*beep*beep*beep*.....

[Tater]

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Sorry, just have to vent.

Why is it that the nurse can call me at 4:30 in the morning to ask if a patient really needs another serum osmol before he gets his mannitol and fails to mention that his left pupil was blown.

Made for an exciting morning and not the good kind of exciting.

Then I find her sitting on her rear end and she tells me that pharmacy will have the mannitol here in about twenty minutes.

I just lost it and I don't usually do that. I know that she is a new nurse, but damn.

-Mike

Yeow. I'm not one for throwing around rampant incident reports, but I hope that was taken up with the charge.

Sounds a little like the time I found out no heparin was started on a patient with a PE because the nurse "couldn't find a pole".

Egregious yes, but let me just edit to add: I don't intend to start an all-out nurse bashing. The transplant nurses saved many lives from my unwieldly assassination attempts.

 

[DoctaJay]

Yeow. I'm not one for throwing around rampant incident reports, but I hope that was taken up with the charge.

Sounds a little like the time I found out no heparin was started on a patient with a PE because the nurse "couldn't find a pole".

Egregious yes, but let me just edit to add: I don't intend to start an all-out nurse bashing. The transplant nurses saved many lives from my unwieldly assassination attempts.

But is it safe to say that most of the crazy pages you will receive are from nurses or from ER Docs who haven't looked at their patient for real?

 

[Tigger14]

But is it safe to say that most of the crazy pages you will receive are from nurses or from ER Docs who haven't looked at their patient for real?

That's exactly right, and the reason it disturbs me when it happens.

 

[Chronic Student]

Yeow. I'm not one for throwing around rampant incident reports, but I hope that was taken up with the charge.

Sounds a little like the time I found out no heparin was started on a patient with a PE because the nurse "couldn't find a pole".

Egregious yes, but let me just edit to add: I don't intend to start an all-out nurse bashing. The transplant nurses saved many lives from my unwieldly assassination attempts.

No, this is limited to a single individual and not a group.

All of the other ICU/CCU nurses that I work with are spot-on and I really do realize that this nurse is new to nursing and critical care.

However, if a neurologist comes in and finds a blown pupil and sets the ICU on its ear, rushes her to the CT scanner and tells them to page the neurosurgeon immediately, then you might pick up on the fact that bad stuff is happening.

If the neurosurgeon then tells you that he will be there as fast as he possibly can, that the patient will be going to surgery immediately and that she needs mannitol right away...

Then you might think about getting the patient ready for surgery, getting the medicine that was ordered ready in a timely matter and darned sure not be on the computer websurfing when the neurosurgeon and his PA come trotting around the corner.

Just my opinion, anyway.

BTW, I did talk with the charge nurse and no one was more horrified at her behavior than he was.

-Mike

 

[Hoo\/er]

BEEP-BE...

Wait, I don't own a pager. Woot.

 

[MS3er]

Sorry, just have to vent.

Why is it that the nurse can call me at 4:30 in the morning to ask if a patient really needs another serum osmol before he gets his mannitol and fails to mention that his left pupil was blown.

Made for an exciting morning and not the good kind of exciting.

Then I find her sitting on her rear end and she tells me that pharmacy will have the mannitol here in about twenty minutes.

I just lost it and I don't usually do that. I know that she is a new nurse, but damn.

-Mike

Just out of curiousity, did the nurse not realize the patient had a blown left pupil until it was pointed out or was it something she realized but neglected to mention?

 

[Chronic Student]

Were still in the process of sorting that out.

It's really hard to get a straight answer out of someone who does not really understand what was going on.

In addition, we had orders for neuro checks q1h and they were not all charted and the ones that were had a GCS of 3 listed. A rock has a GCS of three and this guy had been following commands and was easily arousable and was opening his eyes spontaneously.

The nursing notes from the day before show a GCS of 3 and that was clearly not the case. So, how do you trust any of that persons notes.

Sigh.

I checked the guy out the day before and his PERRLA and I gave him a GCS of 11I. The neurologist was there 45 minutes after I was and his progress note agreed with mine.

So, the only thing we are really sure of is that the day before he was neurologically stable.

Upon further questioning, the nurse says that overnight he was getting more somnolent and she just thought it was his meds.

Strangely enough, they are about to get an inservice on how to perform neuro checks correctly and I am hopefull that some good can come of all of this.

Sorry for the threadjack but thanks for letting me get it off my chest.

-Mike

 

[Apollyon]

From the Pedi ER (sadly, this is a common one): "Please consult on 13 y/o M with abdominal pain."
Me: Hi, this is surgery, what can I do for you?
ER resident: Thanks for calling back. We have a kid down here with abdominal pain.
Me: Okay, sure. Tell me more about him.
ER resident: Well, I haven't seen him yet. He just rolled in here.
Me: Okay, where is his pain?
ER resident: I don't know.
Me: Do you know anything about him except the fact that he has abdominal pain?
ER resident: Not yet.
Me: Then what makes you think surgery should be involved?
ER resident: Well, we just wanted you to know that he's here.
(These encounters usually end with me examining & interviewing the patient before anyone else, w/ the ER resident peering over my shoulder and copying the findings of my H&P. I"m not joking.)

I know I'll think of more......

That sounds a LOT more like a Peds resident working in the Peds ED. (I don't know if you know it, but, if you have a Peds ED in the hospital, and there are residents in it, the majority of residents will be peds residents working in it.)

This is a page I received last night, verbatim:

"Hi, consult in ER on 11 y/o w/ MRSA post-op 3 weeks ago for same thing. Please call. Thanks."

Um......yeah.

Again, probably a peds resident.

Then again, you seem to have an issue with emergency medicine and the ED. The last time I consulted surgery was for a trauma patient that I told them I would manage (instead of leveling it higher and them taking over management), and they said that they would talk to their attending, but would probably be 24 hour obs. I told them my plan was that I would let him sober up and go with a head sheet (as his trauma workup was clean except for cocaine positive), and their attending went with that, and the residents thanked me for "not having this piece of **** on our service".

 

[Winged Scapula]

While I appreciate that most EDs and EM residents and physicians are as thoughtful and thorough as Appolyon's and of course, cannot comment on the situation of the poster to which he responds, the fact is that there ARE EDs and EM attendings who do not examine patients before calling consults or even before discharging the patient.

As I noted above, I have personally been seen in an ED, by an EM trained attending and resident, neither of whom examined me (one time I had a full blown migraine and another most likely gastroenteritis) but yet documented in their H&P that they had. I have also personally received many calls from the ED, from residents, attendings and nurses, none of whom knew anything about the patient other than they had abdo pain and nothing was charted outside of the vitals.

So, sadly it can and does happen and I'm sure our ED was not the only place. Unfortunately, not everyone in the field (or every field) is as conscientious as Appolyon.

 

[MediCane2006]

Apollyon, I want to work at your hospital 😉

In my experience, the quality of EM attendings/residents/interns varies wildly, from those who call knee-jerk consults to others who complete thorough, thoughtful workups before calling in the appropriate service. Typically this is variation correlates quite well with how busy our ER happens to be.

 

[FoughtFyr]

Apollyon, I want to work at your hospital 😉

In my experience, the quality of EM attendings/residents/interns varies wildly, from those who call knee-jerk consults to others who complete thorough, thoughtful workups before calling in the appropriate service. Typically this is variation correlates quite well with how busy our ER happens to be.

Actually, as an EM resident who has taken "home call" for the ortho hand service, I have found EXACTLY the same, poor, absolute BS consults. But I find it to correlate not with the pace in the ED but in who called the consult. My fellow ED residents called in complete and proper consults after evaluating the patient. The "off-service" residents and IM/FP trained faculty equalled "yeah there is a guy/gal here that may have injured their hand..."

And I have no bigger pet peeve than hearing said "off-service" residents identifying themselves as "Hi, this is Dr. Incompetant, an ER resident..." when calling a consult. After my ortho-hand experience, I fully believe these stories, but I don't think you guys realize that most of the staff in the ED, both residents and attendings, are EM trained...

- H

 

[Apollyon]

I'm not trying to fan the flames of dissention and division - I was and am privileged to have worked with as a resident, and now work with as an attending, surgical residents that strongly buck the stereotype of surgeons, and the collegiality makes the day move much more pleasantly. I just have a sense of personal pride about doing my job before I ask someone else to do theirs. Then again, I'm the first person in years to do anoscopies routinely (want to irk the hell out of me? Tell me (when you're the tech) "oh, we don't do that here."), because I find it professionally lame to refer the rectal bleeding patient back to the PMD or GI for colonoscopy when the patient has internal hemorrhoids. That's black-letter abrogating your duty.

When I was a prelim IM intern, the pages were weak and lame, but, so regular, not worthy of documenting. Now, I don't carry a pager, don't carry my cell phone, and don't even wear a watch. Glorious!

 

[FoughtFyr]

So when you called back for Ortho Hand, did you say, "Hi, this is Dr. FoughtFyr, ER resident, returning a page"? 😀

Yep - I said "This is Dr. Foughtfyr, I'm one of the EM residents assigned to the ortho-hand service, how can I help you?". That actually saved lots of time when it turned out to be an ortho attending paging looking for a "hand" in the OR with a case.

- H

 

[MediCane2006]

Actually, as an EM resident who has taken "home call" for the ortho hand service, I have found EXACTLY the same, poor, absolute BS consults. But I find it to correlate not with the pace in the ED but in who called the consult. My fellow ED residents called in complete and proper consults after evaluating the patient. The "off-service" residents and IM/FP trained faculty equalled "yeah there is a guy/gal here that may have injured their hand..."

In retrospect, you have a good point. Most of the ER docs and residents at our program are quite good and manage the majority of problems themselves. In my opinion, a well-trained ER doctor is one of the more competent medical specialists in the hospital...and some of the best docs I've worked with have been the EM folks. 👍

I posted in anger after a poorly worked up ED consult had been called in. I retract my previous criticism 😉

 

[ajce9]

Oh wow...I have a ton of these. It seems like the pages just get better and better as the year goes on.

From a floor nurse (at 3 AM) - "Doctor, the patient's troponin just came back. It's < 0.05."

Me - "Uh...okay. Thanks."
Nurse - "But normal is 0.05-0.5. So...isn't that low?"
Me - "[afraid to say anything]"

And then, a true classic, from a frantic-sounding medicine intern,
"IS THIS COLORECTAL SURGERY?!"
Me - "Yeah."
Med Intern - "I'm calling about a patient who you saw last week and signed off of...we got a new CT scan and it shows that his tumors are still there..."

Me - "Uh-huh. He's got a belly full of unresectable tumor. That's not news."
Med Intern - "No, but that's not why I'm calling you. The radiology read said that there's HEMORRHAGIC FECAL MATERIAL in the colon!!"

Me - "Hemorrhagic fecal material."
Med Intern - "!!!!"
Me - "So his feces are bleeding, huh? Yeah, someone should probably do something about that..."
[The radiology read said nothing about hemorrhagic feces, by the way. I think some bored radiology resident was just screwing around with her.]

And finally, from my urology rotation, at 10 PM on a weeknight (not on call, just trying to get done with a horrendous day)

Medicine Resident - "[chirpy] Hi, I'd like to call in a consult?"
Me - "You do realize it's after 10 PM, right?"
Med Resident - "Yeah, but we'd like you to see this patient tonight."
Me - "So this is an urgent consult?"
Med Resident - "Yes. This patient is a pregnant lady who came in with hyperemesis gravidum, and our med student did a rectal and found a prostate."
Me - "A prostate. So did you confirm this?"
Med Resident - "Oh yes. There is definitely a prostate."
Me - "Well, either she's pregnant or she has a prostate, but..."
Med Resident - "Well, she's definitely pregnant and definitely has a prostate. Can you please come see her now?"
Me - [getting irritated] "Let me get this straight. You palpated a rectal mass. Can you kindly explain to me how you came to the brilliant conclusion that it's a prostate?"
Med Resident - "I mean...what else would it be?"
Me - "I am NOT coming down to see a pregnant lady with a rectal mass, you idiot."
Med Resident - "But...I mean, she has a..."
Me - "DID YOU GO TO MEDICAL SCHOOL OR DIDN'T YOU?! I changed my mind. I'm coming down there and we're discussing this in person."

I stormed down to the patient's room to find, not a justly terrified medicine intern but the entire trauma team sitting at the nurse's station laughing their asses off ...that was weeks ago, but I still haven't lived it down....

IT DOESN'T GET BETTER THAN THAT. LOL.

 

[Bull's eye]

ok, i'll play.

beep i answered this week. "this is attending soandso from the ER, we consulted your resident on a lesion in the coccyx. he said to get a CT."

i say, "ok. why are you consulting us (ortho)?"

er attending "well he has back pain after being hit with a chair in his back."

i say, "ok. but does he have ass pain?"

er attending "well i don't know."

i say, "well you do know that the 'cockix' is near the dingus?"

er attending (pause), "well we just feel someone from ortho should see him."

i say, "no problem, we will examine him for you since you haven't bothered to examine the patient and are going off a radiographic reading that has no relation to the actual clinical complaint."

in the end, he had back pain from being hit in the back by a chair. everything including rectal exam done by orthopaedics, normal.

(i love when another attending tries to get my residents in trouble. my resident is always right until proven otherwise.)

Yeah, That was me. I hadn't done a DRE since spine trauma, thanks for the memories.

 

[whoopsie_1]

http://www.hostingphpbb.com/forum/v...=kinetic&sid=74a08e965f7b826b0fb3496eb4a7214e

An excerpt:

Now, everyone talks about how nurses have "lots more experience than a resident" so if they're concerned about something, you'd best pay attention and that ER physicians have a point when they say, "well, I don't know what's going on, but I know this guy doesn't look right (classic ER line)." I always laugh at that because, once again, it's demonstrably FALSE. If they were so insightful, then even if they didn't know what was wrong, they'd have some sort of filter on their lame brains.

The reason people get these ******ed nursing pages is because as soon as they hear the patient say ANYTHING, they immediately make a mad dash for the phone -- and at the same time, holler out, "ANYONE ELSE WANT TO TALK TO THE DOC?" (I've seen it too many times, so don't bother trying to say it doesn't happen.) I've also had the classic "are you from [so and so service]?!" or "are you covering [so and so]?!" and you say, "no" and expect them to go LOOK for the person who IS for this important question ...and they just sit there and return to reading a magazine. You know what that was? That was them KNOWING something was absolutely irrelevant and STILL wanting to bother someone with it, but only as long as it was convenient for them. I always wanted to punch them in the face for that.

And the reason you're getting paged at 3 AM for meaningless crap isn't because "oh, you're horrible, so they're just toying with you" -- it's because THEY'RE ******ED. If they were just aggravating residents who were mean to them, then presumably all the "nice and sweet" residents who make up the VAST MAJORITY of people would never get these pages. Think that's true? Then you're just smart enough to be a nurse. The best part is that, if they page you for a "plan" and you tell them the plan is in the chart, guess what? They lose all interest -- reading sucks, eh, ladies (and gay men, I guess)? If you can't get the answers by bothering someone else, then I guess the question just became irrelevant ...oh, wait, my bad, it started out that way.

 

[Bifid Uvula]

1:30am- BEEP BEEP BEEP
Me: hi this is OMFS answering a page.
ER Doc: I got a doozy of a mandible fracture for you (starts rambling about anything and everything IRRELEVANT to the patient). This dude's jaw is definitely shattered.
Me: Did you get an X-ray? A panorex?
Er Doc: Yep, definitely broken. He's in bed 15.
Me: OK see you in a few
So I get there all weary-eyed, stumbling down the hall exhausted from a busy day. Look at the panorex hanging on the view box. NO FRACTURE! NADA. I'm thinking this has to be a mistake, he swore to me it was clearly shattered. I look in the room, and that patient is talking to himself and munching on a candy bar (the crunchy nut thing) that he pulled out of his pocket. I find the ER doc, and show him to the patient's door...
Me: does he look like his jaw is fractured?
ER Doc: Sorry. Have a good night.

2 nights later:
3:30am BEEP BEEP BEEP
ME: Hi this is OMFS answering a page.
Same ER DOC: Remember that guy that was here two days ago?
ME: Yah.
ER Doc: He's back again. I'm pretty sure his jaw is broken this time.
ME: (thinking i'm smarter this time around). Did you look at his x-ray? How about getting a CT this time?
ER Doc: I already got the CT... i see a fracture.
ME: Ok, I'm coming...
I stop by the computer and look at the CT scan. NO FRACTURE. NADA. I walk into the room and examine the patient. He's TOTALLY ATRAUMATIC. But he's having a schizophrenic moment and he's fighting with the "invisble man" No fractures, nada. I get the ER doc again and it turns out that once again he NEVER EXAMINED THE PATIENT. So by now its too late to go back to bed, gotta go start rounding on patients.

2 days later...
BEEP BEEP BEEP: 3 in the afternoon
ER Doc Answers the phone: You are gonna think i'm crazy now, but I swear the guy's jaw is broken this time. He's back. He got assaulted at the homeless shelter this morning.
I got the CT waiting for u.
And sure enough, this time the guy had a left angle and right parasymphysis fracture.

Goes to show you... the guy must have some psychic powers in predicting his impending mandible fracture. I was at my breaking point.... totally ready to strangle this ER attending for Resident Abuse.

 

[MediCane2006]

1:30am- BEEP BEEP BEEP
Me: hi this is OMFS answering a page.
ER Doc: I got a doozy of a mandible fracture for you (starts rambling about anything and everything IRRELEVANT to the patient). This dude's jaw is definitely shattered.
Me: Did you get an X-ray? A panorex?
Er Doc: Yep, definitely broken. He's in bed 15.
Me: OK see you in a few
So I get there all weary-eyed, stumbling down the hall exhausted from a busy day. Look at the panorex hanging on the view box. NO FRACTURE! NADA. I'm thinking this has to be a mistake, he swore to me it was clearly shattered. I look in the room, and that patient is talking to himself and munching on a candy bar (the crunchy nut thing) that he pulled out of his pocket. I find the ER doc, and show him to the patient's door...
Me: does he look like his jaw is fractured?
ER Doc: Sorry. Have a good night.

2 nights later:
3:30am BEEP BEEP BEEP
ME: Hi this is OMFS answering a page.
Same ER DOC: Remember that guy that was here two days ago?
ME: Yah.
ER Doc: He's back again. I'm pretty sure his jaw is broken this time.
ME: (thinking i'm smarter this time around). Did you look at his x-ray? How about getting a CT this time?
ER Doc: I already got the CT... i see a fracture.
ME: Ok, I'm coming...
I stop by the computer and look at the CT scan. NO FRACTURE. NADA. I walk into the room and examine the patient. He's TOTALLY ATRAUMATIC. But he's having a schizophrenic moment and he's fighting with the "invisble man" No fractures, nada. I get the ER doc again and it turns out that once again he NEVER EXAMINED THE PATIENT. So by now its too late to go back to bed, gotta go start rounding on patients.

2 days later...
BEEP BEEP BEEP: 3 in the afternoon
ER Doc Answers the phone: You are gonna think i'm crazy now, but I swear the guy's jaw is broken this time. He's back. He got assaulted at the homeless shelter this morning.
I got the CT waiting for u.
And sure enough, this time the guy had a left angle and right parasymphysis fracture.

Goes to show you... the guy must have some psychic powers in predicting his impending mandible fracture. I was at my breaking point.... totally ready to strangle this ER attending for Resident Abuse.

This one made me for the first time all day. VA call is just plain weird...I'm one of three docs in the hospital right now (the other two being a medicine senior and medicine intern) and my call room is at the top (very deserted) floor. Reading SDN just to keep from getting jumpy...

...and got another good page to add to the list. As only the VA can do it:
BEEP BEEP
Me - Hi, it's Dr. Medicane from surgery
Nurse - Hi there, just calling in a consult from the nursing home
Me - Okay...
Nurse - This patient got an injection this morning and hasn't stopped bleeding from the injection site.
Me - Well, it's after 7 at night....
Nurse - Yes, and he's still bleeding. He's on aspirin and plavix, so we held those tonight.
Me - Uh...so why was surgery consulted?
Nurse - (in a "duh" voice) For surgical management of the bleeding
Me - (resisting the impulse to ask whether she wanted me to manufacture a platelet plug) Okay. I'll be right down.

Lo and behold, the poor guy really had been bleeding all day from an IM injection site (and yet the consult hadn't been put in until after 6). I held pressure for 15 minutes, made sure there was no hematoma, and put a pressure dressing on. Worked like a charm, but this ornery vet was pretty angry that I was leaning on his butt cheek for 15 minutes. Gotta love the VA.

 

[tussy]

This one made me for the first time all day. VA call is just plain weird...I'm one of three docs in the hospital right now (the other two being a medicine senior and medicine intern) and my call room is at the top (very deserted) floor. Reading SDN just to keep from getting jumpy...

...and got another good page to add to the list. As only the VA can do it:
BEEP BEEP
Me - Hi, it's Dr. Medicane from surgery
Nurse - Hi there, just calling in a consult from the nursing home
Me - Okay...
Nurse - This patient got an injection this morning and hasn't stopped bleeding from the injection site.
Me - Well, it's after 7 at night....
Nurse - Yes, and he's still bleeding. He's on aspirin and plavix, so we held those tonight.
Me - Uh...so why was surgery consulted?
Nurse - (in a "duh" voice) For surgical management of the bleeding
Me - (resisting the impulse to ask whether she wanted me to manufacture a platelet plug) Okay. I'll be right down.

Lo and behold, the poor guy really had been bleeding all day from an IM injection site (and yet the consult hadn't been put in until after 6). I held pressure for 15 minutes, made sure there was no hematoma, and put a pressure dressing on. Worked like a charm, but this ornery vet was pretty angry that I was leaning on his butt cheek for 15 minutes. Gotta love the VA.

I always answer those kind of pages with a "please apply firm pressure on the site for 15 minutes continuously without peaking" and then confirm that i mean a "real" 15 minutes by the clock. And if it doens't stop after that then, and only then will i show up to see the patient. And, if i get there and find that it wasn't done then i leave and tell them that i won't return until they do the "basic first aid measures that we all learned in Junior High school". That usually gets rid of them.

 

[Dr. Dukes]

Not really the same thing, but as an EMT I've been called to a house for a LifeAlert activation (Help, I've fallen and I can't get up), only to rush in the door and find the supposedly injured lady sitting in a rocking chair with a stop watch, timing us on how long it would take to get there. This was a 3am. Needless to say, I woke up her PCP, yelled at him for a couple of minutes telling him he needs to explain to his patients these things aren't toys, sat there while he yelled at her, then went back to bed. I think she also got a ticket from the PD for something equivalent to filing a false police report, but I'm not sure.

 

[supercut]

recently while on home call..

beep beep beep.. at 2am
Nurse: Just thought you'd like to know we gave Mrs X her vicodin 45 minutes early.
Me: Sigh. Ok. *click*

The funniest part is on morning rounds the next day, when I told the NP (excellent NP who works hard, and has a great apprecation for how much harder we work) though only weekdays and has never taken call). She was stunned, thought I was kidding, then went off to find the nurses to try to tell them not to page us for stuff like that. Didn't work.

 

[blotto geltaco]

Needless to say, I woke up her PCP, yelled at him for a couple of minutes telling him he needs to explain to his patients these things aren't toys

You are SO cool

 

[SLUser11]

You are SO cool

There's a lot of that in this thread......

 

[Tigger14]

I always answer those kind of pages with a "please apply firm pressure on the site for 15 minutes continuously without peaking" and then confirm that i mean a "real" 15 minutes by the clock. And if it doens't stop after that then, and only then will i show up to see the patient. And, if i get there and find that it wasn't done then i leave and tell them that i won't return until they do the "basic first aid measures that we all learned in Junior High school". That usually gets rid of them.

The only problem I run into here is that "pressure" to me is one or two fingers directly on the bleeding site. "Pressure" to a non-surgeon is 6 boxes of 4x4 gauze and three hands holding them down. A patient came in like that with a carotid blow out and they couldn't understand why it continued to bleed. 😡

 

[danielmd06]

Why is it that the nurse can call me at 4:30 in the morning to ask if a patient really needs another serum osmol before he gets his mannitol and fails to mention that his left pupil was blown.

Yikes. Is the patient okay?

 

[Chronic Student]

Yikes. Is the patient okay?

No.

The family pulled the plug.

Not something I'll forget anytime soon.

-Mike

 

[Bifid Uvula]

Got a page at 2:30am from a fresh grad nurse...

Beep Beep Beep...

ME: Hello... I was sleeping, what can I do for you?
Nurse: The patient's labs are back, his BUN is a little low.
ME: Ok, give him 4 units of BUN... Click and back to sleep.

In the morning, pre-rounding on patients the head nurse gave me a real @$$ reaming. Said her new nurse spent the rest of the night searching all over the hospital to find some BUN to give the patient!

 

[Winged Scapula]

Got a page at 2:30am from a fresh grad nurse...

Beep Beep Beep...

ME: Hello... I was sleeping, what can I do for you?
Nurse: The patient's labs are back, his BUN is a little low.
ME: Ok, give him 4 units of BUN... Click and back to sleep.

In the morning, pre-rounding on patients the head nurse gave me a real @$$ reaming. Said her new nurse spent the rest of the night searching all over the hospital to find some BUN to give the patient!

Are you sure this isn't a medical Urban Legend?

I've heard this story as least as many times as the rat in the KFC chicken, but I've never once seen a nurse actually try to give some BUN (I have heard then pronounce it as if it were a bread product, but that's a different story).

 

[QuikClot]

Apollyon, I want to work at your hospital 😉

In my experience, the quality of EM attendings/residents/interns varies wildly, from those who call knee-jerk consults to others who complete thorough, thoughtful workups before calling in the appropriate service. Typically this is variation correlates quite well with how busy our ER happens to be.

Perhaps that's more exculpatory then you realize. The dogma of emergency medicine is that abdominal pain of >1 hr.s duration is a surgical emergency until proven otherwise. So maybe, if you have a bunch of other patients, it makes sense to order the consult before the exam.

It was a surprise to me, coming from EMS into medicine, to discover that the medical thought process and they EM thought process are very different. Most specialities think in terms of interview-->exam-->tests-->diagnosis(or consult)-->treatment. The assumption is that you have the time to do those things, in that order, and you do unless you're lazy or stupid. But in EM the process is a little different. Things don't always go in order, time sometimes prevents you from doing the things you might like to do.

I don't want to leap to the defense of every EM doc who turfs their work at the drop of a hat. A lot of that, I'm sure, is personality-based and driven by laziness or insecurity. Just wanted to suggest that cultural differences, driven by different working conditions and demands, may be part of the story.

 

[Bull's eye]

BEEP.... BEEP... BEEP...
Hi this is Bobby, a Peds intern in the ER. I have a 57 mo old kid with Left Leg Pain. I haven't ordered x-rays or labs and no one has evaluated the patient. Can you come down to take a look?
Me: No (Click)

I have come to the conclusion that if you are not there in the ER, they think you are doing nothing.

 

[Winged Scapula]

I have come to the conclusion that if you are not there in the ER, they think you are doing nothing.

Lol. You may be on to something there. I can recall an EM resident rotating with us on Trauma who constantly complained that we never stopped moving, we never sat down, that everything took too long (like holding pressure on a femoral line site that had the catheter removed...for some reason "hold for 30 minutes and don't peek" became "hold lightly for 5 minutes, if it doesn't bleed for 3 seconds, its ok to walk away"), we started too early and stayed too late, never had lunch or took breaks, and that we didn't consult enough people to do stuff for us.

No specialty really understands the other.

 

[Winged Scapula]

Perhaps that's more exculpatory then you realize. The dogma of emergency medicine is that abdominal pain of >1 hr.s duration is a surgical emergency until proven otherwise.

Really? Wow... I can think of lots of reasons why someone would have abdominal pain for more than 1 hr that wouldn't even be surgical, let alone a emergency.😕

Heck, I ate too much ice cream tonight and my belly has hurt for more than an hour. I guess I'd better rush over to the ED and get myself some surgerizin'...

 

[surgdo]

It was a surprise to me, coming from EMS into medicine, to discover that the medical thought process and they EM thought process are very different. Most specialities think in terms of interview-->exam-->tests-->diagnosis(or consult)-->treatment. The assumption is that you have the time to do those things, in that order, and you do unless you're lazy or stupid. But in EM the process is a little different. Things don't always go in order, time sometimes prevents you from doing the things you might like to do.

.

If someone comes in the E.R. with a complaint and you order labs and/or consult before even seeing the patient then why not just staff the E.R. with P.A.'s or N.P.'s? I understand after doing rotations in E.R. that the system generally works against E.R. physicians, but I don't how you can defend not even seeing a patient before calling consults.

 

[whoopsie_1]

Most specialities think in terms of interview-->exam-->tests-->diagnosis(or consult)-->treatment. The assumption is that you have the time to do those things, in that order, and you do unless you're lazy or stupid. But in EM the process is a little different. Things don't always go in order, time sometimes prevents you from doing the things you might like to do.

This, of course, is untrue. What you say sounds fine, until you actually stop and think about it. If a specialist has time to interview and examine the patient, then so would anyone else. How many times do you think a surgeon or internist or pediatrician or anyone gets called for an ER consult and it's a true "emergency" where they basically have less than a minute to evaluate the situation and determine an action? Probably less than 5% of the time, and that's being extremely generous. Meanwhile, this excuse of "I would have worked up the patient properly or at least obtained an actual H&P, but things are going bananas down here!" is used to basically deflect attention from what is (at the least) pure laziness or (at the worst) total incompetence.

You can tell there's no thought process going on because every person has the exact same labs. Everything is exactly the same for every patient. They come in, get a Chem-7 and CBC, CXR, EKG. (No interpretation occurs of the CXR or EKG; they're just on the chart.) Then you get the magical phone call with the chief complaint. If the person says "chest pain," it's a call to Medicine for "r/o MI." If it's "RUQ abdominal pain," it's a call to Surgery for "r/o cholecystitis." If it's a woman with vaginal bleed, it's a call to GYN for "evaluate vaginal bleed."

ER physicians are no more than triage nurses at this point. Everyone recognizes this; the only problem is that saying it is rude because it damages the pride of the ER physican, who wants to feel as if they are "equally a doctor" even if they aren't doing things that a physician would do.

For example, the only times I have EVER gotten a good history and physican and consult from an ER physician ...were when they were reading off an EARLIER consult sheet from another service that was recommending the second consult. Usually, it's more like, "yeah, um, we got a guy down here, uh ...I don't have his name, but he's in bed 8 ...aaaanyway, he says his belly hurts and he's also got a history of asthma. Nothing's back yet, but the labs are cooking." I mean, that is literally painful to listen to. I mean, forget the complete lack of vital signs or exam; it's like they were in a boxing match just before they called you and took too many head shots, the way they present a patient.

 

[Bifid Uvula]

Are you sure this isn't a medical Urban Legend?

I've heard this story as least as many times as the rat in the KFC chicken, but I've never once seen a nurse actually try to give some BUN (I have heard then pronounce it as if it were a bread product, but that's a different story).

This is the real BIFID here... I don't know who typed that under my name (but i have my list of suspects ).

I heard almost that exact same story from a pathologist.

My humble apologies.

This is a very enjoyable thread. Cheers guys and gals.

 

[Apollyon]

If the person says "chest pain," it's a call to Medicine for "r/o MI."

Umm, in the real world, no. In the real world, cardiologists want 3 things: EKG, markers, and pain. That is ALL.

ER physicians are no more than triage nurses at this point. Everyone recognizes this

The "common knowledge" or "Everyone recognizes this" statement is fraught with error and unsubstantiation. You can say that EM sucks all you want, but money talks. The hospital system my group contracts with is only one of four in the entire US with a bond rating of "AAA". They know their money, and they are tight with it - and we just got a big raise. At least where I'm at, we don't (apparently) suck. Then again, the residents (hate to say it, my friend) have a much better perspective.

 

[core0]

Are you sure this isn't a medical Urban Legend?

I've heard this story as least as many times as the rat in the KFC chicken, but I've never once seen a nurse actually try to give some BUN (I have heard then pronounce it as if it were a bread product, but that's a different story).

I don't know I sent someone for 50 feet of flightline when I was in the Army.

David Carpenter, PA-C

 

[whoopsie_1]

Umm, in the real world, no. In the real world, cardiologists want 3 things: EKG, markers, and pain. That is ALL.

I've known ER physicians to consult Cardiology without any of those things; rarely, but it has happened. I also happen to know for a fact that ER physicians who do obtain studies such as those don't interpret them at all (except to perhaps read the writing at the top of the EKG, the machine interpretation). I also happen to know for a fact that ER physicians don't look at films they order, other than perhaps the Radiologist interpretation. I also happen to know that ER physicians often don't obtain a reliable history. I suppose you could tell me that this is not the case and then we could get into a "he said-she said" scenario, but I believe that the experiences of the majority of residents would prove me right and you wrong if that were the case.

Also, if an ER "shotguns" things, is that then evidence that they are effective? Or know what they're doing? Because that's the OTHER end of the spectrum for the ER. It's like when you tell them they've called too late -- then they overcompensate by calling everything way too early (because they don't know why they're calling, to be honest). With labs and studies, people get shotgunned all the time ...then the ER points to the fact that one of the labs was the correct one to order, demonstrating that they did the right thing. The common joke is that you can't get out of an ER without getting CT scanned, often unecessarily so. It's not completely true, but almost.

Finally, I'd say that while I've met many ER physicians who literally are clueless (i.e., ignorant), there are a small number who know what to do, but are just intellectually lazy. For example, if I were to talk to them and just quiz them on random scenarios, they'd do fairly well -- respectably enough for a non-specialist. So you figure that they'd follow through in the real world. But that's not the case. Why? Because they don't want to take the time to think. It's unnecessary. Far easier to pick up the phone, which is what happens.

Now, as to your other comment, it's nice that your group is getting paid a lot of money. Do you know why it is? Because ERs bring money to the hospitals. That's a FACT. That's where patients come to the hospital. That also gives ERs a great deal of political pull. And that is why ERs never improve; they are powerful enough to defy any change. Do I like that? No. But that doesn't mean I can deny the truth. Does that mean that ER physicians are good? No. All you need to be a "good" ER physician is have good "throughput," or turn-over. The ER guys obsess about that statistic as much as Surgeons obsess about morbidity and mortality -- that's the sad part. For an ER, the time for disposition is their "quality control." That's not the way to be a good physician.

 

[dpmd]

Ummm, can we get back to the funny pages? That is much more entertaining than specialty bashing (whether warranted or not). I would contribute, but I have yet to experience any (although while a nurse I had to make a few stupid pages due to hospital regulations and JCAHO-like calling a doc because he didn't sign the med recon for the patient being discharged...like there was any way he wouldn't want to continue the post op vag hyst patient on their synthroid-at least that was daytime).

 

[Winged Scapula]

Beep, beep beep:

Me: Hi, its Kim Cox, on Trauma. I got paged.

Nurse: Uh, yeah. I was wondering, your order says strict Is and Os for Mr. Slimebag in Room 4235. Do I have to include semen?

Me: Huh?

Nurse: Well, I caught him having sex with his <underage> girlfriend again and was just wondering if I have to count his, you know <whispers and spells> c-u-m, in his outs.

Me: Yes, you do (figuring I'll play along)

Nurse: Ok, well I'll have to put an NGT down <underage> GF then.

Snickers galore in the background as the posse of nurses couldn't suppress their laughter anymore.

They were goading me because I was so pissed when I was informed that since <underage> GF had just given birth to Slimebag's (who was a double amputee, BTW with a scrotal abscess) baby, I couldn't report him for statutory and had been stomping around the ward mad all day.

 

[southerndoc]

I've known ER physicians to consult Cardiology without any of those things; rarely, but it has happened. I also happen to know for a fact that ER physicians who do obtain studies such as those don't interpret them at all (except to perhaps read the writing at the top of the EKG, the machine interpretation). I also happen to know for a fact that ER physicians don't look at films they order, other than perhaps the Radiologist interpretation. I also happen to know that ER physicians often don't obtain a reliable history. I suppose you could tell me that this is not the case and then we could get into a "he said-she said" scenario, but I believe that the experiences of the majority of residents would prove me right and you wrong if that were the case.

Also, if an ER "shotguns" things, is that then evidence that they are effective? Or know what they're doing? Because that's the OTHER end of the spectrum for the ER. It's like when you tell them they've called too late -- then they overcompensate by calling everything way too early (because they don't know why they're calling, to be honest). With labs and studies, people get shotgunned all the time ...then the ER points to the fact that one of the labs was the correct one to order, demonstrating that they did the right thing. The common joke is that you can't get out of an ER without getting CT scanned, often unecessarily so. It's not completely true, but almost.

Finally, I'd say that while I've met many ER physicians who literally are clueless (i.e., ignorant), there are a small number who know what to do, but are just intellectually lazy. For example, if I were to talk to them and just quiz them on random scenarios, they'd do fairly well -- respectably enough for a non-specialist. So you figure that they'd follow through in the real world. But that's not the case. Why? Because they don't want to take the time to think. It's unnecessary. Far easier to pick up the phone, which is what happens.

Now, as to your other comment, it's nice that your group is getting paid a lot of money. Do you know why it is? Because ERs bring money to the hospitals. That's a FACT. That's where patients come to the hospital. That also gives ERs a great deal of political pull. And that is why ERs never improve; they are powerful enough to defy any change. Do I like that? No. But that doesn't mean I can deny the truth. Does that mean that ER physicians are good? No. All you need to be a "good" ER physician is have good "throughput," or turn-over. The ER guys obsess about that statistic as much as Surgeons obsess about morbidity and mortality -- that's the sad part. For an ER, the time for disposition is their "quality control." That's not the way to be a good physician.

Wow, you must really work in a suckarse hospital. None of the emergency physicians I have worked with (both as a paramedic and as a resident) are that careless with patient care. Where I am, we don't consult OB/gyn on every vaginal bleeder (<5% get consults, most are managed in the ED and discharged with follow-up in their clinic), we don't consult cardiology on every chest pain patient (we have our own chest pain center), nor do we consult surgery for every abdominal pain (we do our own ultrasounds for right upper quadrants, and if we suspect they have acute cholecystitis or appendicitis, then we consult surgery).

Interestingly enough, I've seen way too many of our surgeons refuse to take young, healthy patients to the OR for likely acute appendicitis based on clinical exam. We rely too much on CT where I work, and quite frankly, I've stopped calling surgery for male patients with RLQ pain, rebound, etc. until the CT is done. They never took them to the OR based on clinical findings, so I was just wasting everyone's time. (I never called for females based on clinical findings unless they were septic appearing. Many of these patients get transvaginal ultrasounds to rule out ovarian pathology.)

Despite the vast differences in care received in many emergency departments, there are vast differences in care received in every service of the hospital. Some medicine teams suck, just as some surgery teams suck.

I guess I have it much easier since I am the referring physician. One thing I've learned is that it's always easier to consult rather than to be consulted.

Please don't let your experiences turn you into a bitter surgeon. When you become bitter at other services, you often show this to your patients, and they in turn will tell others. When you are in private practice, this will cost you referrals.

 

[FoughtFyr]

Please don't let your experiences turn you into a bitter surgeon. When you become bitter at other services, you often show this to your patients, and they in turn will tell others. When you are in private practice, this will cost you referrals.

SD,

Whoopsie_1 just is another reincarnation of Kinetic. Don't even bother.

Long live the Prez-o-dent!

- H

 

[dynx]

Umm, in the real world, no. In the real world, cardiologists want 3 things: EKG, markers, and pain. That is ALL.

Where is your real world? If our ER did this they would be drop kicked by the much tougher cardiology fellows. If you really do act like this...maybe our capable ED folks are the exception to the rule.

Here folks are seen, tests are ordered and interpreted and the patient is in line for the appropriate further work-up...echo, treadmill, nuke-med and has a bed request in for the appropriate level of care before a cardiologist is even paged. very RARELY the cardiologist changes the plan on admit. And this is a busy level 1 trauma center.

 

[Apollyon]

Where is your real world? If our ER did this they would be drop kicked by the much tougher cardiology fellows. If you really do act like this...maybe our capable ED folks are the exception to the rule.

No cards fellow here - 5 total private cards groups, but 3 of them have most of the juice (10, 20, and 30+ docs in the groups - all do interventional). Where I was a resident, we did all the stuff you say. Your "maybe our capable ED folks are the exception to the rule" insult is the hallmark of the academic medical center - almost by definition "NOT the real world". When I was a resident, I called the admitting doc and said that "this guy needs a stress" or "this woman needs a cath" and the cards person (originally an attending, then later became a fellow) agreed. Here, the cards people make all the calls. That's what happens in a community ED with 90K visits per year (and our own 'chest pain center' - however, with 5 groups, it's not clear who would interpret echos and stresses daily, versus one academic group that has all the docs under one umbrella).

Oh, and, where I was a resident was at Duke - and the cards people there also are on the "pain, markers, EKG, see ya!" page, and just look up Magnus Ohman and Robert Califf (as both were just quoted in the past week), so your insult has little juice, as I'd recommend Duke Cards to anyone - bar none. So, if your cards fellows are drop-kicking you, they are scutting you and pimping you (as in, you are doing their jobs for them).

Sorry to derail - my pager has a dead battery - I'm only on-call once a month for overflow and sick call!

 

[dynx]

No cards fellow here - 5 total private cards groups, but 3 of them have most of the juice (10, 20, and 30+ docs in the groups - all do interventional). Where I was a resident, we did all the stuff you say. Your "maybe our capable ED folks are the exception to the rule" insult is the hallmark of the academic medical center - almost by definition "NOT the real world". When I was a resident, I called the admitting doc and said that "this guy needs a stress" or "this woman needs a cath" and the cards person (originally an attending, then later became a fellow) agreed. Here, the cards people make all the calls. That's what happens in a community ED with 90K visits per year (and our own 'chest pain center' - however, with 5 groups, it's not clear who would interpret echos and stresses daily, versus one academic group that has all the docs under one umbrella).

Oh, and, where I was a resident was at Duke - and the cards people there also are on the "pain, markers, EKG, see ya!" page, and just look up Magnus Ohman and Robert Califf (as both were just quoted in the past week), so your insult has little juice, as I'd recommend Duke Cards to anyone - bar none. So, if your cards fellows are drop-kicking you, they are scutting you and pimping you (as in, you are doing their jobs for them).

Sorry to derail - my pager has a dead battery - I'm only on-call once a month for overflow and sick call!

No insult...im not for academic med myself...but if you need to call the admit doc and suggest the next step for him to agree...than you're his bitch, why not just order it? Oh yeah, they make the calls. Forgot...thought you were a doc for a sec.
I don't blame the Duke cards folks for being "pain, markers, EKG see YA" kinda people...if I had half asses in the ER I would be too, so while I do see why I would respect Duke cards, I dont see why I would respect the Duke ED. And finally, Im not an ED res. but I do respect them, so they must be doing something right that they are not doing at a lot of hospitals, their job. You're role is limited because people cant trust you to do it...thats how it normally works.

 

[Smurfette]

Beep, beep beep:

Me: Hi, its Kim Cox, on Trauma. I got paged.

Nurse: Uh, yeah. I was wondering, your order says strict Is and Os for Mr. Slimebag in Room 4235. Do I have to include semen?

Me: Huh?

Nurse: Well, I caught him having sex with his <underage> girlfriend again and was just wondering if I have to count his, you know <whispers and spells> c-u-m, in his outs.

Me: Yes, you do (figuring I'll play along)

Nurse: Ok, well I'll have to put an NGT down <underage> GF then.

Snickers galore in the background as the posse of nurses couldn't suppress their laughter anymore.

They were goading me because I was so pissed when I was informed that since <underage> GF had just given birth to Slimebag's (who was a double amputee, BTW with a scrotal abscess) baby, I couldn't report him for statutory and had been stomping around the ward mad all day.

That is hilarious!

 

[Mayhem]

They were goading me because I was so pissed when I was informed that since <underage> GF had just given birth to Slimebag's (who was a double amputee, BTW with a scrotal abscess) baby, I couldn't report him for statutory and had been stomping around the ward mad all day.

This is the funniest thing I've seen in a while, but I don't get it, why can't you report him? Because she had his child?

 

[Winged Scapula]

This is the funniest thing I've seen in a while, but I don't get it, why can't you report him? Because she had his child?

That is what I was told - if a minor has a child then they become an adult in the eyes of the law. So this slimebag would not have been guilty of child rape or statutory or whatever you want to call it.

Still gets me mad just thinking about it.😡

 

[BlackSails]

That is what I was told - if a minor has a child then they become an adult in the eyes of the law. So this slimebag would not have been guilty of child rape or statutory or whatever you want to call it.

Still gets me mad just thinking about it.😡

But didnt he have sex with her before she had the child?

Also, I dont think having a child is enough to be emancipated. Check with your legal advisors.