Post your boring, nonsense shifts!

[CoolDoc1729]

I've used "this is like going to McDonalds and asking for a whopper. We don't do that here" but I think I prefer yours as it better encapsulates the absurdity of the request.

I agree, but I have more faith that our patients know every detail of both fast food menus, than that they know what they sell at HD, so yours may be more effective.

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[RustedFox]

I've used "this is like going to McDonalds and asking for a whopper. We don't do that here" but I think I prefer yours as it better encapsulates the absurdity of the request.

What drives me nuts is when people insist on (procedure, study, whatever) because "the other doctor did it in the office, and this is the ER; which means you can do that here, too".

Most commonly they want a joint space injection injection, epidural, whatever.

 

[The Knife & Gun Club]

Out for drinks with my wife + her friend who’s a general surgeon. Poor girl literally can’t help herself, even when my wife try’s to change the subject she just defaults back to how ER doctors aren’t real doctors, ER doctors don’t do a real residency because they only work 35 hours a week, ER doctors are basically midlevels and she can’t wait until she can “order me around once I’m an attending”.

If you ever have a moment of feeling like maybe some other fields actually know what we do…they don’t.

 

[Vandalia]

Out for drinks with my wife + her friend who’s a general surgeon. Poor girl literally can’t help herself, even when my wife try’s to change the subject she just defaults back to how ER doctors aren’t real doctors, ER doctors don’t do a real residency because they only work 35 hours a week, ER doctors are basically midlevels and she can’t wait until she can “order me around once I’m an attending”.

If you ever have a moment of feeling like maybe some other fields actually know what we do…they don’t.

Ehh, just tell her that up until the '70s, "general practitioners" with one year of internship performed most of the operations she is doing now.

(Not just the "intern level" cases, but there were such people doing colectomies, gastrectomies, etc. If you ever watched MASH, part of the conflict is that Burns was an "one year of internship (badly) trained by his father" surgeon whereas Hawkeye and B.J. were part of the new wave of residency trained surgeons. Not all of the "self-taught" were incompetent: Potter, Blake, etc. were in that category and were competent.)

And people survived and recovered just fine.

Surgeons are just glorified barbers.

(As an actual point, keep in mind that in anyone over the age of 60 or so, that procedure may have had as a kid or young adult was possibly done by someone with the most rudimentary surgical training.)

 

[thegenius]

Out for drinks with my wife + her friend who’s a general surgeon. Poor girl literally can’t help herself, even when my wife try’s to change the subject she just defaults back to how ER doctors aren’t real doctors, ER doctors don’t do a real residency because they only work 35 hours a week, ER doctors are basically midlevels and she can’t wait until she can “order me around once I’m an attending”.

If you ever have a moment of feeling like maybe some other fields actually know what we do…they don’t.

Little does she know that it's more important for surgeons to like us, than for us to like surgeons.

It's that simple.

 

[turkeyjerky]

Working on some BS so far tonight:

32F Seizure--h/o seizures, not on meds x6 years. Wants head CT b/c "I went urgent care earlier today for my headaches and the told me I needed one". Says she had a head CT a few weeks ago (for same HA) at another ER out of state. DC w/ med refill.

28 F Foot injury. XR neg, dc

26F Otalgia. Bullous myringitis. DC on zpak

26F "White spots in my throat". No actual pain. Wants STI throat swab. DC

9 month M Fever. 40.1C. DC

52F diarrhea x 3 weeks. 3rd ER visit, already had neg stool culture, neg c diff. Bought some loperamide but didn't take it. DC

88F RLE cellulitis. DC

63F pneumonia/copd exacerbation. Mildly hypoxic. Admit

30M Cerumen impaction. Irrigated. DC

62F Shoulder pain vs cervical radiculopathy. Gave pain meds. DC

67M Right sided weakness/numbness. 3rd time in past two months coming in with this. Had a thalamic infarct first time, but keeps stating it resolved and then came back. Can't tell extent of deficit from inpatient documentation. Admit.

20 F Piece of earring stuck in ear lobe. Removed. DC

65M near syncope. Likely orthostasis from polypharmacy. DC

26 M chest pain after inhaling fumes at work. DC

32F crazy anxiety. 5th visit this week. Refused to see psych, DC. Went to CSU, faked a seizure then brought to other hospital per ems.

6F small chin lac. Dermabond, DC

19F 1st trimester bleeding. Probably spont Ab. we'll see

72F Abd Pain. Thinks it's her hiatal hernia. Husband freely states that she was inducing vomiting at home like its a normal thing to do. Why would anyone do that, much less admit to it?? WBC 20k. probably has something.

61M mild etoh withdrawal, requesting detox placement.

56F Crazy, chronically psychotic. 3rd visit this week for same. Psych transfer.

93M from NH with urinary retention, no UOP x 24 hrs. Peed a few minutes after he got here. Labs nml. DC

Gotta go, another earache just checked in

Update: Earache was basically a little bit of ear pressue w/ viral sinusitis. Mid 20s F w/ a 'let's go brandon' tshirt on. DC w/ nasal steroids. Abd pain above ended up being an SBO. Pregnant chick had a negative US, quant 600. Home w/ OB f/u.

Got one more, 47F h/o renal tranplant w/ pyelo. Admitted

 

[GonnaBeADoc2222]

Working on some BS so far tonight:

32F Seizure--h/o seizures, not on meds x6 years. Wants head CT b/c "I went urgent care earlier today for my headaches and the told me I needed one". Says she had a head CT a few weeks ago (for same HA) at another ER out of state. DC w/ med refill.

28 F Foot injury. XR neg, dc

26F Otalgia. Bullous myringitis. DC on zpak

26F "White spots in my throat". No actual pain. Wants STI throat swab. DC

9 month M Fever. 40.1C. DC

52F diarrhea x 3 weeks. 3rd ER visit, already had neg stool culture, neg c diff. Bought some loperamide but didn't take it. DC

88F RLE cellulitis. DC

63F pneumonia/copd exacerbation. Mildly hypoxic. Admit

30M Cerumen impaction. Irrigated. DC

62F Shoulder pain vs cervical radiculopathy. Gave pain meds. DC

67M Right sided weakness/numbness. 3rd time in past two months coming in with this. Had a thalamic infarct first time, but keeps stating it resolved and then came back. Can't tell extent of deficit from inpatient documentation. Admit.

20 F Piece of earring stuck in ear lobe. Removed. DC

65M near syncope. Likely orthostasis from polypharmacy. DC

26 M chest pain after inhaling fumes at work. DC

32F crazy anxiety. 5th visit this week. Refused to see psych, DC. Went to CSU, faked a seizure then brought to other hospital per ems.

6F small chin lac. Dermabond, DC

19F 1st trimester bleeding. Probably spont Ab. we'll see

72F Abd Pain. Thinks it's her hiatal hernia. Husband freely states that she was inducing vomiting at home like its a normal thing to do. Why would anyone do that, much less admit to it?? WBC 20k. probably has something.

61M mild etoh withdrawal, requesting detox placement.

56F Crazy, chronically psychotic. 3rd visit this week for same. Psych transfer.

93M from NH with urinary retention, no UOP x 24 hrs. Peed a few minutes after he got here. Labs nml. DC

Gotta go, another earache just checked in

I don't irrigate cerumen impaction. Especially not on a busy shift like this. I tell them to pick up some debrox and they get ENT referral if they want to follow up. Not an ER issue.

 

[RustedFox]

I don't irrigate cerumen impaction. Especially not on a busy shift like this. I tell them to pick up some debrox and they get ENT referral if they want to follow up. Not an ER issue.

Yep.
Go home and hit the drugstore on the way.
Byeee.

 

[RustedFox]

Working on some BS so far tonight:

32F Seizure--h/o seizures, not on meds x6 years. Wants head CT b/c "I went urgent care earlier today for my headaches and the told me I needed one". Says she had a head CT a few weeks ago (for same HA) at another ER out of state. DC w/ med refill.

28 F Foot injury. XR neg, dc

26F Otalgia. Bullous myringitis. DC on zpak

26F "White spots in my throat". No actual pain. Wants STI throat swab. DC

9 month M Fever. 40.1C. DC

52F diarrhea x 3 weeks. 3rd ER visit, already had neg stool culture, neg c diff. Bought some loperamide but didn't take it. DC

88F RLE cellulitis. DC

63F pneumonia/copd exacerbation. Mildly hypoxic. Admit

30M Cerumen impaction. Irrigated. DC

62F Shoulder pain vs cervical radiculopathy. Gave pain meds. DC

67M Right sided weakness/numbness. 3rd time in past two months coming in with this. Had a thalamic infarct first time, but keeps stating it resolved and then came back. Can't tell extent of deficit from inpatient documentation. Admit.

20 F Piece of earring stuck in ear lobe. Removed. DC

65M near syncope. Likely orthostasis from polypharmacy. DC

26 M chest pain after inhaling fumes at work. DC

32F crazy anxiety. 5th visit this week. Refused to see psych, DC. Went to CSU, faked a seizure then brought to other hospital per ems.

6F small chin lac. Dermabond, DC

19F 1st trimester bleeding. Probably spont Ab. we'll see

72F Abd Pain. Thinks it's her hiatal hernia. Husband freely states that she was inducing vomiting at home like its a normal thing to do. Why would anyone do that, much less admit to it?? WBC 20k. probably has something.

61M mild etoh withdrawal, requesting detox placement.

56F Crazy, chronically psychotic. 3rd visit this week for same. Psych transfer.

93M from NH with urinary retention, no UOP x 24 hrs. Peed a few minutes after he got here. Labs nml. DC

Gotta go, another earache just checked in

Polite request to finish the box score for the shift, here.

 

[BoardingDoc]

I don't irrigate cerumen impaction. Especially not on a busy shift like this. I tell them to pick up some debrox and they get ENT referral if they want to follow up. Not an ER issue.

I have the tech irrigate then then pop in and get out what little is left with a curette. Easy 0.61 rvus.

FYI: if you don't curette it, it's 0 rvus. If you don't have a tech, they can GTFO.

Yes, I know how mercenary this is. If you're coming into the ED for obvious b***s*** I'm going to make it worth my while, or I'm not going to bother at all.

 

[turkeyjerky]

I have the tech irrigate then then pop in and get out what little is left with a curette. Easy 0.61 rvus.

FYI: if you don't curette it, it's 0 rvus. If you don't have a tech, they can GTFO.

Yes, I know how mercenary this is. If you're coming into the ED for obvious b***s*** I'm going to make it worth my while, or I'm not going to bother at all.

So, for some reason I thought that you could bill for either the E/M code, or the cerumen removal, but not both. Or is it that you can bill for both, but only if you use a curette?

Not gonna lie, I always hope that the vertigo they get from irrigation will dissuade them from coming back.

Polite request to finish the box score for the shift, here.

Updated above.

 

[BoardingDoc]

So, for some reason I thought that you could bill for either the E/M code, or the cerumen removal, but not both. Or is it that you can bill for both, but only if you use a curette?

Not gonna lie, I always hope that the vertigo they get from irrigation will dissuade them from coming back.

Updated above.

Requirements for reporting impacted cerumen removal with an E/M on the same DOS
When reporting an E/M visit AND cerumen removal on the same date of service, the following criteria must be met:
• The main reason for the patient’s visit was separate from the cerumen removal
• Otoscopic examination of the tympanic membrane is not possible due to the impaction
• Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner
• The procedure requires a significant amount of time and effort, and all of the above criteria are clearly
documented in the patient’s medical record

The only hard part is the first one. You need to be able to document a visit for something other than "ears plugged." Otitis media works. Dizziness works. Headache works.

As for your vertigo hopes... sometimes tap water is really cold and you don't realize that it hasn't warmed up yet when you're filling the spray bottle. Just saying.

 

[thegenius]

10 hr shift:

1. 56 yo F assaulted on face yesterday by a friend's cane. Didn't need imaging. d/c
2. 65 yo M with renal transplant, DM, with cellulitis on hand and wrist after cutting himself. Rx keflex/doxy. d/c
3. 81 yo F who is homeless, 15th visit this year, p/w weakness. Just seen 2 days ago for same thing. Nothing done on this visit. d/c
4. 24 yo F 21 wks pregnant had a failed PICC for TPN due to hyperemesis. Also has catheter induced blood clot. Admit to L&D for another PICC.
5. 69 yo F had outpatient renal US and showed possible aortic dissection flap. Rads sent in for angio. Angio neg. d/c
6. 75 yo F has LH and nausea. Just hospitalized a few days ago for mild type 2 MI. Eveyrthing is normal but didn't want to go home until she was "back to normal." Took several hours of nonsense interventions but she got better. "I'm getting better! I'm not dead yet!" d/c
7. 75 yo F with symptomatic afib 110-130. She feels palpitations. Marked dyspnea on exertion. Labs, CXR, dilt x2, metop, and admit.
8. 60 yo F with chronic pancytopenia (from MDS) has b/l leg cellulitis. Labs OK. admit
9. 64 yo F with trach from anaplastic thyroid cancer has cellulitis around her trach. Standard labs, abx, and admit.
10. 27 yo M with DM has FSG 700, colitis and ascites. Weird combo. admit.
11. 21 yo F fainted while starting a job today. EKG normal. vasovagal syncope. d/c
12. (signout) 80 yo F with left facial droop. Likely bells and asked to f/u MRI. MRI neg. d/c
13. 74 yo M with foley problems, possibly leakage. Nurse twiddled the foley. Bladder empty on US. d/c
14. 70 yo F p/w leg cellulitis, just discharged 3 days ago for same thing. Home health nurse sent her in to be "evaluated". Eval performed and no medical emergency. f/u PCP/podiatry. d/c
15. (signout) 9 yo F with asthma and hypoxic 84%. Required a lot of treatment but eventually got much better. She never appeared sick. d/c O2 was 93-94%. Spend about 10 hrs total in ED. d/c
16. 75 yo M with CP. No CP in ED, EKG and two trops neg. HEART 3? maybe 4? I don't really remember. d/c for PCP workup.
17. 56 yo F, morbidly obese, w/ R flank pain for a few days. Labs, UA, CT, US are normal. She is visibly upset "It's usually a kidney stone? It's not a kidney stone this time? the UA is normal?!?!?" "Yes it is ma'am. Can I d/c you with a few days of norco?" "yes doc, please. I ran out of my norco a few days ago." d/c
18. 25 yo F with brief RUQ pain. Feeling better. Probably her fatty liver causing her problem. d/c
19. 74 yo M, regularly drunk, brought in on 5150 because he shoved his wife and made bad comments about her. He is drunk today. Wow how about that. asked SS to take care of this case. presumably discharged on a subsequent shift.
20. 16 yo F hurt BOTH ankles playing volleyball. Both are not broken. She was able to hop out of the ED on her better ankle. I gave her a high-five in front of her parents and said "you are going places my dear! You are a keeper!" She smiled and was obviously very happy with the outcome. d/c
21. 48 yo F sent in by PCP for Hg 5. She gets post-coital bleeding and prior notes suggests she has a cervical mass. I said "Please no more sex until you get this fixed" and she smiled. She wasn't bleeding in the ED. after pRBC and IV iron sucrose, d/c
22. 13 yo F with no BM for 5 days. Rx 4 different medicines to make her to poop! d/c
23. 15 yo F with traumatic foot pain, has broken 5th metatarsal. d/c
24. 30 yo M with post-surgical wrist pain. exam benign, XR stable. d/c
25. 38 yo M with LBP and scrotal pain. Exam, UA, and scrotal US are OK. He was very comfortable. d/c
26. 43 yo F with traumatic pinky toe pain. It's broke. d/c
27. 42 yo F has broken qtip in her ear. I pulled it out. d/c


Wish I could go back in time to 1980 and see what a day in the life was like for ER docs.

 

[Mount Asclepius]

10 hr shift:

1. 56 yo F assaulted on face yesterday by a friend's cane. Didn't need imaging. d/c
2. 65 yo M with renal transplant, DM, with cellulitis on hand and wrist after cutting himself. Rx keflex/doxy. d/c
3. 81 yo F who is homeless, 15th visit this year, p/w weakness. Just seen 2 days ago for same thing. Nothing done on this visit. d/c
4. 24 yo F 21 wks pregnant had a failed PICC for TPN due to hyperemesis. Also has catheter induced blood clot. Admit to L&D for another PICC.
5. 69 yo F had outpatient renal US and showed possible aortic dissection flap. Rads sent in for angio. Angio neg. d/c
6. 75 yo F has LH and nausea. Just hospitalized a few days ago for mild type 2 MI. Eveyrthing is normal but didn't want to go home until she was "back to normal." Took several hours of nonsense interventions but she got better. "I'm getting better! I'm not dead yet!" d/c
7. 75 yo F with symptomatic afib 110-130. She feels palpitations. Marked dyspnea on exertion. Labs, CXR, dilt x2, metop, and admit.
8. 60 yo F with chronic pancytopenia (from MDS) has b/l leg cellulitis. Labs OK. admit
9. 64 yo F with trach from anaplastic thyroid cancer has cellulitis around her trach. Standard labs, abx, and admit.
10. 27 yo M with DM has FSG 700, colitis and ascites. Weird combo. admit.
11. 21 yo F fainted while starting a job today. EKG normal. vasovagal syncope. d/c
12. (signout) 80 yo F with left facial droop. Likely bells and asked to f/u MRI. MRI neg. d/c
13. 74 yo M with foley problems, possibly leakage. Nurse twiddled the foley. Bladder empty on US. d/c
14. 70 yo F p/w leg cellulitis, just discharged 3 days ago for same thing. Home health nurse sent her in to be "evaluated". Eval performed and no medical emergency. f/u PCP/podiatry. d/c
15. (signout) 9 yo F with asthma and hypoxic 84%. Required a lot of treatment but eventually got much better. She never appeared sick. d/c O2 was 93-94%. Spend about 10 hrs total in ED. d/c
16. 75 yo M with CP. No CP in ED, EKG and two trops neg. HEART 3? maybe 4? I don't really remember. d/c for PCP workup.
17. 56 yo F, morbidly obese, w/ R flank pain for a few days. Labs, UA, CT, US are normal. She is visibly upset "It's usually a kidney stone? It's not a kidney stone this time? the UA is normal?!?!?" "Yes it is ma'am. Can I d/c you with a few days of norco?" "yes doc, please. I ran out of my norco a few days ago." d/c
18. 25 yo F with brief RUQ pain. Feeling better. Probably her fatty liver causing her problem. d/c
19. 74 yo M, regularly drunk, brought in on 5150 because he shoved his wife and made bad comments about her. He is drunk today. Wow how about that. asked SS to take care of this case. presumably discharged on a subsequent shift.
20. 16 yo F hurt BOTH ankles playing volleyball. Both are not broken. She was able to hop out of the ED on her better ankle. I gave her a high-five in front of her parents and said "you are going places my dear! You are a keeper!" She smiled and was obviously very happy with the outcome. d/c
21. 48 yo F sent in by PCP for Hg 5. She gets post-coital bleeding and prior notes suggests she has a cervical mass. I said "Please no more sex until you get this fixed" and she smiled. She wasn't bleeding in the ED. after pRBC and IV iron sucrose, d/c
22. 13 yo F with no BM for 5 days. Rx 4 different medicines to make her to poop! d/c
23. 15 yo F with traumatic foot pain, has broken 5th metatarsal. d/c
24. 30 yo M with post-surgical wrist pain. exam benign, XR stable. d/c
25. 38 yo M with LBP and scrotal pain. Exam, UA, and scrotal US are OK. He was very comfortable. d/c
26. 43 yo F with traumatic pinky toe pain. It's broke. d/c
27. 42 yo F has broken qtip in her ear. I pulled it out. d/c


Wish I could go back in time to 1980 and see what a day in the life was like for ER docs.

Based upon a few of your shift posts, it seems that your job’s volume level (pph) is decently high but acuity level pretty low (admit and cc percentage). Perhaps you just need a change of scenery. I agree though, I’d be curious to relive a day in the ED in 1980.

 

[thegenius]

Can't just get a "change of scenery" as you suggest, and have it at least pan out the way you want it to.

Admitted 5 I think...and had like 3 CC time. This was an average shift, maybe below average for acuity. I tend to admit less than my partners. For instance that 75 M with CP...I think more than 1/2 of all ER docs would just admit that guy although I saw no point in doing that.

Most of the posts / shifts from others have nonsense stuff.

 

[Mount Asclepius]

Can't just get a "change of scenery" as you suggest, and have it at least pan out the way you want it to.

Admitted 5 I think...and had like 3 CC time. This was an average shift, maybe below average for acuity. I tend to admit less than my partners. For instance that 75 M with CP...I think more than 1/2 of all ER docs would just admit that guy although I saw no point in doing that.

Most of the posts / shifts from others have nonsense stuff.

Fair enough. Just seems you are a little extra crispy as of late, which isn’t like your typical prior posts. 2.7 pph consistently is pretty busy and by itself can lead to burnout (especially if boring with lower acuity). I also know though you’re not going to post good shifts with interesting patients in this type of thread given the theme so the sample may be skewed.

It seemed like only 1 out of 27 of those patients was cc so maybe I missed something. I usually work our high acuity zone so perhaps I’m just not used to seeing so many shifts without multiple procedures and clear cut critical care patients. 18% admit rate is kind of low. I also admit less than average (once you factor for acuity). I’m typically somewhere between 20-30% admit rate. Agree that discharging the 75M with CP and negative testing isn’t unreasonable.

 

[thegenius]

Next time I have a good shift I'll post it. Occasionally I get some. My impression is that all of us seem to have a nonsense % factor somewhere in the 50-75% range. One dude a while ago posted a shift where he admitted like 10-12 people, many to the ICU.

I had one crispy day a week ago. My last shift was fine. I'm fine 98% of the time.

We all work like 14-16 shifts somewhere in that range. I reckon 75% of those shifts are neutral, you go to work and you leave work and nothing else to it. Of the remaining 25%...the majority of those should be good. Maybe you have 1-2 hard shifts / month. It's like all work, whether you are plumber, statistician, horse manure cleaner-upper, middle salesman for an auto-parts store, IP lawyer, or an elite escort in St. Louis.

 

[Groove]

10 hr shift:

1. 56 yo F assaulted on face yesterday by a friend's cane. Didn't need imaging. d/c
2. 65 yo M with renal transplant, DM, with cellulitis on hand and wrist after cutting himself. Rx keflex/doxy. d/c
3. 81 yo F who is homeless, 15th visit this year, p/w weakness. Just seen 2 days ago for same thing. Nothing done on this visit. d/c
4. 24 yo F 21 wks pregnant had a failed PICC for TPN due to hyperemesis. Also has catheter induced blood clot. Admit to L&D for another PICC.
5. 69 yo F had outpatient renal US and showed possible aortic dissection flap. Rads sent in for angio. Angio neg. d/c
6. 75 yo F has LH and nausea. Just hospitalized a few days ago for mild type 2 MI. Eveyrthing is normal but didn't want to go home until she was "back to normal." Took several hours of nonsense interventions but she got better. "I'm getting better! I'm not dead yet!" d/c
7. 75 yo F with symptomatic afib 110-130. She feels palpitations. Marked dyspnea on exertion. Labs, CXR, dilt x2, metop, and admit.
8. 60 yo F with chronic pancytopenia (from MDS) has b/l leg cellulitis. Labs OK. admit
9. 64 yo F with trach from anaplastic thyroid cancer has cellulitis around her trach. Standard labs, abx, and admit.
10. 27 yo M with DM has FSG 700, colitis and ascites. Weird combo. admit.
11. 21 yo F fainted while starting a job today. EKG normal. vasovagal syncope. d/c
12. (signout) 80 yo F with left facial droop. Likely bells and asked to f/u MRI. MRI neg. d/c
13. 74 yo M with foley problems, possibly leakage. Nurse twiddled the foley. Bladder empty on US. d/c
14. 70 yo F p/w leg cellulitis, just discharged 3 days ago for same thing. Home health nurse sent her in to be "evaluated". Eval performed and no medical emergency. f/u PCP/podiatry. d/c
15. (signout) 9 yo F with asthma and hypoxic 84%. Required a lot of treatment but eventually got much better. She never appeared sick. d/c O2 was 93-94%. Spend about 10 hrs total in ED. d/c
16. 75 yo M with CP. No CP in ED, EKG and two trops neg. HEART 3? maybe 4? I don't really remember. d/c for PCP workup.
17. 56 yo F, morbidly obese, w/ R flank pain for a few days. Labs, UA, CT, US are normal. She is visibly upset "It's usually a kidney stone? It's not a kidney stone this time? the UA is normal?!?!?" "Yes it is ma'am. Can I d/c you with a few days of norco?" "yes doc, please. I ran out of my norco a few days ago." d/c
18. 25 yo F with brief RUQ pain. Feeling better. Probably her fatty liver causing her problem. d/c
19. 74 yo M, regularly drunk, brought in on 5150 because he shoved his wife and made bad comments about her. He is drunk today. Wow how about that. asked SS to take care of this case. presumably discharged on a subsequent shift.
20. 16 yo F hurt BOTH ankles playing volleyball. Both are not broken. She was able to hop out of the ED on her better ankle. I gave her a high-five in front of her parents and said "you are going places my dear! You are a keeper!" She smiled and was obviously very happy with the outcome. d/c
21. 48 yo F sent in by PCP for Hg 5. She gets post-coital bleeding and prior notes suggests she has a cervical mass. I said "Please no more sex until you get this fixed" and she smiled. She wasn't bleeding in the ED. after pRBC and IV iron sucrose, d/c
22. 13 yo F with no BM for 5 days. Rx 4 different medicines to make her to poop! d/c
23. 15 yo F with traumatic foot pain, has broken 5th metatarsal. d/c
24. 30 yo M with post-surgical wrist pain. exam benign, XR stable. d/c
25. 38 yo M with LBP and scrotal pain. Exam, UA, and scrotal US are OK. He was very comfortable. d/c
26. 43 yo F with traumatic pinky toe pain. It's broke. d/c
27. 42 yo F has broken qtip in her ear. I pulled it out. d/c


Wish I could go back in time to 1980 and see what a day in the life was like for ER docs.

I like your style. Keep it up. Very productive and lean.

 

[BoardingDoc]

17. 56 yo F, morbidly obese, w/ R flank pain for a few days. Labs, UA, CT, US are normal. She is visibly upset "It's usually a kidney stone? It's not a kidney stone this time? the UA is normal?!?!?" "Yes it is ma'am. Can I d/c you with a few days of norco?" "yes doc, please. I ran out of my norco a few days ago." d/c

Side question: maybe she looked proper miserable (and not just whiny and miserable) and that merited the narcs, but is it common for you (or others here) to give a day or two of narcotics for "unidentifiable source pain?" At my shop, basically no one does that. This lady would have gotten a shot of toradol and maybe an rx for flexeril / lidoderm if MSK was suspected, but definitely nothing controlled. Our whole group has more or less adopted that philosophy and I feel it keeps a lot of the drug seekers at the ER across town.

 

[CoolDoc1729]

Next time I have a good shift I'll post it. Occasionally I get some. My impression is that all of us seem to have a nonsense % factor somewhere in the 50-75% range. One dude a while ago posted a shift where he admitted like 10-12 people, many to the ICU.

I had one crispy day a week ago. My last shift was fine. I'm fine 98% of the time.

We all work like 14-16 shifts somewhere in that range. I reckon 75% of those shifts are neutral, you go to work and you leave work and nothing else to it. Of the remaining 25%...the majority of those should be good. Maybe you have 1-2 hard shifts / month. It's like all work, whether you are plumber, statistician, horse manure cleaner-upper, middle salesman for an auto-parts store, IP lawyer, or an elite escort in St. Louis.

I think I would consistently not like horse manure shoveling.
Lately most of what I do (midnights) once I’ve worked down the somatic nonsense in the waiting room is try to dispo the psych patients in the waiting room. Otherwise they get covid sitting out there and become undispoable. We don’t have a social worker and the nurses usually only sort of try. Tonight this work was interrupted by a perforated viscus (waiting room), a PE (waiting room), a stroke alert (in back), a peds asthma resp distress I sent to the hospital that has a picu on nRB (waiting room again), and a nursemaid elbow. Still, I was able to get 2 admitted to psych hospital , one sent to the crisis home and one to the friendly local drunk tank. Lol what a life

 

[thegenius]

Side question: maybe she looked proper miserable (and not just whiny and miserable) and that merited the narcs, but is it common for you (or others here) to give a day or two of narcotics for "unidentifiable source pain?" At my shop, basically no one does that. This lady would have gotten a shot of toradol and maybe an rx for flexeril / lidoderm if MSK was suspected, but definitely nothing controlled. Our whole group has more or less adopted that philosophy and I feel it keeps a lot of the drug seekers at the ER across town.

Variable and dependent on the patient and my mood. I generally fight patients on NOT giving narcs. On the spectrum of "I never give narcs (which I don't believe when people espouse this)" to "I don't give a F I give them all the time" I'm probably in the -1.0 STD because...as we know...it is a normal distribution variable. LOL

That relatively annoying pt I wanted out of the ER so fast I did not hesitate to write for 6 pills (the "I don't give a F Rx" is norco 5-325 TID PRN pain dispense 6)

 

[RustedFox]

12-hour overnight fun:

1. 68 F - COPD power level of *OVER 9000*. Haircut like Vegeta from DragonBall-Z. Admit.

2. 48 M - Fall and headbonk on Xarelto. Everything is drama. Brought his mommy. DC.

3. 37 F - Migraine again. "Here's my note from my SPECIAL neurologist that says I should get DILAUDID." DC.

4. 76 F - Accidentally took an extra Tramadol 50mg tablet. Is terrified she's going to die. Not today - but soon, honey. Keep those rosary beads warm. This got dark. I'm sorry that I wrote that. DC.

5. 92 F - Vomiting x1. Doesn't know what galaxy this is. UTI. DC. Family won't come pick her up. Yes, you will. DC.

6. 88 M - Mechanical fall from stepping off of curb too fast. DOAC on board. CT cantaloupe/celery stick normal. DC.

7. 14 F - Fever and headache. Home COVID test positive. Mom "isn't sure what that means, so brought her here". DC.

8. 91 M - Transfer from Hee-Haw Regional for stroke. Admit.

9. 71 M - On home hospice care and "not waking up". Family scared he might die. SPOILER ALERT: He will. Admitted to hospice.

10. 29 M - MVC with seat-belt contusion. Too fat to care. May have tried to eat damaged sedan. DC.

11. 9 M - Fever. COVID+. DC.

12. 14 F - Fever and sore throat. No fever or sore throat. Mom requests work note. DC.

13. 44 M - Chest pain. Cath'ed 2 days ago. Troponin is actually *OVER 9000*. EKG changes. Admit.

14. 3 M - Fussy. Mom says he plays with his penis too much. "Listen, lady - I'm 40 years old; that never stops." DC.

15. 35 F - "VP Shunt headache" (we have a LOT of these at NewJob). Call to her neurosurgeon. "Again?!" DC.

16. 67 M - Stroke alert. LVO on CTA. I didn't even perform a physical exam. Kinda. Admit.

17. 41 F - RUQ pain for 1 day. Shamu-caliber obesity. Workup overwhelmingly negative. So fat she slurs her words because the InceptChin ("Inception-Chin") stops her from fully opening her mouth. DC.

18. 76 F - Near-syncope. Rx List: Percocet. Valium. Ativan. Tramadol. ETOH = 212. Sassy! Call me, maybe. DC.

19. 87 F - Abdominal pain. No abdominal pain. Thinks Nixon is the president. Workup negative. DC.

20. 69 F - Took CBD gummy from bottle given to her by friend prior to sleep. Now afraid to go back to sleep, certain that she will die. Label says: "50mg High Purity Delta-8 THC". On a scale from "1" to "Cheech", she was "Chong". Counseled on reading comprehension. DC.

21. 86 M - Found by wife in blood/emesis pool on floor of home. Aspiration pneumonia. INR = 5.2. Admit.

22. 58 M - "Wants rehab placement". Refused rehab placement. DC.

23. 39 M - End-stage liver disease/alcohol withdrawal. On a scale from "1" to "Canary", he was "School Bus". Admit.

24. 85 M - Spreichen sie Deutch? NO! Signed out to oncoming physician. Don't even know what the chief complaint was.

 

[Apollyon]

13. 44 M - Chest pain. Cath'ed 2 days ago. Troponin is actually *OVER 9000*. EKG changes. Admit.

Did cards or hospitalist admit that pt? I can just imagine "of course the trop is sky high - we were just mucking around in there!" The EKG changes, that had to be the money.

 

[GonnaBeADoc2222]

12-hour overnight fun:

1. 68 F - COPD power level of *OVER 9000*. Haircut like Vegeta from DragonBall-Z. Admit.

2. 48 M - Fall and headbonk on Xarelto. Everything is drama. Brought his mommy. DC.

3. 37 F - Migraine again. "Here's my note from my SPECIAL neurologist that says I should get DILAUDID." DC.

4. 76 F - Accidentally took an extra Tramadol 50mg tablet. Is terrified she's going to die. Not today - but soon, honey. Keep those rosary beads warm. This got dark. I'm sorry that I wrote that. DC.

5. 92 F - Vomiting x1. Doesn't know what galaxy this is. UTI. DC. Family won't come pick her up. Yes, you will. DC.

6. 88 M - Mechanical fall from stepping off of curb too fast. DOAC on board. CT cantaloupe/celery stick normal. DC.

7. 14 F - Fever and headache. Home COVID test positive. Mom "isn't sure what that means, so brought her here". DC.

8. 91 M - Transfer from Hee-Haw Regional for stroke. Admit.

9. 71 M - On home hospice care and "not waking up". Family scared he might die. SPOILER ALERT: He will. Admitted to hospice.

10. 29 M - MVC with seat-belt contusion. Too fat to care. May have tried to eat damaged sedan. DC.

11. 9 M - Fever. COVID+. DC.

12. 14 F - Fever and sore throat. No fever or sore throat. Mom requests work note. DC.

13. 44 M - Chest pain. Cath'ed 2 days ago. Troponin is actually *OVER 9000*. EKG changes. Admit.

14. 3 M - Fussy. Mom says he plays with his penis too much. "Listen, lady - I'm 40 years old; that never stops." DC.

15. 35 F - "VP Shunt headache" (we have a LOT of these at NewJob). Call to her neurosurgeon. "Again?!" DC.

16. 67 M - Stroke alert. LVO on CTA. I didn't even perform a physical exam. Kinda. Admit.

17. 41 F - RUQ pain for 1 day. Shamu-caliber obesity. Workup overwhelmingly negative. So fat she slurs her words because the InceptChin ("Inception-Chin") stops her from fully opening her mouth. DC.

18. 76 F - Near-syncope. Rx List: Percocet. Valium. Ativan. Tramadol. ETOH = 212. Sassy! Call me, maybe. DC.

19. 87 F - Abdominal pain. No abdominal pain. Thinks Nixon is the president. Workup negative. DC.

20. 69 F - Took CBD gummy from bottle given to her by friend prior to sleep. Now afraid to go back to sleep, certain that she will die. Label says: "50mg High Purity Delta-8 THC". On a scale from "1" to "Cheech", she was "Chong". Counseled on reading comprehension. DC.

21. 86 M - Found by wife in blood/emesis pool on floor of home. Aspiration pneumonia. INR = 5.2. Admit.

22. 58 M - "Wants rehab placement". Refused rehab placement. DC.

23. 39 M - End-stage liver disease/alcohol withdrawal. On a scale from "1" to "Canary", he was "School Bus". Admit.

24. 85 M - Spreichen sie Deutch? NO! Signed out to oncoming physician. Don't even know what the chief complaint was.

This is an awful shift.

LOL @ InceptChin....gonna use that.

 

[CoolDoc1729]

This is an awful shift.

LOL @ InceptChin....gonna use that.

I don’t know .. sounds kind of average shift to me .. maybe thats my Stockholm syndrome shining through.

Appreciate the massively obese mva story. While ago I had a girl shot at short range rlq (walked in, we are level 3 TC) thankfully she was so obese that the bullet just ricocheted around the fat and ended up in the left flank area - there was a visible air tract through subQ tissue. Amazing.

I enjoy the scales 1 to whatever. Please keep them coming.

 

[thegenius]

@VA Hopeful Dr

You need to post what you see in one day.

 

[VA Hopeful Dr]

@VA Hopeful Dr

You need to post what you see in one day.

I can, but are y'all actually interested in what a day of outpatient FM looks like?

 

[thegenius]

I’m actually am … I’m curious what the overlap is like. My impression is that ambulatory medicine basically never sees sick people or people in pain. I know that’s not true, but a lot of people have written things like that.

 

[bravotwozero]

I can, but are y'all actually interested in what a day of outpatient FM looks like?

Most definitely. My wife is a PCP, but still interesting to see the other side of the equation.

 

[RustedFox]

Did cards or hospitalist admit that pt? I can just imagine "of course the trop is sky high - we were just mucking around in there!" The EKG changes, that had to be the money.

Hospitalist did. I called cards and said: "Hey. Here's what's up. Yes, I read the cath lab report. It's... Curious. Got no pushback.

 

[Dred Pirate]

Ehh, just tell her that up until the '70s, "general practitioners" with one year of internship performed most of the operations she is doing now.

(Not just the "intern level" cases, but there were such people doing colectomies, gastrectomies, etc. If you ever watched MASH, part of the conflict is that Burns was an "one year of internship (badly) trained by his father" surgeon whereas Hawkeye and B.J. were part of the new wave of residency trained surgeons. Not all of the "self-taught" were incompetent: Potter, Blake, etc. were in that category and were competent.)

And people survived and recovered just fine.

Surgeons are just glorified barbers.

(As an actual point, keep in mind that in anyone over the age of 60 or so, that procedure may have had as a kid or young adult was possibly done by someone with the most rudimentary surgical training.)

data point- I grew up in BFE midwest- town of 700 - we had a general practioner doctor in town that was probably 60 years old back in the 80's. He was all excited that he got to deliver triplet at our local hospital (now a critical access hospital) that has maybe 25 beds. Now in 2022 our gigantic city hospital that average like 18 births a day generally defers those patients to the local academic medical center.

 

[VA Hopeful Dr]

I’m actually am … I’m curious what the overlap is like. My impression is that ambulatory medicine basically never sees sick people or people in pain. I know that’s not true, but a lot of people have written things like that.

Fair enough. Today is my half day so its truncated a bit:

28 yo refill of anxiety meds, wants to come off of them so discussed how to wean to prevent withdrawal from SSRI. Technically obese so doing lipid and DM screening.

53 yo DM/HTN/lipid/gout follow up. All doing well, refilled all meds and ordered standard labs. Microalbuminuria found, added Jardiance for renal protection. Also bugged about getting a tetanus shot (I've been pushing that hard of late as I had a case of lockjaw back in May that's got me scared).

40 yo gout f/u. No flares since last visit. Refilled and repeated labs.

37 yo no show. Our policy is 3 no shows in a rolling 12M period warrants dismissal. He runs 3 no shows in 17 months consistently for 2 years. If he has another no-show between now and 2024 he's getting dismissed. Office manager on board.

57 yo hospital f/u from hip replacement. Healing well, even 2 week post op pain less than original OA pain. Happy as a clam, thanks me for picking a good surgeon.

72 yo f/u for HTN/DM/CAD/lipid. All doing well, meds/labs. Big lipoma (6-ish cm) referred to surgery. Allergies worse, add flonase. Thanks me for referring to urology for elevated PSA, biopsies all normal.

43 yo f/u for DM/lipids. Ran out of meds last week, gets mild lecture of calling for refills to prevent this. Obese and wants help, Ozempic to the rescue.

75 yo index finger pain after smashing it between pieces of PVC pipe while drilling a hole in said pipe (this woman is a badass). XR normal. Also recheck lipids/TSH after changing synthroid and lipitor dose 2 months ago.

75 yo neck pain. Left trapezius muscle spasm. Instant relief with trigger point injection. XR neck as well given h/o ACDF. Significant degeneration in remaining discs. Will refer to neurosurgery if any pain after injection.

5 yo fever, cough. Looks OK. RSV positive, supportive care discussed.

94 yo with cough, COVID exposure. COVID+, paxlovid given. CXR OK.

22 yo ED follow up for BPPV. Refer to vestibular rehab. Also with painful jaw nodule for 1 day. Inflammed lymph node. Watch for 3 weeks, if still there will get US.

20 yo with recurrent cerumen impaction. Nurse irrigated. I spent total 70 seconds with him. Leaves happy.

70 yo with elevated BP at dentist. Elevated in office. Start BP meds. RTC in 2 weeks, has cataract surgery in 1M, doesn't want it to get postponed. Reassured we can handle this.

Got to work at 7:55am, walked out at noon.

 

[myocardinal infarction]

Fourth year resident here and enjoy this thread. 8-hr moonlighting shift in our fast track area

1) 29 M w/ ear pain and sinus congestion. Ears nl. DC w/ flonase
2) 48 F sciatica flare after bending over to pick something up. Meds and DC
3) 71 F c/o neck pain. Everyone else avoiding the pt because "OMG old person with neck pain". Very musculoskeletal on exam/history. Meds and DC
4) 46 M w/ autoimmune disease history presenting w/ chest pain/SOB and every complaint imaginable x1 week. Amazingly not an emergency until he was arrested this morning. Labs/EKG/CXR nl. Tell him he's discharged and he starts tearing suction canisters/oxygen off the wall and slamming himself into the wall and stretcher trying to injure himself. Cop stands there and just watches....RN hits panic button over and over and security doesn't receive it. Finally I wrangle security to restrain him while the officer handcuffs his other hand to the bed. Now screaming his hand is broken. It isn't. DC
5)71 F with all over pain since fall 6 months ago. Meds dc
6) 68 F w/ MCP swelling after hyper extending finger putting on underwear. XR shows arthritis. Finger splint and given ortho number. DC
7) 36 M with all over pain after MVC. Chased the driver of other car down with no problem. Now can't walk or turn his head at all. Demanding x-rays. Proceeds to walk all over the ED completely fine to yell about his wait time and that he feels no better. Left prior to x-ray reads. DC
8) 52 F with 4 days traumatic bilat biceps/thigh pain. Rpt visit so sent BMP/CPK that were nl. Felt much better after meds. DC
9) 32 to M w/ palps/near syncope at work this morning. Tachy to 120s. Heavy Etoh last night. New RBBB on EKG. Labs/dimer negative. DC after IVF.
10) 22 F w/ palpitations/SOB/chest pain x2 weeks since COVID dx. Went to UC who did an EKG they said showed short PR int and delta wave and referred to the ED. EKG they sent with her had neither a short PR int or a delta wave....EKG here nl. Labs/dimer negative. DC
11) 73 F itching all over. Urticarial rash. DC w/ benadryl/hydrocort ointment.
12) 24 F woke up with neck pain. Meds->DC
13) 28 M w/ epigastric "bubbling" x months. Abd completely nontender. Outpt US canceled due to insurance issue. US neg. Labs nl. DC
14) 24 M here for 1 staple removal placed 2 weeks ago after being pistol whipped. DC
15) 23 M 5 days post-op rhinoplasty after being punched. Ran out of pain meds last night. ENT refilled but when he got to pharmacy they hadn't gotten a script. Called ENT again who told him to go to the ER for pain meds. Almost consulted ENT to make them come see that BS.
16) 58 F ankle pain after MVC last night. XR neg. DC
17) 38 M ankle pain/swelling after twisting it. Signed out to night team. Probably sprained.
18) 60 M homeless. Hit with rock in back of head 10+ hours ago. Meds and dc.
19) 69 F with atraumatic red eye since this afternoon after using eye drops. UC told her she had a hyphema and nonreactive pupil and should go to the hospital by ambulance. Pupils reactive. Subconjunctival hemorrhage....which is rare SE of her drops. In fairness it was basically her entire sconjunctiva so kinda see how an UC PA/NP might freak out. Counseled to hold eye drops and discuss with her ophtho. DC
20) 81 F w/ urticarial rash. Meds and DC.
21) 32 F w/ neck pain x 24 hours started while picking up something off floor. Looks like torticollis. Seen night prior by PA and given toradol/valium/morphine... CTA was ordered. Walked out waiting for scan. Now back and wants scan. Signed out to night team. CTA wound up negative...surprise

 

[thegenius]

Fourth year resident here and enjoy this thread. 8-hr moonlighting shift in our fast track area

1) 29 M w/ ear pain and sinus congestion. Ears nl. DC w/ flonase
2) 48 F sciatica flare after bending over to pick something up. Meds and DC
3) 71 F c/o neck pain. Everyone else avoiding the pt because "OMG old person with neck pain". Very musculoskeletal on exam/history. Meds and DC
4) 46 M w/ autoimmune disease history presenting w/ chest pain/SOB and every complaint imaginable x1 week. Amazingly not an emergency until he was arrested this morning. Labs/EKG/CXR nl. Tell him he's discharged and he starts tearing suction canisters/oxygen off the wall and slamming himself into the wall and stretcher trying to injure himself. Cop stands there and just watches....RN hits panic button over and over and security doesn't receive it. Finally I wrangle security to restrain him while the officer handcuffs his other hand to the bed. Now screaming his hand is broken. It isn't. DC
5)71 F with all over pain since fall 6 months ago. Meds dc
6) 68 F w/ MCP swelling after hyper extending finger putting on underwear. XR shows arthritis. Finger splint and given ortho number. DC
7) 36 M with all over pain after MVC. Chased the driver of other car down with no problem. Now can't walk or turn his head at all. Demanding x-rays. Proceeds to walk all over the ED completely fine to yell about his wait time and that he feels no better. Left prior to x-ray reads. DC
8) 52 F with 4 days traumatic bilat biceps/thigh pain. Rpt visit so sent BMP/CPK that were nl. Felt much better after meds. DC
9) 32 to M w/ palps/near syncope at work this morning. Tachy to 120s. Heavy Etoh last night. New RBBB on EKG. Labs/dimer negative. DC after IVF.
10) 22 F w/ palpitations/SOB/chest pain x2 weeks since COVID dx. Went to UC who did an EKG they said showed short PR int and delta wave and referred to the ED. EKG they sent with her had neither a short PR int or a delta wave....EKG here nl. Labs/dimer negative. DC
11) 73 F itching all over. Urticarial rash. DC w/ benadryl/hydrocort ointment.
12) 24 F woke up with neck pain. Meds->DC
13) 28 M w/ epigastric "bubbling" x months. Abd completely nontender. Outpt US canceled due to insurance issue. US neg. Labs nl. DC
14) 24 M here for 1 staple removal placed 2 weeks ago after being pistol whipped. DC
15) 23 M 5 days post-op rhinoplasty after being punched. Ran out of pain meds last night. ENT refilled but when he got to pharmacy they hadn't gotten a script. Called ENT again who told him to go to the ER for pain meds. Almost consulted ENT to make them come see that BS.
16) 58 F ankle pain after MVC last night. XR neg. DC
17) 38 M ankle pain/swelling after twisting it. Signed out to night team. Probably sprained.
18) 60 M homeless. Hit with rock in back of head 10+ hours ago. Meds and dc.
19) 69 F with atraumatic red eye since this afternoon after using eye drops. UC told her she had a hyphema and nonreactive pupil and should go to the hospital by ambulance. Pupils reactive. Subconjunctival hemorrhage....which is rare SE of her drops. In fairness it was basically her entire sconjunctiva so kinda see how an UC PA/NP might freak out. Counseled to hold eye drops and discuss with her ophtho. DC
20) 81 F w/ urticarial rash. Meds and DC.
21) 32 F w/ neck pain x 24 hours started while picking up something off floor. Looks like torticollis. Seen night prior by PA and given toradol/valium/morphine... CTA was ordered. Walked out waiting for scan. Now back and wants scan. Signed out to night team. CTA wound up negative...surprise

Good times. You think 19 was just a subconjunctival hemorrhage from using eyedrops? Sounds unlikely. Funny she didn't have a hyphema NOR a nonreactive pupil.

 

[myocardinal infarction]

Good times. You think 19 was just a subconjunctival hemorrhage from using eyedrops? Sounds unlikely. Funny she didn't have a hyphema NOR a nonreactive pupil.

It was restasis, which I looked up, and apparently can sometimes cause subconjunctival hemorrhage. She'd had the same thing happen twice before both after using restasis.

 

[The Knife & Gun Club]

Pod blocked night shift where nothing in the department was moving because we had 20 boarded patients in our area:

1) 78yo M 4 days LLQ pain and hematuria. CTd, turns out the guy has a new Cecal mass that eroded into his kidney. Pooping into GU system. Septic. Admitted for IV abx and possible surgery.

2) 44F with 3 years of abdominal pain. Says it got worse yesterday. Allegedly got “admitted to OSH for a liver infection” discharged 5 days ago. Afebrile, CT/US negative, labs pristine, discharged.

3) 22F, took misoprostol at home yesterday for induced AB. Terrible pain, vomiting, and bleeding. US shows incomplete AB, Hb stable. Discharged with pain meds to complete the AB at home, syncopized in the lobby and got rushed back in. Dropped her Hb 2 points, admit to obs unit for serial hemoglobins and pain control.

3) 83 yo male, in “SVT” per EMS. They shocked him, he got combative, so they hit him with 5 of versed and shocked again. EKG In ED shows sinus tach. Family says do everything. Obtunded from versed, de satting, intubated. Septic from a UTI. BP 50/35, lined and levo. MICU refuses to admit, says extubate him in ED and admit to floor. MICU director called. Signed out pending suits getting involved.

4) 58 yo M with 1 day of epigastric pain. CT negative. Better with famotidine. Discharged

5) 48 year old female with RUQ pain. US shows cholelithisis. Pain control and DC

6) 40 yo female undocumented, just got here from venezuela, has ESRD. Has been getting cash pay intermittent dialysis through a nasty looking IJ cath during her migrant journey through Central America. BP 250/150, pulmonary edema, K 7. Admit for dialysis and placement of a new catheter.

7) 26M firefighter syncopized while training. Labs and EKG normal. Dc w PCP followup.

8) 36F from the same EMS crew as #3. Of her 8mg daily Xanax + klonopin x3 days. HR 130. Shocked by EMS for SVT. Also in sinus tach. Better with ativan. Admitted for benzo withdrawal.

9) 24F with 20% TBSA burns from cooking with oil. Admitted to burns ICU, pain meds, IVF.

10) 54F with 1 day of sudden RLE weakness, headache, CP, bp 230/something. CTA dissection protocol. Turns out she has a sarcoma of the R pelvis, with Mets to brain, lung, and mediastinum. Midline shift and vasogenic edema on CT. Dex, dilaudid, admit.

11) 35M just got back from a diving trip, R ear pain. Prefer TM with otitis externa. Abx drops and discharge.

12) 26F 6 weeks pregnant with abdominal pain. Subchorionic hemorrhage. Tylenol, dc with OV followup.

 

[Cinclus]

3) 83 yo male, in “SVT” per EMS. They shocked him, he got combative, so they hit him with 5 of versed and shocked again. EKG In ED shows sinus tach. Family says do everything. Obtunded from versed, de satting, intubated. Septic from a UTI. BP 50/35, lined and levo. MICU refuses to admit, says extubate him in ED and admit to floor. MICU director called. Signed out pending suits getting involved.

8) 36F from the same EMS crew as #3. Of her 8mg daily Xanax + klonopin x3 days. HR 130. Shocked by EMS for SVT. Also in sinus tach. Better with ativan. Admitted for benzo withdrawal.

Nearly died laughing at these (with the first one, it was laughter mixed with "oh no's" and "JEEZUS"). I've got a local EMS crew that calls STEMIs on every LBBB. Saw them a couple times yesterday.

 

[thegenius]

Pod blocked night shift where nothing in the department was moving because we had 20 boarded patients in our area:

1) 78yo M 4 days LLQ pain and hematuria. CTd, turns out the guy has a new Cecal mass that eroded into his kidney. Pooping into GU system. Septic. Admitted for IV abx and possible surgery.

2) 44F with 3 years of abdominal pain. Says it got worse yesterday. Allegedly got “admitted to OSH for a liver infection” discharged 5 days ago. Afebrile, CT/US negative, labs pristine, discharged.

3) 22F, took misoprostol at home yesterday for induced AB. Terrible pain, vomiting, and bleeding. US shows incomplete AB, Hb stable. Discharged with pain meds to complete the AB at home, syncopized in the lobby and got rushed back in. Dropped her Hb 2 points, admit to obs unit for serial hemoglobins and pain control.

3) 83 yo male, in “SVT” per EMS. They shocked him, he got combative, so they hit him with 5 of versed and shocked again. EKG In ED shows sinus tach. Family says do everything. Obtunded from versed, de satting, intubated. Septic from a UTI. BP 50/35, lined and levo. MICU refuses to admit, says extubate him in ED and admit to floor. MICU director called. Signed out pending suits getting involved.

4) 58 yo M with 1 day of epigastric pain. CT negative. Better with famotidine. Discharged

5) 48 year old female with RUQ pain. US shows cholelithisis. Pain control and DC

6) 40 yo female undocumented, just got here from venezuela, has ESRD. Has been getting cash pay intermittent dialysis through a nasty looking IJ cath during her migrant journey through Central America. BP 250/150, pulmonary edema, K 7. Admit for dialysis and placement of a new catheter.

7) 26M firefighter syncopized while training. Labs and EKG normal. Dc w PCP followup.

8) 36F from the same EMS crew as #3. Of her 8mg daily Xanax + klonopin x3 days. HR 130. Shocked by EMS for SVT. Also in sinus tach. Better with ativan. Admitted for benzo withdrawal.

9) 24F with 20% TBSA burns from cooking with oil. Admitted to burns ICU, pain meds, IVF.

10) 54F with 1 day of sudden RLE weakness, headache, CP, bp 230/something. CTA dissection protocol. Turns out she has a sarcoma of the R pelvis, with Mets to brain, lung, and mediastinum. Midline shift and vasogenic edema on CT. Dex, dilaudid, admit.

11) 35M just got back from a diving trip, R ear pain. Prefer TM with otitis externa. Abx drops and discharge.

12) 26F 6 weeks pregnant with abdominal pain. Subchorionic hemorrhage. Tylenol, dc with OV followup.

What the F is wrong with your hospital re: your second #3.

What is wrong with your MICU

 

[BoardingDoc]

I don't think your EMS crews should be allowed to have a defib. Honestly, just replace it with an AED.

 

[Mount Asclepius]

What the F is wrong with your hospital re: your second #3.

What is wrong with your MICU

Yeah, something doesn’t add up.

 

[The Knife & Gun Club]

What the F is wrong with your hospital re: your second #3.

What is wrong with your MICU

Academic county hospital. Some people just don’t want to do their job.

I love it here because it’s a lot of working poor patients that are very grateful for their care and you can do quite a bit of good if the system is manipulated correctly. But also all the BS that comes with county/unions/etc and the annoying burnt out holier than thou subspecialists who think they’re gods gift to modern medicine.

 

[thegenius]

Academic county hospital. Some people just don’t want to do their job.

I love it here because it’s a lot of working poor patients that are very grateful for their care and you can do quite a bit of good if the system is manipulated correctly. But also all the BS that comes with county/unions/etc and the annoying burnt out holier than thou subspecialists who think they’re gods gift to modern medicine.

Its simply a failure of the hospital AND ER admin to allow that to happen. You have an intubated patient on a pressor and where does the attending think that patient is going to go? Just stay indefinitely in the ED?

I would write up that MICU attending!

What happened to that patient anyway?

 

[The Knife & Gun Club]

Its simply a failure of the hospital AND ER admin to allow that to happen. You have an intubated patient on a pressor and where does the attending think that patient is going to go? Just stay indefinitely in the ED?

I would write up that MICU attending!

What happened to that patient anyway?

Escalated to department chairs, MICU chair apologized for his fellows behavior and placed admit orders himself. So a reasonable outcome, albeit with a few phone calls and 8 hours in the ED waiting for orders.

Our medical director was livid.

The issue is a recurring one this time of year/in general. We take a LOT of Latin American IMGs for residency and fellowship in medicine/surgery. Where they trained outside the US, the ER is usually still someone who flunked out of or never did a residency, and basically functions just to triage people to other specialities, but doesn’t have the power to make dispo decisions or do critical interventions. I distinctly remember one fellow being visibly shocked to find out we even do airways, and calling her on call attending at 3am, in the resus bay, to confirm the ED was allowed to intubate.

It usually takes a few chastisements but their department heads before they realize in America emergency medicine is it’s own speciality with its own body of knowledge. And of course there’s always the nighthawks who will do everything possible to push a dispo off until 7am when they do home and the day team arrives.

 

[The Knife & Gun Club]

Its simply a failure of the hospital AND ER admin to allow that to happen. You have an intubated patient on a pressor and where does the attending think that patient is going to go? Just stay indefinitely in the ED?

I would write up that MICU attending!

What happened to that patient anyway?

Oh and the patient was fine. He went to the ICU, was extubated to bipap that evening, and is now in the IMCU Getting weaned off his levo drip.

 

[CoolDoc1729]

83 yo male, in “SVT” per EMS. They shocked him, he got combative, so they hit him with 5 of versed and shocked again. EKG In ED shows sinus tach. Family says do everything. Obtunded from versed, de satting, intubated. Septic from a UTI. BP 50/35, lined and levo. MICU refuses to admit, says extubate him in ED and admit to floor. MICU director called. Signed out pending suits getting involved.

1) what in the actual F. What is the MICU for then!?

2) not long ago had a guy with sinus tachycardia to 180.. ems had given adenosine 6/12/12 and shocked him twice .. i said (squinting at the monitor) idk I think there’s P Waves .. the medics say Yeah there were definitely p waves on our 12 lead! 🤦🏻‍♀️

 

[The Knife & Gun Club]

1) what in the actual F. What is the MICU for then!?

2) not long ago had a guy with sinus tachycardia to 180.. ems had given adenosine 6/12/12 and shocked him twice .. i said (squinting at the monitor) idk I think there’s P Waves .. the medics say Yeah there were definitely p waves on our 12 lead! 🤦🏻‍♀️

I had another one last night with a guy who was 35, on methotrexate for RA, came in for SOB/CP, endorses doing some coke 3 days ago at a party.

Trop (from triage) was 0.65. For reference our upper limit of normal is 0.033. Medicine refuses to admit because “it’s probably just the cocaine I don’t know what we even would do for him, he can get an echo outpatient. Methotrexate is cardioprotective.”

Ma’am a trop 20x the upper limit of normal needs to be investigated. Healthy 35 year olds without heart disease shouldn’t bump a trop like that just from a bit of demand ischemia.

 

[RustedFox]

I had another one last night with a guy who was 35, on methotrexate for RA, came in for SOB/CP, endorses doing some coke 3 days ago at a party.

Trop (from triage) was 0.65. For reference our upper limit of normal is 0.033. Medicine refuses to admit because “it’s probably just the cocaine I don’t know what we even would do for him, he can get an echo outpatient. Methotrexate is cardioprotective.”

Ma’am a trop 20x the upper limit of normal needs to be investigated. Healthy 35 year olds without heart disease shouldn’t bump a trop like that just from a bit of demand ischemia.

The last STEMI that I sent to the cath lab was a 34 year old female. Stented the LAD.

 

[thegenius]

I had another one last night with a guy who was 35, on methotrexate for RA, came in for SOB/CP, endorses doing some coke 3 days ago at a party.

Trop (from triage) was 0.65. For reference our upper limit of normal is 0.033. Medicine refuses to admit because “it’s probably just the cocaine I don’t know what we even would do for him, he can get an echo outpatient. Methotrexate is cardioprotective.”

Ma’am a trop 20x the upper limit of normal needs to be investigated. Healthy 35 year olds without heart disease shouldn’t bump a trop like that just from a bit of demand ischemia.

Looks like you are in residency? Do you guys have admitting privileges? I remember when I was in residency, the ER could admit anyone. Now...obviously that led to nonsense admissions, but we certainly didn't have to deal with that crap above.

At least you guys can order/demand a consult from medicine. They have to come per EMTALA. The question to them is "Does this patient need admission?" They have to put in a note and you can tell the patient "It's not me denying you admission, it's them" and if you guys get dragged to court you can say "I tried as hard as I could to admit that patient"

 

[greatnt249]

1) what in the actual F. What is the MICU for then!?

2) not long ago had a guy with sinus tachycardia to 180.. ems had given adenosine 6/12/12 and shocked him twice .. i said (squinting at the monitor) idk I think there’s P Waves .. the medics say Yeah there were definitely p waves on our 12 lead! 🤦🏻‍♀️

I keep reading about EMS shocking patients for "SVT" and I have to ask...why the urgency to shock? Were these patients hypotensive, or is your guys' EMS crews that trigger-happy?

 

[bravotwozero]

Yeah, lots of trigger happy EMS crews out there