A picture is worth

[BoardingDoc]

So I could be going to see the guy with strep throat in room 4 right now, but I had a better idea. I'd use chat-gpt to illustrate some of my patients.

1: Guy I just intubated for being unresponsive to sternal rub. Has a WBC of 37 which bought him an LP, but also has an etoh of 444 which more likely explains his mental status.

2: Guy who feels generally weak and sleepy with an Na of 117. He has rather impressive telangiectasias on his face from a life of hard boozing. They came out rather well I thought.

3: We all know this patient.

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[southerndoc]

The patient in the second pic resembles Abe Lincoln a bit.

 

[s/p epilepticus]

All of the "post your boring shifts" need to be like this in the future.

 

[RustedFox]

Holy smoke, these are rad.

 

[Groove]

I can see you did like me and had your IT dept lift your web proxy restrictions... "I can't get to my MEDICAL websites!"

I'm jealous... I can pull up most stuff now but I still can't access openai.com from work. That would make my shift pass so much faster.

 

[BoardingDoc]

I can see you did like me and had your IT dept lift your web proxy restrictions... "I can't get to my MEDICAL websites!"

I'm jealous... I can pull up most stuff now but I still can't access openai.com from work. That would make my shift pass so much faster.

I can access it from work, but honestly for most non clinical things I just remote into my home server and do things that way. That way if I need to do banking or whatever there's no risk of a snooping IT guy looking at my stuff. That said, I highly doubt that our IT department is even capable of doing so.

 

[Groove]

I can access it from work, but honestly for most non clinical things I just remote into my home server and do things that way. That way if I need to do banking or whatever there's no risk of a snooping IT guy looking at my stuff. That said, I highly doubt that our IT department is even capable of doing so.

How do you remote into your desktop from work? I know how to set up a VPN but do you have a VPN client that's installed on your work workstation or one that they allowed you to install? I'm a Mac user, so there may be one built into Windows that I don't know about?

 

[BoardingDoc]

How do you remote into your desktop from work? I know how to set up a VPN but do you have a VPN client that's installed on your work workstation or one that they allowed you to install? I'm a Mac user, so there may be one built into Windows that I don't know about?

Just use chrome remote desktop. Less secure than a proper VPN but much more accessible at work. As long as you have chrome at your computer at work and can log into your Gmail you can get access that way.

 

[CoolDoc1729]

I can access it from work, but honestly for most non clinical things I just remote into my home server and do things that way. That way if I need to do banking or whatever there's no risk of a snooping IT guy looking at my stuff. That said, I highly doubt that our IT department is even capable of doing so.

The last sentence made me laugh..at my hospital they haven’t even added covid swabs to any of the order sets, dyspnea, fever etc and I keep being told they “can’t” 🤣

 

[RustedFox]

The last sentence made me laugh..at my hospital they haven’t even added covid swabs to any of the order sets, dyspnea, fever etc and I keep being told they “can’t” 🤣

Meditech?

 

[Rekt]

So I could be going to see the guy with strep throat in room 4 right now, but I had a better idea. I'd use chat-gpt to illustrate some of my patients.

1: Guy I just intubated for being unresponsive to sternal rub. Has a WBC of 37 which bought him an LP, but also has an etoh of 444 which more likely explains his mental status.
View attachment 380342


2: Guy who feels generally weak and sleepy with an Na of 117. He has rather impressive telangiectasias on his face from a life of hard boozing. They came out rather well I thought.

View attachment 380343

3: We all know this patient.

View attachment 380344

I love those AI generated pics. Definitely get us some more.

 

[Apollyon]

I love those AI generated pics. Definitely get us some more.

A buddy of mine deals with retro games and systems (like Atari and Intellivision, and others less well known). He asked AI to generate a retro picture for one of the Nintendo systems, and it did - with Dad playing the game, and the 6 year old girl smoking a cigarette!!

 

[CoolDoc1729]

Meditech?

It’s not even, it’s cerner … I also asked for a CIWA set for Valium since we don’t have any Ativan .. that was “too hard” too so I made it myself

 

[ScepticSkeksis]

I just bring my laptop. That way I can do telemed, banking, video games, or watch Netflix if it's slow.

 

[RustedFox]

It’s not even, it’s cerner … I also asked for a CIWA set for Valium since we don’t have any Ativan .. that was “too hard” too so I made it myself

Can't even make our own order sets in Medievaltech.

 

[Cinclus]

Y'all making realistic stuff at work, and here I am creating my own AI acid trip like...

 

[DocEspana]

They need their Dilaldid and are allergic to everything else

 

[ScepticSkeksis]

They need their Dilaldid and are allergic to everything else

Don't forget the IV Benadryl chaser. I love to order this PO or IM and the response is entertaining.

 

[DocEspana]

Don't forget the IV Benadryl chaser. I love to order this PO or IM and the response is entertaining.

about 5-6 years ago there was a hurricane that hit Puerto Rico and, as it turns out, an absolutely massive chunk of IV benadryl in the US supply chain is created there. As such, all three of the hospital systems I was working with at the time sent similar emails basically saying that IV benadryl is in short supply and that it truly is only ever indicated for anaphylaxis or dystonia reversal. They explained that po benadryl has shockingly similar time of efficacy as IV. Then all of them said that until further notice IV benadryl was restricted to those uses.

It's been 5-6 years and no one has ever emailed me back that IV benadryl is back on the free use menu. So as far as I'm concerned, that policy is still active. I am 100% following the rules to make it my personal policy that IV benadryl is only used to reverse active anaphylaxis and dystonia and that there appears to be uniformity within multiple hospitals' administration that this policy is still in place. They are all told they can get their benadryl PO and pre-emptively if they have a concern.

 

[DocEspana]

Don't forget the IV Benadryl chaser. I love to order this PO or IM and the response is entertaining.

about 5-6 years ago there was a hurricane that hit Puerto Rico and, as it turns out, an absolutely massive chunk of IV benadryl in the US supply chain is created there. As such, all three of the hospital systems I was working with at the time sent similar emails basically saying that IV benadryl is in short supply and that it truly is only ever indicated for anaphylaxis or dystonia reversal. They explained that po benadryl has shockingly similar time of efficacy as IV. Then all of them said that until further notice IV benadryl was restricted to those uses.

It's been 5-6 years and no one has ever emailed me back that IV benadryl is back on the free use menu. So as far as I'm concerned, that policy is still active. I am 100% following the rules to make it my personal policy that IV benadryl is only used to reverse active anaphylaxis and dystonia and that there appears to be uniformity within multiple hospitals' administration that this policy is still in place. They are all told they can get their benadryl PO and pre-emptively if they have a concern.

I also tell people that dilaudid is 100% an option and can be used, but I would prefer to start with morphine (4, 6, or 8mg, their choice as long as their weight justifies it) first just to make sure "that first dose of morphine doesn't solve the problem."

I even tell them to set their watch to 20 minutes as soon as they get the morphine and at 20 minutes to holler for me if they arent feeling better. 6 years of doing this. 6 years. I've never had a single person who 1) got the morphine 2) stayed for 20 minutes and 3) said they needed the dilaudid after that. Not one. I've had some who have requested more *morphine* after, saying that actually 8mg morphine got really close to handling it all. But obviously generally they sprint out because having to wait even 20 minutes for that IV push da-la-la, even with other opiates onboard, its just too much effort for them. Its the bizarrely ass-backwards effort by them that drives me nuts. They will drop something heavy on their own foot and break their own bones (we all know that person), but they wont tolerate even the slightest deviation from the specific high they want and will leave and travel to another hospital 30 minutes away and wait 60 minutes to be seen and another 30 minutes to be medicated to get it exactly how they want it rather than try appropriate escalation of analgesics over 20 minutes.

 

[thegenius]

I also tell people that dilaudid is 100% an option and can be used, but I would prefer to start with morphine (4, 6, or 8mg, their choice as long as their weight justifies it) first just to make sure "that first dose of morphine doesn't solve the problem."

I even tell them to set their watch to 20 minutes as soon as they get the morphine and at 20 minutes to holler for me if they arent feeling better. 6 years of doing this. 6 years. I've never had a single person who 1) got the morphine 2) stayed for 20 minutes and 3) said they needed the dilaudid after that. Not one. I've had some who have requested more *morphine* after, saying that actually 8mg morphine got really close to handling it all. But obviously generally they sprint out because having to wait even 20 minutes for that IV push da-la-la, even with other opiates onboard, its just too much effort for them. Its the bizarrely ass-backwards effort by them that drives me nuts. They will drop something heavy on their own foot and break their own bones (we all know that person), but they wont tolerate even the slightest deviation from the specific high they want and will leave and travel to another hospital 30 minutes away and wait 60 minutes to be seen and another 30 minutes to be medicated to get it exactly how they want it rather than try appropriate escalation of analgesics over 20 minutes.

You practice medicine in the metaverse? Have you not treated a single pt with SCA?

 

[DocEspana]

You practice medicine in the metaverse? Have you not treated a single pt with SCA?

I trained in Harlem and work in Miami. Sickle cell is basically my specialty and have been seeing multiple patients per shift since I was an intern. And in both my residency and over where I work multiple hematologists (who have zero qualms about using Dilaudid) have been abundantly clear that there is zero need for Dilaudid in sickle cell management, it is purely an option if you're not feeling like multimodal therapy (of which opiates are a part of it, but dilaudid is fully inferior to fentanyl and, if you're not using hefty doses, non inferior to morphine). An option they generally don't recommend we go with in the ER. And I follow their recommendations on that - more so that way I have an even and non-judgement based protocol I follow for everyone.

Only real exception is trauma and/or obvious bone deformity gets dilaudid (or fentanyl + morphine, my preference) upfront because I don't want them waiting for pain relief with obvious trauma.

And my sickle cell patients rarely every need more than the first dose of morphine, which is given with Tylenol, nsaids, muscle relaxants, oxygen, and fluids all at once. And when they do, they essentially always request more morphine - not the Dilaudid upgrade I offered them. But that request also gets them an admission.

 

[BoardingDoc]

3 more. I was going to make more of my patients but last shift was real not fun. I decided to make a few of y'all instead. DALL-E presents: @RustedFox @Birdstrike and @cyanide12345678

 

[RustedFox]

@BoardingDoc

Now I have to know what you fed to the AI to make it so damn accurate.
That elevated bridge and swampland is really what Florida MTB is all about; except the elevation changes (yes, there are many) come from old phosophate mine walls. I wonder what's coming out of the water as well.

 

[cyanide12345678]

3 more. I was going to make more of my patients but last shift was real not fun. I decided to make a few of y'all instead. DALL-E presents: @RustedFox @Birdstrike and @cyanide12345678

View attachment 380796

Lol the day mpw fell 30 percent which was 4-5 days ago, i fully reloaded with 650 puts at $3 strike for March and got $27k premium for it. 27k in 70 days, the damn thing just needs to hold $3. So…. Quite the accurate picture lol.

 

[BoardingDoc]

@BoardingDoc

Now I have to know what you fed to the AI to make it so damn accurate.
That elevated bridge and swampland is really what Florida MTB is all about; except the elevation changes (yes, there are many) come from old phosophate mine walls. I wonder what's coming out of the water as well.

The prompts were:
Make a new image. A metal fox riding a mountain bike through the woods, jumping over a stream. The fox is so rusted that the color is more rust than silver.
...
Good. Now add a fat 60 year old man, shirtless, sitting in a lawn chair, holding a cigarette and a can of soda with a florida state flag flying from the lawn chair.

I had it regenerate the images based on those prompts several times until I got one I liked. Throughout the recycling of images I would add minor correction requests each time. E.g. make the man fatter. Add wildlife. Change the scene to be more like the Florida wetlands. Etc etc....

 

[thegenius]

I trained in Harlem and work in Miami. Sickle cell is basically my specialty and have been seeing multiple patients per shift since I was an intern. And in both my residency and over where I work multiple hematologists (who have zero qualms about using Dilaudid) have been abundantly clear that there is zero need for Dilaudid in sickle cell management, it is purely an option if you're not feeling like multimodal therapy (of which opiates are a part of it, but dilaudid is fully inferior to fentanyl and, if you're not using hefty doses, non inferior to morphine). An option they generally don't recommend we go with in the ER. And I follow their recommendations on that - more so that way I have an even and non-judgement based protocol I follow for everyone.

Only real exception is trauma and/or obvious bone deformity gets dilaudid (or fentanyl + morphine, my preference) upfront because I don't want them waiting for pain relief with obvious trauma.

And my sickle cell patients rarely every need more than the first dose of morphine, which is given with Tylenol, nsaids, muscle relaxants, oxygen, and fluids all at once. And when they do, they essentially always request more morphine - not the Dilaudid upgrade I offered them. But that request also gets them an admission.

Of course there is zero need for dilaudid. But we have probably hundreds of thousands of people (and a subset of them with sickle cell) who are addicted to it. Just not clear how you handle those patients. We have about 10-15 who come through monthly and they are all on dilaudid PO as an outpatient. So what is tylenol, flexeril, toradol, and morphine 8 mg going to do for them?

I would love to see you work a shift at our place, because I guess you would just admit them within the first 30 minutes. I'm not throwing shade here, it's just we have a bunch of pts addicted to dilaudid. And that's true in every ER

 

[Mount Asclepius]

You guys are still allowed to treat with opioids?

 

[thegenius]

The prompts were:
Make a new image. A metal fox riding a mountain bike through the woods, jumping over a stream. The fox is so rusted that the color is more rust than silver.
...
Good. Now add a fat 60 year old man, shirtless, sitting in a lawn chair, holding a cigarette and a can of soda with a florida state flag flying from the lawn chair.

I had it regenerate the images based on those prompts several times until I got one I liked. Throughout the recycling of images I would add minor correction requests each time. E.g. make the man fatter. Add wildlife. Change the scene to be more like the Florida wetlands. Etc etc....

What the link (or a link) to make these chat gpt images?
Oh I see DALL-E is $20/month?

 

[DocEspana]

Of course there is zero need for dilaudid. But we have probably hundreds of thousands of people (and a subset of them with sickle cell) who are addicted to it. Just not clear how you handle those patients. We have about 10-15 who come through monthly and they are all on dilaudid PO as an outpatient. So what is tylenol, flexeril, toradol, and morphine 8 mg going to do for them?

I would love to see you work a shift at our place, because I guess you would just admit them within the first 30 minutes. I'm not throwing shade here, it's just we have a bunch of pts addicted to dilaudid. And that's true in every ER

Your patients are the easiest on earth.
1) some of them get that and feel better. It's true. 8mg is all it takes usually. But the addicts won't bother because morphine isn't a clean high and they would rather withdraw than have a dirty high.... Which brings me to:
2) most of them (like.... MOST) of them just walk out the second you explain that you have a strict regiment and won't be adjusting it and that they are free to work with pain management and heme upstairs (who practice the exact same way as me except for a one or two opiate happy heme guys). The addicts know damn well that admitting them means no Dilaudid AND is a hassle and they just book it. But if they don't book it and do take the regiment then:
3) if first round of pain meds dont work, I start talking 0.2 mg/kg ketamine to them as a way to eliminate all of their pain while they await admission. Purely as an option (since I did say they could get the big D then). This is a bit sneaky, but I push it hard because it works. Every time. On every addict. (This is straight from my hospitals research on sickle cell patients). And if they say it didn't, they're full fledged malingering. The ones who feel better actually get paradoxically admitted still because now I know their pain is legit and needs pain management ASAP.

Plus get electrophoresis on these people. It's MIND BLOWING how many only have trait but because they have concurrent beta thalassemia or some other pro-anemic disorder they've been misdiagnosed as HgSS their whole life and are just fully dependent and need a opiate taper down rather than any increased dosing. Get their hematologists on the phone. Show them the electrophoresis (which they probably never ran themselves because incredible gullibility seems to be a prerequisite for that specialty), and ask them to make a pain contract with taper down for these people. Now they come by and they have pain contracts that specifically ban Dilaudid use and a 1 year goal to get down to no chronic opiate use that you can hold them to.

I think you just lack either the creativity to dismantle their shenanigans or the motivation to actually deal with these patients in a way that isn't just giving in to the momentum and actually questioning them and trying to manage them for their stated complaint not their stated "what always works is...". I get it. Whenever I hit a new hospital in the area I have to break a lot of the other providers out of the funk they are in with the native population. We are seeing 8-10 per day (so 2-3 per provider every single shift). And Harlem is the single highest population of sickle cell patients in America. Was probably seeing 5 per shift (personally) every shift all residency long.

 

[cyanide12345678]

What the link (or a link) to make these chat gpt images?
Oh I see DALL-E is $20/month?

I believe you can just buy some image credits. I think you can get like 1000 credits for $20 or something. Each prompt resulting in a picture is one credit, each edit is another.

Or at least that’s how their pricing model was 3 months ago

 

[Birdstrike]

3 more. I was going to make more of my patients but last shift was real not fun. I decided to make a few of y'all instead. DALL-E presents: @RustedFox @Birdstrike and @cyanide12345678

View attachment 380794View attachment 380795View attachment 380796

Oh wow. That's incredible. I love it. That captures more about me than you know. It's so damn good I almost want to make it my profile picture. I'm saving a screenshot.

 

[BoardingDoc]

What the link (or a link) to make these chat gpt images?
Oh I see DALL-E is $20/month?

Yeah, I've got a subscription for chat GPT 4.0. It's 20 a month and comes with DALL-E access.

 

[thegenius]

Your patients are the easiest on earth.
1) some of them get that and feel better. It's true. 8mg is all it takes usually. But the addicts won't bother because morphine isn't a clean high and they would rather withdraw than have a dirty high.... Which brings me to:
2) most of them (like.... MOST) of them just walk out the second you explain that you have a strict regiment and won't be adjusting it and that they are free to work with pain management and heme upstairs (who practice the exact same way as me except for a one or two opiate happy heme guys). The addicts know damn well that admitting them means no Dilaudid AND is a hassle and they just book it. But if they don't book it and do take the regiment then:
3) if first round of pain meds dont work, I start talking 0.2 mg/kg ketamine to them as a way to eliminate all of their pain while they await admission. Purely as an option (since I did say they could get the big D then). This is a bit sneaky, but I push it hard because it works. Every time. On every addict. (This is straight from my hospitals research on sickle cell patients). And if they say it didn't, they're full fledged malingering. The ones who feel better actually get paradoxically admitted still because now I know their pain is legit and needs pain management ASAP.

Plus get electrophoresis on these people. It's MIND BLOWING how many only have trait but because they have concurrent beta thalassemia or some other pro-anemic disorder they've been misdiagnosed as HgSS their whole life and are just fully dependent and need a opiate taper down rather than any increased dosing. Get their hematologists on the phone. Show them the electrophoresis (which they probably never ran themselves because incredible gullibility seems to be a prerequisite for that specialty), and ask them to make a pain contract with taper down for these people. Now they come by and they have pain contracts that specifically ban Dilaudid use and a 1 year goal to get down to no chronic opiate use that you can hold them to.

I think you just lack either the creativity to dismantle their shenanigans or the motivation to actually deal with these patients in a way that isn't just giving in to the momentum and actually questioning them and trying to manage them for their stated complaint not their stated "what always works is...". I get it. Whenever I hit a new hospital in the area I have to break a lot of the other providers out of the funk they are in with the native population. We are seeing 8-10 per day (so 2-3 per provider every single shift). And Harlem is the single highest population of sickle cell patients in America. Was probably seeing 5 per shift (personally) every shift all residency long.

It sounds like there needs to be buyin, and probably even directed by, Heme. Our sicklers are not being admitted and getting morphine 4mg IV q6 PRN. 1/2 are getting dilaudid 2mg q4, 1/4 are getting higher doses, and 1/4 are on PCA pumps. THese orders are written by Heme consults.

I could easily just say no to them and give one dose of morphine, then they either 1) complain at which point I'll end up having to defend myself, or 2) leave, come back in 12 hours when I'm not there and someone else gives them narcotics.

I suppose some of them can have trait or malingering, but I think all of our sicklers have complications like AVNs, on CKD or on dialysis, etc. I mean they have reasons to have pain.

The only problem I had with your original post is the notion that you could walk into our ER and just only give morphine, tylenol and motrin. And maintain a smile, and be productive and see 2.5/hr, and not have nurses and staff get on your case. It would require culture change and buyin from 35 docs (the size of our group) and with Hematology, and it is certainly possible! And would require a lot of time.

 

[The Knife & Gun Club]

Your patients are the easiest on earth.
1) some of them get that and feel better. It's true. 8mg is all it takes usually. But the addicts won't bother because morphine isn't a clean high and they would rather withdraw than have a dirty high.... Which brings me to:
2) most of them (like.... MOST) of them just walk out the second you explain that you have a strict regiment and won't be adjusting it and that they are free to work with pain management and heme upstairs (who practice the exact same way as me except for a one or two opiate happy heme guys). The addicts know damn well that admitting them means no Dilaudid AND is a hassle and they just book it. But if they don't book it and do take the regiment then:
3) if first round of pain meds dont work, I start talking 0.2 mg/kg ketamine to them as a way to eliminate all of their pain while they await admission. Purely as an option (since I did say they could get the big D then). This is a bit sneaky, but I push it hard because it works. Every time. On every addict. (This is straight from my hospitals research on sickle cell patients). And if they say it didn't, they're full fledged malingering. The ones who feel better actually get paradoxically admitted still because now I know their pain is legit and needs pain management ASAP.

Plus get electrophoresis on these people. It's MIND BLOWING how many only have trait but because they have concurrent beta thalassemia or some other pro-anemic disorder they've been misdiagnosed as HgSS their whole life and are just fully dependent and need a opiate taper down rather than any increased dosing. Get their hematologists on the phone. Show them the electrophoresis (which they probably never ran themselves because incredible gullibility seems to be a prerequisite for that specialty), and ask them to make a pain contract with taper down for these people. Now they come by and they have pain contracts that specifically ban Dilaudid use and a 1 year goal to get down to no chronic opiate use that you can hold them to.

I think you just lack either the creativity to dismantle their shenanigans or the motivation to actually deal with these patients in a way that isn't just giving in to the momentum and actually questioning them and trying to manage them for their stated complaint not their stated "what always works is...". I get it. Whenever I hit a new hospital in the area I have to break a lot of the other providers out of the funk they are in with the native population. We are seeing 8-10 per day (so 2-3 per provider every single shift). And Harlem is the single highest population of sickle cell patients in America. Was probably seeing 5 per shift (personally) every shift all residency long.

We got an official protocol in our peds hospital that says treatment for sickle crisis is intra-nasal fentanyl —> morphine 0.1 mg/kg —> ketamine 0.2 mg/kg —> ED decision to admit + IV fentanyl or morphine for pain.

No where in the protocol is dilaudid even offered. Same with Benadryl IV. They can have PO if they want. If you deviate from the protocol you need to document why you deviated from the hospital standard in the MDM.

It’s beautiful and we keep begging to get one on the adult side.

 

[DocEspana]

It sounds like there needs to be buyin, and probably even directed by, Heme. Our sicklers are not being admitted and getting morphine 4mg IV q6 PRN. 1/2 are getting dilaudid 2mg q4, 1/4 are getting higher doses, and 1/4 are on PCA pumps. THese orders are written by Heme consults.

I could easily just say no to them and give one dose of morphine, then they either 1) complain at which point I'll end up having to defend myself, or 2) leave, come back in 12 hours when I'm not there and someone else gives them narcotics.

I suppose some of them can have trait or malingering, but I think all of our sicklers have complications like AVNs, on CKD or on dialysis, etc. I mean they have reasons to have pain.

The only problem I had with your original post is the notion that you could walk into our ER and just only give morphine, tylenol and motrin. And maintain a smile, and be productive and see 2.5/hr, and not have nurses and staff get on your case. It would require culture change and buyin from 35 docs (the size of our group) and with Hematology, and it is certainly possible! And would require a lot of time.

Let's keep in mind that there are emergency departments that have entire days of the week where they give out zero opiates no matter what the complaint is. (And yes, they have to do some creative bookkeeping to accomplish the long bone fracture criteria). The only thing limiting change is the lack of desire to start it.

 

[DocEspana]

We got an official protocol in our peds hospital that says treatment for sickle crisis is intra-nasal fentanyl —> morphine 0.1 mg/kg —> ketamine 0.2 mg/kg —> ED decision to admit + IV fentanyl or morphine for pain.

No where in the protocol is dilaudid even offered. Same with Benadryl IV. They can have PO if they want. If you deviate from the protocol you need to document why you deviated from the hospital standard in the MDM.

It’s beautiful and we keep begging to get one on the adult side.

I know you know this, but for everyone else, we work in the same community. Probably in the top 3 highest densities of sickle cell patients in the US (probably #2, but I'm not certain). Everyone else should take from this that this is fully accomplishable and normal in areas that actually have to deal with huge amounts of sickle cell patients

What holds the community hospitals back for adults in our area is that there is a decently sized cadre of hematologist that became extremely rich running pill mills. Most of them have lost hospital privileges, but they made it hard for the hematologist who mean well to fully enforce something like that since fringe hematologists who also "meant well" by following the trends set by pill mill docs are also still on staff.

 

[The Knife & Gun Club]

It sounds like there needs to be buyin, and probably even directed by, Heme. Our sicklers are not being admitted and getting morphine 4mg IV q6 PRN. 1/2 are getting dilaudid 2mg q4, 1/4 are getting higher doses, and 1/4 are on PCA pumps. THese orders are written by Heme consults.

I could easily just say no to them and give one dose of morphine, then they either 1) complain at which point I'll end up having to defend myself, or 2) leave, come back in 12 hours when I'm not there and someone else gives them narcotics.

I suppose some of them can have trait or malingering, but I think all of our sicklers have complications like AVNs, on CKD or on dialysis, etc. I mean they have reasons to have pain.

The only problem I had with your original post is the notion that you could walk into our ER and just only give morphine, tylenol and motrin. And maintain a smile, and be productive and see 2.5/hr, and not have nurses and staff get on your case. It would require culture change and buyin from 35 docs (the size of our group) and with Hematology, and it is certainly possible! And would require a lot of time.

I know you know this, but for everyone else, we work in the same community. Probably in the top 3 highest densities of sickle cell patients in the US (probably #2, but I'm not certain). Everyone else should take from this that this is fully accomplishable and normal in areas that actually have to deal with huge amounts of sickle cell patients

What holds the community hospitals back for adults in our area is that there is a decently sized cadre of hematologist that became extremely rich running pill mills. Most of them have lost hospital privileges, but they made it hard for the hematologist who mean well to fully enforce something like that since fringe hematologists who also "meant well" by following the trends set by pill mill docs are also still on staff.

That’s exactly the rub is you just need a critical mass of people on hospital leadership to put something in writing about how these cases should be managed.

Honestly just like everything in medicine - whenever there’s lots of practice variation it’s easy for care to get lazy. It doesn’t even need to be set in stone just a guideline signed by the chair of the involved departments saying “this is how we usually do things here.”

Because then no one wants to rock the boat and when patients complain you have a protocol to point to and say “hey we did it the way we said we’d do it!”