Anyone else's ED on fire?

[GonnaBeADoc2222]

Our LWBS is through the roof, wait times 7+ hours, patients are agitated and yelling.

Issues are: ED boarding, perceived lack of space to place new ED patients, underperforming physicians and nurses.

I could fix this situation in 1 week if given the power, yet admin (including physician "leadership") offers nothing.

I'll just disappear into the shadows and keep collecting my check I guess.

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[RuralEDDoc]

Same. Each shift is difficult and it’s sad because it’s not difficult from managing sick patients. Difficult due to trying to see and treat patients in waiting rooms, orders not being implemented, spending hours per shift tracking down patients and wayward labs. Sick or not sick these patients are getting very poor care.

 

[Pudortu]

Our LWBS is through the roof, wait times 7+ hours, patients are agitated and yelling.

Issues are: ED boarding, perceived lack of space to place new ED patients, underperforming physicians and nurses.

I could fix this situation in 1 week if given the power, yet admin (including physician "leadership") offers nothing.

I'll just disappear into the shadows and keep collecting my check I guess.

How would you fix it?

 

[NYEMMED]

The dumpster fire is burning!!!

 

[Rekt]

Yep. Some of the busiest days I've ever had recently. Working nights has been rough. All the crap built up during the day leaks into the night and we still have 20-30 in the WR at 1am while I'm still getting emergency traffic ems tying up the short staffed department.. then finally when the others come back it's my fault that I couldn't find a reason why grandpa Joe, who's 97 years old, has been lightheaded for two months. Like it's a miracle his ass even wakes up every day. I'm about to lose my mind

 

[NYEMMED]

Yep. Some of the busiest days I've ever had recently. Working nights has been rough. All the crap built up during the day leaks into the night and we still have 20-30 in the WR at 1am while I'm still getting emergency traffic ems tying up the short staffed department.. then finally when the others come back it's my fault that I couldn't find a reason why grandpa Joe, who's 97 years old, has been lightheaded for two months. Like it's a miracle his ass even wakes up every day. I'm about to lose my mind

Of course you are probably solo staffed at night “because nobody comes in at night” never take into account the 20-30 that never made it back yet

 

[GonnaBeADoc2222]

How would you fix it?

a) Boarding: Force inpatient units to take hallway inpatients

b) "Lack of space": Put a vertical patient in a hallway spot every 10 ft; double up rooms

c) Underperformance: set strict performance metrics for pph (something reasonable - people are seeing 1.2 pph at my shop, which is ridiculous) for physicians / midlevels; and time from order input to completion for nurses (I am waiting 1-3 hours for lab draws; 2-6 hours for urine). Terminate those that do not comply.

Terminate middle management who don't subscribe to your new culture and replace them with ones that do.

Plenty of young new grad nurses and physicians out there who are willing to work hard for more incentive.

 

[CoolDoc1729]

Of course you are probably solo staffed at night “because nobody comes in at night” never take into account the 20-30 that never made it back yet

🙋🏻‍♀️

 

[thegenius]

Last 2 months running daily capacities at 1.3 - 1.5x normal volumes. It's exhausting, largely because people still, in 2022, have the expectation that we have magic elixirs for their cold symptoms.

But it's also an increasing burden of other things that slowly take their toll:
- minor workplace injuries where employers demand an immediate ER evaluation for their non-injury and a work note saying something
- people coming to ER to get a work note saying they can go back to work
- occupational health saying go to the ER first for your workplace injury, then we will see you 2-3 days later
- PD getting medical clearance on over 50% (or so it appears) of all arrests they do

the list goes on and on and on

ER is a failed health care model. It needs to be completely revamped or else the overall health of the nation will steadily decrease due to lack of capacity to treat truly sick people. We are going down a green circle ski run....so it's not difficult on a turn by turn basis, but we cannot stop and we cannot go back up the hill and start over. The classic slippery slope where the slope in this case is rather shallow but irreversible.

 

[WilcoWorld]

Last 2 months running daily capacities at 1.3 - 1.5x normal volumes. It's exhausting, largely because people still, in 2022, have the expectation that we have magic elixirs for their cold symptoms.

But it's also an increasing burden of other things that slowly take their toll:
- minor workplace injuries where employers demand an immediate ER evaluation for their non-injury and a work note saying something
- people coming to ER to get a work note saying they can go back to work
- occupational health saying go to the ER first for your workplace injury, then we will see you 2-3 days later
- PD getting medical clearance on over 50% (or so it appears) of all arrests they do

the list goes on and on and on

ER is a failed health care model. It needs to be completely revamped or else the overall health of the nation will steadily decrease due to lack of capacity to treat truly sick people. We are going down a green circle ski run....so it's not difficult on a turn by turn basis, but we cannot stop and we cannot go back up the hill and start over. The classic slippery slope where the slope in this case is rather shallow but irreversible.

It's almost like we could solve 95% of the problem if we actually empowered ER Docs to say "that's not an emergency, move along".

 

[thegenius]

It's almost like we could solve 95% of the problem if we actually empowered ER Docs to say "that's not an emergency, move along".

Ehhh...I think every ER doc wants to say this. I do.

We can't because most hospitals need high ER volumes to stay financially solvent. It's the reason why I look forward to a different payment model instead of FFS. One where a community gets a yearly lump sum from fed and state to take care of that population and that's it. So hospitals will be incentivized to see and do less instead of the opposite.

I know it sounds draconian. That hospitals and doctors should be incentivized to do less. I don't know another way to handle this unless we continue to charge people more and more money. I'm not opposed to that either.

Our system is so f'ed up. There is no easy way to fix this and there is little will power to fix it. We have so much money to spend on people and most of it gets siphoned away from the patient.

 

[WilcoWorld]

hospitals and doctors should be incentivized to do more effective care and less ineffective care

There, that's not draconian

 

[GonnaBeADoc2222]

I don't do work clearances. People bring their workman's comp paperwork in and I refuse to fill it out.

 

[thegenius]

I don't do work clearances. People bring their workman's comp paperwork in and I refuse to fill it out.

I would love to hear those conversations.

 

[GonnaBeADoc2222]

I would love to hear those conversations.

"Sorry, we don't fill this out here. You have to go to your primary care doctor."

Walks out of the room.

Nurse "Patient wants you to fill out his paperwork."

Me "I already explained that I don't fill that out."

Continues to do what I was doing.

 

[thegenius]

HAHAHA
Somehow I can imagine not every conversation goes like that.
But yea I get your point.

You say "We" or "I"?
Is this an longstanding ER policy you guys have? Or just you?

 

[CoolDoc1729]

HAHAHA
Somehow I can imagine not every conversation goes like that.
But yea I get your point.

You say "We" or "I"?
Is this an longstanding ER policy you guys have? Or just you?

Are we talking about actual workman’s comp insurance, or a form that says what restrictions a patient has for return to work, and what tests they had?
I’ve never been asked to do workman comp paperwork.
My hospital is near a large auto manufacturing plant, and we get all their after hours injuries .. I do the 3 line forms for those …

 

[turkeyjerky]

Are we talking about actual workman’s comp insurance, or a form that says what restrictions a patient has for return to work, and what tests they had?
I’ve never been asked to do workman comp paperwork.
My hospital is near a large auto manufacturing plant, and we get all their after hours injuries .. I do the 3 line forms for those …

What's a "3 line form"? My old hospital used to be near an amazon warehouse and a few plants. We'd get a fair amount of minor injuries as well as aches and pains from repetitive overuse, where basically the whole reason for the visit was to get some form filled out. These forms were inevitably several pages long, w/ a litany of questions unanswerable in the ER setting and basically looked like a wall of tiny text. Many of these patients had refused to be evaluated by the company's occ health clinic in order to come to the ER in the middle of the night. I never had any qualms telling them that I didn't fill out any work forms, but that I'd give them a note saying they were seen and what type injury and restrictions they had ("wrist pain" "needs PCP or occupational health followup" and "able to return to restricted duty as tolerated").

 

[thegenius]

Are we talking about actual workman’s comp insurance, or a form that says what restrictions a patient has for return to work, and what tests they had?
I’ve never been asked to do workman comp paperwork.
My hospital is near a large auto manufacturing plant, and we get all their after hours injuries .. I do the 3 line forms for those …

yea I guess there are a variety of forms, i wasn't specific enough.

 

[RustedFox]

Yep. Some of the busiest days I've ever had recently. Working nights has been rough. All the crap built up during the day leaks into the night and we still have 20-30 in the WR at 1am while I'm still getting emergency traffic ems tying up the short staffed department.. then finally when the others come back it's my fault that I couldn't find a reason why grandpa Joe, who's 97 years old, has been lightheaded for two months. Like it's a miracle his ass even wakes up every day. I'm about to lose my mind

 

[Tenk]

 

[NYEMMED]

HAHAHA
Somehow I can imagine not every conversation goes like that.
But yea I get your point.

You say "We" or "I"?
Is this an longstanding ER policy you guys have? Or just you?

We do have a policy at my ED that we don’t fill out any workers comp forms. They are told by all the nurses and docs, that “it will not be filled out here” and you need to see your pcp or call your job for an occupational health facility.

We happily see and treat all injuries, but will not fill out the forms, especially for work clearance

 

[BoardingDoc]

HAHAHA
Somehow I can imagine not every conversation goes like that.
But yea I get your point.

You say "We" or "I"?
Is this an longstanding ER policy you guys have? Or just you?

Yeah, this is similarly a non-issue at my shop. None of my colleagues do these forms. "You have to see your PCP or occ health for this." Most people say OK and go away. Some complain and give some reason why we have to make an exception for them, at which point we don't, and they go away.

 

[sylvanthus]

Our LWBS is through the roof, wait times 7+ hours, patients are agitated and yelling.

Issues are: ED boarding, perceived lack of space to place new ED patients, underperforming physicians and nurses.

I could fix this situation in 1 week if given the power, yet admin (including physician "leadership") offers nothing.

I'll just disappear into the shadows and keep collecting my check I guess.

I get some satisfaction watching all these quality metrics goto complete ****.

 

[emergentmd]

When I started EM
20 yrs ago - 60ppd, decent coverage, saw 2pph, many nights you slept 4-6 hrs. Winter busy with rare holds, summer slow to recharge. Had dedicated sleep room.
15 yrs. ago - 80 ppd, decent coverage, added app, saw 2pph but more complicated, rarely slept at nights. Winter busy with holds, summer slow to recharge.
10 yrs ago - 120 ppd, same MD coverage, added multiple app, saw 2pph but now everyone complicated. Winter busy, holds every minute of the day, summer busy with some sporadic holds. Took sleep room away.
5 yrs ago - 140 ppd, one added md coverage, more app, saw 2pph, but now half ER always holding pts and sometimes all beds with holds. Winter like a zoo, summer feels like winter 10 yrs ago. Holds all the time.

For some reason pay never increased. Glad I left. Our EM group 20 yrs ago almost never had anyone leave. Now they leave in droves in a top 10 city to live.

Sad where EM has become even in "unicorn places". When I finally got out, something always tugged at me to do some shifts. Now I would not do it for $800/hr.

 

[miacomet]

When I started EM
20 yrs ago - 60ppd, decent coverage, saw 2pph, many nights you slept 4-6 hrs. Winter busy with rare holds, summer slow to recharge. Had dedicated sleep room.
15 yrs. ago - 80 ppd, decent coverage, added app, saw 2pph but more complicated, rarely slept at nights. Winter busy with holds, summer slow to recharge.
10 yrs ago - 120 ppd, same MD coverage, added multiple app, saw 2pph but now everyone complicated. Winter busy, holds every minute of the day, summer busy with some sporadic holds. Took sleep room away.
5 yrs ago - 140 ppd, one added md coverage, more app, saw 2pph, but now half ER always holding pts and sometimes all beds with holds. Winter like a zoo, summer feels like winter 10 yrs ago. Holds all the time.

For some reason pay never increased. Glad I left. Our EM group 20 yrs ago almost never had anyone leave. Now they leave in droves in a top 10 city to live.

Sad where EM has become even in "unicorn places". When I finally got out, something always tugged at me to do some shifts. Now I would not do it for $800/hr.

Damn. But you have other gigs, no?

 

[sylvanthus]

I just checked, we have 900 incomplete charts still sitting on the ED board from our clusterF of an epic hack a few weeks back. ALL the metrics are fuxxored. Hahhahahahhahahaha

 

[bravotwozero]

Patient volumes at my shop haven't been bad, but the patients themselves are quite a volatile bunch in these parts, with most of my volume being med clearence, intoxication patients, and involuntary psych holds.

On shift right now, just had mr jailbird brought in by PD for vomiting after some alcohol. after i clear and dc him, he proceeds to break off the IV pole with his bare hands, use it to destroy the cardiac monitor (and we're already short) throw a container full of his pee at the sherriff, flip over his bed while still being handcuffed to it and attempt to use it as a barricade. Sherriffs had to call for backup, with one of them showing up with a fluorescent orange gun that fired large buckshot pepper rounds lol. I so wanted him to use it, but disappointingly it didn't happen and he finally got escorted out by 6 cops.

 

[VA Hopeful Dr]

Ehhh...I think every ER doc wants to say this. I do.

We can't because most hospitals need high ER volumes to stay financially solvent. It's the reason why I look forward to a different payment model instead of FFS. One where a community gets a yearly lump sum from fed and state to take care of that population and that's it. So hospitals will be incentivized to see and do less instead of the opposite.

I know it sounds draconian. That hospitals and doctors should be incentivized to do less. I don't know another way to handle this unless we continue to charge people more and more money. I'm not opposed to that either.

Our system is so f'ed up. There is no easy way to fix this and there is little will power to fix it. We have so much money to spend on people and most of it gets siphoned away from the patient.

Medicare Advantage plans already work that way. Bunch of them are currently being sued by the government for various fraud type things.

 

[sylvanthus]

Patient volumes at my shop haven't been bad, but the patients themselves are quite a volatile bunch in these parts, with most of my volume being med clearence, intoxication patients, and involuntary psych holds.

On shift right now, just had mr jailbird brought in by PD for vomiting after some alcohol. after i clear and dc him, he proceeds to break off the IV pole with his bare hands, use it to destroy the cardiac monitor (and we're already short) throw a container full of his pee at the sherriff, flip over his bed while still being handcuffed to it and attempt to use it as a barricade. Sherriffs had to call for backup, with one of them showing up with a fluorescent orange gun that fired large buckshot pepper rounds lol. I so wanted him to use it, but disappointingly it didn't happen and he finally got escorted out by 6 cops.

Was gonna brag about my quiet night in the icu until a paranoid schizo on meth tweaked out and tried tk break into the fire dept, said people were trying to kill him, got handcuffed tazed, bunch of ketamine, intubated, comminuted humerus fx, now its my prob. Merde. 1 1/2 hours to go.

 

[BoardingDoc]

Was gonna brag about my quiet night in the icu until a paranoid schizo on meth tweaked out and tried tk break into the fire dept, said people were trying to kill him, got handcuffed tazed, bunch of ketamine, intubated, comminuted humerus fx, now its my prob. Merde. 1 1/2 hours to go.

Extubate, titrate droperidol to effect, transfer to floor.

I guess the 1.5 hrs to go is the limiter there and it's not worth the effort.

 

[WilcoWorld]

Patient volumes at my shop haven't been bad, but the patients themselves are quite a volatile bunch in these parts, with most of my volume being med clearence, intoxication patients, and involuntary psych holds.

On shift right now, just had mr jailbird brought in by PD for vomiting after some alcohol. after i clear and dc him, he proceeds to break off the IV pole with his bare hands, use it to destroy the cardiac monitor (and we're already short) throw a container full of his pee at the sherriff, flip over his bed while still being handcuffed to it and attempt to use it as a barricade. Sherriffs had to call for backup, with one of them showing up with a fluorescent orange gun that fired large buckshot pepper rounds lol. I so wanted him to use it, but disappointingly it didn't happen and he finally got escorted out by 6 cops.

Please press charges.

 

[sylvanthus]

Extubate, titrate droperidol to effect, transfer to floor.

I guess the 1.5 hrs to go is the limiter there and it's not worth the effort.

Dayshift problem. errrrr opportunity, at this point.

 

[Boatswain2PA]

News all talks about the fentanyl problem in America but ignores the horrific meth problem.

Fentanyl problem IS bad and kills a lot of people, but they just die or are quickly resuscitated to do it all over again.

Meth is a bigger problem for society. The brain damage from it just makes meth zombies who are destroying society. Cops don't want to deal with the crazy tweakers because judges just let them out so bring to the ED, we admit to psych for 3 days, and then they go right back to stealing anything and everything to get the next hit.....and repeat. Haven't seen many (pure) opioid addicts tear up a place as described above.

 

[CajunMedic]

Our volumes are overall down, but the boarding problem makes it seem like they aren’t.

Everyone lost their damn minds on Saturday night. My residents and I managed to get the department cleared out with the exception of 5 psych holds, 1 intoxicated needing to metabolize to freedom, and a few random cough, colds and belly pains. Problem was, the psych holds were all feeding off each other and getting amped up. The most disruptive one wound up with Geodon, Versed, Ketamine, and 4 points. Another one is boarding for 5 days from Thanksgiving because of a positive COVID test and no one will take them. We had a 3 day hip pain come in by EMS, who was so obnoxious (singing how much morphine she wanted, how the doctors didn’t care how much she was suffering, screaming her bed number over and over, etc. Which was spinning up the psych patients) I walked up, asked her age, and told her she should act like it. Miraculously, she was able to walk to the waiting room completely unaided after D/C to wait for her ride

 

[CajunMedic]

News all talks about the fentanyl problem in America but ignores the horrific meth problem.

Fentanyl problem IS bad and kills a lot of people, but they just die or are quickly resuscitated to do it all over again.

Meth is a bigger problem for society. The brain damage from it just makes meth zombies who are destroying society. Cops don't want to deal with the crazy tweakers because judges just let them out so bring to the ED, we admit to psych for 3 days, and then they go right back to stealing anything and everything to get the next hit.....and repeat. Haven't seen many (pure) opioid addicts tear up a place as described above.

I was not ready for the meth when I came to WV. I had seen some of it working EMS in Arkansas, but holy crap it’s bad here. They’ve stolen ambulances, set themselves on fire in the ED, beaten themselves ( a la Jim Carrey in “Liar Liar”, you name it. One in particular required the use of the term “aggressively masturbating” in an MDM.

 

[BoardingDoc]

I really need to be more actively grateful that I don't get a lot of meth heads in my neck of the woods. Everyone here just likes etoh or opioids and thankfully both of those are sedating.

 

[CoolDoc1729]

Our volumes are overall down, but the boarding problem makes it seem like they aren’t.

Everyone lost their damn minds on Saturday night. My residents and I managed to get the department cleared out with the exception of 5 psych holds, 1 intoxicated needing to metabolize to freedom, and a few random cough, colds and belly pains. Problem was, the psych holds were all feeding off each other and getting amped up. The most disruptive one wound up with Geodon, Versed, Ketamine, and 4 points. Another one is boarding for 5 days from Thanksgiving because of a positive COVID test and no one will take them. We had a 3 day hip pain come in by EMS, who was so obnoxious (singing how much morphine she wanted, how the doctors didn’t care how much she was suffering, screaming her bed number over and over, etc. Which was spinning up the psych patients) I walked up, asked her age, and told her she should act like it. Miraculously, she was able to walk to the waiting room completely unaided after D/C to wait for her ride

Where I trained we had a mental health area with one padded room and 5 curtained areas. Most of the time it was just a drunk tank with a couple homeless with a side of psych to round it out. Every once in awhile there were 5 legitimately insane people back there, feeding off each other, one rocking their doll-baby, all doing the long term antipsychotic shuffle … yikes. Another high point back there was when a “suicidal “ patient back there revealed he had actually attempted by gsw to abdomen and everyone lost their **** for a few minutes 😂

 

[GonnaBeADoc2222]

Do the meth heads behave differently than PCP, or pretty similar?

 

[sloh]

I really need to be more actively grateful that I don't get a lot of meth heads in my neck of the woods. Everyone here just likes etoh or opioids and thankfully both of those are sedating.

 

[thegenius]

There, that's not draconian

When did I even write that? Your quote of my quote?

 

[thegenius]

Patient volumes at my shop haven't been bad, but the patients themselves are quite a volatile bunch in these parts, with most of my volume being med clearence, intoxication patients, and involuntary psych holds.

On shift right now, just had mr jailbird brought in by PD for vomiting after some alcohol. after i clear and dc him, he proceeds to break off the IV pole with his bare hands, use it to destroy the cardiac monitor (and we're already short) throw a container full of his pee at the sherriff, flip over his bed while still being handcuffed to it and attempt to use it as a barricade. Sherriffs had to call for backup, with one of them showing up with a fluorescent orange gun that fired large buckshot pepper rounds lol. I so wanted him to use it, but disappointingly it didn't happen and he finally got escorted out by 6 cops.

Did you have to medically clear him again?

 

[thegenius]

Medicare Advantage plans already work that way. Bunch of them are currently being sued by the government for various fraud type things.

Jeez
Maybe another way to do this is just have the fed and state give everyone "$X" (adjusted for age) every year in a health care spending account and the govt pays for NOTHING ELSE.
Like we get rid of Medicare.

I know...it will never fly. However fraud issues and improprieties seem to be mitigated when people spend their own money the way they see fit. We don't see an explosion of administrators for all the lawyers, grocery store operators, and waste management companies.

 

[WilcoWorld]

When did I even write that? Your quote of my quote?

Yesterday afternoon, but...I edited your quote

 

[allantois]

Last 2 months running daily capacities at 1.3 - 1.5x normal volumes. It's exhausting, largely because people still, in 2022, have the expectation that we have magic elixirs for their cold symptoms.

But it's also an increasing burden of other things that slowly take their toll:
- minor workplace injuries where employers demand an immediate ER evaluation for their non-injury and a work note saying something
- people coming to ER to get a work note saying they can go back to work
- occupational health saying go to the ER first for your workplace injury, then we will see you 2-3 days later
- PD getting medical clearance on over 50% (or so it appears) of all arrests they do

the list goes on and on and on

ER is a failed health care model. It needs to be completely revamped or else the overall health of the nation will steadily decrease due to lack of capacity to treat truly sick people. We are going down a green circle ski run....so it's not difficult on a turn by turn basis, but we cannot stop and we cannot go back up the hill and start over. The classic slippery slope where the slope in this case is rather shallow but irreversible.

I would argue ER is a symptom of a failed healthcare model where patients who have no access to other care utilize ER inappropriately for care

 

[sylvanthus]

I was not ready for the meth when I came to WV. I had seen some of it working EMS in Arkansas, but holy crap it’s bad here. They’ve stolen ambulances, set themselves on fire in the ED, beaten themselves ( a la Jim Carrey in “Liar Liar”, you name it. One in particular required the use of the term “aggressively masturbating” in an MDM.

The dude I admitted last night had degloved his penis in the past.

 

[Tenk]

Do the meth heads behave differently than PCP, or pretty similar?

In general: less aggressive and far crazier. Also a lot of parasitosis. I swear they cut the stuff with the csf of a schizophrenic.

 

[southerndoc]

We routinely have >40 admitted patients boarding. I walked into work at 6 am this morning with 107 admission holds. Reportedly, we got up to 112 at one point. (Yes, those numbers are correct.) I know I work in a large ED (almost 200 beds), but I felt like I was in the wrong place when I showed up for work.

 

[RuralEDDoc]

I would argue ER is a symptom of a failed healthcare model where patients who have no access to other care utilize ER inappropriately for care

Yes that’s a part of it. Where I work in California despite government cheese (Medicaid) covering most patients, it’s not even these patients choking the ER. Yes they come to the ER. But even more well insured Blue Shield and even Kaiser patients come for convenience, anxiety, or the dreaded “my primary care sent me for X” which is only emergent about 1/4 of the time at most.
Not blaming primary care. They’ve learned from specialists who give the middle finger to everyone and they are trying to survive like everyone else.

 

[allantois]

Yes that’s a part of it. Where I work in California despite government cheese (Medicaid) covering most patients, it’s not even these patients choking the ER. Yes they come to the ER. But even more well insured Blue Shield and even Kaiser patients come for convenience, anxiety, or the dreaded “my primary care sent me for X” which is only emergent about 1/4 of the time at most.
Not blaming primary care. They’ve learned from specialists who give the middle finger to everyone and they are trying to survive like everyone else.

I’m surprised it’s 1/4 and not 1/10 of cases that actually warrant ED care