I hate you, muggles.

[RustedFox]

Yep. 3:30 AM.

Chief Complaint: "I think my girl gotta UTI."

Sure, simple enough.

I walk into the room, interrupting intimacy.

"Hi. I'm Dr. RustedFox. I can wait until you're done if you'd like."

Nawww, doc. It burn when she pee.

"Sure. Can you get out of the hospital bed and we can conduct a proper [ffuucking] history and physical exam?"

Nawww.... it dun matter (she said, not stopping from kissing him and reaching into the front of his pants).

It didn't matter to me. UA/UCG.

UTI.

"Okay, here are your prescriptions. Let's get you home safely."

They seriously wanted me to wait for them to stop making out.

I called security.

In the words of GeneralVeers: 'When you make something free, demands become infinte.'

---

Members don't see this ad.

 

[thegenius]

Reminds me of a young Type 1 diabetic woman in DKA. My colleague was taking care of her.

Her bicarb was 5, pH was 6.8. I asked him "is she still alive? You going to tube her?"

he responded "she wasn't all that bad....I take a look at her again."

I followed him into the room.

She was mildly encephalopathic and would attend to questions but wasn't saying much.

We look at her body, and see she had her hand down her pants - masturbating.

I slowly put a bed sheet over her legs and body, covered her up and we walked out.

"I think it takes bilateral brain function to coordinate masturbation. She'll be OK."

 

[Birdstrike]

"I think it takes bilateral brain function to coordinate masturbation. She'll be OK."

That's actually not true. It only takes lizard brain.

 

[RustedFox]

I put (record, no exaggeration) 6 central lines into one specific "party girl" (Type-1 DM, loved cocaine) at the shop where I used to work with dchristismi. Yep. I'm going to estimate that she has had 18+ central lines given her history. Did she ever pay a dime for her care?



No.


But you did. and I did.


#let her die?

 

[Lawpy]

Man I love the EM forums

 

[RustedFox]

#deathpanels.

Veers and I will be happy to sit upon the death panel.

*Oooh,Nooo* cry the liberals. She has a *disease* that must be *met with resources*.

Guess what, bitches?

We have met it with all the resources that we 'got.

T-minus ten posts before "Godwin's Law" applies.

Goodnight, amigos. I'm exhausted after a shift of resuscitating people who want to die.

 

[enalli]

#deathpanels.

Veers and I will be happy to sit upon the death panel.

*Oooh,Nooo* cry the liberals. She has a *disease* that must be *met with resources*.

Guess what, bitches?

We have met it with all the resources that we 'got.

T-minus ten posts before "Godwin's Law" applies.

Goodnight, amigos. I'm exhausted after a shift of resuscitating people who want to die.

You're now on the death panel for your DM/Cocaine patient. Assuming we're starting from scratch, how many free central lines, if any, does she get?

 

[GeneralVeers]

#deathpanels.

Veers and I will be happy to sit upon the death panel.

*Oooh,Nooo* cry the liberals. She has a *disease* that must be *met with resources*.

Guess what, bitches?

We have met it with all the resources that we 'got.

T-minus ten posts before "Godwin's Law" applies.

Goodnight, amigos. I'm exhausted after a shift of resuscitating people who want to die.

That's two for the death panel then!

I suggest we start with the question: "Society has already expended vast resources on you. What contribution have you made back to society that would make us consider expending even more? Getting pregnant, missing dialysis appointments, and repeatedly overdosing on drugs/alcohol do not constitute a contribution"

 

[enalli]

That's two for the death panel then!

I suggest we start with the question: "Society has already expended vast resources on you. What contribution have you made back to society that would make us consider expending even more? Getting pregnant, missing dialysis appointments, and repeatedly overdosing on drugs/alcohol do not constitute a contribution"

More details, please.

Is this decision made at the bedside by the physician? If so, can a midlevel make the same call? How much "free" care is too much?

 

[Birdstrike]

I had a couple that were pretty sure they were actually having sex under the sheet in an ED hallway bed, but by the time we got to them they had stopped enough that we didn't really have the energy to kick them out over it. It's pretty hard to imagine you're coding or septic if you're doin' the nasty in an ED hold bed under a sheet. In fact, it guarantees you'll outlive everyone else with a supra-invertebrate brain and not infested with such epic skull--ckery.

Only in the ED can you do this kind of stuff and people blow it off, like, Damn, its 4 am, this place is such a ---ing circus and this is not even the most insane thing I've scene this shift let alone month. I'm too tired to make a big deal out of this malarky. "Just take your discharge instructions and get out. Get out!" Now imagine someone does this in a primary care office, a restaurant or Costco. Police would be painfully hog-tying them within minutes and throwing them in the back of the paddy wagon, with no remorse. No way anyone else other than the ED would put of with this level of bovine scatology.

 

[njac]

That's actually not true. It only takes lizard brain.

Definitely this.

We’ve named it at our shop.

“nah, he’s still got a positive *insertnamehere* sign”

 

[RustedFox]

You're now on the death panel for your DM/Cocaine patient. Assuming we're starting from scratch, how many free central lines, if any, does she get?

Three strikes and you're out.

You want to end your life with your behavior? Don't let me get in the way.

We have too many people on this planet. You can't buy a house in SF for less than a few million dollars, and people in China are living in cages stacked atop one another (saw an article about this with pictures of old men living in cubicle-sized spaces with chain-link fences between them).

21 Harrowing Images Of Life Inside Hong Kong's Tiny Cage Homes

#thintheherd.

 

[RustedFox]

There's a standing joke between me and my wife (she is a former research biochemist for Merck/GSK) about how she is secretly developing an "@sshole flu" that is fatal to all the @ssholes out there to thin the herd.

I said this at work one day and got a few chuckles except for one PA who herself is exceptionally funny:

"Well... what if you're kind of an @sshole? Do you just get real sick? 'Cause I feel like I can be kind of an @sshole sometimes, but not overall."

I laughed for three minutes straight.

 

[throwaway90210]

for each government handout one should lose a freedom. bleeding heart liberals dont have enough sense to realize you cannot make everything free and without consequences. you cant give free things to those with a mind less able than a 5 year olds and expect good things to happen. but this is america so whatever just dont expect me to pay more taxes to fund your bleeding heart

 

[RustedFox]

The one thing that millennials are getting right is not having kids.
Can't feed 'em, don't breed 'em.

 

[RustedFox]

Listening to talk radio now:

"A Florida woman was treated for self-inflicted abdominal stab wounds after telling authorities that she 'didn't want to live in Trump's country anymore'."

Okay. Have fun. Don't let us get in your way.

 

[RustedFox]

More details, please.

Is this decision made at the bedside by the physician? If so, can a midlevel make the same call? How much "free" care is too much?

1. No. The decision is made several months after the fact by a crew of administrators between 9:30 AM and 3 PM, with an hour and a half for a catered lunch. No physicians are permitted to sit on the committee. Because that's how we do things in America. We put people who don't have a clue about patient care in charge of patient care, and they need to be paid a lot of money to do very little.

2. After reading my last batch of MLP charts for signature, I'm pretty sure that they can't click buttons on a computer screen correctly despite multiple attempts at instruction... let alone make a decision regarding when to appropriately withhold care. I'll say it again: If you cannot SPELL correctly, I doubt your capacity to read, and thus your capacity to do much of anything important. If I read one more HPI that says: "Patient cant breath", I might throw a dictionary at the nearest MLP. Without exaggeration, I signed 23 MLP charts last shift. I am refusing to sign 7 of them until some indefensible omission is corrected (like... vital signs... a physical exam of the relevant body part/system... a diagnosis... etc.) This comes AFTER a call from corporate letting us know that our charting and billing is "exemplary for what not do do".

3. "Free" care becomes too much whenever we are involuntarily forced to pay for it all. I'm a charitable human, and I'll give a lot willingly. Point a gun at me and tell me to pay or else face the wrath of tax crimes? That's too much.

 

[scummie]

Many, many valid points in this thread. I don’t think M4A as Sanders has defined it is sustainable at all. We must have some level of cost sharing or you end up with the effects of moral hazard like the cases described here. I also greatly dislike these outcome measures when patient compliance has a huge role. Don’t get me wrong, the system is broken and has tons of holes. Simply opening up the doors of hospitals like a free for all is not the answer. As my mother said, and still says, “Take some responsibility!”

You want to do drugs, smoke, or dare I say, live a healthy lifestyle and reduce risk factors? Fine, let’s change your premiums and see how that effects consumer behavior. Godforbid we tell people to lose weight to improve their health.

 

[Vandalia]

#deathpanels.

Veers and I will be happy to sit upon the death panel.

*Oooh,Nooo* cry the liberals. She has a *disease* that must be *met with resources*.

The only problem is that the opposition to "deathpanels" came from the conservative, "natural conception to natural death" crowd. The liberals I know - admittedly few - would love the "deathpanels" to reduce the human footprint so there is more room on the planet for salamanders.

 

[RustedFox]

The only problem is that the opposition to "deathpanels" came from the conservative, "natural conception to natural death" crowd. The liberals I know - admittedly few - would love the "deathpanels" to reduce the human footprint so there is more room on the planet for salamanders.

Is that so?
Hmm.
Well, I like most salamanders more than most people.

 

[bravotwozero]

I had a couple that were pretty sure they were actually having sex under the sheet in an ED hallway bed, but by the time we got to them they had stopped enough that we didn't really have the energy to kick them out over it. It's pretty hard to imagine you're coding or septic if you're doin' the nasty in an ED hold bed under a sheet. In fact, it guarantees you'll outlive everyone else with a supra-invertebrate brain and not infested with such epic skull--ckery.

Only in the ED can you do this kind of stuff and people blow it off, like, Damn, its 4 am, this place is such a ---ing circus and this is not even the most insane thing I've scene this shift let alone month. I'm too tired to make a big deal out of this malarky. "Just take your discharge instructions and get out. Get out!" Now imagine someone does this in a primary care office, a restaurant or Costco. Police would be painfully hog-tying them within minutes and throwing them in the back of the paddy wagon, with no remorse. No way anyone else other than the ED would put of with this level of bovine scatology.

Mad props on your use of bovine scatology. Well played sir.

 

[Birdstrike]

There's a standing joke between me and my wife (she is a former research biochemist for Merck/GSK) about how she is secretly developing an "@sshole flu" that is fatal to all the @ssholes out there to thin the herd.

I said this at work one day and got a few chuckles except for one PA who herself is exceptionally funny:

"Well... what if you're kind of an @sshole? Do you just get real sick? 'Cause I feel like I can be kind of an @sshole sometimes, but not overall."

I laughed for three minutes straight.

I like the way you and Mrs. Fox think. But there’s a flaw in your plan:

Total a-holes are cosmically immune to dying young and tragically. They get your specially engineered virus and survive by calling upon their reserves of sheer a$sholery, all while the virus is mutating into a form that kills only the kind, blameless, innocent and young. Then, after surviving and spreading the virus to the young, elderly, weak and infirm, the a-holes look around and are so overjoyed that being shameless as$hats has again protected them from senseless tragedy, they breed out of sheer bliss, repopulating the world with uncountable little stinkstar clones of themselves.

They survive, you get sick and check into the ICU and the cycle repeats.

 

[thegenius]

for each government handout one should lose a freedom. bleeding heart liberals dont have enough sense to realize you cannot make everything free and without consequences. you cant give free things to those with a mind less able than a 5 year olds and expect good things to happen. but this is america so whatever just dont expect me to pay more taxes to fund your bleeding heart

I do think there should be stricter criteria on deciding those who want to be on dialysis, get pacemakers, and trachs / pegs.

 

[throwaway90210]

Many, many valid points in this thread. I don’t think M4A as Sanders has defined it is sustainable at all. We must have some level of cost sharing or you end up with the effects of moral hazard like the cases described here. I also greatly dislike these outcome measures when patient compliance has a huge role. Don’t get me wrong, the system is broken and has tons of holes. Simply opening up the doors of hospitals like a free for all is not the answer. As my mother said, and still says, “Take some responsibility!”

You want to do drugs, smoke, or dare I say, live a healthy lifestyle and reduce risk factors? Fine, let’s change your premiums and see how that effects consumer behavior. Godforbid we tell people to lose weight to improve their health.

but that would be fat shamming says the goodie two shoes. Fat people are not to blame for their weight its all "genetic" has nothing to do with that whopper they just threw down

 

[Birdstrike]

but that would be fat shamming says the goodie two shoes. Fat people are not to blame for their weight its all "genetic" has nothing to do with that whopper they just threw down

Everyone is a victim of something or someone. No one ever has any responsibility for their lot in life, ever.

Or so some will try to get you to believe.

 

[EsTxDr]

I put (record, no exaggeration) 6 central lines into one specific "party girl" (Type-1 DM, loved cocaine) at the shop where I used to work with dchristismi. Yep. I'm going to estimate that she has had 18+ central lines given her history. Did she ever pay a dime for her care?



No.


But you did. and I did.


#let her die?

I need coffee, switching from night shifts here.

I spent an embarrassingly long amount of time trying to figure out where in the hell you would have placed all those central lines. I was like damn these guys are better than me, I could only fit maybe 4 or 5 central lines in one person.

 

[Apollyon]

but that would be fat shamming says the goodie two shoes. Fat people are not to blame for their weight its all "genetic" has nothing to do with that whopper they just threw down

White and black folks on the mainland say, "It's genetic", while two-fisting hot dogs at a baseball game.

When I was in Hawai'i, people would say, "I eat too much", but, as my former medical director said, he had at least two patients over 500lbs, who had no heart disease, not diabetic, not hyperlipidemic, and no hypertension.

 

[deleted109597]

When I was in Hawai'i, people would say, "I eat too much", but, as my former medical director said, he had at least two patients over 500lbs, who had no heart disease, not diabetic, not hyperlipidemic, and no hypertension.

"yet"
The polynesians certainly suffer the ravages of T2DM, and it's the scourge of the south pacific.

 

[Groove]

I need coffee, switching from night shifts here.

I spent an embarrassingly long amount of time trying to figure out where in the hell you would have placed all those central lines. I was like damn these guys are better than me, I could only fit maybe 4 or 5 central lines in one person.

Was this because of difficult access? I don't even bother with central lines in these people anymore. I place an EZ IJ and let them consult PICC team on the floor. Saves me a lot of time.

 

[scummie]

White and black folks on the mainland say, "It's genetic", while two-fisting hot dogs at a baseball game.

When I was in Hawai'i, people would say, "I eat too much", but, as my former medical director said, he had at least two patients over 500lbs, who had no heart disease, not diabetic, not hyperlipidemic, and no hypertension.

I’ve had the GERD, pancreatitis, cholelithiasis, HTN, asthma, etc talk with people. I’ve been very open and said “You could change these behaviors or you’ll end up on X medication.” Lose some weight and you won’t need 4 anti-hypertensives and metformin. Stop drinking coffee and eat smaller meals and you won’t need Pepcid or a PPI. Stop smoking and I won’t have to prescribe you your third albuterol inhaler this month. Maybe 9 out of 10 times they say “Doc, just write me for the prescription.”

 

[Apollyon]

"yet"
The polynesians certainly suffer the ravages of T2DM, and it's the scourge of the south pacific.

Well, when the pts are normoglycemic, I don't know where you get the "yet". These pts were enormous, with stone cold normal labs.

 

[deleted109597]

Well, when the pts are normoglycemic, I don't know where you get the "yet". These pts were enormous, with stone cold normal labs.

As in, they won't be forever. I don't disagree that they are that way now.

 

[thegenius]

Was this because of difficult access? I don't even bother with central lines in these people anymore. I place an EZ IJ and let them consult PICC team on the floor. Saves me a lot of time.

What is an EZ IJ? Just like a long peripheral IV placed in the IJ?

You use US to do this? Or go by landmarks

 

[BoardingDoc]

What is an EZ IJ? Just like a long peripheral IV placed in the IJ?

You use US to do this? Or go by landmarks

Long 18 in the IJ. I use U/S. Chloraprep the neck in a wide area. Sterile probe cover and gloves. No drape. IV in. Gloves on to gloves off in 2 minutes.

 

[EsTxDr]

Was this because of difficult access? I don't even bother with central lines in these people anymore. I place an EZ IJ and let them consult PICC team on the floor. Saves me a lot of time.

That was mostly sarcasm because I read his post as putting 6 lines in the same person at one time. But yes, difficult access is one of the major reasons I place them these days. I'll still place one in the multiple pressers, terrible DKA, post code, etc. The amount of time I have to place lines is much less than I expected as a resident.

I haven't done the EZ IJ yet, guess I should look into it.

 

[thegenius]

Long 18 in the IJ. I use U/S. Chloraprep the neck in a wide area. Sterile probe cover and gloves. No drape. IV in. Gloves on to gloves off in 2 minutes.

So at your hospital (not necessarily your ER)...is this an accepted IV for an indeterminate amount of time...or
- do hospitalists get upset with it
- do ICU docs get upset with it
- do ICU docs ask you to change it out for a central line
- do you run contrast through it? do the radiology techs get nervous about that?
- you run pressors, KCl, D50, and other hyperosmolar agents through it?

Seems like a great thing for poor access, dialysis patients, sicklers, etc. But I'm just wondering if our hospital or hospitalists would get all up in a tizzy if I did this.

 

[Groove]

What is an EZ IJ? Just like a long peripheral IV placed in the IJ?

You use US to do this? Or go by landmarks

Same technique as @BoardingDoc except that ours are 20g 1.8” angiocaths. I place them all the time. No issues with admitting docs, rads or ICU.

 

[thegenius]

Same technique as @BoardingDoc except that ours are 20g 1.8” angiocaths. I place them all the time. No issues with admitting docs, rads or ICU.

Can you get high enough flow rates through a long 20g PIV? Good enough to do angiography....which I think you need to get at least 4 cc/sec for flow.

If the internal carotid is about 2-2.5 cm deep on the US, is that still OK for using these long PIVs? For instance sometimes when I put them in the basilic vein....it’s deep enough that they can wiggle themselves out and become dislodged.

 

[Groove]

Can you get high enough flow rates through a long 20g PIV? Good enough to do angiography....which I think you need to get at least 4 cc/sec for flow.

If the internal carotid is about 2-2.5 cm deep on the US, is that still OK for using these long PIVs? For instance sometimes when I put them in the basilic vein....it’s deep enough that they can wiggle themselves out and become dislodged.

Rads hasn’t given me any issues with CTAs through the EZ IJs but you should prob check with your department. My pt’s have blubber necks down here and I tailor my technique as to avoid extravasation. I’ll go hyperacute until cannulation and then level it out. It’s rare for any of mine to come out but it does happen on rare occasion...usually from the pt moving around too much. I’d honestly prefer 2.5” catheters but 1.8 works fine. There were two pretty decent studies on the EZ IJ and one used 1.8“ and the other 2.5” I believe. They are good for 24-48h. I feel it’s the perfect solution for these difficult access people where all you really need is a workable IV. CVL seems so overkill on those.