Overnight pages - memorable/dismal/ridiculous/unique

[Jolie South]

I miss being able to let my alcoholics drink while in house.

I have a man on my service who gets whiskey every evening. So much easier than managing withdrawal.

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[dpmd]

I have a man on my service who gets whiskey every evening. So much easier than managing withdrawal.

Not sure if is true but I heard the issue was not having a liquor license for the beer that was technically being sold. Seems like something that would be true though.

 

[OrthoTraumaMD]

I miss being able to let my alcoholics drink while in house.

We did give him alcohol. But it wasn’t enough. He usually drinks 10 beers a day.

 

[deleted547339]

I had a similar one recently, day two ankle fracture with fever and clear withdrawal symptoms. White count stone cold normal. Hospitalist ordered a pan CT scan of everything: chest abdomen pelvis AND ankle, and infectious disease consult. I caught it in time, said absolutely not, took him on my service and canceled everything. He ended up leaving AMA to go drink. Probably better for him. Reminds me of that house of God tenet....The best thing to do is as little as possible.

There’s only a fever if you check a temp.

 

[VincentAdultman]

I’ll have to see if beer is on the formulary.

 

[ThoracicGuy]

There’s only a fever if you check a temp.

One reason I don't do a bunch of post-op labs...

 

[Winged Scapula]

I’ll have to see if beer is on the formulary.

We had St Pauli Girl on the formulary where I did residency.

 

[Apollyon]

We had St Pauli Girl on the formulary where I did residency.

The Durham VA had beer, but it was rotgut - like, Busch or something else cheap and domestic. No imports there! However, I recall one of the staffers stating that another VA at which they had worked nearly had a fully functioning bar, including the pharmacist mixing up drinks!

 

[dpmd]

The Durham VA had beer, but it was rotgut - like, Busch or something else cheap and domestic. No imports there! However, I recall one of the staffers stating that another VA at which they had worked nearly had a fully functioning bar, including the pharmacist mixing up drinks!

Fancy. Ours was just labeled beer. Could only get two per meal also so once the house supervisor had to go out to a liquor store to get some hard liquor for a guy who was withdrawing on the beers because it wasn't enough.

 

[HighPriest]

Had a guy fly in from a remote location when I was a resident. This was for a consultation for a big cancer whack (I used to call them smile-ectomies, because we were literally wiping the smile off their face). In any case, he came of the plane in near DTs. Had to leave his appointment, stop at a bar for some scotch, and then came back. He was totally fine when he returned.

 

[evilbooyaa]

Had a guy fly in from a remote location when I was a resident. This was for a consultation for a big cancer whack (I used to call them smile-ectomies, because we were literally wiping the smile off their face). In any case, he came of the plane in near DTs. Had to leave his appointment, stop at a bar for some scotch, and then came back. He was totally fine when he returned.

Welcome to the head and neck cancer population! Smoke and drink till your tongue gets fixed to all the other things in the mouth.

 

[HighPriest]

Welcome to the head and neck cancer population! Smoke and drink till your tongue gets fixed to all the other things in the mouth.

You're not really a member until you can smoke through your tracheostoma.

 

[LucidSplash]

Welcome to the head and neck cancer population! Smoke and drink till your tongue gets fixed to all the other things in the mouth.

Honestly everytime people talk about the misery of the vascular patient population, I remember my 1 week on ENT as an MS3. Head and neck cancer was miserable.

 

[HighPriest]

Honestly everytime people talk about the misery of the vascular patient population, I remember my 1 week on ENT as an MS3. Head and neck cancer was miserable.

Head and neck cancer is miserable. But they also end up being (typically) some of the most grateful patients you can manage. I'd rather do 10 head and neck cases than 1 cosmetic case. But, you know, the cosmetic cases have a much lower probability of dying on you.

Traditionally, btw, there's a pretty good overlap between vascular patients and the head and neck population, because the same crap that gets you head and neck cancer gets you a fem-pop. But now-a-days the majority of my head and neck cancer patients are in their late 40s, otherwise healthy, and never smoked or drank heavily. Thank you HPV.

 

[HighPriest]

the same crap that gets you head and neck cancer gets you a fem-pop

Military service. That's what gets you head and neck cancer and a fem-pop. Because it's disproportionally VA patients. Must be agent orange, doc. (takes a drag on his second cigarette since the conversation started).

 

[Psai]

Head and neck cancer is miserable. But they also end up being (typically) some of the most grateful patients you can manage. I'd rather do 10 head and neck cases than 1 cosmetic case. But, you know, the cosmetic cases have a much lower probability of dying on you.

Traditionally, btw, there's a pretty good overlap between vascular patients and the head and neck population, because the same crap that gets you head and neck cancer gets you a fem-pop. But now-a-days the majority of my head and neck cancer patients are in their late 40s, otherwise healthy, and never smoked or drank heavily. Thank you HPV.

Huh maybe I should get vaccinated

 

[HighPriest]

Huh maybe I should get vaccinated

What's a little more autism?

 

[Jolie South]

Honestly everytime people talk about the misery of the vascular patient population, I remember my 1 week on ENT as an MS3. Head and neck cancer was miserable.

The private plastic surgery type population is what does me in. We get a whiff of that with outpatient veins though.

 

[MediCane2006]

The private plastic surgery type population is what does me in. We get a whiff of that with outpatient veins though.

Cosmetic plastics patients are their own special kind of horrible...

 

[coldleg]

3am last night:

Do you want the CT angiogram with or without contrast?

3:30am

Are you sure about the contrast? He doesn't seem like he can swallow very well

 

[dpmd]

3am last night:

Do you want the CT angiogram with or without contrast?

3:30am

Are you sure about the contrast? He doesn't seem like he can swallow very well

That is your fault for not specifying iv versus oral vs both with the initial order. Just because you know it needs iv contrast doesn't mean anyone outside of radiology will (and even then some techs are better than others)

 

[ThoracicGuy]

That is your fault for not specifying iv versus oral vs both with the initial order. Just because you know it needs iv contrast doesn't mean anyone outside of radiology will (and even then some techs are better than others)

CT angiogram is with iv contrast by definition... I had a patient that I ordered one on to look for any retroperitoneal bleeding from a cardiologist cath stick. The CT tech took it upon himself to make it a non contrast study because he figured i misordered it. Nevermind the written indication was to assess for bleeding...

 

[dpmd]

CT angiogram is with iv contrast by definition... I had a patient that I ordered one on to look for any retroperitoneal bleeding from a cardiologist cath stick. The CT tech took it upon himself to make it a non contrast study because he figured i misordered it. Nevermind the written indication was to assess for bleeding...

You know that and I know that, but I guarantee you the ward clerk and nurse don't know that. The tech knowledge varies as well. Gotta idiot proof your orders.

 

[VA Hopeful Dr]

You know that and I know that, but I guarantee you the ward clerk and nurse don't know that. The tech knowledge varies as well. Gotta idiot proof your orders.

That's a systems issue, a CT angiogram should include the IV contrast order intrinsically

 

[dpmd]

That's a systems issue, a CT angiogram should include the IV contrast order intrinsically

You would think, but whatever computer person created the orders didn't know that. Same reason there is no option for iv ad po contrast for my abd ct and if I order the one with iv and order the oral contrast separately it won't get done right. If I put a comment in to give po contrast they will end up giving only po or calling me for clarification. So I order the one with iv contrast and put a note in to give po and if contrast. And if the creatinine isn't normal I put a comment in that it is ok with me to proceed with contrast despite the creatinine. Just like if there is an allergy to contrast I put a comment in as well as ordering the premeditation. Or if their allergy isn't real I fix it in the allergy section but also address it in the comments. I mean you can either complain about dumb calls or you can try to prevent them (not always but enough)

 

[HighPriest]

On one hand: totally agree that you have to specify, even when it should be obvious (angiogram with contrast), but on the other hand that should be fixed. The techs should be trained to know what test they're performing and why. Don't get me wrong, this type of thing has been an issue everywhere I've ever worked, but I still don't understand why the system finds it acceptable that a tech doesn't know what the test he's performing involves. It's really not that hard to learn, and it doesn't really require much medical knowledge, and it would save time and money. But, that'll never happen, so I continue to expect dumb calls.

 

[dpmd]

On one hand: totally agree that you have to specify, even when it should be obvious (angiogram with contrast), but on the other hand that should be fixed. The techs should be trained to know what test they're performing and why. Don't get me wrong, this type of thing has been an issue everywhere I've ever worked, but I still don't understand why the system finds it acceptable that a tech doesn't know what the test he's performing involves. It's really not that hard to learn, and it doesn't really require much medical knowledge, and it would save time and money. But, that'll never happen, so I continue to expect dumb calls.

That tech who changed it to a noncon maybe at least knew that ct angio meant contrast, but thought it was an error since some doctors order stupid ****.

 

[HighPriest]

That tech who changed it to a noncon maybe at least knew that ct angio meant contrast, but thought it was an error since some doctors order stupid ****.

That could be the case. But I've certainly had more calls asking dumb questions than I have reasonable ones. eg: CT angiogram of the brain and asked if I want contrast (that's happened, and I guarantee I didn't mean oral contrast) Or inappropriate studies. eg: I order a ultrasound of the lateral neck and what I get is a thyroid and a tech who says he just assumed that's what I wanted.

 

[dpmd]

That could be the case. But I've certainly had more calls asking dumb questions than I have reasonable ones. eg: CT angiogram of the brain and asked if I want contrast (that's happened, and I guarantee I didn't mean oral contrast) Or inappropriate studies. eg: I order a ultrasound of the lateral neck and what I get is a thyroid and a tech who says he just assumed that's what I wanted.

Thank your colleagues who order stuff they didn't mean. I am telling you just put more detail in the comments and you will get fewer calls. The ultrasound one is one that could have been avoided had you put in the comments that you need the lateral neck to look for lymph nodes or whatever and it probably would have been done right.

 

[HighPriest]

Thank your colleagues who order stuff they didn't mean. I am telling you just put more detail in the comments and you will get fewer calls. The ultrasound one is one that could have been avoided had you put in the comments that you need the lateral neck to look for lymph nodes or whatever and it probably would have been done right.

The request stated: left lateral soft tissue US of the neck to evaluate left neck mass.

If that's not specific enough, they need a new tech.

Generally, I agree with you. But it's a two-way street. And explain how they call about whether or not I wanted contrast in a CT, Angio of the brain was reasonable.

My point is: it definitely pays to be more specific, and if you aren't then you're asking for trouble. But at the same time, they could educate the techs more as well.

If I ordered (for some reason) CT with contrast of the abdomen with no other detail, then I would expect a call.

 

[dpmd]

The request stated: left lateral soft tissue US of the neck to evaluate left neck mass.

If that's not specific enough, they need a new tech.

Generally, I agree with you. But it's a two-way street. And explain how they call about whether or not I wanted contrast in a CT, Angio of the brain was reasonable.

My point is: it definitely pays to be more specific, and if you aren't then you're asking for trouble. But at the same time, they could educate the techs more as well.

If I ordered (for some reason) CT with contrast of the abdomen with no other detail, then I would expect a call.

The asking about contrast for the ct angio I attribute to too many times people ordering an angio when they didn't really mean it. But you are right it might just be due to ****ty techs. Don't know how to fix that issue without expending a lot of effort to make a paper trail for every ****up.

 

[TraumaLlamaMD]

You would think, but whatever computer person created the orders didn't know that. Same reason there is no option for iv ad po contrast for my abd ct and if I order the one with iv and order the oral contrast separately it won't get done right. If I put a comment in to give po contrast they will end up giving only po or calling me for clarification. So I order the one with iv contrast and put a note in to give po and if contrast. And if the creatinine isn't normal I put a comment in that it is ok with me to proceed with contrast despite the creatinine. Just like if there is an allergy to contrast I put a comment in as well as ordering the premeditation. Or if their allergy isn't real I fix it in the allergy section but also address it in the comments. I mean you can either complain about dumb calls or you can try to prevent them (not always but enough)

I guess you need the last available permutation here: Communication order “NO PO CONTRAST NEEDED PLEASE, I promise I didn’t forget to order it.”

Or a talk with the IT manager I guess. We had a somewhat similar situation with one of my sites and we complained enough that now the orders are bundled - you can order CT w/ contrast, which tells radiology you want IV contrast given, and then you can check or uncheck the PO contrast button which will place the order for PO contrast at the same time. Or CT w/o contrast and the same bundle options.

 

[swoopyswoop]

3 AM: patient's pain meds expired at midnight (admitted for 2 weeks), she is sleeping peacefully right now but can you re-order them for when she wakes up? what do you mean a verbal order? what do you mean you're not in house?

 

[Winged Scapula]

@dpmd is right.

For all of you arguing that the tech should know better or should be trained yada yada yada, that maybe so but that’s not the real world. Please take her advice to heart because once you get out into the real world, especially in a community practice, please don’t be surprised at the level of ignorance, inertia amongst nurses, techs, therapists etc.

Even if you try to get IT involved, there will still be calls. Dummy proof your orders and you’ll get less phone calls.

 

[dpmd]

3 AM: patient's pain meds expired at midnight (admitted for 2 weeks), she is sleeping peacefully right now but can you re-order them for when she wakes up? what do you mean a verbal order? what do you mean you're not in house?

In a paper based system that would mean the daytime folks ignored the renewal form for a few days. In a ehr it means the ordering provider ignored the renewal request for probably the same time. Thank your colleagues for not tucking in their patient appropriately.

Or possibly thank your hospital system for expiring stuff in the middle of the night without sending a renewal request ahead of time. Haven't seen that at any hospital I have worked at, but I recognize that it could happen.

 

[swoopyswoop]

In a paper based system that would mean the daytime folks ignored the renewal form for a few days. In a ehr it means the ordering provider ignored the renewal request for probably the same time. Thank your colleagues for not tucking in their patient appropriately.

Or possibly thank your hospital system for expiring stuff in the middle of the night without sending a renewal request ahead of time. Haven't seen that at any hospital I have worked at, but I recognize that it could happen.

It's CPRS so I'm pretty sure there's no expiration notification...

 

[dpmd]

It's CPRS so I'm pretty sure there's no expiration notification...

That sucks. Lobby your pharmacy to have al meds expire during working hours.

 

[swoopyswoop]

While sitting next to my intern one evening...

Page to my intern's pager to #1234
30 seconds later, page to my pager (second call on the schedule) to #1234

I call the nurse and ask what's going on, assuming it is something emergent to page the first call and second call pagers simultaneously

Patient is requesting melatonin

 

[WinslowPringle]

While sitting next to my intern one evening...

Page to my intern's pager to #1234
30 seconds later, page to my pager (second call on the schedule) to #1234

I call the nurse and ask what's going on, assuming it is something emergent to page the first call and second call pagers simultaneously

Patient is requesting melatonin

Did the nurse tell you, "Yeah, I tried calling the intern a few times but he didn't answer, so I had to call you" ?

 

[swoopyswoop]

Did the nurse tell you, "Yeah, I tried calling the intern a few times but he didn't answer, so I had to call you" ?

I played dumb and said "oh, did you look at the call schedule and page the first call number?" and she said yes. I asked how long ago and she said "um... two minutes ago."

I may or may not have performed some education on the purpose of the second call pager and to please refrain from simultaneously paging both pagers.

 

[HighPriest]

So, that used to happen to me ALL OF THE TIME in residency. They don’t understand that’s there’s a $&@king delay between when you hang up the phone and when the pager goes off. It’s not an$&@king cell phone. It’s 1990 technology. I used to get 5 or 6 consecutive pages, one every 2-4 minutes and then a complaint to my PD that we weren’t answering pages.

It’s amazing I’m not in prison.

 

[Radetzky]

A few years ago. At 4 am.

Patient is on clexane for an MI but he's going for dental surgery in the morning so should we give or withhold his morning dose of clexane?

I am neither a cardiologist nor a dentist so why don't you call the on call cardiologist who saw him yesterday and ask him.

5 mins later my senior gets a call complaining I'm being unhelpful.

Seriously this dental procedure would have been organised days in advance. How do you get to 4am on the morning of and only just realise this is going to be a problem!?

 

[swoopyswoop]

So, that used to happen to me ALL OF THE TIME in residency. They don’t understand that’s there’s a $&@king delay between when you hang up the phone and when the pager goes off. It’s not an$&@king cell phone. It’s 1990 technology. I used to get 5 or 6 consecutive pages, one every 2-4 minutes and then a complaint to my PD that we weren’t answering pages.

It’s amazing I’m not in prison.

I mean... and for melatonin... that's the kind of thing that if you don't get a response, page again in 15-30 minutes, then maybe try one more time, then give up and decide no one has ever died for lack fo melatonin.

 

[Pir8DeacDoc]

I mean... and for melatonin... that's the kind of thing that if you don't get a response, page again in 15-30 minutes, then maybe try one more time, then give up and decide no one has ever died for lack fo melatonin.

Unless it's a really annoying pt who will badger the nurse about it until they get it. You know the type

 

[swoopyswoop]

Another misplaced page to the 2nd call pager...
Patient admitted for an SBO with NGT orders

1 AM: patient refusing to take IV metoprolol, says he doesn't know what medicine that is, says he takes PO Coreg. Says he has no trouble swallowing.
1:05 AM: please give OK to use NGT order

Called back various different numbers for 15 minutes before giving up as no one would answer. Was looking forward to explaining why I was holding PO meds in this high-grade bowel obstruction.

Nurse documented that she paged me with no response.

 

[Jolie South]

Coming out of OR with patient I just did brachial embolectomy on.

PACU nurse: does this patient really need step down? There are no beds.
Me: Yes, but I can make them ICU if that helps.
PACU nurse: oh no, there are no ICU beds. The patient will be here all night. Are you sure you want step down?
Me: *what in the actual f$&@?* I guess they are staying here all night then.
PACU nurse: so you’re sure?


Yea, cool. I operated on this patient. Send them to a broom closet in the basement. I am sure the rats down there will check his Dopplers.

 

[LucidSplash]

<Phone rings>
Nurse: Hello Dr. Lucidsplash this is Nurse Rita in Angio Recovery. Just checking, but the patient says she called her pharmacy and there is no prescription called in.
Me: There aren’t any new prescriptions. Just the aspirin she needs to start taking. I wrote it on her discharge paperwork.
Nurse: Yes the prescription for the aspirin.
Me: ...aspirin is not a prescription medication. She can just buy a bottle over the counter.
Nurse: Oh! <Giggle> ok then. Also the patient complains of pain 2/10 in her arm, can I give her a Percocet before she leaves?
Me: Did you try Tylenol?
Nurse: No, she says it is very bad pain 2/10.
Me: She can have Tylenol.

 

[swoopyswoop]

Coming out of OR with patient I just did brachial embolectomy on.

PACU nurse: does this patient really need step down? There are no beds.
Me: Yes, but I can make them ICU if that helps.
PACU nurse: oh no, there are no ICU beds. The patient will be here all night. Are you sure you want step down?
Me: *what in the actual f$&@?* I guess they are staying here all night then.
PACU nurse: so you’re sure?


Yea, cool. I operated on this patient. Send them to a broom closet in the basement. I am sure the rats down there will check his Dopplers.

Wait, I'm sorry- are we the same person? I did an ex lap on someone today who came from the med/surg floor and I said he needed step down unit post op and had this EXACT conversation.

RN: "are you sure? there are no beds."
Me: OK, then I'll put him in the ICU.
RN: "well there are no ICU beds either."
Me: well I guess he's staying here until space is available!

 

[HighPriest]

Coming out of OR with patient I just did brachial embolectomy on.

PACU nurse: does this patient really need step down? There are no beds.
Me: Yes, but I can make them ICU if that helps.
PACU nurse: oh no, there are no ICU beds. The patient will be here all night. Are you sure you want step down?
Me: *what in the actual f$&@?* I guess they are staying here all night then.
PACU nurse: so you’re sure?


Yea, cool. I operated on this patient. Send them to a broom closet in the basement. I am sure the rats down there will check his Dopplers.

Bro. He’ll call if his arm starts falling off. Calm down. He can still dial a phone with the other hand.

 

[HighPriest]

Got a call from a lady via our answering service. She said her daughter had had her tonsils out 4 days ago by my partner. She’s 13 and bigger, so we had given her some narcotics for her pain. But she was having itching and nausea and couldn’t sleep. So the caller had given her some of her grandmother’s leftover tramadol. That worked great and it’s “not a narcotic,” so she was hoping she could get a refill. I told her I would look in to it and give her a call back when I filled the Rx. She said she was in a hurry, they were out of town because of a funeral, and she really needed it as soon as possible.

You can see where this is going.

Shockingly, her daughter hadn’t ever been in to see us. The lady came up on our narcotics monitoring system. Or, at least, her children did. She’d been calling all over the region and having painkillers filled for her kids for procedures they either had or hadn’t had. She had filled at least 60 tabs of tramadol in the last two weeks. Or her kids had. You know. Whatever.

Apparently she works at a family medical practice (not a provider).