Post your boring, nonsense shifts!

[VA Hopeful Dr]

Have y'all not gotten any URIs in this time or do you just stay home for a week if you do and not worry about testing?

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[thegenius]

Have y'all not gotten any URIs in this time or do you just stay home for a week if you do and not worry about testing?

I maybe have gotten 2 mild URI's over the past 2 years and just worked through it.

Mild meaning I blew my nose 6-8x/day for 2 days. No coughing, no fever or any other symptoms.

 

[thegenius]

I maybe have gotten 2 mild URI's over the past 2 years and just worked through it.

Mild meaning I blew my nose 6-8x/day for 2 days. No coughing, no fever or any other symptoms.

@VA Hopeful Dr
What can I say. I think one can make a reasonable argument that I should have tested myself if this occurred within the first ~6 months of the pandemic, but I'm certainly not going to quarantine myself now...2 years after all of this started...if I get sniffles for a day. Especially when the entire Bay Area is coming to my hospital getting tested over the past week.

There is absolutely nothing I can do to slow the spread of the disease. Nothing. Nada! I can sit in a tree for 10 years and wait this out...and have food and toilet paper airlifted to me. And the disease is going to spread the way it does.

The fact is...I'm more protected from COVID than the vast majority of people who come into contact with grandpa who is on chemo for his metastatic cancer, which is the cohort of people we care about.

 

[VA Hopeful Dr]

@VA Hopeful Dr
What can I say. I think one can make a reasonable argument that I should have tested myself if this occurred within the first ~6 months of the pandemic, but I'm certainly not going to quarantine myself now...2 years after all of this started...if I get sniffles for a day. Especially when the entire Bay Area is coming to my hospital getting tested over the past week.

There is absolutely nothing I can do to slow the spread of the disease. Nothing. Nada! I can sit in a tree for 10 years and wait this out...and have food and toilet paper airlifted to me. And the disease is going to spread the way it does.

The fact is...I'm more protected from COVID than the vast majority of people who come into contact with grandpa who is on chemo for his metastatic cancer, which is the cohort of people we care about.

I don't disagree with that and I certainly don't get tested for 1 day of some mild sniffles either.

I test my kids for that, but purely so they can go back to school. I wouldn't if it was left up to me.

 

[Dr Mantis Toboggan]

Have y'all not gotten any URIs in this time or do you just stay home for a week if you do and not worry about testing?

Haven’t had a URI in over 2 years.

 

[bravotwozero]

I’ve done one and only because my PRN gig forced me to do surveillance testing

 

[Cinclus]

Back on track a bit: During my most recent shift, it seemed that almost every demented patient from the local nursing homes fell down and became covered in lacerations. It was the most boring of time-consuming things. One woman would randomly scream names of various food items while I was suturing, and I have to say that it was the clear highlight of the shift.

 

[thegenius]

Back on track a bit: During my most recent shift, it seemed that almost every demented patient from the local nursing homes fell down and became covered in lacerations. It was the most boring of time-consuming things. One woman would randomly scream names of various food items while I was suturing, and I have to say that it was the clear highlight of the shift.

LINGUINE!
VERY LARGE WATERMELON!
TEPID GREEN TEA!

 

[bravotwozero]

Reminds me of the time I had to put in a central line on a demented patient. Told me to ‘knock it off or I’ll throw you in the fuggin lake!’

 

[southerndoc]

Reminds me of the time I had to put in a central line on a demented patient. Told me to ‘knock it off or I’ll throw you in the fuggin lake!’

Something special for that. Geodon for the win

 

[turkeyjerky]

Ugh, tonight was trying...

1. Mid 40s F, h/o ESRD 3rd vist for abd pain this week. (20th this year), neg CT and CTA past two visits. Labs wnl, feeling great after haldo. DC
2. 70s M concerned about hernia. Has generalized lymphadnopathy, known chronic leukemia. Really nice guy though and is greatly reassured. DC
3. 30s M w/ etoh related fall, facial lac. Here w/ mom, who's also drunk and belligerent and had to be kicked out. CT neg, Face sewed up. DC.
4. 70s F w/ gastro. Labs wnl, feels fine in ED and tol PO. DC.
5. 2 month old M w/ 2 days of vomiting and diarrhea, mom sick w/ same. Looks fine. "He won't drink anything!" Required no therapy and fed fine in ER. DC.
6. 20s M w/ syncope and work and Chin lac. DC
7. 20s pregnant F. Here w/ "confusion". Not confused. DC.
8. 60s M w/ 2 weeks of "confusion". Not confused. Came in because urgent care told him to 2 days ago when he mentioned it during a visit for an ear cleaning. On disability due to chronic anxiety. DC
9. 20s F, has a G tube due to "ehlors danlos and POTS". Despite this has chronic intractable n/v. "I'm trying to get a port put in". DC (demanded discharge after I told her no fentanyl)
10. 20s F w/ palpitations and anxiety. 5th visit this year for same. Has already had negative outpatient holter, starting another one in 2 days. EKG is sinus. DC
11. 20s M with chest pain shortly after taking an edible. DC
12. 20s M with epigastric pain after a few beers. "It's my hiatal hernia, I think it's ruptured". DC
13. 30s F wrist sprain. DC
14. 70s F R arm/leg/face paresthesias x 6 hrs. No objective findings. Admit for CVA workup.
15. 40s F w/ pain & paresthesia to RUE. DC
16. 60s M w/ abd pain h/o complicated chole 4 weeks ago and still has a JP in place. Labs, CT normal. Turned out he ran out of his norco today. DC.
17. 20s F or M (I couldn't tell and didn't ask) w/ cough for 3-4 days. DC
18. 40s F wit abd pain. Might actually have something.
19. 50s F with alcohol intoxication and belly pain/dizziness. Patient #3's mom. Haldol and DC.
20. teenager from group home with SI. Awaiting transfer.
21. teenager from same group home. Cut her toe on glass trying to escape. "Squirting blood" per EMS. Has a nongaping superficial lac on her toe. Dermabond and DC.
22. 2 year old with croup from covid. Decadron and DC.
23. 20s F with some bumps and bruises and couple of lacerations after a low speed MVA. DC

 

[Janders]

My most recent normal old shift, shockingly no procedures, a couple brain-use cases but very run of the mill. This is w/ a very solid PA who staffed about half the low acuity below with me.

(1) 50s w/ wk of fever to 104, back pain, malaise, previously w/u days prior unremarkable labs, MRI spine (-) for abscess. Admitted with likely dx babesiosis w/ significant parasite load.
(2) 90s w/ fall, weakness, head strike, found to be +Covid and delirious admitted
(3) 90s w/ classic witnessed TIA syndrome, a week into COVID and hyponatremic. Admitted.
(4) 80s w/ NSTEMI versus Takusubo, multi-doc-sign-out d/t no EMS around, eventually xfer for cath lab.
(5) 30s lumbar radiculopathy
(6) 40s bad balanitis
(7) 40s ETOH >500, obs for sober
(8) 50s shoulder strain
(9) 30s minor GYN issue
(10) Toddler head lac
(11) 60s syncope in setting of heat advisory and ETOH >300
(12) 30s grief/panic reaction
(13) 70s post-op fever, likely UTI. Home after significant work up.
(14) 40s GERD
(15) teenager w/ gastroenteritis
(16) 20s pharyngitis
(17) kid w/ foot contusion
(18) 60s hyperglycemia w/ DM toe (mild)
(19) 70s fall Minimal trauma
(20) 20s depression sans SI
(21) 30s pharyngitis
(22) elderly shoulder injury
(23) 60s heat related dehydration w/ AKI, eventually d/c’d
(24) 20s schizophrenic known well, a bit agitated. Held for psych

And about 4 other psych holds in long stay, one of whom I discharged and one of whom I spent some time on restarting meds on, and 2 of whole were tucked in.

 

[Kryptocoin]

Ugh, tonight was trying...

1. Mid 40s F, h/o ESRD 3rd vist for abd pain this week. (20th this year), neg CT and CTA past two visits. Labs wnl, feeling great after haldo. DC
2. 70s M concerned about hernia. Has generalized lymphadnopathy, known chronic leukemia. Really nice guy though and is greatly reassured. DC
3. 30s M w/ etoh related fall, facial lac. Here w/ mom, who's also drunk and belligerent and had to be kicked out. CT neg, Face sewed up. DC.
4. 70s F w/ gastro. Labs wnl, feels fine in ED and tol PO. DC.
5. 2 month old M w/ 2 days of vomiting and diarrhea, mom sick w/ same. Looks fine. "He won't drink anything!" Required no therapy and fed fine in ER. DC.
6. 20s M w/ syncope and work and Chin lac. DC
7. 20s pregnant F. Here w/ "confusion". Not confused. DC.
8. 60s M w/ 2 weeks of "confusion". Not confused. Came in because urgent care told him to 2 days ago when he mentioned it during a visit for an ear cleaning. On disability due to chronic anxiety. DC
9. 20s F, has a G tube due to "ehlors danlos and POTS". Despite this has chronic intractable n/v. "I'm trying to get a port put in". DC (demanded discharge after I told her no fentanyl)
10. 20s F w/ palpitations and anxiety. 5th visit this year for same. Has already had negative outpatient holter, starting another one in 2 days. EKG is sinus. DC
11. 20s M with chest pain shortly after taking an edible. DC
12. 20s M with epigastric pain after a few beers. "It's my hiatal hernia, I think it's ruptured". DC
13. 30s F wrist sprain. DC
14. 70s F R arm/leg/face paresthesias x 6 hrs. No objective findings. Admit for CVA workup.
15. 40s F w/ pain & paresthesia to RUE. DC
16. 60s M w/ abd pain h/o complicated chole 4 weeks ago and still has a JP in place. Labs, CT normal. Turned out he ran out of his norco today. DC.
17. 20s F or M (I couldn't tell and didn't ask) w/ cough for 3-4 days. DC
18. 40s F wit abd pain. Might actually have something.
19. 50s F with alcohol intoxication and belly pain/dizziness. Patient #3's mom. Haldol and DC.
20. teenager from group home with SI. Awaiting transfer.
21. teenager from same group home. Cut her toe on glass trying to escape. "Squirting blood" per EMS. Has a nongaping superficial lac on her toe. Dermabond and DC.
22. 2 year old with croup from covid. Decadron and DC.
23. 20s F with some bumps and bruises and couple of lacerations after a low speed MVA. DC

Sigh. I don't think the average American can survive in other countries.

 

[thegenius]

@turkeyjerky and @Janders
Your shifts are the exact same as mine and everybody else's on this forum.

I read these...and it's like we collectively all see like 4-5 real patients a shift that may have an emergency (often don't), and the other 20 is literally just BS.

 

[Janders]

Yeah I think my ratio is typically—
1/3 Emergency or potential thereof (I’m being generous, but renal colic pain or chest pain NOS in a 60yo I’m going in as “potentially bad”)
1/3 need some medical input but a PCP, GYN, or solid Urgent care could handle their issues, and its not exactly emergent.
and 1/3 don’t really need to engage the medico-industrial complex whatsoever… but they do either for personal reasons, lack of life skills, anxiety/worry, or lack of a more appropriate venue for minor psych / intoxication / worried VERY well.

 

[VA Hopeful Dr]

Yeah I think my ratio is typically—
1/3 Emergency or potential thereof (I’m being generous, but renal colic pain or chest pain NOS in a 60yo I’m going in as “potentially bad”)
1/3 need some medical input but a PCP, GYN, or solid Urgent care could handle their issues, and its not exactly emergent.
and 1/3 don’t really need to engage the medico-industrial complex whatsoever… but they do either for personal reasons, lack of life skills, anxiety/worry, or lack of a more appropriate venue for minor psych / intoxication / worried VERY well.

I'm always shocked by both the people that use the ED when UC would do and vice versa.

When I was doing urgent care full time I would regularly have these people with huge lacerations come in. We're talking 2 layer closure with 30+ sutures. I had the lidocaine toxicity figures memorized at that place and often went right to the limit. Or the time a guy came in with super obvious cauda equina - hadn't peed in 30 hours despite really really needing to.

Now as a PCP I see my patients going in for joint pain or a cough when I have openings that same day.

 

[Janders]

I'm always shocked by both the people that use the ED when UC would do and vice versa.

When I was doing urgent care full time I would regularly have these people with huge lacerations come in. We're talking 2 layer closure with 30+ sutures. I had the lidocaine toxicity figures memorized at that place and often went right to the limit. Or the time a guy came in with super obvious cauda equina - hadn't peed in 30 hours despite really really needing to.

Now as a PCP I see my patients going in for joint pain or a cough when I have openings that same day.

Yeah, I occasionally have pulled shifts at our affiliated UC’s (which tend to be on the robust side, i.e. lots of labs and significant imaging available) and still you get things like… elderly grandma woke up altered, can’t stand on her own, drug in by children, BP 70 on arrival… brought by private car to the UC with multiple ER’s available within a 10-15min drive. People are curious

 

[thegenius]

Now as a PCP I see my patients going in for joint pain or a cough when I have openings that same day.

Yea...can you do a chest xray though in the office?

I don't think people come to the ER to see a doctor. I think they want a test. In this case they want a CXR. Or antibiotics. They don't want an evaluation. You can just as easily Rx antibiotics as I. But can you order a stat CXR? Do you have one in your office?

 

[Kryptocoin]

I'm always shocked by both the people that use the ED when UC would do and vice versa.

Medicaid patients. They don't want to pay a co-pay at UC.

 

[VA Hopeful Dr]

Yea...can you do a chest xray though in the office?

I don't think people come to the ER to see a doctor. I think they want a test. In this case they want a CXR. Or antibiotics. They don't want an evaluation. You can just as easily Rx antibiotics as I. But can you order a stat CXR? Do you have one in your office?

Yes, we do. Most offices do in my area.

 

[CoolDoc1729]

Yea...can you do a chest xray though in the office?

I don't think people come to the ER to see a doctor. I think they want a test. In this case they want a CXR. Or antibiotics. They don't want an evaluation. You can just as easily Rx antibiotics as I. But can you order a stat CXR? Do you have one in your office?

What amazes me lately is the number of healthy working age adults who presumably have other things to do, who come for a covid test, not for fever or for cough but literally “I want a covid test” when the Walgreens literally on the same corner as the hospital has a sign FREE COVID TESTING .. they’re in my ER for up to 8 hours !

 

[thegenius]

What amazes me lately is the number of healthy working age adults who presumably have other things to do, who come for a covid test, not for fever or for cough but literally “I want a covid test” when the Walgreens literally on the same corner as the hospital has a sign FREE COVID TESTING .. they’re in my ER for up to 8 hours !

Imagine you are going to get something from free.

That free thing can be had at multiple different buildings around the USA.

One building has cheap items in it: candies, deodorants, hallmark cards, trinkets, amulets, soaps, and other things. All of those things can be had for little cost, often a few percent above wholesale. The free thing you want is still free though. Everything else costs just a little more than wholesale though. And the people are often not that educated...although usually they are nice enough.

The other building houses some of the smartest and well-trained people on earth. They have a wealth of knowledge about a very broad topic. They save lives! They also have access to technology, often very expensive. Technology that costs millions of dollars. They have expensive drugs. Lots of people to dote over your needs. There is food, heat, bathrooms, and you get all of that...for free! All of it is free. That one thing you want is also free there. But basically everything is free. You never see a bill.

If you are an uninformed and irrational adult and can't obviously see the problem here...or don't care about the problem...where would you go?

 

[Groove]

I usually work at our academic center where the acuity is much higher but over the weekend worked at one of our remote single coverage sites. Not sure about the volume, probably 20K or so. Shift 1:

1) 20s Corneal abrasion while working when a ceiling tile fell down and smacked his face. DC
2) 70s super morbid obesity lady who's husband usually rolls her around the house and he suddenly decided enough is enough so she's been sitting in her own urine and feces over the past 3 days but is here for "SOB". Admitted for COPD exac on paper, so hospital can bill a legit encounter but really she was admitted for being too fat to move and now SW/CM will have to find her a fat house with paid medicare servants to help feed her.
3) 30s URI "Feels like my pneumonia I had 3 years ago!" VSS, lungs clear, no CXR. DC
4) 30s F here for arthralgia "I think I got the lupus! Google said I might even have Rocky Mountain Spickled Fevers!" DC
5) 80s F s/p D&C(eh?) few days ago seen a day later by another doc who worked her up and d/c her with 24% bands. Now back, septic, admitted.
6) 20s male with shoulder dislocation. Cunningham/Park at bedside with fail, he just won't relax. Prop, modified kocher, reduced. Wake up, dc.
7) 60s F, N/V/D. Work up, infectious enteritis. DC
8) 50s M here for HTN. Immediate DC. Dx: Asymptomatic hypertensive urgency
9) 30s F here for HA. Dx: Tension headache. DC
10) 60s F, morbid obesity, keeps falling. Stable L ankle fx and some stable T compression fx. Can't really ambulate without a motorized wheelchair. Needs admission and rehab but lady is deathly afraid of rehab "My friend died there!!". Tried my best to talk her into admission/transfer but she keeps crying when I say the word "rehab". Tried to enlist husband to talk her into it but no go. Left AMA.
11) 40s CP. Atypical. Neg work up, DC.
12) 60s F syncope. Afib RVR, heparin, dilt gtt, stable. Transfer.
13) 2yo ATV accident where mommy let her baby daddy's friend carry it on the 4 wheeler, flip and rolled on top of the 2yo. Kid screaming to high heaven. Possible C/T fx. VSS. Had to search for pediatric c-collar. Stabilized. Transferred by WING to local peds tertiary.
14) 50s F with infected bug bite. DC
15) 8yo M with viral syndrome. DC
16) 65 F with generalized weakness. Mild hyponatremia, fiddled with some offending meds. DC
17) 60s F train wreck brought in for septic shock. Urosepsis with PNA. Aggressive resus. GCS 10. Periarrest. Kept thinking this lady is gonna code as soon as I tube her or connect her to vent. Mixed up some push dose epi and gave her a sniff before and after the intubation, lined her out, stabilized, couldn't find a place less than hour away. Inner monologue: "I just know she's gonna arrest the longer I keep her here and I'm gonna be sucked into that room like a singularity. She reminds me of that 2hr code I had at this same site 10 years ago... Damn, that one sucked..." WING FTW.
18) 40s M with facial lacs while trying to do a Tik Tok dance while drunk. Almost chopped off his nose and L eyebrow. Lac repair. DC.
19) 6mo M with diarrhea. DC
20) 20s M with rhabdo, CK 1000, renal function essentially normal. IVF, DC with strict instructions no work outside, recheck chemistries in 3-4 days. Lots of fluids.
21) 40s F with cervical radiculopathy. DC
22) 80s F CP. ACS r/o, admit for obs.
23) 50s F bed bound s/p remote CVA here for PEG tube malfunction. Replaced. DC
24) 60s M with COVID. DC
25) 60s M NSTEMI, usual management, no Cath lab here and academic site on diversion. Transferred 1.5hrs away to one of our other sites cross state lines.
26) 50s M NSTEMI, usual management, no Cath lab here and all hospitals in our system on diversion. Transferred 1 hr away to another hospital in opposite direction.

Radio reports CPR in progress, 15 mins out. I look at my watch, new doc here in 5 mins. Fist pump.

 

[s/p epilepticus]

really she was admitted for being too fat to move and now SW/CM will have to find her a fat house with paid medicare servants to help feed her.

 

[mheat3]

13) 2yo ATV accident where mommy let her baby daddy's friend carry it on the 4 wheeler, flip and rolled on top of the 2yo. Kid screaming to high heaven. Possible C/T fx. VSS. Had to search for pediatric c-collar. Stabilized. Transferred by WING to local peds tertiary.

These read so much worse once you are a parent.

 

[bravotwozero]

These read so much worse once you are a parent.

Such unbelievably irresponsible people are walking around with children. Scary.

 

[thegenius]

It's fun reading other shifts.

Below is from a double shift (18 hrs...)

1) 58 F with nonsense mid back pain. UA/CXR normal. She was pissed off that I didn't give her narcotic Rx. DC
2) 29 F with diarrhea, possibly mild methadone withdraw. No labs needed. DC
3) 2 mo M with diarrhea, son of #2 above. No workup. DC
4) 67 F with abd pain and hematochezia, workup of mild colitis and normal labs belies the way she looks. I almost admitted her, but family wanted her home.
5) 41 F with metastatic pancreatic CA here for worsening pain. Labs are all wacky. Basically wanted pain control. Sad case. DC
6) 23 F with cold symptoms, C+, DC
7) 76 M with exacerbation of his R sciatica. No labs/imaging. DC with analgesia
8) 50 F wants phenytoin refill. DC with Rx
9) 83 F with symptomatic anemia / lymphoma, Hg 6.9, tx 1U pRBC and DC
10) 47 yo man traumatic shoulder pain 5 days ago, near FROM, no xray needed, DC
11) 26 M punched a windows, has a few tiny lacs on hand, bandaids applied, DC
12) 62 yo traumatic toe pain, xray neg, trephinated the toenail, DC
13) 65 yo chronic CP/SOB, labs/EKG/CXR normal (as usual...), DC
14) 53 M wants abx for possible STD. UA/GC/CT sent but I don't know results. Meds Given. DC (EDIT: just checked, + for both GC and CT!!)
15) 6 yo boy with lateral humeral condylar fracture, splinted and DC to peds/Ortho.
16) 17 M with a mild ingrown toenail that I didn't bother to do anything at all. Referred to podiatry. DC
17) 26 F with uncomplicated urticaria, she already took benadryl. DC
18) 20 F with traumatic ankle pain, XR neg, DC
19) 62 M with CP, everything was normal x2. Not a bad story though...told him to see his PCP this week. DC
20) 48 M regular ER user, is drunk and lord knows what else. FSG 558. Known diabetic. Standard labs OK, he felt better. DC
21) 84 F fell out of bed, has impressive ecchymosis on arm. Xrays, CTH neg. DC
22) 60 F witih weakness and tremors for maybe 1 week. This was the one pain in my ass pt this shift. She was OK (although weird) but a very weird family dynamic. I spent 6x the normal time with them vs other patients. I don't know what was causing it..I suspect it's polypharmacy. offered admission several times. pt wanted to go home. DC
23) 68 F with thrombosed AVF. K+ 4.5. Admitted
24) 30 F with offcycle vag bleeding. Labs/US normal. UPreg neg. DC
25) 35 M binge EtOh p/w HR 135. maybe dehydration? maybe withdraw? Phenobarb 260 IV x1, IVF, felt better. DC
26) 22 F came to get a second opinion on how to control her pseudoseizures. Has had all MRI/EEG done as outpatient. Spent a lot of time counseling to largely mitigate any chance of a lawsuit. Sent tons of labs that I knew would be normal, and they were. DC
27) 74 F came in a stroke alert. Very large IPH. Very sleepy but didn't require a tube. Went to OR.
28) 73 M with terrible chronic venous stasis of legs (and obviously doesn't clean them either) with superimposed cellulitis. Labs/vitals normal. DC with abx.
29) 39 yo man with a leaky colostomy bag, ? blood in stool (although not there now) and a variety of other weird complaints. Changed bag and will dc
30) 59 M punched in jaw. mandible XR neg. DC
31) 49 M with recurrent pancreatitis pain. Possible by EtOH? Everytime he is admitted, it's just for one day. Lipase 1000. He's had ~10 CT's prior with just pancreatitis and no pseudocyst. I suppose one day he will develop one...but I didn't scan him today and just sent him home with 6 norcos and clear liquid diet instructions. I don't think he was happy about that.
32) 22 F 38 wks pregnant with dizziness. Vitals/Exam normal. EKG normal. DC
33) 34 M with dizziness. Kind of a cool case. He was Rx clonidine 0.3mg QID PRN anxiety (!!). Prior was naive to clonidine. Took 8 of them over 24 hours. No wonder why he was falling and felt weak and wobbily. HR 47, BP 95/45. Last clonidine was about 12 hours ago. Lying down he was fine. Thankfully over the next 3 hours or so his vitals improved and he felt fine. DC
34) 54 F said "I had some syncope earlier." Sounded like she just had an accidental fall. EKG/Labs OK. DC
35) 46 F with R sided abd pain. Labs / UA / CT / US all neg. DC
36) 51 M sent in by NH for fatigue for one day? Maybe has UTI. DC with abx
37) 25 yo man with syncope while making food. EKG w/ RBBB+LAFB. Normal intervals. Labs normal. D/w cards, DC
38) 59 F in a minor fender bender and tapped her head. + HA. No imaging. DC
39) 25 F with a potentially failed medical AB at Planned Parenthood. No symptoms. About 5 wks by dates. US shows something in the uterus, adnexa and tubes are normal. DC
40) 37 F p/w HA. history of MS. Another weird and interesting case. She was at another hospital 3 days ago with acute neuro symptoms, given tPA, and admitted to ICU. She AMA'ed 4 hours later citing nobody could take care of her kids. Comes here 3! days later with HA. CT Head neg. I ultimately said she needs to see a neurologist and I offered admission and she politely refused again due to daycare problems. AMA
41) 24 M with psychosis, 5150. transferred to crisis unit
42) 15 M with SI, 5150. transferred to crisis unit
43) 36 F with uncomplicated dental pain. DC with T3
44) 10 F with intermittent left hand weakness. Currently asymptomatic. Pediatrics sent in for a stroke workup. I said to family that was ridiculous...10 F don't really have strokes, it's like 1 in a million. CT head non-con did show a developmental venous anomaly over R central sulcus. Transferred to academic center with neurovascular.

45) 58 F returns for mid back pain. Same patient as #1. I said to her "I do not prescribe narcotics for your kind of pain." Labs were normal. D/C. She wanted to talk to my manager.
46) 44 M with traumatic toe/foot pain, XR neg. DC



Kind of a nonsense shift. Although on the annoying side especially with #22, 26, and 40.

 

[turkeyjerky]

It's fun reading other shifts.
Below is from a double shift (18 hrs...)

1) 58 F with nonsense mid back pain. UA/CXR normal. Was pissed off that I didn't give her narcotic Rx. DC
2) 29 F with diarrhea, possibly mild methadone withdraw. No labs needed. DC
3) 2 mo M with diarrhea, son of #2 above. No workup. DC
4) 67 F with abd pain and hematochezia, workup of mild colitis and normal labs belies the way she looks. I almost admitted her, but family wanted her home.
5) 41 F with metastatic pancreatic CA here for worsening pain. Labs are all wacky. Basically wanted pain control. Sad case. DC
6) 23 F with cold symptoms, C+, DC
7) 76 M with exacerbation of his R sciatica. No labs/imaging. DC with analgesia
8) 50 F wants phenytoin refill. DC with Rx
9) 83 F with symptomatic anemia / lymphoma, Hg 6.9, tx 1U pRBC and DC
10) 47 yo man traumatic shoulder pain 5 days ago, near FROM, no xray needed, DC
11) 26 M punched a windows, has a few tiny lacs on hand, bandaids applied, DC
12) 62 yo traumatic toe pain, xray neg, trephinated the toenail, DC
13) 65 yo chronic CP/SOB, labs/EKG/CXR normal (as usual...), DC
14) 53 M wants abd for possible STD. UA/GC/CT sent but I don't know results. Meds Given. DC (EDIT: just checked, + for both GC and CT!!)
15) 6 yo boy with lateral humeral condylar fracture, splinted and DC to peds/Ortho.
16) 17 M with a mild ingrown toenail that I didn't bother to do anything at all. Referred to podiatry. DC
17) 26 F with uncomplicated urticaria, she already took benadryl. DC
18) 20 F with traumatic ankle pain, XR neg, DC
19) 62 M with CP, everything was normal x2. Not a bad story though...told him to see his PCP this week. DC
20) 48 M regular ER user, is drunk and lord knows what else. FSG 558. Known diabetic. Standard labs OK, he felt better. DC
21) 84 F fell out of bed, has impressive ecchymosis on arm. Xrays, CTH neg. DC
22) 60 F witih weakness and tremors for maybe 1 week. This was the one pain in my ass pt this shift. She was OK (although weird) but a very weird family dynamic. I spent 6x the normal time with them vs other patients. I don't know what was causing it..I suspect it's polypharmacy. offered admission several times. pt wanted to go home. DC
23) 68 F with thrombosed AVF. K+ 4.5. Admitted
24) 30 F with offcycle vag bleeding. Labs/US normal. UPreg neg. DC
25) 35 M binge EtOh p/w HR 135. maybe dehydration? maybe withdraw? Phenobarb 260 IV x1, IVF, felt better. DC
26) 22 F came to get a second opinion on how to control her pseudoseizures. Has had all MRI/EEG done as outpatient. Spent a lot of time counseling to largely mitigate any chance of a lawsuit. Sent tons of labs that I knew would be normal, and they were. DC
27) 74 F came in a stroke alert. Very large IPH. Very sleepy but didn't require a tube. Went to OR.
28) 73 M with terrible chronic venous stasis of legs (and obviously doesn't clean them either) with superimposed cellulitis. Labs/vitals normal. DC with abx.
29) 39 yo man with a leaky colostomy bag, ? blood in stool (although not there now) and a variety of other weird complaints. Changed bag and will dc
30) 59 M punched in jaw. mandible XR neg. DC
31) 49 M with recurrent pancreatitis pain. Possible by EtOH? Everytime he is admitted, it's just for one day. Lipase 1000. He's had ~10 CT's prior with just pancreatitis and no pseudocyst. I suppose one day he will develop one...but I didn't scan him today and just sent him home with 6 norcos and clear liquid diet instructions. I don't think he was happy about that.
32) 22 F 38 wks pregnant with dizziness. Vitals/Exam normal. EKG normal. DC
33) 34 M with dizziness. Kind of a cool case. He was Rx clonidine 0.3mg QID PRN anxiety (!!). Prior was naive to clonidine. Took 8 of them over 24 hours. No wonder why he was falling and felt weak and wobbily. HR 47, BP 95/45. Last clonidine was about 12 hours ago. Lying down he was fine. Thankfully over the next 3 hours or so his vitals improved and he felt fine. DC
34) 54 F said "I had some syncope earlier." Sounded like she just had an accidental fall. EKG/Labs OK. DC
35) 46 F with R sided abd pain. Labs / UA / CT / US all neg. DC
36) 51 M sent in by NH for fatigue for one day? Maybe has UTI. DC with abx
37) 25 yo man with syncope while making food. EKG w/ RBBB+LAFB. Normal intervals. Labs normal. D/w cards, DC
38) 59 F in a minor fender bender and tapped her head. + HA. No imaging. DC
39) 25 F with a potentially failed medical AB at Planned Parenthood. No symptoms. About 5 wks by dates. US shows something in the uterus, adnexa and tubes are normal. DC
40) 37 F p/w HA. history of MS. Another weird and interesting case. She was at another hospital 3 days ago with acute neuro symptoms, given tPA, and admitted to ICU. She AMA'ed 4 hours later citing nobody could take care of her kids. Comes here 3! days later with HA. CT Head neg. I ultimately said she needs to see a neurologist and I offered admission and she politely refused again due to daycare problems. AMA
41) 24 M with psychosis, 5150. transferred to crisis unit
42) 15 M with SI, 5150. transferred to crisis unit
43) 36 F with uncomplicated dental pain. DC with T3
44) 10 F with intermittent left hand weakness. Currently asymptomatic. Pediatrics sent in for a stroke workup. I said to family that was ridiculous...10 F don't really have strokes, it's like 1 in a million. CT head non-con did show a developmental venous anomaly over R central sulcus. Transferred to academic center with neurovascular.
View attachment 358253View attachment 358254
45) 58 F returns for mid back pain. Same patient as #1. I said to her "I do not prescribe narcotics for your kind of pain." Labs were normal. D/C. She wanted to talk to my manager.
46) 44 M with traumatic toe/foot pain, XR neg. DC



Kind of a nonsense shift. Although on the annoying side especially with #22, 26, and 40.

Yeesh, I'm tired just reading this.

It triggers me when someone says "stroke workup" when they really mean "workup for neurological symptoms"

 

[Mount Asclepius]

It's fun reading other shifts.

Below is from a double shift (18 hrs...)

1) 58 F with nonsense mid back pain. UA/CXR normal. She was pissed off that I didn't give her narcotic Rx. DC
2) 29 F with diarrhea, possibly mild methadone withdraw. No labs needed. DC
3) 2 mo M with diarrhea, son of #2 above. No workup. DC
4) 67 F with abd pain and hematochezia, workup of mild colitis and normal labs belies the way she looks. I almost admitted her, but family wanted her home.
5) 41 F with metastatic pancreatic CA here for worsening pain. Labs are all wacky. Basically wanted pain control. Sad case. DC
6) 23 F with cold symptoms, C+, DC
7) 76 M with exacerbation of his R sciatica. No labs/imaging. DC with analgesia
8) 50 F wants phenytoin refill. DC with Rx
9) 83 F with symptomatic anemia / lymphoma, Hg 6.9, tx 1U pRBC and DC
10) 47 yo man traumatic shoulder pain 5 days ago, near FROM, no xray needed, DC
11) 26 M punched a windows, has a few tiny lacs on hand, bandaids applied, DC
12) 62 yo traumatic toe pain, xray neg, trephinated the toenail, DC
13) 65 yo chronic CP/SOB, labs/EKG/CXR normal (as usual...), DC
14) 53 M wants abx for possible STD. UA/GC/CT sent but I don't know results. Meds Given. DC (EDIT: just checked, + for both GC and CT!!)
15) 6 yo boy with lateral humeral condylar fracture, splinted and DC to peds/Ortho.
16) 17 M with a mild ingrown toenail that I didn't bother to do anything at all. Referred to podiatry. DC
17) 26 F with uncomplicated urticaria, she already took benadryl. DC
18) 20 F with traumatic ankle pain, XR neg, DC
19) 62 M with CP, everything was normal x2. Not a bad story though...told him to see his PCP this week. DC
20) 48 M regular ER user, is drunk and lord knows what else. FSG 558. Known diabetic. Standard labs OK, he felt better. DC
21) 84 F fell out of bed, has impressive ecchymosis on arm. Xrays, CTH neg. DC
22) 60 F witih weakness and tremors for maybe 1 week. This was the one pain in my ass pt this shift. She was OK (although weird) but a very weird family dynamic. I spent 6x the normal time with them vs other patients. I don't know what was causing it..I suspect it's polypharmacy. offered admission several times. pt wanted to go home. DC
23) 68 F with thrombosed AVF. K+ 4.5. Admitted
24) 30 F with offcycle vag bleeding. Labs/US normal. UPreg neg. DC
25) 35 M binge EtOh p/w HR 135. maybe dehydration? maybe withdraw? Phenobarb 260 IV x1, IVF, felt better. DC
26) 22 F came to get a second opinion on how to control her pseudoseizures. Has had all MRI/EEG done as outpatient. Spent a lot of time counseling to largely mitigate any chance of a lawsuit. Sent tons of labs that I knew would be normal, and they were. DC
27) 74 F came in a stroke alert. Very large IPH. Very sleepy but didn't require a tube. Went to OR.
28) 73 M with terrible chronic venous stasis of legs (and obviously doesn't clean them either) with superimposed cellulitis. Labs/vitals normal. DC with abx.
29) 39 yo man with a leaky colostomy bag, ? blood in stool (although not there now) and a variety of other weird complaints. Changed bag and will dc
30) 59 M punched in jaw. mandible XR neg. DC
31) 49 M with recurrent pancreatitis pain. Possible by EtOH? Everytime he is admitted, it's just for one day. Lipase 1000. He's had ~10 CT's prior with just pancreatitis and no pseudocyst. I suppose one day he will develop one...but I didn't scan him today and just sent him home with 6 norcos and clear liquid diet instructions. I don't think he was happy about that.
32) 22 F 38 wks pregnant with dizziness. Vitals/Exam normal. EKG normal. DC
33) 34 M with dizziness. Kind of a cool case. He was Rx clonidine 0.3mg QID PRN anxiety (!!). Prior was naive to clonidine. Took 8 of them over 24 hours. No wonder why he was falling and felt weak and wobbily. HR 47, BP 95/45. Last clonidine was about 12 hours ago. Lying down he was fine. Thankfully over the next 3 hours or so his vitals improved and he felt fine. DC
34) 54 F said "I had some syncope earlier." Sounded like she just had an accidental fall. EKG/Labs OK. DC
35) 46 F with R sided abd pain. Labs / UA / CT / US all neg. DC
36) 51 M sent in by NH for fatigue for one day? Maybe has UTI. DC with abx
37) 25 yo man with syncope while making food. EKG w/ RBBB+LAFB. Normal intervals. Labs normal. D/w cards, DC
38) 59 F in a minor fender bender and tapped her head. + HA. No imaging. DC
39) 25 F with a potentially failed medical AB at Planned Parenthood. No symptoms. About 5 wks by dates. US shows something in the uterus, adnexa and tubes are normal. DC
40) 37 F p/w HA. history of MS. Another weird and interesting case. She was at another hospital 3 days ago with acute neuro symptoms, given tPA, and admitted to ICU. She AMA'ed 4 hours later citing nobody could take care of her kids. Comes here 3! days later with HA. CT Head neg. I ultimately said she needs to see a neurologist and I offered admission and she politely refused again due to daycare problems. AMA
41) 24 M with psychosis, 5150. transferred to crisis unit
42) 15 M with SI, 5150. transferred to crisis unit
43) 36 F with uncomplicated dental pain. DC with T3
44) 10 F with intermittent left hand weakness. Currently asymptomatic. Pediatrics sent in for a stroke workup. I said to family that was ridiculous...10 F don't really have strokes, it's like 1 in a million. CT head non-con did show a developmental venous anomaly over R central sulcus. Transferred to academic center with neurovascular.
View attachment 358253View attachment 358254
45) 58 F returns for mid back pain. Same patient as #1. I said to her "I do not prescribe narcotics for your kind of pain." Labs were normal. D/C. She wanted to talk to my manager.
46) 44 M with traumatic toe/foot pain, XR neg. DC



Kind of a nonsense shift. Although on the annoying side especially with #22, 26, and 40.

You did 18 hours straight seeing ~2.5 patients/hour? Would be draining. I guess lower acuity than average based upon admit/cc percentage, but also makes seem sole crushing.

 

[thegenius]

You did 18 hours straight seeing ~2.5 patients/hour? Would be draining. I guess lower acuity than average based upon admit/cc percentage, but also makes seem sole crushing.

Yea..I get to drive into work less. I do that once/month. I end up being able to get like a 4-5 day stretch of consecutive off days.

Yesterday was a medium difficulty day. Sometimes I only see like 36, a few times I've exceeded 50.

 

[GassYous]

It's fun reading other shifts.

Below is from a double shift (18 hrs...)

1) 58 F with nonsense mid back pain. UA/CXR normal. She was pissed off that I didn't give her narcotic Rx. DC
2) 29 F with diarrhea, possibly mild methadone withdraw. No labs needed. DC
3) 2 mo M with diarrhea, son of #2 above. No workup. DC
4) 67 F with abd pain and hematochezia, workup of mild colitis and normal labs belies the way she looks. I almost admitted her, but family wanted her home.
5) 41 F with metastatic pancreatic CA here for worsening pain. Labs are all wacky. Basically wanted pain control. Sad case. DC
6) 23 F with cold symptoms, C+, DC
7) 76 M with exacerbation of his R sciatica. No labs/imaging. DC with analgesia
8) 50 F wants phenytoin refill. DC with Rx
9) 83 F with symptomatic anemia / lymphoma, Hg 6.9, tx 1U pRBC and DC
10) 47 yo man traumatic shoulder pain 5 days ago, near FROM, no xray needed, DC
11) 26 M punched a windows, has a few tiny lacs on hand, bandaids applied, DC
12) 62 yo traumatic toe pain, xray neg, trephinated the toenail, DC
13) 65 yo chronic CP/SOB, labs/EKG/CXR normal (as usual...), DC
14) 53 M wants abx for possible STD. UA/GC/CT sent but I don't know results. Meds Given. DC (EDIT: just checked, + for both GC and CT!!)
15) 6 yo boy with lateral humeral condylar fracture, splinted and DC to peds/Ortho.
16) 17 M with a mild ingrown toenail that I didn't bother to do anything at all. Referred to podiatry. DC
17) 26 F with uncomplicated urticaria, she already took benadryl. DC
18) 20 F with traumatic ankle pain, XR neg, DC
19) 62 M with CP, everything was normal x2. Not a bad story though...told him to see his PCP this week. DC
20) 48 M regular ER user, is drunk and lord knows what else. FSG 558. Known diabetic. Standard labs OK, he felt better. DC
21) 84 F fell out of bed, has impressive ecchymosis on arm. Xrays, CTH neg. DC
22) 60 F witih weakness and tremors for maybe 1 week. This was the one pain in my ass pt this shift. She was OK (although weird) but a very weird family dynamic. I spent 6x the normal time with them vs other patients. I don't know what was causing it..I suspect it's polypharmacy. offered admission several times. pt wanted to go home. DC
23) 68 F with thrombosed AVF. K+ 4.5. Admitted
24) 30 F with offcycle vag bleeding. Labs/US normal. UPreg neg. DC
25) 35 M binge EtOh p/w HR 135. maybe dehydration? maybe withdraw? Phenobarb 260 IV x1, IVF, felt better. DC
26) 22 F came to get a second opinion on how to control her pseudoseizures. Has had all MRI/EEG done as outpatient. Spent a lot of time counseling to largely mitigate any chance of a lawsuit. Sent tons of labs that I knew would be normal, and they were. DC
27) 74 F came in a stroke alert. Very large IPH. Very sleepy but didn't require a tube. Went to OR.
28) 73 M with terrible chronic venous stasis of legs (and obviously doesn't clean them either) with superimposed cellulitis. Labs/vitals normal. DC with abx.
29) 39 yo man with a leaky colostomy bag, ? blood in stool (although not there now) and a variety of other weird complaints. Changed bag and will dc
30) 59 M punched in jaw. mandible XR neg. DC
31) 49 M with recurrent pancreatitis pain. Possible by EtOH? Everytime he is admitted, it's just for one day. Lipase 1000. He's had ~10 CT's prior with just pancreatitis and no pseudocyst. I suppose one day he will develop one...but I didn't scan him today and just sent him home with 6 norcos and clear liquid diet instructions. I don't think he was happy about that.
32) 22 F 38 wks pregnant with dizziness. Vitals/Exam normal. EKG normal. DC
33) 34 M with dizziness. Kind of a cool case. He was Rx clonidine 0.3mg QID PRN anxiety (!!). Prior was naive to clonidine. Took 8 of them over 24 hours. No wonder why he was falling and felt weak and wobbily. HR 47, BP 95/45. Last clonidine was about 12 hours ago. Lying down he was fine. Thankfully over the next 3 hours or so his vitals improved and he felt fine. DC
34) 54 F said "I had some syncope earlier." Sounded like she just had an accidental fall. EKG/Labs OK. DC
35) 46 F with R sided abd pain. Labs / UA / CT / US all neg. DC
36) 51 M sent in by NH for fatigue for one day? Maybe has UTI. DC with abx
37) 25 yo man with syncope while making food. EKG w/ RBBB+LAFB. Normal intervals. Labs normal. D/w cards, DC
38) 59 F in a minor fender bender and tapped her head. + HA. No imaging. DC
39) 25 F with a potentially failed medical AB at Planned Parenthood. No symptoms. About 5 wks by dates. US shows something in the uterus, adnexa and tubes are normal. DC
40) 37 F p/w HA. history of MS. Another weird and interesting case. She was at another hospital 3 days ago with acute neuro symptoms, given tPA, and admitted to ICU. She AMA'ed 4 hours later citing nobody could take care of her kids. Comes here 3! days later with HA. CT Head neg. I ultimately said she needs to see a neurologist and I offered admission and she politely refused again due to daycare problems. AMA
41) 24 M with psychosis, 5150. transferred to crisis unit
42) 15 M with SI, 5150. transferred to crisis unit
43) 36 F with uncomplicated dental pain. DC with T3
44) 10 F with intermittent left hand weakness. Currently asymptomatic. Pediatrics sent in for a stroke workup. I said to family that was ridiculous...10 F don't really have strokes, it's like 1 in a million. CT head non-con did show a developmental venous anomaly over R central sulcus. Transferred to academic center with neurovascular.
View attachment 358253View attachment 358254
45) 58 F returns for mid back pain. Same patient as #1. I said to her "I do not prescribe narcotics for your kind of pain." Labs were normal. D/C. She wanted to talk to my manager.
46) 44 M with traumatic toe/foot pain, XR neg. DC



Kind of a nonsense shift. Although on the annoying side especially with #22, 26, and 40.

A few cool cases but wow amazing how the general public cannot cope with minor conditions

Pseudoseizure patients are the worst. So much waste in the system with the million dollar neuro workup that shows nothing.

 

[RustedFox]

A few cool cases but wow amazing how the general public cannot cope with minor conditions

Pseudoseizure patients are the worst. So much waste in the system with the million dollar neuro workup that shows nothing.

Waaaait for it....

 

[Groove]

A few cool cases but wow amazing how the general public cannot cope with minor conditions

Pseudoseizure patients are the worst. So much waste in the system with the million dollar neuro workup that shows nothing.

The ED is essentially the PCP office and urgent care clinic for 100% of the homeless, poor, psych population as well as 100% of the entitled and insured who want to be able to get a prescription/work note/massive and non indicated work up at any time of the day or night. It's an enormous waste of healthcare resources and tax dollars. What's more is that with EMTALA, none of these patients can truly be turned away and there's the looming threat of litigation if you spend too little time on the person, discharge them and miss something.

I sometimes wish we could work in a similar ED environment to the 50s-60s but then we'd all be out of a job. In fact, I was truly terrified during the COVID pandemic when volume precipitously dropped and APC/MD hours were slashed. If the major insurance carriers and/or the government ever find a way to disincentivize the general public from seeking out non emergent medical care in the ED, we are in for a world of hurt. That's why I try not to get upset anymore and see all the ridiculousness as good job security.

 

[Groove]

Yea..I get to drive into work less. I do that once/month. I end up being able to get like a 4-5 day stretch of consecutive off days.

Yesterday was a medium difficulty day. Sometimes I only see like 36, a few times I've exceeded 50.

Hardcore man. You remind me of a guy I worked with at a busy level 2 trauma center that lived 1.5 hrs away and would work a shift, go in the call room and take a nap, then get up and work another full shift. I never understood how he could do it. I work more hours than almost all of my colleagues but I can't do that double shift stuff, that's brutal....especially given that kind of volume. Gonna change your ED mailbox to Cyberdyne Systems Model 101.

 

[BoardingDoc]

none of these patients can truly be turned away and there's the looming threat of litigation if you spend too little time on the person, discharge them and miss something.

True, but I increasingly don't GAF.

Cannabinoid hyperemesis guy recently. 8 ED visits in 4 days for the same. My 2nd time seeing him in 3 days. Basic exam, you have no medical emergency as I've seen you tolerate liquids. DCed immediately. No meds, no labs, no Rx.

Lady coming in yesterday with "vomiting a few times a week for 4 months."
- Abd exam benign.
- GI referral
- DC. No labs.

36F w/ arms and legs tingling. Recently evaluated for identical sx with a huge negative workup incl CT/CTA head/neck. Wants an MRI and neuro consult. Benign neuro exam. DC with existing neuro followup.

I frequently do the "here are your BS labs to make you feel like we did something" thing, but lately I don't care and just want them gone ASAP.

 

[Apollyon]

14) 53 M wants abx for possible STD. UA/GC/CT sent but I don't know results. Meds Given. DC (EDIT: just checked, + for both GC and CT!!)

30) 59 M punched in jaw. mandible XR neg. DC

Wonky SDN software. I was thinking 14 was the one that punched 30!

 

[thegenius]

Yea I like saying to people "I'm sorry you came to the wrong place. I don't work up intermittent vomiting for 4 months. I'm not trained to do so." And literally just discharging them. I probably need to do it more though.

On these double shifts that I do rarely...I tend to do less workups.

 

[Apollyon]

Such unbelievably irresponsible people are walking around with children. Scary.

Almost 30 years ago now, working on the ambulance, we would be amazed/disgusted when there would be the 1-2am call for "child struck by car".

 

[thegenius]

Wonky SDN software. I was thinking 14 was the one that punched 30!

he punched him in the face with his chlamydia-infested ding dong! LOL

 

[s/p epilepticus]

10 F with intermittent left hand weakness. Currently asymptomatic. Pediatrics sent in for a stroke workup. I said to family that was ridiculous...10 F don't really have strokes, it's like 1 in a million. CT head non-con did show a developmental venous anomaly over R central sulcus. Transferred to academic center with neurovascular.

Cmon man 🤦‍♂️

 

[thegenius]

Cmon man 🤦‍♂️

what are you referring to

 

[s/p epilepticus]

what are you referring to

The asymptomatic 10 y/o who had transient hand weakness who ended up with a vascular abnormality on imaging.

 

[thegenius]

I guess I just don't understand your comment. Like what is the chance of that happening kind of thing? Pretty damn rare.

Technically she's had three episodes over the last year when her left hand went clumsy for about 1 hour.

I almost didn't scan her, because she doesn't have an emergency. She had time to get the superior study which would have been an MRI. I did it thinking maybe she has some weird small mass that was causing transient simple partial seizures. But ultimately, I scanned her because she has public insurance, and her getting any imaging what-so-ever would have taken weeks if not longer...and her pediatrician is useless for sending her to the ED anyway. So what was I going to do....do nothing and send her back to her pediatrician?

It is so hard to find doctors that do the right thing. In all fields actually...unless you are a doctor that takes care of established diagnoses. Like "You have a diagnosis of appendicitis. I didn't make it. Someone else did. I'll take care of it."

 

[s/p epilepticus]

I guess I just don't understand your comment. Like what is the chance of that happening kind of thing? Pretty damn rare.

Technically she's had three episodes over the last year when her left hand went clumsy for about 1 hour.

I almost didn't scan her, because she doesn't have an emergency. She had time to get the superior study which would have been an MRI. I did it thinking maybe she has some weird small mass that was causing transient simple partial seizures. But ultimately, I scanned her because she has public insurance, and her getting any imaging what-so-ever would have taken weeks if not longer...and her pediatrician is useless for sending her to the ED anyway. So what was I going to do....do nothing and send her back to her pediatrician?

It is so hard to find doctors that do the right thing. In all fields actually...unless you are a doctor that takes care of established diagnoses. Like "You have a diagnosis of appendicitis. I didn't make it. Someone else did. I'll take care of it."

My comment wasn’t intended to be a criticism of your work-up, more a thought of “damn, what are the chances” with such a benign sounding presentation.

 

[thegenius]

My comment wasn’t intended to be a criticism of your work-up, more a thought of “damn, what are the chances” with such a benign sounding presentation.

Oh ok right on. I understand now.

 

[Groove]

True, but I increasingly don't GAF.

Cannabinoid hyperemesis guy recently. 8 ED visits in 4 days for the same. My 2nd time seeing him in 3 days. Basic exam, you have no medical emergency as I've seen you tolerate liquids. DCed immediately. No meds, no labs, no Rx.

Lady coming in yesterday with "vomiting a few times a week for 4 months."
- Abd exam benign.
- GI referral
- DC. No labs.

36F w/ arms and legs tingling. Recently evaluated for identical sx with a huge negative workup incl CT/CTA head/neck. Wants an MRI and neuro consult. Benign neuro exam. DC with existing neuro followup.

I frequently do the "here are your BS labs to make you feel like we did something" thing, but lately I don't care and just want them gone ASAP.

I’m kind of the same but have only arrived at that comfort level after enough years where I've gotten the experience and comfort level to discharge more and more people immediately. I definitely didn't have that when I was fresh out of residency. I would work people up...just to make sure. It's funny how you see your practice pattern evolve over the years. I'm much more of a minimalist now than I was earlier on in my career but I think....at least for myself, that's come after seeing thens of thousands of patients over the years and realizing that you can justify no work up on the majority of these people. If they are eating/drinking/voiding/stooling normally, have normal VS, no high risk historical features or stigmata on exam...you can justify no need for emergent/urgent hematologic or metabolic work up and no indication for imaging, etc.. I hate saying this but I also learned after watching some seasoned, veteran, solid docs who had been through lawsuits...that it's hard to fault you for not addressing an abnormal result if there was no indication for running a test to arrive at an abnormal result in the first place. It's difficult in a lawsuit to prove that there was an abnormality at the time of the visit... I'm not saying that I don't work up people that need it, but I like to think that I'm much better at differentiating the pt's that need a work up these days versus people who don't.

It's funny...I used to criticize docs like myself when I was new out. I would think to myself "Oh, they don't have the differentials that I have...I can't believe they didn't order x, y or z." Now, I get it.

 

[thegenius]

I’m kind of the same but have only arrived at that comfort level after enough years where I've gotten the experience and comfort level to discharge more and more people immediately. I definitely didn't have that when I was fresh out of residency. I would work people up...just to make sure. It's funny how you see your practice pattern evolve over the years. I'm much more of a minimalist now than I was earlier on in my career but I think....at least for myself, that's come after seeing thens of thousands of patients over the years and realizing that you can justify no work up on the majority of these people. If they are eating/drinking/voiding/stooling normally, have normal VS, no high risk historical features or stigmata on exam...you can justify no need for emergent/urgent hematologic or metabolic work up and no indication for imaging, etc.. I hate saying this but I also learned after watching some seasoned, veteran, solid docs who had been through lawsuits...that it's hard to fault you for not addressing an abnormal result if there was no indication for running a test to arrive at an abnormal result in the first place. It's difficult in a lawsuit to prove that there was an abnormality at the time of the visit... I'm not saying that I don't work up people that need it, but I like to think that I'm much better at differentiating the pt's that need a work up these days versus people who don't.

It's funny...I used to criticize docs like myself when I was new out. I would think to myself "Oh, they don't have the differentials that I have...I can't believe they didn't order x, y or z." Now, I get it.

The more and more I practice, the more I realize that people are not sick. I used to workup lots of stuff early on and only recently, probably in the past 12-18 months, am I comfortable not working up numerous complaints. Or just sending the minimum workup. Yes I also agree that it takes a lot of experience to get to this point (at least it should). First and second year attendings should not do this.

I also have gravitated towards the rather conservative stance that the ER should only be used for emergencies, or perceived emergencies, period. I've gotten to be a stickler on this issue too. I'm regularly not touching, and discharging, things like ingrown toenails. It's just not an emergency at all. Ever. I know why we are taught how to manage ingrown toenails, but it's not worth my time on any level when the waiting room is > 15. I regularly send home small abscesses (periapical, armpit, etc.) that probably should be drained but I know tb-cell hey will be extremely painful and frankly take up A LOT OF TIME and resources. I tell them "Hey...this could get better with Abx alone...maybe a 33% chance. I&D + Abx will give you a 95% chance of resolution. But draining this will be very painful...despite using lidocaine. I can get to this in about 2-3 hours. What do you want to do?" When faced with that...people often just will take the 33% chance and accept abx and leave. I don't care about a cough with normal vital signs in a relatively healthy person with clear lungs because I don't care if it's pneumonia or not. Frankly, it's not clinical pneumonia. I do about one paracentesis a year...the rest of the time I tell patients your discomfort is just not an emergency. And i've heard that 25% of all ascites analyses might end up being SBP...but I don't really buy that. Not in my experience. I do only a handful of pelvic exams a year.

I remember I used to have great differentials...and do extra cool workups, and now I see the young guys fresh out of residency doing the same thing that I don't do anymore. Like I used to send LDH's and Uric Acid for vague fevers and weakness and other **** suggestive of B-cell lymphoma. Not anymore.

There are so few true emergencies. Tintinalli's and Rosen's is chock full of stuff...but most of it is actually not an emergency.

The other nice thing about minimal workups is you get to minimize the chance of finding an incidentaloma!

 

[Mount Asclepius]

The more and more I practice, the more I realize that people are not sick. I used to workup lots of stuff early on and only recently, probably in the past 12-18 months, am I comfortable not working up numerous complaints. Or just sending the minimum workup. Yes I also agree that it takes a lot of experience to get to this point (at least it should). First and second year attendings should not do this.

I also have gravitated towards the rather conservative stance that the ER should only be used for emergencies, or perceived emergencies, period. I've gotten to be a stickler on this issue too. I'm regularly not touching, and discharging, things like ingrown toenails. It's just not an emergency at all. Ever. I know why we are taught how to manage ingrown toenails, but it's not worth my time on any level when the waiting room is > 15. I regularly send home small abscesses (periapical, armpit, etc.) that probably should be drained but I know tb-cell hey will be extremely painful and frankly take up A LOT OF TIME and resources. I tell them "Hey...this could get better with Abx alone...maybe a 33% chance. I&D + Abx will give you a 95% chance of resolution. But draining this will be very painful...despite using lidocaine. I can get to this in about 2-3 hours. What do you want to do?" When faced with that...people often just will take the 33% chance and accept abx and leave. I don't care about a cough with normal vital signs in a relatively healthy person with clear lungs because I don't care if it's pneumonia or not. Frankly, it's not clinical pneumonia. I do about one paracentesis a year...the rest of the time I tell patients your discomfort is just not an emergency. And i've heard that 25% of all ascites analyses might end up being SBP...but I don't really buy that. Not in my experience. I do only a handful of pelvic exams a year.

I remember I used to have great differentials...and do extra cool workups, and now I see the young guys fresh out of residency doing the same thing that I don't do anymore. Like I used to send LDH's and Uric Acid for vague fevers and weakness and other **** suggestive of B-cell lymphoma. Not anymore.

There are so few true emergencies. Tintinalli's and Rosen's is chock full of stuff...but most of it is actually not an emergency.

The other nice thing about minimal workups is you get to minimize the chance of finding an incidentaloma!

I agree with most of this, minus the loss of billing for not doing an I&D. It’s also better care to just do it. Nurses set everything up for an I&D before I even see the patient. Procedure less than 5 minutes practically doing will I’m taking the history. Well worth doing for the billing. They say no, then encounter slightly quicker and don’t have to smell pus to make a few more bucks.

 

[BoardingDoc]

And i've heard that 25% of all ascites analyses might end up being SBP...but I don't really buy that

Yeah, I agree that 25% is definitely not correct. We had a lot of liver patients where I did residency and it was SOP to get a para on every single one of them who was being admitted with abd pain.

I've done literally hundreds of paras. I'd say that my SBP+ rate was probably around 5% at the absolute most.

I now tap maybe 2 bellies a year.

 

[BoardingDoc]

I agree with most of this, minus the loss of billing for not doing an I&D. It’s also better care to just do it. Nurses set everything up for an I&D before I even see the patient. Procedure less than 5 minutes practically doing will I’m taking the history. Well worth doing for the billing. They say no, then encounter slightly quicker and don’t have to smell pus to make a few more bucks.

Agree. I find that talking people out of an I+D takes as much time as just doing one. Plus, it's good money.

Abscess I+D = 1.22 wRVU if simple. It's 2.45 wRVU if complex (pro tip: any abscess which requires blunt/sharp dissection to break up loculations is complex. Same with any abscess where you place a wick).

I also almost always use US to localize and confirm the abscess. If your shop records images, that's another 0.67 wRVU for the US.

Seeing the patient and doing the Rx gets you a lvl 3 chart. That's 1.6 wRVU.
Seeing the patient and doing the I+D gets you 4.72 wRVU (lvl3 chart + US + I+D). That's more than a lvl 5 chart.