Normal patients

[GeneralVeers]

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I had a question that is along the lines of the original thread topic. On the rare occasions you do see a "normal" patient, do you notice that they actually tend to be sick more often than the normal clientele? Its a trend I've noticed at the ER I transport to as a medic and observe in, was curious if anyone else sees this.

Yes. Every time I walk out of a room thinking "gee that was a nice patient" it makes me worry, because they usually have some sort of horrible incurable cancer.

 

[Pharmavixen]

I had a hernia repair a couple of years ago, no problems except I was overdosed on opioids post-op. Talking to the docs at work, both of them had similar experiences with minor surgery. We've decided that when "normal" people end up in hospital, they can end up overdosed with opioids because the the "regular" patients you see creates a bias where you tend to overestimate opioid tolerance.

This is what I mean: when I had an abdominal laparoscopy, they offered me 15mg morphine post-op, and I said, that's ridiculous for a such a little tiny cut. The nurse let me choose, and anyway, I had total pain relief from 3mg morphine.

I'd be curious to hear your perspectives on how the treatment of "normal" pts can be affected by skewed perceptions created by your "regular" pts.

 

[GeneralVeers]

I had a hernia repair a couple of years ago, no problems except I was overdosed on opioids post-op. Talking to the docs at work, both of them had similar experiences with minor surgery. We've decided that when "normal" people end up in hospital, they can end up overdosed with opioids because the the "regular" patients you see creates a bias where you tend to overestimate opioid tolerance.

This is what I mean: when I had an abdominal laparoscopy, they offered me 15mg morphine post-op, and I said, that's ridiculous for a such a little tiny cut. The nurse let me choose, and anyway, I had total pain relief from 3mg morphine.

I'd be curious to hear your perspectives on how the treatment of "normal" pts can be affected by skewed perceptions created by your "regular" pts.

On normal patients I typically have a lower threshold for ordering imaging studies, as they usually will not come to the hospital unless they are actually sick.

I also tend to give them less pain medication, since I know I can titrate it reliably. Normal people will tell me honestly if they are still having pain, versus a narcotics seeker who wants an infinite amount.

 

[Arcan57]

On normal patients I typically have a lower threshold for ordering imaging studies, as they usually will not come to the hospital unless they are actually sick.

I also tend to give them less pain medication, since I know I can titrate it reliably. Normal people will tell me honestly if they are still having pain, versus a narcotics seeker who wants an infinite amount.

I still find it very difficult to distinguish people with exceptionally low pain tolerance from addicts. Which leads to prescribing the wrong medication to the patient(ie. dilaudid instead of testosterone).

 

[Jeff698]

I'd be curious to hear your perspectives on how the treatment of "normal" pts can be affected by skewed perceptions created by your "regular" pts.

I absolutely agree. I had a 69 y/o woman with a distal radius fx today. She's athletic (FOSH while playing tennis). I ordered 10 of morphine as I'm walking out the door, thinking it would be the first of several doses.

My nurse, having spent more than 2 minutes in the room with her, kindly suggested we perhaps start with a smaller dose. After 2 mg, she's was happy as a clam.

So many of my patients take dilaudid like I drink diet coke, I do get skewed. I'd never really thought of it though. Thanks for bringing it up.

Take care,
Jeff

 

[deleted109597]

My anesthesiologist actually told me yesterday that the reason I didn't want any pain meds was because I was still not fully out of anesthesia. They tried to force me to take some percocet before going home.
I'm really not trying to be a badass, it just doesn't hurt (at least not anymore than it did before durgery, when I wasn't using narcotics either.)

 

[Stitch]

Yes. Every time I walk out of a room thinking "gee that was a nice patient" it makes me worry, because they usually have some sort of horrible incurable cancer.

So true. Happened to me just last night. 🙁

 

[docB]

I had a question that is along the lines of the original thread topic. On the rare occasions you do see a "normal" patient, do you notice that they actually tend to be sick more often than the normal clientele? Its a trend I've noticed at the ER I transport to as a medic and observe in, was curious if anyone else sees this.

I do see that but I also see an awful lot of normal patients who are dumped into the ED by their PMDs for tests that would be inconvenient to get approved as an out patient, eg. on and off belly pain for 6 months that "somehow" needed an "emergent" CT at 4:45pm on a Friday🙄.

 

[GeneralVeers]

I do see that but I also see an awful lot of normal patients who are dumped into the ED by their PMDs for tests that would be inconvenient to get approved as an out patient, eg. on and off belly pain for 6 months that "somehow" needed an "emergent" CT at 4:45pm on a Friday🙄.

My favourite is: "My doctor sent me here because my sugar was high..."

 

[Jeff698]

My favourite is: "My doctor sent me here because my sugar was high..."

..."because my blood pressure was high" (asymptomatic at 190/90).

Take care,
Jeff

 

[DrMom]

..."because my blood pressure was high" (asymptomatic at 190/90).

Take care,
Jeff

And then they get upset that you're not panicking and giving them a bazillion meds to bring it down because their PCP told them they could stroke out.

My favorite are the CC: HTN
Triage BP 142/85, no other complaints
At least they are an easy in and out.

 

[docB]

..."because my blood pressure was high" (asymptomatic at 190/90).

Take care,
Jeff

I got into a fight with a PMD recently about this. He sent in a guy from his office who was 215/110 refractory to his four antihypertensives with a complaint of "dissiness." I gave him some Labetalol and worked him up. His Cr was 2.7 so I call this yahoo to admit. He doesn't want to admit. Says the guys Cr is always like that and I should send him home and he'll see him again in 2 days. Ok, whatever, if it really is all chronic then I'm ok with outpatient but I ask this doc what med changes he wants me to make. He didn't want to make a decision, he wanted to make it for him. Well, I don't know what the fifth line antihypertensive for this guy should be so I kept pushing back. "Look, the point of sending this guy down here was to get his BP down which I did with IV Labetalol which he can't go home on. Now what do you want for an additional med?" I asked. "No. The point was to not have him stroke out in my office." he replied. He eventually settled on clonidine (whatever) and then complained to administration that I was not being collegial. Jerk!

 

[GeneralVeers]

I got into a fight with a PMD recently about this. He sent in a guy from his office who was 215/110 refractory to his four antihypertensives with a complaint of "dissiness." I gave him some Labetalol and worked him up. His Cr was 2.7 so I call this yahoo to admit. He doesn't want to admit. Says the guys Cr is always like that and I should send him home and he'll see him again in 2 days. Ok, whatever, if it really is all chronic then I'm ok with outpatient but I ask this doc what med changes he wants me to make. He didn't want to make a decision, he wanted to make it for him. Well, I don't know what the fifth line antihypertensive for this guy should be so I kept pushing back. "Look, the point of sending this guy down here was to get his BP down which I did with IV Labetalol which he can't go home on. Now what do you want for an additional med?" I asked. "No. The point was to not have him stroke out in my office." he replied. He eventually settled on clonidine (whatever) and then complained to administration that I was not being collegial. Jerk!

I think I know that doctor......

 

[southerndoc]

I got into a fight with a PMD recently about this. He sent in a guy from his office who was 215/110 refractory to his four antihypertensives with a complaint of "dissiness." I gave him some Labetalol and worked him up. His Cr was 2.7 so I call this yahoo to admit. He doesn't want to admit. Says the guys Cr is always like that and I should send him home and he'll see him again in 2 days. Ok, whatever, if it really is all chronic then I'm ok with outpatient but I ask this doc what med changes he wants me to make. He didn't want to make a decision, he wanted to make it for him. Well, I don't know what the fifth line antihypertensive for this guy should be so I kept pushing back. "Look, the point of sending this guy down here was to get his BP down which I did with IV Labetalol which he can't go home on. Now what do you want for an additional med?" I asked. "No. The point was to not have him stroke out in my office." he replied. He eventually settled on clonidine (whatever) and then complained to administration that I was not being collegial. Jerk!

What about PO labetalol?

 

[Speed Racer]

I do see that but I also see an awful lot of normal patients who are dumped into the ED by their PMDs for tests that would be inconvenient to get approved as an out patient, eg. on and off belly pain for 6 months that "somehow" needed an "emergent" CT at 4:45pm on a Friday🙄.

You mean like yesterday when I started getting PMD referrals to the ED (Friday afternoon at 2pm, Duh!) at the rate of 3/hour for HA, HA, Fever, Needs an emergent lower back MRI.

F&*K not to be too morbid. But has our specialty become a joke? We are the 24hour convenience store of doctors?

 

[WilcoWorld]

I think I may have mentioned it here before, but the most infuriating ED referral I've had was for a G-tube REMOVAL on a nursing home patient that was sent to the ED at 10pm on a (really busy) Saturday night. I called the PMD to explain that this likely didn't require ambulance transfer to the ED and he responded, "Why, aren't you guys open on weekends?"

grrrrr

 

[docB]

I think I know that doctor......

You probably do.

What about PO labetalol?

Guy was already on 100 of po Lopressor bid, and Norvasc and Lasix and an ace and one other class. I was really looking for a dosage change or maybe hydralazine. I really wasn't looking to make the call totally on my own.

You mean like yesterday when I started getting PMD referrals to the ED (Friday afternoon at 2pm, Duh!) at the rate of 3/hour for HA, HA, Fever, Needs an emergent lower back MRI.

F&*K not to be too morbid. But has our specialty become a joke? We are the 24hour convenience store of doctors?

Are we a joke? Maybe. We definitely get treated like other doctor's interns. Who else has had docs call up and ask you to go upstairs to do nasal packings, central lines, chest tubes, etc.?

I think I may have mentioned it here before, but the most infuriating ED referral I've had was for a G-tube REMOVAL on a nursing home patient that was sent to the ED at 10pm on a (really busy) Saturday night. I called the PMD to explain that this likely didn't require ambulance transfer to the ED and he responded, "Why, aren't you guys open on weekends?"

grrrrr

Yeah we're open. And, to our discredit, we like the money we make on those patients. Believe me no administrator will ever tell a doc not to send a full insured nursing home patient (and one =s the other) to the ED for any reason.

 

[dchristismi]

Are we a joke? Maybe. We definitely get treated like other doctor's interns. Who else has had docs call up and ask you to go upstairs to do nasal packings, central lines, chest tubes, etc.?

This happens occasionally, and usually the calling physician is very nice about it. IME, it's someone already on bipap who is crumping at 5am, and they recognise our mad airway skilz. (I arrived once to find an oncologist futzing around who, while a really nice guy, hadn't actually intubated someone in decades. He was glad to see me.

My personal goal is to try to get whoever called me to ask this favor admit SOMEONE while I have them on the phone in exchange for the tube. Chances are, it's one of our pulmonary guys calling (from home), and I always have a COPDer or two needing to come in.
(But nasal packing? Central lines? Call someone else. We just do airway and codes)

 

[GeneralVeers]

My personal goal is to try to get whoever called me to ask this favor admit SOMEONE while I have them on the phone in exchange for the tube. Chances are, it's one of our pulmonary guys calling (from home), and I always have a COPDer or two needing to come in.
(But nasal packing? Central lines? Call someone else. We just do airway and codes)

I've done nasal packing, but only because I get to bill for it (we have a separate "consult log" where we keep track of this). I only do it for hospitalists I like who admit my patients without arguing.

As for central lines, no. Rarely is a line needed emergently, and if there are complications or problems with the line then you are responsible.

 

[leviathan]

I've done nasal packing, but only because I get to bill for it (we have a separate "consult log" where we keep track of this). I only do it for hospitalists I like who admit my patients without arguing.

As for central lines, no. Rarely is a line needed emergently, and if there are complications or problems with the line then you are responsible.

Are you not able to bill for a central line, or is just that the risk is too high?

 

[GeneralVeers]

Are you not able to bill for a central line, or is just that the risk is too high?

I can bill for one, but often the ICU/hospitalists will request one non-emergently.

It's an invasive procedure and has known complications (pneumothorax, arterial injury, line infection). If it's a patient not directly under my care, and not emergent I am not going to take the risk of doing it. It also takes significant time away from the ER to do one as well.