Signing EKGs

[docB]

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One of the techs asked me "Why do you always frown when I hand you and EKG?" Let me explain that for you.

We will accept as a given that I am pretty busy. I have not eaten in the last 8 hours or peed in the last 6. There are 10 charts in my to be seen rack and 10 more in my dispo rack. So I HIGHLY SUGGEST not arguing with me about my business, especially not right now.

All of my EDs have a policy that whenever an EKG is done it must be handed IMMEDIATELY to the doctor to interpret, sign and time that EKG so that the hospital and all of its agents and employees will be absolved of all liability in perpetuity regarding said EKG (initial here:____).

This ED sees ~140 patients per day. I am on an 11 am to 9 pm shift. A disproportionate number of those 140 come in during those hours, lets say ~90.

Of those ~70% will have EKGs. That's because unless you have an isolated ortho injury you're very likely to get an EKG on protocol. 20 yo F with "weak and dizzy?" you're getting and EKG. 55 yo with back pain, EKG. Visitor sitting in a chair the tech mistook for a patient, EKG. So that's ~63 EKGs during my shift. And that doesn't count the other random EKGs that show up on admitted holds that you want me to sign even though you know they are not mine because "Somebody has to sign it."

We are double covered during those hours so I will get at least half of those handed to me. That means that while I am trying to work I will be interrupted 31.5 times to sign your EKGs. Every 19 minutes, more than 3 times per hour I will have to quit what I'm doing and sign your EKG.

So clearly this is not conducive to my productivity and it is very irritating. That is why I frown every time you hand me an EKG.

 

[GeneralVeers]

I just make them wait until I am finished whatever task it is I'm doing, like dictating, writing a prescription, or speaking with a consultant. Unless the patient is having a STEMI, or their heart is literally exploding, I expect them to sit quietly and patiently until I have a moment to look at it and sign it.

 

[Arcan57]

I just make them wait until I am finished whatever task it is I'm doing, like dictating, writing a prescription, or speaking with a consultant. Unless the patient is having a STEMI, or their heart is literally exploding, I expect them to sit quietly and patiently until I have a moment to look at it and sign it.

I'm the approachable doc in my group, so even though there is a dedicated physician out at triage I still get most of the triage EKGs as well as the ones that come back directly to my area. I've learned to hate LBBB because that means instead of 10 seconds it will take 3 minutes for me to log into the records and find out if it's old. If by chance we don't have any old records, I'm then left with tracking down the patient and trying to determine if their story is plausible for an AMI. Other favorites include being asked "Do they need to come right back?" which is difficult to tell from a piece of paper.

If I'm working the major side I have about 15% fewer EKGs to sign, but I then get the fun of having the transfer phone. The powers that be have essentially decided that every outlying ED patient must be accepted personnally by us as the ED physician, which means a couple of times an hour I get a call from an OSH about a chest pain patient that has no EKG changes and no troponin bump because their cardiologist comes to our hospital.

This sets up a cascade as follows
1) They will take up an ED bed until I call their cardiologist to confirm that yes, the patient is still alive and on a heparin gtt, and then wait for the patient to go upstairs.
2) They will then tie up a monitored bed causing my patients in the ED needing a cardiac monitor to wait even longer to go upstairs.
3) This will increase our turn-around times as the waiting room fills up without anywhere to put them.
4) This will cause our Press-Ganey scores to nose-dive as the discharged patients that fill out the survey wait disproportionately longer to see a doctor because they aren't as sick
5) This will cause administration to threaten us (including the implied threat of losing the contract) because a low Press-Ganey obviously means we are bad doctors. They will also yell at us regarding cardiac monitor utilization
6) This will cause my average stress level at work to go up, making the various admistrative BS I have to do during a shift seem even more soul-crushing.

And with that the circle is completed.

Also, our hospital just bought us a 46" flat screen in our work room that is slaved to the OR board so we can tell if our surgeons are lying to us about being in the OR when we get a call regarding a transfer of a patient needing surgical services.

 

[dchristismi]

I was trying to explain this phenomenon to my mother, and came up with the Harrison Bergeron analogy.

Every 20 seconds, someone throws an EKG in my face and totally disrupts my thought process, just like the gifted people in the story have buzzers in their heads.

Ok, so maybe not every 20 seconds, but still.

It's still the best analogy I can think of, even if it does involving quoting Vonnegut.
I'm just glad I don't have to wear the mask or drag the weights around, as a doc of my stunning beauty and grace would require excessive handicapping.
🙂

 

[BJJVP]

I used to be the approachable one in my group but I think that is starting to change for some of the reasons listed above by others. EKGs are not helping the situation. EKGs are horrendously annoying, even when I am the one ordering them!

Not sure where I heard it but it's been said that the majority of missed MIs due to obvious EKG misinterpretations are a result of a distracted physician rather than a truly incompetent physician. I don't know if it was an actual study or just anecdotal but I easily can see how this happens.

Even a bunch of simple questions and requests in a constantly disruptive fashion will frazzle you. Can pt in rm 8 eat? Can they walk to the bathroom? Rm 5 doesnt want the xray you ordered till they get pain meds. Rm 7 wants to leave. Dr Blah is calling back for your pt in rm 11. EMS is on the phone and this pt hit his head, no LOC, 1 beer but sober, can he refuse transport? All this while pondering those iffy pts you are not sure what to do with yet. This is when no one is actually crashing in the dept. Sometimes I am trying to get through all of the above ASAP because I've gotten a heads up that a sick pt is coming by EMS. Add an EKG to this and I am ready to explode...even if I was the one who ordered the EKG.

I am very glad to hear that I am not the only one who gets annoyed with all of these fricken EKGs.

 

[tkim]

As a side note, I absolutely hate it when one of the nurses tracks me down to tell me about a 'critical labe value' - specifically when it's on a patient no one has seen yet. They hop back and forth on their feet like they're gonna piss themselves or the patient's head will explode unless they tell me the value. Then they chart it, absolving them of all responsbility if the patient's head indeed explodes, since they told me about the lab.

Like WTF am I supposed to do with it? Yeah I get it, now it's on me, but it does me and the patient no good that they told me this, since I can't get to them in a timely fashion anyway.

 

[The right Path]

As a side note, I absolutely hate it when one of the nurses tracks me down to tell me about a 'critical labe value' - specifically when it's on a patient no one has seen yet. They hop back and forth on their feet like they're gonna piss themselves or the patient's head will explode unless they tell me the value. Then they chart it, absolving them of all responsbility if the patient's head indeed explodes, since they told me about the lab.

Like WTF am I supposed to do with it? Yeah I get it, now it's on me, but it does me and the patient no good that they told me this, since I can't get to them in a timely fashion anyway.

It's a JCAHO thing. The whole critical lab values being reported within a certain timeframe- needless to say, we're not enamored of it either.

 

[shopsteward]

When I worked in an international organisation, it was the rule that anyone writing any document which wasn't in their mother tongue had to get it initialled by a native speaker before it went to the outside world. As only the second native English speaker in a unit of 24 polyglots, nearly all of whom had better English than I do, I have a friend for life in the Irishman who was there when I joined.

 

[Pose]

I do understand why this all bothers you guys. But I am a tech, and it is very awkward for me when I need someone to show an EKG to.

1. If the patient has been seen (or at least 'picked up' by a physician), but the nurse decides the patient needs an EKG without the physician order, I get attitude from you guys when I hand it to you. But I cannot say no to the nurse.

2. If the patient is at triage, I do the EKG, print out a previous EKG, and then find out from the secretaries who the newest doc on is, and show them. I get attitude there, because they're picking up time consuming patients and can't be bothered. If I show a doc that is getting off shift, and is perhaps just seeing low acuity patients, I get attitude because they can't be bothered seeing the patient if the EKG is abnormal.

3. Sometimes when I find a physician to show an EKG to, I get this response: "I only want to see it if it is normal." Uhm...okay. And if it isn't? See #post 2. Also, whether or not I feel confident in basic EKG interpretation or not, I can't decide if it is normal.

4. I do the EKG that may or may not have been ordered by a physician on the confused, 200 year old lady with a smelly UTI and chills...and after trying to get a good baseline for fifteen minutes, I have to show the PA that has seen the patient. Once I find them, they ask me to show you guys. Once I find you, I get attitude. Damn.

5. Some of you won't sign the EKG because you do not want to take the responsibility. I still don't know if this is against policy or not since you're contractors and not hospital employees, but I do not really care either way. So I write "s/b Dr. Whoever 00:00" and then get attitude if you see me doing that.

6. When I walk in the doctor cave to have one of you see an EKG on an unassigned patient, you all see me but pretend I am not standing there.

7. I really respect most of you, and I feel bad when I get attitude because it is unavoidable from my side. I have no choice, unless I torment one of the few "more approachable" docs on.

If you do not like it, help change the culture/practice/bull****. This would help us both. 😳

 

[BJJVP]

I do understand why this all bothers you guys. But I am a tech, and it is very awkward for me when I need someone to show an EKG to.

1. If the patient has been seen (or at least 'picked up' by a physician), but the nurse decides the patient needs an EKG without the physician order, I get attitude from you guys when I hand it to you. But I cannot say no to the nurse.

2. If the patient is at triage, I do the EKG, print out a previous EKG, and then find out from the secretaries who the newest doc on is, and show them. I get attitude there, because they're picking up time consuming patients and can't be bothered. If I show a doc that is getting off shift, and is perhaps just seeing low acuity patients, I get attitude because they can't be bothered seeing the patient if the EKG is abnormal.

3. Sometimes when I find a physician to show an EKG to, I get this response: "I only want to see it if it is normal." Uhm...okay. And if it isn't? See #post 2. Also, whether or not I feel confident in basic EKG interpretation or not, I can't decide if it is normal.

4. I do the EKG that may or may not have been ordered by a physician on the confused, 200 year old lady with a smelly UTI and chills...and after trying to get a good baseline for fifteen minutes, I have to show the PA that has seen the patient. Once I find them, they ask me to show you guys. Once I find you, I get attitude. Damn.

5. Some of you won't sign the EKG because you do not want to take the responsibility. I still don't know if this is against policy or not since you're contractors and not hospital employees, but I do not really care either way. So I write "s/b Dr. Whoever 00:00" and then get attitude if you see me doing that.

6. When I walk in the doctor cave to have one of you see an EKG on an unassigned patient, you all see me but pretend I am not standing there.

7. I really respect most of you, and I feel bad when I get attitude because it is unavoidable from my side. I have no choice, unless I torment one of the few "more approachable" docs on.

If you do not like it, help change the culture/practice/bull****. This would help us both. 😳

Are you sure it's really attitude you're getting and not just a stressed out, rushed doc? Here are my 2 most common responses and attitude is never intended:

1) I may look sort of annoyed and say, "Yeah, yeah. EKG looks fine. This pt can wait."

2) As I sort-of rip the EKG out of the tech's hand I may say, "Another old lady with vague sx's? God#*$#^%!"

Now that I've typed it out, I can see why you think you're getting attitude. But with all sincerity, it's not meant to be directed toward you.

 

[Venko]

I do understand why this all bothers you guys. But I am a tech, and it is very awkward for me when I need someone to show an EKG to.

1. If the patient has been seen (or at least 'picked up' by a physician), but the nurse decides the patient needs an EKG without the physician order, I get attitude from you guys when I hand it to you. But I cannot say no to the nurse.

2. If the patient is at triage, I do the EKG, print out a previous EKG, and then find out from the secretaries who the newest doc on is, and show them. I get attitude there, because they're picking up time consuming patients and can't be bothered. If I show a doc that is getting off shift, and is perhaps just seeing low acuity patients, I get attitude because they can't be bothered seeing the patient if the EKG is abnormal.

3. Sometimes when I find a physician to show an EKG to, I get this response: "I only want to see it if it is normal." Uhm...okay. And if it isn't? See #post 2. Also, whether or not I feel confident in basic EKG interpretation or not, I can't decide if it is normal.

4. I do the EKG that may or may not have been ordered by a physician on the confused, 200 year old lady with a smelly UTI and chills...and after trying to get a good baseline for fifteen minutes, I have to show the PA that has seen the patient. Once I find them, they ask me to show you guys. Once I find you, I get attitude. Damn.

5. Some of you won't sign the EKG because you do not want to take the responsibility. I still don't know if this is against policy or not since you're contractors and not hospital employees, but I do not really care either way. So I write "s/b Dr. Whoever 00:00" and then get attitude if you see me doing that.

6. When I walk in the doctor cave to have one of you see an EKG on an unassigned patient, you all see me but pretend I am not standing there.

7. I really respect most of you, and I feel bad when I get attitude because it is unavoidable from my side. I have no choice, unless I torment one of the few "more approachable" docs on.

If you do not like it, help change the culture/practice/bull****. This would help us both. 😳

This is very well written and it is easy to see how frustrating this would be for you and your colleagues.

 

[deleted109597]

Truthfully most of it comes from protocol. Probably 15% of the patients that get EKGs actually need them. No, the 8 year old with normal vitals and chest pain post coughing does not need it, dammit.

But if you tell the nurses to use discretion, then suddenly the 39 year old with FHx of 5 siblings with MI in their 40s with crushing chest pain doesn't get it either.

 

[southerndoc]

I don't pretend a tech isn't standing there. I've learned not to stop mid-sentence of my documentation to sign it or I'll lose my train of thought.

 

[STLINI]

Man you guys are making me feel bad about being that annoying tech now. Maybe we're just lucky where I work but I don't think I've EVER gotten attitude for needing to have an EKG read. We typically have 3 docs working our main department and we just hand them to whoever is assigned to the room the patient is in. I generally try not to be too disruptive and just set it next to them as long as they're aware I'm doing so, and the printout doesn't indicate an MI. I've never had an issue with this and the other docs are generally ok with checking their coworkers' EKGs if they're otherwise occupied.

 

[ccfccp]

Where I'm at they get seen by the upper level residents. Usually the only time the attending sees them (other than when reviewing the chart) is when it's a borderline stemi call or some other judgement case.

 

[TrumpetDoc]

Have to admit, even the best of us will get frustrated from time to time.
I get MuCH more livid with "critical values" reported to as if I have not already seen this or was not expecting it 98% pct of the time.
My passion is emergency cardiology so actually take joy in reading these.

 

[Dial71]

I understand why you guys, as attendings, are aggravated by protocol EKG's. That said, as a former ER tech, it is not cool to shoot the messenger.

Trust me, most techs understand that the majority of protocol EKGs are BS, but we're slaves to hospital policies and nursing judgment. We recognize that the 21 y/o anxiety patient and the 18 y/o "cough for a week" patient do not merit an EKG, but to the nurse in triage, an EKG is indicated to absolve her liability. Why should she care anyways? She doesn't have to record it or even look at it again.

I hate these CYA EKGs as much as you do. Please be nice to the techs, though. They're responsible for most of the nursing work, but paid only a fraction of what a nurse makes.

Besides, we're responsible for making sure that your patients' labs are sent in a timely manner, so that you can dispo in a timely manner.

 

[deleted92121]

Another friendly tech in the ED here.

Usually I have little issue getting an EKG signed. Usually the docs are busy and I respect that. I wait patiently unless there is something funk, then I may push the issue a bit.

I will never ask a physician if the patient is okay to go through the triage process (we have physician-in-triage with initial workup order, IV, labs, etc). My job as a paramedic in the ED is to act as the eyes and the ears for the doc and I take it seriously. Building a good rapport with the docs and showing that you know your stuff is important. It takes time, but once you prove yourself then things get much easier. If I let a patient slip through to triage that the PIT thinks should have gone straight back, it is never a major deal. They normally discuss it with me, normally understanding my decision making, and then interject their thoughts and attempt to help build my knowledge and improve clinical decision making. Never have I been made to feel inferior or incompetent.

7+ years in EMS has been great but my 1 year in a busy Level 2 Trauma Center has been where I have learned the most about patient assessment and clinical decision making. It has been wonderful. Thank you to all the physicians who take time to teach. It is a major reason I enjoy coming to work.

 

[deleted109597]

I understand why you guys, as attendings, are aggravated by protocol EKG's. That said, as a former ER tech, it is not cool to shoot the messenger.

They likely aren't shooting the messenger. You're likely taking their frustration personally.
Look, I was a tech once, and I know the rolled eyes when you give them the EKG. But to sit there and say that you're the reason labs are timely (which they aren't at many shops anyway) is at best laughable, and at worst an idle threat. I'd fire you if I were the manager and you made a statement like that.

 

[Pose]

I hope I did not spawn a tech revolution or uprising here in the emergency medicine forum. I just wanted to add the frustrations from the other side of the coin, not to detract from the venting and or points raised by the original poster.

No doubt, I understand it isn't pesonal, but rather just a distraction throughout your shifts.

 

[docB]

I used to be an ER tech. It was my first job in an ED 20 years ago. Back then there was not as much liability shifting as there is today so we didn't have to get the EKGs signed immediately.

I understand your frustration with getting "attitude." But you need to understand our frustration with this EKG issue contributing to not being able to think about anything uninterrupted for more then 1 to 2 minutes at a time. The other thing you should know is that the reason you have to have us sign is to transfer liability to us and away from the hospital and any of its employees.

If you write my name on an EKG after I have said it's not my patient and it needs to go to another doc or if I just break down and sign it to save time it could land me in a lawsuit.

We have all tried to change the culture but this is not just some random manager's wacky idea. This is industry practice to shield from liability and to maintain chest pain center accreditation (i.e. $$$) and it's not going away. We are all having to develop survival strategies. Mine is usually to take the EKG, sign it and give it back without looking up or talking and generally trying not to break my train of thought. I may sometimes sneer or groan or even whine. If that "attitude" disturbs you then consider how you react when a nurse forces you to clean up a diarrhea soaked patient or some other miserable task. We all have our job woes, messengers and attitudes.

 

[Dial71]

I guess "shoot the messenger" was the wrong way to put it. I've never been frustrated by a doctor's reaction to signing an EKG.

I just wanted to express that techs recognize that many protocol EKGs are ordered without proper indications. We don't like interrupting your work. We hate the system too.

And as for Dr. McNinja, I wasn't making a threat, just a joke. I hope that you're not mad, though.

 

[Ischiowhat]

I was a full-time EKG tech for two years before med school, so I've been through this encounter thousands of times.

I don't mind a frown and I don't need a thank-you, but if you ignore me or react rudely, next time don't be surprised to find it in the chart instead of your hands. For $9.36 an hour I ain't gonna deal with it. I have 20+ pts per day elsewhere in the hospital so I'll be glad to chart the benign protocol 12-lead to avoid mistreatment.

That said, I've almost never experienced that kind of reaction, but sometimes it's happened with locum tenens or someone new.

 

[hitchhiker]

I'm getting my EKG cert right now, so this is good to hear.

 

[Apollyon]

if you ignore me or react rudely, next time don't be surprised to find it in the chart instead of your hands. For $9.36 an hour I ain't gonna deal with it.

This attitude is fail. The national standard is within 10 minutes. When you put it in the chart due to your personal attack of pique, something subtle (or not so subtle) can easily be missed (or not picked up in a timely matter), while you still get your satisfaction. Having seen it happen, I would not like to be the person whose grandmother's infarct completes because someone didn't give the EKG to a doc - because the doc ignored the tech.

Seriously? Are you that mercenary and venal?

 

[tkim]

I was a full-time EKG tech for two years before med school, so I've been through this encounter thousands of times.

I don't mind a frown and I don't need a thank-you, but if you ignore me or react rudely, next time don't be surprised to find it in the chart instead of your hands. For $9.36 an hour I ain't gonna deal with it. I have 20+ pts per day elsewhere in the hospital so I'll be glad to chart the benign protocol 12-lead to avoid mistreatment.

That said, I've almost never experienced that kind of reaction, but sometimes it's happened with locum tenens or someone new.

Remember this attitude when the nurse sabotages you during the clinical years because she/he feels that you need to be 'taught a lesson'.

 

[The White Coat Investor]

This is way down on my list of gripes. I don't think I'm signing more than 10 a shift, almost all of them ones I ordered. I think this is far better than the alternative, where it is stuck in the chart and I don't see a STEMI for an hour. Same with critical labs. I'll take that call every time. I WANT this information. It took a long time to get nurses/techs to do EKGs in 10 minutes. It took a long time to get them to bring them immediately to a doc. Have you guys ever worked in an ED where chest pain patients sat in the waiting room WITHOUT an EKG? I have. You want liability-that's liability. If you're getting too many unnecessary EKGs done, amend the protocol.

Seriously, if you guys can't work with interruptions you've really chosen the wrong field. Even our oral boards are designed to test our ability to manage multiple patients while being interrupted. That's what we do.

I'd be happy if I could just order a lab and have it handed to me in 30-60 minutes without me having to do anything else, like remind the clerk to order it, remind the nurse to draw it, call the lab to remind them to run it etc.

 

[pinipig523]

Better than where I'm at... I have to hunt for the EKGs.

 

[docB]

I got to work 28 minutes ago. In that time I have signed 6 EKGs.

This is bad on several levels. I now have liability on 6 patients I have yet to see (we're backed up with holds so no one actually has beds yet, hence my ability to write this post). I also know I'm going to get at least 6, most likely more, patients dumped on me all at once when the new nurse arrives to open a new assignment at any moment.

Another point about the topic as a whole is that I not only have to sign EKGs. I have to sign all the restraint and transfer forms for all of the psych holds (in Vegas every ER has dozens of psychs who hold indefinitely, it's a long story). The nurses try to get me to sign off on all the forms and orders for the admitted holds. I don't do these, they have to go to the actual admitting doctors, but each question is another interruption.

Finally, when I do get the magna dump of patients that's coming in the next few minutes I will suddenly have 10 people to deal with. Each nurse will get 1 or 2. Each nurse will approach me with questions about how to "get things going" and basically want me to outline my intended plan based on the chief complaint alone.

If I get 2 minutes at a time to concentrate on anything during the course of the day it's unusual.

 

[MassEDRN]

One of the techs asked me "Why do you always frown when I hand you and EKG?" Let me explain that for you.

We will accept as a given that I am pretty busy. I have not eaten in the last 8 hours or peed in the last 6. There are 10 charts in my to be seen rack and 10 more in my dispo rack. So I HIGHLY SUGGEST not arguing with me about my business, especially not right now.

All of my EDs have a policy that whenever an EKG is done it must be handed IMMEDIATELY to the doctor to interpret, sign and time that EKG so that the hospital and all of its agents and employees will be absolved of all liability in perpetuity regarding said EKG (initial here:____).

This ED sees ~140 patients per day. I am on an 11 am to 9 pm shift. A disproportionate number of those 140 come in during those hours, lets say ~90.

Of those ~70% will have EKGs. That's because unless you have an isolated ortho injury you're very likely to get an EKG on protocol. 20 yo F with "weak and dizzy?" you're getting and EKG. 55 yo with back pain, EKG. Visitor sitting in a chair the tech mistook for a patient, EKG. So that's ~63 EKGs during my shift. And that doesn't count the other random EKGs that show up on admitted holds that you want me to sign even though you know they are not mine because "Somebody has to sign it."

We are double covered during those hours so I will get at least half of those handed to me. That means that while I am trying to work I will be interrupted 31.5 times to sign your EKGs. Every 19 minutes, more than 3 times per hour I will have to quit what I'm doing and sign your EKG.

So clearly this is not conducive to my productivity and it is very irritating. That is why I frown every time you hand me an EKG.

I'm surprised anyone has the time to notice a frown. We're all much too busy for that.

 

[MassEDRN]

I just make them wait until I am finished whatever task it is I'm doing, like dictating, writing a prescription, or speaking with a consultant. Unless the patient is having a STEMI, or their heart is literally exploding, I expect them to sit quietly and patiently until I have a moment to look at it and sign it.

👎 Those poor techs/CNA's - they're just doing their job. Take it easy and do yours, there actually might be a STEMI while you finish your non urgent task.

No bueno.

 

[MassEDRN]

As a side note, I absolutely hate it when one of the nurses tracks me down to tell me about a 'critical labe value' - specifically when it's on a patient no one has seen yet. They hop back and forth on their feet like they're gonna piss themselves or the patient's head will explode unless they tell me the value. Then they chart it, absolving them of all responsbility if the patient's head indeed explodes, since they told me about the lab.

Like WTF am I supposed to do with it? Yeah I get it, now it's on me, but it does me and the patient no good that they told me this, since I can't get to them in a timely fashion anyway.

sometimes nurses don't go about it the right way... the lab value of whatever might necessitate you to see this patient now or in a few minutes. I highly doubt anyone is jumping all over themselves unless it's a K of 9. Or 1.

 

[MassEDRN]

I do understand why this all bothers you guys. But I am a tech, and it is very awkward for me when I need someone to show an EKG to.

1. If the patient has been seen (or at least 'picked up' by a physician), but the nurse decides the patient needs an EKG without the physician order, I get attitude from you guys when I hand it to you. But I cannot say no to the nurse.

2. If the patient is at triage, I do the EKG, print out a previous EKG, and then find out from the secretaries who the newest doc on is, and show them. I get attitude there, because they're picking up time consuming patients and can't be bothered. If I show a doc that is getting off shift, and is perhaps just seeing low acuity patients, I get attitude because they can't be bothered seeing the patient if the EKG is abnormal.

3. Sometimes when I find a physician to show an EKG to, I get this response: "I only want to see it if it is normal." Uhm...okay. And if it isn't? See #post 2. Also, whether or not I feel confident in basic EKG interpretation or not, I can't decide if it is normal.

4. I do the EKG that may or may not have been ordered by a physician on the confused, 200 year old lady with a smelly UTI and chills...and after trying to get a good baseline for fifteen minutes, I have to show the PA that has seen the patient. Once I find them, they ask me to show you guys. Once I find you, I get attitude. Damn.

5. Some of you won't sign the EKG because you do not want to take the responsibility. I still don't know if this is against policy or not since you're contractors and not hospital employees, but I do not really care either way. So I write "s/b Dr. Whoever 00:00" and then get attitude if you see me doing that.

6. When I walk in the doctor cave to have one of you see an EKG on an unassigned patient, you all see me but pretend I am not standing there.

7. I really respect most of you, and I feel bad when I get attitude because it is unavoidable from my side. I have no choice, unless I torment one of the few "more approachable" docs on.

If you do not like it, help change the culture/practice/bull****. This would help us both. 😳

Door to EKG time, usually 10 minutes - let's help the process. We're all stressed and hurried.

Truthfully most of it comes from protocol. Probably 15% of the patients that get EKGs actually need them. No, the 8 year old with normal vitals and chest pain post coughing does not need it, dammit.

But if you tell the nurses to use discretion, then suddenly the 39 year old with FHx of 5 siblings with MI in their 40s with crushing chest pain doesn't get it either.

Just as you cannot paint a broad brush about all doctors, neither can you with all nurses. Some of us use critical thinking and don't need physician guidance in the order of an appropriate EKG.

Have to admit, even the best of us will get frustrated from time to time.
I get MuCH more livid with "critical values" reported to as if I have not already seen this or was not expecting it 98% pct of the time.
My passion is emergency cardiology so actually take joy in reading these.

Perhaps you haven't spent much time in an ER, but RARELY do the docs know about a critical lab value, primarily because it is called to me prior to the lab releasing the result. Then when it is released, it has my first and last name attached to it, so I'm obligated to pass it on. Usually, it's critically high or low, so it's necessary information. You may expect it, but the nurse actually has what you need.

I used to be an ER tech. It was my first job in an ED 20 years ago. Back then there was not as much liability shifting as there is today so we didn't have to get the EKGs signed immediately.

I understand your frustration with getting "attitude." But you need to understand our frustration with this EKG issue contributing to not being able to think about anything uninterrupted for more then 1 to 2 minutes at a time. The other thing you should know is that the reason you have to have us sign is to transfer liability to us and away from the hospital and any of its employees.

If you write my name on an EKG after I have said it's not my patient and it needs to go to another doc or if I just break down and sign it to save time it could land me in a lawsuit.

We have all tried to change the culture but this is not just some random manager's wacky idea. This is industry practice to shield from liability and to maintain chest pain center accreditation (i.e. $$$) and it's not going away. We are all having to develop survival strategies. Mine is usually to take the EKG, sign it and give it back without looking up or talking and generally trying not to break my train of thought. I may sometimes sneer or groan or even whine. If that "attitude" disturbs you then consider how you react when a nurse forces you to clean up a diarrhea soaked patient or some other miserable task. We all have our job woes, messengers and attitudes.

Awesome.

This is way down on my list of gripes. I don't think I'm signing more than 10 a shift, almost all of them ones I ordered. I think this is far better than the alternative, where it is stuck in the chart and I don't see a STEMI for an hour. Same with critical labs. I'll take that call every time. I WANT this information. It took a long time to get nurses/techs to do EKGs in 10 minutes. It took a long time to get them to bring them immediately to a doc. Have you guys ever worked in an ED where chest pain patients sat in the waiting room WITHOUT an EKG? I have. You want liability-that's liability. If you're getting too many unnecessary EKGs done, amend the protocol.

Seriously, if you guys can't work with interruptions you've really chosen the wrong field. Even our oral boards are designed to test our ability to manage multiple patients while being interrupted. That's what we do.

I'd be happy if I could just order a lab and have it handed to me in 30-60 minutes without me having to do anything else, like remind the clerk to order it, remind the nurse to draw it, call the lab to remind them to run it etc.

Awesome. Totally agree. 👍

It's a great thing to know all jobs in an ER and to be able to understand each other's plights and struggles. It takes a great deal of teamwork, and as well all know, not every member of a team is a worthy member. We're only as strong as our weakest link.

 

[docB]

Awesome.



Awesome. Totally agree. 👍

It's a great thing to know all jobs in an ER and to be able to understand each other's plights and struggles. It takes a great deal of teamwork, and as well all know, not every member of a team is a worthy member. We're only as strong as our weakest link.

You sound like the captions from those motivational posters that hang in administrator's offices.

Sure everyone has to work as a team. But by interrupting me every 2 minutes I am being turned into the weakest link you mentioned. You note that nurses use critical thinking. That's true. The critically thinking nurses are the ones who don't bother me with a K of 3.2 or the creatinine of 7 in the known ESRD patient. It's all the others that are slowly (quicker some days) killing me.

 

[TysonCook]

...I finish what I'm doing (although I let the tech/RN know that I see them), and then take the EKG, and say "thank you". I agree with the mentality that I want to see EKG, its information we need, and they are the messenger.

I do not sign for EKG's that are ordered by the admitting team, nor restraint orders, etc ordered by anyone else. I do make the tech/RN/Secretary call that team and let them deal with it.

....I agree with DocB's frustration with the never ending sl#tfest of crap that we sign and constant interruptions. I've even changed where I sit during my shift to avoid the "busy" areas, due to the complete inability to get anything done...
Including:
Transfer line
Critical lab call
radiologist call
EKG read
MD to radio
MD to flight radio
Trauma clearance (hallway)
restraint order
IV team order
"standing protocol order signature"
Obs Unit questions
ED Hold unit questions
...this is just the normal stuff we get 👎 Not including patient stuff, consultant stuff etc.

I'm not angry about it, but it makes a HUGE difference in my quality of work...

 

[NKMU]

It makes it all a little better that we EKG-signers are not alone in this. I work at a place that sees >>100K pt's per year, so there sure are lots of EKGs to go around.

My main problem at work is all the distractions as discussed above. I can't sit for more than one or two minutes to chart or think without interruptions. I regularly have three nurses waiting in line to ask me something! Although I understand why they want EKGs signed, criticals noted, etc, a big part of the whole thing is shifting liability to the doctor. Yes, it's what I signed up for, but I guess I didn't know I was in it for that much.

The one I hate the most: usually right when I arrive at work for a critical pod shift, there are 3 or 4 patients waiting to be seen. I'll start right away in the first room, and the nurses will come in and interrupt me mid-history, to say "doctor, I just wanted to inform you of a chest pain in 2 and a septic old lady in 5."

Me: "Yes, what about them?"
Nurse: "Just that they need to be seen."

Not a huge problem, right? Except they diligently go chart on those patients, "Doctor X aware of patient." So then it looks really bad if you review a chart and see that I was informed of the sick patient 30 minutes (or more) ago, and I was unable to see them immediately because of the 3 or 4 others who needed "immediate" attention.

 

[WilcoWorld]

It makes it all a little better that we EKG-signers are not alone in this. I work at a place that sees >>100K pt's per year, so there sure are lots of EKGs to go around.

My main problem at work is all the distractions as discussed above. I can't sit for more than one or two minutes to chart or think without interruptions. I regularly have three nurses waiting in line to ask me something! Although I understand why they want EKGs signed, criticals noted, etc, a big part of the whole thing is shifting liability to the doctor. Yes, it's what I signed up for, but I guess I didn't know I was in it for that much.

The one I hate the most: usually right when I arrive at work for a critical pod shift, there are 3 or 4 patients waiting to be seen. I'll start right away in the first room, and the nurses will come in and interrupt me mid-history, to say "doctor, I just wanted to inform you of a chest pain in 2 and a septic old lady in 5."

Me: "Yes, what about them?"
Nurse: "Just that they need to be seen."

Not a huge problem, right? Except they diligently go chart on those patients, "Doctor X aware of patient." So then it looks really bad if you review a chart and see that I was informed of the sick patient 30 minutes (or more) ago, and I was unable to see them immediately because of the 3 or 4 others who needed "immediate" attention.

Great point - if the aforementioned note was meant to convey the full situation, it should read "at 0800 Dr. NKMU notified of presence of 4 critically ill patients at once, all of which need to be seen first."

 

[quinsy]

I long for the days I had EKGs handed to me. People did not demand to visualize me signing them, I just had to make some sort of indication that I had registered the EKG and that they were dismissed.

Now in my new location the EKGs are stuffed into a crevice or thrown on a countertop near the patient, and I have to figure out myself if and when they are done. Every time I dig up an abnormal EKG that may have been sitting there for an hour, I heave a sigh. You don't know how good you've got it, people!