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"You can see the bone."

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e30ftw

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I like procedures and don’t mind sewing these people up but always feel bad for them. They made the “right” decision going to an urgent-care for their non-emergent injury then got punked by someone who doesn’t understand basic wound care.
 
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RuralEDDoc

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I hope I don't stroke any EM docs out by sharing this
Oh man. Thankfully no TIA for me but sure brought back flashbacks to the days I had to sign 30-50 midlevel charts at the end of my shifts often several hours after the midlevel left. Holy cow. That was 8x as stressful as running two codes simultaneously. (For the medical students - that’s not a joke - codes become relatively low stress events at a certain point in ones career, but bad supervision policies never do).
 
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SCREW IT!
I put my finger on a guys exposed skull the other night while he was wasted. Always fun.
Just as long as you didn't sign it with a Sharpie, right? (If I recall correctly, some neurosurgeon did that. However, I am just way too busy (haha, lazy) to even look it up.)
 
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Tenk

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Just as long as you didn't sign it with a Sharpie, right? (If I recall correctly, some neurosurgeon did that. However, I am just way too busy (haha, lazy) to even look it up.)
Yeah there are a few nut jobs who have done that. Honestly, none of our patients are worthy of my sig.
 
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docB

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I like procedures and don’t mind sewing these people up but always feel bad for them. They made the “right” decision going to an urgent-care for their non-emergent injury then got punked by someone who doesn’t understand basic wound care.
I agree. One of our local urgent care chains got dinged on a hand case a few years back. Their response was to completely stop treating hand issues. Anyone who showed up was given first aid, like a bandage or a splint, sometimes an X-ray, and sent to the ED. They charged a full visit and co pay for this. They weren't bound by EMTALA so they could have told the patient "We don't do hand. Go to the ER." and charged them nothing. But that's not what they did. The worst was when I saw this poor guy who broke his 4th finger. Very clean fx mid shaft of the middle phlange angulated to about 45 degrees. They had X-rayed him, splinted him exactly as is in this weird, huge volar splint that went from about 6 cm above the wrist out past the fingertips, and sent him. The finger was just laying there on this big splint pointing off to the side. I took off the splint, looked at the film they sent (this was back in the days of film), straightened the finger and put on a proper splint. He was a regular guy so the traction and straightening was quick and less painful than a dig block. He was really nice to me but he kept asking why they hadn't done that it the urgent care. I couldn't give him a good answer. I just kept apologizing for their silliness.
 
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NYEMMED

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I was sent a greatest urgent care referral last night....

Urgent care referral form: Patient has a Baker’s cyst...

I actually called the urgent care and spoke with Jenny McJenerson...

She said: “well that what the ultrasound showed and I figured it would need a emergent ortho consult and surgery”

Sure, I’ll be happy to give your patient a referral to an outpatient Ortho, for a non-urgent finding....
Click ...
 
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docB

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I hear you. I've found there's a list of things that all translate to one thing:
- Urgent consult
- IV antibiotics
- Stat (some king of imaging they don't have)

Translation - I don't know what to do and I don't want to be the last to touch this.

There's also the classic "Needs observation" which means "My shift is over." I get this one from surgery centers a lot when the patient is still puking at 1701.

I always wonder what these people think I really have access to in the ED. Do they really think I can get an "emergent consult" for anything. I can count on 1 hand the number of conditions that require an emergent consult for each specialty and even then I get push back and the consults get deferred to morning on most of them. Do they really think I can get an MRI of anything for any reason at any time? "They said if I really needed an MRI for my 10 years of knee pain I should come here. What difference does it make if it's 2am Sunday morning? Aren't you an ER? I'm calling your CEO who I golf with."
 
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Detective SnowBucket

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Had TWO of these last shift sent by Jenny McJennyson.
You guys know what I'm talking about:

"The laceration is so deep that you can see the bone."

One glance and you see... fascia.

Keep it up, Jennies.
If I were a mod here I would start a new sub-forum under MD/DO for Jenny McJennyson stories, please don't stop with these
 
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RustedFox

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I was sent a greatest urgent care referral last night....

Urgent care referral form: Patient has a Baker’s cyst...

I actually called the urgent care and spoke with Jenny McJenerson...

She said: “well that what the ultrasound showed and I figured it would need a emergent ortho consult and surgery”

Sure, I’ll be happy to give your patient a referral to an outpatient Ortho, for a non-urgent finding....
Click ...

Similarly, Jenny sent me a superficial thrombophlebitis about 2 months ago for "evaluation".
 

turkeyjerky

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I hear you. I've found there's a list of things that all translate to one thing:
- Urgent consult
- IV antibiotics
- Stat (some king of imaging they don't have)

Translation - I don't know what to do and I don't want to be the last to touch this.

There's also the classic "Needs observation" which means "My shift is over." I get this one from surgery centers a lot when the patient is still puking at 1701.

I always wonder what these people think I really have access to in the ED. Do they really think I can get an "emergent consult" for anything. I can count on 1 hand the number of conditions that require an emergent consult for each specialty and even then I get push back and the consults get deferred to morning on most of them. Do they really think I can get an MRI of anything for any reason at any time? "They said if I really needed an MRI for my 10 years of knee pain I should come here. What difference does it make if it's 2am Sunday morning? Aren't you an ER? I'm calling your CEO who I golf with."

Can someone explain the need for a stat US to r/o DVT? This is one of the most frequent referrals I seem to see and I just don't get it. Recently, an outside ED tried to transfer a patient to us for a stat US. After explaining to the doc there that I also don't have after hours US available, I declined the transfer (they sent the patient anyway but via private vehicle).

Once, a PCP sent in a patient for a stat US--she had already given the patient a shot of lovenox in the office and provided a sample pack of rivaroxaban. This was in a system where they easily could've gotten an US the next day.

I don't get it--is a DVT really such a time-dependent diagnosis?
 
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VA Hopeful Dr

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Can someone explain the need for a stat US to r/o DVT? This is one of the most frequent referrals I seem to see and I just don't get it. Recently, an outside ED tried to transfer a patient to us for a stat US. After explaining to the doc there that I also don't have after hours US available, I declined the transfer (they sent the patient anyway but via private vehicle).

Once, a PCP sent in a patient for a stat US--she had already given the patient a shot of lovenox in the office and provided a sample pack of rivaroxaban. This was in a system where they easily could've gotten an US the next day.

I don't get it--is a DVT really such a time-dependent diagnosis?
There are physicians out there who don't like to start anticoagulants unless there's a proven problem. They are relatively risk meds so I get the concern, but a single dose of lovenox for next day U/S seems fairly low risk to me.
 
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docB

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Similarly, Jenny sent me a superficial thrombophlebitis about 2 months ago for "evaluation".
Yeah. I agree that it goes beyond the fear of last touch. There's a real issue with providers (docs, apps, nurses operating essentially on their own in SNFs and LTACs, etc.) who have a vague idea about what to order to "rule out" this or that. But they don't have enough knowledge or experience to know what to do with an abnormality. They can't discern what's an incidental finding or meaningless radiology blather.

Can someone explain the need for a stat US to r/o DVT? This is one of the most frequent referrals I seem to see and I just don't get it. Recently, an outside ED tried to transfer a patient to us for a stat US. After explaining to the doc there that I also don't have after hours US available, I declined the transfer (they sent the patient anyway but via private vehicle).

Once, a PCP sent in a patient for a stat US--she had already given the patient a shot of lovenox in the office and provided a sample pack of rivaroxaban. This was in a system where they easily could've gotten an US the next day.

I don't get it--is a DVT really such a time-dependent diagnosis?

I think there's this misperception on the part of transferring entities that there is less liability if they transfer for a study than if they arrange the study and the patient doesn't show. There's also a lot of laziness in that they don't want to arrange the study or deal with the results (see above about competence). There are a few funny things about this. Often the patient no shows to the ED, especially the light patients who would have kept a radiology appointment but don't want the drama or expense of an ED visit. They don't seem to feel they have any liability then. And we have similar liability too. If I diagnose the DVT and they don't take their meds it's all the same.

As for your comment about declining the transfer and the patient being sent POV having been lied to about the availability of US all of our SNFs now, as a policy, call report after they've sent the patient. They do this because they feel that having the patient directed to an appropriate facility takes too much of their time and isn't their problem. Seriously.
 

thegenius

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I hear you. I've found there's a list of things that all translate to one thing:
- Urgent consult
- IV antibiotics
- Stat (some king of imaging they don't have)

Translation - I don't know what to do and I don't want to be the last to touch this.

I really wish they would just call us and say something like "I think this patient might be sick and would appreciate your opinion" rather than lying about why they are sending the patient over, or relying on the patient to tell us everything.

Sometimes I get Urgent Care referrals because they want labs. And they call me prior. Like someone with a stupid chronic chest pain with non-specific EKG changes. Like TW flattening in the lateral precordium. One urgent care guy calls me from time to time and says "I would really like some labs for this low risk chest pain patient." Fine. (I'm not going to argue with him.) Then I ask "can you set up the patient for outpatient Cardiology or PCP follow-up? Since by the time I'm finished with the patient it will be 7:30 PM and doctor's offices are closed." He usually says "yes". I'm much more willing to help out in that case.

I had a PCP!!! send me a teenage girl for "r/o appendicitis". The pt went to the PCP earlier that day for an eval of crampy abdominal pain and diarrhea for 2 weeks after coming back from Africa. This was the second time at her PCP's office during that time.

I laughed out loud when the pt's father said she was concerned for appendicitis (I soon after apologized for laughing). I think I said something like "I think your PCP knows this isn't appendicitis."

It was clear after about 1 minute of history taking that she had some sort of infectious colitis from Africa. I got on the phone with my ID doc, he said immediately "I bet this is salmonella typhi." Send x, y, and z and start her on these two abx. Sure enough the salmonella Abs came back several days later as positive and the pt is now fine.

Just absurd. Why can't these PCP's call their fellow doctors sometimes? Maybe they do it more often than not.

Lastly, I made sure to thank the pt and her father for going to the PCP first, because that is the right thing to do in this case.
 
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thegenius

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Can someone explain the need for a stat US to r/o DVT? This is one of the most frequent referrals I seem to see and I just don't get it. Recently, an outside ED tried to transfer a patient to us for a stat US. After explaining to the doc there that I also don't have after hours US available, I declined the transfer (they sent the patient anyway but via private vehicle).

Once, a PCP sent in a patient for a stat US--she had already given the patient a shot of lovenox in the office and provided a sample pack of rivaroxaban. This was in a system where they easily could've gotten an US the next day.

I don't get it--is a DVT really such a time-dependent diagnosis?

We've had this question on here before.

I used to think not, then I looked up the dozens and dozens of personal-injury lawyer websites who specialize in missed DVT diagnoses.

Now I don't even think about it. I don't f'ing care. It's the lawyers who are driving up 20-40% of the cost of medicine. Making our health care premiums skyrocket.

(I know it's not all the lawyers fault, but they get some of the blame)
 
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RustedFox

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Evaluated.

$80 in my pocket.

Next.

See, amigo - I love you, but this is the wrong attitude to have.
This hurts the patient and the system; and is the primary reason why the Pretend-Level-Providers need to be held accountable.
That 80 should come from the PLP.
 
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VA Hopeful Dr

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Just absurd. Why can't these PCP's call their fellow doctors sometimes? Maybe they do it more often than not.

Lastly, I made sure to thank the pt and her father for going to the PCP first, because that is the right thing to do in this case.
I'll take this one:

When I was working urgent care fresh out of residency, I was across the parking lot from a hospital owned by the same corporation so all of my patients that needed an ED went there.

My first month (so a handful of weeks out of residency) a woman came in with what I thought was a really worrisome laceration so I sent her over there. Turns out it just looked bad but was an easy fix. The EP working that day called me to tell me that and then proceeded to berate me and tell me that I shouldn't be working urgent care if I couldn't handle something like that.

About a month later I sent a probable bowel obstruction over as well (radiologist called that based on x-ray). That same asshat called to berate me for not having the surgeons direct admit the patient.

After that, I never called when I sent a patient over anymore.

Now I'm certainly not saying that's universal because I'm sure its not. But that's one possible reason.
 
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VA Hopeful Dr

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Sad

(although what you bolded in my response was meant as a critique as to why can't a PCP called the ID doc on call for advice.)

There is a direct relationship between a burdened ER with burdened ER doctors and yelling at Urgent Care docs.
Ah, my bad.
 

Hercules

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Sad

(although what you bolded in my response was meant as a critique as to why can't a PCP call the on-call ID doc for advice.)

There is a direct relationship between a burdened ER with burdened ER doctors and yelling at Urgent Care docs.

There’s one other key variable at play in terms of whether the ED rails against UCs. Does the ED doc own their own practice and revenue? If they’re an hourly employee with minimal productivity bonus then these UC visits can be annoying. If they’re a small business owner, these are easy visits that have already been prescreened for insurance since most UCs aren’t going to see an uninsured patient.
 

thegenius

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There’s one other key variable at play in terms of whether the ED rails against UCs. Does the ED doc own their own practice and revenue? If they’re an hourly employee with minimal productivity bonus then these UC visits can be annoying. If they’re a small business owner, these are easy visits that have already been prescreened for insurance since most UCs aren’t going to see an uninsured patient.

Yup. We have had this conversation in the past as well.

I am 100% RVU so I should be very happy to see the superficial thrombophlebitis from UC. Presumably sent over to get an ultrasound to confirm the physical exam.

That's why I told Rusted Fox "$80 in my pocket. Ching."

I am right that it's easy money and that kind of behavior, along with a few other high level things we do (hire PA's, demand we 2.5 pt/hr or more, etc) help contribute to our high salaries.

RF is right that we shouldn't be condoning this kind of bad behavior, it distracts away from real emergency care and is wasteful, wastes patient's time, and is all around wasteful. That is three "wastes" almost in a row.

The day will come, and perhaps it's soon, when insurers will say "I'm paying for one visit for that person's superficial thrombophlebitis. You guys can decide who gets the money." Now guess what is going to happen.
 
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BoardingDoc

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I think the patients are the ones who get burned by this. I don't mind getting the $80 for a quick eval, but it's not fair that the patient has to pay a big ED co-pay for something the urgent care could have handled.
Yep. Had a patient get an outpatient CT scan recently which read epiploic appendagitis. Sent in at 10pm by the ordering NP for urgent surgery. One shot of toradol and a quick explanation about what that is and why they don't need surgery (and why their NP absolutely should know what this is if they're going to try to treat patients) and they were out the door.

Easy money for me. Felt bad about it though.
 
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southerndoc

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Why would you want to tell a patient that an NP or PA should've known what it is and shouldn't have sent you to the ER? We all can't know everything, and if they don't know at least they aren't just sending the patient home.

I certainly don't pretend to know everything, and I would hate it if an orthopaedic surgeon badmouthed me to a patient based on lack of knowledge or inappropriate care.
 
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SXMMD

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While I agree with the sentiments re: jenny's, I would add to southerndoc's point that in medicine we have a tendency to one up each other, within and across specialties. Once we get started on that "this other guy should have caught it" train, we won't be able to get off...

That said having standards should, you know, be a thing. Looking at you, Jenny.
 
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ShockIndex

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The day will come, and perhaps it's soon, when insurers will say "I'm paying for one visit for that person's superficial thrombophlebitis. You guys can decide who gets the money." Now guess what is going to happen.

My last job in EM was a large academic shop that accepted all surgical transfers and most medical transfers through the ED. The surgeons insisted on this because they felt that they couldn’t “trust” what they were being told by the send providers - even when that facility was in our network or advanced imaging was readily available on PACS. So, all cases of perfed hollow viscous, gangrenous cholecystitis, complicated SBOs were sent from one ED to ours so that our surgeons could make sure that we found the perfect intern to write the H&P.

To be fair, much of this excess originated from within the ED as the leadership branded our facility as a 1-stop shop for advanced imaging and diagnostic center. Part of the idea was that it was very difficult to get imaging and consults once the patient was admitted. It was also very lucrative for the ED group right up until the boarding and bed crunch hit about 7-8 years ago. All of a sudden, we found ourselves with an ED locked down with used transfers waiting on beds and unable to see the new patients.

My gut tells me that we will soon see insurers telling hospitals that they will pay for 1 out-patient visit (probably the first one) within 24 hours of an admission. That would incentivize hospitals to directly admit more of these patients. I can’t say that I disagree, especially for those patients coming from another ED where a reasonable work-up is done.
 
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docB

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Wow! Tons of good discussion here.
Evaluated.
$80 in my pocket.
Next.
I agree that financially this is good for us, to see primary care and urgent care stuff. But simply, I don't wanna. I don't want to be the clinic of convenience. I know it's good money, better RVUs/hr than Level 5s or critical care, but it's just not what I went into this for. The fact that it falls to us and that we are heavily incentivized for it makes me see how broken the system is. I point out to my students and residents how under the current system the ED is actually in competition with the PMD clinics in our own MOB. They get kind of dejected and angry once I explain it.
I laughed out loud when the pt's father said she was concerned for appendicitis (I soon after apologized for laughing). I think I said something like "I think your PCP knows this isn't appendicitis."
I recently got in a lot of trouble for telling a patient their PMD was lying to them. The PMD had led the patient to believe that they had ordered a diagnostic study for them when what they had actually done was just tell them to go to an ED and ask for it. I told the patient the PMD had lied to them because they were getting angry that the test wasn't started the instant they hit the door. And, when I walked in, they realized that there were going to be bills for the ED visit.
This has been another beating on my path to complete submission. In the future I will simply say "Absolutely! Coming right up!" and order whatever they want. I've discovered that at least at present the customer service metric shills hold sway over the utilization metric shills.
(I know it's not all the lawyers fault, but they get some of the blame)
I disagree. I think the lawyers are fully to blame. Their profession has created this whole industry for the purpose of enriching lawyers. It does not do an adequate job of either of its purported goals, to compensate the aggrieved and punish the incompetent. It has been grown and crafted to maximize job security and income for lawyers. It is kept alive and protected by legislators who are lawyers. Our profession has a lot to answer for but the legal profession owns this. This could all be fixed with the stroke of a pen but they will fight it to the end.
My gut tells me that we will soon see insurers telling hospitals that they will pay for 1 out-patient visit (probably the first one) within 24 hours of an admission. That would incentivize hospitals to directly admit more of these patients. I can’t say that I disagree, especially for those patients coming from another ED where a reasonable work-up is done.
I think you're right. I actually can't believe we haven't been squeezed on this already.
 
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RustedFox

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Why would you want to tell a patient that an NP or PA should've known what it is and shouldn't have sent you to the ER? We all can't know everything, and if they don't know at least they aren't just sending the patient home.

I certainly don't pretend to know everything, and I would hate it if an orthopaedic surgeon badmouthed me to a patient based on lack of knowledge or inappropriate care.

The issue at hand is that they send the patient AND set the expectation with the patient that "this is an emergency!" when really what they should do is call their supervising physician and act appropriately instead of blindly sending the patient and (ahem) continuing to act like a physician-equal.

I'm 10 years out. I'm pretty sure it was year 2 that I had an epiploic appendagitis. I didn't know what that was. Really; it had just never come up. You know what I did? I looked it up, read about it, learned quickly about it, and called my on-call surgeon to confirm my plan instead of reflexively admit "for them to figure it out", thereby pissing off IM, GS, and the patient.
 
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erdoc00

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While I agree with the sentiments re: jenny's, I would add to southerndoc's point that in medicine we have a tendency to one up each other, within and across specialties. Once we get started on that "this other guy should have caught it" train, we won't be able to get off...

That said having standards should, you know, be a thing. Looking at you, Jenny.

It's not about standards, it's about the fact that many new NPs have no business practicing medicine. Especially urgent care or emergency level care.
 
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alpinism

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You guys think those medical transfers are bad you should have seen the trauma transfers we had in residency.

Talk about absolutely worthless wasteful medicine. We'd routinely get things like minor MVCs with a little neck pain or numbness and tingling. Patients were already pan scanned and had a full set of labs which were all negative but they'd be sent for urgent surgical evaluation. The hospital would never refuse any transfers no matter how ridiculous and upon arrival they'd get a full trauma activation. Of course all the trauma labs would be reordered and they would always want repeat x rays and CT scans. At the end of the day you're looking at hundreds of thousands of dollars in completely unnecessary charges for the patient. The best part is there's absolutely zero incentive to stop this behavior since its a huge cash cow while making their numbers look good which allows them to get more government funding.
 
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thegenius

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You guys think those medical transfers are bad you should have seen the trauma transfers we had in residency.

Talk about absolutely worthless wasteful medicine. We'd routinely get things like minor MVCs with a little neck pain or numbness and tingling. Patients were already pan scanned and had a full set of labs which were all negative but they'd be sent for urgent surgical evaluation. The hospital would never refuse any transfers no matter how ridiculous and upon arrival they'd get a full trauma activation. Of course all the trauma labs would be reordered and they would always want repeat x rays and CT scans. At the end of the day you're looking at hundreds of thousands of dollars in completely unnecessary charges for the patient. The best part is there's absolutely zero incentive to stop this behavior since its a huge cash cow while making their numbers look good which allows them to get more government funding.

It’s like doctors don’t want the liability of being a doctor anymore. Transfer, transfer, and transfer.
 
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Why would you want to tell a patient that an NP or PA should've known what it is and shouldn't have sent you to the ER? We all can't know everything, and if they don't know at least they aren't just sending the patient home.

I certainly don't pretend to know everything, and I would hate it if an orthopaedic surgeon badmouthed me to a patient based on lack of knowledge or inappropriate care.

I kind of agree with you....but at the same time, as a former PA who worked in EM, I knew what epiploic appendigitis is....and if I didn't, I'd sure as hell LOOK IT UP BEFORE TELLING A PATIENT THEY NEED EMERGENT SURGERY. So I can't condone a midlevel getting all worked up about something if they don't know what it is and are too lazy to do a quick google search.
 
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yeasports

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The issue at hand is that they send the patient AND set the expectation with the patient that "this is an emergency!" when really what they should do is call their supervising physician and act appropriately instead of blindly sending the patient and (ahem) continuing to act like a physician-equal.

I'm 10 years out. I'm pretty sure it was year 2 that I had an epiploic appendagitis. I didn't know what that was. Really; it had just never come up. You know what I did? I looked it up, read about it, learned quickly about it, and called my on-call surgeon to confirm my plan instead of reflexively admit "for them to figure it out", thereby pissing off IM, GS, and the patient.

I can't like this enough!
 

yeasports

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Right!

Lemme change that to say "Cha-Ching"

That is hopefully less offensive.
The sound formally known as an onomatopoeia that was expressed when a cash register which was designed to use a mechanical bell was struck. This has been used lately as a pejorative to express exchange in monetary value, usually in an unscrupulous fashion. better?
 
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AlmostAnMD

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Sometimes, late in my shift, I want to send a very basic community acquired pneumonia patient with minimal med history that I'm obs'ing from my ED in the tertiary care center I'm at and transfer him to a critical access hospital 2 hours away by med flight

Sort of relevant, but not really
 
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SCREW IT!
The sound formally known as an onomatopoeia that was expressed when a cash register which was designed to use a mechanical bell was struck. This has been used lately as a pejorative to express exchange in monetary value, usually in an unscrupulous fashion. better?
Not even just lately. There was a Doonesbury strip back in the 80s that had a panel with a dermatologist cutting off a skin CA, and saying, "$500, cha-ching!"
 
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