Does anyone just like....hate this?

[GonnaBeADoc2222]

Feeling extra crispy this week. Working 10 shifts in 11 days because when you take a week of vacation here you don't get PTO (does anyone get PTO??) and thus have to cram all your other shifts into what's left in the month. Ridiculous. Anyway:

-Seeing more COVID, mostly in unvaccinated patients, which makes me furious that I have to be exposed to this in the setting of decreasing vaccine effectiveness, and potentially exposing my unvaccinated children to the virus

-Non-cohorting of COVID confirmed pts and suspects within the department, which makes absolutely no sense.

-Q Anon nurses posting bat **** anti vax stuff on social media

-Boomer docs making like 100k more than I do for less work cause of the ridiculous compensation structure we have here (employee model, not an SDG)

-Massive radiology/consultant delays, which makes patients crispy too - rightfully so. But why should I be the one to face the brunt of this? Get admin down here and let them get yelled at.

-Massive nursing shortage + new grad nurses + nurses can't get lines + nurses don't use ultrasound or do EJs. Insane.

-Non functional equipment (computers, otoscopes, the usual ED garbage)

-Med director never works an evening shift or a weekend. Sure, I'll just get slammed on a weekend evening shift while you chill.

I don't see a solution other than save save save and get out. I'm not doing a fellowship. My goal for 2021 is to venture into new investment areas (??real estate syndications), hope the crypto takes off, continue to shovel money into mutual funds, and not spend money on stupid stuff.

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[bravotwozero]

I'm with you man, not easy going right now. Hopefully this delta wave peters out sooner rather than later and people learn their lesson.
See if you can cut back on shifts in the time being, lord knows i'm trying to do that.

You have the right idea otherwise.

 

[GonnaBeADoc2222]

Cutting back on shifts not really the solution for me idt. I want to make money before the inevitable resident surplus + midlevel takeover ****storm happens. It's not so much the number of shifts for me, as it is the nature of the work and abject lack of admin support for both physicians and nurses.

 

[deleted836128]

Fun times.

My favorite is throwing patients wherever they will fit (rectal pain out in a hallway, real smart) and then demanding they be seen by a doc or PA right away (PROVIDER PLEASE!!!!!! on the tracking board) when we are already stretched to our limit and are down a PA shift. Then we rush to see these patients because it’s so urgent and then they don’t get lined and labbed for an hour and a half.

I love it when I have a few patients to dispo but I cannot because I am stuck doing tasks support staff should be doing. Like being stuck on the phone doing a transfer for ten minutes. Or paging cardiology myself because the clerk is either not on site or doesn’t give a crap.

The “staffing on demand” is great too. It is so nice to get hounded with text messages from the Director on my day off asking me if I can please please please work extra shifts, only to have those shifts get canceled in a week.

I love having to see an eye pain to find out the slit lamp is broken. Or when they ask me to PLEASE SEE THIS EAR PAIN REAL QUICK and then put the patient in a room with a broken otoscope. Or going to the suture cart to do a laceration and everything. Is. Not. Stocked.

Then of course we get emails about needing to improve our dispo times. Because if we don’t they’re threatening to banish us to only working at the other slower paced ERs. Like working at the busy ER is a “privilege.” Really, really fun.

 

[southerndoc]

Training our nurses to do ultrasound guided IV's was a time well spent. It has helped immensely.

 

[MechEDoc]

Training our nurses to do ultrasound guided IV's was a time well spent. It has helped immensely.

I "love" watching "ultrasound trained" nurses do IVs. It makes me die inside almost every time.

Clean probe - not really.
Probe cover - nope.
Sterile gel - nah.
Technique - variable.

I've seen one nurse in the last 5 years get all of the above right. I'd like to keep my nosocomial infections at a minimum, thanks!

 

[GeneralVeers]

I "love" watching "ultrasound trained" nurses do IVs. It makes me die inside almost every time.

Clean probe - not really.
Probe cover - nope.
Sterile gel - nah.
Technique - variable.

I've seen one nurse in the last 5 years get all of the above right. I'd like to keep my nosocomial infections at a minimum, thanks!

I don't really care how the nurses get an IV.... So long as they don't bother me to come do it.

 

[DoctwoB]

Does it actually matter? Regular IV gets an alcohol swab, hardly a bastion of sterile technique. It’s not a central line that is staying in for week.

 

[GatorCHOMPions]

Feeling extra crispy this week. Working 10 shifts in 11 days because when you take a week of vacation here you don't get PTO (does anyone get PTO??) and thus have to cram all your other shifts into what's left in the month. Ridiculous. Anyway:

-Seeing more COVID, mostly in unvaccinated patients, which makes me furious that I have to be exposed to this in the setting of decreasing vaccine effectiveness, and potentially exposing my unvaccinated children to the virus

-Non-cohorting of COVID confirmed pts and suspects within the department, which makes absolutely no sense.

-Q Anon nurses posting bat **** anti vax stuff on social media

-Boomer docs making like 100k more than I do for less work cause of the ridiculous compensation structure we have here (employee model, not an SDG)

-Massive radiology/consultant delays, which makes patients crispy too - rightfully so. But why should I be the one to face the brunt of this? Get admin down here and let them get yelled at.

-Massive nursing shortage + new grad nurses + nurses can't get lines + nurses don't use ultrasound or do EJs. Insane.

-Non functional equipment (computers, otoscopes, the usual ED garbage)

-Med director never works an evening shift or a weekend. Sure, I'll just get slammed on a weekend evening shift while you chill.

I don't see a solution other than save save save and get out. I'm not doing a fellowship. My goal for 2021 is to venture into new investment areas (??real estate syndications), hope the crypto takes off, continue to shovel money into mutual funds, and not spend money on stupid stuff.

Maybe we worked at the same place. More likely this is just how EM is in many departments, unfortunately. Sounds exactly like my job before I left for fellowship.

 

[xaelia]

Does it actually matter? Regular IV gets an alcohol swab, hardly a bastion of sterile technique. It’s not a central line that is staying in for week.

I'm with @DoctwoB. Clean, sure, but doesn't need to be sterile.

 

[DoctorJDO]

Feeling extra crispy this week. Working 10 shifts in 11 days because when you take a week of vacation here you don't get PTO (does anyone get PTO??) and thus have to cram all your other shifts into what's left in the month. Ridiculous. Anyway:

-Seeing more COVID, mostly in unvaccinated patients, which makes me furious that I have to be exposed to this in the setting of decreasing vaccine effectiveness, and potentially exposing my unvaccinated children to the virus

-Non-cohorting of COVID confirmed pts and suspects within the department, which makes absolutely no sense.

-Q Anon nurses posting bat **** anti vax stuff on social media

-Boomer docs making like 100k more than I do for less work cause of the ridiculous compensation structure we have here (employee model, not an SDG)

-Massive radiology/consultant delays, which makes patients crispy too - rightfully so. But why should I be the one to face the brunt of this? Get admin down here and let them get yelled at.

-Massive nursing shortage + new grad nurses + nurses can't get lines + nurses don't use ultrasound or do EJs. Insane.

-Non functional equipment (computers, otoscopes, the usual ED garbage)

-Med director never works an evening shift or a weekend. Sure, I'll just get slammed on a weekend evening shift while you chill.

I don't see a solution other than save save save and get out. I'm not doing a fellowship. My goal for 2021 is to venture into new investment areas (??real estate syndications), hope the crypto takes off, continue to shovel money into mutual funds, and not spend money on stupid stuff.

this is a wonderful post. you're not the only one. thank you.

 

[GeneralVeers]

To the OP: You are where I was 5 years ago.

I was able to get a few more years out of the specialty by not worrying about any of that stuff. The rectal exam patient for example. Just put on the tracking board "MD will see patient when in a room and undressed" and punt it back to nursing. Just remember you are a cog in a widget factory. Try to move the widgets through so you get paid. Don't worry about the stuff that's not yours to worry about.

Clock in, move the widgets, sign your charts, and go home on time. Don't stay late to "go the extra mile" as you aren't paid for that, and no one will give you any recognition.

Always understand that you will only ever get grief and demotivation from talking to your medical directors. They never pull you aside to say "Job well done" or "I'm giving you a raise for great work". No conversation with them is the best conversation.

 

[bravotwozero]

Always understand that you will only ever get grief and demotivation from talking to your medical directors. They never pull you aside to say "Job well done" or "I'm giving you a raise for great work". No conversation with them is the best conversation.

THIS. Some real wisdom being spoken here. Been there and done that way too many times, learned a hard lesson here.

 

[Angry Birds]

I don't really care how the nurses get an IV.... So long as they don't bother me to come do it.

This guy is a pro

 

[Angry Birds]

To the OP: You are where I was 5 years ago.

I was able to get a few more years out of the specialty by not worrying about any of that stuff. The rectal exam patient for example. Just put on the tracking board "MD will see patient when in a room and undressed" and punt it back to nursing. Just remember you are a cog in a widget factory. Try to move the widgets through so you get paid. Don't worry about the stuff that's not yours to worry about.

Clock in, move the widgets, sign your charts, and go home on time. Don't stay late to "go the extra mile" as you aren't paid for that, and no one will give you any recognition.

Always understand that you will only ever get grief and demotivation from talking to your medical directors. They never pull you aside to say "Job well done" or "I'm giving you a raise for great work". No conversation with them is the best conversation.

This x 1000
I just work nights and avoid admin people, do my work, and leave a low profile. I try to get in as little confrontation as possible, whether with patients, nurses, other docs, and especially admin. But, then again, I consider my job like working at McDonald’s. I just want the paycheck. My intellectual fulfillment is elsewhere in life.

 

[Birdstrike]

Feeling extra crispy this week...

To the OP: You are where I was 5 years ago...

...and where I was 15 years ago.

@GonnaBeADoc2222 You are correct in that getting out absolutely is a potential solution.

EM is like an abusive relationship. EM will never change for you, but it'll constantly demand you change for it. It that works for you, then change for EM. If not, you must change from EM.

 

[EMhawkeye]

I "love" watching "ultrasound trained" nurses do IVs. It makes me die inside almost every time.

Clean probe - not really.
Probe cover - nope.
Sterile gel - nah.
Technique - variable.

I've seen one nurse in the last 5 years get all of the above right. I'd like to keep my nosocomial infections at a minimum, thanks!

Versus the sterility of their usual peripherals where they pop a finger off the glove and then stick a needle through the area they were touching with their dirty finger?

 

[sylvanthus]

Came in tonite to see two new covid patients intubated. One 83 yo, the other with a bmi >50. Take a guess on vaccination status and prognosis?

 

[LibBum]

Came in tonite to see two new covid patients intubated. One 83 yo, the other with a bmi >50. Take a guess on vaccination status and prognosis?

Had a patient w/ HCC tell me the other night: "I don't need to be vaccinated, I have a strong immune system".

GG sir. GG.

 

[thegenius]

Had a patient w/ HCC tell me the other night: "I don't need to be vaccinated, I have a strong immune system".

GG sir. GG.

Scoreboard:
COVID = 1
Patient = 0

 

[Apollyon]

Had a patient w/ HCC tell me the other night: "I don't need to be vaccinated, I have a strong immune system".

GG sir. GG.

I mean, adriamycin IS an antibiotic, besides being kick-ass chemo!

 

[GeneralVeers]

Also with regard to charts, I see other docs dictating these long narratives. They make for great literature, but realize in all liklihood, no one will ever read the chart again. Don't wast time with extra, extraneous HPI details. For admitted patients, do the minimum. Since they are admitted then low liability and don't try to write the next great novel.

 

[southerndoc]

Also with regard to charts, I see other docs dictating these long narratives. They make for great literature, but realize in all liklihood, no one will ever read the chart again. Don't wast time with extra, extraneous HPI details. For admitted patients, do the minimum. Since they are admitted then low liability and don't try to write the next great novel.

Nobody reads it until you get sued. Then you wish you had documented more.

 

[GeneralVeers]

Nobody reads it until you get sued. Then you wish you had documented more.

That's why everyone writes ridiculous novels. Not needed on the vast majority of patients.

 

[Angry Birds]

Nobody reads it until you get sued. Then you wish you had documented more.

I’m not confident the novel will help. More you write the more they can hang you on.
but I admit this is just a theory I have.

 

[MechEDoc]

I don't really care how the nurses get an IV.... So long as they don't bother me to come do it.

Fine, I'm OCD, but deep down inside there is still a part of me that wants to do the right thing for patients and help them.

 

[MechEDoc]

Versus the sterility of their usual peripherals where they pop a finger off the glove and then stick a needle through the area they were touching with their dirty finger?

Yeah, I hate that too. I guess I hate everything. Especially faked vitals on every patient.

 

[turkeyjerky]

Nobody reads it until you get sued. Then you wish you had documented more.

Eh. I've seen people justify their decision to order a cbc ("We will order a CBC to check for leukocytosis, and a BMP to check renal function and electrolytes".)

Although I do agree that there's a role for documenting some of the more ridiculous hpi details people mention. Ultimately, though, I don't think most docs have a good appreciation for what matters in their note from a RM perspective.

 

[WilcoWorld]

My documentation is typically:
1-2 sentences so that future docs understand what I was doing.
2-3 sentences showing that I considered the badness & that there wasn't enough evidence of badness to warrant the workup I chose not to do (i.e.: "don't sue me mr. lawyer- you'll loose")
Extra documentation of important conversations (consultants, AMA decision) or decisions to deviate from protocols (why I didn't give the ESRD/HFrEF pt with SIRS 30 cc/kg of NS) or things that will justify a higher code on the chart (CC time).

If something is just amazing, or hilarious, I'll take the time to document that...it keeps life fun.

My charts don't take long, but people tell me they're quite useful.

 

[GeneralVeers]

Fine, I'm OCD, but deep down inside there is still a part of me that wants to do the right thing for patients and help them.

That deep down part will die too....eventually. The blood vessels supplying it with oxygen will wither with time..

 

[WilcoWorld]

Fine, I'm OCD, but deep down inside there is still a part of me that wants to do the right thing for patients and help them.

Don't let this die. For me, that is what saved me from burnout. This job is just too hard to do for money alone.

 

[Birdstrike]

That deep down part will die too....eventually. The blood vessels supplying it with oxygen will wither with time..

This part of me was dying, too. Once I was able to sleep when it's dark, be awake when it's light out, and no longer be abused and gaslighted for only trying to help, it started gaining oxygen again.

 

[Brigade4Radiant]

I’m not confident the novel will help. More you write the more they can hang you on.
but I admit this is just a theory I have.

Yes the lawyer will take everything apart sentence by sentence. If you write a novel it can be used against you

 

[Angry Birds]

Yes the lawyer will take everything apart sentence by sentence. If you write a novel it can be used against you

There is one physician in our group who exaggerates everything and puts the patient's words in the chart verbatim ("worst headache of my life"). This person thinks she is insulating herself from litigation, but in reality, I think she is going to hang herself (and the poor SOB that takes sign-out from her--who is often me, especially when I go down her list and click "discharge, discharge, discharge...")

 

[GeneralVeers]

There is one physician in our group who exaggerates everything and puts the patient's words in the chart verbatim ("worst headache of my life"). This person thinks she is insulating herself from litigation, but in reality, I think she is going to hang herself (and the poor SOB that takes sign-out from her--who is often me, especially when I go down her list and click "discharge, discharge, discharge...")

I never put "worst headache of their life" even if they say it is. I also don't document the incidental chest pain found on ROS if they are clearly there for another complaint. The truth is the enemy, and fudging the chart a bit can save you from doing big unnecessary workups. Remember, if you didn't document it....then it didn't happen.

 

[Clean7795]

I never put "worst headache of their life" even if they say it is. I also don't document the incidental chest pain found on ROS if they are clearly there for another complaint. The truth is the enemy, and fudging the chart a bit can save you from doing big unnecessary workups. Remember, if you didn't document it....then it didn't happen.

I honestly don't see it as fudging the chart.

You can get a patient to say yes to any symptom if you question them enough and in the right way. If it isn't why they're presenting, and they're not making a big deal of it, chances are it's probably more right to call it negative than positive.

 

[skougess]

Totally agree. We are the doctor, not the patient. When a patient says they have chest tightness with their URI, I certainly don’t document positive chest pain.

Charts should tell a story supporting your A/P. If they don’t, you are either charting wrong or you are caring for patients wrong.

 

[GeneralVeers]

Totally agree. We are the doctor, not the patient. When a patient says they have chest tightness with their URI, I certainly don’t document positive chest pain.

Charts should tell a story supporting your A/P. If they don’t, you are either charting wrong or you are caring for patients wrong.

The problem is that my triage nurses document "Chest Pain" then get a fraudulent, non-indicted EKG before I even see the patient.

 

[alpinism]

My favorite are the homeless patients.

Hmm what brings you here today?

Well its just a few things but I've been having head pain, face pain, neck pain, chest pain, back pain, abdominal pain, and terrible foot pain.

Hmm you like turkey sandwiches?

 

[GeneralVeers]

My favorite are the homeless patients.

Hmm what brings you here today?

Well its just a few things but I've been having head pain, face pain, neck pain, chest pain, back pain, abdominal pain, and terrible foot pain.

Hmm you like turkey sandwiches?

Yeah, I always document "Patient states he is hungry, and wants a place to stay" as the primary reason for visit. Then "Malingering" as discharge diagnosis.

 

[Apollyon]

Yeah, I always document "Patient states he is hungry, and wants a place to stay" as the primary reason for visit. Then "Malingering" as discharge diagnosis.

But that's not really "malingering", as that is "feigning illness". "Unspecified psychosocial problem" is Z modifier (and will downcode your chart, even if level 5), along with "hunger" as a dx. "Homeless status" is another you can tack on.

 

[HemorrhagicShock]

But that's not really "malingering", as that is "feigning illness". "Unspecified psychosocial problem" is Z modifier (and will downcode your chart, even if level 5), along with "hunger" as a dx. "Homeless status" is another you can tack on.

As if you're actually going to collect on this patient's bill...

 

[bravotwozero]

My documentation is typically:
1-2 sentences so that future docs understand what I was doing.
2-3 sentences showing that I considered the badness & that there wasn't enough evidence of badness to warrant the workup I chose not to do (i.e.: "don't sue me mr. lawyer- you'll loose")
Extra documentation of important conversations (consultants, AMA decision) or decisions to deviate from protocols (why I didn't give the ESRD/HFrEF pt with SIRS 30 cc/kg of NS) or things that will justify a higher code on the chart (CC time).

If something is just amazing, or hilarious, I'll take the time to document that...it keeps life fun.

My charts don't take long, but people tell me they're quite useful.

This is perfect.

People think charting is simply for medicolegal and billing reasons. It's also enormously helpful to your colleagues if charted properly for a bounce back etc. So many of my colleagues chart tell absolutely nothing about the doc's decision making and you're left to put the pieces of the puzzle together on your own. The MDM/ED Course part is by far the most important part of the chart.

 

[GeneralVeers]

As if you're actually going to collect on this patient's bill...

Most are medicaid, so it's likely

 

[emergentmd]

To decrease burn out you have to work less. Either decrease shifts or be efficient at work.

When I worked the pits, I never felt burned out and Covid may have changed things in the past 3 yrs. I see docs spending way too much time with pts, ordering too much labs, ordering labs after getting results back, charting 2 hrs after their shift ends, never taking breaks, having a board full of long haulers.

Learn that History & physicals adds very little on 90% of the patients. Order labs/imaging once and stop Nickle/diming the pts. Take frequent breaks. Pts are to be moved quickly and not take residence in the ER.

Working 15 dys a month, staying back 2+ hrs every shift, never taking a break, taking home charting = early burn out.

 

[thegenius]

I’m not confident the novel will help. More you write the more they can hang you on.
but I admit this is just a theory I have.

In my limited experience being sued and being subpoenaed to testify about my own chart, the more I write the more defensible my care is.

someone once said “if you didn’t write about it, you didn’t think about it. “

im sure there are diminishing returns on writing a novel, but I think it’s better than the alternative which is write nothing.

 

[Angry Birds]

In my limited experience being sued and being subpoenaed to testify about my own chart, the more I write the more defensible my care is.

someone once said “if you didn’t write about it, you didn’t think about it. “

im sure there are diminishing returns on writing a novel, but I think it’s better than the alternative which is write nothing.

If you thought about a diagnosis and missed it, how does that help?

 

[dadaddadaBATMAN]

Eh. I've seen people justify their decision to order a cbc ("We will order a CBC to check for leukocytosis, and a BMP to check renal function and electrolytes".)

Although I do agree that there's a role for documenting some of the more ridiculous hpi details people mention. Ultimately, though, I don't think most docs have a good appreciation for what matters in their note from a RM perspective.

I don’t write “will order CBC to check for” but I do quickly dictate an interpretation of values to increase complexity for billing. Not sure how much it adds, but my charts bill well and it takes no more time than looking at the labs cost in first place.

 

[GeneralVeers]

If you thought about a diagnosis and missed it, how does that help?

If I mention "PE" then miss one, a lawyer will zero in on it. Better to not give them help. Also, write the chart so the history/exam don't make it look like a possible PE.

 

[Brigade4Radiant]

In my limited experience being sued and being subpoenaed to testify about my own chart, the more I write the more defensible my care is.

someone once said “if you didn’t write about it, you didn’t think about it. “

im sure there are diminishing returns on writing a novel, but I think it’s better than the alternative which is write nothing.

In my experience if you do a big chart they will zero in. Thinking about stuff and not doing it if it’s a lawsuit is negligence. I was thinking of an AAA but he wasn’t in distress so I didn’t get an ultrasound or CT scan.

Also if you document all these abnormal like “diaphoretic” or “murmur” on physical exam that means to work it up. A family do it or can write murmur on a chart with no issue but in the ED a murmur may be acute.