Time To Kick Some PMD Butt!

[docB]

---

Members don't see this ad.

OK, excuse me while I rant but if one more PMD sends a patient to the ER for chest pain and doesn't tell them that they'll get admitted I'm going come to the office and beat them.
Pt: "But I don't want to be admitted. My doctor said you'd just do an EKG and let me go home."
Me: "I see. Your doctor did an EKG in the office. If that's the case why didn't he just let you go home?"
Pt: "He said I needed to be checked in the ER."
So your doctor was hoping that I'd be stupid enough to see you, sign my name to your chart and discharge you so that when you die I can be liable instead of him. Great plan and everything but to Hell with that. You need enzymes and a stress and HE KNOWS THAT!

Oh, and by the way, any PMD whose pt comes in for "rule out meningitis" and I hear "What do you mean SPINAL TAP?!" you're getting beat even worse.

 

[Cristagali]

OK, ok, I'll be a FM doc WHO WILL do stress test and enzyme work-ups, (billable procedure 😀 ) but another question.
Pt. -Doc, i have chest pain and my fingers in the left arm are tingling. Can I come see you?
FM doc- Sure come see me. I have no hospital beds nor ICU beds, nor cath lab, but come spend an extra two hours with me, I haven't seen you in awhile anyway!!
Lawyer- So FM doc, when the pt called you, why did you not refer him to the ER? Why did you have to call 911 to get an ambulance to the FM clinic?
FM doc- Well, the ER guys are really getting pissed at us, so I was just trying to help them out.
Lawyer-Too bad for the pt.
FM doc- yeah, too bad. But at least the ER docs like me?
Judge- You may step down now. And on your way out, please hand your medical license over to the bailiff. Have a nice day! 😀

 

[southerndoc]

Crista, are you in GA by chance?

 

[DrQuinn]

OK, excuse me while I rant but if one more PMD sends a patient to the ER for chest pain and doesn't tell them that they'll get admitted I'm going come to the office and beat them.
Pt: "But I don't want to be admitted. My doctor said you'd just do an EKG and let me go home."
Me: "I see. Your doctor did an EKG in the office. If that's the case why didn't he just let you go home?"
Pt: "He said I needed to be checked in the ER."
So your doctor was hoping that I'd be stupid enough to see you, sign my name to your chart and discharge you so that when you die I can be liable instead of him. Great plan and everything but to Hell with that. You need enzymes and a stress and HE KNOWS THAT!

Oh, and by the way, any PMD whose pt comes in for "rule out meningitis" and I hear "What do you mean SPINAL TAP?!" you're getting beat even worse.

Add to the list: "But my doctor told me I'd be seen right away, and wouldn't have to wait!"

or

"My doctor told me he'd see me here in the ER, where is he?!"

Q

 

[deleted6669]

also :
my doctor told me I would get an mri/percocet/stat ortho consult/off work note right away for my( fill in benign, self limited minor ortho problem here) 🙂

advice nurses are even worse than pmd's. their answer to ANYquestion is go to the er right now at 3 am ( for chronic fungal toenail, runny nose, chronic back pain from industrial accident in 1975, etc)

 

[docB]

OK, ok, I'll be a FM doc WHO WILL do stress test and enzyme work-ups, (billable procedure 😀 ) but another question.
Pt. -Doc, i have chest pain and my fingers in the left arm are tingling. Can I come see you?
FM doc- Sure come see me. I have no hospital beds nor ICU beds, nor cath lab, but come spend an extra two hours with me, I haven't seen you in awhile anyway!!
Lawyer- So FM doc, when the pt called you, why did you not refer him to the ER? Why did you have to call 911 to get an ambulance to the FM clinic?
FM doc- Well, the ER guys are really getting pissed at us, so I was just trying to help them out.
Lawyer-Too bad for the pt.
FM doc- yeah, too bad. But at least the ER docs like me?
Judge- You may step down now. And on your way out, please hand your medical license over to the bailiff. Have a nice day! 😀

I know you have to send them in to the ER. That's not the issue. Just tell them what to expect. I've got post CABG diabetics with chest pain screaming because their PMD told them I would just "check them out" and let them go home.

 

[Sessamoid]

I know you have to send them in to the ER. That's not the issue. Just tell them what to expect. I've got post CABG diabetics with chest pain screaming because their PMD told them I would just "check them out" and let them go home.

I've lost track of the number of times I've had to deal with this situation.

 

[Cristagali]

Just kidding guys. I was an ER tech for 3 years before med school, and I am sympathetic. I learned a lot what NOT to do as a referral doc. But you'll always have the 3:00 am abd pain x 5 mo pt, but thats what made ER life so much fun!! I actually miss it sometimes...hmmm maybe FM with an urgent care emphasis???hmmm?

 

[doc05]

the PMD may know the patient better than you think. Most patients wouldn't come in if they knew they'd end up being admitted --- and then they'd die at home. not a good option.

 

[EctopicFetus]

I think the bottom line of this thread is poor dr/pt communication skills. I will admit I am a lowly 3rd year but I have run into this numerous times. The most uncomfortable was when I was doing my Surgery Rotation. We got a consult on a woman who just had a colonoscopy and they found some cancer looking stuff. Anyhow I see this lady and I expected her doctor (GI) to tell her whats up and that he would have Surgery come talk to her. So I stroll up to this really nice older lady and I tell her who I am and where I am from. She basically freaks out and is like WHY ARE YOU talking to me? Meaning why is surgery here? Anyhow I decided to defer and wait for my resident cause I didnt want to say anything bad. This was a crappy job done by her doctor.

I am currently doing pysch and when I tell patients what service I am on they all say why? does my doctor think I am crazy? Doctors should tell patients what consults they order. In the end this will make everyones job easier.

 

[Apollyon]

the PMD may know the patient better than you think. Most patients wouldn't come in if they knew they'd end up being admitted --- and then they'd die at home. not a good option.

Knowing the patient better is a given (unless it's a frequent flyer with a PMD they actually see, which is rare, or the pt in the PMD's office is a new patient), so what you're saying implies cowardice or inability on the part of the PMD to convince the patient of what is in their best interest. The option of going home and dying there, versus sending them to the ED and blindsiding the EP when the EP says the patient needs to be admitted, sounds like a VERY weak play by the PMD - if the way the PMD avoids patient dissatisfaction (or litigation) is by pawning them off on the ED, then that PMD is yet another reason why the ED is jammed to the gills. It's bad enough when people come to the ED because they can't/won't wait for an appointment; it's worse to come FROM an appointment, if there is something the PMD could have done around the ED, instead of through it.

 

[Sessamoid]

the PMD may know the patient better than you think. Most patients wouldn't come in if they knew they'd end up being admitted --- and then they'd die at home. not a good option.

That's the most horrible excuse I've ever heard. Never mind the 20+ minutes that I and my nurse each have to spend trying to convince the patient that admission is necessary. This is especially annoying when it happens at night when I'm single covered with a 20 bed ER in a level 2 trauma center.

What if the patient assumes that since you anticipate him going home that it's not an urgent enough problem to come to the ER immediately. It can probably wait til the next day or the day after right? Well then guess who's on the hook if that happens? Not me, that's for sure.

 

[The White Coat Investor]

the PMD may know the patient better than you think. Most patients wouldn't come in if they knew they'd end up being admitted --- and then they'd die at home. not a good option.

What do you mean not a good option? Would you rather die in an ICU with 2 central lines, an art line, on pressors and a vent, with a tube in your bladder, restraints on your limbs and someone pressing on your chest while every student nurse in the hospital is watching your purple body bounce up and down on the bed? I'd rather die at home, or at the bottom of a big cliff, or at the scene of a horrible accident.

And what do you mean "may know the patient better...?" Are you suggesting primary doctors are trying to trick their patients into going to the ED where they can be tricked into being admitted? I doubt it. Most PMDs I know want what's best for the patient, but don't feel a need into tricking patients into doing what they feel is best.

 

[spyderdoc]

What do you mean not a good option? Would you rather die in an ICU with 2 central lines, an art line, on pressors and a vent, with a tube in your bladder, restraints on your limbs and someone pressing on your chest while every student nurse in the hospital is watching your purple body bounce up and down on the bed? I'd rather die at home, or at the bottom of a big cliff, or at the scene of a horrible accident.

Don't forget most ICU pts also have the ole rectal tube You do not die with dignity in the hospital, that's for sure...

My opinion on this issue...I kinda don't mind when the PMD doesn't tell the patient what their ED dispo is going to be...There are a good amount of patients that the PMD's send, who think the patient is going to be admitted, tell the patient that, but we see the patient and say, well, we are going to send you home....Now the patient may be resistant to go home based on the fact that the pmd told them they would be admitted....I like the dispo decision to be mine....

 

[Snoopy]

I'm working in the Peds ED right now and got the dreaded "my doctor sent us in to have a Plastic Surgeon fix my daughter's laceration" today. This led to the EM attending calling the PCP to inform them of our hospital policy that uncomplicated lacs (which this was) presenting to the ED get sutured by the ED MDs/NPs unless the referring MD has made prior arrangements with a Plastic Surgeon to meet the patient in the ED. Or, if the patient/family chooses we refer them for closure of the wound in Plastics Clinic within 24 hours. This policy has been in effect for almost 2 years and has been widely circulated in the community. It puts me in a very difficult position to have to explain to a family that I am fully competent to fix their child's laceration when their own doctor has suggested that nothing less than a Plastic Surgeon will do.

 

[southerndoc]

What do you mean not a good option? Would you rather die in an ICU with 2 central lines, an art line, on pressors and a vent, with a tube in your bladder, restraints on your limbs and someone pressing on your chest while every student nurse in the hospital is watching your purple body bounce up and down on the bed? I'd rather die at home, or at the bottom of a big cliff, or at the scene of a horrible accident.

And what do you mean "may know the patient better...?" Are you suggesting primary doctors are trying to trick their patients into going to the ED where they can be tricked into being admitted? I doubt it. Most PMDs I know want what's best for the patient, but don't feel a need into tricking patients into doing what they feel is best.

At my hospital, the nursing students are called upon to do compressions.

 

[FoughtFyr]

I'm working in the Peds ED right now and got the dreaded "my doctor sent us in to have a Plastic Surgeon fix my daughter's laceration" today. This led to the EM attending calling the PCP to inform them of our hospital policy that uncomplicated lacs (which this was) presenting to the ED get sutured by the ED MDs/NPs unless the referring MD has made prior arrangements with a Plastic Surgeon to meet the patient in the ED. Or, if the patient/family chooses we refer them for closure of the wound in Plastics Clinic within 24 hours. This policy has been in effect for almost 2 years and has been widely circulated in the community. It puts me in a very difficult position to have to explain to a family that I am fully competent to fix their child's laceration when their own doctor has suggested that nothing less than a Plastic Surgeon will do.

Even better here. We will call plastics. Unfortunately plastics call is usually handled by a general surgery intern, who is unlikely to call their senior for an uncomplicated face laceration. So your options are the EM resident, who has likely stitched several lacerations that shift, or the intern who may have done a few surgical skin closures. It is your choice.

BTW - for complicated lacerations our attendings call the plastics senior directly.

- H

 

[tonem]

When I was a medical student in the ED I was embroiled in a similar situation.

Uncomplicated hand laceration...PCP sent patient in to be seen by plastics to fix it. He actually came in to make sure it got done. Didn't want me...the lowly medical student to touch his patient (he must have been born a doctor). Unfortunately for him, ortho was on call for hand that week. Plastics refused to come in to see the patient. Ortho said they'd be happy to do it as a professional courtesy even though it was uncomplicated...finally after the Plastics attending was called at home...still refusing to see the patient...the PCP relented and "let" ortho fix the simple laceration. Two hours later....I walked by the room to see one of my classmates who was doing an ortho rotation suturing the lac. The poor patient spent an extra 4 hours in the ED for the priviledge of letting a "specialist" fix her boo boo.

 

[docB]

My opinion on this issue...I kinda don't mind when the PMD doesn't tell the patient what their ED dispo is going to be...There are a good amount of patients that the PMD's send, who think the patient is going to be admitted, tell the patient that, but we see the patient and say, well, we are going to send you home....Now the patient may be resistant to go home based on the fact that the pmd told them they would be admitted....I like the dispo decision to be mine....

I hear that and for the abdominal pain and vague stuff I agree, keep it open. But I'm talking about the clear admits, diabetic, cardiac history with new chest pain. No way I' going to "check them out" and send them home. Ditto the "r/o meningitis" I hate those. If they're sick and their PMD didn't tell them about the LP they freak. If they're not sick they've got "r/o meningitis" all over their chart and if I feel they don't need an LP I've got to document the snot out of it and still bear a huge amount of liability.

 

[deleted6669]

When I was a medical student in the ED I was embroiled in a similar situation.

Uncomplicated hand laceration...PCP sent patient in to be seen by plastics to fix it. He actually came in to make sure it got done. Didn't want me...the lowly medical student to touch his patient (he must have been born a doctor). Unfortunately for him, ortho was on call for hand that week. Plastics refused to come in to see the patient. Ortho said they'd be happy to do it as a professional courtesy even though it was uncomplicated...finally after the Plastics attending was called at home...still refusing to see the patient...the PCP relented and "let" ortho fix the simple laceration. Two hours later....I walked by the room to see one of my classmates who was doing an ortho rotation suturing the lac. The poor patient spent an extra 4 hours in the ED for the priviledge of letting a "specialist" fix her boo boo.

this happens to me all the time as an er pa. some pts demand to see the "head er dr" for their lac repair, wait 2+ hrs as the attending is generally busy(and they have just earned themselves a "therapeutic wait for attitude") , only to be told by the attending that the pa's do most of the closures on a day to day basis and that he hasn't done one in 10 yrs but would be happy to practice on them. they then elect for me to do the 10 minute procedure and have spent a grand total of 3+ hrs to get it done.

 

[docB]

Care pathway for PMDs (at least in DocB's area):

Your pt lost their insurance- Send to ER
Your pt is an HMO pt- Send to ER
Your pt has more than one complaint- Send to ER
Your pt has a blood sugar of 280- Send to ER
Your pt needs an US (you are an OB and have US in your office)- Send to ER
Your pt is at a nursing home and they're short a nurse- Send to ER
It's 4:45 pm and you still have 5 pts in you waiting room, what to do with them?- Send to ER
Your pt has a rash- Refer to Derm... Just Kidding! Send to ER
Your chronically demented pt who forgets stuff can't remember something- Send to ER

 

[beanbean]

Your dead patient wakes up in the morgue-> send to ER

Man declared dead found breathing in morgue
N.C. emergency medical team suspended after screw-up

The Associated Press
Updated: 9:11 a.m. ET Jan. 27, 2005

RALEIGH, N.C. - A medical examiner studying a body in a morgue was startled when the man took a shallow breath.

Emergency medical technicians had declared 29-year-old Larry D. Green dead almost two hours earlier, after he was hit by a car.

Medical examiner J.B. Perdue was called to the accident scene Monday but did not examine Green then. Later, he was documenting Green’s injuries when he noticed the man was breathing.

“I had to look twice myself just to make sure it was there, that’s how subtle it was,” Perdue said.

Green, 29, was taken to Duke University Medical Center in Durham, where he was in critical condition Wednesday.

Several members of the Franklin County emergency medical service have been suspended pending an investigation, said Darnell Batton, the county attorney.

 

[Apollyon]

Some say suspended, some say fired:

http://rdu.news14.com/content/headlines/?ArID=63080&SecID=2

Report: Paramedics, doctor made mistakes in NC false-death case
Updated: 2/1/2005 8:44 AM
By: Brett Tackett & Web Staff

(LOUISBURG) - Two EMS workers have been fired after a report says they declared a man dead by mistake.

An EMS crew declared Larry D. Green of Louisburg dead after a car struck him January 24th at the intersection of US 401 and NC 39. But two hours later, the medical examiner later discovered Green alive during an examination at the morgue.

The county attorney read the report during a meeting on Monday. It states neither EMS worker Paul Kilmer nor Randy Kearney followed protocol to ensure a person had died.

The report also said that at least twice on the night of January 24th, paramedics told a doctor they thought Green might be alive.

It also states Medical Examiner J.B. Perdue brushed off movements by Green as post-death twitches.

Green's family said they're shocked by all the mistakes.

"How are you going to stick someone in a body bag if he's still breathing?” asked his brother, Steve Green. “I think they asking for trouble."

Green is in critical condition at Duke Medical Center. His family said they plan to file a lawsuit.

 

[docB]

So a PMD dumps a pt on me yesterday who needs a DVT ultrasound. The PMD actually saw the guy in his office (Amazing!) and tried to order the US as an outpt (extrordinarily amazing!). But.... the pt can't get the US until 4:45 pm. It's 11 am. So what to do? Let the pt get his US? Of course not! Send the pt to the ER for the US. I almost told the pt that the doc just didn't want to get a call from the rads after hours and that was why he sent the pt to the ED incurring a multi thousand $ charge. As things worked out the pt wound up getting the US at about 5pm because, believe it or not, we're busy. I made it a big point to call that PMD to happily inform him of the negative US results.

 

[USCDiver]

So a PMD dumps a pt on me yesterday who needs a DVT ultrasound. The PMD actually saw the guy in his office (Amazing!) and tried to order the US as an outpt (extrordinarily amazing!). But.... the pt can't get the US until 4:45 pm. It's 11 am. So what to do? Let the pt get his US? Of course not! Send the pt to the ER for the US. I almost told the pt that the doc just didn't want to get a call from the rads after hours and that was why he sent the pt to the ED incurring a multi thousand $ charge. As things worked out the pt wound up getting the US at about 5pm because, believe it or not, we're busy. I made it a big point to call that PMD to happily inform him of the negative US results.

Here's what we get all the time... Pt goes to PMD with unilateral leg swelling, goes to the outpatient ultrasound place, gets ultrasound, actually has a DVT, radiologist calls PMD with results, PMD tells patient to come to the ED.

I usually call the PMD, especially if it's after hours, and ask him what, exactly, he would like for me to do with his patient. Usually it's "he's got a DVT, he needs to be admitted for heparin and coumadin". At which time I say, "You know, you could save your patient an ED charge if you just called the hospitalist directly and had the patient admitted, because that's all I'm gonna do. I'm not even going to order any labs. Would you like his pager number?"

Then the hospitalist comes down, puts the pt on Lovenox and sends him home. Which the PMD could have done from his office of course.

 

[Faebinder]

the PMD may know the patient better than you think. Most patients wouldn't come in if they knew they'd end up being admitted --- and then they'd die at home. not a good option.

I totally see what Doc05 means.. seriously.. some patients.. (mostly ambulatory) if told they will get a procedure done on them, would out right refuse to go... end up going home and when the situation worsens, then they call ambulance/911 and possibly end up dead either in the ER or on the way and that is a bad thing for the patient obviously but for the ER docs as well as the Primary doc. Some families will be looking to sue both ER and Primary, whichever is an easier target.

Why do people freak out when they hear the word surgery/procedure? I'm sure you read about it back in the days of behavioural sciences. (I have seen this in the one year surgical research that I did. The patient would score outcomes as EXCELLENT and VERY statisfactory... but when asked if they would have done the operation knowing what they know now they would say NO!)

 

[Freeeedom!]

This has been a daily occurance for me this entire year.

Example:

Pt: I called my doctor so that I could see him for my chronic abdominal pain...he told me to go to the ER because he couldn't see me today.

Pt: I tried to see my doctor today for my bleeding hemorrhoid, butt (he he) he couldn't get me in today

Pt: But my Dr. said that he would be her waiting for me

Pt: Grandma needs to be admitted to the hospital...we are going out of town and our doctor said to bring her here.

Pt: Dr. so and so said that I need a (CAT scan/MRI/Doppler/blood work/massage) and that I could get it done right away here.

Or my favorite:

Pt (sitting in exam room after child has xray): Dr. X said I was NOT supposed to go to the ER, he has already seen the xray and that I can leave the ER now.
Me: What do you mean leave the ER, you haven't been discharged by me yet

Pt: Yeah, but Dr. X said I could just leave over the phone...

Me: Uhhh no.

 

[sophiejane]

Your dead patient wakes up in the morgue-> send to ER

Man declared dead found breathing in morgue
N.C. emergency medical team suspended after screw-up

The Associated Press
Updated: 9:11 a.m. ET Jan. 27, 2005

RALEIGH, N.C. - A medical examiner studying a body in a morgue was startled when the man took a shallow breath.

Emergency medical technicians had declared 29-year-old Larry D. Green dead almost two hours earlier, after he was hit by a car.

Medical examiner J.B. Perdue was called to the accident scene Monday but did not examine Green then. Later, he was documenting Green’s injuries when he noticed the man was breathing.

“I had to look twice myself just to make sure it was there, that’s how subtle it was,” Perdue said.

Green, 29, was taken to Duke University Medical Center in Durham, where he was in critical condition Wednesday.

Several members of the Franklin County emergency medical service have been suspended pending an investigation, said Darnell Batton, the county attorney.

Guess it's good that he noticed that spontaneous breathing BEFORE starting the autopsy.

I thought a dr. had to pronounce death? Can EMTs pronounce??

 

[deleted87716]

I think the bottom line of this thread is poor dr/pt communication skills.

It's a two-way street, too, let me tell you.

I've lost count of the number of patients I've seen who come in for "ER follow-up" (usually I have no idea they've even been to the ER, as they weren't sent by me and never bothered calling us first) who have no idea what their diagnosis was, and aren't taking whatever medicines (if any) they were prescribed because they didn't know what they were for. I'll ask, "So, what did they tell you was wrong with you?" They'll say, "They couldn't find anything wrong, but they said I needed to see you the next day." Thanks. 🙄

Sometimes they'll hand me a big sheaf of discharge instructions that they haven't read. Occasionally, that's useful. 😉

And before you argue, "But we told them everything, it's not our fault that the patient didn't understand or didn't remember," keep in mind that most of us tell our patients what to expect when we refer them to the ER, too. People hear what they want to hear.

 

[DropkickMurphy]

Not technically.....we determine non-viability. Normally the coroner (or medical examiner) actually signs off on the death. That is, unless we've started resuscitations and the patient does not respond....then we have to call in and tell the ED doc "Well, he's tubed, pumped and drugged, but his EKG is flatter than one of the Olson twins' chests. Can we call it?" Then the ED doc technically pronounced the patient no longer among the ranks of the living. Ah....legal technicalities.

 

[deleted87716]

This has been a daily occurance for me this entire year.

Honestly, you guys really do have my sympathy, as I know from my residency what it's like seeing other peoples' B.S. cases in the ED. However, I try very hard not to be a contributor. Believe me, I work patients in whenever I can for same-day visits, handle all of my uncomplicated DVTs as an outpatient, etc. That being said, I can't accurately diagnose everything over the phone, and sometimes a patient needs to be seen urgently and there's no recourse. Mea culpa.

Most of the scenarios you presented are probably not what they appear on first blush. Allow me to translate...

Pt: I called my doctor so that I could see him for my chronic abdominal pain...he told me to go to the ER because he couldn't see me today.

Translation: The patient called the doctor's office (probably at 3:00pm) demanding a same-day appointment for stable, chronic abdominal pain. The doctor's office offered an appointment the following day, but the patient didn't want to wait.

Pt: I tried to see my doctor today for my bleeding hemorrhoid, butt (he he) he couldn't get me in today

Translation: The doctor's office suggested some OTC remedies, or may have even offered to call in something to alleviate the patient's symptoms until they could be seen in the office. The patient didn't want to wait.

Pt: But my Dr. said that he would be her waiting for me

Translation: Wishful thinking. Nobody tells a patient that.

Pt: Grandma needs to be admitted to the hospital...we are going out of town and our doctor said to bring her here.

Translation: The patient's doctor probably has no idea she is even at the E.R. This is a classic "Granny dump."

Pt: Dr. so and so said that I need a (CAT scan/MRI/Doppler/blood work/massage) and that I could get it done right away here.

Translation: The patient's insurance company is throwing up a roadblock to getting an outpatient study in a timely fashion, so the doctor sent the patient through the E.D. to get it done faster. Don't like it? Neither do we. Incidentally, I would only do this sort of thing as an absolute last resort, and I'd call ahead and tell the ER attending what the deal was so they didn't waste any more time than absolutely necessary.

Pt (sitting in exam room after child has xray): Dr. X said I was NOT supposed to go to the ER, he has already seen the xray and that I can leave the ER now.

Translation: The patient has no idea how things work, and is impatient. The doctor, who does know how things work, probably said no such thing.

Food for thought. Anyway, if it weren't for PMDs, who would you guys have to dump on? 😉

 

[positiveaob]

Here's what we get all the time... Pt goes to PMD with unilateral leg swelling, goes to the outpatient ultrasound place, gets ultrasound, actually has a DVT, radiologist calls PMD with results, PMD tells patient to come to the ED...

It's a matter of billing, is what I've been told. They can bill higher or something if the patient comes in as an ER admit. Not that that makes it right, or makes our life any easier. But I guess just know it's greed not stupidity that drives this.

 

[deleted87716]

It's a matter of billing, is what I've been told. They can bill higher or something if the patient comes in as an ER admit. Not that that makes it right, or makes our life any easier. But I guess just know it's greed not stupidity that drives this.

It's not really a billing issue. I've had to deal with this lots of times. If the NIVs are positive, you simply change the diagnosis code on your encounter form from "leg swelling" to "DVT." STAT NIVs come back the same day you order them, so this is a no-brainer. (If you've done it right, the medical decision-making already gets an office visit like that up to a 99214 anyway, so the ICD-9 code you use doesn't really matter.)

For a stable DVT, you can start a patient on Lovenox and Coumadin as an outpatient. I usually have the conversation about what we'll do if the NIVs are positive when the patient is still in the office. I'll call the prescriptions in to their pharmacy of choice. Prefilled syringes make the Lovenox pretty easy. The only issue is if they have trouble injecting themselves, in which case you have to bring them back in the office for some education (usually a nurse visit only). If this all transpires right before the weekend or something, that can make things more complicated.

 

[Jeff698]

Most of the scenarios you presented are probably not what they appear on first blush. Allow me to translate...

You are right on the money here. Whenever I hear what another doctor said via a patient, I automatically assume it has, at best, 10% truth to it. I've heard from other doctors what patients tell them I said and know how inaccurate it is.

This is especially true (as you point out in your excellent translations) when the patient has a clear agenda that they suspect would not be supported by relaying what their doctor really said. Somehow most patients correctly determine that "get out of my office you drug-seeking troll" isn't going to get them a narcotic Rx from the ER very quickly.

Food for thought. Anyway, if it weren't for PMDs, who would you guys have to dump on? 😉

Fear not. We'd find someone. It's the way of medicine, afterall. I promise that in the days before EM, all the other specialties still found someone to dump on.

The one thing we were granted when graduating from medical school is the right to assume every other medical school graduate is an idiot. Sad, but true.

Take care and thanks for the great comments.

Jeff

PS, I hope you won't mind if I continue to vent about 'those lazy PCPs who dump on me". At least you'll know I don't really mean it. And, I promise, I'll take it with a grain of salt when you vent about all the ER follow ups I send you. 🙂

 

[USCDiver]

Or my favorite:

Pt (sitting in exam room after child has xray): Dr. X said I was NOT supposed to go to the ER, he has already seen the xray and that I can leave the ER now.
Me: What do you mean leave the ER, you haven't been discharged by me yet

Pt: Yeah, but Dr. X said I could just leave over the phone...

Me: Uhhh no.

The correct response is:

"Ok, bye. NEXT!"

 

[RuralMedicine]

It's a matter of billing, is what I've been told. They can bill higher or something if the patient comes in as an ER admit. Not that that makes it right, or makes our life any easier. But I guess just know it's greed not stupidity that drives this.

Your quote is rather ignorant. Whether I admit a patient from my office as a direct or through the ED what I can bill is based on the services I provide to the patient (what insurance actually pays me is another matter but let's not go there). Actually going through the ED might result in less service provided (and less billing) by the admitting doctor as it is possible that necessary procedures would be taken care of by the ED physician. Personally if I see a patient in my office I will rarely send them through the ED after that. I say rarely because there are exceptions and situations where they need something that could be provided in the ED, but could not or could not be provided in a sufficiently timely fashion on our medical floor and we have no available ICU beds. I also had an unfortunate patient who refused to use her walker or her daughters help and attempted to climb the front steps of my office (rather than use the ramp to take her in the handicap accessible entrance) lost her balance and fell down the steps struck her head on the concrete walkway and lost consciousness. I sent her (via EMS with collar) across the street to our ED she ended up with traumatic subdural and we ended up flying her out to have neurosurgery evacuate her hematoma. I will say that if I send patients to the ED I call and speak to the ED physician while the patient is in transit. I agree it is a matter of communication. One thing I will add is that how ED physicians react to PCP calls definitely can influence behavior. If you are jerk they will be less likely to call. We have one provider who is very difficult to deal with and I call him because I know it's the right thing to do but I admit it's tempting to not.

I realize that you are all frustrated but please remember that not all PCPs are the same. Just as not all ED providers are the same. I'm sure that none of you would ever.........
-Tell parents "yeah your child has an arrhythmia...yeah I guess your doctor should do something about it" (and then D/C home without checking electrolytes, and EKG etc)
-Start pressors through a peripheral IV for hypotension but ignore the fact that the patient is severely acidotic (pH 7.08)and volume depleted.
-Refuse to call a PCP at a parent's insistence. (After you had spent five minutes yelling at the same parent because you disagreed on disposition of the child--I know patients can sometimes misinterpret, embelish etc but one of the nurses later corroborated the parents story).
-Tell the admitting doctor on call who was in the department admitting another patient--"Oh wow Dr. ----'s patient looks bad can you deal with that? I have another patient to see a child in triage stubbed their toe,". It got better an hour later when the patient intubated by the doctor on call was on the ventilator on his way to the ICU the same doctor asked us to "Hold up I've got to write down something so it looks like I saw him" [Just a little bit fraudulent there]
Unfortunately these things all happened within the past month.

 

[deleted87716]

The one thing we were granted when graduating from medical school is the right to assume every other medical school graduate is an idiot.

What's that old saying? "By the time you graduate from medical school, you have a list of diseases you never want to get, and a list of people you never want to treat you." 😉

 

[Dr. Wexler]

the PMD may know the patient better than you think. Most patients wouldn't come in if they knew they'd end up being admitted --- and then they'd die at home. not a good option.

Lying to the patient "for his own good". Isn't that a bit paternalistic?

If they choose to die at home by choosing not to be admitted the the hospital so be it.

 

[a_ditchdoc]

Not technically.....we determine non-viability. Normally the coroner (or medical examiner) actually signs off on the death. That is, unless we've started resuscitations and the patient does not respond....then we have to call in and tell the ED doc "Well, he's tubed, pumped and drugged, but his EKG is flatter than one of the Olson twins' chests. Can we call it?" Then the ED doc technically pronounced the patient no longer among the ranks of the living. Ah....legal technicalities.

A lot of it depends on the state and local protocols. Some EMS providers are allowed to cease resuscitations without oversight if certain criteria are met. Where I worked we were allowed to declare death (Not sure of the legal definition) but the medical examiner or PMD had to sign off on it. If they refused to sign it I am not sure what would happen. I guess the person would still be technically alive. Since we also performed some of the ME's duties, it was generally not a problem.

As far as the live guy being stuffed in a body bag...sheesh. I hear that is the way they do things in NC...

 

[roja]

What's that old saying? "By the time you graduate from medical school, you have a list of diseases you never want to get, and a list of people you never want to treat you." 😉

😍

So true. Every field has people you wouldn't let treat your worst enemy and people you would put your most loved ones life in.

I can think of at least one person on each end of this spectrum in each field I encounter, including my own.

I must admit though, PMD's that send patients in with a scrip that says "w/u numbness" and that's it, annoy the hell out of me...Call me. Talk to me. I am trying to take care of YOUR patient adn do what's best for YOUR patient.

 

[signomi]

OK, ok, I'll be a FM doc WHO WILL do stress test and enzyme work-ups, (billable procedure ) but another question.

Oh wow. You aren't in practice yet are you? Where I practiced in NY our group lawyers told us to never ever EVER order an outpatient troponin. NEVER! There had been several lawsuits after trops were sent when the doc really thought they would just confirm that the CP wasn't cardiac. Well surprise, they came back positive and they were sent at 1pm - the results came in at midnight! That is the reality of office based lab work. It can take up to 12 hours for it to be shipped out to the local hospital and tested. Is you think of ordering it STAT the lab tells you that the patient should be going to the ER, because the turn around on STAT labs is 3-4 hours.

So these people spent 10-12 hours sitting at home with an MI, even though the EKG was benign. The lawyers told us the docs lost all these cases. And thus, my old group could not order trops on outpatients. And now I am a hospitalist because primary care was miserable.

 

[corpsmanUP]

Don't forget that the average PMD has about as much EM training as a graduating med student these days! And that experience was back sometimes decades ago! They truly don't always know what to expect. I do sympathize with them because I did family medicine for several long years. I was clueless about how long a workup would take and I wholeheartedly admit that I routinely blew smoke up people's rears to just GET them to the ED. An EM doc is way more equipped to convince them how serious their problem may or not be....it's their specialty (our specialty). The fact we make twice the salary of the PMD should allow us a bit of a empathetic tone. I'm less for "bichin" and instead I just try and keep the PMD looking good to the patient and explain that the workup now needs to be more thorough based on my own findings. If you can't communicate something this simple to a patient without wanting to kill the PMD then you are eally stressing over the small stuff. Don't forget that in the real "customer driven" world of EM that you will be wanting PMD's to send you business, just like cards will be welcoming all your chest pains to pay their overhead!!

Academics can be really warped!

 

[BKN]

Fear not. We'd find someone. It's the way of medicine, afterall. I promise that in the days before EM, all the other specialties still found someone to dump on.

.

🙂

Right you are!

One of my senior residents and her husband back in the day created a board game called intern. They got it into the game stores. It went like this, 4 players, an intern each in IM, Surg, OBGYN and Neuro. Each started with the same number of patients with a variety of diagnoses. the goal is to get your patients worked up, appropriate consults and discharged. Intstead of money you get paid in hours away from the hospital. The absolute winning strategy was to find an excuse to dump your patients on another service while not picking up anybody else's problems. Pretty realistic representation of 70's teaching hospitals.

BTW if you don't know what a board game is, ask your parents.😀

p.s. I still maintain that if the guy on the other end of the line thinks the patient needs to see a doc, even if he is one, he's right.

 

[docB]

I must admit though, PMD's that send patients in with a scrip that says "w/u numbness" and that's it, annoy the hell out of me...Call me. Talk to me. I am trying to take care of YOUR patient adn do what's best for YOUR patient.

See that's the problem. I don't mind seeing the pateints. But when the PMDs make my lafe so much harder I get 😡 . Don't send your chest painer to the ER and tell him that I'm just going to "check him out" and send him home. I don't want to be the last one to touch him any more than you did.

In all fairness I've got several PMDs here who are really good. They send their pateints in with reasonable work up requests and when I call them to admit their pateints they never whine. One today sent 2 pateints in and he actually showed up in the ED before I even called to check on them and do their admissions. I'll bend over backward for those guys.

 

[GeneralVeers]

Just had an insane referral on my shift tonight.

A 26 year old AA female is referred to my busy county ED. She'd been having lower abdominal pain, and some bleeding. The clinic doctor did a pelvic, and diagnosed her with fibroids. He then told her to come to the county ED for STAT ultrasound to demonstrate the fibroids, and told her she'd get surgery for them.

This lady waited in the waiting room for 9 hours to get a "STAT" ultrasound that easily could have been scheduled on an outpatient basis by the clinic physician. At the very least he could have referred her to GYN clinic, not the ER.

 

[emtp6811]

I thought a dr. had to pronounce death? Can EMTs pronounce??

In my area EMT's, firefighters, and police can pronounce an "obvious" death. These parameters are specifically outlined in SOPs. Often, if the first in FF announces a 10-100, I will cut code and cancel my response. Otherwise, Paramedics pronounce. If there is any questions, we have a dedicated medical control line to an MD at the level two trauma center so that we can get a speedy consult.

 

[signomi]

Don't forget that the average PMD has about as much EM training as a graduating med student these days!

Please don't lump us all in together. I am an internist in hospitalist medicine, but I used to do primary care. During residency we did 2.5 months of ER and the ER residents did ZERO months of med wards. It would be easy to point fingers at the ER residents coming out of that program, in terms of their lack of wards experience. Comparing a PMD to a med student is insulting to them and to the amount of work they do. I used to work 60+ hours a week before I joined you guys in the land of beautiful shift work.

 

[Annette]

See that's the problem. I don't mind seeing the pateints. But when the PMDs make my lafe so much harder I get 😡 . Don't send your chest painer to the ER and tell him that I'm just going to "check him out" and send him home. I don't want to be the last one to touch him any more than you did.
. . . {nice bit deleted} . . .

Have you EM guys even read the infamous thread "What I learned from my patients?" You all seem very bright about not trusting SOCMOB, but you believe what they say their doctor told them?????????????? Come on! You all know better! 😀

 

[BKN]

Have you EM guys even read the infamous thread "What I learned from my patients?" You all seem very bright about not trusting SOCMOB, but you believe what they say their doctor told them?????????????? Come on! You all know better! 😀

Another piece of great wisdom. If the story seems strange, call the PMD. Been doing that for 30 years, the patient is right about what they were told maybe 20% of the time.

The language we speak is not english, the patients often misunderstand. The rest have an agenda.

 

[beyond all hope]

PMDs send patients to the ER for all the right and wrong reasons, just like everything else.

Some are extremely appropriate (my personal favorite is the note that includes a brief hx/pe, suggested w/u, a contact phone number and 'admit to my service' with an appropriate complaint) and some are just plain absurd (go to the ED for your routine tests, call the cheif of Cardiology when you get there and don't talk to the stupid ER doc, nonurgent complaints, etc)

And as I've mentioned before, I've admitted patients for all of the right reasons and all of the wrong reasons. It goes both ways.

I honestly think that phone calls are nice but mostly unnecessary. I take PMD referral calls and while I appreciate the thought, I think that a patient carrying a note is more helpful. In a multi-doc ED, there's a good chance I will never see that patient. I try to call PMDs about their patients, but I've got to be honest, I don't make it a priority.

ED docs should remember the medicolegal situation makes it very difficult for PMDs to address any complaint that's even remotely dangerous over the phone. Have some consideration. When you get a 'phone consult', what do you say? Go to the ED if you have any concerns...

We should be partners in health care, not enemies. I've worked in environments where no one had PMDs, and I am extremely grateful that most of my patients have PMDs now. For the most part they are overworked, underpaid and really care for their patients.

Props to the PMDs. Keep up the good work.