"They're going to be fine"

[WilcoWorld]

To complement, rather than hijack the "Ominous Signs" thread, I thought we could start a new threat to list the signs that let you know someone will likely be fine.

1) When the patient is screaming so loud I can hear them clear across the ED - at least I know they've got cardiopulmonary stability.

2) Perioral cheetosis in the abdominal pain patient.

3) If your chief complaint is about the wait, the blankets, or the nurses - you probably don't need to be in the ED.

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[southerndoc]

If you request Dilaudid by name, chances are you don't have a real emergency. If you request a specific dose, you have a 100% probability of being a seeker.

 

[GeneralVeers]

If you're talking on the cell-phone in the room while you have "10 out of 10" abdominal pain, chances are it's nothing emergent.

 

[docB]

Breathers who can speak full sentences. I have no data on this but in my experience when they can talk I can almost always turn them around without the tube.

 

[Stitch]

positive slushy sign. Give a toddler a slushy. If he eats it happily, he's probably ok.

 

[goofE1]

Tweeting from a cell phone while collared and boarded and being rolled in by EMS s/p MVC.

 

[deleted109597]

Edwin Leap's scoring system for critical illness:


The Leap Non-severity scale:
Profanity:
3 Unable to speak profanity or make profane gestures.
2 Slurs profanity, exposes genitalia or makes confusing lewd gestures.
1 Speaks profanity clearly, but with the same poor sentence structure he or she uses for English. Recognizable, but not very interesting.
0 Profanity used like poetry, flowing and uninterrupted. Suggests physical acts neither legal nor, in many instances, actually possible. Elaborate gestures.
Smoking:
3 Unable to smoke unless actually on fire.
2 Asks for cigarette, but realizes he cannot hold cigarette or inhale smoke.
1 Smokes in room, with oxygen on high flow and friends smoking for company.
0 Wanders parking lot still partially attached to backboard, asking everyone for cigarette.
Violence:
3 So ill or impaired that behavior can be controlled without Droperidol.
2 Threatens doctor and staff with death, but can't actually move due to pain or disability.
1 Points to each staff member individually and says "I know where you live and I'll kill you" as police officers hold him down on bed.
0 Actually attacks staff member.
Scoring:
0 – 3: Can be discharged to jail or home without actually being examined.
4 – 6: Probably will require evaluation, although odds of dying still relatively low.
6 – 9: Most likely has real injury or illness. However, requires diligent re-evaluation using Leap Non-severity Scale (LNSS) so that patient can be down-graded as he or she improves or becomes increasingly annoying.

 

[doctorFred]

positive slushy sign. Give a toddler a slushy. If he eats it happily, he's probably ok.

similar to the positive lollypop sign after reducing a nursemaid's

 

[Apollyon]

I echo the "txting" sign - if you won't stop the text in which you are the middle of composing, I am internally reassured that your stay will be brief and mild.

 

[Rendar5]

vociferous refusal of a rectal temperature.

 

[illegallysmooth]

While signing in with the friendly ED clerk, pt has to juggle coffee and/or McDonald's Value Meal in order to produce an insurance card.

Also, complaining of 10/10 pain with clear, calm speech.

 

[Arcan57]

Being a vet (soldier, not animal doc) - cannot be killed in the ED

Symptoms developed after fight with boss

Vigourously cursing staff... only had one guy that did that code in the ED, and he made it through over an hour of CPR and came out neuro-intact

 

[gutonc]

Being a vet (soldier, not animal doc) - cannot be killed in the hospital

Fixed it for you. Although the "nicest person on the planet/widely metastatic cancer" rule does still apply to Vets.

 

[WilcoWorld]

Symptoms developed after fight with boss

Similarly, if your symptoms began after being placed under arrest you're going to be fine.

Caveat: If your symptoms are related to trauma, or swallowed bags full of drugs, then having began after being placed under arrest belongs in the "Ominous Signs" thread.

 

[GeneralVeers]

Vigourously cursing staff... only had one guy that did that code in the ED, and he made it through over an hour of CPR and came out neuro-intact

We call that the "Protective Cockroach Aura" in that the more of a belligerent ass you are, the less likely you are to die or have serious complications.

 

[Apollyon]

We call that the "Protective Cockroach Aura" in that the more of a belligerent ass you are, the less likely you are to die or have serious complications.

A/k/a "the law of inverse value" - it's on the first page of "Things I Learn From My Patients".

 

[Cerberus]

I echo the "txting" sign - if you won't stop the text in which you are the middle of composing, I am internally reassured that your stay will be brief and mild.

At my old hospital we called it a "positive cell phone sign". It was usually present in a 20'ish black female who needed dilaudid due to the 11/10 pain she was experiencing from her sickle cell crisis.

 

[Arcan57]

Let us not forget the "having more than 3 organ systems involved" sign, especially in young people. Worst headache of life, + severe chest pain +horrible abdominal pain = virus (obviously not applicable if you're 80).

 

[po' boy]

eating chips in waiting room, regardless of chief complaint. negative predictive value highest if presenting with abdominal pain.

double score if said chips are bought from the waiting room vending machine, the one that has a sign taped to it saying "do not eat or drink until evaluated by the emergency physician."

 

[Anastasis]

+ White Castle Sign

I almost wanted to write that on a chart once.

 

[docB]

+ White Castle Sign

I almost wanted to write that on a chart once.

I write that (we don't have white castle but I write + McD's and the like). I also diagnose malingering and narcotic dependence frequently.

 

[southerndoc]

I write that (we don't have white castle but I write + McD's and the like). I also diagnose malingering and narcotic dependence frequently.

I read one of the funniest notes the other day for a frequent flyer who was admitted and pain management was consulted for:

"Of note, upon entering the room the patient was talking on her cell phone, watching TV, and eating peanut butter and Grahams crackers with a complimentary ginger ale laughing and giggling. She immediately started screaming in agony when I entered the room stating she needed 2 mg of Dilaudid rapid push IV to stop her pain."

 

[GeneralVeers]

I write that (we don't have white castle but I write + McD's and the like). I also diagnose malingering and narcotic dependence frequently.

I put "drug-seeking behavior" and more rarely "malingering" on patients who are especially egregious. It's more to alert my colleagues (at least the ones who look at the past visit notes) than anything.

 

[nlax30]

When as a 3rd year student on IM rotations I'm told to go to the ER and start that Chest Pain r/o MI admission.... they usually end up perfectly fine, and it's never an MI.

 

[Rendar5]

When as a 3rd year student on IM rotations I'm told to go to the ER and start that Chest Pain r/o MI admission.... they usually end up perfectly fine, and it's never an MI.

Well, yeah =p it's an admission for a 5% chance of a life-threatening disease.

 

[WilcoWorld]

I put "drug-seeking behavior" and more rarely "malingering" on patients who are especially egregious. It's more to alert my colleagues (at least the ones who look at the past visit notes) than anything.

I do the same thing, but I phrase it as, "strong concern for drug-seeking".

 

[diphenyl]

I hated having to write this under physical exam for a PT w/ 10/10 abd/ chest/ neck/ back pain.

Constitutional:
A/O x 3
VS's reviewed/ stable
Afebrile
Eating/ drinking copious ETOH w/o difficulty or emesis upon MD's arrival to bedside.
Pt able to ambulate/ run around gurney UMDS w/o assistance.

 

[SoCuteMD]

If they come from jail and have been there for a day or two and are without any signs of EtOH withdrawal, they are going to be JUST FINE.

 

[The right Path]

+ White Castle Sign

I almost wanted to write that on a chart once.

Lol, I had to google White Castle.

 

[dchristismi]

When as a 3rd year student on IM rotations I'm told to go to the ER and start that Chest Pain r/o MI admission.... they usually end up perfectly fine, and it's never an MI.

Usually. But not always.

I coded one last night up in the cardiac obs unit... you know, one of those probably-nothing-but-not-gonna-chance-it-admits.

Tele caught the fib, the shocks worked, shipped up to ICU...



It's nothing compared to the perioral cheetosis. (Which is one of my FAVORITE prognostic signs)

 

[tkim]

Usually. But not always.

I coded one last night up in the cardiac obs unit... you know, one of those probably-nothing-but-not-gonna-chance-it-admits.

Tele caught the fib, the shocks worked, shipped up to ICU...



It's nothing compared to the perioral cheetosis. (Which is one of my FAVORITE prognostic signs)

I'm waiting for 'lortabpenia' to get it's own ICD-9 code.

 

[Stitch]

I'm waiting for 'lortabpenia' to get it's own ICD-9 code.

Sort of like dilaudid deficiency?

 

[All4MyDaughter]

Sort of like dilaudid deficiency?

In my world, dilaudid deficiency ALWAYS presents with severe allergies to EVERY other painkiller known to man...

 

[tkim]

Sort of like dilaudid deficiency?

Allergic to motrin, tylenol, toradol = pathognomonic.

 

[WilcoWorld]

Sort of like dilaudid deficiency?

Sort of, except that conditions such as lortabpenia and percocetopenia (which has a much higher prevalence in my community) tend to have a more chronic and indolent course whereas dilaudid deficiency tends to be very acute and much more severe in nature. Also, percocetopenia often responds to monotherapy and can be diagnosed and treated as an outpatient while dilaudid deficiency usually only responds to the synergistic effects of phenergan and benadryl, requires multiple radiographic studies to be diagnosed, and sometimes even necessitates admission.

 

[tkim]

I made a lortabpenia cascade:

kicked out of
pain management
|
|
|
|
V
run out of lortab --->no money to buy
lortab off street
|
|
|
|
V
go to ER and complain of
'all over body pain 15/10!!!!!' ------------> lortabpenia

 

[tkim]

it was funnier when it kept the line spacing.

 

[docB]

If the patient presents you with a timeframe during the first 2 minutes of the interaction they can really just leave right then.

E.g. "Doctor I've had this excrutiating non specific pain in vague areas of my body but I have to leave in 45 minutes to do something important so I can't stay any longer than that."

 

[Dwindlin]

Sorry if this is old news, but I was just informed about it the other day. . .

opiophile.org

Forum for drug abusers/seekers. Was enlightening to peruse some of the topics. . .

 

[NYRN]

If the patient is youngish, the more visitors they have and they more they are talking about "how sick they are" to said visitors, is a pretty good indicator that they will be discharged before the rest of the visitors arrive.

 

[Laryngophed]

positive slushy sign. Give a toddler a slushy. If he eats it happily, he's probably ok.

Haha! I was going to post this as the popsicle sign. In my 5 years in the hospital as tech/aide/phleb, only the really sick kids turned down a free popsicle.

 

[deleted109597]

If symptoms started more than 3 days ago, then they're fine.

 

[WilcoWorld]

If symptoms started more than 3 days ago, then they're fine.

Unless it's urosepsis, or CHF, or progressive cellulitis, or hepatic encephalopathy, or DKA, or...

 

[Kubed]

Sorry if this is old news, but I was just informed about it the other day. . .

opiophile.org

Forum for drug abusers/seekers. Was enlightening to peruse some of the topics. . .

... wow. I'm reading a thread on how to find a doctor. Just.... wow.

 

[rph3664]

Sorry if this is old news, but I was just informed about it the other day. . .

opiophile.org

Forum for drug abusers/seekers. Was enlightening to peruse some of the topics. . .

Wow! That's a website you don't want anyone to know you post on! Had no idea anything like this existed, although I'm not really all that surprised.

How about the patient who walks in and announces that their visit reason is "Can't find pulse"?

 

[Powdermonkey]

Sorry if this is old news, but I was just informed about it the other day. . .

opiophile.org

Forum for drug abusers/seekers. Was enlightening to peruse some of the topics. . .

Thats just freaking ridiculous...

 

[Katydid]

... wow. I'm reading a thread on how to find a doctor. Just.... wow.

I found that thread. Holy crap.

Of course, delivering for the pharmacy, I have figured out which doctors around here are pretty free with the prescription pad. It's the same half-dozen doctors, and they have all these nice older ladies hooked on these painkillers.

 

[Laryngophed]

Sorry if this is old news, but I was just informed about it the other day. . .

opiophile.org

Forum for drug abusers/seekers. Was enlightening to peruse some of the topics. . .

Wow. That site makes me feel so much better that the two times in my life I was given narcs, I couldn't even finish the 'script.

At the small ED in my hometown, there was one doc who was famous for handing out the candy. We had a few patients who literally knew his schedule and to make things worse, people would cruise the lot looking for his car. If they saw one of his two vehicles (both were highly conspicuous) they would stop. The year before I took a job in the ED, I worked in security at the same hospital and for the life of me, I couldn't figure out why cars would be trollin' the lot. A year later, after seeing the same drug-seeker (a cancer survivor who conveniently had a port and an aversion to peripheral sticks) for the 4th time that week, it hit me. I can't tell if he was really gullible or just didn't give a damn about handing out narcotics but I hear he was asked to leave that ED not long after I went back to school.

 

[deleted77919]

…

 

[Katydid]

Wow. That site makes me feel so much better that the two times in my life I was given narcs, I couldn't even finish the 'script.

At the small ED in my hometown, there was one doc who was famous for handing out the candy. We had a few patients who literally knew his schedule and to make things worse, people would cruise the lot looking for his car. If they saw one of his two vehicles (both were highly conspicuous) they would stop. The year before I took a job in the ED, I worked in security at the same hospital and for the life of me, I couldn't figure out why cars would be trollin' the lot. A year later, after seeing the same drug-seeker (a cancer survivor who conveniently had a port and an aversion to peripheral sticks) for the 4th time that week, it hit me. I can't tell if he was really gullible or just didn't give a damn about handing out narcotics but I hear he was asked to leave that ED not long after I went back to school.

I know, right?

I've been prescribed narcotics (aside from demerol when the ortho on call wasn't sure if my arm was broken, and it was extremely painful, and morphine for a migraine, WTF, that I specifically told the ED doc on call I did NOT want after the first IV push because it made me feel worse) twice.

Both times? Vicodin. I hate Vicodin. I hate the nightmares, I hate the drunk feeling, I hate the loss of control over my own brain. I only took it the bare minimum for the wisdom teeth removal recovery, and the recovery from the bone bruise/joint bruise of my right forearm (which sucked mightily...I'm right-handed).

The people on that forum? Wow. I've never seen addicts who are so blunt about it, and happy to be addicted.