“Well then why do I have this pain?” UGH!

[deleted836128]

We obviously all have cases in which we can’t crack why a patient is having particular symptoms. In these cases I typically explain that here in the emergency department we did these labs and those imaging studies and we determined that we don’t think any emergent connections are warranted. Usually patients are pretty satisfied with that and they leave the ER for outpatient PCP follow up.

That’s fine and dandy... but do any of you ever have days where it seems like most of your cases are medical mysteries? And the patient is so bothered that they have no answers that it kills you to not be able to give them an answer? They don’t stop asking questions and seeking answers? Today was one of those days for me. An old lady with severe left flank pain that resolved spontaneously and she wasn’t passing a stone, wasn’t dissecting, wasn’t having acute coronary syndrome, didn’t have a pulmonary embolism, didnt have a renal infarct, didn’t have pyelonephritis, didn’t seem to have a muscle strain, etc. Another old lady with right lower abdominal pain and an old man with right interscapular pain and another one with low back pain with epigastric pain. It’s one thing to have a case or two a shift that stumps me but to have half of my work ups today end with no answers for my patients - I feel stupid and incredibly defeated. With all of these patients I gave my usual lines, for example - “Your imaging showed that your kidneys looked normal; I didn’t see that you’re passing stones. I didn’t see blood clots in your lungs. Your pancreatic, liver and kidney tests look normal. I checked your heart, too, and I don’t think you’re heart attack. Your urine test shows you don’t have a UTI. So while I don’t have an exact answer for your symptoms my job here in the ER is to rule out emergency conditions, and I don’t think there are any emergency conditions going on today. So what we will do is send you home with some medications and have you see your PCP next week. Please come back if you get worsening pain, fevers or any new or worsening symptoms, okay?” Usually patients are good with that but today everyone said “Well, WHY am I HAVING this PAIN? Why did my left hand tingle? Why do I feel like something is in my throat? Why did I have diarrhea last week?” When diagnoses of muscle strain or viral syndrome just don’t cut it. And after about the fifteenth time of having zero answers I just feel... defeated.

Not sure what I am looking for by posting this... guess I just needed to vent and I know it’s gonna be a long night of insomnia wondering how my patients will fare, if I missed anything or if they felt they got crappy care...

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[GeneralVeers]

When diagnoses of muscle strain or viral syndrome just don’t cut it. And after about the fifteenth time of having zero answers I just feel... defeated.

Not sure what I am looking for by posting this... guess I just needed to vent and I know it’s gonna be a long night of insomnia wondering how my patients will fare, if I missed anything or if they felt they got crappy care...

Just tell them all they got "The Fiber Myalgia"

Seriously this is normal and you will see it every day. Get used to not being able to tell people why they have whatever minor symptom they came in for.

 

[Birdstrike]

We obviously all have cases in which we can’t crack why a patient is having particular symptoms. In these cases I typically explain that here in the emergency department we did these labs and those imaging studies and we determined that we don’t think any emergent connections are warranted. Usually patients are pretty satisfied with that and they leave the ER for outpatient PCP follow up.

That’s fine and dandy... but do any of you ever have days where it seems like most of your cases are medical mysteries? And the patient is so bothered that they have no answers that it kills you to not be able to give them an answer? They don’t stop asking questions and seeking answers? Today was one of those days for me. An old lady with severe left flank pain that resolved spontaneously and she wasn’t passing a stone, wasn’t dissecting, wasn’t having acute coronary syndrome, didn’t have a pulmonary embolism, didnt have a renal infarct, didn’t have pyelonephritis, didn’t seem to have a muscle strain, etc. Another old lady with right lower abdominal pain and an old man with right interscapular pain and another one with low back pain with epigastric pain. It’s one thing to have a case or two a shift that stumps me but to have half of my work ups today end with no answers for my patients - I feel stupid and incredibly defeated. With all of these patients I gave my usual lines, for example - “Your imaging showed that your kidneys looked normal; I didn’t see that you’re passing stones. I didn’t see blood clots in your lungs. Your pancreatic, liver and kidney tests look normal. I checked your heart, too, and I don’t think you’re heart attack. Your urine test shows you don’t have a UTI. So while I don’t have an exact answer for your symptoms my job here in the ER is to rule out emergency conditions, and I don’t think there are any emergency conditions going on today. So what we will do is send you home with some medications and have you see your PCP next week. Please come back if you get worsening pain, fevers or any new or worsening symptoms, okay?” Usually patients are good with that but today everyone said “Well, WHY am I HAVING this PAIN? Why did my left hand tingle? Why do I feel like something is in my throat? Why did I have diarrhea last week?” When diagnoses of muscle strain or viral syndrome just don’t cut it. And after about the fifteenth time of having zero answers I just feel... defeated.

Not sure what I am looking for by posting this... guess I just needed to vent and I know it’s gonna be a long night of insomnia wondering how my patients will fare, if I missed anything or if they felt they got crappy care...

Your job is to rule out life and limb threatening causes of these symptoms. If you tell them that they're in no acute danger from their symptoms and that you've ruled out the most serious causes, you've done your job. That should ease the fear of most rational people. If not, then at that point, you're dealing with anxiety that the patient has about the unknown. Yes, it is incredibly draining, because you can't cure a lifetime of overwrought, hardwired anxiety in a brief ED visit (if ever).

Patients should understand you can't be the ER doctor AND the internist/neurologist/Derm/psych/gyn/chiro/naturopath/plastics/peds-endocrine/hand-holder all in one body. But they don't.

As long as you've convinced yourself you've ruled out the bad stuff, you discharge them and move on. That's all you can do. You can be an ER doctor and you can be human. But you can't be all things to all people, all the time.

 

[GonnaBeADoc2222]

There's no medical mystery here. Americans have extremely low thresholds for running to the ED for every minor ache and pain.

 

[southerndoc]

"Your tests do not show anything serious. That doesn't mean you're not in pain. It could be (insert whatever here). I've reached the limit for what I can test for in the ER. I'm going to refer you back to your primary care physician for further workup and management."

Most of the time I tell them it's nerve pain (maybe an inflamed nerve). That usually gets them quiet enough until discharge.

Last night I had a 31 year old with a kidney stone who was pain free. Her mother wanted her admitted in case her pain came back. I told her I was prescribing ketorolac, oxycodone, etc. and gave her the location of a 24-hour pharmacist. "Can't you give her something before she goes home?" "Sure, I'll give her an oxycodone." "When will that wear off?" "It lasts for 6 hours." "So what are we going to do when it wears off at 4 am?" "As I said, you need to go to a 24-hour pharmacy to get her pain medications filled." "Are you seriously going to send her home and expect us to go to the pharmacy at midnight?" "Yes."

I'm sure she'll be selected for a Press-Ganey.

Perhaps I should've told her it lasts for 8-10 hours.

 

[GonnaBeADoc2222]

"Your tests do not show anything serious. That doesn't mean you're not in pain. It could be (insert whatever here). I've reached the limit for what I can test for in the ER. I'm going to refer you back to your primary care physician for further workup and management."

Most of the time I tell them it's nerve pain (maybe an inflamed nerve). That usually gets them quiet enough until discharge.

Last night I had a 31 year old with a kidney stone who was pain free. Her mother wanted her admitted in case her pain came back. I told her I was prescribing ketorolac, oxycodone, etc. and gave her the location of a 24-hour pharmacist. "Can't you give her something before she goes home?" "Sure, I'll give her an oxycodone." "When will that wear off?" "It lasts for 6 hours." "So what are we going to do when it wears off at 4 am?" "As I said, you need to go to a 24-hour pharmacy to get her pain medications filled." "Are you seriously going to send her home and expect us to go to the pharmacy at midnight?" "Yes."

I'm sure she'll be selected for a Press-Ganey.

Perhaps I should've told her it lasts for 8-10 hours.

You expect me to drive to a place where prescriptions are filled continuously 24 hours a day, where the script has already been sent literally through space, where it's already ready to be picked up, at a drive through where I don't need to exit my car?!?!?! Where is your compassion doctor?!

 

[Birdstrike]

"Sure, I'll give her an oxycodone." "When will that wear off?" "It lasts for 6 hours." "So what are we going to do when it wears off at 4 am?" "As I said, you need to go to a 24-hour pharmacy to get her pain medications filled." "Are you seriously going to send her home and expect us to go to the pharmacy at midnight?" "Yes."

I'm sure she'll be selected for a Press-Ganey.

Perhaps I should've told her it lasts for 8-10 hours.

"Yes, it will wear off in 6 hours, at the same exact time an IV or IM dose of opiates would wear off. And yes, you'll still have to go to the pharmacy at midnight. Or you can just go to the pharmacy now. (Why would you wait for the medications to wear off in the middle of the night and then go to the pharmacy if you know that's going to happen, when you could just go there on your way home now and sleep all night?! &^&^$@$^!)"

Some people want an instant cure and have unrealistic expectations. They want you to scoop right up in there in the kidney itself and pluck out those stones one by one, yourself, and do it painlessly while they scroll their facebook timeline and they munch on complimentary, vegan, gluten-free, non-GMO, compassionately grown, veggie munchies. (Just don't tell them they're 0% healthier than potato chips).

 

[Tenk]

Most people who act like this I just tell them that sometimes I order a ct and the person has metastatic cancer or they have to be rushed off to surgery and a select few will just have a terminal diagnosis and die. This will bring me to my take home point to the patient: you don’t want me to find anything because when I do it’s always bad. 100% bad. I never find a winning lotto ticket with a ct or a vacation to Hawaii. I find pain, suffering and death. When you frame it like this and make them realize they are upset about not having badness, the vast majority of people go “oh yeah” and “you’re right!” The key is how you say it. You can’t be annoyed that they are upset, you have to sound somewhat concerned but also relieved nothing is wrong with them.

 

[Perrin]

We obviously all have cases in which we can’t crack why a patient is having particular symptoms. In these cases I typically explain that here in the emergency department we did these labs and those imaging studies and we determined that we don’t think any emergent connections are warranted. Usually patients are pretty satisfied with that and they leave the ER for outpatient PCP follow up.

That’s fine and dandy... but do any of you ever have days where it seems like most of your cases are medical mysteries? And the patient is so bothered that they have no answers that it kills you to not be able to give them an answer? They don’t stop asking questions and seeking answers? Today was one of those days for me. An old lady with severe left flank pain that resolved spontaneously and she wasn’t passing a stone, wasn’t dissecting, wasn’t having acute coronary syndrome, didn’t have a pulmonary embolism, didnt have a renal infarct, didn’t have pyelonephritis, didn’t seem to have a muscle strain, etc. Another old lady with right lower abdominal pain and an old man with right interscapular pain and another one with low back pain with epigastric pain. It’s one thing to have a case or two a shift that stumps me but to have half of my work ups today end with no answers for my patients - I feel stupid and incredibly defeated. With all of these patients I gave my usual lines, for example - “Your imaging showed that your kidneys looked normal; I didn’t see that you’re passing stones. I didn’t see blood clots in your lungs. Your pancreatic, liver and kidney tests look normal. I checked your heart, too, and I don’t think you’re heart attack. Your urine test shows you don’t have a UTI. So while I don’t have an exact answer for your symptoms my job here in the ER is to rule out emergency conditions, and I don’t think there are any emergency conditions going on today. So what we will do is send you home with some medications and have you see your PCP next week. Please come back if you get worsening pain, fevers or any new or worsening symptoms, okay?” Usually patients are good with that but today everyone said “Well, WHY am I HAVING this PAIN? Why did my left hand tingle? Why do I feel like something is in my throat? Why did I have diarrhea last week?” When diagnoses of muscle strain or viral syndrome just don’t cut it. And after about the fifteenth time of having zero answers I just feel... defeated.

Not sure what I am looking for by posting this... guess I just needed to vent and I know it’s gonna be a long night of insomnia wondering how my patients will fare, if I missed anything or if they felt they got crappy care...

I have a script I say to them. There are a thousand things that can cause chest/abdominal/back pain or whatever symptom they have. There are about 10 that are life threatening that I can rule out by examining you and doing tests. My exam findings an the tests point to you not having any of these. The rest on the list have to be tested for or seen by a specialist. I believe you that you are feeling symptom X. It is frustrating to not be able to get an answer right away. It is also frustrating for me to not be able to give you an answer. However, I can tell you that it is very unlikely that it is something life threatening based on my exam and the tests we have run. Keep in mind that during the disease process, some symptoms don’t show themselves until later. If X concerning symptoms do happen, you can return and we will re-examine you and adjust our approach. In the meantime, I will refer you back to your PMD or a specialist for more focused testing.

This is almost always done while sitting on the bedside stool and making eye contact with the patient and concerned family member(s).

 

[GeneralVeers]

Last night I had a 31 year old with a kidney stone who was pain free. Her mother wanted her admitted in case her pain came back. I told her I was prescribing ketorolac, oxycodone, etc. and gave her the location of a 24-hour pharmacist. "Can't you give her something before she goes home?" "Sure, I'll give her an oxycodone." "When will that wear off?" "It lasts for 6 hours." "So what are we going to do when it wears off at 4 am?" "As I said, you need to go to a 24-hour pharmacy to get her pain medications filled." "Are you seriously going to send her home and expect us to go to the pharmacy at midnight?" "Yes."

You are far nicer than I would have been. I don't prescribe narcotics for pain that is resolved that "might" come back. I also wouldn't have given her a pain pill to go home with....since she had no freakin' pain!

Percogesic was invented for a reason.....

 

[BoardingDoc]

Percogesic was invented for a reason.....

For those like me that had never heard of it, but are too lazy to google it: it's a combo pill of tylenol and benadryl.

 

[southerndoc]

You are far nicer than I would have been. I don't prescribe narcotics for pain that is resolved that "might" come back. I also wouldn't have given her a pain pill to go home with....since she had no freakin' pain!

Percogesic was invented for a reason.....

You wouldn't prescribe opiates for a 3 mm stone in the UVJ with moderate hydro because they're pain free at the time? Almost all of them develop pain again until they actually pass it.

 

[GeneralVeers]

You wouldn't prescribe opiates for a 3 mm stone in the UVJ with moderate hydro because they're pain free at the time? Almost all of them develop pain again until they actually pass it.

You didn't put that in your vignette. You said "had a kidney stone" but not that it was still there, and with hydro. I'd probably prescribe ketorolac anyway rather than narcs as I find it generally works better for the colicky pain.

 

[thegenius]

We obviously all have cases in which we can’t crack why a patient is having particular symptoms. In these cases I typically explain that here in the emergency department we did these labs and those imaging studies and we determined that we don’t think any emergent connections are warranted. Usually patients are pretty satisfied with that and they leave the ER for outpatient PCP follow up.

That’s fine and dandy... but do any of you ever have days where it seems like most of your cases are medical mysteries? And the patient is so bothered that they have no answers that it kills you to not be able to give them an answer? They don’t stop asking questions and seeking answers? Today was one of those days for me. An old lady with severe left flank pain that resolved spontaneously and she wasn’t passing a stone, wasn’t dissecting, wasn’t having acute coronary syndrome, didn’t have a pulmonary embolism, didnt have a renal infarct, didn’t have pyelonephritis, didn’t seem to have a muscle strain, etc. Another old lady with right lower abdominal pain and an old man with right interscapular pain and another one with low back pain with epigastric pain. It’s one thing to have a case or two a shift that stumps me but to have half of my work ups today end with no answers for my patients - I feel stupid and incredibly defeated. With all of these patients I gave my usual lines, for example - “Your imaging showed that your kidneys looked normal; I didn’t see that you’re passing stones. I didn’t see blood clots in your lungs. Your pancreatic, liver and kidney tests look normal. I checked your heart, too, and I don’t think you’re heart attack. Your urine test shows you don’t have a UTI. So while I don’t have an exact answer for your symptoms my job here in the ER is to rule out emergency conditions, and I don’t think there are any emergency conditions going on today. So what we will do is send you home with some medications and have you see your PCP next week. Please come back if you get worsening pain, fevers or any new or worsening symptoms, okay?” Usually patients are good with that but today everyone said “Well, WHY am I HAVING this PAIN? Why did my left hand tingle? Why do I feel like something is in my throat? Why did I have diarrhea last week?” When diagnoses of muscle strain or viral syndrome just don’t cut it. And after about the fifteenth time of having zero answers I just feel... defeated.

Not sure what I am looking for by posting this... guess I just needed to vent and I know it’s gonna be a long night of insomnia wondering how my patients will fare, if I missed anything or if they felt they got crappy care...

I hear ya man. Sometimes you can’t win. I think these encounters are sometimes difficult because of pt education and their overall sense of how the health care system can help them. I work at two hospitals....one is in a low-to-mid socioeconomic area and the other is in a very wealthy neighborhood. I have lots of your encounters in the first ER I described and few in the second ER.

Some patients just don’t understand the concept that the ER is NOT a one-stop place for all your ailments. And I often tell them as such. I’ll say **** like...”I literally cannot run every test possible and call every consultant and expect them to come to the ER, or admit you to cure you.” “It simply doesn’t work that way.”

Plus....most of the time these patients aren’t telling you the truth anyway.....like the 28 yo woman with vomiting, or cyclic vomiting, who comes in 2-3x/month for a year. They don’t tell you that they are eating Popeye’s every single f’ing day.....or they are stressed out at work or they do unhealthy stuff but they won’t tell you.

“Have you had this symptom before?”

“Uhh no.”

<you do a chart review, come back 5 mins later...>

“Then why have you been here 18 times over the past 2 years for this same symptom?”

 

[thegenius]

Most people who act like this I just tell them that sometimes I order a ct and the person has metastatic cancer or they have to be rushed off to surgery and a select few will just have a terminal diagnosis and die. This will bring me to my take home point to the patient: you don’t want me to find anything because when I do it’s always bad. 100% bad. I never find a winning lotto ticket with a ct or a vacation to Hawaii. I find pain, suffering and death. When you frame it like this and make them realize they are upset about not having badness, the vast majority of people go “oh yeah” and “you’re right!” The key is how you say it. You can’t be annoyed that they are upset, you have to sound somewhat concerned but also relieved nothing is wrong with them.

Dude that is sweet....I like this. I say a variant of this often but your approach is much more direct.

I’m using your lines

 

[Zebra Hunter]

The most obnoxious patient encounters are the ones showing up expecting answers for their subacute to chronic complaint that has already been evaluated by other physicians and actually has appointment that same day with a specialist for that specific complaint, but decided to come to the f***ing ER instead. Seems like this happens at least once a month.

Recently had a woman with a mildly painful rash for 2 months who had an appointment with their dermatologist an hour after they showed up to the ER because she wanted blood work to figure out what was going on. "Well I had an appointment with the dermatologist in an hour, but I just HAD to come here instead." It is one of the few times where I was openly disparaging to a patient. "Really, you HAD to come here? So you decided to come get the opinion of an ER doctor in lieu of an appointment with the literal skin specialist for an issue that has been going on for 2 months, and all you had to do was wait a whole hour?" ....."So you aren't going to do any blood work?" ....facepalm.... "No, you've seen multiple physicians for this complaint, none of them have a clear answer for you and I am no different, you have an appointment in an hour with the skin specialist, I strongly advise that you leave here and make that appointment."

 

[dadaddadaBATMAN]

The most obnoxious patient encounters are the ones showing up expecting answers for their subacute to chronic complaint that has already been evaluated by other physicians and actually has appointment that same day with a specialist for that specific complaint, but decided to come to the f***ing ER instead. Seems like this happens at least once a month.

Recently had a woman with a mildly painful rash for 2 months who had an appointment with their dermatologist an hour after they showed up to the ER because she wanted blood work to figure out what was going on. "Well I had an appointment with the dermatologist in an hour, but I just HAD to come here instead." It is one of the few times where I was openly disparaging to a patient. "Really, you HAD to come here? So you decided to come get the opinion of an ER doctor in lieu of an appointment with the literal skin specialist for an issue that has been going on for 2 months, and all you had to do was wait a whole hour?" ....."So you aren't going to do any blood work?" ....facepalm.... "No, you've seen multiple physicians for this complaint, none of them have a clear answer for you and I am no different, you have an appointment in an hour with the skin specialist, I strongly advise that you leave here and make that appointment."

Reading this thread is bad for my blood pressure.

 

[GeneralVeers]

My least favorite are the back pain patients. Points if they show up by EMS! So you've had this back pain for 20 years, you had surgery 10 years ago for, you saw your specialist last week, and you are already taking oxycodone. What can I do for you today? Seriously, there is not a damn thing I can do for these people but they show up anyway.

 

[Birdstrike]

EVERYTHING'S NORMAL.

Britney is a 39-yr-old female, hair sassy and perfect, expensive earrings and unquestionable clothes. She comes in demanding a CT because she's convinced she's dying of hidden, metastatic cancer. You sense the anxiety, decided you just don't have the energy to fight it tonight, so you order the CT and every other test that you might possibly need to see this woman at ease that you've ruled out every legitimately possible life or limb threatening zebra. You set that all in motion and move on the the next ever enlarging swarm of patients.

A time later, you check the results. It's all normal. You sigh in relief, glad you have good news to diffuse the tension, set this person at ease, so you both can go about your very busy day.

You then proceed to tell her everything is okay, everything is normal. Then, like a depth charge has exploded somewhere in the bowels of her core, her eyes bug out of her head, HORRIFIED, of the result. "Oh my God. You're telling me it's NORMAL!!!??" She's starts to get angry at you, you can feel the tension building. "No *#&$^ing WAY it's all normal!"

You rock back on your heels, stunned. You think, what the fark have I gotten myself into? Why did I choose this career, this thankless life...? You hear rumblings in the background of a pediatric code coming in. You're painfully reminded that it's 4am, your last partner just left and you're the only doc in the ED for the next three hours. There's too many in the waiting room to count.

"No way! I'm not going home until you tell me what's wrong! Why the hell do I feel this way? Call my doctor right now. I want you to call my doctor! He'll figure this out."

The older woman next to her, who's been shaking her head in disgust the entire visit decides to chime in, "This same thing happened to my friend's ex-mother in law and it turned out she had mold BLOOD poisoning and they ended up suing the doctor. It ended up on the news. You better do something."

You hear some chaos to your right and a nurse say, "The peds code's here doc."

Just another day at the office. Everything's normal.

 

[Birdstrike]

My least favorite are the back pain patients. Points if they show up by EMS! So you've had this back pain for 20 years, you had surgery 10 years ago for, you saw your specialist last week, and you are already taking oxycodone. What can I do for you today? Seriously, there is not a damn thing I can do for these people but they show up anyway.

First question, "Were you discharged by your doctor last week?"

 

[thegenius]

I hate back pain for other reasons too.... it is seemingly the only pain that is refractory to analgesics of any kind. Nothing seems to make these people feel better. So damn frustrating and hard to take care of.

 

[GonnaBeADoc2222]

EVERYTHING'S NORMAL.

Britney is a 39-yr-old female, hair sassy and perfect, expensive earrings and unquestionable clothes. She comes in demanding a CT because she's convinced she's dying of hidden, metastatic cancer. You sense the anxiety, decided you just don't have the energy to fight it tonight, so you order the CT and every other test that you might possibly need to see this woman at ease that you've ruled out every legitimately possible life or limb threatening zebra. You set that all in motion and move on the the next ever enlarging swarm of patients.

A time later, you check the results. It's all normal. You sigh in relief, glad you have good news to diffuse the tension, set this person at ease, so you both can go about your very busy day.

You then proceed to tell her everything is okay, everything is normal. Then, like a depth charge has exploded somewhere in the bowels of her core, her eyes bug out of her head, HORRIFIED, of the result. "Oh my God. You're telling me it's NORMAL!!!??" She's starts to get angry at you, you can feel the tension building. "No *#&$^ing WAY it's all normal!"

You rock back on your heels, stunned. You think, what the fark have I gotten myself into? Why did I choose this career, this thankless life...? You hear rumblings in the background of a pediatric code coming in. You're painfully reminded that it's 4am, your last partner just left and you're the only doc in the ED for the next three hours. There's too many in the waiting room to count.

"No way! I'm not going home until you tell me what's wrong! Why the hell do I feel this way? Call my doctor right now. I want you to call my doctor! He'll figure this out."

The older woman next to her, who's been shaking her head in disgust the entire visit decides to chime in, "This same thing happened to my friend's ex-mother in law and it turned out she had mold BLOOD poisoning and they ended up suing the doctor. It ended up on the news. You better do something."

You hear some chaos to your right and a nurse say, "The peds code's here doc."

Just another day at the office. Everything's normal.

This is usually about the time that I call security

 

[Zebra Hunter]

This is usually about the time that I call security

Yup. This is where I print out dc paperwork. Tell the charge nurse this patient is going to be a problem; however, I have performed a more than thorough evaluation of her with multiple CTs, already spoke w/ her at length, and stated that she has been discharged, and if she refuses to leave, call security to escort her out.

She then gets an appropriate psychiatric diagnosis listed on her chart which has the added benefit of this leading to her not getting a patient satisfaction survey for her visit.

 

[deleted836128]

The most obnoxious patient encounters are the ones showing up expecting answers for their subacute to chronic complaint that has already been evaluated by other physicians and actually has appointment that same day with a specialist for that specific complaint, but decided to come to the f***ing ER instead. Seems like this happens at least once a month.

Recently had a woman with a mildly painful rash for 2 months who had an appointment with their dermatologist an hour after they showed up to the ER because she wanted blood work to figure out what was going on. "Well I had an appointment with the dermatologist in an hour, but I just HAD to come here instead." It is one of the few times where I was openly disparaging to a patient. "Really, you HAD to come here? So you decided to come get the opinion of an ER doctor in lieu of an appointment with the literal skin specialist for an issue that has been going on for 2 months, and all you had to do was wait a whole hour?" ....."So you aren't going to do any blood work?" ....facepalm.... "No, you've seen multiple physicians for this complaint, none of them have a clear answer for you and I am no different, you have an appointment in an hour with the skin specialist, I strongly advise that you leave here and make that appointment."

Oh...my God. My blood is absolutely boiling reading this. I have had patients do this. I had a guy come in for six YEARS of back pain and "it's not bothering me right now but I wanted to get checked." When I asked him why he came to the emergency department today of all days for the pain, he said, "Well I am tired of it and I finally just want to figure out what is going on" (we have all heard that line...are you f-ing kidding me?). I told him he did not need any emergent MRI but that I can get a quick x-ray. He said, "Okay, but I need to be out of here by 11:00. I am seeing my doctor for this back pain after this."

 

[RustedFox]

Oh...my God. My blood is absolutely boiling reading this. I have had patients do this. I had a guy come in for six YEARS of back pain and "it's not bothering me right now but I wanted to get checked." When I asked him why he came to the emergency department today of all days for the pain, he said, "Well I am tired of it and I finally just want to figure out what is going on" (we have all heard that line...are you f-ing kidding me?). I told him he did not need any emergent MRI but that I can get a quick x-ray. He said, "Okay, but I need to be out of here by 11:00. I am seeing my doctor for this back pain after this."

Reason number 212 why it's okay to hate the muggles.

 

[deleted836128]

I had a lady come in for headaches and neck pain. It was one of those classic "I have never had this before; this is all new" and you go back and look at their chart and they've been diagnosed with "migraines" and "chronic neck pain" and they've been seen for this every month for the last two years. I went back in the room and told her "I looked at your chart and it actually looks like this has been going on for a long time." It was not until THEN that she told me "Yeah, but I have seen three neurologists, a neurosurgeon, an orthopedist, and my PCP. I have gone to pain management for Botox and steroid injections. I did physical therapy. I had an MRI of the cervical spine last month. And no one can tell me what is causing this!" I again asked her if there is anything new going on and she said no. So I said in the nicest way possible, "What were you hoping to accomplish by coming to the emergency department today?" She said "I need a head CT; I think I could have brain cancer." I ordered labs on this woman along with a head CT, and ordered some pain medication for her. An hour later I went back to see her and tell her the results and the nurse said she had just walked out "because no one was listening to her and she said you didn't address her pain." Later on there was a Google review and this patient was talking sh-t about me for having asked her what she was trying to accomplish by coming to the emergency department...

 

[thegenius]

She then gets an appropriate psychiatric diagnosis listed on her chart which has the added benefit of this leading to her not getting a patient satisfaction survey for her visit.

For real? That is true?

Word.

"Number of non-compliant schizophrenics in Northern California has skyrocketed 1,200% in the last 3 months. It is now estimated that 1 out of every 3 people have recalcitrant schizophrenia and anxiety."

 

[thegenius]

I had a lady come in for headaches and neck pain. It was one of those classic "I have never had this before; this is all new" and you go back and look at their chart and they've been diagnosed with "migraines" and "chronic neck pain" and they've been seen for this every month for the last two years. I went back in the room and told her "I looked at your chart and it actually looks like this has been going on for a long time." It was not until THEN that she told me "Yeah, but I have seen three neurologists, a neurosurgeon, an orthopedist, and my PCP. I have gone to pain management for Botox and steroid injections. I did physical therapy. I had an MRI of the cervical spine last month. And no one can tell me what is causing this!" I again asked her if there is anything new going on and she said no. So I said in the nicest way possible, "What were you hoping to accomplish by coming to the emergency department today?" She said "I need a head CT; I think I could have brain cancer." I ordered labs on this woman along with a head CT, and ordered some pain medication for her. An hour later I went back to see her and tell her the results and the nurse said she had just walked out "because no one was listening to her and she said you didn't address her pain." Later on there was a Google review and this patient was talking sh-t about me for having asked her what she was trying to accomplish by coming to the emergency department...

I was kind of hopin you said the CT did show brain cancer. Then our world would be out of that misery in another 1-2 years

 

[Zebra Hunter]

Why do you always make threads/ posts in which you try to present yourself as a physician? It seems to be quite a common occurrence from your history. It’s beyond disingenuous.

Is it unreasonable to ask for a single thread on this board that does not turn into med students vs mid-levels? Nothing he/she said in this thread is disingenuous. Please take your crusade elsewhere.

 

[deleted836128]

Why do you always make threads/ posts in which you try to present yourself as a physician? It seems to be quite a common occurrence from your history. It’s beyond disingenuous.

When have I ever pretended to be a physician? I don’t misrepresent myself here or anywhere else. I have been completely transparent about the fact that I am a PA on this forum. I love what I do and am proud to do what I do. I respect the hell out of and value the physicians I work with and the physicians on this forum and love hearing what you all have to say. This is my favorite forum of all time! I don’t think that being a PA should prevent me from posting in an emergency medicine forum.

 

[Merely]

EVERYTHING'S NORMAL.

Britney is a 39-yr-old female, hair sassy and perfect, expensive earrings and unquestionable clothes. She comes in demanding a CT because she's convinced she's dying of hidden, metastatic cancer. You sense the anxiety, decided you just don't have the energy to fight it tonight, so you order the CT and every other test that you might possibly need to see this woman at ease that you've ruled out every legitimately possible life or limb threatening zebra. You set that all in motion and move on the the next ever enlarging swarm of patients.

A time later, you check the results. It's all normal. You sigh in relief, glad you have good news to diffuse the tension, set this person at ease, so you both can go about your very busy day.

You then proceed to tell her everything is okay, everything is normal. Then, like a depth charge has exploded somewhere in the bowels of her core, her eyes bug out of her head, HORRIFIED, of the result. "Oh my God. You're telling me it's NORMAL!!!??" She's starts to get angry at you, you can feel the tension building. "No *#&$^ing WAY it's all normal!"

You rock back on your heels, stunned. You think, what the fark have I gotten myself into? Why did I choose this career, this thankless life...? You hear rumblings in the background of a pediatric code coming in. You're painfully reminded that it's 4am, your last partner just left and you're the only doc in the ED for the next three hours. There's too many in the waiting room to count.

"No way! I'm not going home until you tell me what's wrong! Why the hell do I feel this way? Call my doctor right now. I want you to call my doctor! He'll figure this out."

The older woman next to her, who's been shaking her head in disgust the entire visit decides to chime in, "This same thing happened to my friend's ex-mother in law and it turned out she had mold BLOOD poisoning and they ended up suing the doctor. It ended up on the news. You better do something."

You hear some chaos to your right and a nurse say, "The peds code's here doc."

Just another day at the office. Everything's normal.

LOL

 

[Saddleshoes]

What ever happened to...
Hit them with a rubber chicken and say, "Don't do that!"

 

[The Knife & Gun Club]

Just last night - youngish guy, chronic constipation and hemorrhoids x1 year. Has seen PCP, GI, had a scope 2 weeks ago, been to the ED 5 times in the last 6 months with multiple negative CTs, and his wife was a neurologist.

Came in because “I just can’t take it anymore.” Asked if he took the lactulose we gave him last time he was here...nope...he didn’t like the taste. Instead he’s been taking “hundreds of different natural herbs from a pharmacy in Hong Kong” that he bought on the internet.

 

[The Knife & Gun Club]

Why do you always make threads/ posts in which you try to present yourself as a physician? It seems to be quite a common occurrence from your history. It’s beyond disingenuous.

Go find one of the 5 other midlevel threads and go bitch over there please.

 

[d2305]

Having had a recent bout of renal lithiasis, they only hurt when they're moving.

 

[BoardingDoc]

Just last night - youngish guy, chronic constipation and hemorrhoids x1 year. Has seen PCP, GI, had a scope 2 weeks ago, been to the ED 5 times in the last 6 months with multiple negative CTs, and his wife was a neurologist.

Came in because “I just can’t take it anymore.” Asked if he took the lactulose we gave him last time he was here...nope...he didn’t like the taste. Instead he’s been taking “hundreds of different natural herbs from a pharmacy in Hong Kong” that he bought on the internet.

Easy enough, just tell him to take the damn lactulose and DC him.

Also, as an aside, your signature should read "primum non nocere sine documentum." Sans is French, not Latin.

 

[The Knife & Gun Club]

Easy enough, just tell him to take the damn lactulose and DC him.

Also, as an aside, your signature should read "primum non nocere sine documentum." Sans is French, not Latin.

Yea not actually bad just stupefying how someone who’s clearly educated and has a physician spouse can still think we’ll fix chronic constipation in the ED.

And thanks for the catch - my Latin is not as good as it once was (not that it ever was good).

 

[GeneralVeers]

Yea not actually bad just stupefying how someone who’s clearly educated and has a physician spouse can still think we’ll fix chronic constipation in the ED.

And thanks for the catch - my Latin is not as good as it once was (not that it ever was good).

I have no qualms about just discharging this BS as quickly as possible with no testing. The nurses love it, and I get major bonus points from staff when I do it.

 

[RoyBasch]

Yea not actually bad just stupefying how someone who’s clearly educated and has a physician spouse can still think we’ll fix chronic constipation in the ED.

A lot of physicians do not understand the role of the emergency medicine and ER in general. The number of patients referred to the ER 'stat' for their asymptomatic blood pressure of 180/95 directly from their outpatient physicians' office confirms that fact.

 

[thegenius]

My least favorite are the back pain patients. Points if they show up by EMS! So you've had this back pain for 20 years, you had surgery 10 years ago for, you saw your specialist last week, and you are already taking oxycodone. What can I do for you today? Seriously, there is not a damn thing I can do for these people but they show up anyway.

Yea I tell these miserable folks that they came to the wrong doctor.

 

[thegenius]

A lot of physicians do not understand the role of the emergency medicine and ER in general. The number of patients referred to the ER 'stat' for their asymptomatic blood pressure of 180/95 directly from their outpatient physicians' office confirms that fact.

So this is interesting....

I think this way as well. And I often wonder if I need to change my approach and accept an alternative definition of the purpose of the ER in our health care system. Every single day I spend valuable energy and time trying to educate people on the role of the ER, what it means to have an emergency medical condition, this and that. It probably works 1 out of 100.

Maybe I should accept the new-age belief that the ER is really just a fancy urgent care for you come whenever you want to get your problems fixed. We are here for the convenience of citizens, physicians, and anyone else who musters enough energy to walk into the ER. Then I won't waste valuable energy every shift like I do, and I'll probably be happier.

If the following didn't bother me
- g-tube malfunction
- nephrostomy tube fell out
- stitch removal
- vag spotting for 6 weeks
- all chronic orthopedic problems
- "I just don't feel right"
- asymptomatic HTN
- mildly symptomatic HTN
- intermittent abd pain for 236 years
- skin tags
- every fever in a kid

I would probably be a happier person

 

[Perrin]

Later on there was a Google review and this patient was talking sh-t about me for having asked her what she was trying to accomplish by coming to the emergency department...

I had a lady come in for some vague complaints. Exam and workup were negative. I explained this to her and reassured her. She demanded I call her specialist who did a procedure on her 3 months ago to get her admitted. I explained that I wasn’t going to wake him up in the middle of the night for a now resolved problem that was unrelated to his specialty.

Later on, one of the nurses told me that the patient was posting screen caps of my online reviews and disparaging me in a local Facebook group for parents with children who are disabled.

I followed up and she went to our other hospital. She got admitted by the hospital it’s and her specialist wrote that there was nothing wrong with her and to discharge.

 

[southerndoc]

You can turn your online reviews off. Email HealthGrades, etc. and tell them that you are an emergency physician and do not want your online reviews posted or allow patients to review you. You may have to send them three or four emails, but they will eventually turn them off. Mine have been turned off for 4 years now. I turned them off despite having good reviews just to prevent a situation like you describe.

 

[RoyBasch]

You can turn your online reviews off. Email HealthGrades, etc. and tell them that you are an emergency physician and do not want your online reviews posted or allow patients to review you. You may have to send them three or four emails, but they will eventually turn them off. Mine have been turned off for 4 years now. I turned them off despite having good reviews just to prevent a situation like you describe.

I don't enjoy bad reviews as much as the next guy; however, for our business do they really matter? Does anybody choose which ER to go to by first checking the online reviews? For the kind of patients who do that, I think I would be glad if they self select to go to other facilities.

Furthermore; how do the patients know, which physicians are on shift? Are your unit clerks and triage teams in the habit of giving that information to inquiring patients? I work with a fair number of incompetent people and they do not do that.

 

[RustedFox]

I had a lady come in for some vague complaints. Exam and workup were negative. I explained this to her and reassured her. She demanded I call her specialist who did a procedure on her 3 months ago to get her admitted. I explained that I wasn’t going to wake him up in the middle of the night for a now resolved problem that was unrelated to his specialty.

Later on, one of the nurses told me that the patient was posting screen caps of my online reviews and disparaging me in a local Facebook group for parents with children who are disabled.

I followed up and she went to our other hospital. She got admitted by the hospital it’s and her specialist wrote that there was nothing wrong with her and to discharge.

Sue for libel.
Until one of us bites back, this nonsense will continue.

 

[Cheeni17]

Why do you always make threads/ posts in which you try to present yourself as a physician? It seems to be quite a common occurrence from your history. It’s beyond disingenuous.

Do you even lift or just argue with everyone in every thread. Midlevel got ur tongue bro?

 

[southerndoc]

I don't enjoy bad reviews as much as the next guy; however, for our business do they really matter? Does anybody choose which ER to go to by first checking the online reviews? For the kind of patients who do that, I think I would be glad if they self select to go to other facilities.

Furthermore; how do the patients know, which physicians are on shift? Are your unit clerks and triage teams in the habit of giving that information to inquiring patients? I work with a fair number of incompetent people and they do not do that.

I would think -- although I have no solid proof -- that if a patient has a bad experience, reads negative reviews of you, then they are more likely to complain/sue/etc. No, they can't review you prior to you seeing them.

 

[scummie]

Most people who act like this I just tell them that sometimes I order a ct and the person has metastatic cancer or they have to be rushed off to surgery and a select few will just have a terminal diagnosis and die. This will bring me to my take home point to the patient: you don’t want me to find anything because when I do it’s always bad. 100% bad. I never find a winning lotto ticket with a ct or a vacation to Hawaii. I find pain, suffering and death. When you frame it like this and make them realize they are upset about not having badness, the vast majority of people go “oh yeah” and “you’re right!” The key is how you say it. You can’t be annoyed that they are upset, you have to sound somewhat concerned but also relieved nothing is wrong with them.

This is actually really good. Gonna use this one next time.

 

[Apollyon]

This is actually really good. Gonna use this one next time.

I have been using it. I do give credit, though, with "A guy online wrote this".

 

[n2b8me]

We obviously all have cases in which we can’t crack why a patient is having particular symptoms. In these cases I typically explain that here in the emergency department we did these labs and those imaging studies and we determined that we don’t think any emergent connections are warranted. Usually patients are pretty satisfied with that and they leave the ER for outpatient PCP follow up.

That’s fine and dandy... but do any of you ever have days where it seems like most of your cases are medical mysteries? And the patient is so bothered that they have no answers that it kills you to not be able to give them an answer? They don’t stop asking questions and seeking answers? Today was one of those days for me. An old lady with severe left flank pain that resolved spontaneously and she wasn’t passing a stone, wasn’t dissecting, wasn’t having acute coronary syndrome, didn’t have a pulmonary embolism, didnt have a renal infarct, didn’t have pyelonephritis, didn’t seem to have a muscle strain, etc. Another old lady with right lower abdominal pain and an old man with right interscapular pain and another one with low back pain with epigastric pain. It’s one thing to have a case or two a shift that stumps me but to have half of my work ups today end with no answers for my patients - I feel stupid and incredibly defeated. With all of these patients I gave my usual lines, for example - “Your imaging showed that your kidneys looked normal; I didn’t see that you’re passing stones. I didn’t see blood clots in your lungs. Your pancreatic, liver and kidney tests look normal. I checked your heart, too, and I don’t think you’re heart attack. Your urine test shows you don’t have a UTI. So while I don’t have an exact answer for your symptoms my job here in the ER is to rule out emergency conditions, and I don’t think there are any emergency conditions going on today. So what we will do is send you home with some medications and have you see your PCP next week. Please come back if you get worsening pain, fevers or any new or worsening symptoms, okay?” Usually patients are good with that but today everyone said “Well, WHY am I HAVING this PAIN? Why did my left hand tingle? Why do I feel like something is in my throat? Why did I have diarrhea last week?” When diagnoses of muscle strain or viral syndrome just don’t cut it. And after about the fifteenth time of having zero answers I just feel... defeated.

Not sure what I am looking for by posting this... guess I just needed to vent and I know it’s gonna be a long night of insomnia wondering how my patients will fare, if I missed anything or if they felt they got crappy care...

"I don't know why... really I don't"

Our shifts are filled with uncertainty. I think your job satisfaction might improve the more you can accept this. And some shifts are harder than others for sure.