The crap we have to deal with…

[Apollyon]

(Fact is...I spent another 3 minutes getting a history and the kid probably has PND.)

I was racking my brain for "PND". I was thinking "paroxysmal nocturnal dyspnea" (if you recall, mild, self limited CHF, manifesting after fluid shifts from standing to becoming supine at bedtime). Then, duh, "postnasal drip"!

---

Members don't see this ad.

 

[maxxor]

I'm so outta the loop on how to use the stick figures that I'm basically accustomed to excel spreadsheet numbers now.
Sad

I can't even remember how to do stick figure LFTs

 

[thegenius]

I was racking my brain for "PND". I was thinking "paroxysmal nocturnal dyspnea" (if you recall, mild, self limited CHF, manifesting after fluid shifts from standing to becoming supine at bedtime). Then, duh, "postnasal drip"!

LOL

"Sir....Dad....how dare you bring your son to the ER for paroxysmal nocturnal dyspnea. His recurrent meth use at age 9 has caused a cardiomyopathy and now he needs beta blockers, ace inhibitors, diuretics, and god knows what else. GOOD LORD USE YOUR BRAIN! This is all outpatient stuff."

 

[RustedFox]

Chipotle doesn't have to delivery data on demand to CMS

Noted; but that's not an excuse for Epic/Cerner/Meditech to fail to display data in a better fashion.

Especially for what they charge hospital systems.

 

[VA Hopeful Dr]

Noted; but that's not an excuse for Epic/Cerner/Meditech to fail to display data in a better fashion.

Especially for what they charge hospital systems.

No argument, and I'm not defending them to any big degree. But their priorities are, in order: billing, quality, usefulness.

 

[Apollyon]

Noted; but that's not an excuse for Epic/Cerner/Meditech to fail to display data in a better fashion.

Especially for what they charge hospital systems.

I've said it, now, many times: Google, Apple, even Facebook could write a bulletproof, completely intelligible, secure, compliant program that would meet any federal guidelines. Why not? Because EPIC can charge $100 million for an enterprise install. Priorities being billing, quality, and usefulness, billing is the supermajority, with the other two being parenthetical afterthoughts at most.

 

[CoolDoc1729]

I'm not making this up.
I don't know what I did to deserve it; but I live some kind of bizarre life. Swear I'm cursed or something.
I keep it tame on here because I've been warned by mods for far, far less.
You guys have a very, very limited idea of just how strange my life often is

I mean c’mon….what are we doing here?????View attachment 356066

Last night I asked a young adult that was in a mva if she needed a work note. “No, I don’t work , but can you give me a note so my roommates don’t ask me to do anything HARD?”
Sure.

Name
Date
Not capable of doing anything hard.
Cooldoc1729, MD

 

[Siggy]

View attachment 356067

 

[Siggy]

Makes dispo easy (assuming not in FSED).

Or depending on the ICU fellow on, give 10 unit of insulin, a liter or 10 of LR and recheck those numbers will be stable for floor

I don't get the push back... that patient from seen to note completed couldn't take more than 10 minutes.

"You came in for fatigue, drinking a lot, peeing a lot, and shortness of breath... and you aren't taking your insulin?"

:: puts in insulin infusion power plan::

::writes very short note stating DKA, fluids, insulin, q6 hour BMPs::

::goes back to watching YouTube overnight.::

It'll literally take longer to try to dispo to the floor inappropriately than to just do the consult.

I don't get why people like making this job harder for themselves.

 

[Kuratz]

It makes me genuinely very sad and upset to hear what clinical medicine has become, with EM and mid level dominated primary care being the canaries in the coal mine. We see some of this indirectly in Rads and what some people are willing to come in for at 3am is ridiculous. These same people wouldn’t call a plumber for a long-standing issue in the middle of the night because it would actually cost them money. But come on in to the ED for an on-demand medical team and CT scan for your troubles for some minor issue that’s been there for months. Medicaid and others who essentially don’t pay can treat it like a McDonald’s drive thru and EM docs are the fast food workers. Always available and at your service. Would you like fries with your runny nose? It’s so ridiculous. I’m all for helping the needy but there needs to be more skin in the game for these people to act as some sort of deterrent and incentive for outpatient visits. I had Medicaid as a med student briefly and it cost me $0 for an ER visit (including an ambulance) and $3 for the prescription medication. Gee I wonder why people abuse this service?

While other fields like tech and business have made huge strides in compensation and perks for their workers (work from home, half day Fridays, big stock bonuses), healthcare workers across the board are working harder and harder for less and less. Talented people including damn good EM docs are looking to exit ASAP. We are going to have a massive issue with piss-poor medical care and it makes me worried for my own healthcare when I get older. What talented college kid looks at the trajectory of tech/finance and then at medicine and says “yeah I’ll put myself through 10 years of hell and hundreds of thousands of debt for that moral-injury laden sweatshop”.

Had to get it off my chest. Rads is great for now but what I see from other clinicians pisses me off and makes me depressed. Im sorry for y’all.

 

[Rekt]

It makes me genuinely very sad and upset to hear what clinical medicine has become, with EM and mid level dominated primary care being the canaries in the coal mine. We see some of this indirectly in Rads and what some people are willing to come in for at 3am is ridiculous. These same people wouldn’t call a plumber for a long-standing issue in the middle of the night because it would actually cost them money. But come on in to the ED for an on-demand medical team and CT scan for your troubles for some minor issue that’s been there for months. Medicaid and others who essentially don’t pay can treat it like a McDonald’s drive thru and EM docs are the fast food workers. Always available and at your service. Would you like fries with your runny nose? It’s so ridiculous. I’m all for helping the needy but there needs to be more skin in the game for these people to act as some sort of deterrent and incentive for outpatient visits. I had Medicaid as a med student briefly and it cost me $0 for an ER visit (including an ambulance) and $3 for the prescription medication. Gee I wonder why people abuse this service?

While other fields like tech and business have made huge strides in compensation and perks for their workers (work from home, half day Fridays, big stock bonuses), healthcare workers across the board are working harder and harder for less and less. Talented people including damn good EM docs are looking to exit ASAP. We are going to have a massive issue with piss-poor medical care and it makes me worried for my own healthcare when I get older. What talented college kid looks at the trajectory of tech/finance and then at medicine and says “yeah I’ll put myself through 10 years of hell and hundreds of thousands of debt for that moral-injury laden sweatshop”.

Had to get it off my chest. Rads is great for now but what I see from other clinicians pisses me off and makes me depressed. Im sorry for y’all.

I hope most of my rads realize this to some extent. I always feel like they think we're completely ******ed. Yes I know this knee x-ray for two months of knee pain at 2am is going to be negative. I can argue with the patient and have them threaten to kill me or write a scathing complaint to the clueness admins or just order it and move on.

And it's true. It's ALWAYS the medicaid patients that come in at 3am with nothing wrong with them for free testing and prescriptions. Completely abusing the system. I also had Medicaid in med school. Never once used it for EM/urgent care.

 

[maxxor]

I hope most of my rads realize this to some extent. I always feel like they think we're completely ******ed. Yes I know this knee x-ray for two months of knee pain at 2am is going to be negative. I can argue with the patient and have them threaten to kill me or write a scathing complaint to the clueness admins or just order it and move on.

And it's true. It's ALWAYS the medicaid patients that come in at 3am with nothing wrong with them for free testing and prescriptions. Completely abusing the system. I also had Medicaid in med school. Never once used it for EM/urgent care.

I love the ER docs cuz they see the patients, and I don’t have to.

 

[CoolDoc1729]

I hope most of my rads realize this to some extent. I always feel like they think we're completely ******ed. Yes I know this knee x-ray for two months of knee pain at 2am is going to be negative. I can argue with the patient and have them threaten to kill me or write a scathing complaint to the clueness admins or just order it and move on.

And it's true. It's ALWAYS the medicaid patients that come in at 3am with nothing wrong with them for free testing and prescriptions. Completely abusing the system. I also had Medicaid in med school. Never once used it for EM/urgent care.

In my state the rx is actually FREE even for OTC ie Tylenol if they have a prescription.. It used to really anger me to be asked to write rx for Tylenol for the 2 year old with a fever for an hour after they took the free ambulance at 3 am then demanded we feed the parent the child and the other several children that had been toted along while they were there .. always with a better phone than any of us worker bees, nails and hair perfect etc. after a while I realize it’s not the kids fault their parents are stupid and they really won’t pay money for the Tylenol if they don’t get the rx. The people who “abuse the system” don’t really get anywhere living government check to government check and it’s sad that they can’t see a better way. I’m thankful my kids are growing up under better circumstances and as you say there’s very little possible gain to arguing, so if things aren’t actively harmful (knee xray, Tylenol rx) I usually just order and move on.

 

[CajunMedic]

Just one of many...

 

[BoardingDoc]

View attachment 356171

Just one of many...

11:16 pm. It's a little early for the "night shift patients" but that still tracks.

 

[The Knife & Gun Club]

My shift last night:
Well diagnosed and documented Idiopathic intracranial hypertension, HA x1 year, missed 3 appts with neurology, never filled her diamox despite it being free because “it made her pee too much.” Demanding neurology consult and admission.

Migraines x12 years. Multiple negative MRIs. Comes to ED at 10 pm demanding another MRI and consult with a neurologist but not the neurologist from before

Patient transferred from OSH with gigantic mediastinal mass and hemopheumothorax. Tubed and chest tube. CT surgery says nothing to do, mass is not respectable. sad.

Patient with pain all over after missing 3 dialysis appointments. Bradycardic. Nurse is too busy to get EKG x4 hrs. “He’s a tough stick”, USIV. Nurse trips over iv tubing, disloges IV. Lab loses the labs. US machine breaks.

Pt with BMI of 52, here for chronic chest/back/abd pain. Tough stick again. USIV again. Turns out she’s having an NSTEMI. Admit. signed out pending admit orders x5 hours, IM resident says she’s too busy to admit Pt.

Chronic alcoholic brought in for drunk in the street. Bad Abdominal tenderness on exam. No vitals charted. I order labs. Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids. Turns out he has acute hepatitis and pancreatitis.

Patient presents for paracentesis because he missed his appointment. Tell him he needs to go to his scheduled appointment and this isn’t an emergency. He leaves and checks back in, assigned to a new ED area. New attending transfers the patient back to our area for paracentesis and assigns the patient back to me.

Pregnant G1P0 at 14 weeks. Here for generalized malaise. Covid + 3 days ago with normal work up. Check the baby, Tylenol, discharged. Complaint because I “didn’t do anything.”

Patient took 3000 mg amytryptiline overdose. PC’d. Refuses labs and ekg, only wants dilaudid. HR 130, BP 150/110, temp 39.5. Per RN “that’s between you and the patient.” Explained the meaning of protective custody. RN still declines. IM Versed and restraints ordered so I can get work up and save their life. RN prints lab labels and throws them away so I can’t send labs. EKG machine can’t do EKG unless I scan the guys bracelet, but he pooped on it. Pushes of ativan for tachycardia and bicarb titrated to what looks like a wide QRS on telemetry. ICU accepts patient on paper but no bed because they don’t have a sitter for the PC’d patient.

The burn is real.

 

[Dr Mantis Toboggan]

My shift last night:
Well diagnosed and documented Idiopathic intracranial hypertension, HA x1 year, missed 3 appts with neurology, never filled her diamox despite it being free because “it made her pee too much.” Demanding neurology consult and admission.

Migraines x12 years. Multiple negative MRIs. Comes to ED at 10 pm demanding another MRI and consult with a neurologist but not the neurologist from before

Patient transferred from OSH with gigantic mediastinal mass and hemopheumothorax. Tubed and chest tube. CT surgery says nothing to do, mass is not respectable. sad.

Patient with pain all over after missing 3 dialysis appointments. Bradycardic. Nurse is too busy to get EKG x4 hrs. “He’s a tough stick”, USIV. Nurse trips over iv tubing, disloges IV. Lab loses the labs. US machine breaks.

Pt with BMI of 52, here for chronic chest/back/abd pain. Tough stick again. USIV again. Turns out she’s having an NSTEMI. Admit. signed out pending admit orders x5 hours, IM resident says she’s too busy to admit Pt.

Chronic alcoholic brought in for drunk in the street. Bad Abdominal tenderness on exam. No vitals charted. I order labs. Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids. Turns out he has acute hepatitis and pancreatitis.

Patient presents for paracentesis because he missed his appointment. Tell him he needs to go to his scheduled appointment and this isn’t an emergency. He leaves and checks back in, assigned to a new ED area. New attending transfers the patient back to our area for paracentesis and assigns the patient back to me.

Pregnant G1P0 at 14 weeks. Here for generalized malaise. Covid + 3 days ago with normal work up. Check the baby, Tylenol, discharged. Complaint because I “didn’t do anything.”

Patient took 3000 mg amytryptiline overdose. PC’d. Refuses labs and ekg, only wants dilaudid. HR 130, BP 150/110, temp 39.5. Per RN “that’s between you and the patient.” Explained the meaning of protective custody. RN still declines. IM Versed and restraints ordered so I can get work up and save their life. RN prints lab labels and throws them away so I can’t send labs. EKG machine can’t do EKG unless I scan the guys bracelet, but he pooped on it. Pushes of ativan for tachycardia and bicarb titrated to what looks like a wide QRS on telemetry. ICU accepts patient on paper but no bed because they don’t have a sitter for the PC’d patient.

The burn is real.

Sorry man.

Why is such nursing insolence tolerated? Union shop?

 

[PianoMedic]

My shift last night:
Well diagnosed and documented Idiopathic intracranial hypertension, HA x1 year, missed 3 appts with neurology, never filled her diamox despite it being free because “it made her pee too much.” Demanding neurology consult and admission.

Migraines x12 years. Multiple negative MRIs. Comes to ED at 10 pm demanding another MRI and consult with a neurologist but not the neurologist from before

Patient transferred from OSH with gigantic mediastinal mass and hemopheumothorax. Tubed and chest tube. CT surgery says nothing to do, mass is not respectable. sad.

Patient with pain all over after missing 3 dialysis appointments. Bradycardic. Nurse is too busy to get EKG x4 hrs. “He’s a tough stick”, USIV. Nurse trips over iv tubing, disloges IV. Lab loses the labs. US machine breaks.

Pt with BMI of 52, here for chronic chest/back/abd pain. Tough stick again. USIV again. Turns out she’s having an NSTEMI. Admit. signed out pending admit orders x5 hours, IM resident says she’s too busy to admit Pt.

Chronic alcoholic brought in for drunk in the street. Bad Abdominal tenderness on exam. No vitals charted. I order labs. Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids. Turns out he has acute hepatitis and pancreatitis.

Patient presents for paracentesis because he missed his appointment. Tell him he needs to go to his scheduled appointment and this isn’t an emergency. He leaves and checks back in, assigned to a new ED area. New attending transfers the patient back to our area for paracentesis and assigns the patient back to me.

Pregnant G1P0 at 14 weeks. Here for generalized malaise. Covid + 3 days ago with normal work up. Check the baby, Tylenol, discharged. Complaint because I “didn’t do anything.”

Patient took 3000 mg amytryptiline overdose. PC’d. Refuses labs and ekg, only wants dilaudid. HR 130, BP 150/110, temp 39.5. Per RN “that’s between you and the patient.” Explained the meaning of protective custody. RN still declines. IM Versed and restraints ordered so I can get work up and save their life. RN prints lab labels and throws them away so I can’t send labs. EKG machine can’t do EKG unless I scan the guys bracelet, but he pooped on it. Pushes of ativan for tachycardia and bicarb titrated to what looks like a wide QRS on telemetry. ICU accepts patient on paper but no bed because they don’t have a sitter for the PC’d patient.

The burn is real.

And here I thought I was a poo magnet… Sorry to have the system (and your colleagues) literally curb stomping you. I am blessed to work in a system where nursing staff isn’t my issue (lab is unbearably slow, 2 hours for a stat cmp and/or troponin seems excessive to me for a max 30 minute test). I get pushback on admits but never the “too busy to see the patient”. If memory serves, you’re doing fellowship next year, yes? Hopefully it is in a different area so you can have a better experience, and hope that system figured out how to better care for their patients.

 

[The Knife & Gun Club]

And here I thought I was a poo magnet… Sorry to have the system (and your colleagues) literally curb stomping you. I am blessed to work in a system where nursing staff isn’t my issue (lab is unbearably slow, 2 hours for a stat cmp and/or troponin seems excessive to me for a max 30 minute test). I get pushback on admits but never the “too busy to see the patient”. If memory serves, you’re doing fellowship next year, yes? Hopefully it is in a different area so you can have a better experience, and hope that system figured out how to better care for their patients.

Yea I love EM when done right but with the current state of our healthcare system that’s just not feasible. I’m off to fellowship in ICU where the nurses rock and most of my patients are in comas.

 

[CoolDoc1729]

Sorry man.

Why is such nursing insolence tolerated? Union shop?

I’m at a union shop and nothing like these nursing actions would ever, ever be tolerated… WTF.. throwing out lab labels ? Refusing to work up anyone?

As a weekend night “specialist” myself the patient population .. unfortunately sounds very familiar 🤣

 

[wholeheartedly]

Yea I love EM when done right but with the current state of our healthcare system that’s just not feasible. I’m off to fellowship in ICU where the nurses rock and most of my patients are in comas.

WTF is up with nursing there? sheesh.

 

[The Knife & Gun Club]

Sorry man.

Why is such nursing insolence tolerated? Union shop?

Yea unionized and county funded. By unionized/county standards it’s actually decent. But by real hospital standards it can be a bit much lol.

The new grad nurses who did all of their practicals online are excruciating as well.

 

[wholeheartedly]

Yea unionized and county funded. By unionized/county standards it’s actually decent. But by real hospital standards it can be a bit much lol.

The new grad nurses who did all of their practicals online are excruciating as well.

too bad you’re a resident. i normally don’t believe in airing dirty laundry in the chart but “nurse refused x, delayed care by x hours” might be appropriate in some situations.

 

[wholeheartedly]

also, even if the union doesn’t care the nursing board should. walking out mid shift is patient abandonment

 

[BoardingDoc]

Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids.

You must be in NY.

 

[thegenius]

My shift last night:
Well diagnosed and documented Idiopathic intracranial hypertension, HA x1 year, missed 3 appts with neurology, never filled her diamox despite it being free because “it made her pee too much.” Demanding neurology consult and admission.

Migraines x12 years. Multiple negative MRIs. Comes to ED at 10 pm demanding another MRI and consult with a neurologist but not the neurologist from before

Patient transferred from OSH with gigantic mediastinal mass and hemopheumothorax. Tubed and chest tube. CT surgery says nothing to do, mass is not respectable. sad.

Patient with pain all over after missing 3 dialysis appointments. Bradycardic. Nurse is too busy to get EKG x4 hrs. “He’s a tough stick”, USIV. Nurse trips over iv tubing, disloges IV. Lab loses the labs. US machine breaks.

Pt with BMI of 52, here for chronic chest/back/abd pain. Tough stick again. USIV again. Turns out she’s having an NSTEMI. Admit. signed out pending admit orders x5 hours, IM resident says she’s too busy to admit Pt.

Chronic alcoholic brought in for drunk in the street. Bad Abdominal tenderness on exam. No vitals charted. I order labs. Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids. Turns out he has acute hepatitis and pancreatitis.

Patient presents for paracentesis because he missed his appointment. Tell him he needs to go to his scheduled appointment and this isn’t an emergency. He leaves and checks back in, assigned to a new ED area. New attending transfers the patient back to our area for paracentesis and assigns the patient back to me.

Pregnant G1P0 at 14 weeks. Here for generalized malaise. Covid + 3 days ago with normal work up. Check the baby, Tylenol, discharged. Complaint because I “didn’t do anything.”

Patient took 3000 mg amytryptiline overdose. PC’d. Refuses labs and ekg, only wants dilaudid. HR 130, BP 150/110, temp 39.5. Per RN “that’s between you and the patient.” Explained the meaning of protective custody. RN still declines. IM Versed and restraints ordered so I can get work up and save their life. RN prints lab labels and throws them away so I can’t send labs. EKG machine can’t do EKG unless I scan the guys bracelet, but he pooped on it. Pushes of ativan for tachycardia and bicarb titrated to what looks like a wide QRS on telemetry. ICU accepts patient on paper but no bed because they don’t have a sitter for the PC’d patient.

The burn is real.

Where in gods name do you work? That ER sounds horrible. Is there not a single good nurse there? And attending?

Good lord.

 

[Fox800]

My shift last night:
Well diagnosed and documented Idiopathic intracranial hypertension, HA x1 year, missed 3 appts with neurology, never filled her diamox despite it being free because “it made her pee too much.” Demanding neurology consult and admission.

Migraines x12 years. Multiple negative MRIs. Comes to ED at 10 pm demanding another MRI and consult with a neurologist but not the neurologist from before

Patient transferred from OSH with gigantic mediastinal mass and hemopheumothorax. Tubed and chest tube. CT surgery says nothing to do, mass is not respectable. sad.

Patient with pain all over after missing 3 dialysis appointments. Bradycardic. Nurse is too busy to get EKG x4 hrs. “He’s a tough stick”, USIV. Nurse trips over iv tubing, disloges IV. Lab loses the labs. US machine breaks.

Pt with BMI of 52, here for chronic chest/back/abd pain. Tough stick again. USIV again. Turns out she’s having an NSTEMI. Admit. signed out pending admit orders x5 hours, IM resident says she’s too busy to admit Pt.

Chronic alcoholic brought in for drunk in the street. Bad Abdominal tenderness on exam. No vitals charted. I order labs. Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids. Turns out he has acute hepatitis and pancreatitis.

Patient presents for paracentesis because he missed his appointment. Tell him he needs to go to his scheduled appointment and this isn’t an emergency. He leaves and checks back in, assigned to a new ED area. New attending transfers the patient back to our area for paracentesis and assigns the patient back to me.

Pregnant G1P0 at 14 weeks. Here for generalized malaise. Covid + 3 days ago with normal work up. Check the baby, Tylenol, discharged. Complaint because I “didn’t do anything.”

Patient took 3000 mg amytryptiline overdose. PC’d. Refuses labs and ekg, only wants dilaudid. HR 130, BP 150/110, temp 39.5. Per RN “that’s between you and the patient.” Explained the meaning of protective custody. RN still declines. IM Versed and restraints ordered so I can get work up and save their life. RN prints lab labels and throws them away so I can’t send labs. EKG machine can’t do EKG unless I scan the guys bracelet, but he pooped on it. Pushes of ativan for tachycardia and bicarb titrated to what looks like a wide QRS on telemetry. ICU accepts patient on paper but no bed because they don’t have a sitter for the PC’d patient.

The burn is real.

Wow. This is insane. That's blatant nursing malpractice. I know you're a resident, but that crap needs to be reported. To the director of nursing, the hospital ethics/compliance line, and the state. Fire these idiots who are collecting a paycheck to literally harm people. That's some psychopathy right there.

 

[pkwraith]

I suspect the problem if you complain at all as a resident (or even an attending) there, is that the nurses band together, you get labeled as a "problematic personality", any small thing you do gets brought up as a complaint, and you get **** rained on you for the rest of your tenure there.

 

[s/p epilepticus]

I suspect the problem if you complain at all as a resident (or even an attending) there, is that the nurses band together, you get labeled as a "problematic personality", any small thing you do gets brought up as a complaint, and you get **** rained on you for the rest of your tenure there.

Not a problem if you have a mechanism in place for anonymously reporting problems like this. Because some of these nursing stories are egregious.

 

[The Knife & Gun Club]

I suspect the problem if you complain at all as a resident (or even an attending) there, is that the nurses band together, you get labeled as a "problematic personality", any small thing you do gets brought up as a complaint, and you get **** rained on you for the rest of your tenure there.

Precisely. Nurses have strength in numbers and will always circle the wagons around even the most preposterous of their group.

Also just on a theoretical level which would you prefer, fire a crappy nurse and have no nurse or be stuck with crappy nurse? The nursing shortage is still pretty real even at hospitals that have money, there’s no guarantee they could get another warm body to work the weekend night shift.

 

[TeddyBoomBoom]

You must be in NY.

This

 

[MedicineZ0Z]

That picture is so old. Pretty sure it was... 2013....
My first attending year was 2012, and this was before I worked with dchristismi in 2014, so had to be about then.

I had the DC papers in my hand and walked in the room, said - "I simply can't refill these; and there's not an ER doc anywhere that will. Refills for medications like these need to come from your pain management physician."

I remember the room the guy was in (room 8), In the old ER (before it was renovated). I remember his black T-shirt and beard.

In the era of angry patients who can just show up to shoot a doctor later cause they're angry, is it perhaps more wise to provide a very small supply (few tablets) to "get them to the next appointment" ?

 

[Robotic Wis-Hipple]

My shift last night:
Well diagnosed and documented Idiopathic intracranial hypertension, HA x1 year, missed 3 appts with neurology, never filled her diamox despite it being free because “it made her pee too much.” Demanding neurology consult and admission.

Migraines x12 years. Multiple negative MRIs. Comes to ED at 10 pm demanding another MRI and consult with a neurologist but not the neurologist from before

Patient transferred from OSH with gigantic mediastinal mass and hemopheumothorax. Tubed and chest tube. CT surgery says nothing to do, mass is not respectable. sad.

Patient with pain all over after missing 3 dialysis appointments. Bradycardic. Nurse is too busy to get EKG x4 hrs. “He’s a tough stick”, USIV. Nurse trips over iv tubing, disloges IV. Lab loses the labs. US machine breaks.

Pt with BMI of 52, here for chronic chest/back/abd pain. Tough stick again. USIV again. Turns out she’s having an NSTEMI. Admit. signed out pending admit orders x5 hours, IM resident says she’s too busy to admit Pt.

Chronic alcoholic brought in for drunk in the street. Bad Abdominal tenderness on exam. No vitals charted. I order labs. Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids. Turns out he has acute hepatitis and pancreatitis.

Patient presents for paracentesis because he missed his appointment. Tell him he needs to go to his scheduled appointment and this isn’t an emergency. He leaves and checks back in, assigned to a new ED area. New attending transfers the patient back to our area for paracentesis and assigns the patient back to me.

Pregnant G1P0 at 14 weeks. Here for generalized malaise. Covid + 3 days ago with normal work up. Check the baby, Tylenol, discharged. Complaint because I “didn’t do anything.”

Patient took 3000 mg amytryptiline overdose. PC’d. Refuses labs and ekg, only wants dilaudid. HR 130, BP 150/110, temp 39.5. Per RN “that’s between you and the patient.” Explained the meaning of protective custody. RN still declines. IM Versed and restraints ordered so I can get work up and save their life. RN prints lab labels and throws them away so I can’t send labs. EKG machine can’t do EKG unless I scan the guys bracelet, but he pooped on it. Pushes of ativan for tachycardia and bicarb titrated to what looks like a wide QRS on telemetry. ICU accepts patient on paper but no bed because they don’t have a sitter for the PC’d patient.

The burn is real.

What service was the accepting physician from for the unresectable mediastinal mass? I’d assume CT.

I’m not a surgeon and as such obviously don’t have the knowledge of the actual logistics when accepting acute/urgent/emergent surgical candidates from OSH’s but seems to me OSH would’ve had a scan that was similar to yours…..

It’s a bit interesting to me that some surgeons just auto-accept surgical transfers that aren’t resectable etc. Seems like a huge waste of healthcare dollars. But I too see this often, typically with a surgeon currently in the OR that gets a rudimentary report via answering service for a “type A” that gets a new scan on arrival that doesn’t show that.

Our system is F’d, and you guys have a thankless gig.

 

[RustedFox]

In the era of angry patients who can just show up to shoot a doctor later cause they're angry, is it perhaps more wise to provide a very small supply (few tablets) to "get them to the next appointment" ?

No.

 

[Rekt]

What service was the accepting physician from for the unresectable mediastinal mass? I’d assume CT.

I’m not a surgeon and as such obviously don’t have the knowledge of the actual logistics when accepting acute/urgent/emergent surgical candidates from OSH’s but seems to me OSH would’ve had a scan that was similar to yours…..

It’s a bit interesting to me that some surgeons just auto-accept surgical transfers that aren’t resectable etc. Seems like a huge waste of healthcare dollars. But I too see this often, typically with a surgeon currently in the OR that gets a rudimentary report via answering service for a “type A” that gets a new scan on arrival that doesn’t show that.

Our system is F’d, and you guys have a thankless gig.

Everything in emergency medicine comes down to the disposition. The second we sign up for a patient/pick up a chart it becomes "How do I get this patient out of here?"

Me calling the surgeon and him telling me it's a unresectable mass is not helpful to my disposition. Hospitalist sure as hell won't take it if you don't have CT surgery in house to document the same thing. So we end up with a useless transfer wasting time and money.

 

[The Knife & Gun Club]

What service was the accepting physician from for the unresectable mediastinal mass? I’d assume CT.

I’m not a surgeon and as such obviously don’t have the knowledge of the actual logistics when accepting acute/urgent/emergent surgical candidates from OSH’s but seems to me OSH would’ve had a scan that was similar to yours…..

It’s a bit interesting to me that some surgeons just auto-accept surgical transfers that aren’t resectable etc. Seems like a huge waste of healthcare dollars. But I too see this often, typically with a surgeon currently in the OR that gets a rudimentary report via answering service for a “type A” that gets a new scan on arrival that doesn’t show that.

Our system is F’d, and you guys have a thankless gig.

I actually don’t have a problem with that one. The surgeon came to the ER, looked at the dude, looked at the scans, and was like “hell no.” And was nice enough to pull up the scan and point to the anatomical reason for the hell no.

More just a bummer for the guy because he’s going to die hundreds of miles from home on a ventilator.

And the other minor headache that our ICUs can all accept or refuse independently, so SICU can say “na that’s non-op, MICU” and the MICU can say “na we’re not gonna babysit for a surgical disease, that’s SICU” and then the person boards in the ED indefinitely.

 

[EctopicFetus]

My shift last night:
Well diagnosed and documented Idiopathic intracranial hypertension, HA x1 year, missed 3 appts with neurology, never filled her diamox despite it being free because “it made her pee too much.” Demanding neurology consult and admission.

Migraines x12 years. Multiple negative MRIs. Comes to ED at 10 pm demanding another MRI and consult with a neurologist but not the neurologist from before

Patient transferred from OSH with gigantic mediastinal mass and hemopheumothorax. Tubed and chest tube. CT surgery says nothing to do, mass is not respectable. sad.

Patient with pain all over after missing 3 dialysis appointments. Bradycardic. Nurse is too busy to get EKG x4 hrs. “He’s a tough stick”, USIV. Nurse trips over iv tubing, disloges IV. Lab loses the labs. US machine breaks.

Pt with BMI of 52, here for chronic chest/back/abd pain. Tough stick again. USIV again. Turns out she’s having an NSTEMI. Admit. signed out pending admit orders x5 hours, IM resident says she’s too busy to admit Pt.

Chronic alcoholic brought in for drunk in the street. Bad Abdominal tenderness on exam. No vitals charted. I order labs. Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids. Turns out he has acute hepatitis and pancreatitis.

Patient presents for paracentesis because he missed his appointment. Tell him he needs to go to his scheduled appointment and this isn’t an emergency. He leaves and checks back in, assigned to a new ED area. New attending transfers the patient back to our area for paracentesis and assigns the patient back to me.

Pregnant G1P0 at 14 weeks. Here for generalized malaise. Covid + 3 days ago with normal work up. Check the baby, Tylenol, discharged. Complaint because I “didn’t do anything.”

Patient took 3000 mg amytryptiline overdose. PC’d. Refuses labs and ekg, only wants dilaudid. HR 130, BP 150/110, temp 39.5. Per RN “that’s between you and the patient.” Explained the meaning of protective custody. RN still declines. IM Versed and restraints ordered so I can get work up and save their life. RN prints lab labels and throws them away so I can’t send labs. EKG machine can’t do EKG unless I scan the guys bracelet, but he pooped on it. Pushes of ativan for tachycardia and bicarb titrated to what looks like a wide QRS on telemetry. ICU accepts patient on paper but no bed because they don’t have a sitter for the PC’d patient.

The burn is real.

I don’t know where this is but this is the 💩 iest sounding hospital I ever heard of. Time for a new director or a new job if the director isn’t the issue. Also a call to the ceo cno and cmo. Wtf is this nonsense.
why do the nurses not respect you?
serious question do you not respect them? I cant even fathom some of these cases you have above.

 

[EctopicFetus]

I actually don’t have a problem with that one. The surgeon came to the ER, looked at the dude, looked at the scans, and was like “hell no.” And was nice enough to pull up the scan and point to the anatomical reason for the hell no.

More just a bummer for the guy because he’s going to die hundreds of miles from home on a ventilator.

And the other minor headache that our ICUs can all accept or refuse independently, so SICU can say “na that’s non-op, MICU” and the MICU can say “na we’re not gonna babysit for a surgical disease, that’s SICU” and then the person boards in the ED indefinitely.

Have one service talk to the other and figure it out. You don’t need to be in the middle. They can’t play nice then escalate. This IS NOT YOUR PROBLEM.

 

[Robotic Wis-Hipple]

I actually don’t have a problem with that one. The surgeon came to the ER, looked at the dude, looked at the scans, and was like “hell no.” And was nice enough to pull up the scan and point to the anatomical reason for the hell no.

More just a bummer for the guy because he’s going to die hundreds of miles from home on a ventilator.

And the other minor headache that our ICUs can all accept or refuse independently, so SICU can say “na that’s non-op, MICU” and the MICU can say “na we’re not gonna babysit for a surgical disease, that’s SICU” and then the person boards in the ED indefinitely.

So who accepted/initiated the transfer?

But yeah, now you’ve got a guy where the family either decides to go comfort care and he’s tubed having never had the chance to say goodbye or he gets extubated and dies miles from home. It’s sad.

 

[Robotic Wis-Hipple]

Everything in emergency medicine comes down to the disposition. The second we sign up for a patient/pick up a chart it becomes "How do I get this patient out of here?"

Me calling the surgeon and him telling me it's a unresectable mass is not helpful to my disposition. Hospitalist sure as hell won't take it if you don't have CT surgery in house to document the same thing. So we end up with a useless transfer wasting time and money.

Yeah I get that. So who accepted the patient? If CT surgery accepted the transfer the patient is theirs right? Or was this an ED -> ED transfer without a surgeon having been consulted prior to transfer?

 

[BoardingDoc]

Have one service talk to the other and figure it out. You don’t need to be in the middle. They can’t play nice then escalate. This IS NOT YOUR PROBLEM.

Yeah, agree with this completely.
Page to both teams: "Patient needs an ICU admit. Both MICU/SICU recommending admission to the other. Surgery: MICU extension is xxxx. Please call them to discuss. Whoever winds up accepting, please call me back at XXX"
If you don't get a response within a reasonable timeframe, send another page asking if you need to get your attending involved.

 

[CoolDoc1729]

Have one service talk to the other and figure it out. You don’t need to be in the middle. They can’t play nice then escalate. This IS NOT YOUR PROBLEM.

It took me several years to realize this. Especially when it’s two in house services. You want medicine to admit the patient so you can do vascular surgery in the morning? Here’s their spectra link number , y’all work it out, thanks. Frees me up to discharge nonsense from the waiting room faster 🤣

 

[ToliBro]

Chronic alcoholic brought in for drunk in the street. Bad Abdominal tenderness on exam. No vitals charted. I order labs. Nurse refuses, says I’m being dramatic and and actually walks out (“calls out”) mid shift and goes home. I do my own labs and hang my own fluids. Turns out he has acute hepatitis and pancreatitis.

Unless that nurse handed the patients over to someone else that's straight up abandonment, open and shut, nursing board in the states I've worked in would come down on that like the hammer of God. Given the other stuff in that post maybe that state is different... sorry that my supposed colleagues are so worthless there

 

[BoardingDoc]

I had a 26F last night who presented with facial numbness 2 days after hitting her head. Also CP and SOB. Looked at her chart. 114 ED visits in the past 12 months. I asked if she had anxiety. Her response was that someone told her that once, but that all her visits were because of some rheum condition, the name of which escaped her. She was very unhappy when I opted not to CT scan her head. She also didn't care for me very much when I pointed out that she had spent almost as many days in the ER in the past year as I had ... and I work here.

Non-emergent psych patients with absolutely no insight are perhaps my least favorite demographic.

 

[Dr Mantis Toboggan]

I had a 26F last night who presented with facial numbness 2 days after hitting her head. Also CP and SOB. Looked at her chart. 114 ED visits in the past 12 months. I asked if she had anxiety. Her response was that someone told her that once, but that all her visits were because of some rheum condition, the name of which escaped her. She was very unhappy when I opted not to CT scan her head. She also didn't care for me very much when I pointed out that she had spent almost as many days in the ER in the past year as I had ... and I work here.

Non-emergent psych patients with absolutely no insight are perhaps my least favorite demographic.

We have one with daily chest pain.

The other day they checked into the ED with chest pain. Cardiology appt was an hour later.
Seen, discharged. Went to cardiology appt, checked back into the ER.

It takes 2 min to deal with this but I agree it’s annoying

 

[The Knife & Gun Club]

We have one with daily chest pain.

The other day they checked into the ED with chest pain. Cardiology appt was an hour later.
Seen, discharged. Went to cardiology appt, checked back into the ER.

It takes 2 min to deal with this but I agree it’s annoying

Do you routinely EKG these people? Or just MSE and discharge?

We have a similar gentleman who is quite persistent.

 

[Dr Mantis Toboggan]

Do you routinely EKG these people? Or just MSE and discharge?

We have a similar gentleman who is quite persistent.

Usually the nurse does a protocol ECG in triage and that’s about it.

 

[alpinism]

I had a 26F last night who presented with facial numbness 2 days after hitting her head. Also CP and SOB. Looked at her chart. 114 ED visits in the past 12 months. I asked if she had anxiety. Her response was that someone told her that once, but that all her visits were because of some rheum condition, the name of which escaped her. She was very unhappy when I opted not to CT scan her head. She also didn't care for me very much when I pointed out that she had spent almost as many days in the ER in the past year as I had ... and I work here.

Non-emergent psych patients with absolutely no insight are perhaps my least favorite demographic.

The only thing more frustrating than dealing with these patients are colleagues that will always order stroke workups and specialist consults whenever patients report having any neurological symptoms. In my experience many physicians are constantly enabling these patients which results in them stopping by the hospital on a daily basis for the most ridiculous complaints.

 

[RustedFox]

The only thing more frustrating than dealing with these patients are colleagues that will always order stroke workups and specialist consults whenever patients report having any neurological symptoms. In my experience many physicians are constantly enabling these patients which results in them stopping by the hospital on a daily basis for the most ridiculous complaints.

I'll take credit for this:

"Young women that have brief neurologic symptoms get a diagnosis of anxiety and a prescription for Xanax.

Old women that have brief neurologic symptoms get a diagnosis of TIA and a prescription for Plavix."

 

[southerndoc]

I'll take credit for this:

"Young women that have brief neurologic symptoms get a diagnosis of anxiety and a prescription for Xanax.

Old women that have brief neurologic symptoms get a diagnosis of TIA and a prescription for Plavix."

Had a 23 year old the other day who was dizzy. I was tied up with a transfer center issue. Resident ordered an MRI. I asked him why when I finally got off this long TC call and his justification was the patient was dizzy when lying flat, didn't seem positional, and had brief trouble ambulating. In all fairness, this resident is the top in his class.

I always let residents order a lot of CTs and other tests that I normally wouldn't order. It's always been my feeling that a resident needs a certain number of negative studies to feel comfortable with their own judgement. Sure, an attending can say "you don't need to order that" but it doesn't sink in as much as a negative study.

At any rate, end of story was he had 2 small cerebellar infarcts. 23!