when is it appropriate...

[stinkycheese]

I find that a lot of the residents and attendings I worked with in the ED during my rotation last month were extremely annoyed at people who came in with BS complaints, frequent fliers, etc, and I understand and agree with their annoyance. However, I was surprised to find out that sometimes this annoyance extends to things that I thought were rather valid reasons for coming to an emergency dept - such as intractable headache. So many times I would see a headache patient in the ED who really seemed miserable and was puking right in front of us, and the resident or attending would seem annoyed that they had to spend time on this. What is your threshold for deciding whether a complaint is a valid reason for coming to the ED? Please note I am not criticizing at all, I am just curious what your thoughts are on when it is appropriate to use ED resources for things like migraines, bad flu/gastro, belly pain, etc.

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[EM_Rebuilder]

I find that a lot of the residents and attendings I worked with in the ED during my rotation last month were extremely annoyed at people who came in with BS complaints, frequent fliers, etc, and I understand and agree with their annoyance. However, I was surprised to find out that sometimes this annoyance extends to things that I thought were rather valid reasons for coming to an emergency dept - such as intractable headache. So many times I would see a headache patient in the ED who really seemed miserable and was puking right in front of us, and the resident or attending would seem annoyed that they had to spend time on this. What is your threshold for deciding whether a complaint is a valid reason for coming to the ED? Please note I am not criticizing at all, I am just curious what your thoughts are on when it is appropriate to use ED resources for things like migraines, bad flu/gastro, belly pain, etc.

Unfortunately, us as clincians soon too quickly lose touch with 'reality' and what the general public considers an emergency. I agree, that as a lay person, a HA that is making you puke is an 'emergency' but oftentimes these patient are on their 7 visit in the past 3 months for the SAME complaint, they have had their head scanned, MRI'ed, etc etc... told to FU with PCPs... patient just does not end up with relief so they are back in the ED...as if something changed. Frustrating to the resident who finds NO sig physical exam findings, spends another grand scanning the head when they know there will be nothing, and has to do the charting and paperwork to finish out the job... and deal with the patient who is going to belly ache over why on earth do I have this HA??

There is no right or wrong answer. Everyone hollars about something... we hollar about people that need to stay out of our EDs and that will never change. If every patient knew when they were having appendicitis, a stroke, etc...our job would be easier and we wouldnt need as many of us.

I think the hard decision are those phone calls we get from friends and family because we are 'doctors'. These people may be thousands of miles away..they have a bad HA or something and want to know what to do. What do we tell them? Obviously, if they cannot move their arm, we know what to say... but what about the questionable signs/symptoms? Do we go ahead and tell them to go their local ED? Tell them to take tylenol and go to bed? When you are 'in the ED' it seems much easier to make those judgements about live beings in front of you, but myself (albeit a very very junior person here) struggle greatly on what to tell friends and family hundreds of miles away....and tend to err on the safe side. Luckily at this point I can still play the 'I am in traning card'....but what about as an attending.... some of it will be easier, but still it will be difficult on what to do/say.

 

[southerndoc]

I rarely get annoyed when patients come in. Even patients who show up with URI symptoms I just see them and send them on their way. However, I do sometimes question why triage will put certain patients in a critical care area that's designed for high acuity. Sometimes their justification is correct (risk factors, looked horrible in triage, etc.), or sometimes it's just because the central teams are busy, the patient is a VIP, or they realize that a fourth-year resident can treat and street them a lot quicker than an intern can.

Some people are burned out, and that's sad.

Stress is not an action, it's a reaction. You can have the world falling apart in front of you and not be stressed out about it. Some people can have two patients and become stressed about it. It's all in how you react to it, and some people react differently than others. Some people get stressed about patient volume, some people get stressed about the "GOMER's", and others don't get stressed at all.

 

[kungfufishing]

wait, you mean TWO patients at the SAME TIME? impossible.

 

[deleted77919]

Admittedly I am a medical student, so I don't have the length (or depth, or really anything that can compare) to the experience of residents and attendings, but after working in the ED this summer it wasn't the BS complaints from pts who thought they were sick that bothered me, it was the pts who tried to bite me, spit at me, play nice and then flail when I'd try to stick them, the people on PCP, people trying to hit me, etc, etc. Those were the ones who would drive me nuts.

Fortunately the residents, a few restraints (which we never had enough of), and some haldol and ativan would take care of most of it.

 

[Febrifuge]

I hung around an academic EM department as a tech for 3 years, and the residents who thought they were being cool by acting all jaded and dismissive were few, and that behavior was slapped out of them by staff.

The folks you saw might be burned out, they might be covering their own insecurity by acting gruff and "too cool for school," or to be more kind toward them, they might be honestly trying to distance themselves from the frustration they feel at not being able to help that headache patient. An abundance of sympathy can manifest in weird ways, when a caring person realizes they can't do jack to help.

But whatever the reason, they need to knock that crap off when they're around conscious patients with working eyes and/or ears. Staff need to set a better example, and pay attention to how the residents are comporting themselves. Studies show you reduce lawsuits if you avoid acting like a tool.

 

[Powdermonkey]

When the tool satchel coming in smells so strongly of blue listerene and feet that you can smell him as he is pushed past the desk by ems on the way to his room and you are five feet away, it is appropriate to be annoyed. And also to start bilateral 16g IVs in him. He wont wake up for it anyways...

 

[roja]

I rarely get annoyed. This is just one of the things that is a reality about EM. You will have to see stuff that isn't really an emergency. Sometimes its because people can't get into to see thier PMD, or they don't know any better, or they have no insurance and have no other choice.

Whatever the reason, they need to be seen. Getting annoyed is like living in the desert and complaining about the heat. (okay, I suck at analogies) Ocassionaly I will mutter that something has to be done about one of our 'regular' alcoholics who has triaged himself for the 3rd time in less than 24 hours but I try not to let it bother me.

 

[Dr.Evil1]

People get annoyed when treating patients for various reasons. Some of the time it is due to feeling that the visit is inappropriate but much more often it is another cause.

One big causes of annoyance for me is frustration. This may be because I know that I am not going to be able to fix this patients problem, it may be because this patient is going to require resources that I don't have at this time, or it may be because I will have to call someone who I don't like talking to. More often then not the patient has very little control over this.

Whatever the reason for the frustration the overall need is to act in a professional manner. This means that we SHOULD suppress the felling of annoyance and frustration during the patient interaction and act in a professional manner. After or before the patient encounter you may need to get this frustrated feeling off your chest. This is the reason we bitch so much here on SDN and other places about frustrating patient encounters. Much of the time the descriptions of these patient encounters are embellished and represent what the interaction as it would have been in our mind where we were not restrained by professional behavior.

I personally believe that it is our duty to see every patient who walks through the door asking for help. Sometimes it will be our job to offer reassurance or redirection to the worried well or those with minor problems. Whatever the patient complaint we should act in a professional manner towards the patient. We just might have to bitch about it later though.

 

[The White Coat Investor]

You want to talk about stupid complaints in the ED, try a military ED where the care is totally free. I saw a 19 y.o. guy yesterday with a chief complaint of "bug bite." I walked in the room and he said..."it's gone now, can I go?"

I'm not sure what you civilians are complaining about. Non-emergencies are fast, easy, and sometimes can be billed at exactly the same level as an emergency. I can bill just about anything as a level three anyway For the 2 minute I spend on them, that's easy money. (assuming a reasonable percentage of these people actually pay their bill) There have been good studies done that show non-emergent complaints aren't really the cause of ED overcrowding. That is multi-factorial, but usually has to do with consultants and difficulties moving admitted patients upstairs.

 

[Apollyon]

You want to talk about stupid complaints in the ED, try a military ED where the care is totally free. I saw a 19 y.o. guy yesterday with a chief complaint of "bug bite." I walked in the room and he said..."it's gone now, can I go?"

The "bug bite" complaint that is totally resolved: I see that - EVERY SINGLE DAY. With the "self-pay/no-pay" people, it is, again, totally free. I can't get my head around why they come in.

Likewise is the "I vomited once 20 minutes ago" crowd. Ugh.

 

[Jeff698]

Wow, bug bite resolution prior to your assessment. Cool.

Apparently, all of the Central Texas bug bites come from the same species of MRSA infected spider.

Take care,
Jeff

 

[The White Coat Investor]

Wow, bug bite resolution prior to your assessment. Cool.

The really impressive thing is we have a door-to-doctor time of less than 10 minutes here.

 

[bulgethetwine]

I'm not sure what you civilians are complaining about. Non-emergencies are fast, easy, and sometimes can be billed at exactly the same level as an emergency. I can bill just about anything as a level three anyway For the 2 minute I spend on them, that's easy money. (assuming a reasonable percentage of these people actually pay their bill) There have been good studies done that show non-emergent complaints aren't really the cause of ED overcrowding. That is multi-factorial, but usually has to do with consultants and difficulties moving admitted patients upstairs.

Hey Active Duty,

I think part of the problem is that many of us frustrated by 'bug bites' are not assuaged by the fact that we can get "easy money" from it. Let me be clear: There is nothing at all wrong with your perspective, I am not trying to take the "high ground" by invoking some stilted position that is predicated on doing good for all humankind for the minimum possible compensation; But many of us are here because we wanted to be intellectually engaged in treating real disease -- figuring out complex problems and having a special skill set that kicks into gear when the sickest of the sick show up in our resuscitation room. It can be frustrating when reality hits and we have that long shift of seemingly low acuity complaints. Of course, it's a modern reality of the specialty, though But I couldn't give a rat's ass what level it gets billed at. I'd just as soon they come to you --

 

[anonymousEM]

In the military ED where I contract I see at least as much BS as I do in the county hospital...the difference is that the folks who drove 8 hours past 10 other hospitals actually do have some specialist to see for their exasperating medical mystery and their doctor will call you back when you try to figure out what to do with their chronic pain...but it doesn't mean i still don't see lots of people who want work notes, or check in because their husband is here for a clinic appointment at the same time etc. The thing that bothers me about the folks who check in for something nonemergent is that they leave without being seen within 15 min (sometimes I get too busy for 10 min triage to MD Active Duty, rare but it happens!) because it will make them late for their ophtho or derm or whatever apt...this is such a waste of everyone's time to write up a chart, taking the triage nurse away from the old WWII vet with Chest pain etc...

I may wonder what someone was thinking when they come to the ED but I went into EM because I like being the "safety net" to some degree too. Access to care is such a problem. Until we figure out what is right for this country (Did you see Edwards' solution to achieve universal healthcare today? He would plan to pull the insurance of everyone in congress if they don't get it enacted by Jan 10. hmm....) to ensure everybody has the ability to get the care they need, I recognize that sometimes I will have to pick up the slack. I just wish that the gvt would recognize that the money to pay for it has to come from somewhere too...

 

[EctopicFetus]

We have a frequent flier here who comes in for weekly US of his known DVT and another visit per week for Mylanta.. Often time he takes EMS, we started sitting him in the hallway to reduce some of the pleasantry of our ED. Additionally, this leaves a higher acuity bed for someone who needs it.

I get somewhat frustrated (occassionally) when people have something wrong with them it gets taken care of and they say.... " I decided that since I was feeling better I didnt need follow up, but im feeling bad today so I came back in."

I have had 3 of these with gall stones this month. one had insurance issues so she couldnt see a surgeon (totally not annoyed) but the other 2 were told that the ONLY way to get better was with surgery.... One annoyed me cause it was a long day and the other didnt at all.

That being said I somewhat cherish being someones last (or first line) into the medical system.

 

[docB]

I maintain that it is inappropriate for patients with chronic pain conditions to use the ED for narcotics. These patients should be being treated by pain docs and they should be on contracts. If they are not or if they are breaking their contract then the visit is inappropriate. I still treat them and I still give them narcotics, generously. But chronic pain is not a life or limb threatening emergency. The fact that it routinely falls to us to treat it in the ED is a symptom of the failure of medicine as a system and a profession.

 

[stinkycheese]

So what about chronic pain conditions like migraine - where the pain is not there everyday but sometimes breaks through beyond what one can treat at home? I know sometimes when I get a migraine I feel like I might very well die because of the pain despite rationally knowing it likely isn't an SAH or anything like that-- and I take prophylaxis, have home abortives, and don't take or want narcs. Am I an inappropriate ED patient if I come during one of these attacks after failure of home maxalt x2 and failure of home PO compazine? I am genuinely interested in knowing how this comes across. I usually need toradol, reglan/compazine, fluids, +/- depakote, +/- zofran if I am really vomiting up my spleen, and then am okay.

 

[docB]

So what about chronic pain conditions like migraine - where the pain is not there everyday but sometimes breaks through beyond what one can treat at home? I know sometimes when I get a migraine I feel like I might very well die because of the pain despite rationally knowing it likely isn't an SAH or anything like that-- and I take prophylaxis, have home abortives, and don't take or want narcs. Am I an inappropriate ED patient if I come during one of these attacks after failure of home maxalt x2 and failure of home PO compazine? I am genuinely interested in knowing how this comes across. I usually need toradol, reglan/compazine, fluids, +/- depakote, +/- zofran if I am really vomiting up my spleen, and then am okay.

Yes, I believe that exacerbations of chronic pain or recurrent, episodic pain is not appropriate for the ED. I have several reasons for this:
-These issues, crhonic or recurrent, by definition, should be planned for and dealt with by primary docs or pain management docs. The fact that they are in the ED represents a failure of outpatient management.
-Patients with these conditions usually want particular treatments and often don't want to be worked up. This puts a burden of additional liability on the EP, who doesn't know the patient or the patient's disease process. For example, in the scenario mentioned above, the patient wants certain treatments and will likely refuse other treatments. Most EPs would entertain the idea of doing various diagnostics such as CT head, LP, blood work and so on. When these are refused the EP then has to take more time to document that the patient was competent to refuse, etc. The liability is still there for the EP should the patient turn out to have anything dangerous going on. Since the PMD can fall back on their knowledge of the patient and continuity of care they are less at risk for this.
-These patients generally don't want admission but do want several rounds of drugs, hours of IVF, etc. That's a bed out of commission for other patients for an extended period of time.
-More often than not patients who present to the ED for chronic pain demand narcotics. That throws the whole drug seeking issue into the mix.

So what would I like to see? I'd like to see these patients get treated for their exacerbations in their PMD or pain docs offices. As they know the patients their therapies should be quicker and more effective without the factor of treating an unknown inherent in an ED visit. If a patient really requires hours of treatment they can be directly admitted by the PMD/pain doc to obs status with orders sent by the doc. They would bypass the ED and all of the pitfalls of it.

Will any of that ever happen? No. PMDs and pain docs don't want to deal with any of this when it's easier to send the patient to the ED. Once the patient is told to go to the ED their work and liability is over. They could do simple things in their clinics like IVF and meds but don't want to because they'd rather have me and my bed tied up than them and their bed. They’ve got to see 4-6 an hour and treating chronic pain in the office is not conducive to that. Even if they wanted to direct admit the insurers will deny it so another reason to go to the ED.

So EPs will continue to treat chronic pain. We'll continue to want to work it up more than we would if we knew the patient and the patients will continue to refuse the workups. The patients will take up beds and wait times will continue to get longer. We'll continue to try to figure out if the patient is just seeking and the patients will continue to get offended, seeking or not. I fully understand that it's just how it is but is it "appropriate?" No.

 

[howelljolly]

How do you'all deal with

a) patients that are in your ER because they didnt comply with a physicians reccomendations (follwing up with a specialist, Rx instructions, self d/c of a treatment plan 'cause they "feel better")

b) wanting to repeat a CT (or whatever) for the umpteenth time, though you know its going to be negative; because you need to be sure...

These are probably the two most frustrating things for me.

 

[dmitrinyr]

The frequent fliers or pts with bogus complaints or a secondary gain reason for being there don't usually annoy me. Most of the time I can view the situation from their point of view and can rationalize that they have come to the ED because maybe they have no insurance, no access to PMD, don't know any better, are homeless and need a free meal, or maybe it's just too easy to come to ED rather than keeping your appointment to follow up or filling your prescriptions on time or calling your PMD. I'm just amazed at how do the pts with the BS complaints sit at a busy ED for 3 hours at 4 am to be seen for a complaint such as "shoulder pain s/p trauma 6 months ago" or "bug bite 2 days ago", etc.

As far as the pt asking for another CT/xray/MRI after numreous negative scans in the near past, I have no problem saying to the pt (who I assume has a normal physical exam and neuro exam) that he/she doesn't need the scan because the recent ones have all been negative and so there is no reason to believe that this one will be any different. ED is not burger king (no matter how much the pts wish it was), the pt cannot have it "their way" and just dictate what they want.

 

[Dr. Will]

This is what I get annoyed about...PMD's that don't want to deal with the care of their own patients and just send them to us to figure out. Case in point...yesterday a well known sickler was sent to the ED by the Hem Onc fellow because a presciption of methadone appeared to be tampered with by the patient and the pharmacy refused to fill it. Instead of rewriting the scrip, or calling the pharmacy to sort out the issue, fellow sent the patient in to the ED for us to sort out. Talk about infuriating! What made it worse was that this was a known, non-compliant patient (for many reasons). The scrip was not filled or rewritten in the ED.

 

[southerndoc]

This is what I get annoyed about...PMD's that don't want to deal with the care of their own patients and just send them to us to figure out. Case in point...yesterday a well known sickler was sent to the ED by the Hem Onc fellow because a presciption of methadone appeared to be tampered with by the patient and the pharmacy refused to fill it. Instead of rewriting the scrip, or calling the pharmacy to sort out the issue, fellow sent the patient in to the ED for us to sort out. Talk about infuriating! What made it worse was that this was a known, non-compliant patient (for many reasons). The scrip was not filled or rewritten in the ED.

Was it on a weekend where the fellow could not rewrite the script? Most states have laws prohibiting calling in narcotic scripts.

 

[G0S2]

Wow, bug bite resolution prior to your assessment. Cool.

Apparently, all of the Central Texas bug bites come from the same species of MRSA infected spider.

Take care,
Jeff

I actually started to educate pts and tell them that it was not a spider bite and was MRSA. Most were diabtetics. As an MS3 I have seen one Brown Recluse bite and it looked different from the standard MRSA abscess.

 

[Dr. Will]

Was it on a weekend where the fellow could not rewrite the script? Most states have laws prohibiting calling in narcotic scripts.

To answer the question...no...but that's not the point. The issue was between pharmacy and the fellow who wrote the prescription. He should not have involved the ED by having the patient sent down for a script for methadone, which was a higher dose than most would perscribe. No one in the ED was going to fill that (especially for a patient who is known by us to be non-compliant with treatment) who came in with the story of a possible tampered script. The fellow never contacted the ED to communicate the issue. He just sent the patient down and told him we'd take care of it. Add on the fact it was extremely busy and we were understaffed. Highly inappropriate regardless of the day of the week.

 

[leviathan]

I don't get why people think a sarcastic and apathetic attitude marks a veteran...it's almost as if some people aspire to become that kind of person to show everyone how experienced they are.

 

[Febrifuge]

I don't get why people think a sarcastic and apathetic attitude marks a veteran...it's almost as if some people aspire to become that kind of person to show everyone how experienced they are.

A veteran patient, or care provider?

'Cuz I've seen both, and they're both unpleasant when the attitude comes to the forefront, instead of just being present.

I think in the case of providers, part of the problem is how much fun it is in the Pit to chuckle at the wide-eyed niavete of the new people. "Aww son, the ED isn't like working on the wards upstairs; here we save lives... and we handle a lot of silly stuff." I've been the new kid, and I've been the quasi-grizzled veteran, so I'm not blameless, I'm just saying it's something we perpetuate even as we notice the downside. But there's more to it -- it doesn't have to be malignant.

In its benign form, the EM attitude is about expediency -- getting the resources to where they are most needed. The ED never has all the people to do all the stuff we'd love to do if we could, toward making patients comfortable. People are well-cared for medically, but we can't always do all the stuff that makes that apparent to patients from a... I hate using this term in this context... customer service point of view.

Sure, the high school kid who's been an EMT for a week knows which end of the O2 mask to use, but she has no idea which patients are really in need of something her job class can help with, and which are just going to be time-sinks that keep her from helping the unit. A little detachment and clear-headedness is good; it shouldn't cross into actual apathy. I've chatted with patients about this and that, and discovered potentially important information the docs were happy to know, but I also learned how to extricate myself from a sweet old lady's room because other stuff has to get done.

The sarcasm part is related to dealing with the unpredictability; absurdity is far less threatening and easier to deal with than pure scary chaos. Patients love to ask complex medical questions of people who can only say "I don't know, but I can ask the doctor." They suddenly remember pertinent history info an hour after your workup is underway. Families throw another handful of crazy into the whirling mass that already exists. Trying to handle everything, one at a time, in order, is a sure way to go nuts and/or accomplish nothing.

It's not that we have to be heartless; we simply have to understand the tools that heartless people would use, and apply similar principles to our noble and conscientious work. Because those tools are so much more effective, sometimes. Bottom line, we're giving people what they need, not what they want. And we're doing it without any of the control and predictability that we might want.

 

[southerndoc]

To answer the question...no...but that's not the point. The issue was between pharmacy and the fellow who wrote the prescription. He should not have involved the ED by having the patient sent down for a script for methadone, which was a higher dose than most would perscribe. No one in the ED was going to fill that (especially for a patient who is known by us to be non-compliant with treatment) who came in with the story of a possible tampered script. The fellow never contacted the ED to communicate the issue. He just sent the patient down and told him we'd take care of it. Add on the fact it was extremely busy and we were understaffed. Highly inappropriate regardless of the day of the week.

I assumed you called the fellow? We have a policy in our ED that all patients referred by another physician (fellow, attending, community) must be called in to the senior resident or an attending. We have phone sheets that we use to record the call ins. They are quite time consuming and annoying sometimes.

I have written scripts for people with severe pain (e.g., cancer) on weekends because they ran out and cannot get a refill (federal law prohibits refills on narcs) and the physician cannot call in the script.

If a patient ever tampers with a script I write, then I will void the script if it's a narcotic, and will ask the pharmacist to report it to the police. I've had this happen twice (one patient was stupid enough to add a zero to the script for 20 percocets that was typed on his prescription sheet).