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Recently saw a 50 something year old gentleman with supposed sickle cell disease who still had both native hips, no heart failure, no strokes, no CKD, or any other medical co-morbidities. I found all of that to be beyond abnormal given the low life expectancy and the typical disease burden of someone living that long with SCD. He is apparently a regular at our hospital presenting to the ER at least 5-6x/month and being admitted 1-2x/month and has been doing this for the last 3 years. He was of course presenting for his typical chest pain and pains everywhere and apparently ran out of his pain meds for the 3rd time in last 2 months. I looked back at all his previous presentations which were likely >100 total, and found that he did not have a single heme/onc consult despite years of presentations and no one even bothered to run a Hgb electrophoresis on the guy. He just got his typical 2-3 rounds of dilaudid and then admitted if still requesting meds. I even looked back at all his previous admissions and found that not a single physician openly questioned his reported medical history. Stranger was the fact that apparently hundreds of doctors were perpetuating this cycle of chronic dilaudid despite the patient consistently having a Hgb between 14-16 which is completely unheard of for SCD. I confronted him about this and he said "Oh, I have Hgb SC" which typically have higher Hgb levels, but should still typically be lower than normal and still frequently carries much of the same disease burden as Hgb SS, although typically less severe.

I ordered basic labs and tacked on a hgb electrophoresis, gave him some toradol, and discharged him after his labs all came back normal for the 100th time, with the electrophoresis still pending. His electrophoresis of course eventually came back demonstrating that he had sickle cell trait which I figured was going to be the case, and had 0% Hgb C. Despite the electrophoresis results and me clearly stating in my note that the patient was unlikely to have sickle cell or Hgb SC, the next two ED docs that saw him admitted him and he continued to get round the clock dilaudid during hospital admission. I think at least 10 other docs have now seen him since the last time I saw him and they continue to treat him for his "sickle cell disease" despite his hgb of 15 and an electrophoresis that clearly demonstrates SC trait on his chart. I just don't understand how a bunch of trained physicians can miss such an obvious case of malingering. I've caught people faking sickle cell disease before, but they usually get caught within the 1st or 2nd time of attempting the ruse, at least where I trained at in residency. The only logical conclusion I can make is that none of these docs have any experience with sickle cell disease given that we are in a low prevalence area, although that really shouldn't be an excuse given how obvious this case is.

I'm pretty sure I have a few others like this, as I enjoy catching high resource utilizers in lies regarding their medical history; however, this case is fresh on my mind. Anyone have similar experiences?
 
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Recently saw a 50 something year old gentleman with supposed sickle cell disease who still had both native hips, no heart failure, no strokes, no CKD, or any other medical co-morbidities. I found all of that to be beyond abnormal given the low life expectancy and the typical disease burden of someone living that long with SCD. He is apparently a regular at our hospital presenting to the ER at least 5-6x/month and being admitted 1-2x/month and has been doing this for the last 3 years. He was of course presenting for his typical chest pain and pains everywhere and apparently ran out of his pain meds for the 3rd time in last 2 months. I looked back at all his previous presentations which were likely >100 total, and found that he did not have a single heme/onc consult despite years of presentations and no one even bothered to run a Hgb electrophoresis on the guy. He just got his typical 2-3 rounds of dilaudid and then admitted if still requesting meds. I even looked back at all his previous admissions and found that not a single physician openly questioned his reported medical history. Stranger was the fact that apparently hundreds of doctors were perpetuating this cycle of chronic dilaudid despite the patient consistently having a Hgb between 14-16 which is completely unheard of for SCD. I confronted him about this and he said "Oh, I have Hgb SC" which typically have higher Hgb levels, but should still typically be lower than normal and still frequently carries much of the same disease burden as Hgb SS, although typically less severe.

I ordered basic labs and tacked on a hgb electrophoresis, gave him some toradol, and discharged him after his labs all came back normal for the 100th time, with the electrophoresis still pending. His electrophoresis of course eventually came back demonstrating that he had sickle cell trait which I figured was going to be the case, and had 0% Hgb C. Despite the electrophoresis results and me clearly stating in my note that the patient was unlikely to have sickle cell or Hgb SC, the next two ED docs that saw him admitted him and he continued to get round the clock dilaudid during hospital admission. I think at least 10 other docs have now seen him since the last time I saw him and they continue to treat him for his "sickle cell disease" despite his hgb of 15 and an electrophoresis that clearly demonstrates SC trait on his chart. I just don't understand how a bunch of trained physicians can miss such an obvious case of malingering. I've caught people faking sickle cell disease before, but they usually get caught within the 1st or 2nd time of attempting the ruse, at least where I trained at in residency. The only logical conclusion I can make is that none of these docs have any experience with sickle cell disease given that we are in a low prevalence area, although that really shouldn't be an excuse given how obvious this case is.

I'm pretty sure I have a few others like this, as I enjoy catching high resource utilizers in lies regarding their medical history; however, this case is fresh on my mind. Anyone have similar experiences?

I’ve done the exact same thing twice in my career. Both times I was euphoric, with a high that rivals the thrill I get from my greatest resuscitation saves. Last time I told the patient (who swore he was SS) that if he was lying to me I would turn him in for Medicaid fraud and doctor shopping...

(Narrator: the patient did not have hemoglobin SS).
 

Apollyon

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Are you full time there, and are these other docs your partners? Or are they worried that the pt will pull the race card?

There is a prisoner that I've seen twice in 3 years, with two other admissions in between. This guy, though, had an Hb of 8.4, which is about where he lives. His retic count is always around 10%. His chart says Hb SC. However, this one gives me no heartburn, so, I don't worry.
 
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Are you full time there, and are these other docs your partners? Or are they worried that the pt will pull the race card?

There is a prisoner that I've seen twice in 3 years, with two other admissions in between. This guy, though, had an Hb of 8.4, which is about where he lives. His retic count is always around 10%. His chart says Hb SC. However, this one gives me no heartburn, so, I don't worry.
Yeah, other docs are my partners, all EM residency trained, but I've had issues with a few of them doing wacky things like aggressively treating asymptomatic hypertension or giving opiates out like candy, and then having these patients bounce back to me with expectations that I will treat them the same. I had one of those docs shocked when I told them I had literally never given an atraumatic, chronic headache patient opiates before given that they are contraindicated.
 

BoardingDoc

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Yeah, other docs are my partners, all EM residency trained, but I've had issues with a few of them doing wacky things like aggressively treating asymptomatic hypertension or giving opiates out like candy, and then having these patients bounce back to me with expectations that I will treat them the same. I had one of those docs shocked when I told them I had literally never given an atraumatic, chronic headache patient opiates before given that they are contraindicated.
Are these partners of yours substantially older than you? I've seen both opioids for chronic HA as well as unindicated BP mgmt from some EM faculty during my residency, but it was universally from the older docs who clearly weren't keeping up with the current literature.
 

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Yeah, other docs are my partners, all EM residency trained, but I've had issues with a few of them doing wacky things like aggressively treating asymptomatic hypertension or giving opiates out like candy, and then having these patients bounce back to me with expectations that I will treat them the same. I had one of those docs shocked when I told them I had literally never given an atraumatic, chronic headache patient opiates before given that they are contraindicated.

THANK YOU! I can probably count the number of times I have given narcotics for a headache. Most of the time my Reglan, Benadryl, Toradol works... if not better then Tylenol... I try magnesium, I try dexamethasone, and as a last resort HALDOL works wonders (Side note - I had a fibromyalgia patient come in hysterical with “pain all over my body” and I gave her Haldol IM and when I re-evaluated her she was sitting up on the stretcher smiling. I asked if she was ready to leave and she smiled and in a creepy way said “I’ve never been more ready” It was awesome and she asked for a prescription to go home with - LOL). I always tell patients I try to avoid narcotics for headaches and tell them about the risk of rebound headaches because that usually gets them to pipe down. The problem is with some of these chronic migraineurs, once someone (usually an old school doc) gives them a narcotic they continue to ask for them in the future because “it’s the only thing that works for me” and they act shocked when I tell them I don’t do narcotics for headaches. They say “I don’t get rebound headaches” (then why the F do you have daily headaches and why are you always coming back here?). One of my favorite docs who has been a physician for fifty years once looked at me like I was a complete jerk when I told him this. He said “their pain is real; you have to address it.” I believe the pain is real - I get migraines myself - but narcotics are a no go...
 

TooMuchResearch

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THANK YOU! I can probably count the number of times I have given narcotics for a headache. Most of the time my Reglan, Benadryl, Toradol works... if not better then Tylenol... I try magnesium, I try dexamethasone, and as a last resort HALDOL works wonders (Side note - I had a fibromyalgia patient come in hysterical with “pain all over my body” and I gave her Haldol IM and when I re-evaluated her she was sitting up on the stretcher smiling. I asked if she was ready to leave and she smiled and in a creepy way said “I’ve never been more ready” It was awesome and she asked for a prescription to go home with - LOL). I always tell patients I try to avoid narcotics for headaches and tell them about the risk of rebound headaches because that usually gets them to pipe down. The problem is with some of these chronic migraineurs, once someone (usually an old school doc) gives them a narcotic they continue to ask for them in the future because “it’s the only thing that works for me” and they act shocked when I tell them I don’t do narcotics for headaches. They say “I don’t get rebound headaches” (then why the F do you have daily headaches and why are you always coming back here?). One of my favorite docs who has been a physician for fifty years once looked at me like I was a complete jerk when I told him this. He said “their pain is real; you have to address it.” I believe the pain is real - I get migraines myself - but narcotics are a no go...
I had a chronic migraine patient recently who has been getting IM morphine for 20+ years from regular FP doc. Came in from clinic because primary doc was out of town. Cured with IV valproate, said it worked better than the morphine ever has. Maybe she was lying but she came in angry and left seemingly happy.
 
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One of our docs recently caught a fake sickler by doing the same thing. He saw her several visits later and confronted her with it. She hasn't been back since.

We used to have this girl (25ish) frequently present with her "cancer" related pain. She said she had some sort of cancer that I can't remember. Maybe ovarian? At any rate, she said she got her treatments at a facility across the city that is not affiliated with us. She would shave her head and wear a "chemo cap" all the time. Girl always looked pale, which now I believe is from her phlebotomy anemia as she was in an ER in our system at least every other day.

Finally I called the facility across town to see why she never went there for treatment. Turns out she was telling them that she got her cancer treatment from us and would present there with her uncontrolled pain because they were closer. She was providing two different addresses, none of which were valid.

We confronted her, and she disappeared for a while. She reappeared a few months ago and we found that she's been doing the same thing to two hospitals in South Atlanta not affiliated with us. I called them and asked when I saw her controlled substance prescription history in the state database.

It has always amazed me at how far some people will go to get high from hydromorphone (thankfully, it's not stocked in our ER's anymore except the burn center). She even convinced some knucklehead to put a port in her! Of course her boyfriend bought into everything and felt as if she was mistreated when she didn't get her usual 2 mg dose of hydromorphone.
 

gamerEMdoc

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Yeah I had a young person try to pull the CA thing on me once, gave me a docs number in Florida. I said I would call them and she demanded that she call them on her cell phone in order for me to get in touch with them. When I said our protocol was for us to directly page them through official channels, she immediately eloped from the ED.

Had another guy lose his ADHD meds by leaving them in his parents luggage or some BS story. Amazingly a few months later he came back and tried the same story. Hahaha. Man, you'd think he wouldn't keep forgetting his controlled Rx in his parents luggage over and over.

I can't believe people get away with these stories sometimes. I mean, I'm sure I've been fooled before, but sometimes its so glaringly fake and its ALWAYS for a controlled substance.
 
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GeneralVeers

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I wish I could get hemoglobin electrophoresis real time in my hospital. I see about 5-6 sicklers who frequent hospitals almost weekly. One of them literally goes to a different hospital every night. It's documented in the chart, and everyone knows this but she still gets dilaudid and admission most of the time! I can't figure out why doctors, many smarter than me repeatedly enable this behavior.
 
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I wish I could get hemoglobin electrophoresis real time in my hospital. I see about 5-6 sicklers who frequent hospitals almost weekly. One of them literally goes to a different hospital every night. It's documented in the chart, and everyone knows this but she still gets dilaudid and admission most of the time! I can't figure out why doctors, many smarter than me repeatedly enable this behavior.
I really think because this idea has been perpetuated for decades that the only way to treat sickle cell pain crisis is to give these patients as much IV narcotics as the patient needs. I have heard EM:RAP segments stating to give them a dose of IV dilaudid every 15 minutes until their pain improves. One EM:RAP segment even stated that we should treat these patients like terminal cancer patients given that Hgb SS is a "terminal diagnosis" (ignoring the fact that people live 40-50 years with this disease unlike cancer). I've seen the #FOAMed EM guys go on twitter rants about how it is malpractice to not aggressively give IV opioids, and that you should reconsider your profession if you aren't giving as much IV opioids as the patient needs to have pain control.

What we seem to be ignoring is that we have essentially created a patient population where we are now completely unable to differentiate opioid use disorder from legitimate sickle cell pain crisis. These are individuals who have been on opioids for 20-30-40 years who require humongous doses of dilaudid in order to even touch their pain. I know of two frequent flyer sicklers during residency that died during hospital admission due to opioid overdose after being placed on scheduled 2mg of dilaudid. We have effectively made their standard of care therapy ineffectual by shoving opioids down their mouths and through their veins for years, rather than treat them like every other chronic pain patient population that we see. I usually don't see our rheumatoid arthritis folks coming in every 2-3 days for their 4mgs of dilaudid. I don't know if part of this is related to fear of being perceived as racist, but I hope that as we continue to find effective non-narcotic methods of pain control we re-assess our pain control strategies for SCD.
 

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Recently saw a 50 something year old gentleman with supposed sickle cell disease who still had both native hips, no heart failure, no strokes, no CKD, or any other medical co-morbidities...
First and foremost, Strong work! Nice sleuthing.

As for how to actually deal with a patient like this: It requires some institutional support, which may not be possible at your facility. If your facility and group supports, they can flag this patient as a "high utilization patient" and develop a continuous "care plan" which may include a standardized workup in the ER with some inconvenient although not unreasonable standard practices (patient must always take off all clothes and switch into a patient gown, patient must always be on continuous monitor taking q5min NIBP, all pain medicines to be given IVPB over 60 minutes, patient to be made NPO). Patient is then only to be admitted if admitting criteria beyond "intractable pain" are met such as objective laboratory abnormalities, etc. It should be made clear in the care plan that there is objective evidence the patient does not in fact actually have sickle cell disease, and it should be clear the patient has been appraised of this fact.

The care plan should be drawn and decided by the group and approved by the medical director and the hospital administration. The care plan should be committed to writing. Every time the patient presents to the ER the care plan should be specifically cited in the physician's note in there MDM. Any deviation from the care plan should be noted ("patient actually septic today and needs to be admitted...blah blah blah.")

Note, I work in Texas in a very med-mal friendly environment; however, at one academic, county-type facility I work at these types of care plans have been implemented very effectively to reduce some of the visits of their very numerous "high utilizers." (Probably over 100 patients flagged). Some within a few months, stop presenting to the facility all together.

That being said, I also work at a corporate community hospital, and at that facility there would be no hope of ever putting together a care plan and the administration would eviscerate you for even trying to send a "paying customer" away. So it really depends on your shop; however, for some of the more academic and resource-conscious environments, it may be possible to limit these patients.
 

GeneralVeers

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I can't stand these admissions for "intractable pain". I see all sorts of sicklers get admitted of this, even though they are calmly texting away on their cell phones, in no distress, and with normal labs. If you have normal vitals, can smile, talk calmly and ambulate with no difficulty I'm not giving you dilaudid or any narcotics despite what the advocates say.

Same goes for cyclic vomiting, gastroparesis, sphincter of oddi spasm, chronic back pain, endometriosis, etc. If you don't have a demonstrable AND treatable illness, you are not getting admitted to the hospital.
 

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A few comments:

-I have seen/heard of these kinds of faked HbSS cases too...you can't fool the electrophoresis...good on you guys!

-We should be doing everything in our power to root out people with secondary gain, so that people with true disease are treated fairly

-I'm no expert on HbSS beyond that which we do in the ED, but I think it's a travesty what we've (medicine in general) done with this illness. Seriously, we have nothing to offer aside from hydroxyurea and opiates? I've seen care plans that call for 8 mg hydromorphone q30 mins x 3 for legit sicklers - that's insanity. To a non-heme person, it seems like there's a lack of research/funding directed at this disease. Maybe we should push BMT more aggressively when younger? I dunno.
 

TooMuchResearch

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First and foremost, Strong work! Nice sleuthing.

As for how to actually deal with a patient like this: It requires some institutional support, which may not be possible at your facility. If your facility and group supports, they can flag this patient as a "high utilization patient" and develop a continuous "care plan" which may include a standardized workup in the ER with some inconvenient although not unreasonable standard practices (patient must always take off all clothes and switch into a patient gown, patient must always be on continuous monitor taking q5min NIBP, all pain medicines to be given IVPB over 60 minutes, patient to be made NPO). Patient is then only to be admitted if admitting criteria beyond "intractable pain" are met such as objective laboratory abnormalities, etc. It should be made clear in the care plan that there is objective evidence the patient does not in fact actually have sickle cell disease, and it should be clear the patient has been appraised of this fact.

The care plan should be drawn and decided by the group and approved by the medical director and the hospital administration. The care plan should be committed to writing. Every time the patient presents to the ER the care plan should be specifically cited in the physician's note in there MDM. Any deviation from the care plan should be noted ("patient actually septic today and needs to be admitted...blah blah blah.")

Note, I work in Texas in a very med-mal friendly environment; however, at one academic, county-type facility I work at these types of care plans have been implemented very effectively to reduce some of the visits of their very numerous "high utilizers." (Probably over 100 patients flagged). Some within a few months, stop presenting to the facility all together.

That being said, I also work at a corporate community hospital, and at that facility there would be no hope of ever putting together a care plan and the administration would eviscerate you for even trying to send a "paying customer" away. So it really depends on your shop; however, for some of the more academic and resource-conscious environments, it may be possible to limit these patients.
We use care plans. Community hospitals, state without any significant med mal protection.
 
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thegenius

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To the OP:

Can you email all the docs in your group letting them know what you’ve found? At that point you have done as much as you can, besides educating them more.

I would hate to have SCD....although I suspect we only see a small segment in society that can’t care for themselves. I remember taking care of a sickler in residency who never been to an ER before...and all she wanted was something a little stronger than Tylenol...I offered toradol 30 mg IM and it took her pain away completely.

I suspect most of who we see have pain due to opiate withdraw rather than true VOC.

What a sad disease. It’s a real disease that most docs don’t care about.
 

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We saw a ton in NC due to the high black population.
Most of the docs down here have never seen it. I had a white person walk in to triage one day say they had it, and I just laughed at them. (Yes, I know about Mediterranean variants). Their retic was 0.5%. They did not get brought back instantly and did not get narcotics.
 

GeneralVeers

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To the OP:



What a sad disease. It’s a real disease that most docs don’t care about.
It absolutely is a real and terrible disease. The problem I have is that almost every time I see this disease it is only "diluadid-responsive" which to me is a red flag. I'm not aware of any pathopysiology which would produce allergies to fentanyl, morphine, and toradol but not dilaudid.

I saw one girl yesterday, 21 years old, had just moved back to town (hence the 3 month gap in her weekly ED visits). She had been seen the day before, and that morning the kind doctor before me had given her dilaudid x 2. She came back on my evening shift. I ordered her toradol this time and she flatly refused it. I'm sorry, but if you refuse all treatment alternatives except dilaudid, I'm going to discharge you.
 

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It absolutely is a real and terrible disease. The problem I have is that almost every time I see this disease it is only "diluadid-responsive" which to me is a red flag. I'm not aware of any pathopysiology which would produce allergies to fentanyl, morphine, and toradol but not dilaudid.

I saw one girl yesterday, 21 years old, had just moved back to town (hence the 3 month gap in her weekly ED visits). She had been seen the day before, and that morning the kind doctor before me had given her dilaudid x 2. She came back on my evening shift. I ordered her toradol this time and she flatly refused it. I'm sorry, but if you refuse all treatment alternatives except dilaudid, I'm going to discharge you.
I was looking at the notes for the prisoner sickler, and, as I was surprised he was still in the hospital, the admitting doc (who is not a sucker) dictated that the patient "states that the Toradol is much better than the Dilaudid for his pain".

People in real pain will take anything you offer for pain, even if it is a cup of spit over ice. When someone refuses known and accepted standards, and demands only a drug of abuse, well, that's a way to skyline yourself.

Now, I'm waiting for some non-medical person to come in and condemn us. But, how do you put a reasonable spin on refusing an intervention that, if you comply, might get you to the thing you ARE seeking? After all, it IS the emergency department, not the the convenience department.
 
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GeneralVeers

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Now, I'm waiting for some non-medical person to come in and condemn us. But, how do you put a reasonable spin on refusing an intervention that, if you comply, might get you to the thing you ARE seeking? After all, it IS the emergency department, not the the convenience department.
Right. I'm much more likely to give narcotics if you've taken the toradol and still complain of pain (like kidney stones). I offer all my drug seekers and chronic pain patients toradol. That way when they complain, there is no way they can say I've refused to treat their pain. I always offer some form of medication even if it's bentyl. The exception being when they are allergic to toradol, bentyl, tylenol, fentyl, inapsine, and morphine. They get nothing then.
 
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You guys have to deal with these patients for a few hours; we (IM docs) have to deal with them for days when some of you decide to admit them for no reasons other tossing them to us. Some of them spend days or even weeks in our service getting Dilaudid q2. It's hard to break that cycle when a few docs seemingly don't care and just want to move on to the next patient.
 

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You guys have to deal with these patients for a few hours; we (IM docs) have to deal with them for days when some of you decide to admit them for no reasons other tossing them to us. Some of them spend days or even weeks in our service getting Dilaudid q2. It's hard to break that cycle when a few docs seemingly don't care and just want to move on to the next patient.
If you are so confident the patient is just sitting on your service slurping down dilaudid what is stoping you from discharging them immediately? I assume if a patient is admitted for something like "intractable pain" the actual time per day you spend rounding on the patient is like 2 minutes right? I read inpatient progress notes. The daily progress note subjective after admission H&P typically reads: "Pain today" or "Feels bad."
 

GeneralVeers

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You guys have to deal with these patients for a few hours; we (IM docs) have to deal with them for days when some of you decide to admit them for no reasons other tossing them to us. Some of them spend days or even weeks in our service getting Dilaudid q2. It's hard to break that cycle when a few docs seemingly don't care and just want to move on to the next patient.
I agree with RoyBasch. If you think any of our admissions are BS then just discharge them. I don't take offense to it.
 

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You guys have to deal with these patients for a few hours; we (IM docs) have to deal with them for days when some of you decide to admit them for no reasons other tossing them to us. Some of them spend days or even weeks in our service getting Dilaudid q2. It's hard to break that cycle when a few docs seemingly don't care and just want to move on to the next patient.
They can't get q2 Dilaudid unless you order it that way...
 

GeneralVeers

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They can't get q2 Dilaudid unless you order it that way...
Easiest way to make them leave is to give them PO dilaudid. If they aren't vomiting, and have no surgical issues, then just put them on PO meds. They will AMA quickly. Not sure why we've decided we have to IV pain meds for a host of conditions.
 

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Easiest way to make them leave is to give them PO dilaudid. If they aren't vomiting, and have no surgical issues, then just put them on PO meds. They will AMA quickly. Not sure why we've decided we have to IV pain meds for a host of conditions.
Relatedly, why do most of us give IM Toradol when multiple studies show there's no difference between that and po ibuprofen for pain control? I do this myself. I think it's basically we often feel the need to "add value" by giving our pts something they can't just get at the drug store.
 
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Easiest way to make them leave is to give them PO dilaudid. If they aren't vomiting, and have no surgical issues, then just put them on PO meds. They will AMA quickly. Not sure why we've decided we have to IV pain meds for a host of conditions.
Or cut off the IV benadryl chaser.

"But I always get this when I come hereeeeee!!!!"

Relatedly, why do most of us give IM Toradol when multiple studies show there's no difference between that and po ibuprofen for pain control? I do this myself. I think it's basically we often feel the need to "add value" by giving our pts something they can't just get at the drug store.
Because it makes us look like we are "doing something."
 
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Dr.McNinja

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Relatedly, why do most of us give IM Toradol when multiple studies show there's no difference between that and po ibuprofen for pain control? I do this myself. I think it's basically we often feel the need to "add value" by giving our pts something they can't just get at the drug store.
There are even studies that show no patient perception of difference, so it's not just placebo.
I do it because a) I'm sick of arguing with the patient about it. I offer a shot or by mouth, and they choose (same with decadron). b)I'm more sick of arguing with the nurses about it (We've always done it this way). I have at least decreased the dosage to 15mg.
 
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Janders

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re: Toradol IM/IV

Everyone gets a lagniappe. While I believe in the holy power of PO Ibuprofen (600mg q8h w/ food please), I also believe in the divine masterpiece that is parenteral Toradol. Of all the harms we do, using a needle to administer toradol, even if it is placebo/theatrics, is nearly last on our list. And I really think it may be superior for migraine and renal colic, moderate-quality-evidence-be-damned.
 
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namethatsmell

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I'll give them the benadryl....PO. It's awesome how mad they get, but they really don't have a legitimate reason for why they can't have it PO since it's for "itching".
This. All day long.

IV benadryl is for active anaphylaxis or acute akathisia/AE from compazine/antipsychotics etc.
 
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theseeker4

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You guys have to deal with these patients for a few hours; we (IM docs) have to deal with them for days when some of you decide to admit them for no reasons other tossing them to us. Some of them spend days or even weeks in our service getting Dilaudid q2. It's hard to break that cycle when a few docs seemingly don't care and just want to move on to the next patient.
The real question you have, then, is why your attending is letting these patients sit on their service that long getting those meds......Easy cycle to break if you are willing to let the patient complain; just stop the IV meds. Also, it is cute that an IM PGY1 is thinking he/she can judge EM attendings' admitting decisions.
 
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The real question you have, then, is why your attending is letting these patients sit on their service that long getting those meds......Easy cycle to break if you are willing to let the patient complain; just stop the IV meds. Also, it is cute that an IM PGY1 is thinking he/she can judge EM attendings' admitting decisions.
I am not questioning EM docs admitting decision but the whole hospital (attendings and residents) I am training at is... I try not to do that because I think your job is one of the toughest jobs in medicine.
 

GeneralVeers

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I am not questioning EM docs admitting decision but the whole hospital (attendings and residents) I am training at is... I try not to do that because I think your job is one of the toughest jobs in medicine.
So then if they feel the patient was admitted for no good reason they should discharge. Just because they are too chicken and afraid to say "no" to IV narcotics and discharge someone is not our problem.
 
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thegenius

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It absolutely is a real and terrible disease. The problem I have is that almost every time I see this disease it is only "diluadid-responsive" which to me is a red flag. I'm not aware of any pathopysiology which would produce allergies to fentanyl, morphine, and toradol but not dilaudid.

I saw one girl yesterday, 21 years old, had just moved back to town (hence the 3 month gap in her weekly ED visits). She had been seen the day before, and that morning the kind doctor before me had given her dilaudid x 2. She came back on my evening shift. I ordered her toradol this time and she flatly refused it. I'm sorry, but if you refuse all treatment alternatives except dilaudid, I'm going to discharge you.
So do you just flat out discharge, without any workup or treatment, every single sickler you get who only wants dilaudid?
 

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So do you just flat out discharge, without any workup or treatment, every single sickler you get who only wants dilaudid?
I'm not joking about this: I used to see at least one sickle cell patient every shift. About two years ago, we removed Dilaudid from our ER's. You have to get it from pharmacy (downstairs), which takes a while. We developed a sickle cell protocol and it specifically states to give morphine to patients allergic. Protocol states to premedicate with Benadryl PO and avoid IV Benadryl. Our pharmacists did research and almost all allergies to morphine are itching only. If they have a documented anaphylaxis to morphine, then we use fentanyl. They all get ketorolac unless their creatinine doesn't allow it or they have anaphylaxis to it. We tell patients we must follow the protocol. Even upstairs it's followed, and PCA's require an anesthesia pain management consult for sickle cell patients. Since implementing this, I swear I only see a sickle cell patient every 2-3 months now. Our frequent fliers simply disappeared. The ones who we see now get relief with morphine and they truly are sickling when we see them. Amazing what elimination of hydromorphone and IV diphenhydramine will do to our frequent fliers.
 

theseeker4

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I am not questioning EM docs admitting decision but the whole hospital (attendings and residents) I am training at is... I try not to do that because I think your job is one of the toughest jobs in medicine.
If they are questioning it, why aren't they discharging the patients? Very easy to sit upstairs and say "this patient shouldn't be admitted / doesn't need admission," but often after the patient gets to the floor, they end up in patient for several days, if not longer, from what you are saying. If they don't require admission, shouldn't they be very easy to discharge?
 
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RustedFox

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I'm not joking about this: I used to see at least one sickle cell patient every shift. About two years ago, we removed Dilaudid from our ER's. You have to get it from pharmacy (downstairs), which takes a while. We developed a sickle cell protocol and it specifically states to give morphine to patients allergic. Protocol states to premedicate with Benadryl PO and avoid IV Benadryl. Our pharmacists did research and almost all allergies to morphine are itching only. If they have a documented anaphylaxis to morphine, then we use fentanyl. They all get ketorolac unless their creatinine doesn't allow it or they have anaphylaxis to it. We tell patients we must follow the protocol. Even upstairs it's followed, and PCA's require an anesthesia pain management consult for sickle cell patients. Since implementing this, I swear I only see a sickle cell patient every 2-3 months now. Our frequent fliers simply disappeared. The ones who we see now get relief with morphine and they truly are sickling when we see them. Amazing what elimination of hydromorphone and IV diphenhydramine will do to our frequent fliers.
You work in a sickle cell dense area too, if I am not mistaken.
 
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If they are questioning it, why aren't they discharging the patients? Very easy to sit upstairs and say "this patient shouldn't be admitted / doesn't need admission," but often after the patient gets to the floor, they end up in patient for several days, if not longer, from what you are saying. If they don't require admission, shouldn't they be very easy to discharge?
Many times they do. There are multiple instances we d/c people while they are still in the ED waiting for a bed. I was kind of puzzled at the beginning of PGY1 when I saw other attendings (other than IM docs) taking jabs at ED docs. I would never do it, but now I can understand where some of them are coming from... The ED docs at the VA are at another level when it comes to this issue.
 

RoyBasch

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Many times they do. There are multiple instances we d/c people while they are still in the ED waiting for a bed. I was kind of puzzled at the beginning of PGY1 when I saw other attendings (other than IM docs) taking jabs at ED docs. I would never do it, but now I can understand where some of them are coming from... The ED docs at the VA are at another level when it comes to this issue.
If the medicine/hospitalist team wants to discharge my admission immediately, that is fine with me. I have had this conversation many times before when working at my academic job with the medicine resident. I always say the same thing: "You will come consult on the patient, your attending must staff the patient, if after they see the patient in full consultation they can admit and immediately discharge them. I will be documenting in my note however, that transition of care to the admitting team is complete and the final plan and disposition is per the medicine team. I will document that I did recommend admission and further testing (serial troponin, stress test, cardiology consult etc.)"

90% of the time the patient is then simply admitted. 10% of the time the admitting staff comes to speak to me, we have a brief cordial conversation, I reappraise them of the conversation I had with the resident, and they say "ok" and summarily discharge the patient immediately. That does not hurt my feelings.

Medicine is complicated and subjective. There are different opinions and few absolute guidelines how to manage many conditions and situations. There are different levels of risk tolerance between physicians. If a staff physician (not a resident mind you) is willing to see a patient in full consultation, make a clinical decision, put their nickel down and then stand by it (write a note with the rec and sign it), then I will respect it. That being said, the staff is aware that they are pretty much on the hook medico-legally 100% at this point.

Things I cannot and do not accept: "phone consultations" where somebody tells me over the phone without having seen the patient at all what the disposition should be. Resident/intern physicians trying to over-ride my staff decisions on disposition. If you are gonna make big-boy decisions, you gotta wear big-boy pants and stand on your own license and your own liability. This is not something you can do as a resident by design. Furthermore, enough case review has taught me that my exposure as an ER physician is quite significant until the other staff physician actually sees the patient and then commits their recommendations to writing. Many peer-reviews I have participated in have spiraled downwards with teams from different services shouting hearsay over what another consultant allegedly recommended in a phone call.
 
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GeneralVeers

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So do you just flat out discharge, without any workup or treatment, every single sickler you get who only wants dilaudid?
It depends. If its one of our daily visitors, and they've had labs that are baseline for them within the last 2-3 days I offer toradol and discharge. If they haven't had a set of labs done in a while, I'll send a CBC and reticulocyte count. I'll still order IV fluids and toradol for them.

For the very rare sickler who obviously appears to be in real acute pain, I'll give narcs. This happens infrequently.
 

thegenius

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You work in a sickle cell dense area too, if I am not mistaken.
We have very few sicklers, maybe 5-8. And most of them are established with our Hematology group. So I wonder if we adopted a similar policy whether our Heme/Onc docs would hear about it in clinic, and thus get mad at us. Maybe we need to involve them if we make a department policy on IV narcotic use.
 
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RustedFox

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We have very few sicklers, maybe 5-8. And most of them are established with our Hematology group. So I wonder if we adopted a similar policy whether our Heme/Onc docs would hear about it in clinic, and thus get mad at us. Maybe we need to involve them if we make a department policy on IV narcotic use.
I'm all for the protocol-based approach to this problem. I have a few sickle-cell patients that are regulars at my home-base shop.

Unfortunately, I know of one physician who was canned for the "Toradol and the door" approach. No joke. This was brought up during his meeting with admin about why they were terminating him. It doesn't help that admin is all about "patient satisfaction" and the clientele frequently confuse the hospital for the Hilton.
 
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