Don't be a poopy head sign out doc

[DrQuinn]

just had a horrible sign out today.

No details.

I spent half my shift cleaning up mess.

Just dont' be a crappy sign out doc!

Q

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[Toohotinvegas33]

ok

 

[EctopicFetus]

We are working on this as an intern class as well. Some people get a bad rep because their sign out is crappy. I am surprised this happens at an attending level as well.

 

[Ceez]

I always sign out the DRE part of the physical exam. I've done plenty enough that there's no educational value for me at this point. I'm a kind soul, so I'll let someone else learn by doing.

 

[spyderdoc]

One good thing about my current job in the FFS world is that there is no sign out. One bad thing about this is that I can be at work for an hour or so after my shift ends, although it is a good time to get caught up on my e-charting. At Kaiser, we had sign out, and boy can your day be made horrible depending on who you followed....Yes, this does happen at the attg level as well...

 

[GeneralVeers]

I always sign out the DRE part of the physical exam. I've done plenty enough that there's no educational value for me at this point. I'm a kind soul, so I'll let someone else learn by doing.

Does anyone else think that the DRE is overused? I hate it when I've worked up a patient, and have the patient ready for dispo and the attending says: "What did the rectal exam show?"

Honestly, in 99% of cases it's not going to change the disposition or workup to stick a finger up the butt. Some attendings I know advocate DRE for every abdominal pain, and EVERY trauma.

What do you guys think are the REAL ED indications for DRE?

 

[Daiphon]

What do you guys think are the REAL ED indications for DRE?

1) c/o rectal bleed/gi bleed/butt problems (abscess, etc)
2) "i slipped and landed on a lightbulb, and it magically ended up in my butt"
3) drug-seeking narc heads/hypochondriacs

-t

(obviously kidding with #2 & 3... or am i? d=) )

 

[OB1🤙]

3) drug-seeking narc heads/hypochondriacs

A Foley is also clearly indicated for these patients.

 

[GeneralVeers]

A Foley is also clearly indicated for these patients.

If I don't like the nurse these patients also get fleets enema x 3.

 

[DrMom]

A Foley is also clearly indicated for these patients.

at my facility we find that the trifecta of DRE, foley, and NG tubes work well in discouraging drug-seeking behavior

 

[GeneralVeers]

at my facility we find that the trifecta of DRE, foley, and NG tubes work well in discouraging drug-seeking behavior

I find that the simple act of not feeding patients, will make the most difficult drug seekers leave. Everyone's gotta eat sometimes. They're entitled to a free medical screening under EMTALA, but no one said anything about a free BLT.

 

[DrMom]

no food is a given

also don't put them in a room with cable TV (we have lots of these lovely folks request to be moved to a room with a TV)

 

[GeneralVeers]

TV is a bad idea in the waiting rooms and in patient rooms. If they're well enough that they need to be entertained, they don't belong in the ED.

We should have a tiered service level. If you pay the extra $10, you get TV privileges, a free meal, and a massage from the EKG tech.

no food is a given

also don't put them in a room with cable TV (we have lots of these lovely folks request to be moved to a room with a TV)

 

[Flopotomist]

TV is a bad idea in the waiting rooms and in patient rooms. If they're well enough that they need to be entertained, they don't belong in the ED.

We should have a tiered service level. If you pay the extra $10, you get TV privileges, a free meal, and a massage from the EKG tech.

Hmm.. they SHOULD get a TV - but it should be stuck on a channel that gives health advice, diet information, job training resources, smoking cessation strategies etc. It should be on a mind-numbing loop. Of course, the channel can be changed if the ED visit bill is payed in full in advance.

 

[Daiphon]

at my facility we find that the trifecta of DRE, foley, and NG tubes work well in discouraging drug-seeking behavior

we also like having the med students/nursing students/phlebotomy trainees practice on 'em... many seekers tend to have 1-2 "good" veins, and don't want the young'uns wrecking them. d=)

-t

ps - on the floor, i knew of a surgeon who would order "daily dilating rectals" when on the GI service to facilitate expedient recovery (& discharge). ha!

 

[hyperbaric]

a massage from the EKG tech.

careful now, you are moving to my neck of the woods and i still prn as an EKG tech.

 

[beyond all hope]

Most of us have to give signout. Signout musts:

1) have a clear plan! Don't just say: check the labs. If the K is over 6, admit. If the troponin is positive, start heparin. If he's still tender after hydration -> CT scan. It's best if you have a clear dispo decision, especially with complicated abd pain cases, etc.

2) Do all the scutwork before signout. DREs, pelvics, calling the family, etc.

3) When you're taking signout, best to do face-to-face signout with the patients. I make the mistake not doing this sometime, and I have random people who I don't know but are my patients asking me questions. See their faces, even repeat important parts of the history and PE.

4) Beware double signouts. Some patients get bounced between two or three docs, residents and attendings. No one cares about a signout patient, they're just a burden, and bad things end up happening.

Where I work the overnight attending takes the entire 80K ED, so I get 30-40 patients signed out to be in various stages of dispo between 3-4 residents. Ouch! Signouts are ugly.

Beware and take care of your patients.

 

[Hayduke]

3) When you're taking signout, best to do face-to-face signout with the patients. I make the mistake not doing this sometime, and I have random people who I don't know but are my patients asking me questions. See their faces, even repeat important parts of the history and PE. .

Are you walking bed-to-bed w/ the oncoming attending when doing this, or is your facility one where from a central monitor you can sit and "eyeball" everyone across the room from where you are doing the deed?

Where I work the overnight attending takes the entire 80K ED, so I get 30-40 patients signed out to be in various stages of dispo between 3-4 residents. Ouch!

Wow! How long does this typically take? When oncoming, what percentage of these folks will you see prior to dispo? I guess the real question is, how far into a w/u is this entrusted to resident staff vs. you having to see? In your opinion, how late in a shift should an intern be picking up a new pt.?

As a hope-to-be intern, I appreciate the advice.

 

[The White Coat Investor]

We are working on this as an intern class as well. Some people get a bad rep because their sign out is crappy. I am surprised this happens at an attending level as well.

Yea, wait til you get a Frank sign-out!

 

[The White Coat Investor]

One good thing about my current job in the FFS world is that there is no sign out. One bad thing about this is that I can be at work for an hour or so after my shift ends, although it is a good time to get caught up on my e-charting. At Kaiser, we had sign out, and boy can your day be made horrible depending on who you followed....Yes, this does happen at the attg level as well...

No sign-out and you're only there an hour? How do you pull that off? I'm there an hour late WITH sign-out.

 

[ERMudPhud]

I've worked several places that practice minimal signouts. It works best when you have staggered coverage. Whenever possible we try to arrange it so you pick up no charts for the last hour of your shift. That gives you an hour to clean up your patients and finish your charts. Whoever is on with you has to work extra hard during your last hour but they will get the same deal at the end of their shift plus at the end of the hour they know your fresh replacement is coming on. One place I work has 4 docs and a PA or two on at peak times. That means you've got fresh meat coming on every few hours and several people to pick up the slack toward the end of your shift. Everywhere I've worked people have preferred this system. Sometimes you get an imaging study signed out to you but most cases the patients already have a clear disposition and are just waiting for a bed or for a test which won't change disposition. We average about <10% overtime over the course of the year so about 30 minutes beyond the end of your 8 hour shift. I much prefer this system.

 

[ERMudPhud]

Where I work the overnight attending takes the entire 80K ED, so I get 30-40 patients signed out to be in various stages of dispo between 3-4 residents. Ouch! Signouts are ugly.

The joys of academic EM. I work a lot of single coverage overnights in a >80K ED and rarely signout more than 10 patients. Of course without residents our turn around is much faster and my overnight shift overlaps by an hour with the first AM docs schedule and ends just as the second AM doc comes in so I have a chance to dispo many of my patients

 

[EctopicFetus]

Yea, wait til you get a Frank sign-out!

I havent had too many Tuesdays so I havent had this much. Then again working with him is always an experience. He is amazingly nice and smart but they dont call him the Tank for nothing.. (Old School reference)!!

 

[The White Coat Investor]

I havent had too many Tuesdays so I havent had this much. Then again working with him is always an experience. He is amazingly nice and smart but they dont call him the Tank for nothing.. (Old School reference)!!

Pelvics...rectals....histories....you never know what's left. I just planned on starting over with them.

 

[EctopicFetus]

Pelvics...rectals....histories....you never know what's left. I just planned on starting over with them.

ouch....

I had to do a pelvic with him on a 77 yr old obese lady... I lost my appetite for a week.

 

[MacGyver]

Some attendings I know advocate DRE for every abdominal pain, and EVERY trauma.

Yes I know and its stupid. My institution operates this way:

1) GSW to head? DRE
2) Burn to hand? DRE
3) PTX s/p blunt trauma? DRE
4) Attempted suicide by hanging? DRE

Its pretty ridiculous. Whats even worse is that the trauma team doesnt tell the patient they are about to get a rectal. They just flip him on the backboard, check the spine and immediately stick their finger in with no warning. And they wonder why the patients start punching people or rolling off the stretcher.

 

[gutonc]

Sounds like you're trauma team is using the DRE as a negative reinforcement tool. Going to be a dumba$$ and get shot/stabbed/punched/drunk-and-total-your-car? Then let's teach you a bit of a lesson w/ a FUTA.

 

[The White Coat Investor]

Its pretty ridiculous. Whats even worse is that the trauma team doesnt tell the patient they are about to get a rectal. They just flip him on the backboard, check the spine and immediately stick their finger in with no warning. And they wonder why the patients start punching people or rolling off the stretcher.

If they're sick enough to have 15 people waiting 20 minutes for them to roll in they're sick enough to endure an unnecessary rectal. If they don't need the rectal they probably didn't need that trauma team.

P.S. As the "airway guy" holding the head when you roll him you might want to mention the rectal at some point. It does cut down on the punching.

 

[The White Coat Investor]

I've worked several places that practice minimal signouts. It works best when you have staggered coverage. .

I have worked places with minimal sign-outs and staggered coverage and agree this works out well. I thought you were saying you NEVER signed someone out. The way some of our consultants are and the sheer length of time it takes to get a po contrast abdominal CT performed and read seem to make it impossible to always get out within an hour and never sign out a patient.

 

[bartleby]

Nothing helps a high utilizer realize it's time to go home better than a little benign neglect. Just behind dilaudid in popularity for ED patients is attention. Putting them in a quiet room far away from the desk and having ancillary staff avoid the room usually gets the point across.

I find that the simple act of not feeding patients, will make the most difficult drug seekers leave. Everyone's gotta eat sometimes. They're entitled to a free medical screening under EMTALA, but no one said anything about a free BLT.