Patients love dramatic nonsense.

[RustedFox]

Had a patient last night; 27 year old female who had already been seen on 3 prior occasions in 6 days time at the ER for the precise same constellation of symptoms:

"My throat is closing!"
"I am numb around my mouth and in my hands!"
"I have this dry cough and it hurts to breathe."

Totally healthy. Five-star negative exam. Been worked up to the nines including CT neck (during her last visit) to prove to her that her throat wasn't closing (I'm sure her thyroid thanked her for that needless radiation dose). Rx'd medrol dose-pack, benadryl/pepcid, etc. I read the prior 3 notes and am amazed at the amount of time, effort, and money that has already been wasted on a big nothing.

She's back, and is reporting the same symptoms. The common theme among all these visits is that they moved into a new apartment and there might be "black mold"... somewhere. Or, that she has an "allergic reaction!" to... whatever.

I tried to explain that none of her symptoms were consistent with any immune dysregulation that would constitute an "allergic" reaction, and that (yeah, admittedly so), she may be experiencing an environmental irritant that will lessen and go away with time/ventilation of the space/whatever. She's having none of it and demands an EpiPen! to save her LIFE should she have so much as a whiff of recurrent symptoms (none of which involve wheezing/stridor/urticaria/angioedema/anaphylaxis).

Again, I explain... irritants are not allergens. None of your symptoms are consistent with allergic reaction.

Now, husband shows up. He actually *cries* in the exam room because he loves her so much and "this is how your FAITH is TESTED" and whatever. I reiterate that medicine isn't faith-based, and that there's no evidence of an allergic reaction here.

"But.... what TESTS are you going to DO to SOLVE the MYSTERY!"

I do the right thing. This time, the right thing to do is nothing.

"We do not offer allergen or irritant testing in the emergency department. The right thing to do here is to give you the calm reassurance that the symptoms are certainly not indicative of an emergent condition, and to refer you to the appropriate physician. Also; your symptoms are yes - likely to go away by themselves."

I'll probably field a patient complaint about this one. There's not a single test I could order/repeat, or any magic beans that I could throw at them to get them to go away happy.

They just want drama.


....



The number-one source of burnout is.... the patient.



Also, if you want a great formula for a hysterical and generally unfounded patient fear, just combine a color with a microbe, or a condition. Bonus points if you include a logical paradox.

Black Mold !
Red Tide !
Yellow Fever !
Green Slime !
Dry Drowning !
White... uhh... Walkers !

---

Members don't see this ad.

 

[southerndoc]

In situations like this, I usually send some ridiculous send-out test (like complement factor), tell them the test may take a week to come back, and refer them to a pcp for follow-up of such test. A little Geodon too.

 

[Birdstrike]

Had a patient last night; 27 year old female who had already been seen on 3 prior occasions in 6 days time at the ER for the precise same constellation of symptoms:

"My throat is closing!"
"I am numb around my mouth and in my hands!"
"I have this dry cough and it hurts to breathe."

Totally healthy. Five-star negative exam. Been worked up to the nines including CT neck (during her last visit) to prove to her that her throat wasn't closing (I'm sure her thyroid thanked her for that needless radiation dose). Rx'd medrol dose-pack, benadryl/pepcid, etc. I read the prior 3 notes and am amazed at the amount of time, effort, and money that has already been wasted on a big nothing.

She's back, and is reporting the same symptoms. The common theme among all these visits is that they moved into a new apartment and there might be "black mold"... somewhere. Or, that she has an "allergic reaction!" to... whatever.

I tried to explain that none of her symptoms were consistent with any immune dysregulation that would constitute an "allergic" reaction, and that (yeah, admittedly so), she may be experiencing an environmental irritant that will lessen and go away with time/ventilation of the space/whatever. She's having none of it and demands an EpiPen! to save her LIFE should she have so much as a whiff of recurrent symptoms (none of which involve wheezing/stridor/urticaria/angioedema/anaphylaxis).

Again, I explain... irritants are not allergens. None of your symptoms are consistent with allergic reaction.

Now, husband shows up. He actually *cries* in the exam room because he loves her so much and "this is how your FAITH is TESTED" and whatever. I reiterate that medicine isn't faith-based, and that there's no evidence of an allergic reaction here.

"But.... what TESTS are you going to DO to SOLVE the MYSTERY!"

I do the right thing. This time, the right thing to do is nothing.

"We do not offer allergen or irritant testing in the emergency department. The right thing to do here is to give you the calm reassurance that the symptoms are certainly not indicative of an emergent condition, and to refer you to the appropriate physician. Also; your symptoms are yes - likely to go away by themselves."

I'll probably field a patient complaint about this one. There's not a single test I could order/repeat, or any magic beans that I could throw at them to get them to go away happy.

They just want drama.


....



The number-one source of burnout is.... the patient.



Also, if you want a great formula for a hysterical and generally unfounded patient fear, just combine a color with a microbe, or a condition. Bonus points if you include a logical paradox.

Black Mold !
Red Tide !
Yellow Fever !
Green Slime !
Dry Drowning !
White... uhh... Walkers !

Just drips with: "Anxiety."

In situations like this, I usually send some ridiculous send-out test (like complement factor), tell them the test may take a week to come back, and refer them to a pcp for follow-up of such test. A little Geodon too.

In other words, either:

A. Use medical facts, reason, and logical reassurance, or

B. Order a useless test dressed up as concerned compassion solely as a means of emotional persuasion.

We all know which one results in the irrational complaint letter that administration sides with 100% of the time, and which diffuses the anxiety long enough to hit the discharge button.

 

[RustedFox]

In situations like this, I usually send some ridiculous send-out test (like complement factor), tell them the test may take a week to come back, and refer them to a pcp for follow-up of such test. A little Geodon too.

Yeah; except all of us know that this is the wrong thing to do. Just like a PMD sending asymptomatic HTN to the ER because "you'll have a stroke!"

 

[Rendar5]

If it’s a repeat visit I tell them they’ve ordered every test available for me to order in the ED and unfortunately whatever is going on will need to go to a outpatient doctor for further testing since they have more testing available to them.

 

[southerndoc]

Yeah; except all of us know that this is the wrong thing to do. Just like a PMD sending asymptomatic HTN to the ER because "you'll have a stroke!"

Just returning the favor...

I rarely have to do this as most can be successfully treated with some vitamin G (Geodon).

 

[Stagg737]

You can always try and consult psych for confirmation of illness anxiety disorder and see how the patient reacts when we walk in the room. Have had 1 or 2 that were legit consults for panic disorder who got so insulted that they left and apparently never returned to that ED. Plus when that happens it's a fun note for me to write, as it's one of the times I get to quote expletives in the EMR.

 

[RustedFox]

You can always try and consult psych for confirmation of illness anxiety disorder and see how the patient reacts when we walk in the room. Have had 1 or 2 that were legit consults for panic disorder who got so insulted that they left and apparently never returned to that ED. Plus when that happens it's a fun note for me to write, as it's one of the times I get to quote expletives in the EMR.

Excuse me. I can "always" try to consult psych?

I can never consult psych.

K.Thx.Bye.

 

[Birdstrike]

You can always try and consult psych for confirmation of illness anxiety disorder and see how the patient reacts when we walk in the room. Have had 1 or 2 that were legit consults for panic disorder who got so insulted that they left and apparently never returned to that ED. Plus when that happens it's a fun note for me to write, as it's one of the times I get to quote expletives in the EMR.

Most EDs don't have an academic psych service from which pit docs can consult from, as most private practice psychiatrists of sound mind and body would never, ever, ever voluntarily take ED call. Most of them work on a strictly outpatient, cash pay basis. They'd be stupid to come to the ED fishing for consult dollars they'll never collect, when they can sit in their office and continue to let the money come to them.

 

[MechEDoc]

Excuse me. I can "always" try to consult psych?

I can never consult psych.

K.Thx.Bye.

Never seen a psychiatrist in the ED in > 2 years. They don't handle emergencies nor are they really that relevant anymore.

 

[bearstanley]

trying to convince people who want to be sick that they are actually well is a strange and frustrating experience.

 

[Birdstrike]

trying to convince people who want to be sick that they are actually well is a strange and frustrating experience.

Don't try too hard at this. Some people think they need to be sick.

 

[gamerEMdoc]

Never seen a psychiatrist in the ED in > 2 years. They don't handle emergencies nor are they really that relevant anymore.

In my 12 years of EM, I have never seen a Psychiatrist in the ED.

 

[RustedFox]

In my 12 years of EM, I have never seen a Psychiatrist in the ED.

Getting on 10 years in EM. Never seen psych in the ED. Also?! *in agreement, not distention*...Shut the ffuucckk up.

 

[RustedFox]

Getting on 10 years in EM. Never seen psych in the ED. Also?! *in agreement, not distention*...Shut the ffuucckk up.

Jesus. Sandwich oil is on the phone.


Fuuuuuck.

See you tomorrow

 

[Stagg737]

Seriously? Every ED I worked in/rotated through (10+, most of which were community or VA) could consult psych. Substance induced SI is easy money as it keeps the churn rate low. You all have really never worked anywhere where psych would take ED consults?

 

[InternistDO]

Seriously? Every ED I worked in/rotated through (10+, most of which were community or VA) could consult psych. Substance induced SI is easy money as it keeps the churn rate low. You all have really never worked anywhere where psych would take ED consults?

We can't even get a psychiatrist to come into the hospital where I'm on clinicals, nevermind the ED. And this is in a massive metropolitan area.

 

[gamerEMdoc]

Seriously? Every ED I worked in/rotated through (10+, most of which were community or VA) could consult psych. Substance induced SI is easy money as it keeps the churn rate low. You all have really never worked anywhere where psych would take ED consults?

No. There was a psych residency in my med school, they would come to the ED. But in my residency and career as an attending, I've never seen a psychiatrist in the ED. To be fair, both my residency and where I'm an attending now have phenomenal 24 hour support from psych coordinators and crisis intervention. But Psychiatrists don't set foot in the ED.

 

[southerndoc]

In my 12 years of EM, I have never seen a Psychiatrist in the ED.

We have a dedicated ED psychiatrist. He comes in the ER M-F during business hours and will dispo people, set up resources, etc. Great asset to our ER. It's unfortunate not all ER's have this resource available, but we're seeing 160,000 patients/year. There's no way we could have an ED psychiatrist available if we were seeing 60,000 patients/year.

 

[ridethecliche]

People having anxiety/panic attacks that get mad at you for telling them that they're having said attack will never cease to amuse me.

Never seen a psychiatrist in the ED in > 2 years. They don't handle emergencies nor are they really that relevant anymore.

Show us on the doll where the mean psychiatrist hurt you.

 

[WilcoWorld]

Had a patient last night; 27 year old female who had already been seen on 3 prior occasions in 6 days time at the ER for the precise same constellation of symptoms:

"My throat is closing!"
"I am numb around my mouth and in my hands!"
"I have this dry cough and it hurts to breathe."

Totally healthy. Five-star negative exam. Been worked up to the nines including CT neck (during her last visit) to prove to her that her throat wasn't closing (I'm sure her thyroid thanked her for that needless radiation dose). Rx'd medrol dose-pack, benadryl/pepcid, etc. I read the prior 3 notes and am amazed at the amount of time, effort, and money that has already been wasted on a big nothing.

She's back, and is reporting the same symptoms. The common theme among all these visits is that they moved into a new apartment and there might be "black mold"... somewhere. Or, that she has an "allergic reaction!" to... whatever.

I tried to explain that none of her symptoms were consistent with any immune dysregulation that would constitute an "allergic" reaction, and that (yeah, admittedly so), she may be experiencing an environmental irritant that will lessen and go away with time/ventilation of the space/whatever. She's having none of it and demands an EpiPen! to save her LIFE should she have so much as a whiff of recurrent symptoms (none of which involve wheezing/stridor/urticaria/angioedema/anaphylaxis).

Again, I explain... irritants are not allergens. None of your symptoms are consistent with allergic reaction.

Now, husband shows up. He actually *cries* in the exam room because he loves her so much and "this is how your FAITH is TESTED" and whatever. I reiterate that medicine isn't faith-based, and that there's no evidence of an allergic reaction here.

"But.... what TESTS are you going to DO to SOLVE the MYSTERY!"

I do the right thing. This time, the right thing to do is nothing.

"We do not offer allergen or irritant testing in the emergency department. The right thing to do here is to give you the calm reassurance that the symptoms are certainly not indicative of an emergent condition, and to refer you to the appropriate physician. Also; your symptoms are yes - likely to go away by themselves."

I'll probably field a patient complaint about this one. There's not a single test I could order/repeat, or any magic beans that I could throw at them to get them to go away happy.

They just want drama.


....



The number-one source of burnout is.... the patient.



Also, if you want a great formula for a hysterical and generally unfounded patient fear, just combine a color with a microbe, or a condition. Bonus points if you include a logical paradox.

Black Mold !
Red Tide !
Yellow Fever !
Green Slime !
Dry Drowning !
White... uhh... Walkers !

Just to be sure... are you saying that Red Tide isn't disgusting?

 

[deleted109597]

I've learned that IV haldol fixes a lot of this. Either it takes away the crazy, or it makes them have a dystonic reaction and they feel like leaving anyway. Win win.

 

[GeneralVeers]

I call these people "The Worried Well". Usually they have an enabling and/or frustrated spouse with them. It's generally a lose-lose situation for everyone involved. I usually just try to cut my time and losses and discharge them. Some people can never be convinced that they do not have a rare, as-yet-undiscovered diagnosis.

My personal faves are the meth-heads or undiagnosed schizos who believe there are bugs in their skin and come in for this! I explain to them that no known parasites in North American do what they claim these parasites are doing.....but it to no avail and I discharge a frustrated (usually screaming) patient.

 

[RustedFox]

Getting on 10 years in EM. Never seen psych in the ED. Also?! *in agreement, not distention*...Shut the ffuucckk up.

Lol.
I couldn't edit this last night because the phone became a giant, greasy mess. Apologies if anyone was offended.

 

[RustedFox]

Just to be sure... are you saying that Red Tide isn't disgusting?

Oh, its disgusting - but its not responsible for all the illnesses that muggles claim it to be responsible for, in the same manner as "black mold".

 

[WilcoWorld]

Oh, its disgusting - but its not responsible for all the illnesses that muggles claim it to be responsible for, in the same manner as "black mold".

aaah, gotcha

 

[Birdstrike]

Lol.
I couldn't edit this last night because the phone became a giant, greasy mess. Apologies if anyone was offended.

I was offended and I don't accept your apology.



Just kidding. I am actually a little offended you thought we were offended over that, though.

Actually, not really.

Rock on.

 

[thegenius]

Had a patient last night; 27 year old female who had already been seen on 3 prior occasions in 6 days time at the ER for the precise same constellation of symptoms:

"My throat is closing!"
"I am numb around my mouth and in my hands!"
"I have this dry cough and it hurts to breathe."

Totally healthy. Five-star negative exam. Been worked up to the nines including CT neck (during her last visit) to prove to her that her throat wasn't closing (I'm sure her thyroid thanked her for that needless radiation dose). Rx'd medrol dose-pack, benadryl/pepcid, etc. I read the prior 3 notes and am amazed at the amount of time, effort, and money that has already been wasted on a big nothing.

She's back, and is reporting the same symptoms. The common theme among all these visits is that they moved into a new apartment and there might be "black mold"... somewhere. Or, that she has an "allergic reaction!" to... whatever.

I tried to explain that none of her symptoms were consistent with any immune dysregulation that would constitute an "allergic" reaction, and that (yeah, admittedly so), she may be experiencing an environmental irritant that will lessen and go away with time/ventilation of the space/whatever. She's having none of it and demands an EpiPen! to save her LIFE should she have so much as a whiff of recurrent symptoms (none of which involve wheezing/stridor/urticaria/angioedema/anaphylaxis).

Again, I explain... irritants are not allergens. None of your symptoms are consistent with allergic reaction.

Now, husband shows up. He actually *cries* in the exam room because he loves her so much and "this is how your FAITH is TESTED" and whatever. I reiterate that medicine isn't faith-based, and that there's no evidence of an allergic reaction here.

"But.... what TESTS are you going to DO to SOLVE the MYSTERY!"

I do the right thing. This time, the right thing to do is nothing.

"We do not offer allergen or irritant testing in the emergency department. The right thing to do here is to give you the calm reassurance that the symptoms are certainly not indicative of an emergent condition, and to refer you to the appropriate physician. Also; your symptoms are yes - likely to go away by themselves."

I'll probably field a patient complaint about this one. There's not a single test I could order/repeat, or any magic beans that I could throw at them to get them to go away happy.

They just want drama.


....



The number-one source of burnout is.... the patient.



Also, if you want a great formula for a hysterical and generally unfounded patient fear, just combine a color with a microbe, or a condition. Bonus points if you include a logical paradox.

Black Mold !
Red Tide !
Yellow Fever !
Green Slime !
Dry Drowning !
White... uhh... Walkers !

Love your posts! You articulate, with wit and humor, what we all think in these situations.

"Black Gonorrhea!!" It's from Thailand, very dangerous strain.
Rainbow Fever! It's a combo of red, yellow, orange, green, and blue fevers. Only found on the Asteroid Belt between Mars and Jupiter! You might be the first known case of "Rainbow Fever!!!" Let me send this little used "Lucky Charms" Blood Test.

 

[GeneralVeers]

RustedFox is on a roll the past few days. I want what he's having.....

 

[thegenius]

Seriously? Every ED I worked in/rotated through (10+, most of which were community or VA) could consult psych. Substance induced SI is easy money as it keeps the churn rate low. You all have really never worked anywhere where psych would take ED consults?

We've got a psych doc we can consult during day hours. Helpful in certain situations. I think we are lucky in that respect.

We also use Telepsych, and some of those docs are extremely helpful. Sometimes the recs are not.

 

[southerndoc]

RustedFox is on a roll the past few days. I want what he's having.....

By that, do you mean a ton of dramatic patients?

 

[Rendar5]

By that, do you mean a ton of dramatic patients?

I think I got cursed by this thread. My shift after reading it ended with a woman at 6am who had a toothache but knows her body (yes you’re unique and only you know your body unlike everyone else)and has to have a ct because something is horribly wrong because the pain goes to her head and shoulder and chest but not currently. And her throat is closing up (it’s not) and her lymph nodes are all swollen (they’re not) and her face doesn’t look right (it’s perfectly symmetric) and it didn’t get better with 3 percocets. She already booked an appointment with her dentist at 4pm but couldn’t wait because obviously something horrible was happening. I couldn’t get out of the room for 20 minutes. I actually managed to convince her to abort the ct (even after the useless labs were drawn)

I went in with the paperwork to dc her. “Oh didn’t the nurse just tell you? I just called my ex husband on the phone and described the symptoms to him. He told me I really do need the CT”.

At that point it became my partners problem because my shift had ended.

 

[southerndoc]

@Rendar5 This would be an excellent use of a Star Trek tricorder obtained from eBay. One of these days I'm going to have the nerve to use one.

 

[ridethecliche]

RustedFox is on a roll the past few days. I want what he's having.....

Its apparently very greasy. And a slime phone may be a side effect!

@Rendar5 This would be an excellent use of a Star Trek tricorder obtained from eBay. One of these days I'm going to have the nerve to use one.

I want video.

 

[thegenius]

Love to get me a tricorder! I can pass it over someone's abdomen and say "you have hyperemesis cannabis syndrome! Look, it says it right here!" as I show them the tricorder with different color lights on it.

 

[The White Coat Investor]

In my 12 years of EM, I have never seen a Psychiatrist in the ED.

I've seen a psychiatrist in the ED, but the last time was 2009 in an academic hospital and it was a resident. It was pretty cool. A fair amount of what I admit might be able to be sent home if they could be evaluated in the ED by a psychiatrist instead of a crisis worker. But there's no money in it for anyone but the patient...

 

[tkim]

@Rendar5 This would be an excellent use of a Star Trek tricorder obtained from eBay. One of these days I'm going to have the nerve to use one.

I used one on a psych patient when I was a medic oh so long ago. Hit the sound effect button, circled it around her head, told her she needed special vitamins at the hospital. She hopped on the stretcher willingly. Cops on the call talked about for weeks.

 

[deleted836128]

I had a patient that claimed she couldn’t move her arms. She was like, 12. Parents were eating it up. I had a long day and instead of ordering a million dollar work up I told her I was going to try something to wake up the nerves. I just kinda swirled my hands around the air near her ears. Her eyes got wide and her mouth dropped in amazement as her left arm started slowwwwwly drifting upwards as if not in her control followed by the right. Then hit the DC and said GTFO.

 

[Shufflin]

Most EDs don't have an academic psych service from which pit docs can consult from, as most private practice psychiatrists of sound mind and body would never, ever, ever voluntarily take ED call. Most of them work on a strictly outpatient, cash pay basis. They'd be stupid to come to the ED fishing for consult dollars they'll never collect, when they can sit in their office and continue to let the money come to them.

This is true.

Worked at a hospital where there were contracted psychiatrists and psych NPs. We made the NPs cover the ED. Go to the ED and not get paid the $400 per hr cash we could be making in PP? Heck-to-the-no.... we're so shameless.