A letter to my patient from last night...

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zeitgeber

zeitgeber

CMG doc
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You came in at 11pm last night with a chief complaint of sore throat while munching on a sandwich at triage. Next time you choose a sandwich to bring with you to the ED, try something that will go down easier. Peanut butter and Jelly – while I’m sure was very tasty, made my ENT exam, well… a bit difficult. But alas, we did get through it and I got to see your very normal throat. While I was tempted to leave the diagnosis of “no real complaint” on your chart, after envisioning my directors review of yet another unbillable chart I went ahead and replaced it with “sore throat”. Your chart will be coded with a maximum of billing incompetence by our billing company. In their defense, they follow archaic laws meant to break my balls and keep money out of my pocket. I wanted you to know one last thing. It’s ok… you don’t really have to pay that bill. There will be no consequences. If it arrives at the (fictitious?) address supplied by you, you can chuckle as to how we could possibly charge $350 for doing nothing. I wonder if giving you a depot of 2cc’s of Bicillin into your deltoid would have made us both more satisfied. In the end, you provided for yet another priceless moment in this stage we call the ER.
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This letter needs to be sent to all applicants who are actively pursuing EM residencies.

As I sit here, earning a little extra cash to pay the bills instead of enjoying a little time away from my own residency, waiting for the next ER patient to roll through the door, I am faced with a real internal conflict: Do I want a REAL emergency to present to my ER? Do I want to be the physician that may make a difference as a victim clings to life? Sounds dramatic,eh? Or, do I hope my next patient will do just fine, regardless of what I do for/to them? "A Z-pak for the sniffle, sure, why not?" "Perhaps you would like some Codeine as well, to quite that cough." I think the best answer to this question is simple: I don't want another patient.

I work ER because it pays well - at least during residency. I've taken care of some valid emergencies. It is rewarding. The rest of the work just sucks. People who don't want to go to work, those who are addicted to opiates, toothaches in Meth abusers, smokers who cannot breathe, parents of healthy (neglected/dirty) kids . . . You get the idea. I'm not sure that the 1 MI you stabilize, or the lacerations you repair are worth dealing with the uninsured lazy people who view the ER as their personal clinic. You'll understand when people start referring to you as their primary care physician.
 
The future seems so rosey, PGY1 here I come :laugh:
 
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BS is rampant in EM, as in all specialties.

The sore throat munching a sandwich is easy: 5 min H&P, 2 min to write the chart, 3 min ignoring pleas that "Motrin doesn't work for me" and onto the next patient.

It's the "potentially sick but actually crap" patients that are the worst. The lady I had last night, on MS contin for her fibromyalgia (?!), who says she may have overdosed on Tylenol and wants pain medicine and a refill on her MS contin. Problem is that she actually did OD four years ago with ALT/AST in the 1000s and an ICU admit, and she's got pain in her RUQ.

That being said, a lot of stuff that you think is BS is actually someone frightened that needs a doctor to be kind and understanding and reassure them that they are going to be okay. Because the guy munching on a sandwich may have lost an uncle to throat cancer and he won't say so but he's worried that's what he's got.

Being a doctor is more than making diagnoses and ordering tests.

When you get a patient with an inappropriate complaint, try to ferret out their 'chief concern', or as one of my attendings said 'what does the patient want?' Often it's narcs or a soft and they should be, as I often say, be 'Discharged with extreme prejudice'. Sometimes it's reassurance. Sometimes it's education. Sometimes it's a hard kick to the rear. Whatever it takes.
 
or the 15 yr old female I saw last night...
c/c I want an rx for vitamins( medicaid will pay for them if rx'd).
why? I've been tired my whole life...
do you have a regualr dr? sure, but they make me wait 45 min and I have a copay there.....sigh.......
 
I'm not convinced that they are looking for education, or understanding. If that were the case, we would tell people to quit smoking, give them an Rx for a nic-patch, and really go out of our way to EDUCATE them that smoking will make them ill. Instead we say "You'd better quit . . ." and then document on our charts that we did that part of our duty, in order to satisfy the Quality Assurance measures we're obligated to fulfil. As for understanding, dream on.

I've given up on trying to convince the mother of a 3 year old that their sniffle is going to get better. Nevermind it has been going on now for a whole 48 hours! Try to get them to sign-off on the idea that a decongestant, TLC, and soft Kleenex will do. Better off giving them what they want; Amoxicillin and Codeine.

I believe most people come to the ER because they are bored, loney, or just in the habbit of having what they want, when they want it.
 
docB said:
Did you mean "lonely" or "looney?" I suppose it doesn't really matter since both are equally applicable in the ED.
Click to expand...

Thanks. Fingers got going a little fast. I suppose the answer is "Yes..."

I did, however, mean to type Lonely. These poor people just have nothing better to do with their time. You will agree when you notice the increased ER attendance around 2:00pm on Sunday afternoon. Just about the time church is out, and just before prime time TV comes on.
 
emedpa said:
or the 15 yr old female I saw last night...
c/c I want an rx for vitamins( medicaid will pay for them if rx'd).
why? I've been tired my whole life...
do you have a regualr dr? sure, but they make me wait 45 min and I have a copay there.....sigh.......
Click to expand...

Perfect chance to educate her. "No, I'm not going to give you vitamins. You're abusing the privilege of the ER. Get out of here and go to your doctor." She knows she's abusing the system -> you have to teach her she can't get away with it.

As for the 3 year old with the sniffles, you definately have to tell them that they don't need Amox and why. I do this several times a night. Sure, if you're in an urban ED you get this paranoid look that says 'I don't trust you. You have what I need to make my child better and you won't give it to me.' But if enough people tell them, they'll start to believe.

You won't win the battle every time. However, for each person you convince, they'll tell their friends and so forth. I've actually met more and more parents who understand that Abx are not always good for a child, even ones from low SES backgrounds.

Sounds like you're a little burned out, bonedoc. I've been there, and I'm sure I'll be there again, but right now I'm okay.

Asking patients to quit smoking is no BS. You just have to assess if they're ready to make the step. If not, don't waste your time. If so, help them. It's worth more than treating a hundred BS chest pains.
 
beyond all hope said:
Perfect chance to educate her. "No, I'm not going to give you vitamins. You're abusing the privilege of the ER. Get out of here and go to your doctor." She knows she's abusing the system -> you have to teach her she can't get away with it.

As for the 3 year old with the sniffles, you definately have to tell them that they don't need Amox and why. I do this several times a night. Sure, if you're in an urban ED you get this paranoid look that says 'I don't trust you. You have what I need to make my child better and you won't give it to me.' But if enough people tell them, they'll start to believe.
Click to expand...

Yeah, then they get their Press-Gainey in the mail and crucify you. Then some self-important administrator with a title (typically a nurse who wouldn't know an endotracheal tube from a fallopian tube) informs you by way of a computer graph that your survey scores were lower last month than their arbitrary goal.

We aren't here to educate the patient, we are here to coddle them. The opposite of the old axiom of EM..."Don't give the pt. what they need, give them what they want!"

Community EM can be a different animal. More specifically urban EM in a hospital that is trying to emulate suburban/community EM.

For what it's worth, I agree with you. I rarely give the antibiotic. Just needed the rant. :D
 
edinOH said:
Yeah, then they get their Press-Gainey in the mail and crucify you. Then some self-important administrator with a title (typically a nurse who wouldn't know an endotracheal tube from a fallopian tube) informs you by way of a computer graph that your survey scores were lower last month than their arbitrary goal.

We aren't here to educate the patient, we are here to coddle them. The opposite of the old axiom of EM..."Don't give the pt. what they need, give them what they want!"

Community EM can be a different animal. More specifically urban EM in a hospital that is trying to emulate suburban/community EM.

For what it's worth, I agree with you. I rarely give the antibiotic. Just needed the rant. :D
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Edin make an excellent point. Those of us in the community get caught up in the whole "patient satisfaction" trap that punishes docs who won't do non-indicated things like antibiotics for viruses.
 
docB said:
Edin make an excellent point. Those of us in the community get caught up in the whole "patient satisfaction" trap that punishes docs who won't do non-indicated things like antibiotics for viruses.
Click to expand...

What?

Antibiotics don't work against viruses?

Take care,
Jeff
 
Jeff698 said:
What?

Antibiotics don't work against viruses?

Take care,
Jeff
Click to expand...
Nope. Neither is it appropriate for EPs to rule out chest pain with just an EKG (even if that's what the PMD said you'd do), fill out forms for sports physicals, work notes, disability, handicapped parking permits, etc., admit grandpa because the family's going on vacation, write someone for 90 days worth of their 8 oxycontin a day habit, and so on. But when you stand your ground on these and other issues you will get your a-- handed back to you by administration when the Press-Gainey, Gallup or whatever surveys come back and your satisfaction scores "need improvement." Oh, and try educating patients about their smoking, obesity and med non-compliance and see how your poll numbers do.
 
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docB said:
But when you stand your ground on these and other issues you will get your a-- handed back to you by administration when the Press-Gainey, Gallup or whatever surveys come back and your satisfaction scores "need improvement." .
Click to expand...

Maybe it is time we hired Press-Gainey to come administer a survey where we rate our patients, and their insurance/medicaid gives them higher co-pays if we give them a lower rating.
 
OK, docB, now you're just approaching blasphemy...

Let me get this straight. You're, like, saying our job isn't to write work excuses and vicodin prescriptions?

The next thing I know, your gonna go all Osler on me and say we have a duty to actually, :eek: "examine" :eek: our patients and try to figure out what is actually going on with them.

No, surely that wouldn't happen.

Take care,
Jeff

Just a brick.
 
I think I'm having a genius idea... once I finish school (PA school, thanks, I'm not completely nuts), I'll be negotiating a compensation package.

You think I could convince a group to leave me out of all the quality survey crap? Maybe I do it for six months and score x or better, then never have to do it again.

Maybe I get them to agree to some salary, and then "give" them back some figure I'm happy to do without, if it means no surveys.

Am I dreaming?
 
Some of you guys sound like me, and I'm not even in med school yet. I have worked in an ER for over a year and EM is one of my "thoughts" on what kind of doctor I'd like to be. Or course, I am lost on a lot of your jokes that include names of some drugs and treaments, but I think the point of them hits pretty well. A few things I saw today was

1) There was a 23 year old female who cut her finger 3 days ago, on a crack pipe no less, and was literally crying like a 4 year old because she was "in so much pain." Suck it up honey, you have small cut on your finger that may be infected. That's it.

2) A 23 year old who fell down 2, yes 2, steps at home. no LOC, a few little cuts and bruises, not much else. Again, crying like a b*tch, with his wife/girlfriend/whatever right there. Dude, grow a pair. You fell about a foot. Stop crying.

Growing up I always heard how people from the inner city are so tough. But tough guys don't cry when they stub their toe. (or come to the ER for that matter) A lot of them seem like b*tches to me.

Guess I'm crazy to want to be an ER doc?
 
I was with a doc after seeing this little 2cm lac on her forearm that complained of the incapacitating "so much" kind of pain. She was in the bed next door to a man who had cut his finger off with a chain saw. Only a curtain separated them.

Doc: "We'll give you something for the pain."
Pt: "Naw, I'm fine. It's not bad."
Doc (purposely loud enough for the pt next door): "Well, you did cut your entire finger off. You say the pain isn't bad enough to need medication? You really don't want anything for the pain?"
Pt (he's looking at the doc like he's gone mad): I don't think so?

:laugh:
 
HIPAA prevents me from whipping the curtain back when stuff like that comes up, but man, do I want to sometimes.

If I ever snap, I'm going to introduce "patient with hand pain he says is a 10, although he can work a cellphone keyboard with it" to "patient who has a drywall nail through his palm and tells us it's an 8."
 
I had this woman who made sure to mention several times that she is an EMT-specialist and an ER tech. She was wearing her {Insert prestigious teaching hospital here} ER sweatshirt on. She was trying to blow dry her new kitten and it scratched her hand. She ended up with a half cm lac to the cuticle that would have been fine with a bandaid, which I told her was going to be the plan. The nurse comes up to me and tells me that he saw her trying to open it up and making it bleed. OK, now you are going to get one stitch. Afterwards, she asks me if I am going to send her home with pain medicine. Yup, here's your script for ibuprofen. When she asked me why she wasn't getting vicodin or something stronger, I said, "because you got scratched by a kitten." She wasn't too happy about that.
 
I am not sure what the issue is....

You look at the throat and neck - talk to the pt. It would take maybe 2-3 minutes max ( prob more like 60 secs ) no tests, no Rx Very little time invested

Bill it as a level 2 - easiest damn money you made( or lost) all night .

Ive got a problem with the out of state medical cards that pay us $5-10 for a level 4 . It doesnt even cover the billing costs
 
I am starting M-1 this summer and Ive been working in the ED for 3 years as a tech. I actually had a guy(~17) come in with a cut from a snowball on his finger. I did something I prob could have gotten fired for, I told him to go home.
 
emedpa said:
or the 15 yr old female I saw last night...
c/c I want an rx for vitamins( medicaid will pay for them if rx'd).
why? I've been tired my whole life...
do you have a regualr dr? sure, but they make me wait 45 min and I have a copay there.....sigh.......
Click to expand...

I seriously don't know how you guys do it day in and day out. Props to you.

When FPs see patients for BS complaints, at least it doesn't cost the taxpayer hundreds of dollars and use up valuable emergency medical resources and time. If I was an EP, the fact that I was a cog in that wheel of abuse of the medical system would make me nauseous on a daily basis.
 
IntheDraft6 said:
I had this woman who made sure to mention several times that she is an EMT-specialist and an ER tech. She was wearing her {Insert prestigious teaching hospital here} ER sweatshirt on. She was trying to blow dry her new kitten and it scratched her hand. She ended up with a half cm lac to the cuticle that would have been fine with a bandaid, which I told her was going to be the plan. The nurse comes up to me and tells me that he saw her trying to open it up and making it bleed. OK, now you are going to get one stitch. Afterwards, she asks me if I am going to send her home with pain medicine. Yup, here's your script for ibuprofen. When she asked me why she wasn't getting vicodin or something stronger, I said, "because you got scratched by a kitten." She wasn't too happy about that.
Click to expand...

...wow
 
sophiejane said:
I seriously don't know how you guys do it day in and day out. Props to you.

When FPs see patients for BS complaints, at least it doesn't cost the taxpayer hundreds of dollars and use up valuable emergency medical resources and time. If I was an EP, the fact that I was a cog in that wheel of abuse of the medical system would make me nauseous on a daily basis.
Click to expand...

Well, I think of myself as a little more than a cog in a wheel of abuse.

mike
 
sophiejane said:
I seriously don't know how you guys do it day in and day out. Props to you.

When FPs see patients for BS complaints, at least it doesn't cost the taxpayer hundreds of dollars and use up valuable emergency medical resources and time. If I was an EP, the fact that I was a cog in that wheel of abuse of the medical system would make me nauseous on a daily basis.
Click to expand...

I CALL FATTY MCFATTYPANTS :).

(all y'all love me, admit it)
 
mikecwru said:
Well, I think of myself as a little more than a cog in a wheel of abuse.

mike
Click to expand...

Come on now, I obviously didn't mean that's ALL you are. But you have to admit that you guys have to build up a serious tolerance to BS, more so than most other fields.

What I meant was that someone coming to the EMERGENCY department with a c/c of needing a prescription for vitamins is a little more disturbing than someone showing up at the clinic with that complaint. And way, way more of a drain on resources.
 
leviathan said:
Perhaps it's a brick in the wall of abuse?
Click to expand...

Sing along, boys and girls...

"We don't need no education...!" ;)

pink-floyd-the-wall-2.jpg


(Please, somebody get the reference...)
 
Febrifuge said:
HIPAA prevents me from whipping the curtain back when stuff like that comes up, but man, do I want to sometimes.

If I ever snap, I'm going to introduce "patient with hand pain he says is a 10, although he can work a cellphone keyboard with it" to "patient who has a drywall nail through his palm and tells us it's an 8."
Click to expand...

no kidding...or I could introduce them to this guy:
82 yo ww2 vet with large sah and "bad h/a" rated 6/10....
when was the last time you had a pain this bad sir?
when the germans shot me 3 times in the chest...
isn't that a 10 then sir?
no cutting off all my arms and legs at the same time with a dull hacksaw
would be a 10.

finally someone who understands the pain scale.....
 
SoCuteMD said:
I CALL FATTY MCFATTYPANTS :).
Click to expand...

What is "Fatty Mc Fatpants" mentioned here? I've seen it twice in the past couple of days, and feel like I'm missing something.

Then again, I'm not a regular 'round these parts.
 
Yep, that's what the ER is all about, saving lives.:laugh:
 
geordon said:
What is "Fatty Mc Fatpants" mentioned here? I've seen it twice in the past couple of days, and feel like I'm missing something.

Then again, I'm not a regular 'round these parts.
Click to expand...
If you do a scholar search about McFattypants you may just dig up some old information.

Keywords: Mcfattypants, fatty, In-N-Out, Trolls
 
geordon said:
What is "Fatty Mc Fatpants" mentioned here? I've seen it twice in the past couple of days, and feel like I'm missing something.

Then again, I'm not a regular 'round these parts.
Click to expand...

You should do a medline search to find the answers you seek. Especially seek out publications by chuck norris.
 
emedpa said:
no kidding...or I could introduce them to this guy:
82 yo ww2 vet with large sah and "bad h/a" rated 6/10....
when was the last time you had a pain this bad sir?
when the germans shot me 3 times in the chest...
isn't that a 10 then sir?
no cutting off all my arms and legs at the same time with a dull hacksaw
would be a 10.

finally someone who understands the pain scale.....
Click to expand...

Thats what I think the pain scale is supposed to be. I called my labor-pains (no pain meds) a 6 or 7 which surprised my nurse.
 
IntheDraft6 said:
I had this woman who made sure to mention several times that she is an EMT-specialist and an ER tech. She was wearing her {Insert prestigious teaching hospital here} ER sweatshirt on. She was trying to blow dry her new kitten and it scratched her hand. She ended up with a half cm lac to the cuticle that would have been fine with a bandaid, which I told her was going to be the plan. The nurse comes up to me and tells me that he saw her trying to open it up and making it bleed. OK, now you are going to get one stitch. Afterwards, she asks me if I am going to send her home with pain medicine. Yup, here's your script for ibuprofen. When she asked me why she wasn't getting vicodin or something stronger, I said, "because you got scratched by a kitten." She wasn't too happy about that.
Click to expand...

You should've called psych, if anything just to make her wait around some more and give her a headache.
 
Faze2 said:
You should've called psych, if anything just to make her wait around some more and give her a headache.
Click to expand...

It's a small community hospital. We're lucky we have ortho (usually covered by a podiatrist) much less psych. I figured her fibromyalgia will do her in soon enough.
 
IntheDraft6 said:
It's a small community hospital. We're lucky we have ortho (usually covered by a podiatrist) much less psych. I figured her fibromyalgia will do her in soon enough.
Click to expand...

Being in an ED with no psych is a nightmare. If I get a job in EM, there better be psych in the place.
 
edinOH said:
Yeah, then they get their Press-Gainey in the mail and crucify you. Then some self-important administrator with a title (typically a nurse who wouldn't know an endotracheal tube from a fallopian tube) informs you by way of a computer graph that your survey scores were lower last month than their arbitrary goal.

We aren't here to educate the patient, we are here to coddle them. The opposite of the old axiom of EM..."Don't give the pt. what they need, give them what they want!"
Click to expand...

Sorry to disillusion you, but it generally will not be a nurse that initiates PG ratings. Even though they may be the ones that have to remind you of it.

Nurses, that have actually worked a real nursing job in their life, DESPISE PG like the plague.

While you the MD fuss over coddling them for 5-15 minutes, we(the nursing staff) have to deal with them for hours, or days on the unit...along with their annoying friends and families.

Please place the blame where it actually lies...with the overpaid administrators, with their business degrees. They are the ones that actually push "customer service" in place of actual healthcare. They are the ones that decide to waste big bucks on PG.
 
If it makes any of you feel better about the counseling a patient to do / not do something...my family doc tried to get my dad to wear a hat while he works (he works outside and is bald on top)...after about 10 years, he finally started wearing one faithfully because in his conscious he could hear her telling him to put the hat on or he would get skin cancer. Not that this would necessarily work in the ED, but maybe there is some hope.

On another note, when I was a pesky pt in the ED, I had cut my head open and said my pain was a zero, but then again I had a "few" drinks that night (isn't that how it's usually phrased?) hahaha
 
HIANMI said:
If it makes any of you feel better about the counseling a patient to do / not do something...my family doc tried to get my dad to wear a hat while he works (he works outside and is bald on top)...after about 10 years, he finally started wearing one faithfully because in his conscious he could hear her telling him to put the hat on or he would get skin cancer. Not that this would necessarily work in the ED, but maybe there is some hope.

On another note, when I was a pesky pt in the ED, I had cut my head open and said my pain was a zero, but then again I had a "few" drinks that night (isn't that how it's usually phrased?) hahaha
Click to expand...

Generally the party line is "two" drinks ;)
 
My first experience as a pt with the pain scale was following knee surgery. When I woke up the nurse asked how I would rate the pain. I chose a 4 because 5 was "distressing pain" (at least on their helpful little chart) which I read to mean "severe enough you think you might die without intervention."
 
If the pt fits the bill and someone made the mistake of sending their chronic pain pt to see us because "my doctor told me you would find my problem" Mind you the PMD and all the specialists have not found "the problem" despite multiple expensive workups...

I will at the least tell them about fibromyalgia and then promptly return said pt to the pmd with their newfound dx. :D oh, and your pmd can prescribe your pain/anxiety meds. I will treat said pain/anxiety acutely but then you better follow up with the doc that sent you for your second (read - tenth) opinion in the EMERGENCY department.
 
caroladybelle said:
Sorry to disillusion you, but it generally will not be a nurse that initiates PG ratings. Even though they may be the ones that have to remind you of it.

Nurses, that have actually worked a real nursing job in their life, DESPISE PG like the plague.

While you the MD fuss over coddling them for 5-15 minutes, we(the nursing staff) have to deal with them for hours, or days on the unit...along with their annoying friends and families.

Please place the blame where it actually lies...with the overpaid administrators, with their business degrees. They are the ones that actually push "customer service" in place of actual healthcare. They are the ones that decide to waste big bucks on PG.
Click to expand...

The key to your post is nurses who have actually worked a real nursing job. That is the kicker.

I'm speaking from first hand experience here. I'm talking about adminstrators who happen to have an RN after their name. Most nurses who give a crap and know what the hell they are doing never end up in these jobs.
 
emedpa said:
no kidding...or I could introduce them to this guy:
82 yo ww2 vet with large sah and "bad h/a" rated 6/10....
when was the last time you had a pain this bad sir?
when the germans shot me 3 times in the chest...
isn't that a 10 then sir?
no cutting off all my arms and legs at the same time with a dull hacksaw
would be a 10.

finally someone who understands the pain scale.....
Click to expand...

LOVE IT!! In the ER where I work (now just moonlight) as a tech I often find myself educating the patient as to the finer points of a pain scale....

"Well, I know you say your dental pain is a 10, but according to our nifty JCAHO pain scale diagram you have to be crying to be a 10. a 9 has a really hurt looking face with it, but you don't have that either. Ya know, you look an awful lot like the face with the 5 or 6....."

Or "So the 10 means that this is the worst stubbed toe you've ever had, your toe hurts the most it has all day, or it hurts even more than having your digits removed with a dull pair of tree pruners?"

"Ma'am, you told me that your kids were all natural births without drugs. Are you sure that your sprained thumb hurts more than your first birth?"

Most of the time I end up reporting what the patient states along with an observation of their behavior that may or may not jive....
 
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