Anyone else's ED on fire?

[GonnaBeADoc2222]

Yeah, sorry, COBRA. Isn't this a transfer to a "lower level of care"??

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[Boatswain2PA]

How would that be COBRA? I thought the only medical part of that law (Consolidated Omnibus Budget Reconciliation Act) was to give people health insurance coverage between jobs.

I've always found that Christmas shifts to be $hitshows.

 

[emergentmd]

Night 1: Total of 5 Nurses. 1 charge/triage. 4 Nurses total for 26 beds, 20 of them are boarders. Bed 3 is a Post-op, Open Laparotomy that was brought back to the ED to board after the PACU. Actively trying to die. 2 Mental Health holds-one of them is full of crap trying to avoid Jr. Jail. Other has COVID and waiting 5 days for placement. 2 other ICU holds.

This is why nurses are leaving in droves. If I were taking care of 7-8 critical pts, full waiting room then they better be paying me 2-3x rate or I am finding a new job.

 

[Apollyon]

Yeah, sorry, COBRA. Isn't this a transfer to a "lower level of care"??

It's still in the same hospital. You can't steal from yourself.

 

[emergentmd]

I don't think there is any issues with this. We take pts from the OR to the ER all the time. They just get labeled inpatient, cared for by the specialists/hospitalist and still inpatient. Its not like they go inpatient/Outpt surg to ER. Its all in how they are classified.

 

[RustedFox]

Back to the topic at hand:

My ED is on fire. Zero beds. Capped in terms of holds. Transferring all admits. Every hospital between WhiteTrash General (mine) and SouthCity (4 counties away) is on transfer closure or whatever. Status-Red for EMS, but they still come. Nursing staff at hospital a few blocks down straight walked off their shifts last night. I got hit with the unstemmable resulting tide.

Administrators all snug in their beds.

 

[allantois]

This is why nurses are leaving in droves. If I were taking care of 7-8 critical pts, full waiting room then they better be paying me 2-3x rate or I am finding a new job.

Im surprised they came back to that dumpster fire no matter what they are paying them. Can't make a living without a license/ in jail. They are at/exceeding ICU ratios and then stacking ED patients on top of that? Jeez

 

[FiremedicMike]

Im surprised they came back to that dumpster fire no matter what they are paying them. Can't make a living without a license/ in jail. They are at/exceeding ICU ratios and then stacking ED patients on top of that? Jeez

And the worst of all is, the floors can continue to refuse to take patients. The ED gets stacked, overworked, way over ratios, squads still coming, STEMI in the lobby, memaw fell on blood thinners just got carried in, ED staff ratios continue climbing, meanwhile the floor nurses are like "yeah I have my 4 patients for the shift, f-off" and their charge nurses back them.

 

[allantois]

And the worst of all is, the floors can continue to refuse to take patients. The ED gets stacked, overworked, way over ratios, squads still coming, STEMI in the lobby, memaw fell on blood thinners just got carried in, ED staff ratios continue climbing, meanwhile the floor nurses are like "yeah I have my 4 patients for the shift, f-off" and their charge nurses back them.

Once again I am not familiar with all ED regulations, but at some point surely the ED has to go on diversion/stop accepting new patients?

 

[Dr Mantis Toboggan]

Once again I am not familiar with all ED regulations, but at some point surely the ED has to go on diversion/stop accepting new patients?

No, sadly, it really doesn’t.

 

[wareagle726]

We have 67 official beds. Two nights ago opened up through 80 with hall beds. Trying to keep main trauma rooms open but only had two. Of course had 4 level one traumas come in in the span of a few hours, 3 all at the same time from two events that happened unfortunately at the same time . Holding 56 admits, Somewhere around 15-20 ICU admits with at least 8 vented. Thankfully we have full nursing staff although most are worthless travelers. WR on my arrival usually around 20-30 with 6+hr waits. On diversion but they keep coming and our hospital will come off diversion if a specialist accepts something...which is everything. Cards/NSR/Neuro/Uro etc... are all half asleep when they answer and just "yeah whatever send it" so it's now my problem. So fun. Our PD is doing everything he can but admin just comes and says "it will get better." Somehow we are still able to take care of all the sick people and giving appropriate care for them. Febrile 2yos eating snacks and watching cocomelon in the lobby can wait or leave IDC.

EDIT: Should have said MD(Medical director) not PD

 

[emergentmd]

Wareagle,

You must have a 100-150K volume ER. When I left my main hospital gig 5 yrs ago, we were one of the big hospitals with about 30 beds but would go up to 40 with hall beds. Winter would see us holding 30+ pts and essentially working with hall beds.

THIS was 5 yrs ago, I shudder to think what it is now. I am sure they Built some more rooms and prob pushing 50 beds now. You place feels like some of my Locum gigs, I hope they are paying you 400+/hr for this cluster.

 

[wareagle726]

Wareagle,

You must have a 100-150K volume ER. When I left my main hospital gig 5 yrs ago, we were one of the big hospitals with about 30 beds but would go up to 40 with hall beds. Winter would see us holding 30+ pts and essentially working with hall beds.

THIS was 5 yrs ago, I shudder to think what it is now. I am sure they Built some more rooms and prob pushing 50 beds now. You place feels like some of my Locum gigs, I hope they are paying you 400+/hr for this cluster.

Unfortunately I make nowhere near that. This was an exceptionally bad night. All the cookies crumbled the wrong way.

 

[JacobMcCandles]

I think it'd be more unusual if someone has a normally functioning ED at this point. I'm not sure a normal functioning ED/hospital exists at this point. This would normally be a time that an administrator could prove their worth but they're all empty suits.

 

[VA Hopeful Dr]

I think it'd be more unusual if someone has a normally functioning ED at this point. I'm not sure a normal functioning ED/hospital exists at this point. This would normally be a time that an administrator could prove their worth but they're all empty suits.

Admin here sent out an e-mail basically saying "the ED is overwhelmed don't send anything that isn't a true emergency to the ED".

 

[JacobMcCandles]

Admin here sent out an e-mail basically saying "the ED is overwhelmed don't send anything that isn't a true emergency to the ED".

And they think it's just as simple as that. Clueless.

 

[RustedFox]

Admin here sent out an e-mail basically saying "the ED is overwhelmed don't send anything that isn't a true emergency to the ED".

Lol.
A good number of my vertical patients at my shop are "my doctor sent me to do the thing."

Hey, FM/IM/other subspecialties... You don't get to ostrich and moan about the state of the ER when you use it as an extension of your clinic. Knock it off.

 

[VA Hopeful Dr]

Lol.
A good number of my vertical patients at my shop are "my doctor sent me to do the thing."

Hey, FM/IM/other subspecialties... You don't get to ostrich and moan about the state of the ER when you use it as an extension of your clinic. Knock it off.

You'd be surprised how often that's just not true (not saying its not often true, but it very often isn't).

Not to compare to y'all's current mess, but we're in not a great place at the moment either as far as this goes.

To not lose money I'm expected to:
-See 50 new patients/quarter
-Keep a patient panel (defined as patients I've seen in the last 18 months) of over 2000
-Have an RVU minimum that works out to 20 patients/day
-See all of the acute visits for all of my patients

 

[ScepticSkeksis]

We are full too. I've been DCing most of the low/moderate risk chest pains. Also not keeping on a legal hold the homeless meth head who wants to "jump in front of traffic". We simply don't have the beds to tie up with these idiots.

 

[Fox800]

Meanwhile, our local noctor-staffed urgent cares continue to send us simple finger lacs, perforated otitis media (BC zOMG they need a STAT ENT consult), well-appearing URI kids with a fever of 103F because????? I still don't know.

 

[allantois]

I'm proud to say that I've sent exactly zero patients to ED last year.

 

[JacobMcCandles]

Meanwhile, our local noctor-staffed urgent cares continue to send us simple finger lacs, perforated otitis media (BC zOMG they need a STAT ENT consult), well-appearing URI kids with a fever of 103F because????? I still don't know.

This should go both ways. We should be able to send stuff to the urgent cares.

 

[RustedFox]

This should go both ways. We should be able to send stuff to the urgent cares.

Something, something, lower level of care, something violation.

 

[gutonc]

Lol.
A good number of my vertical patients at my shop are "my doctor sent me to do the thing."

Hey, FM/IM/other subspecialties... You don't get to ostrich and moan about the state of the ER when you use it as an extension of your clinic. Knock it off.

I never complain about the state of the ER. You guys are getting murdered right now (and by right now, I mean for the last 3 years), and anyone who doesn't know and recognize that is a complete POS.

if I'm sending someone your way, I'm calling you and telling you why. Usually it's because I don't have the resources to evaluate/treat whatever disaster my triage RNs decided needed to be seen by us immediately without running it by somebody first.

In the last 2 weeks I've had triage add on urgent clinic evaluations (usually at 4 or 4:30pm after our infusion pharmacy and clinic lab have locked up for the night and all we have are bags of NS and whatever's in the Pyxis):
- Syncope x3 at home with BP 70/40 on presentation
- Massive hematemesis (was horking up blood in the waiting room)
- Sudden onset right hemiparesis with history of GBM
- New onset seizure w/ history of metastatic lung cancer
- Profound diarrhea and fatigue (this one got there in time to get labbed up and had a K of 2.2, Mg of 0.5 and Cr of >8 which is all our POC machine will report)

All 5 of them got pushed across the street while I was on the phone with your colleagues explaining what hot mess was about to roll in.

I'm not saying there aren't a bunch of outpatient "docs" out there turfing BS to you guys, but sometimes we really do need your help and expertise.

 

[RustedFox]

I never complain about the state of the ER. You guys are getting murdered right now (and by right now, I mean for the last 3 years), and anyone who doesn't know and recognize that is a complete POS.

if I'm sending someone your way, I'm calling you and telling you why. Usually it's because I don't have the resources to evaluate/treat whatever disaster my triage RNs decided needed to be seen by us immediately without running it by somebody first.

In the last 2 weeks I've had triage add on urgent clinic evaluations (usually at 4 or 4:30pm after our infusion pharmacy and clinic lab have locked up for the night and all we have are bags of NS and whatever's in the Pyxis):
- Syncope x3 at home with BP 70/40 on presentation
- Massive hematemesis (was horking up blood in the waiting room)
- Sudden onset right hemiparesis with history of GBM
- New onset seizure w/ history of metastatic lung cancer
- Profound diarrhea and fatigue (this one got there in time to get labbed up and had a K of 2.2, Mg of 0.5 and Cr of >8 which is all our POC machine will report)

All 5 of them got pushed across the street while I was on the phone with your colleagues explaining what hot mess was about to roll in.

I'm not saying there aren't a bunch of outpatient "docs" out there turfing BS to you guys, but sometimes we really do need your help and expertise.

1. These are all reasonable, and should indeed be sent.
2. You heme/oncs have a tough gig. I don't envy your job whatsoever. No shade thrown, amigo. I mean this: Hey, I'm happy to help.
3. The BS that I'm generally complaining about is stuff that really is outpatient imaging, or things that can absolutely wait until clinic (most commonly chronic wound care stuff that I do absolutely nothing about and have no idea how this wound is progressing).

 

[Dr Mantis Toboggan]

I never complain about the state of the ER. You guys are getting murdered right now (and by right now, I mean for the last 3 years), and anyone who doesn't know and recognize that is a complete POS.

if I'm sending someone your way, I'm calling you and telling you why. Usually it's because I don't have the resources to evaluate/treat whatever disaster my triage RNs decided needed to be seen by us immediately without running it by somebody first.

In the last 2 weeks I've had triage add on urgent clinic evaluations (usually at 4 or 4:30pm after our infusion pharmacy and clinic lab have locked up for the night and all we have are bags of NS and whatever's in the Pyxis):
- Syncope x3 at home with BP 70/40 on presentation
- Massive hematemesis (was horking up blood in the waiting room)
- Sudden onset right hemiparesis with history of GBM
- New onset seizure w/ history of metastatic lung cancer
- Profound diarrhea and fatigue (this one got there in time to get labbed up and had a K of 2.2, Mg of 0.5 and Cr of >8 which is all our POC machine will report)

All 5 of them got pushed across the street while I was on the phone with your colleagues explaining what hot mess was about to roll in.

I'm not saying there aren't a bunch of outpatient "docs" out there turfing BS to you guys, but sometimes we really do need your help and expertise.

You’re one of the good ones. If everyone gave such effort the patients would be better off for sure.

 

[Fox800]

This should go both ways. We should be able to send stuff to the urgent cares.

EMTALA. Which was designed to protect patients, but has been corrupted to only fatten administrator and lawyer paychecks.

 

[ScepticSkeksis]

I never complain about the state of the ER. You guys are getting murdered right now (and by right now, I mean for the last 3 years), and anyone who doesn't know and recognize that is a complete POS.

if I'm sending someone your way, I'm calling you and telling you why. Usually it's because I don't have the resources to evaluate/treat whatever disaster my triage RNs decided needed to be seen by us immediately without running it by somebody first.

In the last 2 weeks I've had triage add on urgent clinic evaluations (usually at 4 or 4:30pm after our infusion pharmacy and clinic lab have locked up for the night and all we have are bags of NS and whatever's in the Pyxis):
- Syncope x3 at home with BP 70/40 on presentation
- Massive hematemesis (was horking up blood in the waiting room)
- Sudden onset right hemiparesis with history of GBM
- New onset seizure w/ history of metastatic lung cancer
- Profound diarrhea and fatigue (this one got there in time to get labbed up and had a K of 2.2, Mg of 0.5 and Cr of >8 which is all our POC machine will report)

All 5 of them got pushed across the street while I was on the phone with your colleagues explaining what hot mess was about to roll in.

I'm not saying there aren't a bunch of outpatient "docs" out there turfing BS to you guys, but sometimes we really do need your help and expertise.

I wouldn't begrudge you sending any of those things to us. What we are upset by is the non-urgent, or complete BS that should be handled by other people. Unfortunately, the Jennies of the world are too incompetent/lazy to handle what should be in their scope:
- Asymptomatic HTN from PMDs office
- Simple hand/finger lacerations
- Simple Abscesses
- "Needs a PICC Line"
- G-tube not working for 3 days from the nursing home
- "Abnormal labs", but patient doesn't know what's abnormal, and labs not sent with them
- "Xanax Refill", urgent care told them no, but said the ER would refill for them
- "Need stat specialologist consult" for a vague problem that's been going on for year
- Blood sugar is high, but normal vital signs, and no symptoms
- Febrile illness in 20-30 year old who is healthy. Gee you couldn't manage/treat a viral infection from the urgent care? I hear Z-packs are good for this.

All of the above is a list of the nonsense sent to me in the past few weeks.

 

[NYEMMED]

So funny story from this week.

29 year old with multiple complaints, but was narrowed down to: I have been having a year of blood in stools and intermittent abdominal pain. No real change for 1 year. Stable vitals

So what brought you in tonight?? (11pm on a Thursday) full moon, bursting at the seams, you all get it.

“Oh I saw my doc, Dr. X today and he said I should come here and you guys would get me a stat GI to see me and a scan”

Oh, did he?

(I walk over to my unit clerk, “I need you to call Dr. X right now, no way he is sleeping if he is making me deal with this”)

Dr. X is on the line 30 mins later.

“Hey I got this patient you sent in for a STAT GI consult and scan” “so tell me more about what you want and which GI you already called or referred the patient to” “also what scan do you have ordered for the 1 year of complaints, now in the overly packed ED”

Dr. X —“I’m so sorry NYEMMED, I saw the patient earlier today, I told him I would get insurance authorization for a CT, and I would refer him to a GI, I’m so sorry he came to your ED tonight, I spent 30 mins explaining the plan to them”

Oh ok Dr. X, sorry to bother you, sleep well!


Patient remains adamant he was sent in.

We may never know the truth.

 

[VA Hopeful Dr]

So funny story from this week.

29 year old with multiple complaints, but was narrowed down to: I have been having a year of blood in stools and intermittent abdominal pain. No real change for 1 year. Stable vitals

So what brought you in tonight?? (11pm on a Thursday) full moon, bursting at the seams, you all get it.

“Oh I saw my doc, Dr. X today and he said I should come here and you guys would get me a stat GI to see me and a scan”

Oh, did he?

(I walk over to my unit clerk, “I need you to call Dr. X right now, no way he is sleeping if he is making me deal with this”)

Dr. X is on the line 30 mins later.

“Hey I got this patient you sent in for a STAT GI consult and scan” “so tell me more about what you want and which GI you already called or referred the patient to” “also what scan do you have ordered for the 1 year of complaints, now in the overly packed ED”

Dr. X —“I’m so sorry NYEMMED, I saw the patient earlier today, I told him I would get insurance authorization for a CT, and I would refer him to a GI, I’m so sorry he came to your ED tonight, I spent 30 mins explaining the plan to them”

Oh ok Dr. X, sorry to bother you, sleep well!


Patient remains adamant he was sent in.

We may never know the truth.

One of two things will result from this:

a) if he is lying to you and did send the patient, he'll be much less likely to do so in the future

b) if the patient is lying, said patient is getting a talking to next visit.

 

[RustedFox]

So funny story from this week.

29 year old with multiple complaints, but was narrowed down to: I have been having a year of blood in stools and intermittent abdominal pain. No real change for 1 year. Stable vitals

So what brought you in tonight?? (11pm on a Thursday) full moon, bursting at the seams, you all get it.

“Oh I saw my doc, Dr. X today and he said I should come here and you guys would get me a stat GI to see me and a scan”

Oh, did he?

(I walk over to my unit clerk, “I need you to call Dr. X right now, no way he is sleeping if he is making me deal with this”)

Dr. X is on the line 30 mins later.

“Hey I got this patient you sent in for a STAT GI consult and scan” “so tell me more about what you want and which GI you already called or referred the patient to” “also what scan do you have ordered for the 1 year of complaints, now in the overly packed ED”

Dr. X —“I’m so sorry NYEMMED, I saw the patient earlier today, I told him I would get insurance authorization for a CT, and I would refer him to a GI, I’m so sorry he came to your ED tonight, I spent 30 mins explaining the plan to them”

Oh ok Dr. X, sorry to bother you, sleep well!


Patient remains adamant he was sent in.

We may never know the truth.

This nonsense, except substitute "neurosurgery", "oncology", or "nephrology" for GI at my shop.

 

[BigPikachu]

Lol.
A good number of my vertical patients at my shop are "my doctor sent me to do the thing."

Hey, FM/IM/other subspecialties... You don't get to ostrich and moan about the state of the ER when you use it as an extension of your clinic. Knock it off.

As a rural FM, I would like to think I have done my fair share of work in the ER; I worked a shift in the ER at least weekly, and I was on-call to admit patients from ER to the wards under my care at least twice weekly. I try not to send patients I see in clinic to the ER, but if I do, they usually have to go in for a good reason and I call-up the EM physician-in-charge to give a handover and they're welcome to admit the patient under me if required.

I try not to throw rocks in a glass house and be judgemental about my colleagues working in other specialties; we all have our own challenges and we are all doing our best in difficult circumstances, and there are 'good and bad' clinicians in any specialty of medicine. Issues with delayed surgeries, delayed clinics, limited timely radiologypathology diagnostic services, overflowing waiting rooms, bed block and ambulance ramping, coupled with disillusionment of an underfunded, overworked and burntout medical workforce were already known problems that have been exacerbated by the recent/current pandemic.

I imagine hospital and health service executives have their own challenges with a fiscal budget to balance, in addition to board members, share holders and politicians to appease. I hope that some of these executives remember what its clinicians and patients are dealing with at the coalface and avoid a ivory tower mentality. The choas and rapture of the ER can be a crude indicator of how a health service is performing overall; that is, poorer healthcare services for the community often has flowon effects with more ER presentations and acute hospitalisations. Fixing the overcrowding and access block issues in ER is often a whole-of-health/government issue that needs to be tackled from all sides.

 

[CoolDoc1729]

Meanwhile, our local noctor-staffed urgent cares continue to send us simple finger lacs, perforated otitis media (BC zOMG they need a STAT ENT consult), well-appearing URI kids with a fever of 103F because????? I still don't know.

It’s gotten like this by me too .. if the urgent cares can no longer handle even the simplest things, they should be closed, I don’t really understand the purpose? No, ortho isn’t going to see a pinky dislocation that no one has tried to reduce , WTAF

 

[TooMuchResearch]

Once again I am not familiar with all ED regulations, but at some point surely the ED has to go on diversion/stop accepting new patients?

No, we are the medical system's safety net and scape goat.

 

[TooMuchResearch]

1. These are all reasonable, and should indeed be sent.
2. You heme/oncs have a tough gig. I don't envy your job whatsoever. No shade thrown, amigo. I mean this: Hey, I'm happy to help.
3. The BS that I'm generally complaining about is stuff that really is outpatient imaging, or things that can absolutely wait until clinic (most commonly chronic wound care stuff that I do absolutely nothing about and have no idea how this wound is progressing).

Well appearing very elderly man, had an NSTEMI, just out of the hospital, has his clinic follow up appointment. He feels great. His chest does not hurt. They order labs which for whatever reason included a troponin, then sent him in the next day because it was elevated. I see him after his 7+ hour wait and let him go home.

 

[BigPikachu]

Well appearing very elderly man, had an NSTEMI, just out of the hospital, has his clinic follow up appointment. He feels great. His chest does not hurt. They order labs which for whatever reason included a troponin, then sent him in the next day because it was elevated. I see him after his 7+ hour wait and let him go home.

Requesting an outpatient/out-of-hospital troponin blood test...

 

[xaelia]

Requesting an outpatient/out-of-hospital troponin blood test...

We rarely did true outpatient troponins at Kaiser – we did some looking at progression of amyloidosis, a specific carve-out for the cardiologists.

We did POC troponin in the urgent care at Kaiser, though.

Here in NZ we do outpatient troponin with some frequency – pain free, normal ECG, low-risk for ACS by objective assessment. Probably see a case a day or so of an NSTEMI found in the community referred as a direct admission to cardiology. This has been tracked for years in a registry; no one is dropping dead in the hours between seeing the GP and the troponin result returning from the outpatient lab. No big deal.

 

[RustedFox]

What the hell is it with every ostrich coming in for a CXR to "evaluate for aspiration pneumonia" immediately after a minor choking episode because they're too ostriched to chew their damn food?

These people are all satting just fine on room air, without complaint, and impossible to talk out of that almighty x-ray.

 

[CoolDoc1729]

What the hell is it with every ostrich coming in for a CXR to "evaluate for aspiration pneumonia" immediately after a minor choking episode because they're too ostriched to chew their damn food?

These people are all satting just fine on room air, without complaint, and impossible to talk out of that almighty x-ray.

Then while they’re waiting for the pointless x ray they think of 259 other things that have been wrong in the last 6 months .. like .. 🤦🏻‍♀️

 

[Arcan57]

Then while they’re waiting for the pointless x ray they think of 259 other things that have been wrong in the last 6 months .. like .. 🤦🏻‍♀️

Cause the ED is the place you go to have them figure out what's wrong. Likewise, the hospital is where you go to get all better. Everybody knows this. If the ED sends you home without figuring out what's wrong, that's obviously inappropriate. If the hospital sends you home before you're all better, also deplorable.

You can imagine how shook patients are when they start realizing the whole goal of that giant building they went into was to stabilize them long enough to either) have an expensive surgery or) keep them alive long enough to make an outpatient clinic visit.

 

[RustedFox]

Then while they’re waiting for the pointless x ray they think of 259 other things that have been wrong in the last 6 months .. like .. 🤦🏻‍♀️

"But if the x ray is normal why am I coughing like this?"

 

[CoolDoc1729]

"But if the x ray is normal why am I coughing like this?"

Because you’re supposed to chew your food : : discharge