Why are so many cardiologists seemingly afraid of caths?

[Zebra Hunter]

Present. I feel like previous posts are nitpicking the few times that a patient presents with a high-risk/unstable NSTEMI should go to the cath lab early, then extrapolating those experiences to every NSTEMI that comes through the door because they "might" become high risk. Truth be told, short of calling a STEMI alert and activating the cath lab accordingly, unless some rogue cardiologist wants to discharge the patient home, I'm not quite sure what the vested interest is in the work-up beyond getting them admitted.

EDIT: I apologize for the string of edits...phone spazzed while I was typing and I didn't want to lose whole post.

I think you are significantly misunderstanding what I have stated if that is your take away. I call cardiology less than any of my colleagues about patients I think might need cath. My point is that the patient presented in the OP is not a low risk NSTEMI patient, and is someone that likely needs immediate PCI. My other point was that you cannot extrapolate NSTEMI outcomes to patients that are much higher risk for poor outcomes, like patients with subtle evidence of acute coronary occlusion.

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[greatnt249]

The vested interest is caring in what happens to our patients.

Maybe I'm reading too far into this, but your comment reads that you don't feel specialists care enough about the patients you consult them on to provide appropriate, evidence-based care when asked to weigh in; it's a shame if that's your experience. Or am I way off base?

The other reality is that, more often than we'd like, we get asked to perform procedures without an emergent indication and get looked at like we're growing two heads when we state that no emergent indication exists. Maybe give us the benefit of the doubt?

Except for the Lexiscan for the NSTEMI; need more backstory for that decision.

 

[deleted547339]

Maybe I'm reading too far into this, but your comment reads that you don't feel specialists care enough about the patients you consult them on to provide appropriate, evidence-based care when asked to weigh in; it's a shame if that's your experience. Or am I way off base?

The other reality is that, more often than we'd like, we get asked to perform procedures without an emergent indication and get looked at like we're growing two heads when we state that no emergent indication exists. Maybe give us the benefit of the doubt?

Except for the Lexiscan for the NSTEMI; need more backstory for that decision.

No, you’re reading the right tone. If you ask “why does a doctor care what happens to their patient?” the answer is that it’s because we actually give a damn. It’s kind of shocking someone would ask why we care what happens our patients.

And yes, I’ve frequently worked with cardiologists who give exactly 0 f’s about the patient. Syncope, chest pain and diffuse STD with elevation in AVR? Nah, just admit to hospitalist, I’ll see them in the morning. Just discharged from the cardiology service after PCI back with chest pain and new onset heart failure? Admit to MICU because the white count is 15, not my problem. Post-cardiac arrest STEMI? Oh, they don’t have insurance? Nah, let’s heparin gtt and admit. Cardiogenic shock requiring intubation? The CC was dyspnea, that’s a lung problem - call the MICU. These are examples from 3 different hospitals. I have some great friends who are cardiologists, but I also know some who truly couldn’t care less about patients so long as they can make their Porsche payment (with a vanity plate).

 

[greatnt249]

No, you’re reading the right tone. If you ask “why does a doctor care what happens to their patient?” the answer is that it’s because we actually give a damn. It’s kind of shocking someone would ask why we care what happens our patients.

It's because I care that it seems insulting that you think I wouldn't; that was my point, and was why I asked if that was your angle. Because honestly, you shouldn't have to worry about advocating for your patient if you work with specialists you trust. That doesn't mean I think you don't need to show interest in your patient: what I really meant was it's a shame you can't have some faith that they'll be taken care of when you sign them over. I don't care to be lumped in with the group you described, and as I stated before, I'm sorry if that was your experience.

For what it's worth, I'm not an interventional cardiologist, so make of that what you will.

 

[bravotwozero]

No, you’re reading the right tone. If you ask “why does a doctor care what happens to their patient?” the answer is that it’s because we actually give a damn. It’s kind of shocking someone would ask why we care what happens our patients.

And yes, I’ve frequently worked with cardiologists who give exactly 0 f’s about the patient. Syncope, chest pain and diffuse STD with elevation in AVR? Nah, just admit to hospitalist, I’ll see them in the morning. Just discharged from the cardiology service after PCI back with chest pain and new onset heart failure? Admit to MICU because the white count is 15, not my problem. Post-cardiac arrest STEMI? Oh, they don’t have insurance? Nah, let’s heparin gtt and admit. Cardiogenic shock requiring intubation? The CC was dyspnea, that’s a lung problem - call the MICU. These are examples from 3 different hospitals. I have some great friends who are cardiologists, but I also know some who truly couldn’t care less about patients so long as they can make their Porsche payment (with a vanity plate).

The one's that really irk me are the cardiologists that take ischemic limb call and want to do nothing when a patient comes in at an inconvenient time. "you need to call vascular. Oh, vascular is out of the country? Transfer her. I realize her foot is turning purple, just put her on heparin and i'll see here in AM.' Why even take the ischemic limb call?

 

[Brigade4Radiant]

The one's that really irk me are the cardiologists that take ischemic limb call and want to do nothing when a patient comes in at an inconvenient time. "you need to call vascular. Oh, vascular is out of the country? Transfer her. I realize her foot is turning purple, just put her on heparin and i'll see here in AM.' Why even take the ischemic limb call?

lol they take it for $$$

Also for the OP’s post a heart rate of 40 doesn’t necessarily need any intervention. Patient was sinus brady

Also question why do we use heparin drip so much on Lovenox has been shown to decrease the incidence of refractory chest pain.

 

[NITRAS]

lol they take it for $$$

Also for the OP’s post a heart rate of 40 doesn’t necessarily need any intervention. Patient was sinus brady

Also question why do we use heparin drip so much on Lovenox has been shown to decrease the incidence of refractory chest pain.

Our cardiologist prefer IV heparin exclusively. There is a higher risk of bleeding with PCI with the LMW heparins. The explanation they have given me is that they don’t want to canulate the femoral artery while on something they can’t turn off as quickly. I’m just an internist. . . but the cardiologist didn’t have a problem with this were I trained. .. .

 

[Arch Guillotti]

The one's that really irk me are the cardiologists that take ischemic limb call and want to do nothing when a patient comes in at an inconvenient time. "you need to call vascular. Oh, vascular is out of the country? Transfer her. I realize her foot is turning purple, just put her on heparin and i'll see here in AM.' Why even take the ischemic limb call?

Cardiology taking "ischemic limb call" sounds bizarre to me.

 

[Mushdoc]

Actually the exclusion criteria for the TIMACS trial was 1) Age <21 yrs 2) Not suitable for revasculariation 3) comorbid condition with life expectance <6 months. The trial was a multi-center blinded parallel - group randomized controlled trial and had >3000 patients with about half randomized to early intervention and half to delayed intervention so im not sure where you are getting that this study can't be extrapolated.

Additionally thats the entire point of using the grace score if you look at what's included in the score itself patients who are higher risk aka with cardiogenic shock, have heart failure on presentation, or elderly would fall into the high grace score category and would go for early catheterization.

The thing about TIMACS was that the listed exclusions doesn't paint a full picture. Steve Smith emailed the primary investigator and asked for example about refractory ischemia. "Steve had to personally contact Dr. Mehta to find that out. He said he "Cannot Imagine that any investigator would have enrolled a patient with refractory ischemia.”" If anyone has worked at an academic institution, you know how often the research personnel ask you if they can enroll someone and you say no due to things outside the specific inclusion/exclusion criteria. Makes you wonder what else that was NTE ACS fell out of inclusion

Which Patient should get Acute Cath Lab Activation in MI?

Finally in one place, all of the STEMI equivalents with Steve Smith

emcrit.org

 

[RustedFox]

Cardiology taking "ischemic limb call" sounds bizarre to me.

We have several that do this at my shop as well.
Fortunately, ours actually do answer the bell.

 

[deleted547339]

It's because I care that it seems insulting that you think I wouldn't; that was my point, and was why I asked if that was your angle. Because honestly, you shouldn't have to worry about advocating for your patient if you work with specialists you trust. That doesn't mean I think you don't need to show interest in your patient: what I really meant was it's a shame you can't have some faith that they'll be taken care of when you sign them over. I don't care to be lumped in with the group you described, and as I stated before, I'm sorry if that was your experience.

For what it's worth, I'm not an interventional cardiologist, so make of that what you will.

You may care, but a lot of your colleagues don’t. It may not be evident to you, but we see it all the time across a wide range of institutions. We advocate like this because we have to.

 

[ShockIndex]

No, you’re reading the right tone. If you ask “why does a doctor care what happens to their patient?” the answer is that it’s because we actually give a damn. It’s kind of shocking someone would ask why we care what happens our patients.

And yes, I’ve frequently worked with cardiologists who give exactly 0 f’s about the patient. Syncope, chest pain and diffuse STD with elevation in AVR? Nah, just admit to hospitalist, I’ll see them in the morning. Just discharged from the cardiology service after PCI back with chest pain and new onset heart failure? Admit to MICU because the white count is 15, not my problem. Post-cardiac arrest STEMI? Oh, they don’t have insurance? Nah, let’s heparin gtt and admit. Cardiogenic shock requiring intubation? The CC was dyspnea, that’s a lung problem - call the MICU. These are examples from 3 different hospitals. I have some great friends who are cardiologists, but I also know some who truly couldn’t care less about patients so long as they can make their Porsche payment (with a vanity plate).

What you describe is definitely real and it is a culture poor professionalism in certain hospitals. Unfortunately, it has more to do with the institution leadership than academics vs. community or large vs. small. So, it can be very hard to predict until after you’re hired and experience it firsthand.

Moreover, EPs and intensivists are particularly susceptible to the adverse consequences of ****ty consultant professionalism. You know there is a problem when you send cases for peer review and never hear anything back about the steps being taken to prevent future incidents. My best advice is to pop smoke and peace out on any job where the ED or ICU director is tolerating that crap to keep the high revenue generators happy. It’s not worth getting sued because the neurosurgeon didn’t want to evacuate that SDH at midnight or the urologist didn’t want to deal with the infected stone on a weekend.

 

[deleted547339]

What you describe is definitely real and it is a culture poor professionalism in certain hospitals. Unfortunately, it has more to do with the institution leadership than academics vs. community or large vs. small. So, it can be very hard to predict until after you’re hired and experience it firsthand.

Moreover, EPs and intensivists are particularly susceptible to the adverse consequences of ****ty consultant professionalism. You know there is a problem when you send cases for peer review and never hear anything back about the steps being taken to prevent future incidents. My best advice is to pop smoke and peace out on any job where the ED or ICU director is tolerating that crap to keep the high revenue generators happy. It’s not worth getting sued because the neurosurgeon didn’t want to evacuate that SDH at midnight or the urologist didn’t want to deal with the infected stone on a weekend.

Wait. Urologists can deal with infected stones? I thought only IR could do this, lol.

 

[jw3600]

Wait. Urologists can deal with infected stones? I thought only IR could do this, lol.

There is a very narrow window where the patient is sick enough to warrant intervention emrgently but not sick enough for uro to demand IR does the perc neph tubes. This window is as elusive as Haley’s Comet.

 

[dorster]

No, you’re reading the right tone. If you ask “why does a doctor care what happens to their patient?” the answer is that it’s because we actually give a damn. It’s kind of shocking someone would ask why we care what happens our patients.

And yes, I’ve frequently worked with cardiologists who give exactly 0 f’s about the patient. Syncope, chest pain and diffuse STD with elevation in AVR? Nah, just admit to hospitalist, I’ll see them in the morning. Just discharged from the cardiology service after PCI back with chest pain and new onset heart failure? Admit to MICU because the white count is 15, not my problem. Post-cardiac arrest STEMI? Oh, they don’t have insurance? Nah, let’s heparin gtt and admit. Cardiogenic shock requiring intubation? The CC was dyspnea, that’s a lung problem - call the MICU. These are examples from 3 different hospitals. I have some great friends who are cardiologists, but I also know some who truly couldn’t care less about patients so long as they can make their Porsche payment (with a vanity plate).

I think this comment is a little over the top. Of course there are physicians across the board that are in the wrong profession and don't care about their patients just the $$$, but is that specific to cardiology? Hell no. It's also not unheard of to have that attitude exhibited by an ED doctor. These people don't belong in medicine. While cardiology might attract people who are concerned more with prestige and monetary gains than taking care of people, (just based on their high compensation), but thats also seen in many surgical fields as well as ED. So I don't really see how this relates to OPs post regarding NSTEMI and Unstable angina. Also, this brings back the reason the "old school" medical setup was much better for patients. If a consultant sucked and didn't give a **** about the patient, you just wouldn't consult them and pick someone else to give your business to. Wish it could be that simple!

I'm just a lowly resident, but I can't name a single cardiologist at my program that I wouldn't trust with my family members lives, and thats how it should be. I do feel sorry for those of you working at these places with what sounds like awful physicians. My advice? Work somewhere else.

 

[nlax30]

Not sure there’s much left to be said, though I do agree in that on the face of it this patient likely didn’t need an emergent cath. Also not terribly worried about the sinus brady in the 40’s. Could certainly have been vagal induced brady and/or meds. I see a LOT of arrhythmias and frequently asked to see patients with relative bradycardia along a similar scenario have to explain why I’m not putting in a pacemaker. If you’re asking a proceduralist to potentially come do a procedure then try and trust that they know when to and when to not do that procedure.

On another note little disappointed in the cross speciality bashing.... certainly not unique to here. I certainly don’t think it’s fair to say a “lot” of cardiologists don’t care about their patients.... that’s actually insulting. Like EVERY field there are some bad apples, Cardiology and Emergency medicine not excluded. Each of us are biased in this regard, you guys interact with many different specialists and probably more likely to see the bad apples in various specialities. As a specialist I may interact with many different ED docs and thus see more of those bad players.

Also, as a Cardio sub-specialist and proceduralist there is a ton of incentive to actually care about my patients. I will be seeing them every day in the hospital, will have to answer to any procedural complications and seeing them in office f/up even over years building a close relationship with some long term patients. Certainly does not behoove us to not care.

Sorry you’ve had to deal with some of these bad apples though.

 

[deleted547339]

Not sure there’s much left to be said, though I do agree in that on the face of it this patient likely didn’t need an emergent cath. Also not terribly worried about the sinus brady in the 40’s. Could certainly have been vagal induced brady and/or meds. I see a LOT of arrhythmias and frequently asked to see patients with relative bradycardia along a similar scenario have to explain why I’m not putting in a pacemaker. If you’re asking a proceduralist to potentially come do a procedure then try and trust that they know when to and when to not do that procedure.

On another note little disappointed in the cross speciality bashing.... certainly not unique to here. I certainly don’t think it’s fair to say a “lot” of cardiologists don’t care about their patients.... that’s actually insulting. Like EVERY field there are some bad apples, Cardiology and Emergency medicine not excluded. Each of us are biased in this regard, you guys interact with many different specialists and probably more likely to see the bad apples in various specialities. As a specialist I may interact with many different ED docs and thus see more of those bad players.

Also, as a Cardio sub-specialist and proceduralist there is a ton of incentive to actually care about my patients. I will be seeing them every day in the hospital, will have to answer to any procedural complications and seeing them in office f/up even over years building a close relationship with some long term patients. Certainly does not behoove us to not care.

Sorry you’ve had to deal with some of these bad apples though.

I’m a little salty. A lot of medical subspecialists have shown their true colors when they don’t want to see patients or do procedures on patients with COVID.

 

[migm]

We are lysing any stemis with covid concerns. Not sure why it's okay for ED staff to be exposed but we can't put a mask on this pt and do the right thing ..

 

[nlax30]

We are lysing any stemis with covid concerns. Not sure why it's okay for ED staff to be exposed but we can't put a mask on this pt and do the right thing ..

I didn’t really agree with you back to a prior maybe less effective therapy only because of COVID though I do/did agree with avoiding non-urgent stuff as much as we could. Wouldn’t you want to avoid any possible exposure if you could? It’s not just the physician but countless staff that would be involved and exposed, transporting patient across the hospital, using up PPE, etc.... it’s really all those other factors that in my mind played a much bigger role in avoiding certain procedures.
We still took STEMIs to the lab but took a lot of precautions with immediate testing, full PPE, and limiting staff in the room.

 

[Dr Mantis Toboggan]

We are lysing any stemis with covid concerns. Not sure why it's okay for ED staff to be exposed but we can't put a mask on this pt and do the right thing ..

yeah that’s pretty lame.

 

[jw3600]

We are lysing any stemis with covid concerns. Not sure why it's okay for ED staff to be exposed but we can't put a mask on this pt and do the right thing ..

Didn’t the American College of Cardiology actually put out a statement that STEMIs should be cathed even if known to be Covid + because there were enough instances of it not being done?

 

[migm]

I didn’t really agree with you back to a prior maybe less effective therapy only because of COVID though I do/did agree with avoiding non-urgent stuff as much as we could. Wouldn’t you want to avoid any possible exposure if you could? It’s not just the physician but countless staff that would be involved and exposed, transporting patient across the hospital, using up PPE, etc.... it’s really all those other factors that in my mind played a much bigger role in avoiding certain procedures.
We still took STEMIs to the lab but took a lot of precautions with immediate testing, full PPE, and limiting staff in the room.

Sorry I'm having trouble understanding what you're trying to say. Not sure if its because i'm post call or not but, can you try reposting again? Are you saying that STEMIs that have a fever don't deserve to go for PCI because of the concern for possible COVID? If so I guess my point to this was - put a mask on the patient and yourself. I don't think this is an instance of wasted PPE

 

[deleted547339]

I didn’t really agree with you back to a prior maybe less effective therapy only because of COVID though I do/did agree with avoiding non-urgent stuff as much as we could. Wouldn’t you want to avoid any possible exposure if you could? It’s not just the physician but countless staff that would be involved and exposed, transporting patient across the hospital, using up PPE, etc.... it’s really all those other factors that in my mind played a much bigger role in avoiding certain procedures.
We still took STEMIs to the lab but took a lot of precautions with immediate testing, full PPE, and limiting staff in the room.

Your statement is hyperbolic. The number of staff potentially exposed is far from countless. Yes, we should limit staff exposure, but we should also do our job.

 

[ShockIndex]

I trace a lot of this back to the ascension of the EMR. Far too many doctor want to play keyboard-clinician ahead of actually seeing and examining patients. COVID isn’t making this any easier. While having a familiarity with the chart is helpful before walking into a room, you still need to actually walk into the room and have some face-to-face contact. This bull**** of surfing labs and records before telling a doc at the bedside that it’s not your problem, or that thousands of dollars in expensive imaging needs to be ordered before you make your problem needs to stop. Get off your ass and come see the patient.

The flip side of this coin is that bedside clinicians need to have at least a passing familiarity with the chart before calling a consult. Just take a couple of minutes to look at the recent out-patient clinic notes, out-patient vitals, meds, and procedures. Calling an orthopedist to fix a hip fracture and having them ask you if you knew that the patient was on Coumadin should be embarrassing.

 

[deleted547339]

I trace a lot of this back to the ascension of the EMR. Far too many doctor want to play keyboard-clinician ahead of actually seeing and examining patients. COVID isn’t making this any easier. While having a familiarity with the chart is helpful before walking into a room, you still need to actually walk into the room and have some face-to-face contact. This bull**** of surfing labs and records before telling a doc at the bedside that it’s not your problem, or that thousands of dollars in expensive imaging needs to be ordered before you make your problem needs to stop. Get off your ass and come see the patient.

The flip side of this coin is that bedside clinicians need to have at least a passing familiarity with the chart before calling a consult. Just take a couple of minutes to look at the recent out-patient clinic notes, out-patient vitals, meds, and procedures. Calling an orthopedist to fix a hip fracture and having them ask you if you knew that the patient was on Coumadin should be embarrassing.

Preach!

(I thought a like was insufficient).

 

[nlax30]

Sorry I'm having trouble understanding what you're trying to say. Not sure if its because i'm post call or not but, can you try reposting again? Are you saying that STEMIs that have a fever don't deserve to go for PCI because of the concern for possible COVID? If so I guess my point to this was - put a mask on the patient and yourself. I don't think this is an instance of wasted PPE

No, for a true STEMI I agree with taking for urgent cath and NOT changing current standard of care just over COVID concerns. I somewhat understand why some places may be doing that but I don't necessarily agree with it. At least where I am we didn't really switch over to using lytics in leu of urgent cath and if their COVID status was uknown just treated them as positive.

What I was getting it was I understand the current push back on holding off of any non-emergent cases over current COVID concerns. For true clear cut STEMIs sure, take 'em to to the lab and use whatever precautions are needed. For other borderline cases they may, for now, be a little more scrutiny to taking those patients to lab.

 

[Brigade4Radiant]

I trace a lot of this back to the ascension of the EMR. Far too many doctor want to play keyboard-clinician ahead of actually seeing and examining patients. COVID isn’t making this any easier. While having a familiarity with the chart is helpful before walking into a room, you still need to actually walk into the room and have some face-to-face contact. This bull**** of surfing labs and records before telling a doc at the bedside that it’s not your problem, or that thousands of dollars in expensive imaging needs to be ordered before you make your problem needs to stop. Get off your ass and come see the patient.

The flip side of this coin is that bedside clinicians need to have at least a passing familiarity with the chart before calling a consult. Just take a couple of minutes to look at the recent out-patient clinic notes, out-patient vitals, meds, and procedures. Calling an orthopedist to fix a hip fracture and having them ask you if you knew that the patient was on Coumadin should be embarrassing.

Nope things in the ER are always unpredictable, often you’re doing several things at once. While managing several patients and doing code strokes and intubating. If the patient has a hip fracture they will be going to the Medicine service at most hospitals. And by the time we get a x-ray you don’t really need to delay an admission just to go chart surfing, when you could do that. I mean honestly what does it delay?

 

[nlax30]

Your statement is hyperbolic. The number of staff potentially exposed is far from countless. Yes, we should limit staff exposure, but we should also do our job.

While not in the immediate context of a STEMI case, for any non-emergent procedure there is a pretty large risk of exposing a good number of hospital staff for any particular case.... transport, multiple OR/cath lab nurses/techs, Anesthesiologist/CRNAs, etc... For one particular case sure may be a handful of extra workers possibly exposed but it adds up over multiple procedures. We've already had patients present initially without symptoms for unrelated issues only to be readmitted few days later COVID+ now w/ symptoms. Obviously we're learning more and more each day regarding prevalence, true mortality, etc.. though at the time I don't think it was unreasonable to try and do what we could to limit any additional hospital to hospital staff.

 

[nlax30]

I trace a lot of this back to the ascension of the EMR. Far too many doctor want to play keyboard-clinician ahead of actually seeing and examining patients. COVID isn’t making this any easier. While having a familiarity with the chart is helpful before walking into a room, you still need to actually walk into the room and have some face-to-face contact. This bull**** of surfing labs and records before telling a doc at the bedside that it’s not your problem, or that thousands of dollars in expensive imaging needs to be ordered before you make your problem needs to stop. Get off your ass and come see the patient.

The flip side of this coin is that bedside clinicians need to have at least a passing familiarity with the chart before calling a consult. Just take a couple of minutes to look at the recent out-patient clinic notes, out-patient vitals, meds, and procedures. Calling an orthopedist to fix a hip fracture and having them ask you if you knew that the patient was on Coumadin should be embarrassing.

In general I agree with this. This will also be highly dependent on the actual issue being address and the particular specialty, some of which could very easily be answered or at least triaged virtually with a good chart review and discussion with ED attending. I think for some, ? maybe even a lot, of urgent issues emergent face-to-face evaluation may not be as helpful as some think. Obviously for acute surgical issues (threatened limb, acute abd) or things like ongoing questionable chest pain yea those probably need an urgent face to face visit and eval. Though for a someone with a mildly elevated troponin, some nonspecific EKG changes who is now chest pain free that can be triaged over the phone, chart reviewed and seen a little later.

 

[greatnt249]

Nope things in the ER are always unpredictable, often you’re doing several things at once. While managing several patients and doing code strokes and intubating. If the patient has a hip fracture they will be going to the Medicine service at most hospitals. And by the time we get a x-ray you don’t really need to delay an admission just to go chart surfing, when you could do that. I mean honestly what does it delay?

When you tell someone they should go chart surfing for you, it sends the message that you think your time is more valuable than theirs. I don't think it is asking too much to have some cursory information available when you ask for a consult; at a minimum, it gives me an idea of why I need to be involved in the patient's care and how urgently that needs to be done. I appreciate that you guys are busy in the ED, but it's not like we're twiddling our thumbs all day doing nothing while conspiring how to tell you that whatever you call us about is "not our problem."

 

[Brigade4Radiant]

When you tell someone they should go chart surfing for you, it sends the message that you think your time is more valuable than theirs. I don't think it is asking too much to have some cursory information available when you ask for a consult; at a minimum, it gives me an idea of why I need to be involved in the patient's care and how urgently that needs to be done. I appreciate that you guys are busy in the ED, but it's not like we're twiddling our thumbs all day doing nothing while conspiring how to tell you that whatever you call us about is "not our problem."

Well the consult is giving you business. I’m asking you about their fracture does it need surgical intervention. The call gives you the information of why I’m calling you.

It’s part of your job just like when a post op patient comes it’s part of our job to see them. We should not delay patient care if it will not change management.

If you want to hold blood thinners then hold them people come in and fall all the time if the patient is going to be admitted medicine, then they can handle the medical problems.

Why do they take blood thinners? Is it because they have a fibdid you clear it with another doctor?

 

[greatnt249]

Well the consult is giving you business. I’m asking you about their fracture does it need surgical intervention. The call gives you the information of why I’m calling you.

It’s part of your job just like when a post op patient comes it’s part of our job to see them. We should not delay patient care if it will not change management.

If you want to hold blood thinners then hold them people come in and fall all the time if the patient is going to be admitted medicine, then they can handle the medical problems.

Why do they take blood thinners? Is it because they have a fibdid you clear it with another doctor?

I'm not an orthopod, and I wasn't necessarily referring to the obvious admit. What I meant was, if I ask a few more basic questions about the consult and get essentially told, "I don't know, you have access to the same chart I do," well, it's not going to sit well with me. I don't call you back to fight with you (most of the time); I call back to make sure I'm actually understanding and answering your question.

And, believe it or not, an unnecessary consult has the potential to delay patient care by keeping them in the ED longer than they need to be waiting for the consultant to see them and give the okay to discharge home.

 

[Apollyon]

What I meant was, if I ask a few more basic questions about the consult and get essentially told, "I don't know, you have access to the same chart I do," well, it's not going to sit well with me.

As well it should not. What you describe is an EM intern move, and one that should be stomped on firmly.

I have a good friend who is rads. She tells me that, consistently, the best questions she gets are from surgeons, because they ask about a specific issue. The medicine folks are open ended, and that is frustrating.

 

[RustedFox]

I'm not an orthopod, and I wasn't necessarily referring to the obvious admit. What I meant was, if I ask a few more basic questions about the consult and get essentially told, "I don't know, you have access to the same chart I do," well, it's not going to sit well with me. I don't call you back to fight with you (most of the time); I call back to make sure I'm actually understanding and answering your question.

And, believe it or not, an unnecessary consult has the potential to delay patient care by keeping them in the ED longer than they need to be waiting for the consultant to see them and give the okay to discharge home.

Yeah, I'm inclined to agree with you as well - though the IM folk would do well to remember that 99+% of our patients can't give a history for *snit*.

We used to have this one hospitalist. Thank Christ she got fired.
She would demand that we "delve deeper" into the history, and be condescending about it.

I'll never forget this exchange (and yes, I got the soft reprimand for this):

"Okay, so this upper GI bleed is on pepcid; but I see that [in a note, 12 years ago] that he had arthritis of the knees. Did you ask about NSAID use?"

"No."

"Well, why not? It's important that patients with a history of..."

"Nope. Listen. I'm pretty sure his problem is because he drinks a fifth of Jackie Daniels every day, and has doubled that since his wife left him. You think its important that I ask him about NSAID abuse?"

"Well, who is his PMD?"

"I don't know."

"Well, why not? Its important that continuity of care be documented and..."

"Yeah, listen: He doesn't know who his PMD is, either. Probably because he doesn't care. Mickey McPatterson here is from South Boston and has cigarettes for breakfast. If he gets a rash, he goes to a priest and confesses his sins, he doesn't go to public health. Are we done here, or are you going to ask me more questions that neither he nor I can answer?"

 

[nlax30]

I may have to hang out over here. EM forums much more interesting then the snooze-fest Cardio section...

 

[Apollyon]

I may have to hang out over here. EM forums much more interesting then the snooze-fest Cardio section...

Ironically, though, I was telling my wife last week that cards fellowship does something to your writing that makes reading a cath and stent report interesting. I recall one that I read when I worked in HI that was, in a word, art.

 

[nlax30]

Ironically, though, I was telling my wife last week that cards fellowship does something to your writing that makes reading a cath and stent report interesting. I recall one that I read when I worked in HI that was, in a word, art.

At a previous place before we went full EMR one interventional guy would draw out these most incredible diagrams if the coronary anatomy and the lesions and place in the chart. Was really cool. Now with EMR I’ve seen the most horrible templates with some reports I can barely read or follow.

 

[ShockIndex]

We used to have this one hospitalist. Thank Christ she got fired.
She would demand that we "delve deeper" into the history, and be condescending about it.

I spent the last 20 years perfecting Brad Pitt’s gypsy dialect from the movie Snatch that I use when giving report to asshats like that. It’s not Irish...it’s not English...it’s just Pikey...

 

[RustedFox]

I spent the last 20 years perfecting Brad Pitt’s gypsy dialect from the movie Snatch that I use when giving report to asshats like that. It’s not Irish...it’s not English...it’s just Pikey...

That's our local Portuguese-speakers, as well.
It's not Spanish, It's not French, Hell; it's not even Portuguese.

Its just... Spanish? as spoken by a drunk Frenchman?

 

[Dr Mantis Toboggan]

my move there is to say “great question! I’m going to put you on hold and go ask. I’ll be right back.”

repeat PRN until they’re broken.

Yeah, I'm inclined to agree with you as well - though the IM folk would do well to remember that 99+% of our patients can't give a history for *snit*.

We used to have this one hospitalist. Thank Christ she got fired.
She would demand that we "delve deeper" into the history, and be condescending about it.

I'll never forget this exchange (and yes, I got the soft reprimand for this):

"Okay, so this upper GI bleed is on pepcid; but I see that [in a note, 12 years ago] that he had arthritis of the knees. Did you ask about NSAID use?"

"No."

"Well, why not? It's important that patients with a history of..."

"Nope. Listen. I'm pretty sure his problem is because he drinks a fifth of Jackie Daniels every day, and has doubled that since his wife left him. You think its important that I ask him about NSAID abuse?"

"Well, who is his PMD?"

"I don't know."

"Well, why not? Its important that continuity of care be documented and..."

"Yeah, listen: He doesn't know who his PMD is, either. Probably because he doesn't care. Mickey McPatterson here is from South Boston and has cigarettes for breakfast. If he gets a rash, he goes to a priest and confesses his sins, he doesn't go to public health. Are we done here, or are you going to ask me more questions that neither he nor I can answer?"

 

[deleted859535]

I spent the last 20 years perfecting Brad Pitt’s gypsy dialect from the movie Snatch that I use when giving report to asshats like that. It’s not Irish...it’s not English...it’s just Pikey...

Five minutes, Turkish.

Such an underrated movie. I feel like I've found a new friend when I quote it to someone and they actually know what the **** I'm talking about.

 

[RustedFox]

Five minutes, Turkish.

Such an underrated movie. I feel like I've found a new friend when I quote it to someone and they actually know what the **** I'm talking about.

It was two minutes, five minutes ago!

"Do you know what nemesis means?"

 

[RustedFox]

At a previous place before we went full EMR one interventional guy would draw out these most incredible diagrams if the coronary anatomy and the lesions and place in the chart. Was really cool. Now with EMR I’ve seen the most horrible templates with some reports I can barely read or follow.

I seriously took a photo of our EMR screen (Cerner; one of the BETTER ones), printed it out, and highlighted all of the space(s) that is/are occupied by useless nonsense. It was cool in yellow highlighter. It was scary when I blacked-out the same spaces with a perm.marker.

Seriously.

CERNER'S interface is decent, but it lets its hubris run away with its better judgment.

Data needs to be classified as "important" or "optional", and the "important" data (name, vitals, comments immediately relevant to care, labs/rads) needs to be FRONT and CENTER. Right now, the front and center real-estate is populated with symbols that everyone ignores.

 

[greatnt249]

Five minutes, Turkish.

Such an underrated movie. I feel like I've found a new friend when I quote it to someone and they actually know what the **** I'm talking about.

"Heavy is good, heavy is reliable. If it does not work, you can always hit them with it."

"You should never underestimate the predictability of stupidity."

 

[RustedFox]

"Heavy is good, heavy is reliable. If it does not work, you can always hit them with it."

"You should never underestimate the predictability of stupidity."

Vinnie Jones has quite the life apart from being a great actor.
I've seen footage of him as a footballer (SOCCER-player) getting into an argument with another player, then grabbing said other player by the testicles.

 

[GeneralVeers]

Data needs to be classified as "important" or "optional", and the "important" data (name, vitals, comments immediately relevant to care, labs/rads) needs to be FRONT and CENTER. Right now, the front and center real-estate is populated with symbols that everyone ignores.

You mean like the "sepsis ball" or the spikey Koosh "COVID ball" that appears on patients with chest pain, abdominal pain or diarreha?

 

[RustedFox]

Those, and all of the other things that are useless.

I'm logged in from home right now (its raining, can't walk the dog or otherwise do much of anything).

Here are the useless things that take up central real-estate on the screen (from left to right).

There's a column named "Tx Plan", which is always vacant. Now, blank-spaces can be useful; but this ain't it, chief.

There's a column named "CareCoord", which displays icons indicating "READMISSION!" or "ACO", which you don't care about because you're going to to do the right thing anyways.

There's a column named "Info", which has apples, triangles, and other things that make limited sense, and also don't contribute to patient care.

There's a column named "NR", which has a white "clipboard" icon in it at all times and cant be collapsed... seemingly to remind you that a clipboard-toting nurse is watching you at all times.

There's a column named "Note" which is also always vacant. Now, blank-spaces can be useful; but this ain't it, chief.

There's a column named "RA" which has a stethoscope icon it in (invariably), to indicate that a nurse has ignored the patient again.

There's a column named "Chart", which lets you click on the chart icon to access the charting. This could also be done by say, double-clicking on the patient's name... but hey; I'm no computer wizzzzard or anything here!

There's a column named "Activities" which has LOTS of useless icons in it. I tried signing up for activities (like flag football or chess club) using these icons, but... it didn't work.

There's a column named "MAR", which indicates to me that the nurse has or hasn't given the medicines.

There's a column named "IV STOP", which I'm not sure indicates anything beyond the nurses ignoring the patient's IV.

There's a column named "EKG", which tells me to yell at people to do an EKG despite the patient being here an hour with a complaint of chest pain, shortness of breath, dizziness, etc.

There's a column named "Lab", which tells me when labs are done and to click here to see them, this is actually ****ing useful.

There's a column named "Rad", which tells me when radiology studies are done and to click here to see them, this is actually ****ing useful.

There's a column named "Patient Flow", which has lots of other strange icons in it that take up just enough space to push the other columns off of the screen.

That's where the screen ends, before you have to scroll to the right.

Once you scroll right, you see other things that you'd normally never need, like:

"Dispo", "Blood Pressure", "Pulse", "O2", "RR" and "Who the hell is taking care of this patient?!"

 

[RustedFox]

While I'm complaining about EMRs being awful; at least CERNER is getting it right in as much as (is that one word?) it only takes me one click to sign a MLP chart.

With "MediTECH", I counted that it once took me thirteen separate "clicks", "scrolls", and "PINS" to sign a MLP chart. This was without actually reading it.

Hey, ENVISION/HCA:

Get a grip.

Your EMR is one of many, many reasons that I won't take a job at your shops.
It could be a bit better; for so many reasons.
ONE of those reasons is that your EMR is the pits, and you have failed to see how bad it is.
Thus, everyone hates you.

Kay. See you like, never.

 

[GeneralVeers]

I've never understood why they can't have useful things like:

1. Customizing the tracking board to only show the data I want
2. Alarm pop-ups I can set. "Hey that CT read is back after 2 hours!"
3. Doctor-nurse messaging for a particular patient. Instead I have to put something in the comments section and hope it gets read

 

[yeasports]