. By the way, does he realize that he's been getting lopressor po and IV every day for 3 days!
Me: He just really refuses to believe me that using the incentive spirometer and coughing brought the fever down. Even though he's coughed up lots of phlegm.
Pt insisted on having allergy armband placed, and having chart flagged as allergic to lopressor.

 

[Faebinder]

ahh yes... one of those patients who loves to be allergic to everything.. he doesn't know that allergy to a drug is a bad thing cause it means he wont be ever getting it even if he really needs it. Chuck another one to the axis II diagnosis monster.

 

[doc02]

Um, if you guys actually believe they don't have an allergy to the medication, just give it to them anyways. I mean, there was in instance where a patient forgot to tell us she was "allergic" to morphine because it made her throw up once and we were giving it to her. Then, about three days in, she tells me about it. I go, "congratulations, you don't have the allergy any more" and kept giving her morphine.

 

[telenurse]

Unfortunately, giving the med to the pt, after the pt refused would be considered abuse to the powers that be...I know it's not an allergy...just like I know postop atelectasis causes fever and some good deep breaths and coughs can take care of that...but some lay people think they are smarter than all of us...never mind the fact they never even finished high school...

 

[Blade28]

Me: He just really refuses to believe me that using the incentive spirometer and coughing brought the fever down. Even though he's coughed up lots of phlegm.
Pt insisted on having allergy armband placed, and having chart flagged as allergic to lopressor.

Argh, that's painful.

Then again, post-op atelectasis (and the cause for fever) is a mystery to most patients.

 

[telenurse]

Argh, that's painful.

Then again, post-op atelectasis (and the cause for fever) is a mystery to most patients.

The dumbed down nurse explanation to pig ignorant pt's.

you always have lung secretions, you bring them up all day, and swallow them without knowing it. Due to anesthesia, and due to shallow breathing from surgery, the secretions collect in your lungs. Your body notices the secretions collecting, which causes your immune system to think you have a cold, and you get a fever to fight the nonexistant cold.

I say this so many times...it's a broken record...and then it goes on about moist breeding ground for bacteria, developing into pnuemonia...so just deep breath and cough.

I have an even more dumbed down version also...which is sad...

I found it's best to say it in front of the most anxious/nagging family member...it's then a guarantee the pt will use the IS whether they want to or not.

 

[Blade28]

I found it's best to say it in front of the most anxious/nagging family member...it's then a guarantee the pt will use the IS whether they want to or not.

So true!

 

[Faebinder]

The dumbed down nurse explanation to pig ignorant pt's.

you always have lung secretions, you bring them up all day, and swallow them without knowing it. Due to anesthesia, and due to shallow breathing from surgery, the secretions collect in your lungs. Your body notices the secretions collecting, which causes your immune system to think you have a cold, and you get a fever to fight the nonexistant cold.

I say this so many times...it's a broken record...and then it goes on about moist breeding ground for bacteria, developing into pnuemonia...so just deep breath and cough.

I have an even more dumbed down version also...which is sad...

I found it's best to say it in front of the most anxious/nagging family member...it's then a guarantee the pt will use the IS whether they want to or not.

Oh ya, I enjoy that one... except for the fact that the family member works her/his way into out right anxiety and then busts out a list of questions and proceeds to ask me... then asks the chief resident and then the attending all the same questions. At which point I proceed to wish I had that recorder that JD from Scrubs holds with him. I will record myself talking and when asked the same question I will simply replay it.

 

[Tired]

I don't view it as his fault, he was lied to and we both try like hell to help each other out with the long month we've had this past month. I'd probably have done the same for him if I felt I was helping him out.

He may have been lied to, but there are no circumstances where pulling a central line is an emergency. It's really better for everyone if you keep your hands off of other peoples' patients unless it's an emergency.

 

[gasnewby]

the emergency is...THE PATIENT IS READY FOR DISCHARGE!

you'll never see such efficiency/tenacity from a nurse

 

[doc02]

the emergency is...THE PATIENT IS READY FOR DISCHARGE!

you'll never see such efficiency/tenacity from a nurse

You couldn't be more wrong. The nurses try to HOLD ON TO patients who are ready for discharge because if they lose that patient they are wide open to get a new one. And new ones are much more labor intensive because you have to get them "settled in." We have had nurses "raise issues of concerns" on the day of discharge for lots of patients for this very reason. And for anyone who thinks I'm lying, I've actually heard nurses say this to me. They would MUCH RATHER have a completely stable patient who is eating and walking and hanging out.

The only time you'll get paged for a patient who is discharged is when it's totally inevitable, can't be stopped, and their ride is there. Ever notice that? Then it's like crisis time and you're like, "um, you knew this patient was leaving all day and you couldn't tell me you needed this handled before RIGHT NOW?" Yeah, because they were too busy trying to fight the inevitable.

 

[Faebinder]

You couldn't be more wrong. The nurses try to HOLD ON TO patients who are ready for discharge because if they lose that patient they are wide open to get a new one. And new ones are much more labor intensive because you have to get them "settled in." We have had nurses "raise issues of concerns" on the day of discharge for lots of patients for this very reason. And for anyone who thinks I'm lying, I've actually heard nurses say this to me. They would MUCH RATHER have a completely stable patient who is eating and walking and hanging out.

The only time you'll get paged for a patient who is discharged is when it's totally inevitable, can't be stopped, and their ride is there. Ever notice that? Then it's like crisis time and you're like, "um, you knew this patient was leaving all day and you couldn't tell me you needed this handled before RIGHT NOW?" Yeah, because they were too busy trying to fight the inevitable.

so true...

 

[Dr. V]

You couldn't be more wrong. The nurses try to HOLD ON TO patients who are ready for discharge because if they lose that patient they are wide open to get a new one. And new ones are much more labor intensive because you have to get them "settled in." We have had nurses "raise issues of concerns" on the day of discharge for lots of patients for this very reason. And for anyone who thinks I'm lying, I've actually heard nurses say this to me. They would MUCH RATHER have a completely stable patient who is eating and walking and hanging out.

The only time you'll get paged for a patient who is discharged is when it's totally inevitable, can't be stopped, and their ride is there. Ever notice that? Then it's like crisis time and you're like, "um, you knew this patient was leaving all day and you couldn't tell me you needed this handled before RIGHT NOW?" Yeah, because they were too busy trying to fight the inevitable.

Absofrigginlutely right.

Unless that patient is a pain, complaining/wanting pain meds. Then they will also want to get them out of there LOL.

 

[Tired]

You couldn't be more wrong. The nurses try to HOLD ON TO patients who are ready for discharge because if they lose that patient they are wide open to get a new one. And new ones are much more labor intensive because you have to get them "settled in." We have had nurses "raise issues of concerns" on the day of discharge for lots of patients for this very reason. And for anyone who thinks I'm lying, I've actually heard nurses say this to me. They would MUCH RATHER have a completely stable patient who is eating and walking and hanging out.

Except in the ER of course, where every patient must be thrown out the door or upstairs to the wards as fast as possible, regardless of whether or not they are stable or require further tests.

How can you send a r/o MI to the floor before you draw cardiac enzymes? No, they can't just give the septic patient the antibiotics once they get upstairs. No, you can't "stop in" to get a spiral CT on the way up to the wards. Shut up and work. I don't give a crap about your LOS numbers. I don't care that you want to watch Grey's Anatomy. Shut up.

 

[doc02]

Except in the ER of course, where every patient must be thrown out the door or upstairs to the wards as fast as possible, regardless of whether or not they are stable or require further tests.

Yeah, but that's different because the ER doesn't actually take care of people; they just act as a stop-off point. If you examine how much actually goes on in an ER, it's very little. Half the time you're lucky if the patient even gets started on the IV fluids you asked for. Most people will get (the same) labs drawn, an (uninterpreted) EKG, and a(n uninterpreted) CXR in fairly quick progression. They're extremely good at that because, frankly, everyone gets those. But any deviation from those standard things is agonizingly hit-or-miss. Since they don't provide care, the most beneficial thing for them is to move a person because then their job truly is done.

 

[gasnewby]

You couldn't be more wrong. The nurses try to HOLD ON TO patients who are ready for discharge because if they lose that patient they are wide open to get a new one.

I see you have not been introduced to our lovely trauma population!

Who says they are wide open to get a new one? Their oldest trick in the book where I come from is to conveniently forget to list the bed as an empty bed. Ever try to get people transferred out of the unit, when you KNOW there is an empty bed on the floor? They blame it on housekeeping most of the time. There is a nurse manager (I believe there are 3 of them at night, what a waste) who is supposed to walk around the units and cut down on this crap, but not much has changed.

Although on outside rotations at community hospitals, I have gotten pages that the RN took the patients blood pressure just before discharge. Why? You barely took it when he was here!...and guess what, it's high (although it was high on admssion and high the entire stay) and the RN is "uncomfortable" discharging him.

 

[Faebinder]

I see you have not been introduced to our lovely trauma population!

Who says they are wide open to get a new one? Their oldest trick in the book where I come from is to conveniently forget to list the bed as an empty bed. Ever try to get people transferred out of the unit, when you KNOW there is an empty bed on the floor? They blame it on housekeeping most of the time. There is a nurse manager (I believe there are 3 of them at night, what a waste) who is supposed to walk around the units and cut down on this crap, but not much has changed.

Although on outside rotations at community hospitals, I have gotten pages that the RN took the patients blood pressure just before discharge. Why? You barely took it when he was here!...and guess what, it's high (although it was high on admssion and high the entire stay) and the RN is "uncomfortable" discharging him.

Oh your hospital must be old school....there is no chance in hell to do that here at my hospital.

 

[doc02]

Yeah, our nurses constantly try to be inventive with stuff like that. For example, they'll say that five beds have been "reserved" and so even though they "look" open, they're not. But the rule is that nurses are only allowed to screw over residents. When nurses try to screw over nurses, it won't work because they are all equally lazy, equally unionized, and equally knowledgeable about which rules are "real" and which ones they are each making up. In other words, it just won't fly. A nurse can make up any rule she wants to a resident; she could say that the rule is that residents dispense meds for all Caucasian patients and half the people on SDN would be like, "duh, I don't want to rock the boat, so OK! Can I massage your feet, too?" But if she tries that with another nurse, they have no problem in reporting each other all over the place or just cursing each other out.

 

[Tired]

I found out today that no one in my ER knows where the Policies & Procedures Manual is.

I was shocked.

Nonetheless, they were very sure about several particular policies that required me to do stuff and them not to have to do stuff.

 

[doc02]

Note: in the ER, "stuff" = "history and physical."

 

[gasnewby]

I found out today that no one in my ER knows where the Policies & Procedures Manual is.

I was shocked.

Nonetheless, they were very sure about several particular policies that required me to do stuff and them not to have to do stuff.

i was asked to DRAW COAGS on a patient in the ER so they could consult me for a central line. unbelievable. this from an er attending. i asked him if he wasn't able to fem stick the patient or draw from the radial artery and he said, 'i have other patients.' oh yeah? how about the ones i take care of in the whole f-ing hospital connected to this dump of an ER? they're too shameless to be embarrassed by their incompetence.

another one was for a rectal tube. the RN was very sure that she, nor any other nurse, was allowed to place one. i said, that's funny b/c the icu nurses do it all the time. they're all breaking policy? and played the card right back- ok, show me the policy. um...not so much. then i said, ok, let's call nursing administration; they'll have a copy. 15 minutes later, um...there's no such policy...but we're not comfortable having a floor nurse do that.

 

[Tired]

the RN was very sure that she, nor any other nurse, was allowed to place one. i said, that's funny b/c the icu nurses do it all the time. they're all breaking policy? and played the card right back- ok, show me the policy. um...not so much. then i said, ok, let's call nursing administration; they'll have a copy. 15 minutes later, um...there's no such policy...but we're not comfortable having a floor nurse do that.

I just had that conversation! Except one RN was 100% positive they were prohibited from placing rectal tubes, and the charge nurse was 100% positive it was permitted. They argued for 10 minutes, then finally settled on, "Okay, we're technically allowed to do a rectal tube, but we don't feel comfortable with it because we might perf his colon."

What? It's a flexible rubber tube.

"Yeah, but his colon looks distended on the abdominal xray, so we're not comfortable with it."

So now you're all radiologists . . .

I wrote for q4hr soap suds enemas instead. Heh heh.

 

[gasnewby]

since when do RNs check xrays?

just wondering, has there ever actually been a case where the rectum has been perfed by a foley/red rubber tube?

 

[gasnewby]

as an fyi, i used this site as a medical student. it's an online procedure guide for nurses that comes out of UNC. (and rectal tubes are in it, if anyone's really interested!)

http://www.unchealthcare.org/site/Nursing/nurspractice/procedures/procedures/

 

[Winged Scapula]

since when do RNs check xrays?

just wondering, has there ever actually been a case where the rectum has been perfed by a foley/red rubber tube?

I have seen nurses actually look at films, but without the report often they don't know what they are looking at.

I'm sure that someone, somewhere has had a distended colon perf'd by a rectal tube and now everyone is seemingly afraid of them. I can see them not wanting to place mushrooms but only because they often need to be sewn in.

Frankly, I'm not sure why they aren't afraid of NGT, Foleys, etc. for the same reason...I guess "poop" and rectums make people a lot more uncomfortable.

 

[Blade28]

I'm sure that someone, somewhere has had a distended colon perf'd by a rectal tube and now everyone is seemingly afraid of them. I can see them not wanting to place mushrooms but only because they often need to be sewn in.

Frankly, I'm not sure why they aren't afraid of NGT, Foleys, etc. for the same reason...I guess "poop" and rectums make people a lot more uncomfortable.

I've seen a lot more false lumens or strictured urethras from misplaced Foleys, nasal bleeds from misplaced NG tubes, compartment syndromes from infiltrated IV contrast and abscesses from infected peripheral IVs than I have rectal perforations from rectal tubes.

 

[Faebinder]

Hmm...

It's been 5 months in my colorectal surgery service... Not a single perforated rectal tube... heard of them... never saw them on our service (and on our service, every single CT scan is ordered with rectal constrast in addition to iv and PO).

 

[gasnewby]

i'd heard of perfs during maybe a rigid sig or colonoscopy when the colon's dilated, or during enemas- inserting a rectal tube involves the rectum (not the colon!). the rectum shouldn't be thin-walled and dilated, and able to be perforated by inserting a soft rubber tube 4 inches.

 

[Faebinder]

i'd heard of oerfs during maybe a rigid sig or colonoscopy when the colon's dilated, or during enemas- inserting a rectal tube involves the rectum (not the colon!). the rectum shouldn't be thin-walled and dilated, and able to be perforated by inserting a soft rubber tube 4 inches.

Yup common during a rigid as people push the proctoscope downwards and forward instead of straight up forward ... rare during a colonoscopy.

 

[Tired]

Frankly, I'm not sure why they aren't afraid of NGT, Foleys, etc. for the same reason...I guess "poop" and rectums make people a lot more uncomfortable.

In my case, the problem was that the patient was admitted to a medicine floor with a diagnosis of Ogilvies. So of course the nursing staff doesn't know what that is, and someone looks it up and sees the part about toxic megacolon and perforation. That translates, in their minds, into "don't bother the colon or it might blow up on you".

Same reason I keep getting calls from PT that the nurses won't let them ambulate patients with DVTs because they're worried it will cause a PE.

 

[doc02]

oh yeah? how about the ones i take care of in the whole f-ing hospital connected to this dump of an ER? they're too shameless to be embarrassed by their incompetence.

Bingo. This may shock you guys who have read my posts, but this is actually the biggest thing that pisses me off about EM guys. It's not that they're that incompetent (but they are). It's that they don't care that they're that incompetent ...and instead, their way of dealing with it is to pretend that they aren't incompetent AT ALL. In fact, they're the exact opposite, according to them. They'll miss that a guy has AN AMPUTATION on their "physical" (it's happened) and not be fazed when you bring it up. If you ask them about labs, they don't mind just looking at you blankly with a vague smile. The best part is that the heads of these ERs are some of the most arrogent physicians I've ever met, having convinced themselves that they are "in charge" of thousands of patients a day. If you even THOUGHT about pointing out a mistake, you'd get, "YOU'RE A RESIDENT, YOU WORK FOR ME!" (I got that one once, so I next completely shut the attending out of the loop, not communicating anything about the patient or our assessment; I admitted the patient, put in the orders, carried my consult/H&P with me, and left. He was forced to page me hours later to feebly ask me what was going on. I was like, "huh? Oh, right, that guy! You didn't know?" LOL.)

 

[doc02]

I have seen nurses actually look at films, but without the report often they don't know what they are looking at.

Even with the reports they don't know what's going on. One report I had said "post-CABG changes visualized." I kid you not, I got paged by the nurse who frantically told me that the patient was having "surgical changes" on his CXR. She was the same nurse who questioned every order I put in that day, like "oh, you want norvasc? Why? I've never seen anyone do that. Did you call the attending? I'm calling the attending. I'm not giving it until someone who knows what's going on says it's OK." So I played around with her for a while and was like, "wow, this sounds serious!! Get the code cart ready!" (OK, I didn't go that far, but it was pretty fun.)

 

[Farbar]

i was asked to DRAW COAGS on a patient in the ER so they could consult me for a central line. unbelievable. this from an er attending. i asked him if he wasn't able to fem stick the patient or draw from the radial artery and he said, 'i have other patients.' oh yeah? how about the ones i take care of in the whole f-ing hospital connected to this dump of an ER? they're too shameless to be embarrassed by their incompetence.

another one was for a rectal tube. the RN was very sure that she, nor any other nurse, was allowed to place one. i said, that's funny b/c the icu nurses do it all the time. they're all breaking policy? and played the card right back- ok, show me the policy. um...not so much. then i said, ok, let's call nursing administration; they'll have a copy. 15 minutes later, um...there's no such policy...but we're not comfortable having a floor nurse do that.

now, come on, i don't really believe this. gripe about the er all you want but you were actually asked to draw labs and place a central line as a consult? i cannot imagine any er ever asking a simple procedure like a central line to be done by a consulting service. if this is true, i am ashamed of that er doc, you would not be wrong to let him have it.

 

[doc02]

Our ER doesn't do any central lines, either.

 

[OTD]

now, come on, i don't really believe this. gripe about the er all you want but you were actually asked to draw labs and place a central line as a consult? i cannot imagine any er ever asking a simple procedure like a central line to be done by a consulting service. if this is true, i am ashamed of that er doc, you would not be wrong to let him have it.

I can't count the number of times I have been called to the ER just to place a central line in a patient, it's usually a patient in septic shock needing access or renal failure needing a vas cath.

I also can't count the number of times I gotten from the ER doc "yeah, this lac is pretty deep I'm not comfortable sewing it up would you come down here and take care of it?". Mind you this happened even when I was only an INTERN and the ER attending wanted ME to sew up something he was "uncomfortable" with. Bottom line was he didn't want to have to do it and he dumped it on us.

Yes, it's common place here to be called to the ER for lines and sutures.

I'm glad I like lines and suturing LOL.

 

[Farbar]

Our ER doesn't do any central lines, either.

wow. if this is true, you obviously work at a hospital with a terrible er. i am an er resident and need around 50 central lines during residency. i would never turf that to another service. i understand the frustration other services have with the er, and most of it is a difference in philosophy, but sometimes the er screws up and sometimes the im/sugery/etc.. service screws up. if you work at a hospital with no er residency (or even if you do) then you should refuse to do that for them, they are trained to do those basic procedures.

 

[Tired]

wow. if this is true, you obviously work at a hospital with a terrible er. i am an er resident and need around 50 central lines during residency. i would never turf that to another service. i understand the frustration other services have with the er, and most of it is a difference in philosophy, but sometimes the er screws up and sometimes the im/sugery/etc.. service screws up. if you work at a hospital with no er residency (or even if you do) then you should refuse to do that for them, they are trained to do those basic procedures.

For what it's worth, my program doesn't have any ER residents. Our surgeons get called for lacs and central lines all the time.

 

[doc02]

The best is YOU'LL be doing the actual suturing and afterwards they'll act like they could do it, too. Like, you'll be writing your note and a resident or even attending will walk over and grin and go, "so, what, a two-layer repair? You use nylons for the skin? Good choice, it's what I would have done."

 

[Farbar]

The best is YOU'LL be doing the actual suturing and afterwards they'll act like they could do it, too. Like, you'll be writing your note and a resident or even attending will walk over and grin and go, "so, what, a two-layer repair? You use nylons for the skin? Good choice, it's what I would have done."

well, i hate it for you guys. if you worked at a hospital with ER residents you would not face so many obstacales. granted, there would still be some complaints but it would be much better. in the real world an er doc would easily place central lines, place a chest tube, do a cricothyrotomy, do trans-venous pacing for an arresting patient, deliver a baby, do a paracentesis, do a thoracocentisis, i and d all abcesses, do lp's, place difficult peripheral iv's, do pericardiocentesis, and much more. i am required to be able to do all of those procedures. you have had a bad experience but it is not indicative of my profession. maybe you chose a residency at a bad hospital. i am at one of the best. i hope in private practice things work out better for you.

sorry for bad spelling, i am post call.

 

[Winged Scapula]

Just adding my voice to the swell of those surgical residents who get called to the ED to place central lines.

I've done it as well. Many times. As a consult, a "favor" (in the parlance of the ED), without them trying, or after they've tried but can't get it.

It was less common at the university hospital once they got ED residents, but very common at the community hospital without residents. It got so when I was on call, if I heard a code page for the ED, I'd just head down there because I knew I'd be getting a call about the need for central access.

 

[doc02]

I'm at a place with ER residents and it's that bad. But the distinction is irrelevant. Clearly, if an EM resident can do those things, then there's absolutely no reason an EM attending couldn't. And if an EM attending doesn't have to, then there's no reason to train an EM resident to do it. Therefore, to me it's more of "oh, are you at a place without residents? That's why it's like that, but everywhere else it's different."

 

[Apollyon]

Our ER doesn't do any central lines, either.

Just once, will you and Tired nut up and tell us where you're at? I'm in Greenville, SC. We have one level 1 trauma center, one stand-alone ED, and two community hospitals. I put in central lines - all the time. I know the policies (one nurse actually tried to tell others that Ewald tubes were now prohibited, but couldn't come up with the policy - and this was on a patient where we actually recovered pill fragments). I read my EKGs. I have collegial relations with our residents and our attendings. You two guys have been doctors a total of 8 months combined, whereas I have 5 years in. I just want to know where these dreadfully substandard/dangerous docs are. It seems like they can't do anything right, whereas I had a neurosurgeon - attending, not resident - shake my hand for my clinical diagnosis of a cauda equina syndrome, and the single MRI I've ordered since I've been here was on that patient, and it was positive. The radiologist even said to me, "great clinical skills on localizing the lesion".

I'm just sayin' - neither I nor my colleagues are perfect, but what you post that these people do does not meet the standard of care, and, therefore, could easily be litigated.

 

[Tired]

well, i hate it for you guys. if you worked at a hospital with ER residents you would not face so many obstacales. granted, there would still be some complaints but it would be much better. in the real world an er doc would easily place central lines, place a chest tube, do a cricothyrotomy, do trans-venous pacing for an arresting patient, deliver a baby, do a paracentesis, do a thoracocentisis, i and d all abcesses, do lp's, place difficult peripheral iv's, do pericardiocentesis, and much more. i am required to be able to do all of those procedures. you have had a bad experience but it is not indicative of my profession. maybe you chose a residency at a bad hospital. i am at one of the best. i hope in private practice things work out better for you.

Agreed. I complain a lot about the ER at my hospital, but I recognize that a lot of that has to do with the nature of our ER and the lack of residents. There's just simply no incentive for the attendings to do anything but rapid discharge or quick admit. And yes, I recognize that, in different institutions, surgical services and other consultants are just as guilty of being lazy, uninterested, and uncaring. It just so happens that where I work, it's the ED.

Last week one of the ED nurses started explaining to me that, when a patient needs to be admitted, they should be allowed to immediately transfer the patient to the wards before the admitting service sees them or writes orders. That way they don't "clog up" the ER.

 

[doc02]

Wow, that guy is as good as a neurosurgeon and a radiologist combined. Whatever they're paying him, they'd better double it!!

 

[Winged Scapula]

well, i hate it for you guys. if you worked at a hospital with ER residents you would not face so many obstacales. granted, there would still be some complaints but it would be much better. in the real world an er doc would easily place central lines,

Nope. They call surgery.

place a chest tube,

Nope. They call surgery or Medicine (depending on where the patient is going to).

do a cricothyrotomy,

Surgical airway? Nope. They call surgery.

do trans-venous pacing for an arresting patient, deliver a baby, do a paracentesis, do a thoracocentisis,

Nope. They call surgery or medicine (depending on the primary problem). And then medicine calls surgery when they drop the lung doing the thoracentesis.

i and d all abcesses

Nope. They stick an 18 gauge needle into the abscess and call it a day. Or if they actually wield a scalpel, they'll make a simple incision rather than a cruciate, not break down any loculations, not pack the wound and not irrigate it with COPIOUS amounts of saline. Then when the patient comes back septic, they'll call surgery to admit him.

do lp's, place difficult peripheral iv's, do pericardiocentesis, and much more

Nope. They'll call Cards or CTS.

i am required to be able to do all of those procedures. you have had a bad experience but it is not indicative of my profession. maybe you chose a residency at a bad hospital. i am at one of the best. i hope in private practice things work out better for you.

sorry for bad spelling, i am post call.

All of us posting here are at different hospitals, all across the country and we have had the same experiences with EDs. You may be required to learn those procedures but in the real world that we've experienced (ie, in places without residents or even those with residents, but they're "too busy" [but we're not]), the ED either isn't comfortable doing these, figures they don't have time or has some other heretofor non-disclosed reason for the consult.

I respect that you and Apollyon are at wonderful places with well-trained, bright and hard-working ED attendings and residents. But to not realize that these things DO happen at many places is to play the ostrich with its head in the sand (and I've been quite clear about where I trained...FYI).

 

[doc02]

I once had to place a ventriculostomy and I paged Apollyon and he came and did it. True story.

 

[Tired]

I'm just sayin' - neither I nor my colleagues are perfect, but what you post that these people do does not meet the standard of care, and, therefore, could easily be litigated.

Well, I'm pretty sure you know where I'm at, but that's beside the point.

I don't think I've ever described anything that was easily litigated or was obviously outside the standard of care. What I am describing (like so many others here, although you obviously enjoy portraying me and doc02 as the lunatic fringe) is the usual "dump on anyone you can" phenomenon that pervades residency training programs for all specialties. No ED will ever get in trouble for calling more consultants than they needed to. In fact, from what I gather, if anything it is exactly the opposite: ED docs fear that if they don't get an Ortho consultant for an ankle sprain, or gen surg for abdominal pain, or Ophtho for the hyphema, then they will be liable for any adverse outcome.

I can't believe that, what with your "5 years as a doctor" that you continually trot out, you have never encountered these kinds of situations in the ED from your colleagues. I mean really, I may have only a couple months as an intern under my belt, but you don't see me valiantly insisting that no Ortho doc has ever dumped patients on Medicine or Gen Surg, or gotten hematology consults for mild anemia post-op.

 

[doc02]

The beauty of the ER is that the more they consult, the less they can be litigated. Apollyon acts like the reverse is true, like some lawyer is going to go, "huh, you consulted Cardiology, GI, IM, Pediatrics, OB-Gyn, PM&R, Surgery, and Housekeeping? This is grounds for a lawsuit!!" Meanwhile, he's down at his ER running some PCR gels and checking out karyotypes, apparently.