ED Referrals- Memorable/Dismal/Ridiculous/Unique

Started by pkwraith
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pkwraith

pkwraith

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15+ Year Member
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Similar in line to the ridiculous Surgery consult thread and the LP thread.

This is a thread for all your ridiculous ED referrals sent in from Urgent Cares, PMD offices, or other EDs.


Urgent care Referral: bloody tears, to ED emergently
20 Y F Patient with obvious conjunctivitis.
"Yeah, when I wiped, the tears was little pink. They likely basically pushed me out the door to come here."
Dx: conjunctivities. DC'd

Referral from a rheumatology office. Transfer note: "Symptomatic hypercalcemia. Patient altered. Spoke with endocrinologist."
50 yo f Patient is alert, oriented, completely normal. Only complaint is chronic joint pain. Calcium level is mildly elevated, identical to calcium level for the last year.
Pt: "I'm not confused. I drove here. I just said my memory was not so great anymore."
I called the rheumatology office regarding their emergent concern. Reached a MD who is on call, who reviewed chart. The PA that saw the patient is obviousy no longer there. Rheum says "Not sure why he sent patient to ED. Usually we would just refer to ENT for an nonemergent parathyroid evaluation."
I called the endocrinologist that the PA supposedly spoke to. That one obvious not available anymore. I tell the covering endocrinologist that I see no reason for patient to be here, and needs no emegent treatment. He obviously agrees, has no explanation for why patient is here.
patient DC'd

Urgent care referral: rule out DVT
50 Y M was on treatmill on incline when he felt sudden pain in his calf after pushing up. It hurts to touch the calf and with plantarflexion, but he is still ambulatory and no obvious achillies rupture. This injury happens 20 minutes prior to visit.
Transfer note: "calf is tender, to ED to r/o DVT"
I explain to patient that the doctor sent him to a FSED without duplex available, additionaly he does not need a DVT as it makes absolutely no sense. he was happy with that.
I look up urgent care doctor, he is ABEM boarded.

Family medicine referral: GI Bleed with iron deficiency
40 Y M without risk factors with BRBPR. Was seen in ED a week ago and was discharged. PMD repeated labs + iron. Hgb was normal, but the Iron level was low. Sent emergently to ED.

Family medicine referral. Transfer note: "phimosis, spoke to urologist, recommended ED evaluation for a procedure."
Patient had shingles to S3 dermatome for buttock and scrotum, was seen in ED a week ago and discharged with valtrex. At PMD office with evaluated, and phimosis was noted. They called a urologist and then sent patient to ED.
Patient has a phimosis. He is urinating fine, no necrosis or other complications. The shingles rash is improved.
"I don't think you need a circumcusion, I'm not sure why a urologist would send you in, and I doubt they would do any procedure on an area with a shingles infection."
"Well, I don't want a circumcision."
I call Urologist to ask him wtf this guy is here. Obviously someone else is on call now. "Hey, urolgoist, this guy was send in phimosis. He doesn't need a circumcision and he doesn't want one, but your partner sent him in for a "procedure". He reviews chart and doesn't know why patient is here, recommended outpatient f/u.
Apologize to patient and DC.

Urgent care referral. Chest nodule, needs CT.
60 Y M with cough. CXR done, interpreted by Urgent Care provider as a right sided nodule, needs emergent CT to r/o mass.
I reviewed CXR. Radiology interpretation: circular nodule visible only on AP view, not visible on lateral view.
It looks nipple size and shape. I look at patient and yes that is where his nipple is.
Explain that CTs are not needed emergently for lung nodules, and also his nodule is likely his nipple.

Too many useless covid-19 referrals for anything specific. Just a big blur of "Too sick for urgent care, need higher level of care", "Feeling short of breath" with normal vitals, "Not getting better, needs PE workup".

Too many useless HTN referrals for anything specific and there's an individual thread for it.

I'm sure we have plenty of this to fill up several pages.
 
Outpatient work-up for chest pain with a troponin of 15,000. From yesterday. Guy drove himself in too.

Day 10 thrombosed hemorrhoid, getting better.

CRP of 130. In a 92 year old demented guy from high level care nursing home with a very clear advanced care directive not to be admitted to hospital. No symptoms, nothing. "Please see and evaluate Mr Smith for a CRP of 130." That's all the letter said. When I called the GP, I was told it was just a "surveillance CRP." WTF is that.
 
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The large majority of ridiculous outpatient referrals to the ER I see are from UCs sending in patients with "abnormal EKGs" (99% of which are normal and in MSK chest pain/anxious 20 year olds) and lacerations they are "not comfortable repairing, needs hand/ortho/trauma/plastics to repair". The most egregious was an 80 yo with chest pain they sent by private vehicle for an abnormal EKG. The guy casually strolls in holding his EKG with an obvious anterior STEMI with tombstones and all.

I think I get the most pissed about the lacs, though, because that is typically just them being straight up lazy and pawning off annoying, time consuming procedures. I tell every single one of those patients with simple uncomplicated lacs that this could have been managed at an UC if they had a competent provider available and that they should complain to the UC so they are not billed for their visit. This would be the equivalent of us consulting ortho to perform an uncomplicated shoulder reduction without making any sort of attempt ourselves to reduce it.
 
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Get patients sent from jail intake for SBP of 160 at least once a week.

Clinic sends in a patient. 65 yo discharged from hospital 3 weeks ago for covid. Dc'd home and doing well. Sent to clinic to establish primary care. Jenny McJennerson does a battery of labs including a d dimer. Sends patient to ER because it's elevated. Tells me to rule out dvt/ PE. Patient has normal vital signs. He denies chest pain, sob and leg pain/ swelling. Asymptomatic. I call Jenny and ask what her concern was "he has an elevated d dimer, he could have a dvt or PE".
I then explain that D dimer is not specific, that patient is asymptomatic, recovering from covid his dimer will be elevated anyway. Then explain that even had he had symptoms, being recent covid + his pretest probability of VTE would be so high, the only way to rule it out would be a venous duplex or a cta, both of which could be done as an outpatient.
Her response: "uhhhhhhhhh his dimer is high, you need to evaluate him"
Wish I could see the clueless look in her eyes.
 
EMhawkeye said:
Get patients sent from jail intake for SBP of 160 at least once a week.

Clinic sends in a patient. 65 yo discharged from hospital 3 weeks ago for covid. Dc'd home and doing well. Sent to clinic to establish primary care. Jenny McJennerson does a battery of labs including a d dimer. Sends patient to ER because it's elevated. Tells me to rule out dvt/ PE. Patient has normal vital signs. He denies chest pain, sob and leg pain/ swelling. Asymptomatic. I call Jenny and ask what her concern was "he has an elevated d dimer, he could have a dvt or PE".
I then explain that D dimer is not specific, that patient is asymptomatic, recovering from covid his dimer will be elevated anyway. Then explain that even had he had symptoms, being recent covid + his pretest probability of VTE would be so high, the only way to rule it out would be a venous duplex or a cta, both of which could be done as an outpatient.
Her response: "uhhhhhhhhh his dimer is high, you need to evaluate him"
Wish I could see the clueless look in her eyes.
Click to expand...

This is why the Jenny McJennysons need smackdown. Unfortunately, it will only occur once they harm an administrator/executive type.
 
18 y/o M sent by Jenny McJennyson out in BFE for elevated D-Dimer, r/o PE, after a month of pleuritic chest pain and an otherwise negative workup. No shortness of breath, PERC negative, needless to say the CTA was also negative. D/C home

Another PLP at a primary care office sends 60ish male in for "New A-Fib", even sends the EKG that if they bothered to interpret themselves, instead of believing the computer, showed a sinus rhythm. Completely negative workup, to include multiple EKG's and not even a PVC. D/C home and the daughter gets pissy with me when explained that the computer interpretation isn't always right.
 
CajunMedic said:
18 y/o M sent by Jenny McJennyson out in BFE for elevated D-Dimer, r/o PE, after a month of pleuritic chest pain and an otherwise negative workup. No shortness of breath, PERC negative, needless to say the CTA was also negative. D/C home

Another PLP at a primary care office sends 60ish male in for "New A-Fib", even sends the EKG that if they bothered to interpret themselves, instead of believing the computer, showed a sinus rhythm. Completely negative workup, to include multiple EKG's and not even a PVC. D/C home and the daughter gets pissy with me when explained that the computer interpretation isn't always right.
Click to expand...

This drives me nuts, too.
If you can't interpret an EKG, don't order it.
 
CajunMedic said:
Another PLP at a primary care office sends 60ish male in for "New A-Fib", even sends the EKG that if they bothered to interpret themselves, instead of believing the computer, showed a sinus rhythm. Completely negative workup, to include multiple EKG's and not even a PVC. D/C home and the daughter gets pissy with me when explained that the computer interpretation isn't always right.
Click to expand...

Trying to figure out how rate-controlled atrial fibrillation, even if it's a new diagnosis, warrants an ED evaluation.
 
I've had plenty of those. I've had to explain why incomplete RBBB, first degree av block aren't really dangerous, or why that tiny q inflection doesn't mean you had a heart attack. Or that there is clear p waves on the afib ekg.

On the similar line today, I had a 70 yo F transferred to my FSED today for "Hypertensive emergency" for some diarrhea/nausea/vomiting and BP of 188/81 (didn't take her medications today). When she arrived, I didn't give a **** about her BP, but the heart rate of 50 without a BB or CCB was a little odd. I did see urgent care did an EKG but didn't really mention it. I looked at it and looks maybe Mobitz II but poorly done ekg. No mention of this or the bradycardia in the CNP note or transfer note. So I get an actual ekg and she was a complete av dissociation so I shipped off to the main house. At some point, I wonder about the utility of EKGs at urgent cares.
 
Countless times when EKG machine reads Afib when it was NSR or T wave/ST abnormality worrisome for ischemia.
 
greatnt249 said:
Unlikely to happen, as I'm sure admin/executives wouldn't allow themselves to be treated by a nurse practitioner or a physician assistant.
Click to expand...
Too true. One time a C-suite exec at our hospital was going for pre-op eval. Our pre-op clinic is PA run with some hospitalist and anesthesiology supervision. Mr. C-suite not only refuses to be seen by the PA and wants my colleague to see him, but then complains when it's taking too long (due to the disruption to clinic workflow he caused) so he leaves and has one of the PCPs drop everything to do his pre-op note.
 
In residency, my attending got a call from an ER doc from an ER over an hour away. They wanted to transfer a patella dislocation. He tried to talk them through perhaps the most benign procedure we do and they refused. My attending had the comment, “I really wanted to refuse it, but ultimately, I realized that it would be best to see the patient if the provider was that gutless and incompetent.”

Patient was reduced within 2 minutes of hitting the door by a first year resident… me.
 
I don’t mind the silly referrals since they’re easy and I’m rvu but always feel bad for the patient who made the correct decision to go to an outpatient clinic for a non-emergent complaint and ends up with two bills.

In the last few shifts I’ve seen: 22 yo referred from UC for ankle fracture with normal xrays, 25 yo f referred for covid w hypoxia sat 100% after acrylic nail removed, and 2 yo low fall possible head trauma with no sign of injury and normal exam. In EM something like this typically happens at least once a shift so not worth letting it bother you.
 
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One from way back in OMS-3.

Was rotating in a larger community hospital. Preceptor gets a call from a hospital 20 miles up the interstate to accept a 60ish female with chest pain. She's got a cardiac history and her cardiologist is at our hospital, so he accepts. Nurse calls report once the ambulance is headed our way with the patient. Apparently, the ED doc at the sending hospital forgot to talk about the Hemoglobin of 4 and the massive Lower GI bleed. Vitals were starting to tank when she got to us. Stat labs, 2 Units of PRBC's, and a helicopter ride to the academic center. Family was pissed because they felt she should have gone there in the first place.
 
RonWeezy said:
In residency, my attending got a call from an ER doc from an ER over an hour away. They wanted to transfer a patella dislocation. He tried to talk them through perhaps the most benign procedure we do and they refused. My attending had the comment, “I really wanted to refuse it, but ultimately, I realized that it would be best to see the patient if the provider was that gutless and incompetent.”

Patient was reduced within 2 minutes of hitting the door by a first year resident… me.
Click to expand...

I'll bet $400 and the shirt off my back that "ER doc" lied and he wasn't an ER doc.
 
This is such a depressing thread. No wonder doctors are not well regarded in our society these days. First of all, people don't even see doctors regularly and instead are taken care of by PA's and NPs, who en-masse offer s@#$t care. And second, they get transferred around for all sorts of nonsense reasons. I simply can't believe some of the things I have read on this thread.

Transferring someone because their tears are pink? Seriously?

After reading everything above I'm embarrassed for many of my colleagues.
 
Yesterday, urgent care sent a patient in with a rash on their hands. It was classic chemical dermatitis from over-washing her hands while taking care of her infant grandchild. It was not a systemic rash. It didn’t involve her feet. Ms Jennyson wrote on the chart that they had a concern for meningitis. Also a concern for high BP… 165/80- chronic hypertensive off meds because she lost her insurance.

Me: “Do you have a headache?”
Patient: “No.”
Me: …scratch head, shrug shoulders and discharge with topical ointment.
 
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Middle aged male comes in by car with dyspnea for 2 days. rectal CA with mets to lungs, bone, and liver. Tells me that he got an ambulance ride to an outlying hospital and spent 6 hours there. Got Adenosine from EMS and Cardizem there. Tried to transfer him to us, but we declined due to no beds. Patient declined to be transferred anywhere else. Patient also says (and its in his recorded complaint in triage), "They said they couldn't do anything else for me but comfort care. Told me to have my wife put me in the car and drive me here"
 
CajunMedic said:
Middle aged male comes in by car with dyspnea for 2 days. rectal CA with mets to lungs, bone, and liver. Tells me that he got an ambulance ride to an outlying hospital and spent 6 hours there. Got Adenosine from EMS and Cardizem there. Tried to transfer him to us, but we declined due to no beds. Patient declined to be transferred anywhere else. Patient also says (and its in his recorded complaint in triage), "They said they couldn't do anything else for me but comfort care. Told me to have my wife put me in the car and drive me here"
Click to expand...
I do wonder about the frequency with which outpatient docs share realistic prognoses with their patients. I know that some patients request not to know and I know that some ignore or misunderstand the information even when it's given. That still leaves a heck of a lot of puzzled looks when the patients that show up to the hospital with days to weeks left get informed of such.
 
CajunMedic said:
Middle aged male comes in by car with dyspnea for 2 days. rectal CA with mets to lungs, bone, and liver. Tells me that he got an ambulance ride to an outlying hospital and spent 6 hours there. Got Adenosine from EMS and Cardizem there. Tried to transfer him to us, but we declined due to no beds. Patient declined to be transferred anywhere else. Patient also says (and its in his recorded complaint in triage), "They said they couldn't do anything else for me but comfort care. Told me to have my wife put me in the car and drive me here"
Click to expand...
I don't get it.
 
DrSnips said:
I do wonder about the frequency with which outpatient docs share realistic prognoses with their patients. I know that some patients request not to know and I know that some ignore or misunderstand the information even when it's given. That still leaves a heck of a lot of puzzled looks when the patients that show up to the hospital with days to weeks left get informed of such.
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Tbh depending on the specifics of that case it may not be clear they have days to weeks UNTIL they show up to the hospital with issues. People can have stable disease until they don’t
 
HemeOncHopeful19 said:
Tbh depending on the specifics of that case it may not be clear they have days to weeks UNTIL they show up to the hospital with issues. People can have stable disease until they don’t
Click to expand...
This...but we as a specialty (oncology) also generally suck at having the conversation.

Many patients have a really hard time hearing that news from their oncologist as well. Often it takes another physician (or 5) to get them to understand it. I will do 1-2 "2nd opinions" a month where I'm basically just there to tell them that, yes, hospice is the right choice for them.
 
CajunMedic said:
Middle aged male comes in by car with dyspnea for 2 days. rectal CA with mets to lungs, bone, and liver. Tells me that he got an ambulance ride to an outlying hospital and spent 6 hours there. Got Adenosine from EMS and Cardizem there. Tried to transfer him to us, but we declined due to no beds. Patient declined to be transferred anywhere else. Patient also says (and its in his recorded complaint in triage), "They said they couldn't do anything else for me but comfort care. Told me to have my wife put me in the car and drive me here"
Click to expand...

They are probably right. The patient is going to die from metastatic cancer.

Takes a lot of nerve to say to go to another hospital. That's one example of what's wrong with our health care system.
 
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The worse thing about bad ED referrals is that if the UC/PCP does a ridiculous ED consult and they complain 99/100 of the time we will get in trouble for "blocking business" oh the pain of being an independent contractor.
 
turkeyjerky said:
As anyone done this in practice? I'd probably be calling in urology honestly (+/- a suprapubic tap if pt in severe retention).
Click to expand...

I just had a 40 yo guy with severe phimosis and couldn't pee. Had 1L in bladder on scan. He'd been complaining about difficulty urinating for years. I couldn't see the glans despite using a lubricated qtip and trying to force through the foreskin.

I spoke to Urology and he kindly came in and did a dorsal slit. The pt had chronic balanitis and had a shriveled, white, raison looking glans that had chronic, stuck on smegma around the corona (it was obviously disgusting). But I watched the entire dorsal slit procedure and it was cool to see, and apparently kind of easy to do too.
 
ED to ED referrals

Patient sent from affiliate hospital ED.
Foley issue-possible Fournier's. I read through the transfer note multiple times. It's one of those rambling confusing block of texts, aka "wtf are they doing over there". Started off somewhere with foley malfunction and somehow ends up as possible nec-fasc and transfer here for urology.
Fortunately, I can see everything in Epic, so after reading all the notes and context, I can start to make sense of the medical misadeventure.
Patient has indwelling suprapubic catheter. It got clogged and stopped draining. Home nurse reports she can't take down the foley balloon. Patient was sent to the affiliate ED to fix the foley.
ED Doctor (family medicine doctor) orders a CT. The CT mentions distended bladder, tiny bubble of air in seminal vesicles. The doctor documents a normal GU exam, but because of these bubbles, and patient with significant lower abdominal pain, tachypnic, and tachycardic, therefore sepsis, needs 30 cc/kg bolus of fluids and received triple IV antibiotics for possible necrotizing infection, transfer here for urology. Receiving hospitalist was like "WTF is going on, send to ED for our guys to evaluate".

I look at the outside CT image. Big distended bladder with air in there and pretty obvious reason why he would have some air bubbles in his seminal vesicles. I don't see a foley balloon at all.

I go see the patient who is obviously uncomfortable due to have a distended bladder, a transport time of over 1.5 hours to get here (and a few L of fluids since then), with obviously a completely normal GU exam without Fournier.
"Did they try putting a foley in your penis?" "No"
Well, there's no balloon on the CT. So I just pull on his suprapubic catheter, it comes out easily along with a bunch of pressurized urine.
Patient feels better. His sepsis (tachycardia, tachypnea) resolved. I stick a foley back in.

Great, perfect combination of fear-based medical practice, lack of understand of anatomy, physiology of disease, and problem solving skills.




Another one. More leeway because this was a PA. Somewhat.

Patient was referred here for bowel obstruction. This is a FSED staffed by PA in a more rural (touristy) area, two hour ride. I was notified by nurse that patient is not reactive on arrival with EMS and I should probably go see, EMS claims patient was talking and appropriate the entire ride.
I look at the CT read quickly: paraphrasing, severe closed loop bowel obstruction, with ischemia, pneumobilia and portal vein gas.

I see the patient. His abdomen is so distended that he is at real danger of abdominal compartment syndrome. He is barely arousable to stimulus, altered, and he is hypotensive. I get report after I had a nurse page surgery and get airway stuff in room.
Me: "What antibiotic did he get?"
EMS: "Levofloxacin."
Me: "How much fluids total?"
EMS: "I don't think they gave him any."
Me: "How much has that NG put out?"
EMS: "I don't think there has been any output."

Oh perfect. So after I tube the patient (without the massive vomiting/aspiration that I was anticipating), and started resusicitation (probably a little late at this point). We pulled out the NG that clearly was not anywhere near the stomach, but even after several attempts by the surgeons, they couldn't pass an NG in at this point because of two much GI edema.
Needless to say this patient did not do well.
 
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RustedFox said:
That's not the first time I've heard of this.
Click to expand...
I had a dark-skinned pregnant woman who was excreting some purple-ish liquid from her skin that she's been seeing on her bedding. Has her family, pastor, and a couple of friends in room with her. Interrupt prayer circle to do H&P. No other symptoms, denies any new exposures, travel, etc. Mentions in passing that she sees the water turn purple when she's washing her hands. Politely probing to see if there's a psych angle but husband says he's seen the purple stain on the sheet.

Dx: Unspecified complication from topical application of lavender moisturizer, initial encounter
 
Arcan57 said:
I had a dark-skinned pregnant woman who was excreting some purple-ish liquid from her skin that she's been seeing on her bedding. Has her family, pastor, and a couple of friends in room with her. Interrupt prayer circle to do H&P. No other symptoms, denies any new exposures, travel, etc. Mentions in passing that she sees the water turn purple when she's washing her hands. Politely probing to see if there's a psych angle but husband says he's seen the purple stain on the sheet.

Dx: Unspecified complication from topical application of lavender moisturizer, initial encounter
Click to expand...

Pfft.
Yeah; always hate it when I have to break the prayer circle to do my job.
 
pkwraith said:
ED to ED referrals

Patient sent from affiliate hospital ED.
Foley issue-possible Fournier's. I read through the transfer note multiple times. It's one of those rambling confusing block of texts, aka "wtf are they doing over there". Started off somewhere with foley malfunction and somehow ends up as possible nec-fasc and transfer here for urology.
Fortunately, I can see everything in Epic, so after reading all the notes and context, I can start to make sense of the medical misadeventure.
Patient has indwelling suprapubic catheter. It got clogged and stopped draining. Home nurse reports she can't take down the foley balloon. Patient was sent to the affiliate ED to fix the foley.
ED Doctor (family medicine doctor) orders a CT. The CT mentions distended bladder, tiny bubble of air in seminal vesicles. The doctor documents a normal GU exam, but because of these bubbles, and patient with significant lower abdominal pain, tachypnic, and tachycardic, therefore sepsis, needs 30 cc/kg bolus of fluids and received triple IV antibiotics for possible necrotizing infection, transfer here for urology. Receiving hospitalist was like "WTF is going on, send to ED for our guys to evaluate".

I look at the outside CT image. Big distended bladder with air in there and pretty obvious reason why he would have some air bubbles in his seminal vesicles. I don't see a foley balloon at all.

I go see the patient who is obviously uncomfortable due to have a distended bladder, a transport time of over 1.5 hours to get here (and a few L of fluids since then), with obviously a completely normal GU exam without Fournier.
"Did they try putting a foley in your penis?" "No"
Well, there's no balloon on the CT. So I just pull on his suprapubic catheter, it comes out easily along with a bunch of pressurized urine.
Patient feels better. His sepsis (tachycardia, tachypnea) resolved. I stick a foley back in.

Great, perfect combination of fear-based medical practice, lack of understand of anatomy, physiology of disease, and problem solving skills.




Another one. More leeway because this was a PA. Somewhat.

Patient was referred here for bowel obstruction. This is a FSED staffed by PA in a more rural (touristy) area, two hour ride. I was notified by nurse that patient is not reactive on arrival with EMS and I should probably go see, EMS claims patient was talking and appropriate the entire ride.
I look at the CT read quickly: paraphrasing, severe closed loop bowel obstruction, with ischemia, pneumobilia and portal vein gas.

I see the patient. His abdomen is so distended that he is at real danger of abdominal compartment syndrome. He is barely arousable to stimulus, altered, and he is hypotensive. I get report after I had a nurse page surgery and get airway stuff in room.
Me: "What antibiotic did he get?"
EMS: "Levofloxacin."
Me: "How much fluids total?"
EMS: "I don't think they gave him any."
Me: "How much has that NG put out?"
EMS: "I don't think there has been any output."

Oh perfect. So after I tube the patient (without the massive vomiting/aspiration that I was anticipating), and started resusicitation (probably a little late at this point). We pulled out the NG that clearly was not anywhere near the stomach, but even after several attempts by the surgeons, they couldn't pass an NG in at this point because of two much GI edema.
Needless to say this patient did not do well.
Click to expand...

Why does the PA get more leeway? They chose to get inferior training and then chose a job where they were the sole "provider" where superior training would be required.

These dingbat FSEDs or otherwise should be required to hang a sign on their door that says THERE IS NO DOCTOR HERE and then the patient gets to decide their next steps: drive further to see someone who actually knows wtf they're doing or roll the dice on a joke LLP.

Not saying this patient would have done well otherwise, but this is gross negligence (failure to manage sepsis), and I were the plaintiff's consultant, it would be a slam dunk.
 
pkwraith said:
ED to ED referrals

Patient sent from affiliate hospital ED.
Foley issue-possible Fournier's. I read through the transfer note multiple times. It's one of those rambling confusing block of texts, aka "wtf are they doing over there". Started off somewhere with foley malfunction and somehow ends up as possible nec-fasc and transfer here for urology.
Fortunately, I can see everything in Epic, so after reading all the notes and context, I can start to make sense of the medical misadeventure.
Patient has indwelling suprapubic catheter. It got clogged and stopped draining. Home nurse reports she can't take down the foley balloon. Patient was sent to the affiliate ED to fix the foley.
ED Doctor (family medicine doctor) orders a CT. The CT mentions distended bladder, tiny bubble of air in seminal vesicles. The doctor documents a normal GU exam, but because of these bubbles, and patient with significant lower abdominal pain, tachypnic, and tachycardic, therefore sepsis, needs 30 cc/kg bolus of fluids and received triple IV antibiotics for possible necrotizing infection, transfer here for urology. Receiving hospitalist was like "WTF is going on, send to ED for our guys to evaluate".

I look at the outside CT image. Big distended bladder with air in there and pretty obvious reason why he would have some air bubbles in his seminal vesicles. I don't see a foley balloon at all.

I go see the patient who is obviously uncomfortable due to have a distended bladder, a transport time of over 1.5 hours to get here (and a few L of fluids since then), with obviously a completely normal GU exam without Fournier.
"Did they try putting a foley in your penis?" "No"
Well, there's no balloon on the CT. So I just pull on his suprapubic catheter, it comes out easily along with a bunch of pressurized urine.
Patient feels better. His sepsis (tachycardia, tachypnea) resolved. I stick a foley back in.

Great, perfect combination of fear-based medical practice, lack of understand of anatomy, physiology of disease, and problem solving skills.




Another one. More leeway because this was a PA. Somewhat.

Patient was referred here for bowel obstruction. This is a FSED staffed by PA in a more rural (touristy) area, two hour ride. I was notified by nurse that patient is not reactive on arrival with EMS and I should probably go see, EMS claims patient was talking and appropriate the entire ride.
I look at the CT read quickly: paraphrasing, severe closed loop bowel obstruction, with ischemia, pneumobilia and portal vein gas.

I see the patient. His abdomen is so distended that he is at real danger of abdominal compartment syndrome. He is barely arousable to stimulus, altered, and he is hypotensive. I get report after I had a nurse page surgery and get airway stuff in room.
Me: "What antibiotic did he get?"
EMS: "Levofloxacin."
Me: "How much fluids total?"
EMS: "I don't think they gave him any."
Me: "How much has that NG put out?"
EMS: "I don't think there has been any output."

Oh perfect. So after I tube the patient (without the massive vomiting/aspiration that I was anticipating), and started resusicitation (probably a little late at this point). We pulled out the NG that clearly was not anywhere near the stomach, but even after several attempts by the surgeons, they couldn't pass an NG in at this point because of two much GI edema.
Needless to say this patient did not do well.
Click to expand...
#1 is so ridiculous as to be comical. Why wouldn’t changing out the SP cath be the first (and only) thing to do?

#2 I don’t get the criticism— highly doubt that an NG was gonna solve this guys problem. Sure the inappropriate antibiotic choice and lack of IVF didn’t help.
 
emergentmd said:
I would take these 1 inch putts and job security over seeing 80 year old complicated nursing home pts any day.

Give them all to me with their associated job security.
Click to expand...
They’re boring, a waste of resources, time, brain power, and expertise that could be used elsewhere
 
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