Time To Kick Some PMD Butt!

[docB]

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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! 😀

Yup. They do get it wrong a lot. Often they don't get it wrong. Within just the last week I have had PMDs who did in fact send a pt to the ED so I could
"repeat" their EKG and then wanted that patient sent home, a PMD who said that the patient had changed to HMO insurance so he sent the pt to the ER to be referred to an "appropriate" HMO PMD and a guy who had a 3 pm appointment with PMD, at 4 pm he complained to the receptionist and was told to go to the ER "and never come back." All of those were just in the last week and were verified by the docs.

 

[GeneralVeers]

Most of our referrals come from county-subsidized community clinics. Most of the time the actual physician referral sheet is on the chart before I even see the patient, so I can corroborate their stories. We have some absolutely laughable referrals, however I understand that the PMDs working in these communities are overwhelmed with patients, and operate with limited resources, and they do the best they can.

To all PMDs, I would just ask you to consider whether you would want your family waiting in an ED for 6-10 hours for something that could probably be worked up as an outpatient (like MRIs for disc herniation, Ultrasounds for fibroids, etc). I realize it's easy to say to the patient "Go to the Emergency Department for this scan or that test" but make sure that it's an actual emergency before doing so. Any patient who doesn't need to be immediately hospitalized or have a fracture reduced, can probably be sent home.

 

[Anuwolf]

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!)

What made you write such silly and ignorant question like this? If you were having serious headaches and the doctor did lots of tests and then told you “I’m sorry to tell you this Faebinder but we found a tumor on your brain. I’m afraid we’ll going have to remove it very soon. We’ll schedule for surgery in the next couple of days”

Surgery and any kind of procedures is scary for everybody… you can’t sit here and tell me that it doesn’t scare you..

I don’t know if you’re a doctor or not but any doctor knows that serious complications can accrue after surgery. Anything that involves of both general and local anesthetics is scary and sometimes dangerous.

 

[corpsmanUP]

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.

I think you did not understand what I was saying. I stated (and you can go back and read it) that the average PMD has about as much EM experience as the average medical student these days. Most medical schools now have required EM rotations. That is not something that has been around all that long. Most PMD's did on average about 2 months of EM and we all know it is one of the favorites for FM and IM residents for taking vacation time. I'm just saying that the average PMD has not stepped foot in an ED in so long that the medical student is probably more well versed in the happenings of an ED. No one ever said PMD's weren't real doctors, but from my own personal experience in the land of FM, I used to have unrealistic expectations when I sent those patients to the ED for that "quick cardiac" rule out and that "quick LE doppler". Please don't take offense as it was not meant to say you were not a real doctor before you came over to the dark side. We are on the same team dude!

 

[ERMudPhud]

Yesterday I got a guy sent in by his PCP with a note saying "rule out fecal impaction" I asked, "So, did your doc stick his finger in your butt" The answer was no. 🙄

Perhaps docB's new sig should be "Saving your PCP from rectal exams"

 

[southerndoc]

Yesterday I got a guy sent in by his PCP with a note saying "rule out fecal impaction" I asked, "So, did your doc stick his finger in your butt" The answer was no. 🙄

Perhaps docB's new sig should be "Saving your PCP from rectal exams"

Wouldn't you love if we were able to send them back to the PCP with a note stating "Incomplete workup. Please properly perform a correct physical exam before sending the patient to the ED. In other words, stick your finger in the patient's rectum, not your own."

 

[Taaki]

Wouldn't you love if we were able to send them back to the PCP with a note stating "Incomplete workup. Please properly perform a correct physical exam before sending the patient to the ED. In other words, stick your finger in the patient's rectum, not your own."

 

[docB]

Soooooo.... Pt on Coumadin. INR 6.1. Called and told to go straight to the ED by the PMD. Repeat INR in the ED 6.0. Called primary. Primary says "Just send her home. I ask "So why did you send her to the ER if your weren't planning on treating the INR. Answer: "Well, someone needed to see her aobut this." Tag, an the EP gets the liability again. Bastards.

 

[doctawife]

Sometimes I don't like the PMDs 'cause they do things that are just WRONG. Like start a 3 week on on Amoxil for vague respiratory complaints. Three week olds SHOULD NEVER be started on antibiotics without a full work up - which at that age includes a tap. I'm sure that there is an adult equivalent, but damned if I remember what it is.

I had to tube the kid and send him to the ICU. Initial temp after intubation was 94F. GRR!

Other times I don't like PMDs 'cause they tell lies - like that when they call ahead to warn us that the patient is coming, that means the family gets to skip the line and get seen as soon as they show up to triage. Um, no. If we have 150 patients in the ER, you're waiting just like everyone else. Sorry, Charlie.

But every once in a while the PMDs save my bacon. Like telling me that the febrile 8 year old with chest pain actually has sickle cell disease, when the parents had denied any past medical history. I was about to send her out like an uncomplicated pneumonia. 😱 Which would have been bad, since the child ended up having a Hb of 4.2 and a (thankfully mild) case of acute chest syndrome.

So while I frequently want to fart in the general direction of the community pediatricians, I do appreciate them.

 

[Apollyon]

Soooooo.... Pt on Coumadin. INR 6.1. Called and told to go straight to the ED by the PMD. Repeat INR in the ED 6.0. Called primary. Primary says "Just send her home. I ask "So why did you send her to the ER if your weren't planning on treating the INR. Answer: "Well, someone needed to see her aobut this." Tag, an the EP gets the liability again. Bastards.

Got you one better - INR 11.6, Hb has dropped 2 points in 2 weeks, orthostatic. The same story - "patient doesn't need to be admitted - transfuse and IV vitamin K" - and this is from the last group that does not send all their admissions to the hospitalists!

 

[docB]

This is how primary care is done where I am:
68 yo M went to see PMD. CC I've been passing out with increasing frequency for the last month. PMD does nothing. Does not admit, refer to the ER, begin outpatient work up, nada. Tells patient "When it happens again call 911." 😡

 

[la gringa]

pt c/o epigastric pain, failed trial of H2 blockers. PCP sent to ED w/o doing CBC or rectal exam... with a note saying he needs an EGD. uhhhh.... Hb was 12, heme neg, sent him on his merry way. poor guy wasted probably 12 hours dealing with our ED for stuff his PCP could have done in 10 extra minutes, including the blood draw...

 

[xviii]

Belive me, you guys give it back to us in spades when you call us with the "social admit". Family's going on vacation and the FM service needs to babysit grandma. Absolutely freaking wonderful.

 

[docB]

Belive me, you guys give it back to us in spades when you call us with the "social admit". Family's going on vacation and the FM service needs to babysit grandma. Absolutely freaking wonderful.

#1 - You are more than welcome to come eval the patient and the situation and the discharge the pateint yourself.

#2 - The EM board is an excellent place for EPs to gripe. There are plenty of anti EM threads out there.

 

[Jeff698]

Belive me, you guys give it back to us in spades when you call us with the "social admit". Family's going on vacation and the FM service needs to babysit grandma. Absolutely freaking wonderful.

Let's see... babysit grandma.

Surely you're not suggesting that you don't want to take care of your own patients, are you? I'm guessing you're not suggesting that the hallway of a busy ED is the best, most healthy and most secure place for YOUR patient, are you?

Or, alternatively, we could just dump YOUR patient back into an empty house where they'll not be able to care for themselves and die a horrible death.

Your patient, your call. What's it gonna be?

Take care,
Jeff

 

[Toohotinvegas33]

Let's see... babysit grandma.

Surely you're not suggesting that you don't want to take care of your own patients, are you? I'm guessing you're not suggesting that the hallway of a busy ED is the best, most healthy and most secure place for YOUR patient, are you?

Or, alternatively, we could just dump YOUR patient back into an empty house where they'll not be able to care for themselves and die a horrible death.

Your patient, your call. What's it gonna be?

Take care,
Jeff

ouch....

 

[EM2BE]

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.

This is probably the reason why, in the state I'm from, paramedics can't pronounce a person dead unless brain matter is spilled on the ground (or they were obviously dead for 3 or more days, or something similar). As far as I know, they can only call a person dead if it is blatantly obvious.

 

[Apollyon]

This is probably the reason why, in the state I'm from, paramedics can't pronounce a person dead unless brain matter is spilled on the ground (or they were obviously dead for 3 or more days, or something similar). As far as I know, they can only call a person dead if it is blatantly obvious.

Criteria for declaring death are clear, and, invariably, when people are pronounced - but aren't dead - the person declaring them dead hasn't laid hands on the patient. That was the case here, and also when 2 EMT's on Long Island called someone dead in a bathtub - the patient was actually profoundly hypothermic.

Decapitation, obvious decomposition, livor mortis, rigor mortis, asystole (in 2 or more leads - although this is theoretical), and "injuries incompatible with life" (such as transection of the thorax or abdomen, electrocution causing incineration, corporeal explosive injuries, exposed brain matter without vital signs, and so on) are some of the common reasons from state to state for out-of-hospital pronunciation of death.

 

[docB]

So I had a temper tantrum in the ED. I had a ~47 yo F who came in for vag bleed. It was pretty silly. She came to the ER because her period went 1 day long and she had been told she had fibroids years ago. CBC was normal, vitals stable, minimal bleeding on exam. Patient wouldn't wait on the US and left AMA with a referral to the GYN on call.

Here's where the fun begins. She shows up in another ED (where I was working by coincidince) for the same thing. I ask her what happened, why didn't she follow up with GYN. Now I don't expect much. I was expecting her to give me the usual reasons for Vegas, they won't take my Medicaid, they can't see me until 2028 or whatever. No. "They told me I HAVE TO HAVE AN ULTRASOUND IN THE ER BEFORE THEY CAN SEE ME." So, apparently, a BOARD CERTIFIED GYNECOLOGIST can't deal with a complex problem like this (vaginal bleeding) without the patient getting worked up in an ER first.

So there I am shaking with rage when I call the GYN in question. I was then told that indeed the GYN wanted an ultrasound prior to ever seeing the patient. Furthermore, since the patient was referred from the ER the patient should go back to the ER rather than being referred for an outpatient ultrasound because, after all, THE GYN HAS NEVER SEEN THE PATIENT. So I explain to the GYN that it's really not appropriate to abuse the ED like this. Here's the cherry on top. The GYN replies "Oh well. It doesn't matter to me. Now that she's back in the ER SHE SHOULD GO TO WHOEVER IS ON CALL TODAY."

Needless to say this was followed up with a rather heated discussion of bylaws and an animated conference with administration. It was one of the most blatently s----y things I've ever seen a doc do to a patient and the ED.

 

[iliacus]

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

And they wonder why Wal-Mart is is replacing them with NP's 🙄

 

[Wackie]

So I had a temper tantrum in the ED. I had a ~47 yo F who came in for vag bleed. It was pretty silly. She came to the ER because her period went 1 day long and she had been told she had fibroids years ago. CBC was normal, vitals stable, minimal bleeding on exam. Patient wouldn't wait on the US and left AMA with a referral to the GYN on call.

Here's where the fun begins. She shows up in another ED (where I was working by coincidince) for the same thing. I ask her what happened, why didn't she follow up with GYN. Now I don't expect much. I was expecting her to give me the usual reasons for Vegas, they won't take my Medicaid, they can't see me until 2028 or whatever. No. "They told me I HAVE TO HAVE AN ULTRASOUND IN THE ER BEFORE THEY CAN SEE ME." So, apparently, a BOARD CERTIFIED GYNECOLOGIST can't deal with a complex problem like this (vaginal bleeding) without the patient getting worked up in an ER first.

So there I am shaking with rage when I call the GYN in question. I was then told that indeed the GYN wanted an ultrasound prior to ever seeing the patient. Furthermore, since the patient was referred from the ER the patient should go back to the ER rather than being referred for an outpatient ultrasound because, after all, THE GYN HAS NEVER SEEN THE PATIENT. So I explain to the GYN that it's really not appropriate to abuse the ED like this. Here's the cherry on top. The GYN replies "Oh well. It doesn't matter to me. Now that she's back in the ER SHE SHOULD GO TO WHOEVER IS ON CALL TODAY."

Needless to say this was followed up with a rather heated discussion of bylaws and an animated conference with administration. It was one of the most blatently s----y things I've ever seen a doc do to a patient and the ED.

Is the phone jack still in the wall? If so, kudos for not hurling the phone across the department.

 

[ERMudPhud]

I was thinking of this thread just the other day. I got an endstage MS, history of CVA, bedridden nursing home patient transported from more than 25 miles away. She went past several hospitals on her way to see me. The paramedics told me they were ordered to bypass those other hospitals to come all the way to my little ED in the sticks. They were told she was at her neurologic baseline but had hypokalemia (k=2.6) unresponsive to oral therapy. I checked her k and it was 4.2 so I was getting ready to send her back when I found a cryptic order amonsgst her 20 pages of nursing home records to send her to ERMUDPHUD's ER for "CT,EEG, and neuro consult" Now I 'm really confused. I can't get a non-emergent EEG until monday and probably couldn't get a neuro consult until then either. Besides who orders those things for a patient at their baseline in the middle of friday night? I eventually track down the doc listed as having given the above order at home. She is upset I've called her house, denies having issued the above order, but says its not a bad idea since the patient, although at her baseline currently, has had intermittant episodes of depressed mental status over the last 2 weeks. Perhaps she's having seizures. I then track down the doc who actually was on call all day and evening for the nursing home. He also denies the order. So, did the nurses just make up the order to send the patient miles away on friday night to a little tiny ER where I can't possibly get the requested work up until monday? In the end neuro agreed to see her and arrange an outpatient EEG on monday and we sent her all the way back to her nursing home.

 

[docB]

I was thinking of this thread just the other day. I got an endstage MS, history of CVA, bedridden nursing home patient transported from more than 25 miles away. She went past several hospitals on her way to see me. The paramedics told me they were ordered to bypass those other hospitals to come all the way to my little ED in the sticks. They were told she was at her neurologic baseline but had hypokalemia (k=2.6) unresponsive to oral therapy. I checked her k and it was 4.2 so I was getting ready to send her back when I found a cryptic order amonsgst her 20 pages of nursing home records to send her to ERMUDPHUD's ER for "CT,EEG, and neuro consult" Now I 'm really confused. I can't get a non-emergent EEG until monday and probably couldn't get a neuro consult until then either. Besides who orders those things for a patient at their baseline in the middle of friday night? I eventually track down the doc listed as having given the above order at home. She is upset I've called her house, denies having issued the above order, but says its not a bad idea since the patient, although at her baseline currently, has had intermittant episodes of depressed mental status over the last 2 weeks. Perhaps she's having seizures. I then track down the doc who actually was on call all day and evening for the nursing home. He also denies the order. So, did the nurses just make up the order to send the patient miles away on friday night to a little tiny ER where I can't possibly get the requested work up until monday? In the end neuro agreed to see her and arrange an outpatient EEG on monday and we sent her all the way back to her nursing home.

I know for a fact that a few of the nursing home docs have told the nurses not to call them between midnight and six and to just write a verbal order to send to the ER and they'll back them up. Needless to say the nurses use this to dump their problem patients or just clear the house if they're short. We managed to get this practice slowed down dramatically by adopting a "call the attending on arrival to the ED" policy.

 

[iliacus]

There are a great many things I like about EM, but being on-call for lazy PMD's is not one of them. I love the "call the attending on arrival to the ed" policy. I bet the PMD's just send the patients to another ED that doesn't have this policy.

 

[docB]

Ortho sees a patient in his office on Tuesday 3 weeks out from a total knee that's now oozing pus. He tells patient "Here's a script for some antibiotics. I'll operate on you on Friday which is my surgery day. Go the the ER on Thursday to get admitted. Go in early because they're not busy in the mornings."


I didn't really do anything other than get a culture and a CBC, start some antibiotics and call the patient's HMO hospitalist (that's right, the ortho doesn't even admit the patient). ED + physician bill will probably be ~$1500. Going through the ED saved the Ortho having to call the HMO and the hospital to arrange a direct admit. That's $750 per phone call. Only lawyers charge that for a phone call. I you envision health care as being like the festering carcass of a dead animal (as I do) idiots like this are poking it with a stick.

 

[pseudoknot]

If you envision health care as being like the festering carcass of a dead animal (as I do)...

Quote of the day.

 

[BadVB750]

Yesterday at our Children's ED I saw a pt that was sent in for a procedural sedation for suture removal. Granted the kid fought but he wasn't that f&^%ing strong.

In the children's ED we preform whatever test into the PMDs head, which really drives me crazy.

 

[WilcoWorld]

Yesterday at our Children's ED I saw a pt that was sent in for a procedural sedation for suture removal. Granted the kid fought but he wasn't that f&^%ing strong.

In the children's ED we preform whatever test into the PMDs head, which really drives me crazy.

So did you sedate the kid?

Not to thread-hijack - as this is one of our best threads in recent memory - but this is a good time to mention the following pearl; If a kid is obviously going to be a real fighter when you suture him/her then you should use absorbable sutures whenever posible in order to avoid a rematch 5-10 days later.

 

[BadVB750]

So did you sedate the kid?

Not to thread-hijack - as this is one of our best threads in recent memory - but this is a good time to mention the following pearl; If a kid is obviously going to be a real fighter when you suture him/her then you should use absorbable sutures whenever posible in order to avoid a rematch 5-10 days later.

No, I just had one of the strong tech hold him and sip sip I was done.

 

[BKN]

So did you sedate the kid?

Not to thread-hijack - as this is one of our best threads in recent memory - but this is a good time to mention the following pearl; If a kid is obviously going to be a real fighter when you suture him/her then you should use absorbable sutures whenever posible in order to avoid a rematch 5-10 days later.

I disagree. Absorbables will not absorb fast enough and should not be used on skin. Will leave railroad track scars.

 

[tegs15]

I disagree. Absorbables will not absorb fast enough and should not be used on skin. Will leave railroad track scars.

Just use staples and give his parents the staple remover, problem solved!😱

 

[Hawkeye Kid]

I disagree. Absorbables will not absorb fast enough and should not be used on skin. Will leave railroad track scars.

I can't believe I'm about to do this, but I respectfully disagree with BKN, especially with respect to facial lacs. Our OMFS guys use fast absorbing gut on face lacs, and I especially do this in kids (though I usually do it in adults, too--especially if there are follow-up concerns). Here's the one article I know of about this:

Karounis H. Gouin S. Eisman H. Chalut D. Pelletier H. Williams B. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. [Clinical Trial. Comparative Study. Journal Article. Randomized Controlled Trial. Research Support, Non-U.S. Gov't] Academic Emergency Medicine. 11(7):730-5, 2004 Jul.

 

[docB]

I've had problems with fast absorbing gut. It's hard to find. We occasionally had it in residency and I've never seen it in any private hospital. It's packed in a liquid and is very slippery and hard to grasp with instruments. It breaks easily when you do grab it with an instrument. Those factors that make it hard to use under good circumstances make it really difficult to use on kid's faces while trying to work fast with brutane.

 

[Arcan57]

Our plastics guys will use Vicryl Rapide on the face, which isn't fantastic to work with but is more user friendly then gut.

 

[docB]

Attention PMDs:

If you send a patient to the ED of a hospital where you damn well know you don't have privileges or anyone to admit for you we know you are dumping. I will probably explain that to the patient as well.

Don’t tell your patient who you’re sending to the ED from your clinic in the MOB at 4:50pm on Friday that they’ll get seen right away. Every other doc in the building had the same idea about how to clear out their clinics and make their dinner reservations. Just tell your patient to follow the throng of people working their way toward the ED.

 

[docB]

I'm so stinkin' mad. Patient sent to the ER today from a PMD with the following note written on an Rx:

To ER physician:
[Patient's name] is [elderly] and has a history of prostate CA, CAD, s/p CABG and cardiomyopathy. He presented with severe rectal pain and fecal impaction on exam. He needs ER attention for manual disimpaction in a monitored environment.(their underline)

You have got to be kidding me! That's just utter crap! I'd have had more respect to that idiot PMD if he'd have just said he was dumping the guy because he's to squeemish and lazy to unplug the guy himself. What a jackass.

So I disimpacted him and gave him 2 fleets and he gave birth and left. Never went on a monitor for a second.

And I'm now referring all of my drug seeking, soul sucking dementors from Hell straight to that doofus's office and I'm giving them his office back line. Jerk.