MRI in the ER

[Dr. Ice]

So what exactly is the real reason ER docs don’t order MRIs of the spine if someone comes in with clear symptoms suggestive of an acute radiculopathy?

I’ve never been able to give patients a good answer.

Ducttape? Or anyone else who might have insight?

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[deleted875186]

I’m also curious as to the reasoning. I’m wondering if the MRI is actually staffed overnight or if they need to call in a tech to do the scan?

 

[RoloTomassi]

In my area, they do if it's emergent, like cauda, and the on-call will operate. Otherwise acute radic even with neuro deficits isn't emergent. MRI doesn't change management. Outpatient management. No need to hold up one of their bays waiting for an MRI only to DC home with spine referral regardless.

 

[lobelsteve]

I get them all the time by me. Radic and Fx. Expedites care greatly.

 

[Ferrismonk]

Probably a combination of limited MRI availability, long time for the scan compared to CT, and that an acute radic isn't a true emergency without cauda equina. Usually treated with steroids, pain control, and referral to pain or neurosurgery.

 

[Dr. Ice]

Yeah but then patient comes to us in severe pain, oral steroids didn’t work, and now I gotta tell them they have to do PT first 🤦🏽‍♂️

I have on many occasions made the patient encounter seem like their limb is gonna fall off at any second and still have gotten denials for MRI if patient hasn’t don’t PT.

I’m lucky to have an outpatient imaging facility offer cash mri for $300

 

[Status Sciaticus]

cant imagine how much an ER SOS MRI.... funded at the tax payers expense of course

 

[swamprat]

ER doctor here - well I am a pain doctor but am boarded EM.

Our job is rule out life threatening illness - that is pounded into our head from day 1 of residency.

Internal medicine differential for abd pain will be most likely to least likely based on whatever the symptoms are
Emergency medicine differential abd pain will be rule out AAA, appy etc - then if nothing else your diagnosis is "abdominal pain unspecified" FU with your doctor.

Unless we are concerned about cauda equina syndrome, epidural abscess/bleed or a few other things we don't order MRIs that can be done outpatient. Also MRI is limited availability as an aside and a lot of places don't have them or don't have 24.7 accesss.

 

[clubdeac]

ER doctor here - well I am a pain doctor but am boarded EM.

Our job is rule out life threatening illness - that is pounded into our head from day 1 of residency.

Internal medicine differential for abd pain will be most likely to least likely based on whatever the symptoms are
Emergency medicine differential abd pain will be rule out AAA, appy etc - then if nothing else your diagnosis is "abdominal pain unspecified" FU with your doctor.

Unless we are concerned about cauda equina syndrome, epidural abscess/bleed or a few other things we don't order MRIs that can be done outpatient. Also MRI is limited availability as an aside and a lot of places don't have them or don't have 24.7 accesss.

so our ER docs order lumbar and cervical CTs all the time but no MRIs. I still don't understand why if you're going to go ahead and order an imaging study of the spine why not just get one that can effectively r/o an epidural abscess and hematoma. I'm not entirely sure but I always thought a CT can miss these quite frequently

 

[jsaul]

Because mri techs aren't as prevalent as CT techs. They aren't enough to take call 24/7

 

[Dr. Ice]

So much of what we end up telling patients is bureaucratic. What’s right and what is reality are often so diagonally opposite.

If I’m trying to survive however, I’m probably gonna say the evil hospital and ER doc don’t care about your pain and don’t view it as “a true emergency” or “life threatening condition.” Just as they would say, “you need to immediately follow up with your pain doctor and they can take care of this right away.”

We all just pass it along and sell the blame.

 

[Welcome123]

So much of what we end up telling patients is bureaucratic. What’s right and what is reality are often so diagonally opposite.

If I’m trying to survive however, I’m probably gonna say the evil hospital and ER doc don’t care about your pain and don’t view it as “a true emergency” or “life threatening condition.” Just as they would say, “you need to immediately follow up with your pain doctor and they can take care of this right away.”

We all just pass it along and sell the blame.

There is much truth in that statement
Many patients may not have the intellectual capacity to understand it is the insurance company controlling care. The way insurmountable denials are worded it places blame on doctors for not demonstrating medical necessity according to variable and increasing stipulated criteria
Doctors love to blame other docs or pass responsibility. A combination of white knighting and the culture of criticism we all trained in perpetuate this.
My response to the patient when they ask why the previous doc didn’t get the MRI typically is “I can’t say why but this is what I want now. There is a good possibility that your insurance in the disguise of medical necessity but in truth for saving money may deny coverage of this test”

 

[Baron Samedi]

Because the ER's job isn't to expedite treatment.

 

[deleted131481]

I'm not an ER doc but I assume it's because CT scan is orders of magnitude simpler and easier to get done.

You could say the same thing for every headache that walks through the ED. Why not get an MRI instead of a CT scan? It's just not feasible.

 

[plasma.]

I often have to fight for an MRI even when I'm trying to rule out Cauda. "Did you speak to Spine yet?" When Spine invariably says why the hell are you calling me without an MRI. MRIs take longer to do, be read, less techs around and most importantly (possibly selfish) would not change my immediate management of the patient. If they have a high WBC, CRP, homeless and back pain - for sure I need to rule out a discitis. If its a radic, MRI proven or not, as long as no red flags, I'm still sending them home with some pain killers and having them follow up with their GP. We see 250 patients per day in our ER, you could argue many may end up getting MRIs in the outpatient setting, but doing them in the ER would bring the department to a standstill.

 

[Welcome123]

I often have to fight for an MRI even when I'm trying to rule out Cauda. "Did you speak to Spine yet?" When Spine invariably says why the hell are you calling me without an MRI. MRIs take longer to do, be read, less techs around and most importantly (possibly selfish) would not change my immediate management of the patient. If they have a high WBC, CRP, homeless and back pain - for sure I need to rule out a discitis. If its a radic, MRI proven or not, as long as no red flags, I'm still sending them home with some pain killers and having them follow up with their GP. We see 250 patients per day in our ER, you could argue many may end up getting MRIs in the outpatient setting, but doing them in the ER would bring the department to a standstill.

It may delay care by not having the MRI but think of all the increased profit the insurance companies will have. It really should be on the spine specialist to get the MRI. Usually, I will order the MRI before sending out to ortho but if I don’t they should still appreciate the referral

 

[au bon pain]

So what exactly is the real reason ER docs don’t order MRIs of the spine if someone comes in with clear symptoms suggestive of an acute radiculopathy?

I’ve never been able to give patients a good answer.

Ducttape? Or anyone else who might have insight?

If the patient has clear radicular symptoms, it's not an emergency. There may be the perception that "the ER does everything so why not this" but basically everything done in the ED is to rule out badness. Not to rule things in.

When a patient in the ER waits for a stat MRI to r/o cord compression (and in many ERs, that means fighting with the rads tech to bump a scheduled study so the process usually still takes several hours to actually have it completed and then another hour for the read), that takes up a spot that another patient in the waiting room could take and delays their care. Any ER doc with experience can tell you about patients who've coded/died in the ED waiting room while waiting to be seen. Perhaps in the best running ERs, the MR+read could be done in 1.5-3 hours but in the normal short-staffed ER it can take +5 hours. Which mean that ER bed is offline for other patients sitting in the waiting room or coming in by ambulance. Few things slow down an ER like ordering an MRI. Extrapolate that out to John Q Public hearing that an ER will do MRIs for non-emergent things and patient will start coming out of the woodwork to request them. Would bring the place to a grinding halt.

You're indeed lucky to have an outpt MRI center that will do it for $300. If I weren't in a CON state I'd have opened one up years ago for the exact reason you describe.

 

[MitchLevi]

Severe radic may be severe and result in gait/sleep dysfxn but it is still an outpt Dx. ED can give pain meds, Toradol, Medrol dose pack, etc...Pt should go home and be seen by his/her PCP or pain doctor outpt.

No ED MRI IMO.

 

[Ducttape]

1. CT is always available. even then, there may not be an indication for a CT scan.
2. MRI is not. MRI takes much longer to do, and even when MRI techs are available, the machine is not. i have had multiple patients have their "routine" MRI scheduled for 10 pm on Friday night because of lack of time slots.
3. in almost all cases, the MRI is not emergent. ER docs like the rest of us are encouraged not to get MRI scans for acute radic unless there are confounding factors such as cauda equina
4. the ER sees so many patients with back pain. not only from by themselves, but from PCPs and subspecialty docs requesting they go to the ER "so the ER can order an MRI". it is untenable to tie up hospital beds for hours on end on non-critical diagnoses.\
5. it pays to remember that a significant percentage of acute radics will spontaneously resolve.

long story short - the ER is there for acute issues. ER was developed as a triage facility, and while it has devolved to be a primary care office, it cannot accomodate for MRIs for back pain.

 

[Snowmen96]

2. MRI is not. MRI takes much longer to do, and even when MRI techs are available, the machine is not. i have had multiple patients have their "routine" MRI scheduled for 10 pm on Friday night because of lack of time slots.

MRI machines are actually used 24/7 where I am so patients can have their MRI in the middle of the night if they want (optional but allows you to have the exam sooner).

 

[Ducttape]

right. and each scan takes on average 45 minutes.
+10 minutes turnover time.

so 24 MRIs per day is probably max'ing out.

CT scan - 10 min to do the scan, same 10 min turnover. can do 3 CTs at the same time it takes to do 1 MRI.

 

[callmeanesthesia]

right. and each scan takes on average 45 minutes.
+10 minutes turnover time.

so 24 MRIs per day is probably max'ing out.

CT scan - 10 min to do the scan, same 10 min turnover. can do 3 CTs at the same time it takes to do 1 MRI.

single region spine MRI without contrast is about 15 minutes.

 

[MitchLevi]

single region spine MRI without contrast is about 15 minutes.

It is not.

 

[callmeanesthesia]

It is not.

Can personally verify it is, at least at my local imaging center. It was actually a little less than 15 minutes of scanning time.

 

[MitchLevi]

Can personally verify it is, at least at my local imaging center. It was actually a little less than 15 minutes of scanning time.

I can personally verify it isn't...There's more than scan time that must be accounted for.

 

[NJPAIN]

ER doctor here - well I am a pain doctor but am boarded EM.

Our job is rule out life threatening illness - that is pounded into our head from day 1 of residency.

Internal medicine differential for abd pain will be most likely to least likely based on whatever the symptoms are
Emergency medicine differential abd pain will be rule out AAA, appy etc - then if nothing else your diagnosis is "abdominal pain unspecified" FU with your doctor.

Unless we are concerned about cauda equina syndrome, epidural abscess/bleed or a few other things we don't order MRIs that can be done outpatient. Also MRI is limited availability as an aside and a lot of places don't have them or don't have 24.7 accesss.

I find this perspective very interesting. I trained ( in anesthesiology) in the days when ER medicine was in it’s infancy. I spent ALL NIGHT intubating patients in the ED and ICU. During my internship IM attendings and residents (including me) staffed the ED. At the time the expectation was to go somewhat beyond r/o imminent death. We had plenty of people abusing the ED as a clinic so I don’t think that has changed. My observation as both a physician and as a patient who has been in the ED is that the philosophy has changed to “ your life is not threatened, go home and follow-up with your PCP”. I’m not criticizing the change but I’m wondering what has driven it.

 

[RoloTomassi]

I’m not criticizing the change but I’m wondering what has driven it.

I think the growing number of uninsured showing up and ridiculous wait times

 

[deleted875186]

I think the growing number of uninsured showing up and ridiculous wait times

Absolutely, when I have an emergency and show up at the hosptial I’d prefer for there not to be a line of people with things that could be managed with a PCP sick visit clogging up the system.

 

[guytakingboards]

Radiologist here. As most people said, it comes down to finite resources.

-Finite scanner time: which may be a combination of "studies that can be done per X unit of time" as well as MRI technologist availability.
-Finite radiologist capacity: There's only a handful Dx's that merit getting stat MRI. Those get read. When I was in residency and a BS non-stat MRI for radic got done we let it sit on the list. There's plenty enough stat CT/US/PFs to get read. Beyond that, there's a good portion of radiologists who aren't comfortable doing MRI reads. I'm recently out of training (and happen to be a neurorad) but I wouldn't go read MR outside my subspecialty (MSK/body/etc) in the acute setting if i didn't have to.

 

[NJPAIN]

Radiologist here. As most people said, it comes down to finite resources.

-Finite scanner time: which may be a combination of "studies that can be done per X unit of time" as well as MRI technologist availability.
-Finite radiologist capacity: There's only a handful Dx's that merit getting stat MRI. Those get read. When I was in residency and a BS non-stat MRI for radic got done we let it sit on the list. There's plenty enough stat CT/US/PFs to get read. Beyond that, there's a good portion of radiologists who aren't comfortable doing MRI reads. I'm recently out of training (and happen to be a neurorad) but I wouldn't go read MR outside my subspecialty (MSK/body/etc) in the acute setting if i didn't have to.

Thanks for bringing in your perspective. Very helpful.

 

[deleted875186]

Radiologist here. As most people said, it comes down to finite resources.

-Finite scanner time: which may be a combination of "studies that can be done per X unit of time" as well as MRI technologist availability.
-Finite radiologist capacity: There's only a handful Dx's that merit getting stat MRI. Those get read. When I was in residency and a BS non-stat MRI for radic got done we let it sit on the list. There's plenty enough stat CT/US/PFs to get read. Beyond that, there's a good portion of radiologists who aren't comfortable doing MRI reads. I'm recently out of training (and happen to be a neurorad) but I wouldn't go read MR outside my subspecialty (MSK/body/etc) in the acute setting if i didn't have to.

This is definitely part of it, how long does it take to get a scan done, and a stat read from radiology, before you can actually decide what to do with the patient. Or is the stat MRI ever really going to change dispo unless there clinical cauda equine or weakness or something.

 

[swamprat]

I find this perspective very interesting. I trained ( in anesthesiology) in the days when ER medicine was in it’s infancy. I spent ALL NIGHT intubating patients in the ED and ICU. During my internship IM attendings and residents (including me) staffed the ED. At the time the expectation was to go somewhat beyond r/o imminent death. We had plenty of people abusing the ED as a clinic so I don’t think that has changed. My observation as both a physician and as a patient who has been in the ED is that the philosophy has changed to “ your life is not threatened, go home and follow-up with your PCP”. I’m not criticizing the change but I’m wondering what has driven it.

Well I will say EM is definitely its own specialty and staffing it with BE/BC EP rather than a potpourri of other docs is better for patient care. I don't think the critical care is the big thing - like you said you were intubating in the ED, ICU can, we can etc. I think we all are good at managing that initial critical illness in the first hour. I think its the undifferentiated patient circling the drain that you just don't know it yet is where our training shines. Rapid DDX prioritizing the life threatening illness and intervening immediately if necessary. I think these patients probably just went home and died prior to EM training. Most patient's that come in don't read the internal medicine textbook. To me it makes a lot of sense but I don't think I quite understood it before I did my training - maybe its just how many damn patients I've seen that I thought - meh probably not this but let me check and sure enough it was that diagnosis cause yeah all of medical school you are not taught to think that when when a patient comes in with a complaint.

 

[Ducttape]

I find this perspective very interesting. I trained ( in anesthesiology) in the days when ER medicine was in it’s infancy. I spent ALL NIGHT intubating patients in the ED and ICU. During my internship IM attendings and residents (including me) staffed the ED. At the time the expectation was to go somewhat beyond r/o imminent death. We had plenty of people abusing the ED as a clinic so I don’t think that has changed. My observation as both a physician and as a patient who has been in the ED is that the philosophy has changed to “ your life is not threatened, go home and follow-up with your PCP”. I’m not criticizing the change but I’m wondering what has driven it.

- overuse of the ER because lack of availability of primary care, or the cost of primary care.

- the US mores in requiring a quick fix to everything.

Well I will say EM is definitely its own specialty and staffing it with BE/BC EP rather than a potpourri of other docs is better for patient care. I don't think the critical care is the big thing - like you said you were intubating in the ED, ICU can, we can etc. I think we all are good at managing that initial critical illness in the first hour. I think its the undifferentiated patient circling the drain that you just don't know it yet is where our training shines. Rapid DDX prioritizing the life threatening illness and intervening immediately if necessary. I think these patients probably just went home and died prior to EM training. Most patient's that come in don't read the internal medicine textbook. To me it makes a lot of sense but I don't think I quite understood it before I did my training - maybe its just how many damn patients I've seen that I thought - meh probably not this but let me check and sure enough it was that diagnosis cause yeah all of medical school you are not taught to think that when when a patient comes in with a complaint.

there is a lot of this that is not true. maybe in hospitals that were smaller that utilized PCPs to fill shifts and did not have full time doctors in the ER...


as someone who worked in ER as a boarded internist, in a hospital that had a dedicated staff of doctors for the ER - some of whom had alternate board certification or were grandfathered in - the modus operandi previously was that patients that were not simple cut and dry cases were admitted to the hospital for full workups, and ER trained doctors are much more cavalier about discharging patients to follow up with their PCPs.


part of this is due to the increased volumes in the ER. without doubt, ER docs are better able to accommodate the flow and move patient care better than non-ER certified docs, especially compared to the pre ER board certification days of the 1990s.

 

[Vandalia]

I find this perspective very interesting. I trained ( in anesthesiology) in the days when ER medicine was in it’s infancy. I spent ALL NIGHT intubating patients in the ED and ICU. During my internship IM attendings and residents (including me) staffed the ED. At the time the expectation was to go somewhat beyond r/o imminent death. We had plenty of people abusing the ED as a clinic so I don’t think that has changed. My observation as both a physician and as a patient who has been in the ED is that the philosophy has changed to “ your life is not threatened, go home and follow-up with your PCP”. I’m not criticizing the change but I’m wondering what has driven it.

The difference is that people only went to the ED for emergencies. Or for things that immediately needed to be treated.

One can argue that most renal stones are not true medical emergencies, but having had a half-dozen, pain relief is definitely needed.

Outside of that, even up to the 90's people would patiently wait at home for their doctor to be available at 8am on Monday. In addition, physicians would diagnose and treat patients. I had a relative 20 years ago who was seen by her regular doctor and needed to be admitted; her primary care physician hand wrote the orders, put them in an envelope, and sent her to the hospital to the admissions desk completely bypassing the ED. Now at the first instance of a problem, she would have been sent to the ED for a workup and for likely admission to a hospitalist service.

Medicine has changed dramatically, and the ED population changed dramatically from the 70's to the 90's, and then from the 90's until today.

In the Air Force in the 80's, if someone came in with something stupid, the MOD (Medical Officer of the Day - the random physician assigned to cover "emergency" for the day) would leave them there to sit for 5-6 hours as punishment. Even until the 90's, the mystique of the "Emergency Room" scared many people away. That is most definitely no longer true. I blame the TV show.

 

[Baron Samedi]

One can argue that most renal stones are not true medical emergencies, but having had a half-dozen, pain relief is definitely needed.

😬

 

[Vandalia]

😬

One evening the nurses made up a sign “You must be in more pain than the doctor to be seen”

They didn’t have the guts to put it on the door, but it was appreciated.

 

[guytakingboards]

So what exactly is the real reason ER docs don’t order MRIs of the spine if someone comes in with clear symptoms suggestive of an acute radiculopathy?

I’ve never been able to give patients a good answer.

Ducttape? Or anyone else who might have insight?

Semi-redundant post, but short of cauda equina syndrome a CT of the lumbar spine is gonna be faster, (significantly) cheaper, and in many cases make the diagnosis anyway.

At least in younger patients without horrible multilevel degenerative disc disease, if you give me a history of "concern for right L4 radiculopathy", I'll spot the disc herniation more often then not. For example: the 35 y/o guy coming in with acute back pain, I'm probably gonna see the disc herniation if i look hard enough. Granted, I fully admit that as a neurorad who reads 50-60% spine all day every day my eye is way more attuned to disc herniations on CT than a mammographer or other general rad would be.

At that point, if I've found the herniation and made the diagnosis, it's really back on you guys. I've done my job. The question becomes: would you do an injection based off CT rather than MRI?

From my perspective, if I can make the Dx on CT then the patient gets discharged faster. If you or whichever provider decides an MRI has to be done (for diagnostic certainty or whatever) it can be done at a low-cost MRI center on an outpatient basis. Considering the ER MRI wouldn't change management, I think it's best for everyone if the patient finds a low-cost MRI center and pays $300 instead of $2000+

 

[Agast]

My patient acutely herniated her disc and limped/dragged herself into one of those CVS minute clinics because it was close by. The NP said, according to her, “The only thing I can think of that would hurt this much is avascular necrosis” and ordered a CT scan of her hip. My patient is an ER nurse so she at least insisted on a lumbar CT as well. I’ll be interested to see how the rise of minute clinics impacts imaging orders.

 

[soccrwz]

Semi-redundant post, but short of cauda equina syndrome a CT of the lumbar spine is gonna be faster, (significantly) cheaper, and in many cases make the diagnosis anyway.

At least in younger patients without horrible multilevel degenerative disc disease, if you give me a history of "concern for right L4 radiculopathy", I'll spot the disc herniation more often then not. For example: the 35 y/o guy coming in with acute back pain, I'm probably gonna see the disc herniation if i look hard enough. Granted, I fully admit that as a neurorad who reads 50-60% spine all day every day my eye is way more attuned to disc herniations on CT than a mammographer or other general rad would be.

At that point, if I've found the herniation and made the diagnosis, it's really back on you guys. I've done my job. The question becomes: would you do an injection based off CT rather than MRI?

From my perspective, if I can make the Dx on CT then the patient gets discharged faster. If you or whichever provider decides an MRI has to be done (for diagnostic certainty or whatever) it can be done at a low-cost MRI center on an outpatient basis. Considering the ER MRI wouldn't change management, I think it's best for everyone if the patient finds a low-cost MRI center and pays $300 instead of $2000+

CT can miss things, MRI is finer slicing; but I agree most MRIs can be done outpt

 

[Dr. Ice]

Thanks for all the replys. Didn’t realize this thread would get so much traction but appreciate the feedback. Obviously something I have known thought about.

Trying to find a better answer than “your pain doesn’t fit the criteria for something emergent.” Even though believe me, I would have no qualms about saying that if we all lived in reality where people didn’t constantly feel the need to “emote.”

I’m gen x..I would proudly bear the flag if there was one. We have endured boomer parents, we have lived through stuff. In my experience the gen x do not show up in my office and complain about an MRI that wasn’t done In the ER. They say, “sucks it couldn’t be done, but what can we do now?” That is my experience.

My wife is a millennial. So I have been beaten down by her and her generation to believe that “there should be more” that people should “care more.” That their problems supersede all of life, ok that last one was my puppet impression of them.

If I can copy and paste a response to millennials about why their 30 seconds of back pain and their necessity to need an emergency MRI as soon as possible can be answered in a diplomatic fashion, can someone please share??

Unfortunately I need their worthless generation for their private insurance payment of maybe $10 more per injection than Medicare.

Thanks

 

[2brads]

CT can miss things, MRI is finer slicing; but I agree most MRIs can be done outpt

Rad here. Generally speaking, CT has better spatial resolution than MRI. Also, to the poster that said MRI spine is 15 minutes, that's not true unless you're doing a limited number of sequences, which has obvious downsides. It's more like 40 min. Problems with scanning spines out of the ER - a.) not emergent (let's remember what the 'E' in 'ER' stands for b.) these guys don't sit still long enough to complete a study and if they do, it's because their pain is now adequately controlled. And if their pain is adequately controlled, then why are we doing the MR in the first place?

 

[Dr. Ice]

It seems like everyone is missing the point here. Perhaps I just want to offload the very annoying conversation and that’s why I started the thread. I get it, doesn’t make sense, time consuming, blah blah. I realize I’m not in the ER treating “emergencies,” but “they” are also not in my clinic dealing with whinos…

What’s worse? Probably equal on the “gonna go home and have some bourbon” scale

 

[Agast]

How to have a midlife crisis over MRIs lol

 

[Dr. Ice]

How to have a 33.3333 life crisis over lack of MRIs

 

[deleted875186]

I got a page at 2AM last month from my colleagues patient, COT patient, he tells me “I went to the ED because I need a new MRI so I can have surgery, you have to send over the notes so the ED doctor can do an MRI”. He puts the ED doctor on, I ask her any neuro deficits, no, ok have him follow up in the clinic. I had never been more annoyed from a page while on call, I feel for the ED people.

 

[lobelsteve]

I got a page at 2AM last month from my colleagues patient, COT patient, he tells me “I went to the ED because I need a new MRI so I can have surgery, you have to send over the notes so the ED doctor can do an MRI”. He puts the ED doctor on, I ask her any neuro deficits, no, ok have him follow up in the clinic. I had never been more annoyed from a page while on call, I feel for the ED people.

I dismiss patients for less.

 

[MitchLevi]

I got a page at 2AM last month from my colleagues patient, COT patient, he tells me “I went to the ED because I need a new MRI so I can have surgery, you have to send over the notes so the ED doctor can do an MRI”. He puts the ED doctor on, I ask her any neuro deficits, no, ok have him follow up in the clinic. I had never been more annoyed from a page while on call, I feel for the ED people.

That pt gets ass chewed by me. I have a pt I saw Monday who is about to get an ILESI for radic. I will likely fire her afterwards bc she's passive aggressive to the point it makes my veins itch.

She's got one last chance to correct that or she's gone.

Edit. Here it is. I did a left ILESI with significant improvement on ADLs and standing tolerance. Left side much better but she refused to agree with me about it. Repeatedly scoffed when I highlighted the improvements she's seen after that shot. She's awful.

 

[Ferrismonk]

That pt gets ass chewed by me. I have a pt I saw Monday who is about to get an ILESI for radic. I will likely fire her afterwards bc she's passive aggressive to the point it makes my veins itch.

She's got one last chance to correct that or she's gone.

Edit. Here it is. I did a left ILESI with significant improvement on ADLs and standing tolerance. Left side much better but she refused to agree with me about it. Repeatedly scoffed when I highlighted the improvements she's seen after that shot. She's awful.

View attachment 353974

Just be aware that these notes are very easily accessible by patients online now.

I don't know your patient, but I wouldn't do another injection on her unless she reported relief and was nice about it.

 

[au bon pain]

If I can copy and paste a response to millennials about why their 30 seconds of back pain and their necessity to need an emergency MRI as soon as possible can be answered in a diplomatic fashion, can someone please share??

"Do you want to spend $1000?

Do you want to hang out in the waiting room for 7 hours while mingling with the homeless frequent-flier caked in his own feces and the pt with chronic pancreatitis+gastroparesis whose vocal cords never seem to tire as she dry heaves and screams?

Do you want a shot of toradol and a script for #10 flexeril and no MRI?

If yes to all 3, consider going to the ER for your MRI."

 

[Welcome123]

I can personally verify it isn't...There's more than scan time that must be accounted

I can personally verify it isn't...There's more than scan time that must be accounted for.

This is more dependent on infrastructure/workflow efficiency, as well as machine
Some mri scans on the newer more powerful machines are much faster than the older machines
So both of you are speaking from individual experiences that don’t hold true across the board