Two Chief Complaints that drive me nuts.

[TooMuchResearch]

Had one last night that had been out probably 5-6 hours. We had good records, radiology actually had the exact tube available (no one else could find one for some reason). Had to dilate up with several Foleys but got it back in...was not the 5 minute version though.

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[thegenius]

@Gastrapathy I realize you're trying to be helpful but you really have no idea what it's like for us replacing these in the ED. We have ZERO information on the PEG most of the time. It's done somewhere else, nobody knows WHO did it, or what hospital it was done at, or even WHEN it was done. Sometimes, these things have been out for hours before any nurse noticed at the NH which prompted a delayed transfer to the ER. The stoma is half closed and it's a work out getting it re-inserted, praying to God that I didn't just create a new tract or that this isn't a fresh tract after talking to a NH nurse at 2a.m. who just met the pt that day and has no idea how old it is and after asking a next of kin on telephone who again....has no idea when it was placed. It's a classic hail Mary PEG replacement. And you want us to send them back out without contrast verification that it's in the gut? No thanks. Plus, how hard is it to put in 20ccs of gastrografin and shoot an abdominal XR? It takes like 2 minutes.

Yea I think he realizes that.

 

[thegenius]

I have a few times not used gastrografin to confirm tube placement. But it's when I know what's going on and I can get a good history. But most of the time I do. For the reasons listed above. Thankfully we have these really easy to use kits that you just pop them in. Boom, just like that.

The right thing to do when we get these patients at 2:00 AM is to stick a foley in there and send them back, but just so they can wake up in 6 hours and come back to the hospital for an IR procedure? So we are spending another $1000 each way for EMS to take a person to and from their nursing home over a span of 6-8 hours? Sometimes it's just easier to let them sit in the ER for 6 hours, IR replaces the tube in the AM and then send them back.

The reason why I hate doing the easy thing is it continues to encourage the general behavior of "dumping on the ED."

 

[Merely]

This reminded me... we used to have to have this psych pt who would come in for all sorts of various complaints...most docs treated her like a pain seeker because she would ask for dilaudid and phenergan and this was prior to all the opiod craziness. She would be hyper manic and walking around the department, up at the nursing station, asking for hugs, and generally being a nuisance. She had trichotillomania and patches of her hair would be missing on occasion. Hyperverbal, tangential thinking, poor insight, the usual annoying psych pt qualities. She would generally have a chronic pain complaint. People would slug her with all types of meds just to get her to shut up and then discharge her. I finally figured out she was really just there for the attention and not a drug seeker at all. It was 100% psych. So we started offering "Normazaline" = "Normal Saline". She'd come in asking for dilaudid and I'd go..."Listen, all I've got is a Normazaline shot, but listen....I'm only giving you one of these since they are so potent and I want to make absolutely certain you have someone to take you home today. This shot will cure your pain, itching, anxiety, all of it! It's a wonder drug! But listen...we just don't give these out to just anybody...so hold on and let me get your nurse. We'll get this done and get you back home. You'll feel brand new!" Her eyes would get wide and she'd thank us so much for the normazaline. Pretty soon, she started coming into the ER claiming that those "normazaline" shots were from God and were the best thing she'd ever had. She'd show up every few days begging for another one. I haven't seen her in our ED in awhile, but the talk about saline shots reminded me of that. LOL

I’m not entirely sure how ethical that is but I love it

 

[dchristismi]

I had a patient a few years ago, a prisoner with a head and neck cancer who was primarily fed by g-tube. Guy was walkie-talkie and had complained FOR A FEW DAYS about his tube being out but no one bothered to do anything (I think it might have been a weekend/holiday, but poor guy was starving.) By the time he got to me, it was down to a tiny tract. So I found some pedi foleys and slowly dilated the thing back up until we could put a decent tube in it. And I gave him all the ice cream he could eat in the interim.

Ice cream out tube? Tube in right place.
(I can't honestly remember if I shot a film or not, but I felt terrible for the guy, and thankfully had the time to run in and out every 20 minutes and pop a bigger one in.)

 

[deleted497653]

I’m not entirely sure how ethical that is but I love it

I want some normalazine too.

 

[julie29524]

- Once a patient came because his PCP's nurse called him and told him he has something very abnormal on his blood work, and he needs a stat f/u appointment to discuss it with the physician. Patient got scared, came to ED. After a couple of phone calls, I found out it was an abnormal lipid panel.
- nursing home patient send by EMS, CC is "syncope while asleep"
- pt slams hand in car door, went to another ER, had XR, told him that 'no fractures'. Pt came to my ED on day 2, states pain continues, wants to know if broken, states 1st ER did nothing for him, holding an unfilled prescription from first ER for Vicodin.
- pt complains of constipation for few days, ask what OTC medication has she tried, pt states juice and tea, maybe a banana. When asked why not some colace or dulcolax, pt states she doesn't like medicine. What holistic approach can I get from my PYXIS?
- young pt here for anxiety, can't sleep, etc. Offer benzo, pt states doesn't want to be medicated like all those ADHD kids, sooooooo, let me go pull out some cognitive behavior therapy out of the med room then.

I'll take PEG tube and hyperK any day.

 

[frosted2]

- Once a patient came because his PCP's nurse called him and told him he has something very abnormal on his blood work, and he needs a stat f/u appointment to discuss it with the physician. Patient got scared, came to ED. After a couple of phone calls, I found out it was an abnormal lipid panel.
- nursing home patient send by EMS, CC is "syncope while asleep"
- pt slams hand in car door, went to another ER, had XR, told him that 'no fractures'. Pt came to my ED on day 2, states pain continues, wants to know if broken, states 1st ER did nothing for him, holding an unfilled prescription from first ER for Vicodin.
- pt complains of constipation for few days, ask what OTC medication has she tried, pt states juice and tea, maybe a banana. When asked why not some colace or dulcolax, pt states she doesn't like medicine. What holistic approach can I get from my PYXIS?
- young pt here for anxiety, can't sleep, etc. Offer benzo, pt states doesn't want to be medicated like all those ADHD kids, sooooooo, let me go pull out some cognitive behavior therapy out of the med room then.

I'll take PEG tube and hyperK any day.

Syncope while asleep. Literally laughed out loud at that one. WTF are these people thinking when they send folks out for stuff like this.

 

[GeneralVeers]

Dumbest one I've ever had was this one: Bed-bound, non-verbal patient from a nursing home. They sent him in for a "psych eval" because he pointed his fingers at his head as if it was a gun. They put him on a legal hold for "suicidal ideation". We all got a good laugh out of that one as we loaded him in the same ambulance and sent him back.

 

[TheSingularity]

This makes me sad.

Dumbest one I've ever had was this one: Bed-bound, non-verbal patient from a nursing home. They sent him in for a "psych eval" because he pointed his fingers at his head as if it was a gun. They put him on a legal hold for "suicidal ideation". We all got a good laugh out of that one as we loaded him in the same ambulance and sent him back.

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[CajunMedic]

#2.) "Abnormal labs". - OH, HAI ! ARR YOU A FAMBLY DOCTER THAT CANT MEDICINES!? SEND YER PATIENT TO THE ER. I DO YER JOBS FOR YOUU. Granted, a hemoglobin of 4 needs to be sent to the ER, but when you've got a potassium of 6.5 on Thursday, and you call the patient and tell them on Monday.... I hate you. They've been stable all weekend, and are stable now. Do you job. Go do medicines, fambly care dokterrrr.

Had one of these a couple of shifts ago that had me facepalming.

20-something obese patient comes in with 2-3 episodes of sharp chest pain and shortness of breath that last a few seconds, over the past few weeks. They go see Jenny McJennyson who orders the kitchen sink for labs. Then, they get called at 5 PM on Friday and told their “D-Dimer is elevated and go to the ER RIGHT NOW!!!!”

After a 4 hour wait (15 of my 30 beds are boarding for the floor) and labs drawn by protocol in triage (to include a repeat dimer) they get to me. Vitals are better than mine, PERC negative via H&P, absolutely 0 concerning findings for PE. Absolutely no other abnormal lab values. Dimer comes back at .64, our labs high value? .59. Attending begrudgingly says “2 positive dimers, we gotta do it, even though we’re pretty sure it’s negative” Like Oprah, “you get a CTA!, and you get a CTA!”

2 hours later-negative. D/C home and follow up with primary care....




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[migm]

IMO tell pt risk of PE is <2%. Risk of CTA 1/330 risk of lifetime cancer at age 30 and is culmulative. Which would you rather?

 

[frosted2]

IMO tell pt risk of PE is <2%. Risk of CTA 1/330 risk of lifetime cancer at age 30 and is culmulative. Which would you rather?

Wish I would have been told this before I got a CTA the other day.

 

[southerndoc]

IMO tell pt risk of PE is <2%. Risk of CTA 1/330 risk of lifetime cancer at age 30 and is culmulative. Which would you rather?

That's debatable. The oncologists think that the damage caused by ionizing radiation is repaired over time, and after 5 years your risk of cancer returns to baseline.

As far as I know, all data for risk of cancer with radiation exposure has been extrapolated from American use of atomic bombs.

 

[Apollyon]

That's debatable. The oncologists think that the damage caused by ionizing radiation is repaired over time, and after 5 years your risk of cancer returns to baseline.

As far as I know, all data for risk of cancer with radiation exposure has been extrapolated from American use of atomic bombs.

Wasn't there Chernobyl data, too?

 

[maxxor]

That's debatable. The oncologists think that the damage caused by ionizing radiation is repaired over time, and after 5 years your risk of cancer returns to baseline.

As far as I know, all data for risk of cancer with radiation exposure has been extrapolated from American use of atomic bombs.

The linear no threshold theory is the current radiation safety assumption and derived from the BEIR reports. These ultimately came from atomic bomb survivors.

The newer thinking is that radiation hormesis is potentially valid which is that “low” doses can be recovered, given that we know there are stochastic/dose dependent effects from higher doses. The doses used in radiography/CT/nuclear medicine medical imaging are almost all considered “low”. Complex IR/angio/cathlab can get pretty high dose though.

 

[deleted109597]

That's debatable. The oncologists think that the damage caused by ionizing radiation is repaired over time, and after 5 years your risk of cancer returns to baseline.

As far as I know, all data for risk of cancer with radiation exposure has been extrapolated from American use of atomic bombs.

The better data to use against parents is the linear decrease in IQ with head radiation. That usually scares them out of the CT.

 

[Groove]

The better data to use against parents is the linear decrease in IQ with head radiation. That usually scares them out of the CT.

Link? When I googled this, I found the following:

No clinically relevant effect on cognitive outcomes after low-dose radiation to the infant brain: A population-based cohort study in Sweden

While the detrimental effects of cranial radiotherapy on the developing brain are well known, the effects on cognitive performance of low doses of ionizing radiation is less studied. We performed a population-based cohort study to determine whether low ...

www.ncbi.nlm.nih.gov

Which seems to debunk that theory for the most part. They found no effects on logical, spatial, global or technical test scores. There was a very small effect on verbal iQ that seemed related to exposure of the anterior brain and hippocampus, but the effect was very low and only linked with high radiation scores. Plus, the overall radiation exposure in CT post 2001 is much lower than they were previously.

Am I missing an important study somewhere?

 

[deleted109597]

Link? When I googled this, I found the following:

No clinically relevant effect on cognitive outcomes after low-dose radiation to the infant brain: A population-based cohort study in Sweden

While the detrimental effects of cranial radiotherapy on the developing brain are well known, the effects on cognitive performance of low doses of ionizing radiation is less studied. We performed a population-based cohort study to determine whether low ...

www.ncbi.nlm.nih.gov

Which seems to debunk that theory for the most part. They found no effects on logical, spatial, global or technical test scores. There was a very small effect on verbal iQ that seemed related to exposure of the anterior brain and hippocampus, but the effect was very low and only linked with high radiation scores. Plus, the overall radiation exposure in CT post 2001 is much lower than they were previously.

Am I missing an important study somewhere?

They reference it like 100 times in that article.

Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study

Objective To determine whether exposure to low doses of ionising radiation in infancy affects cognitive function in adulthood.Design Population based cohort study.Setting Sweden.Participants 3094 men who had received radiation for cutaneous haemangioma ...

www.ncbi.nlm.nih.gov

 

[Groove]

They reference it like 100 times in that article.

Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study

Objective To determine whether exposure to low doses of ionising radiation in infancy affects cognitive function in adulthood.Design Population based cohort study.Setting Sweden.Participants 3094 men who had received radiation for cutaneous haemangioma ...

www.ncbi.nlm.nih.gov

You do realize that the one I posted is a failed validation study (2014) for the study from 2004 that you're using as the basis of your discussion with the parents, correct?

 

[deleted109597]

You do realize that the one I posted is a failed validation study (2014) for the study from 2004 that you're using as the basis of your discussion with the parents, correct? It's also much greater powered with a combined cohort of 26,000 kids versus 3,094 in the original study.

It's not a validation study, but sure. The 2014 study is better done, but it still doesn't measure what we want it to. Graduating high school=/= intelligence (although a better endpoint than days missed, for sure).
It's just that I've got my recital rehearsed, and the 2014 study isn't enough to change my current tree. They say so themselves in the discussion (and then they want to look for malignancies as future study possibilities).
At the end of the day, I generally don't argue with the parents. If they want the scan they end up getting the scan. It's just not worth it, even in a state like Texas where they can't really sue me. But I rattle off my spiel and tell them they can make their own decision.

 

[pkwraith]

I think the most effective way to deter unecessary CTs would probably be if we could show people the Before and After pictures of the patients that have clearly aged 30 years after their 20+ CT scans in the last 2 years.

 

[Groove]

For the overzealous parents, I generally just dumb it way down and say something along the lines of "Growing child brain = good. Radiation = bad...Cancer, cancer, cancer!" All they hear is the cancer part and they suddenly aren't so crazy about the CT.

 

[Ceke2002]

Paramedic here...

I love asking a NH for valid DNR paperwork. "wElL yOuLl hAvE tO dO wHaT yOu HaVe tO dO!" NO! That is not how that works!!!! Find the paperwork you fool!!

Wait, you mean the patient has a DNR in place and the NH can't access it so they just expect you to go ahead and start a code, or whatever, on them? WTAF?! If the NH my Mum is in tried to pull that **** I'd be ropeable, especially if I'd found out that she'd been put through a code, and even worse they'd managed to bring her back. In some ways I'm kind of glad me working in the medical field didn't work out in the end, I have a feeling I'd be cracking heads left right and centre with some of the stuff I hear.

 

[frosted2]

Wait, you mean the patient has a DNR in place and the NH can't access it so they just expect you to go ahead and start a code, or whatever, on them? WTAF?! If the NH my Mum is in tried to pull that **** I'd be ropeable, especially if I'd found out that she'd been put through a code, and even worse they'd managed to bring her back. In some ways I'm kind of glad me working in the medical field didn't work out in the end, I have a feeling I'd be cracking heads left right and centre with some of the stuff I hear.

Yep. It enrages me. It really peeves me off when they say "oh, I am sure they'll make it to the hospital." YOU NEVER KNOW!
I had a LPN the other day tell me "we send him out so much we don't have any more DNRs left to send." Two things... 1. use some of your nursing diagnosis skills and quit sending him out so much and 2. make more originals of the DNR.

 

[d2305]

I remember the linear hypothesis in regard to Chernobyl survivors. With 1/4 of the control group getting cancer, it's hard to tease out.

 

[thegenius]

The treatment of this chief complaint: Blocked Urinary Catheter (with antibiotics)...drives me nuts. We see this all the time. A dude's catheter is blocked or partially blocked and there are no other symptoms. The catheter is either flushed of the crud or it is replaced. Again...the patient has no symptoms, no fever, nothing. For whatever reason practicioners (and I've seen doctors do this as well) check a UA and it's always positive and they give antibiotics because they think they have a UTI. They don't. They do not have an active urinary tract infection. They may have bacteria in their urine (duh...there's a foley in the bladder what a surprise) but it's not an infection.

I just signed a PA chart where they have Macrobid for a blocked foley catheter from an old dude. Pisses me off. Problem is I see ER docs do this all the time too.

 

[RustedFox]

The treatment of this chief complaint: Blocked Urinary Catheter (with antibiotics)...drives me nuts. We see this all the time. A dude's catheter is blocked or partially blocked and there are no other symptoms. The catheter is either flushed of the crud or it is replaced. Again...the patient has no symptoms, no fever, nothing. For whatever reason practicioners (and I've seen doctors do this as well) check a UA and it's always positive and they give antibiotics because they think they have a UTI. They don't. They do not have an active urinary tract infection. They may have bacteria in their urine (duh...there's a foley in the bladder what a surprise) but it's not an infection.

I just signed a PA chart where they have Macrobid for a blocked foley catheter from an old dude. Pisses me off. Problem is I see ER docs do this all the time too.

There's no reason for this to come to the ER.
My cat can flush a catheter. RNs can replace a catheter.
KTHXBYE.

 

[thegenius]

There's no reason for this to come to the ER.
My cat can flush a catheter. RNs can replace a catheter.
KTHXBYE.

It's easy money for the Doc. We see the patient for 1.5 minutes. RN changes the catheter and d/c. You get $80.

The antibiotics drive me nuts. Why does everybody feel the need to check a UA.....AND THEN TREAT IT....for a blocked catheter.

 

[RustedFox]

It's easy money for the Doc. We see the patient for 1.5 minutes. RN changes the catheter and d/c. You get $80.

The antibiotics drive me nuts. Why does everybody feel the need to check a UA.....AND THEN TREAT IT....for a blocked catheter.

I will refuse the easy money if it sets a precedent that things like this shouldn't come to the ER, but rather be dealt with in the nursing home, as they should be. After all, there are other patients to see for easy money who should be here. I can't stand the fact that they need to come via EMS at 2 AM and waste thousands of dollars of taxpayer money for what should be dealt with either (1) privately, or (2) in a non-emergent setting.

Seriously. ******* NPs send these patients to the ER, when an RN is only going to flush it or replace it and send them back?

HEY! Jenny McJennyson! - Looks like you can't do the work of a *simple* ER:RN, yet you Lord yourself over them and clamor for independent practice rights ? Give me a freaking break.

 

[thegenius]

I will refuse the easy money if it sets a precedent that things like this shouldn't come to the ER, but rather be dealt with in the nursing home, as they should be. After all, there are other patients to see for easy money who should be here. I can't stand the fact that they need to come via EMS at 2 AM and waste thousands of dollars of taxpayer money for what should be dealt with either (1) privately, or (2) in a non-emergent setting.

Seriously. ******* NPs send these patients to the ER, when an RN is only going to flush it or replace it and send them back?

HEY! Jenny McJennyson! - Looks like you can't do the work of a *simple* ER:RN, yet you Lord yourself over them and clamor for independent practice rights ? Give me a freaking break.

LOL

Nursing home RN sends the pt to the ED so another RN flushes the catheter.
This is RN shenanigans to increase their job security!

LMAO

I'm willing to bet 35% of our income is easy money like this.

Who was hotter again? Jenny McJennyson or Mackenzie MackADittles? I can't remember. I think it was Mackenzie, they both get a B for looks but MacKenzie gets a personality upgrade because she is slightly more hip and won't complain as much when you stay out late with the boys at the bar.

 

[RustedFox]

Who was hotter again? Jenny McJennyson or Mackenzie MackADittles? I can't remember. I think it was Mackenzie, they both get a B for looks but MacKenzie gets a personality upgrade because she is slightly more hip and won't complain as much when you stay out late with the boys at the bar.

We've been thru this three times now.
You don't listen.

BOTH Jenny McJennyson and Mackenzie McNurseasaurus are BOTH overweight.

BOTH BOTH
SAME-SAME (if you're military)

You keep asserting that Mackenzie is hotter, but you haven't advanced the mythos to support that claim.

 

[deleted109597]

I would tend to argue that it's the ones that put 35 different acronyms after their names that are the worst.
If you have to tell people that you're someone, you aren't really anyone.

 

[sylvanthus]

I recently had an old dude come in for “syncope for 45 min” at the opera, sent in by his cardiologist......... he fell asleep.....at the opera.....

Also had someone come in sent by their naturopathic primary doc for LFT check as they went binge drinking and had been placed on fluconazole for “systemic hives”.

I gave her zofran, po challenged her and sent her home. Told her its dangerous to be taking antimicrobials from a naturopath for nonexistent diagnoses. Queue pt complaint to hospital administration.

Im starting to become that doc I hated as a resident. You want pain meds? Fuk it, you got it, I dont want to deal with pt complaints and admin. You want an unncessary CT? Sure! Useless xr? Yup! Pcp send you in for xyz unnecessary test? Im just gonna order it as pt expects it.

Call me the fukin candyman. Ive got a wife and kids to support, I dont want the headache of pt complaints and hospital admin. God I hate myself.

 

[TheSingularity]

Knew a person in residency who married a naturopath. Just don't see how I could personally marry someone when I didn't respect their job.

I recently had an old dude come in for “syncope for 45 min” at the opera, sent in by his cardiologist......... he fell asleep.....at the opera.....

Also had someone come in sent by their naturopathic primary doc for LFT check as they went binge drinking and had been placed on fluconazole for “systemic hives”.

I gave her zofran, po challenged her and sent her home. Told her its dangerous to be taking antimicrobials from a naturopath for nonexistent diagnoses. Queue pt complaint to hospital administration.

Im starting to become that doc I hated as a resident. You want pain meds? Fuk it, you got it, I dont want to deal with pt complaints and admin. You want an unncessary CT? Sure! Useless xr? Yup! Pcp send you in for xyz unnecessary test? Im just gonna order it as pt expects it.

Call me the fukin candyman. Ive got a wife and kids to support, I dont want the headache of pt complaints and hospital admin. God I hate myself.

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[SamtheWise]

Im starting to become that doc I hated as a resident. You want pain meds? Fuk it, you got it, I dont want to deal with pt complaints and admin. You want an unncessary CT? Sure! Useless xr? Yup! Pcp send you in for xyz unnecessary test? Im just gonna order it as pt expects it.

Call me the fukin candyman. Ive got a wife and kids to support, I dont want the headache of pt complaints and hospital admin. God I hate myself.

I'm trying to maximize both my length of stay and patient satisfaction metrics.

Healthy 25 year old with 4 days of cough congestion headache myalgias chest pain nausea diarrhea vomiting with normal vital signs, time to engage in some shared decision making.

'Oh my gosh your cough sounds so horrible I'm so worried about you we need to check a chest xray STAT you definitely did the right thing coming to the ED at 3a and waiting in the waiting room for 4 hours. So it's up to you, we can check a chest XR and if it's normal you don't have pneumonia and you don't need any prescriptions, or if you want we can forego the chest XR and just treat you with a Z-pack and give you scripts for percocets for your maylgias, codeine containing cough syrup for your cough, and oxycodone for breakthrough pain when the percocet doesn't work. And please don't forget to fill out your patient satisfaction survey'

 

[sylvanthus]

I'm trying to maximize both my length of stay and patient satisfaction metrics.

Healthy 25 year old with 4 days of cough congestion headache myalgias chest pain nausea diarrhea vomiting with normal vital signs, time to engage in some shared decision making.

'Oh my gosh your cough sounds so horrible I'm so worried about you we need to check a chest xray STAT you definitely did the right thing coming to the ED at 3a and waiting in the waiting room for 4 hours. So it's up to you, we can check a chest XR and if it's normal you don't have pneumonia and you don't need any prescriptions, or if you want we can forego the chest XR and just treat you with a Z-pack and give you scripts for percocets for your maylgias, codeine containing cough syrup for your cough, and oxycodone for breakthrough pain when the percocet doesn't work. And please don't forget to fill out your patient satisfaction survey'

Ive started making sure no matter how stupid the complaint I send them home with something. Congestion? You get a nasal spray script, sore throat? Cepachol. Backpain? Lidoderm patch and yup prob a narcotic because im done fighting. Ive tried the reassurance route, take over the counters motrin tylenol erc, but the public in general wants something from us and wont just take it in themselves to fix their issue. Script for motion 800mg when you could just buy that **** over the counter? Fuk why not. Here ya go.

 

[SamtheWise]

Ive started making sure no matter how stupid the complaint I send them home with something. Congestion? You get a nasal spray script, sore throat? Cepachol. Backpain? Lidoderm patch and yup prob a narcotic because im done fighting. Ive tried the reassurance route, take over the counters motrin tylenol erc, but the public in general wants something from us and wont just take it in themselves to fix their issue. Script for motion 800mg when you could just buy that **** over the counter? Fuk why not. Here ya go.

All joking aside that is so true, America has decided that we prioritize patient satisfaction over value based care and patient outcomes, so I guess here's your Rx for cough syrup you can buy over the counter and 800 mg ibuprofen and good news! your unnecessary chest XR is negative, but still here's your azithromycin.

 

[GeneralVeers]

All joking aside that is so true, America has decided that we prioritize patient satisfaction over value based care and patient outcomes, so I guess here's your Rx for cough syrup you can buy over the counter and 800 mg ibuprofen and good news! your unnecessary chest XR is negative, but still here's your azithromycin.

I just tell them "I'm going to write you for REALLY STRONG _____________" where blank is cough medicine, anti-inflammatory, hydrocortisone cream, etc. It usually gets them out out the door without complaints.

 

[TheSingularity]

Interestingly the huge patient dissatisfaction blow ups where I thought for sure I would hear about them from admin....I didn't.

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[deleted836128]

Ive started making sure no matter how stupid the complaint I send them home with something. Congestion? You get a nasal spray script, sore throat? Cepachol. Backpain? Lidoderm patch and yup prob a narcotic because im done fighting. Ive tried the reassurance route, take over the counters motrin tylenol erc, but the public in general wants something from us and wont just take it in themselves to fix their issue. Script for motion 800mg when you could just buy that **** over the counter? Fuk why not. Here ya go.

OMG... I know. I know.

I send patients home with diclofenac tablets or gel all the time. “It’s a prescription strength anti-inflammatory... don’t take it with ibuprofen or naproxen because it’s super strong.” It’s their “prize” when I know they’ll be pissed if they get send home with nothing (or worse, a prescription for ibuprofen). When people complain it’s “just an NSAID like ibuprofen” I just tell them “I find it’s much stronger. Patients love it, and plus, it lasts for twelve hours...”

For sore throats... “I’ve given you dexamethasone here in the ER! What’s great is that this lasts for a few days so YOU DON’T EVEN HAVE TO FILL A PRESCRIPTION!” I say this with a look of satisfaction on my face like I’ve done something novel and the patient thinks I’ve helped save them from having to stop at the pharmacy.

My favorite is when you have a baby or toddler with the sniffles and a fever, and you order an obligatory chest x-ray and flu swab, and everything is negative, and the parents are ASTOUNDED when you say “she has a URI. A virus.” They then need to be told what to do (fluids, humidifier, ibuprofen at home) and you can see their faces fall as you say “because it’s viral no antibiotics are needed.” Those patients get sent home with Little Noses saline nasal drops. Wish I was kidding. God...

By the way I had a mom bring in her toddler for the sniffles and she mentioned she had already taken Little Johnny to the ER downtown that morning. I asked why she brought the kid back into the ER and she said, “I want answers. They said he had a cold caused by a virus. But I want to know which virus.”

 

[deleted109597]

Knew a person in residency who married a naturopath. Just don't see how I could personally marry someone when I didn't respect their job.

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I know multiple doctors married to chiropractors.

 

[pkwraith]

OMG... I know. I know.

I send patients home with diclofenac tablets or gel all the time. “It’s a prescription strength anti-inflammatory... don’t take it with ibuprofen or naproxen because it’s super strong.” It’s their “prize” when I know they’ll be pissed if they get send home with nothing (or worse, a prescription for ibuprofen). When people complain it’s “just an NSAID like ibuprofen” I just tell them “I find it’s much stronger. Patients love it, and plus, it lasts for twelve hours...”

For sore throats... “I’ve given you dexamethasone here in the ER! What’s great is that this lasts for a few days so YOU DON’T EVEN HAVE TO FILL A PRESCRIPTION!” I say this with a look of satisfaction on my face like I’ve done something novel and the patient thinks I’ve helped save them from having to stop at the pharmacy.

My favorite is when you have a baby or toddler with the sniffles and a fever, and you order an obligatory chest x-ray and flu swab, and everything is negative, and the parents are ASTOUNDED when you say “she has a URI. A virus.” They then need to be told what to do (fluids, humidifier, ibuprofen at home) and you can see their faces fall as you say “because it’s viral no antibiotics are needed.” Those patients get sent home with Little Noses saline nasal drops. Wish I was kidding. God...

By the way I had a mom bring in her toddler for the sniffles and she mentioned she had already taken Little Johnny to the ER downtown that morning. I asked why she brought the kid back into the ER and she said, “I want answers. They said he had a cold caused by a virus. But I want to know which virus.”

Children are where I draw the line at therapeutic radiation. If I don't think they need an XR, they don't get it, and the vast majority of parents seem to get it.

 

[BoardingDoc]

Backpain? Lidoderm patch and yup prob a narcotic because im done fighting.

I'm also a fan of the ED goodie bag, but I hope you're not routinely giving narcotics for back pain as that's just admitting to practicing objectively bad medicine out of laziness.

 

[CajunMedic]

By the way I had a mom bring in her toddler for the sniffles and she mentioned she had already taken Little Johnny to the ER downtown that morning. I asked why she brought the kid back into the ER and she said, “I want answers. They said he had a cold caused by a virus. But I want to know which virus.”

Sure, I’ll be glad to run the viral panel. But, be forewarned:

1. It’s gonna run you about 2 grand
2. It takes about 3 hours to come back. Gets sent across town to the main campus lab to be run
3. It will change absolutely nothing about your care



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[VA Hopeful Dr]

I'm also a fan of the ED goodie bag, but I hope you're not routinely giving narcotics for back pain as that's just admitting to practicing objectively bad medicine out of laziness.

It's not laziness, it's being burnt out arguing with patients and dealing with complaints.

 

[BoardingDoc]

It's not laziness, it's being burnt out arguing with patients and dealing with complaints.

We're splitting hairs. The statement is "I don't want to do x for [reason] and so I'm going to do something which is bad medicine and potentially harmful for the patient because it makes my life easier." I'd call that laziness. Others may disagree.

Moreover, I completely understand the feeling that makes someone do this. I, and I suspect many others here have certainly been in a position when you just say "**** it, give them what they want." I understand that. If you are routinely doing this, I think you need to reevaluate your career because your burnout is starting to harm other people.

 

[SamtheWise]

My favorite is when you have a baby or toddler with the sniffles and a fever, and you order an obligatory chest x-ray and flu swab, and everything is negative,

If you are routinely ordering an 'obligatory' chest xr on uncomplicated URIs in children, I would urge you to do some further reading on the topic, including AAP bronchiolitis guidelines and the choosing wisely campaign. It's not the radiation that hurts the kid, it's the 'obligatory' antibiotics that do when the read of 'atalectasis vs early developing infection' comes back. The american academy of pediatrics takes a pretty hard line stance on chest XRs in kids because it leads to more unnecessary antibiotics and resultant antibiotic resistant bugs and medication related adverse events.

 

[thegenius]

All joking aside that is so true, America has decided that we prioritize patient satisfaction over value based care and patient outcomes, so I guess here's your Rx for cough syrup you can buy over the counter and 800 mg ibuprofen and good news! your unnecessary chest XR is negative, but still here's your azithromycin.

I don't think patient satisfaction is a terrible thing......IF THE PATIENT PAYS FOR THE SERVICE.

You want to be satisfied when you buy a car. You want to be satisfied when you need a lawyer.

But health care is a f***ing entitlement in the US and people want low taxes, MRI's all the time, and a f***ing antibiotic drip going in their arm 24/7 in their home.

 

[thegenius]

If you are routinely ordering an 'obligatory' chest xr on uncomplicated URIs in children, I would urge you to do some further reading on the topic, including AAP bronchiolitis guidelines and the choosing wisely campaign. It's not the radiation that hurts the kid, it's the 'obligatory' antibiotics that do when the read of 'atalectasis vs early developing infection' comes back. The american academy of pediatrics takes a pretty hard line stance on chest XRs in kids because it leads to more unnecessary antibiotics and resultant antibiotic resistant bugs and medication related adverse events.

We all know this is true. Consider these two scenarios:

Frantic mom brings in their snotty nosed 3 yr kid with a fever of 101.4 at 1:35 AM. They wait 1 hour to be seen. The kid is running around the room playing. Mom is SO SCARED about the fever.

The kid needs nothing. Doesn't even need Tylenol. He needs Kleenex.

Scenario 1: You try to explain to frantic Mom why he doesn't need anything. You are in the room for 15 minutes because mom is so scared, and she is saying repeatedly "you are going to do nothing about this?!?!?!" You spend a god-awful amount of time trying to reassure them. 10% chance you will get a bad report from Mom and Admin will talk to you.

Scenario 2: You are in the room for 1 minute. You tell them if CXR is +, they get Abx, if negative, you need Kleenex". Now you know there is a 1/500 chance of CXR + for true lobar pneumonia, and maybe 1/20 chance of reading "atelectasis vs early infiltrate." And you know you don't act on all of those rads hedges either. So the odds are pretty low, maybe 1/40, that you are going to be discharging that kid with Abx. So...Mom and pt leave much earlier with a very low chance of getting Abx. There is a 0.1% chance you will get a bad report from Mom.