Don?t come to the ER if?

[Spinach Dip]

Don't come to the ER if your chief complaint is: "I was just at that other ER across town and they wouldn't do anything for me!"

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[Evisju7]

My favorite fallacy of all, the contrarian:

I'm trying to write something in response, but I'm completely blank-minded. You're meme is right, and I agree. I always have.

 

[TooMuchResearch]

You're welcome in the thread.

Just be open to learn.

I was once a lot like you. I really, really, was. Hate to admit it. Self-assured pre-med with a really good GPA and the idea that there's nothing that I can't master quickly (!) because it was easy to ace that cell-bio final after 2-nights of cramming and even with a moderate hangover on teh (sic) day-off. Therefore, my opinion is more-than-already-validated.

I made that mistake. Several times. And then some more.

Now: I know... what I don't know. And I know enough, to listen up.

Dude, get out of my head!

Sorry for continuation of derailment.

 

[shopsteward]

I clicked on this topic thinking Doc B was back on the boards...

 

[Birdstrike]

Don't bring your 8 month old in for "body bumps" that turn out to be a singular 3x3mm wart on the foot that is entirely non painful.

Why not? Easy work. Easy money.

Don't bring your 6 month old in for non traumatic "lower back pain". I don't even know how to begin retelling how the mother decided that her infant had lower back pain.

The infant probably did have traumatic back pain, and the person who caused it had no problem knowing it was there.

 

[Birdstrike]

Don't come to the ER if your chief complaint is: "I was just at that other ER across town and they wouldn't do anything for me!"

Again. Not sick. Determine patient agenda. Address concern. Next case. Easy money.

 

[Birdstrike]

Don't check in to the ER because your wife thinks she gave you one extra pain pill, then called you in the waiting room to let you know that you actually got the right dose. It's been two hours, you are alert, oriented, not sleepy at all, and breathing just fine.

Sorry, that's my only ridiculous one for today. The other 15 were legit.

Totally legit. Absolutely no reason this patient should not check into the ER. Following the law of the land: EMTALA. Easiest patient of your shift. Next shift, hope for 30 of these.

 

[Birdstrike]

I actually struggled a lot in highschool. I had to leave because of health issues and wasn't motivated to continue. Now, I do very well in school (college), but it took a huge amount of effort to get where I am.
I don't take any of it for granted. My grades are a reflection of overcoming (and still overcoming) struggles. Thankfully, because of what I've been through, I've learned a lot about "life". That's why it's almost painful to hear some of the people here talk about bums as if they're trash. I know some of the cases you see are ridiculous, users of the system. (I wish someone, not necessarily in healthcare, would ask why there is so many people doing this.. maybe there's a solution. Poor behavior is the result of some deeper flaw. Complaining about the behavior doesn't fix the problem. I am just as frustrated and complain too.. I'm a hypocrite.) But each person should be treated as an individual, not a member of a bad stereotype.


Wasn't I leaving!?

Don't worry about it. Stick around. Threads where it's a bunch of 10 yr attendings that are set in their ways are terrible, because no one ever changes their mind and there's never any real discussion. People get bent out of shape over the stuff I post, too. Some get bent out of shape over the stuff I don't post (like my deleted "." posts). It's all good.

 

[DocEspana]

Why not? Easy work. Easy money.

it was. I'll give you that. But almost all of the above are. The spirit of it is people who are misusing the $2,000 emergency triage. Not that we can't adopt an attidue of "look at the silver lining"

The infant probably did have traumatic back pain, and the person who caused it had no problem knowing it was there.

Nah. She Literally believed the baby had lower back pain because she cried more when laying face down rather than face up and the woman used her knowledge of her own lumbagos pain tendency to decide that lumbago was the only explanation.

 

[Birdstrike]

Now: I know... what I don't know. And I know enough, to listen up.

Ain't that the truth.

And when it really comes down to it, no one on this 7-billion-person sun-revolving circus knows a whole hell of a lot more, either. Some have a lot more money. Some have a lot more power. We're all glorified cavemen (sorry, and cave "women") with better toys.

Born the same. Die the same. Everything in between is show business.

 

[Birdstrike]

I clicked on this topic thinking Doc B was back on the boards...

Sorry. You've just got us.

 

[sum dude]

Daily. Every other patient uses that word. I'm not exaggerating.

Think about that.

When someone describes their abdominal pain as "excruciating", while busily texting back their (whoever) about their harrowing experience in the "ER!"... and you're the one trying to make sense of them while assuming all of the risk/responsibility in the situation...

... get back to me.

I have a new way to determine "excruciating" or "12/10 pain"...I grab an 18 g, stick them in the bottom of the foot. If they jump, pain is not 10/10, then ask again

 

[DocEspana]

I have a new way to determine "excruciating" or "12/10 pain"...I grab an 18 g, stick them in the bottom of the foot. If they jump, pain is not 10/10, then ask again

Not sure if serious or brilliant.

 

[Apollyon]

Some get bent out of shape over the stuff I don't post (like my deleted "." posts). It's all good.

Hey, I resemble that remark!

(Although, in abject honesty, to say I get "bent out of shape" might be overselling it.)

 

[tkim]

I have a new way to determine "excruciating" or "12/10 pain"...I grab an 18 g, stick them in the bottom of the foot. If they jump, pain is not 10/10, then ask again

I was in a section meeting, and I told my partners when I hear someone complaining of 12/10 pain, I usually correct them and say "You mean 10/10 - right? There is no twelve." and "10/10 pain is your arm on fire - does it feel like your arm is on fire - no, then what's your pain like?" They ribbed me about it for days. They would ask people when I was in earshot - "You have 10/10 pain - does it feel like your arm is on fire?" Bastards.

 

[DocEspana]

I go with 10/10 being a bear LITERALLY chewing on your arm right now. When they go "yup. 10/10" I repeat. A bear. Chewing. Just. Knawing. On your arm.

Usually gets them to a 9/10 between their rounds of candy crush.

 

[WilcoWorld]

The pain scale attempts to objectively measure an inherently subjective thing. Thus it is not just useless, it's nonsensical. Moreover, it has made taking a history more difficult. I want to know if your pain is crushing or tearing, worsening or improving. I don't need a number to know that it's unpleasant and unwanted. But, thanks to the pain scale, when I ask "What kind of pain is it?" or, the more open-ended "Tell me about your pain" most patients now respond "It's a 10" and then seem irritated that I keep asking about it.

Grrrr

 

[TrumpetDoc]

The pain scale attempts to objectively measure an inherently subjective thing. Thus it is not just useless, it's nonsensical. Moreover, it has made taking a history more difficult. I want to know if your pain is crushing or tearing, worsening or improving. I don't need a number to know that it's unpleasant and unwanted. But, thanks to the pain scale, when I ask "What kind of pain is it?" or, the more open-ended "Tell me about your pain" most patients now respond "It's a 10" and then seem irritated that I keep asking about it.

Grrrr

Exactly


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[Old_Mil]

He's this homeless guy who just really wants to live in the ER.

You have nocturnists where you work?

Sent from my Z10 using Tapatalk

 

[engineeredout]

You've got it all wrong Docb.

These are all easy level three E&Ms. That's how you should view them. These cases make your job easier. A shift with 40 straight, "Need Viagra refills" is the easiest paycheck you'll ever earn. You are bound by the full force of Federal law says to give every one of these a MSE. Good luck trying to get EMTALA over thrown or "educating America" to only use the ED like an ER doctor would. Every shift will have these patients. The mentality that these are somehow wrong headed, a thorn in your side or patients to be annoyed by is just begging for frustration. Make peace with the fact that these patients are the easy, low stress, low liability filler-cases between the "3-year-old accidentally run over by dad, must notify horrified frantic family, must take 5 minute vomit-cry break in bathroom" and "suicidal violent, psychotic murdering drunk/high spitter with spit net over head, blood spraying haldol/geodon/RSI-drugs won't stop him, will be psych hold in my hallway all night" patients.

You're looking at it all wrong. You should pray for a shift with 30 "need handicap sticker" patients in a row. All chip shot level 3's. Do you really want a shift with nothing but 100% unstable vitals petechial rash 3 yr old coding, MI stable now V-fibbing, kidney stone seemed simple now septic and can't get line, neighbor's pregnant wife checked in little tummy ache now pre-eclampsia seizing status can't get her stopped oops this sucks and is looking real real bad, finally an easy one febrile seizure looks bad now is shaken baby case get social services on the phone right lets call the chopper now before I lose it-type shifts?

Don't be a moth to the flame,

Only problem with this are those of us who do not get rewarded for RVUs (resident in my case). It unfortionately takes me just as long to document for these level four and five nothing patients as it does to documents my ICU patients

 

[deleted432032]

.

 

[Arcan57]

Only problem with this are those of us who do not get rewarded for RVUs (resident in my case). It unfortionately takes me just as long to document for these level four and five nothing patients as it does to documents my ICU patients

Just as an FYI. If it takes you as long to document on an ankle sprain as it does on a ICU player, you're doing it wrong.

 

[repititionition]

Just as an FYI. If it takes you as long to document on an ankle sprain as it does on a ICU player, you're doing it wrong.

Do not dismiss the possibility of a terrible EMR.

 

[Arcan57]

Do not dismiss the possibility of a terrible EMR.

Even with a terrible EMR, there's information in an ICU player that needs to be conveyed that doesn't in an ankle sprain. What do you use?

 

[Birdstrike]

Just as an FYI. If it takes you as long to document on an ankle sprain as it does on a ICU player, you're doing it wrong.

Agree. A unit player has lengthy charting requirements if for nothing else, medico-legal reasons. The billing part is easy: just document critical care time.

I don't care what EMR you've got, an ankle sprain should be quick. Getting you're level 3 documentation is very easy. It goes like this,

"Click, click, click, click, done."

If you're taking as long on each, my guess is that way too much is being documented on quickie ankle sprains.

 

[docB]

I clicked on this topic thinking Doc B was back on the boards...

I'm still here. I recert in Sept. so I'm just studying. I will say that trying to sit down and study is much harder now than it was 10 years ago. I think I've just lost the student's mentality and discipline. And my attention span is shorter than ever.

 

[Birdstrike]

I'm still here. I recert in Sept. so I'm just studying. .

That's what I should be doing. So far, stuck on MP3s in the car.

 

[scummie]

BV is not a reason to go to the ER, no matter how important your weekend camping trip was. Bringing said friends along to ED while you get worked up is probably not a good substitute either.

 

[Birdstrike]

BV is not a reason to go to the ER, no matter how important your weekend camping trip was. Bringing said friends along to ED while you get worked up is probably not a good substitute either.

I beg to differ. Those "said friends" lives have been greatly enhanced by your heroic efforts in identifying the problem, and prescribing flagyl before their 72 hour tent-sharing weekend. You've done good, Scummie.

 

[scummie]

I beg to differ. Those "said friends" lives have been greatly enhanced by your heroic efforts in identifying the problem, and prescribing flagyl before their 72 hour tent-sharing weekend. You've done good, Scummie.

I wouldn't have minded as much if she had just come right out and said she had discharge from the beginning. Instead, she presents with a URI, doesn't mention vaginal discharge at all to me or the resident. Attending is about to give her the OK to leave the ER and then she goes, "By the way....."

 

[Birdstrike]

I wouldn't have minded as much if she had just come right out and said she had discharge from the beginning. Instead, she presents with a URI, doesn't mention vaginal discharge at all to me or the resident. Attending is about to give her the OK to leave the ER and then she goes, "By the way....."

The dreaded,

"Oh, doc, b y t h e w a y . . ."

http://upload.wikimedia.org/wikiped...px-Paris_Tuileries_Garden_Facepalm_statue.jpg

 

[dukesbrew]

Don't come in if you won't let us do our jobs. Had a father bring in his 13ish month old daughter in because she had been spiking a fever. The minute I walk in he demands that I "figure this **** out, or else." Guy set off alarms in my head with his demeanor, wouldn't let his wife speak at all. He won't let me take down the diaper because "I'm a sicko" even after explaining why. I push for a chest x-ray and a UA but again he won't let me do it. I finally get him to allow me to do a 1 view CXR which I wanted mostly to see if there was signs of abuse. CXR comes back no alarming signs. Still want a UA but won't let me do it. I get the kid an appointment with their pediatrician for the next day and discharge them. He looks at me and asks "so what the hell did you even do for us?" I think if I was an attending I would sacrifice my PG score to tell him exactly what I thought.

 

[theseeker4]

Don't come in if you won't let us do our jobs. Had a father bring in his 13ish month old daughter in because she had been spiking a fever. The minute I walk in he demands that I "figure this **** out, or else." Guy set off alarms in my head with his demeanor, wouldn't let his wife speak at all. He won't let me take down the diaper because "I'm a sicko" even after explaining why. I push for a chest x-ray and a UA but again he won't let me do it. I finally get him to allow me to do a 1 view CXR which I wanted mostly to see if there was signs of abuse. CXR comes back no alarming signs. Still want a UA but won't let me do it. I get the kid an appointment with their pediatrician for the next day and discharge them. He looks at me and asks "so what the hell did you even do for us?" I think if I was an attending I would sacrifice my PG score to tell him exactly what I thought.

As a medical student who has not done more than shadow in the ED so far, at what point can/should you step in and begin a workup of a minor without the parents' consent, or hold the child against the patients' wills until legal/CPS/the courts can step in? Obviously I am a ways away from making this call myself, but was curious what the threshold is.....

 

[deleted547339]

As a medical student who has not done more than shadow in the ED so far, at what point can/should you step in and begin a workup of a minor without the parents' consent, or hold the child against the patients' wills until legal/CPS/the courts can step in? Obviously I am a ways away from making this call myself, but was curious what the threshold is.....

If you suspect abuse.

 

[theseeker4]

If you suspect abuse.

Physical abuse is pretty clear, but what about medical neglect, in preventing you from caring for a child by running the proper tests and administering the proper treatments?

 

[Arcan57]

Physical abuse is pretty clear, but what about medical neglect, in preventing you from caring for a child by running the proper tests and administering the proper treatments?

Depends on your perception of the acuity of the patient, faith in their availability to follow up, and willingness of security to fight parents if they try to leave with kid.

 

[future_dr_house]

This is a question of if the decision maker is mentally competent to make these decisions. They must not be intoxicated/impaired, not appearing to have an axis disorder that needs acute adjustment, or suspicion of physical abuse. If all you have is a suspicion you will need to massage the heck out of the room to do what you want or be willing to get a court order to do what you want.

 

[WilcoWorld]

I had an interesting case recently: 6+ month old presenting with febrile seizure. Totally unvaccinated as parents think they're harmful. Parents also refuse LP/bloodwork/IV. They agree to UA and you find a UTI. After tylenol the kid looks good, but you're still concerned because of immunization status.

What do you do?

 

[Cooperd0g]

I had an interesting case recently: 6+ month old presenting with febrile seizure. Totally unvaccinated as parents think they're harmful. Parents also refuse LP/bloodwork/IV. They agree to UA and you find a UTI. After tylenol the kid looks good, but you're still concerned because of immunization status.

What do you do?

Ask them why they bother coming to the hospital if they don't want medical treatment. Ask them what, exactly, are they here for. That's what I would want to do anyway.

 

[WilcoWorld]

Haha, sucker! See, this is where I give the useless answer of "move somewhere else (like Texas)!" <-- because "pick up and move" is a completely viable, simply executed maneuver!

Ask them why they bother coming to the hospital if they don't want medical treatment. Ask them what, exactly, are they here for. That's what I would want to do anyway.

See Apollyon - Cooperdog can give unhelpful advice too!

I keed, I keed.

 

[deuist]

I had an interesting case recently: 6+ month old presenting with febrile seizure. Totally unvaccinated as parents think they're harmful. Parents also refuse LP/bloodwork/IV. They agree to UA and you find a UTI. After tylenol the kid looks good, but you're still concerned because of immunization status.

What do you do?

Although, to be fair, most of what you've just suggested is not indicated in a patient with a simple febrile seizure. Even for circumcised males over the age of six months, a urinalysis is not required. If the child looks great in the emergency department and is acting at baseline per the parents, you can discharge home without any intervention.

 

[WilcoWorld]

Although, to be fair, most of what you've just suggested is not indicated in a patient with a simple febrile seizure. Even for circumcised males over the age of six months, a urinalysis is not required. If the child looks great in the emergency department and is acting at baseline per the parents, you can discharge home without any intervention.

I completely agree that a simple febrile seizure doesn't require an LP or bloodwork, and that the necessity of a UA is context-dependent (this was a female). However, I would argue that a totally unvaccinated 6 month old is not quite a simple febrile seizure.

 

[MalachiConstant]

Please don't come to the ED at 2AM to get checked out because you were watching an infomercial that caused you to be worried about low testosterone.

 

[EDMD4LIFE]

DON'T bring your healthy 5 year old to the ER because the mosquito bites he got last night itch.
DO get some DEET, calamine, and a clue. (And, no, I won't write a script for those!!)

 

[Perrin]

DON'T bring your healthy 5 year old to the ER because the mosquito bites he got last night itch.
DO get some DEET, calamine, and a clue. (And, no, I won't write a script for those!!)

Haha, I got a patient complaint for doing that at the peds ER. Told mom she shouldn't bring her kid in for bug bites at 3am and just get some OTC treatment from CVS.