Crappy Sign Outs

[Groove]

Anybody got some great cluster f*** sign outs lately? Man...when I was in residency, we got reamed if we were to even think about signing out someone needing a lac repaired, pelvic exam done, LP, central line, etc.. and I just consider it ridiculously poor form for an attending (or resident for that matter) to sign out these types of patients. For starters, you never forget it and it forever colors my perception of that person. I just can't shake it. I forever think of them as Dr. Sh*tty sign outs.

Case in point: I was doing a shift a few years ago at our sister hospital and one of the long timers there, who has a good reputation I've heard, signed out an "ACS r/o". It went something like this.....

"Dr. Groove! Glad you're here buddy! I'm Dr. Sh*tty Sign Out and I've got this 65y/o male in bed 8 who came in with CP. Lots of risk factors, EKG looks ok but story is kind of suspicious, just getting started on him really and planned to wait for everything to come back and then admit for obs. Anyway, the chart is yours....thanks buddy!"

He proceeds to get his bag, pack up his stuff and as he walks by with a scarf thrown around his neck he goes "Ohbythewaytherewassomeproblemwithafoleyithink?!?! Blood on the penis...don't think it's anything...anywayjustthoughtyoushouldknow..cya man!" And off he runs through the ambulance bay doors, scarf trailing behind him.

I walk into the room and no exaggeration, there's a frail 65 y/o guy lying on a gurney in a pool of blood with blood spurting out the end of his penis all over the place. Long story short, some ***** blows the foley balloon halfway up his d*ck and completely transects the urethra and ruptures his prostatic bed. I spent forever on this guy, ended up having to bring in a urologist who was a complete a**hole on the phone and finally had to come in to take this guy to the OR for foley placement under cystoscope. Nurse tells me later on that she had told the previous doc about everything but he decides to plop that poop sandwich in my lap instead.

Those cases are so aggravating! Anybody else get these from time to time?

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[Apollyon]

Yes. Several ****ty FM docs that work in our rural ED. Frequent.

 

[Zebra Hunter]

Luckily haven’t had sh** sign outs like that. I’ve had a few ridiculous sign outs though, that I happily took because they were easily dispo’d (luckily our group splits RVUs on handoffs, with the one dispo’ing getting most of the RVUs).

One example was a drunk girl, who had “passed out” after a night of drinking. Alcohol level was 300. No medical issues. 20-something years old. The sign out I received was, “I’m worried about her, she’s got a QTc that is prolonged (460 lol). I wanted to have her re-assessed when she’s sober.” Despite the patient telling Dr. Signout and the nurse she was drunk but felt fine, with normal vitals, normal CT head, and normal ECG (I don’t consider a QTc of 460 concerning) and normal labs. So as soon as Dr. Signout walked out, I spoked to and examined the patient, road tested her and discharged.

Or the time I got an asymptomatic hypertension pt with a BP of 220/105 who the doc had placed them on cardene and was waiting on labs, so handed off to me. Pt had no symptoms at all, the doc was worried because the patient had a hx of CAD. Gladly took the signout, stopped the cardene immediately and discharged with oral meds once the labs came back normal.

 

[RustedFox]

One example was a drunk girl, who had “passed out” after a night of drinking. Alcohol level was 300. No medical issues. 20-something years old. The sign out I received was, “I’m worried about her, she’s got a QTc that is prolonged (460 lol). I wanted to have her re-assessed when she’s sober.” Despite the patient telling Dr. Signout and the nurse she was drunk but felt fine, with normal vitals, normal CT head, and normal ECG (I don’t consider a QTc of 460 concerning) and normal labs. So as soon as Dr. Signout walked out, I spoked to and examined the patient, road tested her and discharged.

Or the time I got an asymptomatic hypertension pt with a BP of 220/105 who the doc had placed them on cardene and was waiting on labs, so handed off to me. Pt had no symptoms at all, the doc was worried because the patient had a hx of CAD. Gladly took the signout, stopped the cardene immediately and discharged with oral meds once the labs came back normal.

You work with DNPs, apparently.

 

[DrMcCoyDO]

One of our attendings signed out about 6-7 patients to us about 1.5-2 months ago, completed half-assed work-ups. Ended up having to take the first three hours of shift cleaning up his mess before picking up new patients.

A week and a half later, I signed out a patient to him, completely gift wrapped. The only thing not in was an admit order; because, lab/imaging results had to be back before the admit could be officially placed. Personally walked the patient to get images and dropped the labs off with the lab tech and asked them to run them ASAP as a favor to me. Literally did everything in my power to make his job as simple as a few keystrokes on the computer. The guy comes to me a week later whining that the one thing I said he needed to do wasn’t done until two and a half hours into his shift. Just bit my tongue and nodded my head. What a jerk.

 

[miacomet]

This is one of the many reasons I wish I had not done EM.

 

[southerndoc]

Anybody got some great cluster f*** sign outs lately? Man...when I was in residency, we got reamed if we were to even think about signing out someone needing a lac repaired, pelvic exam done, LP, central line, etc.. and I just consider it ridiculously poor form for an attending (or resident for that matter) to sign out these types of patients. For starters, you never forget it and it forever colors my perception of that person. I just can't shake it. I forever think of them as Dr. Sh*tty sign outs.

Case in point: I was doing a shift a few years ago at our sister hospital and one of the long timers there, who has a good reputation I've heard, signed out an "ACS r/o". It went something like this.....

"Dr. Groove! Glad you're here buddy! I'm Dr. Sh*tty Sign Out and I've got this 65y/o male in bed 8 who came in with CP. Lots of risk factors, EKG looks ok but story is kind of suspicious, just getting started on him really and planned to wait for everything to come back and then admit for obs. Anyway, the chart is yours....thanks buddy!"

He proceeds to get his bag, pack up his stuff and as he walks by with a scarf thrown around his neck he goes "Ohbythewaytherewassomeproblemwithafoleyithink?!?! Blood on the penis...don't think it's anything...anywayjustthoughtyoushouldknow..cya man!" And off he runs through the ambulance bay doors, scarf trailing behind him.

I walk into the room and no exaggeration, there's a frail 65 y/o guy lying on a gurney in a pool of blood with blood spurting out the end of his penis all over the place. Long story short, some ***** blows the foley balloon halfway up his d*ck and completely transects the urethra and ruptures his prostatic bed. I spent forever on this guy, ended up having to bring in a urologist who was a complete a**hole on the phone and finally had to come in to take this guy to the OR for foley placement under cystoscope. Nurse tells me later on that she had told the previous doc about everything but he decides to plop that poop sandwich in my lap instead.

Those cases are so aggravating! Anybody else get these from time to time?

This should have been reported to your QA committee.

 

[Zebra Hunter]

You work with DNPs, apparently.

Unfortunately both were fellow BC EM docs, although both were ancient and semi retired

 

[Angry Birds]

Yes. Several ****ty FM docs that work in our rural ED. Frequent.

Ain’t this the truth!

You know what I hate? When they ask “do you mind doing the lac?”

Why you gotta take advantage of my nice non-confrontational nature??

 

[TheComebacKid]

I thought one of the cardinal tenets of EM was you never sign out a pelvic exam. I have never signed one out and if I did my co-residents would crucify me.

I like the idea of staggered shift schedules, where the new attending comes on and starts seeing new patients and you get the last hour to tie up loose ends, finish procedures/charting etc. before sign out.

While I think most EM people really enjoy procedures, they can really kill your workflow. Struggling on a central line, or a complex lac while you have a pod blowing up is a nightmare, but if you have the new person on to start seeing those patients, makes it so much easier.

I think every practice probably has "that one guy" who is just focused on getting out on time no matter what and will dump a bunch of BS on you. And don't even get me started on the midlevel signouts.

 

[emergentmd]

Ops sign out was not too bad. He should have been more upfront but if you are on an hourly rate, I would not want to stay 2 hrs to get a urologist on board. Maybe stay and talk to him for consult. I have had much worse and usually from a small handful of docs in my lifetime.

There was one particular doc that should not even be practicing medicine, how she was EM trained was beyond me. I think she was EM trained....

One of the worse but a typical patient sign out was.

Baddoc - "This patient has been here for 2 hrs and nurse just got the blood. She is like 70's, fever, looks good. If labs comes back, she can probably go home.".
Emergent - I am quite laid back and trust signs outs. But with her, I block everything out, and just redo the H&P completely. What a waste of time, but I am a locums on an hourly rate so not as much of a big deal. I pull up the ladies initial vitals, and read something like P 130, SBP 70, fever 103. WTF!!!!! but quite typical from this doctor - does she even see the pt? I pull the labs up and of course it is back, with a WBC 30+. Pt septic, admitted, took me about 15 min to get her tucked in.

Some docs are bad, a few are dangerous.

I do concur that non EM docs tend to overall be weaker and I have more difficult shifts working with them.

 

[VA Hopeful Dr]

Yes. Several ****ty FM docs that work in our rural ED. Frequent.

Well that just can't be true. Despite our wildly different training programs, us FPs are just as good as y'all are at EM. You're just being biased due to a turf protection.

 

[emergentmd]

I thought one of the cardinal tenets of EM was you never sign out a pelvic exam. I have never signed one out and if I did my co-residents would crucify me.

I like the idea of staggered shift schedules, where the new attending comes on and starts seeing new patients and you get the last hour to tie up loose ends, finish procedures/charting etc. before sign out.

While I think most EM people really enjoy procedures, they can really kill your workflow. Struggling on a central line, or a complex lac while you have a pod blowing up is a nightmare, but if you have the new person on to start seeing those patients, makes it so much easier.

I think every practice probably has "that one guy" who is just focused on getting out on time no matter what and will dump a bunch of BS on you. And don't even get me started on the midlevel signouts.

Unless you have something you have to go to and convey this to your partner, these should never be signed out

1. Pelvic
2. Central line
3. Abscesses, lacs
4. LP
5. essentially almost any procedure

 

[southerndoc]

Well that just can't be true. Despite our wildly different training programs, us FPs are just as good as y'all are at EM. You're just being biased due to a turf protection.

FP's are also equivalent to cardiologist, neurosurgeons, and obstetricians.

 

[gro2001]

I have the opposite view. I consider it a personal failure if my tired colleague is staying late after their shift to something that I, coming in fresh, can easily do in their place.

You should aim to have a good enough relationship with your colleagues that if you genuinely didn't have time to do the procedure or the dreaded pelvic exam they wouldn't huff and puff but just help you get home on time. I see how this can be hard when you are locums, because you might not have had the chance to develop those realtionships yet and you don't have as much influence over the culture of your department. But for those in more permanent jobs, building a culture where you can sign out to each other without worrying too much should be a priority.

I work in the ED ICU, so most patients that are signed out to me are absolute train wrecks. Also, I do a lot of nights, which are significantly less busy than evening shifts. So I am often in the position of taking messy signouts and handing over well wrapped up, stabilized patients (just due to the circadian rhythm of the hospital, not because I am so much better than my peers). What I've learned is that you shouldn't take credit for a good sign out and shouldn't accept blame for a bad sign out. Do your best, but how good or bad a sign out will be will mostly be due to factors beyond your control (census, time of day, when patients arrive, lab/imaging turn around time, and consultants).

 

[emergentmd]

I have the opposite view. I consider it a personal failure if my tired colleague is staying late after their shift to something that I, coming in fresh, can easily do in their place.

You should aim to have a good enough relationship with your colleagues that if you genuinely didn't have time to do the procedure or the dreaded pelvic exam they wouldn't huff and puff but just help you get home on time. I see how this can be hard when you are locums, because you might not have had the chance to develop those realtionships yet and you don't have as much influence over the culture of your department. But for those in more permanent jobs, building a culture where you can sign out to each other without worrying too much should be a priority.

I work in the ED ICU, so most patients that are signed out to me are absolute train wrecks. Also, I do a lot of nights, which are significantly less busy than evening shifts. So I am often in the position of taking messy signouts and handing over well wrapped up, stabilized patients (just due to the circadian rhythm of the hospital, not because I am so much better than my peers). What I've learned is that you shouldn't take credit for a good sign out and shouldn't accept blame for a bad sign out. Do your best, but how good or bad a sign out will be will mostly be due to factors beyond your control (census, time of day, when patients arrive, lab/imaging turn around time, and consultants).

I can see the merit of this and communication is the key. But you can't check out something because you are lazy or did not plan ahead.

If a pt has been there 3 hrs and you need an LP done - Don't sign this out unless you have a really good reason
If a pt just got there 30 min ago and you are helping flow and an LP needs to be done - Great. I will take this all day long.

This goes with any procedure that gets checked out. If they just got there and you ordered a bunch of labs to help me, I will take over the case and assume all care and responsibility. But if that pt has been there 3 hrs and needs an LP, then all I am doing is getting involved and taking on liability for no real good reason.

Its all about context and communication.

 

[southerndoc]

Work in an ED ICU? You have a dedicated ICU in your ED?

 

[BoardingDoc]

Well that just can't be true. Despite our wildly different training programs, us FPs are just as good as y'all are at EM. You're just being biased due to a turf protection.

Leeroy... how did you get access to @VA Hopeful Dr 's account?

 

[emergentmd]

Work in an ED ICU? You have a dedicated ICU in your ED?

I can not think of a worse place to be in an ER than an ICU ER. Do you pass these ICU pts to the new oncoming ER doc? If so, I would quit.

 

[thegenius]

He proceeds to get his bag, pack up his stuff and as he walks by with a scarf thrown around his neck he goes "Ohbythewaytherewassomeproblemwithafoleyithink?!?! Blood on the penis...don't think it's anything...anywayjustthoughtyoushouldknow..cya man!" And off he runs through the ambulance bay doors, scarf trailing behind him

LOL

At that moment, when someone is just itching to get out, you gotta know it's gonna be a bad signout!

If you have worked long enough, we have all had the experience of giving and receiving intentionally bad signouts.

 

[thegenius]

Luckily haven’t had sh** sign outs like that. I’ve had a few ridiculous sign outs though, that I happily took because they were easily dispo’d (luckily our group splits RVUs on handoffs, with the one dispo’ing getting most of the RVUs).

One example was a drunk girl, who had “passed out” after a night of drinking. Alcohol level was 300. No medical issues. 20-something years old. The sign out I received was, “I’m worried about her, she’s got a QTc that is prolonged (460 lol). I wanted to have her re-assessed when she’s sober.” Despite the patient telling Dr. Signout and the nurse she was drunk but felt fine, with normal vitals, normal CT head, and normal ECG (I don’t consider a QTc of 460 concerning) and normal labs. So as soon as Dr. Signout walked out, I spoked to and examined the patient, road tested her and discharged.

Or the time I got an asymptomatic hypertension pt with a BP of 220/105 who the doc had placed them on cardene and was waiting on labs, so handed off to me. Pt had no symptoms at all, the doc was worried because the patient had a hx of CAD. Gladly took the signout, stopped the cardene immediately and discharged with oral meds once the labs came back normal.

You have ER docs playing asymptomatic hypertension on cardene drips? That's something internal medicine would do.

 

[NYEMMED]

I was signed out a trauma awaiting transport to the level 1 trauma hospital 60mins away. Signed out as “has a small pneumothorax, I didn’t put a chest tube in because it was small”

Failed to mention the patient was intubated and going by air....


Long story short:
Chest tube was placed by me in my first 15 mins of my shift.


There are a few other “partners” that are known to add on needless tests at the end of a workup on risky patients so they don’t have to discharge them and can sign them out.

 

[thegenius]

I have the opposite view. I consider it a personal failure if my tired colleague is staying late after their shift to something that I, coming in fresh, can easily do in their place.

You should aim to have a good enough relationship with your colleagues that if you genuinely didn't have time to do the procedure or the dreaded pelvic exam they wouldn't huff and puff but just help you get home on time. I see how this can be hard when you are locums, because you might not have had the chance to develop those realtionships yet and you don't have as much influence over the culture of your department. But for those in more permanent jobs, building a culture where you can sign out to each other without worrying too much should be a priority.

I work in the ED ICU, so most patients that are signed out to me are absolute train wrecks. Also, I do a lot of nights, which are significantly less busy than evening shifts. So I am often in the position of taking messy signouts and handing over well wrapped up, stabilized patients (just due to the circadian rhythm of the hospital, not because I am so much better than my peers). What I've learned is that you shouldn't take credit for a good sign out and shouldn't accept blame for a bad sign out. Do your best, but how good or bad a sign out will be will mostly be due to factors beyond your control (census, time of day, when patients arrive, lab/imaging turn around time, and consultants).

Nah....imagine you are the patient, a woman, who has pelvic pain. It's nerve wracking as it is to talk to a doctor about your problem. You spend 10 minutes talking...then 3 hours later another doctor comes in and says "OK I'm taking over, I'm going to stick my hand in your vagina."

I think signouts should be designed and structured so the subsequent physician does as little decision making AND little effort as possible. Signouts are unavoidable for the most part. But the new doc knows nothing about the patient; they should not be performing procedures on the patient unless they are emergencies; and really shouldn't have to spend significant time with complex medical decision making. Obviously you have to trust the person signing out to you too.

Don't sign out procedures
Don't sign out consults
Don't sign out complex medical patients with vague symptoms like "old person with dizziness, I sent labs and CT Head, can you follow up." That basically means you have to start all over again

That's the way I want to have signouts given to me....and I try to signout to others thusly.

 

[SamtheWise]

Lol how do you not sign out a dizzy old person if labs and CT head are not back yet? Just order the MRI?

 

[thegenius]

Lol how do you not sign out a dizzy old person if labs and CT head are not back yet? Just order the MRI?

LOL
Leave them for the oncoming doc.
Or admit them
Or order the MRI.

 

[gro2001]

I can see the merit of this and communication is the key. But you can't check out something because you are lazy or did not plan ahead.

If a pt has been there 3 hrs and you need an LP done - Don't sign this out unless you have a really good reason
If a pt just got there 30 min ago and you are helping flow and an LP needs to be done - Great. I will take this all day long.

This goes with any procedure that gets checked out. If they just got there and you ordered a bunch of labs to help me, I will take over the case and assume all care and responsibility. But if that pt has been there 3 hrs and needs an LP, then all I am doing is getting involved and taking on liability for no real good reason.

Its all about context and communication.

Maybe I am just unusually lucky with coworkers, but most of the docs I work with I can be pretty sure that if they left an LP for 3 hours they've had really good reasons to. Obviously if I get someone signing out stuff all the time that I feel could have been done ages ago, they would lose my trust. But thankfully that's not the type of people I work with.

 

[gro2001]

Work in an ED ICU? You have a dedicated ICU in your ED?

Yes, we have a 12 bed area where all the patients with severely abnormal vital signs, titratable drips, and respiratory support have to go. I work shifts exclusively in that area.

 

[gro2001]

I can not think of a worse place to be in an ER than an ICU ER. Do you pass these ICU pts to the new oncoming ER doc? If so, I would quit.

We never have ICU beds immediately available. As a result my intubated patients on pressors stick around for a long time. So, yes, every shift I work I give and receive sign out on 0-12 critically ill patients. Not sure what you mean by it being a bad place. Can you explain further?

 

[emergentmd]

We never have ICU beds immediately available. As a result my intubated patients on pressors stick around for a long time. So, yes, every shift I work I give and receive sign out on 0-12 critically ill patients. Not sure what you mean by it being a bad place. Can you explain further?

Let me explain. We are ER doctors. We are not critical care ICU doctors. We manage and stabilize unstable patients. We do not provide care/cure for unstable patients. ERs are NOT the place to care for ICU patients with ER nurses. ICU patients are best care for by ICU doctors in the ICU with ICU nurses.

We all have facilities that are busy. We all board patients. We also board ICU patients. When I admit an ICU patient or ANY patient, that patient now is the responsibility of the inpatient physician and ALL questions go to them regardless if they live in the ER. Yes, I will help out if something unstable happens no different than if they were in the ICU. But NO, I do not manage them or sign them out to the next ER doc because the sign out will be something like, "Sick guy, intubated b/c of respiratory distress. I know nothing else"

Your place has a back end problem that needs to be addressed because signing our up to 12 ICU patients is a recipe for disaster.

 

[gro2001]

Let me explain. We are ER doctors. We are not critical care ICU doctors. We manage and stabilize unstable patients. We do not provide care/cure for unstable patients. ERs are NOT the place to care for ICU patients with ER nurses. ICU patients are best care for by ICU doctors in the ICU with ICU nurses.

We all have facilities that are busy. We all board patients. We also board ICU patients. When I admit an ICU patient or ANY patient, that patient now is the responsibility of the inpatient physician and ALL questions go to them regardless if they live in the ER. Yes, I will help out if something unstable happens no different than if they were in the ICU. But NO, I do not manage them or sign them out to the next ER doc because the sign out will be something like, "Sick guy, intubated b/c of respiratory distress. I know nothing else"

Your place has a back end problem that needs to be addressed because signing our up to 12 ICU patients is a recipe for disaster.

Yes, my system has the mother of all back end problems. You have no idea how right you are. If I shared some metrics you'd think I was off by an order of magnitude. So yes, absolutely agreed there.

However, I don't see why it would necessarily be a disaster. Yes, they are hard shifts. However, I think disaster is far more likely if you have to constantly split time between critically ill patients who need attention right now and medium/low acuity patients. Something is bound to get dropped in the task switching. In our system, I get to focus on just the sick patients. I am appropriately staffed with nursing and resident help. I don't get distracted by BS (relatively speaking).

Would it be better if there were enough ICU and step down beds available so we didn't have to manage sick patients for an extended period of time in the ER? Sure. But that's just not feasible in my hospital system at this time. So in that setting, I feel it's much better to carve out a dedicated attending to focus on just the sicker patients. The realistic alternative is still to have the sick patients board in the ER for an extended period of time, except now each attending is managing 1-2 of them while getting new non sick patients. Does that sound more sustainable?

 

[NYEMMED]

Let me explain. We are ER doctors. We are not critical care ICU doctors. We manage and stabilize unstable patients. We do not provide care/cure for unstable patients. ERs are NOT the place to care for ICU patients with ER nurses. ICU patients are best care for by ICU doctors in the ICU with ICU nurses.

We all have facilities that are busy. We all board patients. We also board ICU patients. When I admit an ICU patient or ANY patient, that patient now is the responsibility of the inpatient physician and ALL questions go to them regardless if they live in the ER. Yes, I will help out if something unstable happens no different than if they were in the ICU. But NO, I do not manage them or sign them out to the next ER doc because the sign out will be something like, "Sick guy, intubated b/c of respiratory distress. I know nothing else"

Your place has a back end problem that needs to be addressed because signing our up to 12 ICU patients is a recipe for disaster.

You are lucky...

The hospitalists at my place won’t touch an admitted patient until they are upstairs. We once boarded patients for over 50 hours in the ED and it was ED docs caring for the patients as they waited.

Needless to say after this we revolted and the hospitalists are now supposed to take over by policy, many still don’t want to...

 

[miacomet]

You are lucky...

The hospitalists at my place won’t touch an admitted patient until they are upstairs. We once boarded patients for over 50 hours in the ED and it was ED docs caring for the patients as they waited.

Needless to say after this we revolted and the hospitalists are now supposed to take over by policy, many still don’t want to...

That's because you work, it seems, in New York, which hates ED docs and ED patients.

 

[emergentmd]

You are lucky...

The hospitalists at my place won’t touch an admitted patient until they are upstairs. We once boarded patients for over 50 hours in the ED and it was ED docs caring for the patients as they waited.

Needless to say after this we revolted and the hospitalists are now supposed to take over by policy, many still don’t want to...

This is ridiculous. Just completely poor patient care and not sure even legal. How are ER docs credentialed to care for inpatient patients? Who cares if they are in the ER, PACU, the hallway, in the bathroom? They are changed from ER which is an outpt setting to an inpatient status. Why in the world would any ER doc not revolt and deal with this crap? So if an inpatient is in the ER for 50 hrs and gets discharged, then you have to do the discharge planning/med rec? This has to be a Joke.

I can't imagine taking report from an ER doc telling me how to care for an inpatient patient and I would flip and tell another ER doc 4 hrs late what the plan is. How does JCAHO even let this slide and smack hospitals when a Med rec wasn't done?

 

[emergentmd]

Yes, my system has the mother of all back end problems. You have no idea how right you are. If I shared some metrics you'd think I was off by an order of magnitude. So yes, absolutely agreed there.

However, I don't see why it would necessarily be a disaster. Yes, they are hard shifts. However, I think disaster is far more likely if you have to constantly split time between critically ill patients who need attention right now and medium/low acuity patients. Something is bound to get dropped in the task switching. In our system, I get to focus on just the sick patients. I am appropriately staffed with nursing and resident help. I don't get distracted by BS (relatively speaking).

Would it be better if there were enough ICU and step down beds available so we didn't have to manage sick patients for an extended period of time in the ER? Sure. But that's just not feasible in my hospital system at this time. So in that setting, I feel it's much better to carve out a dedicated attending to focus on just the sicker patients. The realistic alternative is still to have the sick patients board in the ER for an extended period of time, except now each attending is managing 1-2 of them while getting new non sick patients. Does that sound more sustainable?

Why do ER docs stand for this? Do you really think the hospitalist will come down to the ER and see pts when there is an hr wait? Will the ICU doc come down to care for crashing patients when the ER is slammed?

So why are ER docs managing ICU patients?

ICU patients are the easiest patients to care for. Call ICU doc immediately. Order Pan Labs, imagine, IV meds/fluids/abx. Takes me 15 minutes to get this patient onto another service.

If I had to care for these unstable patients my whole shift, I would not be able to see the 80% Urgent care patients.

Your system is not only has back end issues but front and middle end issues. It looks like all they do is crap on the ER doc until the pts go upstairs.

Whats next? When L&D is full, they open an L&D section in the ER and an ER doc staffs while they go in labor? That is essentially what you are doing for an ICU pt. No matter how good of a ER doc you are, you can not provide the same care as an ICU doc.

 

[RustedFox]

ICU patients are the easiest patients to care for. Call ICU doc immediately. Order Pan Labs, imagine, IV meds/fluids/abx. Takes me 15 minutes to get this patient onto another service.

"Imagine there is no ICU. Its easy if you try. No floor to admit to to. Above us, no CC guy."

 

[NYEMMED]

This is ridiculous. Just completely poor patient care and not sure even legal. How are ER docs credentialed to care for inpatient patients? Who cares if they are in the ER, PACU, the hallway, in the bathroom? They are changed from ER which is an outpt setting to an inpatient status. Why in the world would any ER doc not revolt and deal with this crap? So if an inpatient is in the ER for 50 hrs and gets discharged, then you have to do the discharge planning/med rec? This has to be a Joke.

I can't imagine taking report from an ER doc telling me how to care for an inpatient patient and I would flip and tell another ER doc 4 hrs late what the plan is. How does JCAHO even let this slide and smack hospitals when a Med rec wasn't done?

Exactly, They had us doing the admission and discharge med recs, Ordering echos and stress tests for cardiac rule outs, MRIs for TIAs, etc, It got so bad we revolted and made a policy change, Now we need to make the hospitalists respect the policy and round on their patients in the ED.

 

[miacomet]

Exactly, They had us doing the admission and discharge med recs, Ordering echos and stress tests for cardiac rule outs, MRIs for TIAs, etc, It got so bad we revolted and made a policy change, Now we need to make the hospitalists respect the policy and round on their patients in the ED.

I don't get NYC EM docs. It's just not worth the crappy pay, liability, poor patient care, and administrative crap. Why do you put up with this? You do realize the rest of the world doesn't function this way? Have you considered a fellowship or a second residency?

 

[GonnaBeADoc2222]

Remind me again why anyone would work in an NYC ED?

For a fantastic rate of $150 / hr (is it even this high?) you get the privilege of
-Outdated facilities
-Union nurses
-Overworked resident consultant services
-Terrible medmal
-Angry patients
-Unsupportive policies

I get it. Some people are city folk. If you love NYC you should live in NYC. Why not do locums? I just don't get it.

 

[miacomet]

Remind me again why anyone would work in an NYC ED?

For a fantastic rate of $150 / hr (is it even this high?) you get the privilege of
-Outdated facilities
-Union nurses
-Overworked resident consultant services
-Terrible medmal
-Angry patients
-Unsupportive policies

I get it. Some people are city folk. If you love NYC you should live in NYC. Why not do locums? I just don't get it.

I also don't get why the otherwise high-maintenance public of NY doesn't revolt. I do get why they are angry. I would be, too.

I know many, many nurses making $150 an hour.

Just received two recruiting emails from NYC. One was for 235k a year, no joke. Bragged about their 401k match, which doesn't vest for three years. Per diem rates started at $140 an hour up to $210 for weekend nights. I don't think they have nurses. Should I email them back and ask what the housing subsidy is?

 

[GeneralVeers]

Exactly, They had us doing the admission and discharge med recs, Ordering echos and stress tests for cardiac rule outs, MRIs for TIAs, etc, It got so bad we revolted and made a policy change, Now we need to make the hospitalists respect the policy and round on their patients in the ED.

Who cares what they do? The patients are admitted to that doctor period. If a nurse brings be a question about an admitted patient I always say "call the admitting doctor". They know not to even ask me now. Hospitalists don't want to round on a patient in the ED? Not my problem.....Nurse please let admin know that Doctor Lazypants isn't doing his job.

 

[GonnaBeADoc2222]

I also don't get why the otherwise high-maintenance public of NY doesn't revolt. I do get why they are angry. I would be, too.

I know many, many nurses making $150 an hour.

Just received two recruiting emails from NYC. One was for 235k a year, no joke. Bragged about their 401k match, which doesn't vest for three years. Per diem rates started at $140 an hour up to $210 for weekend nights. I don't think they have nurses. Should I email them back and ask what the housing subsidy is?

LOLZORZ. Good joke! Honestly, I want to know why people accept this.

 

[emergentmd]

I would love to be a hospitalist in NYC. What a deal. You get Capped when the hospital is full. How do you keep the hospital full? You hang onto patients for a few extra days so now you have all stable, low maintenance patients you can round in about 2 hours. The place is full, No NEW admits.... the ER has to be the new overflow hospitalist.

Im going to tell my friends to look into NY. Go to a small hospital, keep the place full, you won't get any new patients. If the ER calls, great........ not my problem b/c Im not going to the ER to take care of the patient assigned to me. And if all goes well, they will get discharged and I will never have to see the patient.

What a disaster of an ER environment. I think this thread takes the cake. I have heard alot of crap that Er docs had to do including deliver babies if the OB doc doesn't make it in time.

But to admit, care for, do discharge planning, manage ICU patients? Are you doing Swans too? Vent management? Whats next, you going to learn to Bronch b/c its not the pulmonologist's patient? I forgot, Pulm will come to consult on the ICU pt but the ER doc is the primary service......

Geezzzz.... you poooooor souls.

Seriously, I would get fired if I worked in NYC.

Nurse asked me to care for an admitted pt .... Dr emergent "call the admitting team"
Nurse asks me to care for the ICU pt.... Dr emergent "call the ICU doc"
Poor Monkey ER doc tries to give me checkout on admitted pts, Dr emergent "are you kidding me" while I walk out the door
Poor Monkey ER doc asks me to check out, Dr Emergent "if you want to know, asks the admitting doc"

 

[emergentmd]

Yes, my system has the mother of all back end problems. You have no idea how right you are. If I shared some metrics you'd think I was off by an order of magnitude. So yes, absolutely agreed there.

However, I don't see why it would necessarily be a disaster. Yes, they are hard shifts. However, I think disaster is far more likely if you have to constantly split time between critically ill patients who need attention right now and medium/low acuity patients. Something is bound to get dropped in the task switching. In our system, I get to focus on just the sick patients. I am appropriately staffed with nursing and resident help. I don't get distracted by BS (relatively speaking).

Would it be better if there were enough ICU and step down beds available so we didn't have to manage sick patients for an extended period of time in the ER? Sure. But that's just not feasible in my hospital system at this time. So in that setting, I feel it's much better to carve out a dedicated attending to focus on just the sicker patients. The realistic alternative is still to have the sick patients board in the ER for an extended period of time, except now each attending is managing 1-2 of them while getting new non sick patients. Does that sound more sustainable?

I don't even know what to say. Really I don't. I feel this thread is some April fools joke and I am just waiting for someone to fess up that they are pulling my leg.

B/C the hospital is full and an ADMITTED PT with an ADMISSION doctor is boarded in the ED then it is the ER doc's responsibility? How does this even make sense?

If the ER is full and EMS brings them into the ER, then its the EMS's job to care for the pt until a bed opens?

 

[Brigade4Radiant]

At one of my shops we just dont sign out. It's dangerous and you get liability with no RVU's towards the end of your shift you stop picking up non critical patients. If something critical happens you finish it. You get paid overtime for staying. I feel this works the best. Often times you get slipped up on sign out.

 

[miacomet]

NYC docs- why do you do this? Why do you accept poor pay and high liability? What happens if you just say no?

 

[GeneralVeers]

NYC docs- why do you do this? Why do you accept poor pay and high liability? What happens if you just say no?

At least the LA/San Diego/SFO people can use good weather as an excuse for their crappy pay, insane cost-of-living, and traffic congestion. I just don't get NYC. As someone stated, it would be better to live in NYC then just do one block of locums shifts in another state. I could work 6 shifts in TX and it would be the pay equivalent of 14-15 of these miserable shifts in NYC.

 

[miacomet]

At least the LA/San Diego/SFO people can use good weather as an excuse for their crappy pay, insane cost-of-living, and traffic congestion. I just don't get NYC. As someone stated, it would be better to live in NYC then just do one block of locums shifts in another state. I could work 6 shifts in TX and it would be the pay equivalent of 14-15 of these miserable shifts in NYC.

Agreed, and that's my plan when I return to the Big Apple.

California can actually pay well, even nearish the big cities. And the nurses occasionally do their jobs, unlike NYC. The NYC market is insane, yet EM is extremely popular there and most people stay. I don't get it, either.

Perhaps NYCEMMED can enlighten us...

 

[Angry Birds]

At one of my shops we just dont sign out. It's dangerous and you get liability with no RVU's towards the end of your shift you stop picking up non critical patients. If something critical happens you finish it. You get paid overtime for staying. I feel this works the best. Often times you get slipped up on sign out.

Glad you like that system, but I think that's just terrible.

I think we need to find a right medium: don't sign out crap to me, but I want to get you out on time once your shift is over. Sure, it can't happen all the time, but most days than not. I come to my shift 30-60 min early in order to help you get out of time. On the other side, I'll work my butt off in the last 2 hours of my shift, make sure my CT's are done in a way that the report comes back before sign out, etc. etc. But yeah, sometimes I'm gonna have a couple clean sign outs. I come early, but I want to leave on time. And I do 90% of the time. I pride myself on this efficiency.

In any case, I worked at a shop that had a no sign out culture, and I think they should've told me that during the interview. I wanted to quit on the first day, and by the end of the first month I made my decision to peace out, although I finished out the year since they were already bleeding staff.

I guess to each their own, but I bet the 'no sign out' group is a minority.

 

[deleted109597]

A shop I used to work at had variable signouts. However, there was one universal truth. The lazy docs would stop picking up charts overnight after the 2am rush of "admitted patients go upstairs now we pull til full and all these new patients show up". So you would get there at 6a with 15 charts in the rack of people waiting 4 hours after getting to a room.
So yeah, I wouldn't take signout from those guys. I would just start making a dent in the chart rack.

 

[southerndoc]

A shop I used to work at had variable signouts. However, there was one universal truth. The lazy docs would stop picking up charts overnight after the 2am rush of "admitted patients go upstairs now we pull til full and all these new patients show up". So you would get there at 6a with 15 charts in the rack of people waiting 4 hours after getting to a room.
So yeah, I wouldn't take signout from those guys. I would just start making a dent in the chart rack.

That's a huge liability for them to leave patients unseen for that long.