What would you do

[Seaglass]

45 yo previously healthy comes to the ED after a recent diagnosis of Pagets. SHe has diffuse severe chest and extremity pain and has been seen in the ED twice and at her PCP several times for this. She has been on percocet, vicodin, and now oxycontin without relief. She has very little improvement after 2mg Dilaudid x2 and toradol 30mg IV in the ED. Given the number of ohysician visits, persistence of symptoms, and lack of improvement in the ED medicine is consulted for admission for pain control. Discuss - what would happen at your house?

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[Derek]

Private Practice: Patient gets same day referal to pain specialist after speaking with PCP or PCP just admits.

County Program: Try to contact doc who started the Oxycontin, who is some guy covering for the PCP and only saw patient one time. After multiple pages to both, neither calls back. Finally, you opt to increase Oxycontin dose on your own. Several hours later and after several declined meal requests by the patient he/she is discharged home.

 

[DrQuinn]

Scan her chest, and admit her.

The admitting docs at my place wouldn't blink an eye.

I work at a place where there is ZERO questioning the ED doc on admissions.

Its great!
Now if I tried to admit it to the resident's medicine service, I would get a lot of balking, but that's why we have the private docs where I'm at.

I do believe in "intractable pain" as a straighforward admission. As long as its not a BSer.

Q

 

[Seaglass]

This patient had her chest scanned during her recent previous visit. It was private docs (hospitalists that cover for all local practices) that gave me the runaround. "It's just musculoskeletal pain" they yelled (at me).

 

[Apollyon]

This patient had her chest scanned during her recent previous visit. It was private docs (hospitalists that cover for all local practices) that gave me the runaround. "It's just musculoskeletal pain" they yelled (at me).

"Then you come see her and discharge her." Put it directly in their hands.

I find it interesting that hospitalists will give you a hard time. Now, in practice, I have the hospitalists, and they're a joy compared to some residents (but even the residents are more cheery and helpful here, mostly, than with whom I dealt with when I was a resident).

 

[DrQuinn]

This patient had her chest scanned during her recent previous visit. It was private docs (hospitalists that cover for all local practices) that gave me the runaround. "It's just musculoskeletal pain" they yelled (at me).

Do they say the same for sickle cell crisis?

Sometimes, what I do, is bring it down a level.

"Dude, this is a real nice 60 year old woman, with a $hitty diagnosis and a poor prognosis. She's in pain, intractable pain. I dont' need her admitted for a week... just some relief, temporarily, then you can discharge her. If this were your mother, would you want me to boot her out of my ER?!?!"

Thankfully I've only had to do that once during residency.... (not since I'm an attending), but it worked great.

Q

 

[BADMD]

This patient had her chest scanned during her recent previous visit. It was private docs (hospitalists that cover for all local practices) that gave me the runaround. "It's just musculoskeletal pain" they yelled (at me).

If I tried to put the patient in for ACS evaluation, they would probably give me a hard time.

If I tried to bring the patient in for pain control, I'd get the most resistance from case management, but minimal resistance from the inpatient service.

 

[roja]

We have direct admitting here. We get almost no balking for intractable pain admissions.

 

[docB]

In my house I'd get crap if they were uninsured. Less if they were insured. The HMO docs would refuse to admit. They'd come down and discharge the patient themselves. I believe they sign a contract that allows the HMO to cut their nuts off if they admit for pain control.

A few things that may help is that many patients with severe pain have other diagnoses that are more reimbursable than "chronic intractable pain." If they are unable to tolerate PO or can't walk and do ADLs, if they syncopized or have chest pain you can put the emphesis on those which will often result in an easier sale.

 

[Apollyon]

A few things that may help is that many patients with severe pain have other diagnoses that are more reimbursable than "chronic intractable pain." If they are unable to tolerate PO or can't walk and do ADLs, if they syncopized or have chest pain you can put the emphasis on those which will often result in an easier sale.

Again, more jewels and gold from docB. The "I can't walk" is the biggest PITA - bar none - for disposition. However, "can't do ADLs" is a big ol' gift, wrapped up with a big bow - JCAHO loves it, the case managers eat it up, and you have a LOT of leverage to dispo the patient and try to do the right thing.

Also, the other stuff does indeed make it a much easier sale - syncope, chest pain, and unable to tolerate PO. Score! And, likewise, if someone wants to be borderline immoral and refuse those admissions, they can come right down to bedside and look the patient in the eye and say that.

No matter how much people try to say "EM docs suck", God's honest truth, I've seen as many EM docs make the inappropriate discharge or dump as I have seen IM and surgery screwups (that is, rarely).

 

[Haemr Head]

Since we are the experts on disposition, first you want to be sure that the patient really needs an inpatient bed.

If you live, as many of us do, with crowding, then lack of inpatient beds is the single greatest problem facing emergency medicine today. Low case mix admissions with a high chance denial by the insurance company are part of the problem that leads to ED crowding. An OBS unit can be a handy solution for patients like this. You give them optimal pain control overnight and work in the morning with case management, their PCP (if this person exists) or a pain clinic. Not only does it avoid having to negotiate with our lovely colleagues who can’t be bothered caring for the patient, but it transfers income from internal medicine to emergency medicine. OBS can be set up so people know how to set up a pain care protocol that determines when she should use the ED, how her pain should be managed in the ED, and when she should be admitted.

Assuming you don’t have an OBS unit and feel that she needs to be admitted. I fully agree with the strategies outlined by DocB and Apollyon. You need to sell the admission using both medical risk and social reasons. It is critical to document this as well. The reasons listed (can’t function at home – r/o life threats presenting a chest pain) will help avoid denial of payment when the hospital bills the technical fee. Hospital administrators do not like seeing rising denial rates and Medicare among others is on the warpath these days.

If dealing with a consultant who is not totally hopeless, point out that it is not cost effective to send her home because she will keep coming back and using the very expense ED multiple times. Ask them if this is how they would want one of their relatives managed. They do have the right to sign the patient out, but if you really felt she needed to be admitted, it shouldn’t sit well. If you feel it is negligent to send the patient home, do not assume that the consultant seeing the patient and signing the chart will be good legal protection or ethically acceptable. When a crime is being committed you need to do everything you can to stop it. This is when calling the ED director at home is appropriate. If he/she doesn’t want to be wakened for this, they need to think about a new career. If nothing else , call 911 to report an attempted homicide. It actually won’t work and might get you fired but it sure is good for a few laughs.

However, when a reasonable admission is blocked and these efforts fail, you are dealing with a troll. The underlying motive is not cost saving, patient care, or good medicine. It is good old fashion all American work aversion. Some basic rules in dealing with trolls:

• Do not loose your temper.
• Do not joust in the chart.
• Tell them you feel very uncomfortable with the decision and feel it is important that the patient be admitted. That you fully support that the case should be reviewed by the respective heads of department the next day, and that it is always better to be safe than sorry.
• Apologize for bothering them, saying you were actually trying to reach a doctor and must have gotten their number by mistake.
• Tell them that you will keep the patient overnight in the ED and let cooler heads work it out in the morning.

 

[DeLaughterDO]

If nothing else , call 911 to report an attempted homicide. It actually won't work and might get you fired but it sure is good for a few laughs.

snip ...

Apologize for bothering them, saying you were actually trying to reach a doctor and must have gotten their number by mistake.

Holy crap!!

 

[roja]

If dealing with a consultant who is not totally hopeless, point out that it is not cost effective to send her home because she will keep coming back and using the very expense ED multiple times. Ask them if this is how they would want one of their relatives managed. They do have the right to sign the patient out, but if you really felt she needed to be admitted, it shouldn't sit well. If you feel it is negligent to send the patient home, do not assume that the consultant seeing the patient and signing the chart will be good legal protection or ethically acceptable. When a crime is being committed you need to do everything you can to stop it. This is when calling the ED director at home is appropriate. If he/she doesn't want to be wakened for this, they need to think about a new career. If nothing else , call 911 to report an attempted homicide. It actually won't work and might get you fired but it sure is good for a few laughs.

However, when a reasonable admission is blocked and these efforts fail, you are dealing with a troll. The underlying motive is not cost saving, patient care, or good medicine. It is good old fashion all American work aversion. Some basic rules in dealing with trolls:

• Do not loose your temper.
• Do not joust in the chart.
• Tell them you feel very uncomfortable with the decision and feel it is important that the patient be admitted. That you fully support that the case should be reviewed by the respective heads of department the next day, and that it is always better to be safe than sorry.
• Apologize for bothering them, saying you were actually trying to reach a doctor and must have gotten their number by mistake.
• Tell them that you will keep the patient overnight in the ED and let cooler heads work it out in the morning.

Very solid non-antagonistic techniques. I'm definately calling my chair up at 2am this saturday night with this technique... I'm well loved... and furry, I'm sure I can get away with it.


thankfully, we don't get to many of these patients. I will never admit them without several rounds of appropriate pain medication: none of this 4mg of morphine... When I admit, saying several rounds of dilaudid adn patient still can't walk usually keeps the balking at bay.

Obs unit? what is this thing you speak of????????

 

[NinerNiner999]

If you have a cordless phone you can have this dicussion in front of the patient, then inform their doctor that the patient is right here and would like to talk to them. Then, you can ask that they explain to their patient why they don't think they are sick enough to be admitted.

After the PMD has finished ruining what was left of their doctor-patient relationship, you are free to call the hospitalist for admission...

 

[southerndoc]

If you have a cordless phone you can have this dicussion in front of the patient, then inform their doctor that the patient is right here and would like to talk to them. Then, you can ask that they explain to their patient why they don't think they are sick enough to be admitted.

After the PMD has finished ruining what was left of their doctor-patient relationship, you are free to call the hospitalist for admission...

I've actually done this before. The patient cursed and fired the primary care physician as soon as I handed her the phone. The primary care physician complained on me. Go figure. You should have the balls to back up what you say.

 

[USCDiver]

thankfully, we don't get to many of these patients. I will never admit them without several rounds of appropriate pain medication: none of this 4mg of morphine... When I admit, saying several rounds of dilaudid adn patient still can't walk usually keeps the balking at bay.

I don't think I could walk if I had several rounds of dilaudid either.

 

[Seaglass]

Thanks all, that will help me finesse it next time.

 

[roja]

I don't think I could walk if I had several rounds of dilaudid either.

amateur.