Frequent Flyers with Migraines

[goodoldalky]

I don't give narcotics for migraine patients. If they don't get better based on everything else we use for migraines, then I just discharge them. If they are legitimately seeking drugs I will add that in to their diagnoses and that prevents them from getting a PG survey. If they are not clearly seeking drugs I usually have to deal with it because we occasionally have patients like this call, request to view their medical record, and then ask to have their chart edited for xyz, and what a nightmare to deal with that.

I do believe if, for example, a patient is highly anxious about their migraine and you include a DSM diagnosis such as anxiety, that would also prevent a patient from getting a PG.

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[e30ftw]

my go to is 10 compazine + 50 benadryl IM +/- toradol IM. recheck 10 min after administration, if feeling better dc home to sleep.

we are always holding icu/admitted patients in the ED so turning the room over in ~30 min makes a big difference getting that 67 y/o w/ CP and a HR of 140 out of the waiting room.

As soon as I'm satisfied that it's a typical migraine and doesn't need any work up I try to involve the patient as much as possible, ask what works, ask what they think they need, etc.. most people have no idea and after my migraine cocktail they are sleeping and then go home. Some ask for narcotics etc. If someone truly looks uncomfortable, doesn't have many visits or history of drug seeking behavior I sometimes tack on 1 of dilaudid after the cocktail and usually after that they are passed out and ready for DC.

honestly once I know the pt doesn't need SAH/meningitis/thombosis/etc evaluation I really just want to do whatever is necessary (within reason) to fix their problem and discharge them as quickly as possible.

Of course if you give IV narcotics and get that head CT you can bill a level 5 chart.. not that anyone does that of course.......

I generally don't mind seeing true migraine patients because it's basically the easiest dispo in EM and if they actually have migraines you can usually make them feel better prior to dc.

 

[Hair Police]

As an aside, I've been told repeatedly that malpractice attorneys look for evidence that you (the doc) disliked the patient. How do you all document drug-seeking behavior without giving the reader a sense that you made a value judgement on the patient? Some examples of text or language you use would be helpful.

 

[e30ftw]

Interesting question. I try to make my charting as concise and non-biased as possible. My typical drug seeking note is as follows:

"Upon reevaluation pt states that she cannot have toradol due to allergy. Pt states that she does not have any opiate pain medicine at home and the only med that works for her pain is 2mg of dilaudid with 25 mg of phenergan IV. Upon review of medical records and database pt received 120 hydrocodone 4 days ago with several other narcotic prescriptions from separate providers filled at separate pharmacies in the past 60 days. I offered pt anti-inflammatory medicine and continued evaluation and treatment for her condition. At this point the patient became upset and eloped without notifying staff."

I'm sure that could be construed as my somehow not really liking the patient but it also shows that the patient lied to me thereby fundamentally impacting the physician/patient relationship.

 

[Birdstrike]

As an aside, I've been told repeatedly that malpractice attorneys look for evidence that you (the doc) disliked the patient. How do you all document drug-seeking behavior without giving the reader a sense that you made a value judgement on the patient? Some examples of text or language you use would be helpful.

Of course. Ever wonder why many of some of those consultants start their chart with, "Mr Jones is a very unfortunate but likable and appropriate 49 year old male..."?

They're already setting the stage. It goes like this, "Him: nice guy (consultant). You: judgmental jerk (EP) because you labeled patient with migraine with pejorative term, who turned out to have a life threatening SAH on top of his migraine, which you missed because of your pre-determined bias."

This: "Risk of opiates outweigh the potential benefits..." or "I don't doubt the patient is in pain, however opiates are not indicated due to x, y, z..." comes off way better than " d r u g s e e k e r " especially if it turns out there's an acute condition masked by their chronic one.

It's a classic pitfall in EM where people get personally angry and emotionally entangled with a perceived behavior and forget that a chronic condition isn't protective of, and can often mask, an acute one.

That being said, if someone meets true criteria for addiction, that's a valid diagnosis, but "drug seeker" means nothing and just kind of makes you look uniformed, actually.

Lawyer: "Of course he was 'seeking drugs,' Doctor, for his (insert missed acute condition) that you missed."

It's not everyday, but it happens. I'm just saying, make sure everything's ruled out. Always hedge your bets. Just do what you think is indicated, don't do what you think is not indicated and don't get manipulated or dragged, into some battle of wills.

 

[Lymewarrior]

One downside to the IV cocktails is the burden on the RN staff of initiating IV placement vs administering an IM injection. My main roadblock is that most, if not all, of our migraneurs have compazine, reglan, toradol, etc listed as an allergy. The funny thing is most just have "NSAIDS" listed. I'd love to call their bluff and administer these meds anyways and just monitor for adverse reactions but should they have a true allergy I would have no medico-legal leg to stand on.

It's a shame that you all are so arrogant to feel that way. I have a true allergy to phenergan, compazine, and Benadryl, the first two causing seizures at times or severe irritation and loss of control of body movement, and Benadryl the same reaction but sometimes has made my eyes swell shut but usually can cause severe agitation. I have suffered terrible migraines since I got Lyme disease 4 yrs ago and take topamax 200 mg a day and take Imitrex injections. Every time I have to go to the ED the doctor they treat me like a drug seeker and all I want is relief. Toradol is a joke. They make pain relievers for a reason! Is it gonna hurt you to help with someone's pain without judging them? Not everyone is an addict. I have a neurologist. I am a professional like you all and you still think you know everyone's story and can judge them. I can only assume none of you have ever dealt with severe recurring migraines or drug allergies.

 

[alpinism]

It's a shame that you all are so arrogant to feel that way. I have a true allergy to phenergan, compazine, and Benadryl, the first two causing seizures at times or severe irritation and loss of control of body movement, and Benadryl the same reaction but sometimes has made my eyes swell shut but usually can cause severe agitation. I have suffered terrible migraines since I got Lyme disease 4 yrs ago and take topamax 200 mg a day and take Imitrex injections. Every time I have to go to the ED the doctor they treat me like a drug seeker and all I want is relief. Toradol is a joke. They make pain relievers for a reason! Is it gonna hurt you to help with someone's pain without judging them? Not everyone is an addict. I have a neurologist. I am a professional like you all and you still think you know everyone's story and can judge them. I can only assume none of you have ever dealt with severe recurring migraines or drug allergies.

No you don't.

Seizures are not an allergic reaction.

Loss of control of body movement is called akathesia and is a common side effect of antidopaminergic medications (phenegran/compazine).

Agitation is also a common anticholinergic side effect of antihistamines (benadryl). In addition, benadryl acts to cause reduced tissue swelling.
We use it as a treatment for allergic reactions.

No one on here is arrogant, Its just that we went to school for 10+ years in order to learn how to best treat headaches and avoid true allergic reactions. I'm sorry your physicians have never explained this to you, but there's no reason why you can't be taking any of those medications. We want what's best for you and unfortunately using narcotics to treat headaches usually does more harm than good.

The ED is also not the place for treatment of chronic pain/headaches. See your PCP or neurologist.

 

[DrDrummer]

The ED is also not the place for treatment of chronic pain/headaches. See your PCP or neurologist.

You must be unaware of the crippling shortage of Chronic Lyme specialists in this country. I for one am addressing this by starting an ED-based Chronic Lyme Disease Center of Excellence / Quaternary referral center, which will be but one spoke in my wheel-based approach to managing this under-diagnosed and devastating condition. Other spokes to be added include Morgellon's Syndrome, PNES, Fibromyalgia, and Chronic Fati-- I mean, Systemic Exertional Intolera-- I mean, Myalgic Encephalitis. We will also offer vaccination reversal with chelation therapy for those whose CL/MS/PNES/FM/CFS is determined to be a sequelae of the mercury contained therein.

 

[DrDrummer]

If they are legitimately seeking drugs I will add that in to their diagnoses and that prevents them from getting a PG survey.
...
I do believe if, for example, a patient is highly anxious about their migraine and you include a DSM diagnosis such as anxiety, that would also prevent a patient from getting a PG.

That's interesting - I'd heard that floated as a suggestion to improve the quality of PG surveys, but haven't ever heard anything about actual clinical impression / dx's that result in non-distribution of the survey to specific patients. Is there more information on this available somewhere, if it's something that is true nationwide? Or is that just a contract-specific provision?

 

[Arcan57]

That's interesting - I'd heard that floated as a suggestion to improve the quality of PG surveys, but haven't ever heard anything about actual clinical impression / dx's that result in non-distribution of the survey to specific patients. Is there more information on this available somewhere, if it's something that is true nationwide? Or is that just a contract-specific provision?

Contract specific. The issue with excluding patients is that the abstraction can take a couple of days. If you are doing phone surveys and have an efficient billing department you may be calling them after the bill drops due to the delay for abstraction. Surveying after the bill nerfs your PG.

 

[Psai]

You must be unaware of the crippling shortage of Chronic Lyme specialists in this country. I for one am addressing this by starting an ED-based Chronic Lyme Disease Center of Excellence / Quaternary referral center, which will be but one spoke in my wheel-based approach to managing this under-diagnosed and devastating condition. Other spokes to be added include Morgellon's Syndrome, PNES, Fibromyalgia, and Chronic Fati-- I mean, Systemic Exertional Intolera-- I mean, Myalgic Encephalitis. We will also offer vaccination reversal with chelation therapy for those whose CL/MS/PNES/FM/CFS is determined to be a sequelae of the mercury contained therein.

I can't believe that myalgic encephalomyelitis is an actual thing

 

[WilcoWorld]

You must be unaware of the crippling shortage of Chronic Lyme specialists in this country. I for one am addressing this by starting an ED-based Chronic Lyme Disease Center of Excellence / Quaternary referral center, which will be but one spoke in my wheel-based approach to managing this under-diagnosed and devastating condition. Other spokes to be added include Morgellon's Syndrome, PNES, Fibromyalgia, and Chronic Fati-- I mean, Systemic Exertional Intolera-- I mean, Myalgic Encephalitis. We will also offer vaccination reversal with chelation therapy for those whose CL/MS/PNES/FM/CFS is determined to be a sequelae of the mercury contained therein.

You are going to make a killing. Literally and figuratively.

 

[WilcoWorld]

Contract specific. The issue with excluding patients is that the abstraction can take a couple of days. If you are doing phone surveys and have an efficient billing department you may be calling them after the bill drops due to the delay for abstraction. Surveying after the bill nerfs your PG.

You are completely right, but doesn't that show (one of many ways) how PG is total BS? Or at least show that our methods are uncapitalistic?

Patient satisfaction surveys treat patients as consumers, but if we say we only value consumers' impressions before they see the bill than we aren't really operating in a Capitalist economy.

 

[GeneralVeers]

You are completely right, but doesn't that show (one of many ways) how PG is total BS? Or at least show that our methods are uncapitalistic?

Patient satisfaction surveys treat patients as consumers, but if we say we only value consumers' impressions before they see the bill than we aren't really operating in a Capitalist economy.

The public (and politicians) don't believe that capitalism should apply to healthcare. Unfortunately doing PGs AFTER the patient has received the bill might actually be helpful to gauge the value of care that patients feel they received.

 

[WilcoWorld]

The public (and politicians) don't believe that capitalism should apply to healthcare. Unfortunately doing PGs AFTER the patient has received the bill might actually be helpful to gauge the value of care that patients feel they received.

I'm OK with healthcare being non-capitalistic. I'm also OK with healthcare being capitalistic. What frustrates me is trying to have it both ways, which is exactly what we do when admin expects us to treat patients like customers, but those same admins won't let them see the bill until after the patient's already bought the farm.

 

[GeneralVeers]

I'm OK with healthcare being non-capitalistic. I'm also OK with healthcare being capitalistic. What frustrates me is trying to have it both ways, which is exactly what we do when admin expects us to treat patients like customers, but those same admins won't let them see the bill until after the patient's already bought the farm.

Exactly. I would also force all hospitals to have an up-front "Menu pricing" for self pay patients.

 

[TheBlueBlazer]

It's a shame that you all are so arrogant to feel that way. I have a true allergy to phenergan, compazine, and Benadryl, the first two causing seizures at times or severe irritation and loss of control of body movement, and Benadryl the same reaction but sometimes has made my eyes swell shut but usually can cause severe agitation. I have suffered terrible migraines since I got Lyme disease 4 yrs ago and take topamax 200 mg a day and take Imitrex injections. Every time I have to go to the ED the doctor they treat me like a drug seeker and all I want is relief. Toradol is a joke. They make pain relievers for a reason! Is it gonna hurt you to help with someone's pain without judging them? Not everyone is an addict. I have a neurologist. I am a professional like you all and you still think you know everyone's story and can judge them. I can only assume none of you have ever dealt with severe recurring migraines or drug allergies.

I love it when the inmates... eh... patients find out about this site. It truly makes for some of the most entertaining posts. I, for one, vote for an island where we just let all the drug addicts be drug addicts. We can do an airdrop every monday of food and oxys and they can just do whatever the hell they want. If they decide they've had enough, they can enter the detox box and stay there for 2 weeks and get on the boat to come home.

 

[Apod]

How do you usually handle patients that bring in something from their neurologist with an 'emergency' treatment plan?

 

[EM Junkie]

I get so frustrated with a few of my partners at work.

Yesterday a migraine lady came in, she's there monthly for a migraine headache. My partner (a notorious patient-pleasing, drug-giver) picks up the chart, and immediately orders Dilaudid 2 mg IVP and Phenergan 25 mg IVP.

I've asked him before why he practices medicine like that, and his answer is: "I don't want to argue with people, I just want no stress and to go home to my kids".

This. If every single one of your doctors is not on board, any sort of policy to reduce or eliminate narcotic use will not work.

Random reinforcement works outside of Vegas too.

 

[deleted109597]

How do you usually handle patients that bring in something from their neurologist with an 'emergency' treatment plan?

Depends on the "plan"
If it involves narcotics, I politely tell them that it's not a binding agreement, and if she wants those meds, have their neurologist prescribe them for home use.

 

[The White Coat Investor]

How do you usually handle patients that bring in something from their neurologist with an 'emergency' treatment plan?

I call the neurologist. The neurologists in my town don't write those letters. If the neurologist isn't going to put his cell phone on that letter, how do I know it's really from him?

 

[WilcoWorld]

How do you usually handle patients that bring in something from their neurologist with an 'emergency' treatment plan?

If the plan is reasonably in accordance with the medical literature, than I will go ahead with it.

If it's not (e.g. demerol + IV benadryl for a migraine), than I will not.

 

[GeneralVeers]

I get notes all the times from doctors about treatment plans and studies. If it's reasonable and won't harm the patient, then I do it. I don't necessarily get a CT scan if the patient has been sent to the ER for the same. I also won't give any narcotics written by other docs on a notepad or prescription. If the patient has a truly acute emergency requiring them, then I'll give, but otherwise they're out of luck

 

[Janders]

I call the neurologist. The neurologists in my town don't write those letters. If the neurologist isn't going to put his cell phone on that letter, how do I know it's really from him?

I had a patient pulling every card in the books to get high-dose IV-push dilaudid for her migraine. We did all of the best practice things-- dark room, compazine, tylenol, benadryl, toradol, IVF, magnesium IV, decadron, trial of oxygen. Patient eventually pulled out a note with their migraine specialists' card stapled to it... instructing high dose dilaudid. Fascinated, I borrowed the card, and called them. Ivy-tower academic type from a couple states away. Very nice guy in fact, who called me back, and laughed and laughed-- he hadn't given an opiate to a migraine in >>5 years and NEVER recommends them, apparently publishes on the topic. Not the best guy to put on a fake note, ya know?

 

[gman33]

Narcotics probably aren't the best for ha, but I don't see why people get so worked up on this topic.
Narcotics probably aren't the best for most conditions, but we work in a system where patients believe we can eliminate all pain immediately.

Ha is a chronic pain issue.
I'd love to do a mse and just dc.
That's not the standard practice where I work.
I don't start with narcotics, but in a non frequent flier I'm willing to give one dose if that's what it takes to get the person home.

 

[Doctor Bob]

Narcotics probably aren't the best for ha, but I don't see why people get so worked up on this topic.
...
That's not the standard practice where I work.
I don't start with narcotics, but in a non frequent flier I'm willing to give one dose if that's what it takes to get the person home.

For migraines do you also give steroids and/or discuss the post-opioid rebound?

 

[gman33]

I talk the patients about rebound ha.
Thats likely what brought a lot of them to the Ed in the first place.

It is rare that I give steroids.
The literature I have read doesn't show any clear benefit.

If I don't think the patient needs to be worked up, I'm giving some treatment that hopefully improves their pain, but for the most part I just want them to get them out of the department so I can free up the bed for a potentially sick patient.

 

[Angry Birds]

My migraine treatment regimen is as follows:

Round 1: Compazine, benadryl, iv fluids
Round 2: Toradol
Round 3: Magnesium

I don't give narcotics for headache at all, and I hate that my partners do. I don't agree with the "just give them one dose to get them out of the department" approach. This makes it more likely that drug seekers keep coming back, even if it is for just one dose, especially if it is Dilaudid.

To be honest: I'm sick of drug-seekers, and hate that my partners are generally very lax with giving them out like candy. I wish we'd heavily restrict them to identifiable/objective findings, i.e. broken bone, etc.

 

[Hercules]

My migraine treatment regimen is as follows:

Round 1: Compazine, benadryl, iv fluids
Round 2: Toradol
Round 3: Magnesium

I don't give narcotics for headache at all, and I hate that my partners do. I don't agree with the "just give them one dose to get them out of the department" approach. This makes it more likely that drug seekers keep coming back, even if it is for just one dose, especially if it is Dilaudid.

To be honest: I'm sick of drug-seekers, and hate that my partners are generally very lax with giving them out like candy. I wish we'd heavily restrict them to identifiable/objective findings, i.e. broken bone, etc.

The flip side of this is that your partners may hate that you tie up valuable resources (beds and nurses) with a migraine patient who gets an IV and three rounds of drugs and rechecks on a patient that they have out of the department with an IM med in under 30 mins. Not arguing for or against your approach, just pointing out the obvious downside of it. If I am working with one of my partners and chest pain patients are out in the waiting room while they do a 3 round migraine treatment plan, I'm probably going to discuss that fact with them. I would have absolutely no problem with them not wanting to give narcotics, but don't hijack the bed for hours. Just give them your toradol, compazine, and Benadryl cocktail all at once in IM form and discharge them regardless of symptom improvement since you've already drawn a line and won't give narcs.

 

[Angry Birds]

The flip side of this is that your partners may hate that you tie up valuable resources (beds and nurses) with a migraine patient who gets an IV and three rounds of drugs and rechecks on a patient that they have out of the department with an IM med in under 30 mins. Not arguing for or against your approach, just pointing out the obvious downside of it. If I am working with one of my partners and chest pain patients are out in the waiting room while they do a 3 round migraine treatment plan, I'm probably going to discuss that fact with them. I would have absolutely no problem with them not wanting to give narcotics, but don't hijack the bed for hours. Just give them your toradol, compazine, and Benadryl cocktail all at once in IM form and discharge them regardless of symptom improvement since you've already drawn a line and won't give narcs.

Fair enough. Good point.

For now, I work in a single provider shop, where I am not penalizing any other provider for holding on to a patient. And I've never signed out a migraine patient.

But, yours is a good counter-view that I should keep in mind when I switch jobs. Thanks for that insight.

 

[southerndoc]

Magnesium is a 2-hour infusion at my shop...

My cocktail:

- ketorolac 30 mg IV
- diphenhydramine 12.5 mg IV
- prochlorperazine 10 mg or metoclopramide 10 mg IV
- dexamethasone 10 mg IV (if it's been going on for a while)
- 1 L NS

That cures just about any migraine in <30 minutes. No labs. If it doesn't cure them, then we're considering other options (drug seeking, SAH, etc.) and somebody is probably getting a CT/LP. Those that come in saying they usually get "2 of Dilauda" get no opiates.

 

[Arcan57]

Magnesium is a 2-hour infusion at my shop...

My cocktail:

- ketorolac 30 mg IV
- diphenhydramine 12.5 mg IV
- prochlorperazine 10 mg or metoclopramide 10 mg IV
- dexamethasone 10 mg IV (if it's been going on for a while)
- 1 L NS

That cures just about any migraine in <30 minutes. No labs. If it doesn't cure them, then we're considering other options (drug seeking, SAH, etc.) and somebody is probably getting a CT/LP. Those that come in saying they usually get "2 of Dilauda" get no opiates.

Pointing out to the nurses that pre-ecclamptics get 4-6 grams of magnesium in 20 minutes usually is successful in getting the infusion sped up. Something you may want to try (it seems to make a modest difference in my clinical experience) is that the equivalent dose to 10mg of Compazine is 20mg of Reglan.

 

[VA Hopeful Dr]

Magnesium is a 2-hour infusion at my shop...

My cocktail:

- ketorolac 30 mg IV
- diphenhydramine 12.5 mg IV
- prochlorperazine 10 mg or metoclopramide 10 mg IV
- dexamethasone 10 mg IV (if it's been going on for a while)
- 1 L NS

That cures just about any migraine in <30 minutes. No labs. If it doesn't cure them, then we're considering other options (drug seeking, SAH, etc.) and somebody is probably getting a CT/LP. Those that come in saying they usually get "2 of Dilauda" get no opiates.

This is my outpatient approach - though IM, no saline, and more benedryl. Works really well, plus after 4 shots in the rump people really feel like they got their money's worth.

 

[southerndoc]

Pointing out to the nurses that pre-ecclamptics get 4-6 grams of magnesium in 20 minutes usually is successful in getting the infusion sped up. Something you may want to try (it seems to make a modest difference in my clinical experience) is that the equivalent dose to 10mg of Compazine is 20mg of Reglan.

We have a policy that magnesium may only be given quickly for asthmatics, preeclampsia/eclampsia and torsades/arrest situations.

For migraines and any other use, the hospital pharmacy requires it be given over 2 hours to prevent hypotension, flushing and other side effects.

 

[Arcan57]

We have a policy that magnesium may only be given quickly for asthmatics, preeclampsia/eclampsia and torsades/arrest situations.

For migraines and any other use, the hospital pharmacy requires it be given over 2 hours to prevent hypotension, flushing and other side effects.

I've never seen those effects from a 2gm 20 min infusion.

 

[Janders]

I've never seen those effects from a 2gm 20 min infusion.

Agreed. Had to go to P&T at my shop to get this changed.

 

[Apollyon]

Pointing out to the nurses that pre-ecclamptics get 4-6 grams of magnesium in 20 minutes usually is successful in getting the infusion sped up. Something you may want to try (it seems to make a modest difference in my clinical experience) is that the equivalent dose to 10mg of Compazine is 20mg of Reglan.

That's my deal. 20 Reglan, 50 Benadryl, 10 Decadron, all IV, all up front. Consider mag, consider DHE, consider Toradol. Don't have caffeine on formulary. May redose the Reglan (thus, the Benadryl up front). NO role for narcs - EVER. As I said above, only brain tumor or skull fracture get the narcs.

 

[WilcoWorld]

That's my deal. 20 Reglan, 50 Benadryl, 10 Decadron, all IV, all up front. Consider mag, consider DHE, consider Toradol. Don't have caffeine on formulary. May redose the Reglan (thus, the Benadryl up front). NO role for narcs - EVER. As I said above, only brain tumor or skull fracture get the narcs.

Can't resist pointing out the humor in the fact that the one drug you can't give is in the cup of every staff member taking care of the patient. Classic medicine!

 

[Rendar5]

Besides the usual stuff, I do find Depakote to be useful for resistant migraines. and surprisingly it's actually not an off-label use.

 

[PlutoBoy]

Sumatriptan
Decadron
Reglan
Benadryl

Works like a charm

 

[deuist]

There is a lot of good information in this thread. I would like to add that I offer every headache patient the cervical injection:



Although I deviate from this procedure by going higher up, near C3/C4. I tend to have better results by moving the needle higher.

 

[gman33]

Anyone use triptans?

I don't and not really sure why I don't.

 

[Doctor4Life1769]

There is a lot of good information in this thread. I would like to add that I offer every headache patient the cervical injection:



Although I deviate from this procedure by going higher up, near C3/C4. I tend to have better results by moving the needle higher.

How deep do you go with the needle when going near C3/C4?

 

[deuist]

1.5 inches deep, at 1 inch lateral of midline.

 

[TxNerdyNerd101]

No you don't.

Seizures are not an allergic reaction.

The ED is also not the place for treatment of chronic pain/headaches. See your PCP or neurologist.

Question: Has anyone seen any adverse reactions to the standard 4-med migraine cocktail IV? Any seizure or seizure-like response within minutes of administering?

 

[TxNerdyNerd101]

I love it when the inmates... eh... patients find out about this site. It truly makes for some of the most entertaining posts. I, for one, vote for an island where we just let all the drug addicts be drug addicts. We can do an airdrop every monday of food and oxys and they can just do whatever the hell they want. If they decide they've had enough, they can enter the detox box and stay there for 2 weeks and get on the boat to come home.

I'm new here and have thoroughly enjoyed the commentary from the practitioners and crazies alike.

 

[BAM!]

Of course. Ever wonder why many of some of those consultants start their chart with, "Mr Jones is a very unfortunate but likable and appropriate 49 year old male..."?

They're already setting the stage. It goes like this, "Him: nice guy (consultant). You: judgmental jerk (EP) because you labeled patient with migraine with pejorative term, who turned out to have a life threatening SAH on top of his migraine, which you missed because of your pre-determined bias."

Does anyone start off their ED notes with, "Mrs Jones is a very pleasant 38 yo female..."? Seems like it might be a good idea.

I know I write stuff like that for parents who are taking their kids home... "Upon reassessment, Little Joey is improved. Discussed diagnosis and follow up with parents who appear reliable..." etc.

 

[gman33]

Does anyone start off their ED notes with, "Mrs Jones is a very pleasant 38 yo female..."? Seems like it might be a good idea.

I know I write stuff like that for parents who are taking their kids home... "Upon reassessment, Little Joey is improved. Discussed diagnosis and follow up with parents who appear reliable..." etc.

I do not do this, but I am very careful not be put anything that will be interpreted as a negative view of the patient.

Some of my colleagues write notes about drug seeking behavior.

This may be helpful for future visits, but unfortunately those patients gets sick.
I don't want to be in court defending my note saying this patient was there for drugs when it turned out he had x, y, z.

 

[d2305]

Even the drug seekers want to go home after Inapsine.

 

[Apollyon]

Does anyone start off their ED notes with, "Mrs Jones is a very pleasant 38 yo female..."? Seems like it might be a good idea.

I asked a hospitalist about "pleasant", but what if the patient is a pain? He told me the chart says "unfortunate".