@!!#$%*$#

[docB]

55 yo M, morbidly obese sent to ER by clinic in the next building for "an obstruction." Per secretary sending doc didn't want to talk to me because "It's all self explanatory. I'm sending X-rays and a note." I knew what it was before it hit the door. Another PMD sending a patient with a fecal impaction just so he doesn't have to do a rectal.

I'm so sick of these jerks dumping patients into the ED so I can disimpact them and shoot in a couple of Fleets. The patients hate it too. "Why did I have to come over here just for that?" they always ask. I'm so bitter now I just tell them. "Your doctor is too lazy to do it and he didn't want to get his hands dirty."

On today's who came over with a note that said "ER to eval and treat." I almost walked over to the office with the commode pail full of s--t and put in on the PMD's desk. "Here's that work up you wanted a--h---."

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[gman33]

I love that you are just telling the patients the truth.

 

[EctopicFetus]

I love that you are just telling the patients the truth.

Doesnt happen a ton here but we get dumps from urgent care. I just tell the patients the truth as well. Some of those people who work in the UC must have never gone to PA or med school.

 

[GeneralVeers]

I tell them the truth when the worthless urgent care docs dump a simple lac, I&D or ankle "high blood pressure" patient on the ER. If they are that stupid and lazy that they can't take care of some simple things, then they need to be called out. I am more careful criticizing PMDs who are often politically connected at the hospital.

 

[deleted109597]

I tell them the truth when the worthless urgent care docs dump a simple lac, I&D or ankle "high blood pressure" patient on the ER. If they are that stupid and lazy that they can't take care of some simple things, then they need to be called out. I am more careful criticizing PMDs who are often politically connected at the hospital.

Sadly, I agree. The PMDs can criticize us day and night for each and everything we do, but if we say they are being lazy, or worse, practicing bad medicine, it comes back to bite us in the ass.

 

[beanbean]

I don't have too many problems with PMDs sending patients inappropriately. Urgent care centers are another matter. Worst one in recent memory was a kid sent from clinic to our ED/Urgent care for suture removal because she was 3 years old and "Needed to be sedated" for removal of 3 sutures from her chin. Seriously! The child didn't need to be sedated to have the sutures put in and you think she needs conscious sedation to have them taken out.

Nursing homes are a pet peeve of mine especially the ridiculous stuff they send us on Friday evenings. Last one was a gentleman who fell several days earlier and had been treated and admitted at our facility. He was discharged with a wrist fracture that was in an appropriate cast. Sent to the ED at 7:30pm on a Friday for his follow-up ortho consult as no one had called during the week to arrange his follow-up. It actually worked out well because the lovely man was also hypotensive and uroseptic; a fact which had gone unnoticed by the SNF staff.

 

[GeneralVeers]

The worst ones are the UC peds transfers. I was working at one of our two hospitals that DOES NOT HAVE INPATIENT Peds. Got a call from the UC that they were sending a 3 year old for "abdominal pain". When I advised the doc that we didn't have peds and that he should send them to a hospital with peds, he stated that the kid probably wasn't sick and could probably go home after some tests.

*****S!

 

[8654Marine]

As a corollary, I've noticed a trend since our hospital went the hospitalist route: the PMD office sending folks to the ED to be "checked out and admitted", often for the same conditions that the PMD refused to admit prior to hospitalists. The presenting complaint is "I'm here to be admitted."

Sometimes I'll call the primary to ask if they called the hospitalist or surgeon and, seriously, I'll get the reply: " I don't know how".

 

[TrumpetDoc]

I agree!
PCPs. Docs who acually know their pts! I love taking care of them!
I can get info, and follow up, and if they are really worried I can talk with them and I have no problem delaying with those pts...in fact I LOVE it.
Dumpy disimpaction excluded

Having good follow up is worth it's weight in (insert rare precious metal here)!



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[Birdstrike]

.

 

[xaelia]

Now, I have sympathy for the PMD - their lives suck.

No sympathy for the UC guys.

 

[CraftyMed]

One of my favorites:

I called a NH to give the staff the results from a sacral decubitus wound culture that was done a few days earlier. After being transferred no less than 5 times, I finally found a staff member who acknowledged that the patient was actually a resident of the NH. I relayed her the information and she said that she was writing it in his chart.

....ONE HOUR LATER....

The patient shows up in my ED! The transport crew said he was there for "positive cultures." The patient is demented, the wound has obviously been there for several weeks, and he was already on antibiotics. I did take a look at the wound and it looked great. I checked in the computer system and the patient already had his follow up appt scheduled with the Surgery clinic. Done.

I told the transport crew to wait 5 minutes, got his discharge paperwork together, and promptly sent him back to his NH. Of course, when I tried to be polite and call the NH to tell them that he was coming back, I again was transferred 4 or 5 times, and then got "Oh, he's not a resident here. He was sent to the hospital for positive cultures." AARRRGGGHHHH!!!

 

[EctopicFetus]

The frustration is undoubtedly there. On the flip side this pays our bills. We have a UC doc we nicknamed danger dan.

I dont mind the transfers so much.. It does drive me crazy.. what is my pet peeve is when they order a bunch of tests and then send them (knowing they would send them anyhow). I assume this is purely to make money which is a pet peeve of mine.

 

[EvoDevo]

What gets me is the elderly patient sent for "Altered Mental Status" and "aggression" who clearly is neither but the NH refuses to take them back. Grrr....

 

[GeneralVeers]

What gets me is the elderly patient sent for "Altered Mental Status" and "aggression" who clearly is neither but the NH refuses to take them back. Grrr....

I don't mind when they have a troponin done on an elderly patient. It means no work for me. Elderly, with chest pain and negative troponin? Admitted! Done! Easy Level 5 visit for me!

What I hate is when they get a d-dimer on a "cough" and then send them in for rule-out PE. Why they get d-dimers when there are no risk factors for PE is beyond me.

 

[TrumpetDoc]

GV
They do have what appears to be the biggest RF for PE... Lungs!


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[SoCuteMD]

.

 

[docB]

I don't mind when they have a troponin done on an elderly patient. It means no work for me. Elderly, with chest pain and negative troponin? Admitted! Done! Easy Level 5 visit for me!

What I hate is when they get a d-dimer on a "cough" and then send them in for rule-out PE. Why they get d-dimers when there are no risk factors for PE is beyond me.

Had a patient sent by a large, multi site clinic (Veers knows which one I mean) for a VQ scan. This was odd since these clinics have CT and can do PE studies. Turns out the pt presented to them for chronic back pain and is on Coumadin for AF. I am convinced that they ACCIDENTALLY ordered a DDimer instead of an INR (as they never checked the INR). When the patient, who had no respiratory or breathing complaints and turned out to have an INR of 3 had a slightly positive DDimer and a slightly elevated creatinine precluding CT...

You guessed it... transfer to ER for VQ.

 

[southerndoc]

Had a patient sent by a large, multi site clinic (Veers knows which one I mean) for a VQ scan. This was odd since these clinics have CT and can do PE studies. Turns out the pt presented to them for chronic back pain and is on Coumadin for AF. I am convinced that they ACCIDENTALLY ordered a DDimer instead of an INR (as they never checked the INR). When the patient, who had no respiratory or breathing complaints and turned out to have an INR of 3 had a slightly positive DDimer and a slightly elevated creatinine precluding CT...

You guessed it... transfer to ER for VQ.

I'm assuming you just discharged the patient? If they're asymptomatic with an elevated d-dimer, then I would just discharge.

I see a lot of "referrals" for hypertension. Anything form 160-200. If they're asymptomatic, I just write a script and send them home.

 

[la gringa]

Had an NP send in a healthy young woman on BCP's who had flown from Memphis to DC w/ very musculoskeletal sounding CP. I had no problem doing a dimer, but when I called her back to tell her it was negative (per her written request, at a hospital where those sorts of things were routine and expected).... she argued with me that the pt needed a CT, even called a cardiologist who will never turn down a consult to see the patient and debunk everything I'd said b/c he didn't want to lose future consults. i wanted to throw the phone and bash my head against the wall.

have also seen the ED referral for disimpaction... i about saw red over that one the first time it happened. my finger, gloves, and lube are just as good as that PCP's!!!

 

[GeneralVeers]

I'm assuming you just discharged the patient? If they're asymptomatic with an elevated d-dimer, then I would just discharge.

I see a lot of "referrals" for hypertension. Anything form 160-200. If they're asymptomatic, I just write a script and send them home.

The problem is that those asymptomatic hypertension patients think they are dying. They are told be the PCP or UC that they must go IMMEDIATELY to the ER. It takes a good 10 minutes of explanation to get them to calm down enough to go home.

 

[la gringa]

The problem is that those asymptomatic hypertension patients think they are dying. They are told be the PCP or UC that they must go IMMEDIATELY to the ER. It takes a good 10 minutes of explanation to get them to calm down enough to go home.

agree... i wish they'd get so excited about their primary care f/u and filling their rx's!!! but there's no immediate gratification there!

actually though, when i was a resident in big city county hospital, we picked up a lot of crazy crap in people sent in for their BP... usually renal failure or CHF. really haven't seen that in the community hospital world, now in 3 sites - big city upper class hospital, big city large suburb upper middle class hospital, and now medium city middle class hospital.... all of course, with your mix in of the various ED denizens. when i first got out of residency i worked it up a bit more, but now stick to a BMP (almost always faster than a UA b/c the pts never pee fast enough) if i'm worried (like, no PCP for a while), and nothing if i'm not.

 

[docB]

I'm assuming you just discharged the patient? If they're asymptomatic with an elevated d-dimer, then I would just discharge.

I see a lot of "referrals" for hypertension. Anything form 160-200. If they're asymptomatic, I just write a script and send them home.

I didn't send her home because her back pain (the chief complaint for her QC visit in the first place) was "too bad." Her HMO's hospitalist came and sent her to a rehab unit. I didn't do anything with the DDimer and neither did he.

The problem is that those asymptomatic hypertension patients think they are dying. They are told be the PCP or UC that they must go IMMEDIATELY to the ER.

"Or you'll have a stroke!"

I had a PMD who called to send me an asymptomatic HTN. When I asked him why he said "I don't want him to stroke out in my office." He complained to administration that I was rude.

It takes a good 10 minutes of explanation to get them to calm down enough to go home.

And then 10 minutes of explaining to the nurse to get her to d/c the patient without the magic dose of clonidine.

 

[turkeyjerky]

Where does the whole clonidine thing come from anyway?

 

[BADMD]

Blood pressure high.

High blood pressure bad.

Clonidine make numbers in chart good.

Good chart good.

Clonidine good.

Me go club dinner now

 

[leviathan]

And then 10 minutes of esplaining to the nurse to get her to d/c the patient without the magic dose of clonidine.

I don't think these PMDs realize the irony that repeatedly giving short-acting PRN tx to these patients might actually INCREASE their stroke risk.

 

[southerndoc]

I was once having a really horrible day in the ER when a PMD sent a patient in for management of hypertension.

I just wrote bridging orders and told them to call the PMD when he gets upstairs. 30 minutes later I get a call wanting to know why I admitted the patient. I said "well you sent them here for management, so I thought you wanted them admitted since you didn't call me." He said he would've just managed it in the office if he knew I was going to admit it. That confused me. So he can manage it in the office, except if he doesn't want to do it, by which he just sends the guy to the ER but doesn't want him admitted?

Haven't seen anymore hypertensive patients being referred to the ER from this particular PMD.

 

[Daiphon]

Blood pressure high.

High blood pressure bad.

Clonidine make numbers in chart good.

Good chart good.

Clonidine good.

Me go club dinner now

Hahahaha!

Had the exact verbatim conversation with an intern today... Except I went to club the coffee machine.

 

[docB]

Blood pressure high.

High blood pressure bad.

Clonidine make numbers in chart good.

Good chart good.

Clonidine good.

Me go club dinner now

This.

I was once having a really horrible day in the ER when a PMD sent a patient in for management of hypertension.

I just wrote bridging orders and told them to call the PMD when he gets upstairs. 30 minutes later I get a call wanting to know why I admitted the patient. I said "well you sent them here for management, so I thought you wanted them admitted since you didn't call me." He said he would've just managed it in the office if he knew I was going to admit it. That confused me. So he can manage it in the office, except if he doesn't want to do it, by which he just sends the guy to the ER but doesn't want him admitted?

Haven't seen anymore hypertensive patients being referred to the ER from this particular PMD.

That episode goes right to the crux of this whole thread. It's exactly the same as with the enema. It could be managed in the office but they don't WANT to. So they dump it in the ER to get someone else to deal with it and then they get pissy if boomerangs on them as an admit.

 

[GeneralVeers]

Had a great one last night. 80 year old bed-bound patient with prior CVAs had 48 hours of subjective "weakness" and difficulty swallowing so her primary sent her in for eval. She had 24-hour home care already set up.

I checked her out and nothing acute, no acute CVA and she drank several different liquids without difficulty. I was about to discharge her back home and her primary called me and wanted her admitted. I explained to her PMD that she had nothing acute, was swallowing fine and there was no reason to admit her to the hospital. The PMD said "Can't you just keep her overnight for a swallow study?" I replied that a swallow study is usually outpatient. "But she's so hard to transport from her home to anything!" The PMD whined. I again tried to convince her the patient could go home. Ultimately I ended up admitting the patient to avoid a fight with medical staff.

Also please note my hospital is routinely holding 20 patients in 30 beds and we don't have anywhere to put this lady who "just needs a swallow study". What a waste.