All Hands Holding on Deck

[valianteffort]

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I haven’t been an ER doc as long as most of the people in this thread, but recently I have noticed the capacity of patients young and old to handle any sort of minimal issue has declined. I don’t recall it being this way always, but wondering what other docs think. Maybe covid has brought out americas inability to handle everything small or big. My hand holding increases every shift and with each hand held my fuse shortens.

Example 1: middle aged females with unexplained abdominal pain just can’t not get their pain under control with heavy narcs

Example 2: young gen z folks in MVCs with no sig injuries crying from pain? Anxiety? Not sure they even know.

Example 3: elderly folks really worried about their bowel movements and how they haven’t had one in 2 days which has caused them great distress

Example 4: young and old folks calling ems for cold like symptoms without trying any otc meds first. Parents bringing in kids with the same.

I know this was all always happening, but the rate of it happening seems to have climbed and continues to do so.

 

[EctopicFetus]

I haven’t been an ER doc as long as most of the people in this thread, but recently I have noticed the capacity of patients young and old to handle any sort of minimal issue has declined. I don’t recall it being this way always, but wondering what other docs think. Maybe covid has brought out americas inability to handle everything small or big. My hand holding increases every shift and with each hand held my fuse shortens.

Example 1: middle aged females with unexplained abdominal pain just can’t not get their pain under control with heavy narcs

Example 2: young gen z folks in MVCs with no sig injuries crying from pain? Anxiety? Not sure they even know.

Example 3: elderly folks really worried about their bowel movements and how they haven’t had one in 2 days which has caused them great distress

Example 4: young and old folks calling ems for cold like symptoms without trying any otc meds first. Parents bringing in kids with the same.

I know this was all always happening, but the rate of it happening seems to have climbed and continues to do so.

Example 1 - no narcs.. give droperidol.
Example 2 - toradol and “its gonna suck for a while”
Example 3- it’s rarely constipation. If you conclude it is, mag citrate at home and miralax QD.
Example 4 - swift dc.

It aint new.. imo its not any worse than it was.. perhaps regional?

 

[Dr Mantis Toboggan]

Think about what your parents taught you about going to the ED. Many people do still feel that way. But a lot don’t, and that’s who we see.

 

[HemorrhagicShock]

Reason #69 to avoid EM: The patients.

 

[RustedFox]

Reason #69 to avoid EM: The patients.

The number one source of burnout is...

 

[JacobMcCandles]

I think it has gotten significantly worse since COVID. The number of people who can't deal with any kind of pain or discomfort is through the roof. I just shrug my shoulders and move on.

 

[RustedFox]

I haven’t been an ER doc as long as most of the people in this thread, but recently I have noticed the capacity of patients young and old to handle any sort of minimal issue has declined. I don’t recall it being this way always, but wondering what other docs think. Maybe covid has brought out americas inability to handle everything small or big. My hand holding increases every shift and with each hand held my fuse shortens.

"Goood. Let the hate flow through you, young Skywalker."

Example 1: middle aged females with unexplained abdominal pain just can’t not get their pain under control with heavy narcs

More anxiety than pain. I'm sure what also plays a role is that we teach a lot of little girls that they are princesses and that if they tantrum hard enough that their whims will be met.

Example 2: young gen z folks in MVCs with no sig injuries crying from pain? Anxiety? Not sure they even know.

They don't know, bro.

Example 3: elderly folks really worried about their bowel movements and how they haven’t had one in 2 days which has caused them great distress

This has been around since the days of Osler.

Example 4: young and old folks calling ems for cold like symptoms without trying any otc meds first. Parents bringing in kids with the same.

Had a mom call EMS because their kid had a fever of 99.5 the other night. Immediately discharged.

I know this was all always happening, but the rate of it happening seems to have climbed and continues to do so.

Insert chadface "Yes." meme

 

[thegenius]

i get the sense too that we are losing coping skills as a society, based on what shows up at the ER.

 

[Tiger26]

"Goood. Let the hate flow through you, young Skywalker."



More anxiety than pain. I'm sure what also plays a role is that we teach a lot of little girls that they are princesses and that if they tantrum hard enough that their whims will be met.



They don't know, bro.



This has been around since the days of Osler.



Had a mom call EMS because their kid had a fever of 99.5 the other night. Immediately discharged.



Insert chadface "Yes." meme

One the best mic drops is the discharge before EMS gets out of the room at dropoff

 

[Rekt]

I don’t see how it could be possible that it’s always been like this. All the old heads that show up doing locums at my shop say the patient population across the country has gone into the toilet, especially post COVID.

I’m only a few years out and feel like it’s worse nearly monthly. I don’t know how probably 80% of my patients even function day to day. Most of them are completely non contributory to society. Absolutely zero coping skills for even seconds of vague discomfort. I think Sick-tok should also be a big part of the blame. They sit on social media all day long and search for XYZ random symptoms and cling to the flavor of the month diagnosis that mid levels diagnosis these *****s with hoping we will do the same for them.

 

[Mount Asclepius]

If you can’t be a Vietnamese elder, then be an old rancher. If you can’t be an old rancher, then be Amish. If you can’t be Amish, then be a crusty EP after 10+ years in the PIT. All of these avoid the ED like the plague unless they have a fighting chance. If no chance, then it’s death surrounded by your love ones far away from a Hospital. It isn’t for the faint of heart, and it certainly isn’t for TikTok.

 

[Pinner Doc]

I really see the gamut.

On my last shift I saw a 60 ish sheep farmer (that should have been my clue) with a bad headache that had come and gone for the past five days. He’d been dealing with it at home. He had a SAH. (Newbs: respect the farmers.)

Later on I saw a man for one month of dysuria. One month. Came to the ER on a Monday evening, presumably saw the state of the waiting room, and only waited two hours. Both he and his son complained to me repeatedly about the wait. They literally said to me, because they waited 30 min in their room before I saw them, “Did you all die out there?” When I quipped back that in fact, yes, people are dying “out there” because this is an ER, they seemed flummoxed. And still continued to harp on how long they had to wait throughout the encounter. So many treat the ER like the instant diagnostic center.

Edited to add that the fact that people use the ER for convenience or lack of coping skills isn’t actually what fazes me. It’s the dressing me down about wait times aspect that I have never, ever been able to let roll off my back. My number one gripe.

 

[AlmostAnMD]

This has been around since the days of Osler.

Solid missed opportunity for "Osler chodes."

 

[RE-Tired]

Reason #69 to avoid EM: The patients.

full disclosure: Retired pathologist but strongly considered ER, until I did 2mos in internship and 2 12 hr weekend shifts per every 4 weeks as a GMO in the Army. Because of that I feel your pain (even now 40 years later). What I hated most was the 50% plus patients who were abusing the ER and admin who only cared about keeping wait times short.
I don't know how you survive (mentally) these days as so many people use the ER as a Primary care clinic. I read the ER threads because I have a very good young friend in ER now practicing for 5+ years and just went to RVU compensation this year. I talk to her frequently about her work and I couldn't survive one month after the way she gets treated by management and many patients. Her goal like a lot of you is save money then reduce shifts.
One thread on your forum I like is ER docs owning their own clinics; then the money would at least go to the Docs instead of the Venture (Vulture) Capitalists. Good luck, ER is vital for our healthcare system.

 

[WhatJobDoIPick]

It's what I've coined ALS.

Acute Loser Syndrome.

And it has absolutely gotten worse in the past 5 years.

The worst afflicted are the Medicare / Medicaid / self pay (aka zero pay) populations that also contribute nothing to society. (Note the qualifier here before you go all righteous indignation; there are plenty of Medicaid folks that are hard working and perfectly pleasant).

Risk factors for ALS: bad parentage, zero work ethic, not running, not lifting, consuming social media 20 hours / day.

The worst part is the hospitals and groups continue to cater to those with ALS, instead of writing them off as unsolvable problems.

 

[VA Hopeful Dr]

It's what I've coined ALS.

Acute Loser Syndrome.

And it has absolutely gotten worse in the past 5 years.

The worst afflicted are the Medicare / Medicaid / self pay (aka zero pay) populations that also contribute nothing to society. (Note the qualifier here before you go all righteous indignation; there are plenty of Medicaid folks that are hard working and perfectly pleasant).

Risk factors for ALS: bad parentage, zero work ethic, not running, not lifting, consuming social media 20 hours / day.

The worst part is the hospitals and groups continue to cater to those with ALS, instead of writing them off as unsolvable problems.

I had a patient come into the office yesterday wanting me to write a note to her insurance company so they would pay for someone to come clean her house and cook for her.

When I asked her what medical condition she had that made it so she was unable to do that, she told me that she has been sedentary her whole life and was now just too old. She has a walker but that is too much work for her so she is paying out-of-pocket for an electric scooter for her house.

 

[Arcan57]

There's a lot less certainty in society now. At least the perception for mainstream society used to be that there was a path that guaranteed having a certain type of life. For white collar families, it was college=successful middle class life. For blue collar families, it was union jobs or busting your butt in a trade. For upper class, it was don't screw up whatever your parents did too badly. For immigrants, it was work hard, get enough capital to open a business, and your kids and their kids would have access to the white collar world.

Whether that perception was ever really mathed reality was true is a matter for debate, but there was the perception of a path forward for the majority of people. I don't think we have that as a society anymore. And that uncertainty gets internalized and somatized. And if there's one thing that TikTok and Amazon Prime have taught us, the fastest option is always the best option. So they come to us like Harry Potter dementors asking us to solve non-medical problems while either ignoring or actively furthering the processes that are causing the problems in the first place.

 

[Saddleshoes]

It's what I've coined ALS.

Acute Loser Syndrome.

And it has absolutely gotten worse in the past 5 years.

The worst afflicted are the Medicare / Medicaid / self pay (aka zero pay) populations that also contribute nothing to society. (Note the qualifier here before you go all righteous indignation; there are plenty of Medicaid folks that are hard working and perfectly pleasant).

Risk factors for ALS: bad parentage, zero work ethic, not running, not lifting, consuming social media 20 hours / day.

The worst part is the hospitals and groups continue to cater to those with ALS, instead of writing them off as unsolvable problems.

ALS -- Acute Loser Syndrome ---- Love the concept!

I agree with ALS being on the rise. I suspect it is directly related to our overly protected childhood in this society. There was a time that ALS was corrected on the playground. But that is not allowed these days.

 

[Dral]

(Newbs: respect the farmers.)

QFT. Trying to get them in for even routine stuff is like pulling teeth, let alone the serious stuff.

"You have been diagnosed with a bad melanoma. You need to come in for treatment and follow up. This can kill you."

"But do I really need to come to get that scan and see the oncologist in July?"

Having to leave the farm even for a few hours is a huge disruption for them; so when they do, it's gotta be pretty damn important.

 

[WhatJobDoIPick]

ALS -- Acute Loser Syndrome ---- Love the concept!

I agree with ALS being on the rise. I suspect it is directly related to our overly protected childhood in this society. There was a time that ALS was corrected on the playground. Be that is not allowed these days.

I'm fine dealing with ALS. It's quite curable through a security mediated discharge.

What I am less motivated to do is to placate the hospitals/groups in dealing w these trolls, seeing them swiftly and also dealing w the patient satisfaction results.

 

[southerndoc]

I had a patient come into the office yesterday wanting me to write a note to her insurance company so they would pay for someone to come clean her house and cook for her.

When I asked her what medical condition she had that made it so she was unable to do that, she told me that she has been sedentary her whole life and was now just too old. She has a walker but that is too much work for her so she is paying out-of-pocket for an electric scooter for her house.

I thought you were going to say end-stage cardiac fibromyalgia or something. Debilitating POTS treated with antidepressants.

 

[RustedFox]

ALS -- Acute Loser Syndrome ---- Love the concept!

I agree with ALS being on the rise. I suspect it is directly related to our overly protected childhood in this society. There was a time that ALS was corrected on the playground. Be that is not allowed these days.

"Mothers teach you to crawl.
Fathers teach you to rise or fall.
Mothers grieve for us all.
Fathers teach us to take them on."

- Black Rebel Motorcycle Club.

 

[RustedFox]

I don’t see how it could be possible that it’s always been like this. All the old heads that show up doing locums at my shop say the patient population across the country has gone into the toilet, especially post COVID.

I’m only a few years out and feel like it’s worse nearly monthly. I don’t know how probably 80% of my patients even function day to day. Most of them are completely non contributory to society. Absolutely zero coping skills for even seconds of vague discomfort. I think Sick-tok should also be a big part of the blame. They sit on social media all day long and search for XYZ random symptoms and cling to the flavor of the month diagnosis that mid levels diagnosis these *****s with hoping we will do the same for them.

I have several of your posts saved to a file on my desktop.

Gonna add this one.

My favorite to date is where you went off saying: "Do Emergency medicine if you want to take care of greenhaired teenagers, jabba the hutt nursing home dumps, psych that is beyond unfixable (plot twist: it's drugs)... etc."

Jamie, pull that post up.

 

[JacobMcCandles]

I'm fine dealing with ALS. It's quite curable through a security mediated discharge.

What I am less motivated to do is to placate the hospitals/groups in dealing w these trolls, seeing them swiftly and also dealing w the patient satisfaction results.

Sadly, these are the populations most likely to return a Press Ganey. There should be some kind of cutoff that if you’re seen more than 3 times in the ED a year then you can’t participate in Press Ganey.

 

[WhatJobDoIPick]

Sadly, these are the populations most likely to return a Press Ganey. There should be some kind of cutoff that if you’re seen more than 3 times in the ED a year then you can’t participate in Press Ganey.

See all the patients, see them quickly, and make sure to fluff them up to please them. Never mind that half the patients are in the hallway, and that we don't give your the resources to do your job effectively.

 

[Tenk]

I agree that over time, people are definitely becoming weaker and covid seems to have accelerated this process. However, #3 has probably been true since the dawn of mankind and is nothing new at all.

 

[RustedFox]

Can we really call it "ALS" for acute loser syndrome?
Seems chronic to me.
CLS?

It's CLS with exacerbation.
Acute-on-chronic loser syndrome.

 

[WhatJobDoIPick]

Can we really call it "ALS" for acute loser syndrome?
Seems chronic to me.
CLS?

It's CLS with exacerbation.
Acute-on-chronic loser syndrome.

If you say "uncontrolled ALS" you get more points for COPA!

 

[CliveStaples]

I suspect the problem is two-fold:

1) Increasing comforts in all other aspects of life make the relative discomfort of illness even more intolerable. Medical advances have increasingly been devoted to prolonging life and managing chronic disease, but surprisingly little has been developed to revolutionize our perception of symptoms, such as pain, fatigue, and anxiety. Likely nobody wants to tread into this space after how bad opiate pain medication blew up on insurance companies.

2) The medical system has been stretched thin, with efforts spent primarily to produce more high-margin opportunities (elective surgeries, expensive drug therapies like monoclonal antibodies and chemotherapies, etc.) but where the majority of people need access is to acute care primary care. We don't have a system that allows for family doctors to keep open time slots for their patients to see them same-day or next-day, so they will come to the place that is guaranteed and legally obligated to evaluate them, the ED.

 

[alpinism]

I've been working a few shifts a month with the IHS for the last year and despite the presence of relatively quick and 100% free PCP services where patients can schedule their appointment in less than one week I'd still estimate that no less than 50% of all our cases are still viral URIs. Fact of the matter is that EDs are seen as the McDonald's of medical care with all hours on demand labs and scans for even minor illnesses.

 

[WhatJobDoIPick]

I've been working a few shifts a month with the IHS for the last year and despite the presence of relatively quick and 100% free PCP services where patients can schedule their appointment in less than one week I'd still estimate that no less than 50% of all our cases are still viral URIs. Fact of the matter is that EDs are seen as the McDonald's of medical care with all hours on demand labs and scans for even minor illnesses.

What's the metric culture like working for IHS? Does admin care about pt sat and speed?

 

[alpinism]

What's the metric culture like working for IHS? Does admin care about pt sat and speed?

The IHS is in essence socialized medicine so there's no financial incentive to focus on metrics.

If anything they prefer you to not overtest and overtreat since it will cost them money in the budget.

It's certainly not perfect but one of the main benefits is that I get to practice evidence based medicine.

 

[alpinism]

What's the metric culture like working for IHS? Does admin care about pt sat and speed?

But to specifically answer the question there are no PG scores and no PG bonuses.

 

[Apollyon]

I've been working a few shifts a month with the IHS for the last year and despite the presence of relatively quick and 100% free PCP services where patients can schedule their appointment in less than one week I'd still estimate that no less than 50% of all our cases are still viral URIs. Fact of the matter is that EDs are seen as the McDonald's of medical care with all hours on demand labs and scans for even minor illnesses.

Do you work with uniformed PHS docs?

 

[alpinism]

Do you work with uniformed PHS docs?

There's a small number of them at the hospitals but the vast majority are locums docs.

 

[WhatJobDoIPick]

Honestly I don't know how this model of modern EM has survived. Probably 80% of the patients I've seen the last 3 days of been some flavor of nonsense. I don't see how this doesn't end with convergence of the system into some sort of single payor thing, with hard restrictions on patients visiting the ED and a mass firing of ED "providers" as the volume will be nil.

 

[Tiger26]

Honestly I don't know how this model of modern EM has survived. Probably 80% of the patients I've seen the last 3 days of been some flavor of nonsense. I don't see how this doesn't end with convergence of the system into some sort of single payor thing, with hard restrictions on patients visiting the ED and a mass firing of ED "providers" as the volume will be nil.

Couldn't agree more--saw 20ish pts at our critical access hospital during my last shift with nothing resembling even a minor emergency.

 

[Apollyon]

New person signed up for SDN just after midnight Eastern, name of EMRespect. Please don't burn them to a crisp if they show up!

 

[TooMuchResearch]

New person signed up for SDN just after midnight Eastern, name of EMRespect. Please don't burn them to a crisp if they show up!

 

[AlmostAnMD]

Honestly I don't know how this model of modern EM has survived. Probably 80% of the patients I've seen the last 3 days of been some flavor of nonsense. I don't see how this doesn't end with convergence of the system into some sort of single payor thing, with hard restrictions on patients visiting the ED and a mass firing of ED "providers" as the volume will be nil.

I go back and forth on this.

I'm in favor of a massive paycut in that particular scenario. Imagine the QoL increase!

you'd see 0.5 pph most places

virtually all of them would be meaningfully ill

I'd take a 50% paycut in a heartbeat for low volume, moderate-high acuity indefinitely. You can't put a price on job satisfaction, unless you've got multiple divorces/kids to pay for I guess

 

[WhatJobDoIPick]

I go back and forth on this.

I'm in favor of a massive paycut in that particular scenario. Imagine the QoL increase!

you'd see 0.5 pph most places

virtually all of them would be meaningfully ill

I'd take a 50% paycut in a heartbeat for low volume, moderate-high acuity indefinitely. You can't put a price on job satisfaction, unless you've got multiple divorces/kids to pay for I guess

What makes you think you'll be in the 20% that keep their jobs?

I bet they'll use MIPS/MACRA data to pick who gets to work

 

[AlmostAnMD]

What makes you think you'll be in the 20% that keep their jobs?

I bet they'll use MIPS/MACRA data to pick who gets to work

fair point

probably a press-ganey filter

keep admin gears lubed up

 

[HemorrhagicShock]

I go back and forth on this.

I'm in favor of a massive paycut in that particular scenario. Imagine the QoL increase!

you'd see 0.5 pph most places

virtually all of them would be meaningfully ill

I'd take a 50% paycut in a heartbeat for low volume, moderate-high acuity indefinitely. You can't put a price on job satisfaction, unless you've got multiple divorces/kids to pay for I guess

I would take this instantly because when the pace is very reasonable, the job becomes so much more meaningful when you can spend time with patients (usually in their worst moments)

Impossible with how community EM is practiced in desirable areas

 

[The Knife & Gun Club]

I go back and forth on this.

I'm in favor of a massive paycut in that particular scenario. Imagine the QoL increase!

you'd see 0.5 pph most places

virtually all of them would be meaningfully ill

I'd take a 50% paycut in a heartbeat for low volume, moderate-high acuity indefinitely. You can't put a price on job satisfaction, unless you've got multiple divorces/kids to pay for I guess

Basically this is a CCM fellowship.

Sacrifice $600,000 in lost wages over 2 years to make roughly the same amount per year, but like 1/10th of the nonsense.

People complain/admin complains I kindly tell them to get bent cuz it’s the ICU there were more pressing issues at hand, or deploy my NP to have a futile goals of care discussion.

At our busy community shop I just walk down at the start of the shift and tell the ED docs to just call me directly with the sick ones and I’ll take them off their hands if they’d rather. Do the ED + ICU course myself. I get maybe 6 people in a 12 hour shift plus rounding on my rocks which is boring.

Some of the downstairs docs still like doing the resus’ themselves but lots are happy to not be stuck in the hour long resus/line/GOC/POCUS fiesta in the resus room.

 

[HemorrhagicShock]

Basically this is a CCM fellowship.

Sacrifice $600,000 in lost wages over 2 years to make roughly the same amount per year, but like 1/10th of the nonsense.

People complain/admin complains I kindly tell them to get bent cuz it’s the ICU there were more pressing issues at hand, or deploy my NP to have a futile goals of care discussion.

At our busy community shop I just walk down at the start of the shift and tell the ED docs to just call me directly with the sick ones and I’ll take them off their hands if they’d rather. Do the ED + ICU course myself. I get maybe 6 people in a 12 hour shift plus rounding on my rocks which is boring.

Some of the downstairs docs still like doing the resus’ themselves but lots are happy to not be stuck in the hour long resus/line/GOC/POCUS fiesta in the resus room.

The further I get from EM practice even CCM seems tedious.

Appreciate all that you do and glad you got out of EM

 

[The Knife & Gun Club]

The further I get from EM practice even CCM seems tedious.

Appreciate all that you do and glad you got out of EM

It’s totally tedious. But most jobs are tedious to a degree.

 

[valianteffort]

I go back and forth on this.

I'm in favor of a massive paycut in that particular scenario. Imagine the QoL increase!

you'd see 0.5 pph most places

virtually all of them would be meaningfully ill

I'd take a 50% paycut in a heartbeat for low volume, moderate-high acuity indefinitely. You can't put a price on job satisfaction, unless you've got multiple divorces/kids to pay for I guess

The release of this product will correlate the drop in patient volume you desire. One day...

 

[RustedFox]

View attachment 401754
The release of this product will correlate the drop in patient volume you desire. One day...

I have something similar for my bedroom.
Smells amazing now.
Helps me daysleep.

 

[DocEspana]

There is a dramatic increase in "this **** has to be psychosomatic or secondary to chronic depression." and I think *A LOT* of the Icantcopeitis is because of just worsening psych status. Just so many people with simmering depression of various types. Likely secondary to societal changes, but so much harder to say exactly which ones. What I can be certain of is that it isnt because of floride in the water or BPA in the nalgene bottles, no matter how much my patients tells me otherwise.

 

[HemeOncHopeful19]

Honestly I don't know how this model of modern EM has survived. Probably 80% of the patients I've seen the last 3 days of been some flavor of nonsense. I don't see how this doesn't end with convergence of the system into some sort of single payor thing, with hard restrictions on patients visiting the ED and a mass firing of ED "providers" as the volume will be nil.

Is there a single payor system in existence that has "hard restrictions" on ED visits?

That seems politically and culturally impossible in the US... I mean people get up in arms about even having a $8 copay for ED visits for Medicaid patients...