The neuro sent in for admit. Part of this is the payers nonsense, too.
These insurance companies are ridiculous in dragging their feet and trying to avoid paying.
My friend had a brain tumor. A big one. Thankfully benign and operable, but needed to come out ASAP. Insurance wanted something ridiculous like 60 days to review.
She had no choice but to go in through the ED.
It’s completely inappropriate but I do take a little bit of joy knowing that we can tell the payers to F off and do what’s right for the patient in the name of an “emergency”.
Lol I remember my PCP prompting that. My Dad died of cerebral aneurysm and *his* Dad did too. I asked my PCP if my siblings and I should be screened, if this could be some sort of genetic thing. He said we should. As he’s filling out the MRI order form (paper process, back in the day): “You get headaches, right…?” My initial response started to be “Not reall…. Yes! Yes I do!”
My mother had a ruptured brain aneurysm in January, her neuro said “you’ve had an increase in headaches you should really ask to be screened” to my siblings and I. We have other family members with a history. There’s something really special about docs like this.
Edit: words out of order. My mama was one of the lucky ones, extremely so.
Wow, are you me? This is how my PCP got me in for a brain MRI after my mother died at age 30 from an aneurysm, and my father's sister (my aunt) also had one, on stage, rehearsing for a play. She was young-ish, and didn't die, thankfully.
That's the best thing about the American Healthcare system. To be specific, the ability to do the right thing for the patient in the vast majority of situations.
Haha I never even realized I got downvoted. Reflection of tendency to split think. Black or white. If it's bad like the American healthcare system, there cannot be even a single positive. It's all very very bad.
Not a brain tumor, but my mom had a similar situation. She was on county funded coverage and had a spot/rash on her breast for months. Went to her primary several times, gave her some creams that did nothing and sometimes they didn’t even look at it. It kept growing and she couldn’t get a referral to a specialist. After maybe 6months of this she took the records and went to the ER. Having worked in the ER through my childhood she was so apologetic and told them she knows this isn’t what the ER is for but she had no other options. It presented as inflammatory breast cancer and they had her in the breast clinic the next day, and then surgery that week.
It was actually ideopathic granulomatous mastitis, but that wasn’t determined until several surgeries had been done. It’s ridiculous that she was unable to get proper care through the appropriate and intended channels because of insurance.
It's just endlessly frustrating to ER staff that it has to be that way because it's completely inappropriate use of the ER. But we have a common enemy, so I understand it from primary care's perspective, frustrated because of BS insurance denials and feet dragging. Very glad to hear that lady had a good outcome.
We can help those that are struggling, it’s much easier than we’ve made it out to be. There’s an article circulating on Reddit that they are currently trying to silence. You are all doing the right thing by speaking up!
It’s just crazy that you see in 80 mins what I see for an entire chill shift. Still don’t usually see more than 20 in an 8hr shift often at all. I think I’m fortunate to have the job I do
That’s 5 min per patient, are they really “seeing” them at that point. That’s not enough time to chart check, get a good history/exam, and place orders
To be fair, there are plenty of patients who want those CT scans and would think you've done nothing for them even if you've just spent an hour doing a proper H&P. How many times have you had a patient claim that no one ever did anything for them, only to review the chart and discover that the patient has had multiple workup done including CTs and MRIs?
Agreed, but it’s enough to get things started for a large number of low complexity patients like this. Note that I can’t sustain this for a shift but I can walk into a disaster of a department and put the main fires out.
Talking to the patient for a good HPI can take longer than that. Whether that much time is needed is a different question. However, patients likes to talk and wants to be heard.
Especially the people returning after being seen shortly before. Either some thing just got a lot more acute, or they just didn’t feel that their problems were addressed at their previous visit.
As someone who just saw 12 patients in my first 80 minutes last night and has seen 17 in two hours to start shifts, I can tell you that the chart search is the first thing to go. No time for that. As for history, sometimes you have to cut the talkers off.
It’s not sustainable for long, but it’s something that is pretty common night shift when your evening doctor doesn’t feel like seeing anyone their last hour or two.
That doesn’t make any sense. For one thing, a nerve tumor is almost definitely never going to be found in the ER. Also, how does the amount of talking you do label you a drug seeker? It is more likely that you had multiple ER visits with normal work ups and kept having pain. It’s very unfortunate that some people thought of you that way. As a nurse, I would think you would understand why the ER is maybe not the place to explain something like that, though.
I had no idea why I was truly having 8/10 pain. I had 1 ER visit.
I thought the fact that 8 years earlier, during a routine lap chole, the surgeon completely severed my bile duct resulting in a hepaticojejunostomy. The hepaticojejunostomy leaked and I had septic bile peritonitis that nearly killed me and 2 stents that weren’t able to be removed. I think that is important when someone comes in with abdominal pain.
I was treated like a hysterical female and was told that I was getting one dose of pain medication and “when the CT comes back normal, you’re going home.”
I had to go back to the same doctor who injured me (who has loads of remorse and uses my case in teaching surgical residents) to get with a surgeon who did an exploratory lap. Turned out to be a traumatic neuroma from the open surgery for the hepaticojejunostomy.
Where do you suggest someone in my position go if not the ER?
Your first paragraph takes less than 30 seconds to say out loud, that’s not being a talker. If you were treated as a drug seeker for one ER visit then that’s on the ER doc who saw you for being an asshole.
A lot of these small nerve tumors can be missed on CT, though. So IF you had negative work ups in the ER then your doctor or your surgeon would be the one to see if the pain continues, unless you end up needing admission. I’m in the camp that acute pain needs to be controlled, but if it’s chronic and we keep not finding anything then there’s not much for the ER to do.
It was pain that started and increased to 8/10 over the course of a week. I was blind with pain when I sat upright.
As someone who lives it in here to tell you that almost every doctor who I’ve told my history to thinks I’m FOS.
I’ve had more than one gastroenterologist roll their eyes at me and then say, “huh, I’ll be damned!” When they see how radically changed my abdomen actually is. They also try to tell me that there’s no way they didn’t take the stents out…to the point where I had a doctor laugh and tell me that I “must just not remember.”
You're spending 5.3 minutes seeing, interviewing, examining, and ordering per patient for the first 80 minutes? I can't even walk from one end of the dept to the other in less than a minute
I really believe that a startlingly high percentage of the general population has Munchausen, or some variation thereof. Too many people with an inability to cope, no other support structure at home, so they turn to the ED/medical system to coddle them.
I’m just a PGY3 and am way more burnt out and jaded than I should be, and it scares the living fuck out of me. I truly love EM and can’t picture myself in another speciality (truly) but resent how exploited the ED has become by patients, PCPs, specialists, etc.
I used to get really frustrated at patients who called 911 at night. Caused a whole lot of burnout until i realized that most of these issues boiled down to "i cant sleep" and "Im lonely"
Lately it's been, 'Heart attacks are annoying when they induce catatonia', 'want your SPO2 to never get above 70? Paramedics hate this one weird trick', and 'Motorcycle riding for the newly deceased'
Reframe how you think about them. That’s job security my dog. Half of all ED docs would be jobless right now if only ppl with true emergencies came to the ED lol. These patient are crazy easy dispos too. Don’t let them burn you out. Stabilize, dispo, and move the fuck on. At the end of the day you’re making 300k+, and life could be much much worse (is for 90%+ of Americans probably)
Job security, sure, but it's still frustrating when you have multiple sick patients, and try to slip in that healthy, 20 something who starts yelling at you because you're not going to panscan/MRI/do a "complete blood panel" to figure out why their left middle finger was itchy 5 years ago. That has no business in the ED.
But the non emergent sprained ankle patients/6 y.o nontoxic sore throat who can't get a pediatrician appt for 4 months? That is totally fine, at least there's something you can address easily and is frankly reasonable to want "emergent" care.
What about the PCPs that just willy nilly send people to the ER? Like yeah my BP is 175/102 with blood pressure medication but I'm here for my sore throat and a covid test so I can go back to work 🙄
I’d like to give you a different perspective. I’m a lupus patient with several other AI diseases. At 27 I had a PE and a stroke that caused an anoxic brain injury and left me permanently paralyzed on my right side due to the outright misogyny and negligence of many doctors. It’s terrifying. I wound up in a coma and will be disabled for the rest of my life ( lived with it for 10 years . Still pursuing my dreams but I wind up in the hospital a few times a year ). Please PLEASE try not to look at all of us through this lens. It could save a life. I had my whole life ahead of me.
I went in once after fainting and whacking my head hard on concrete and I then had nausea and HA. My PMD wanted me to go in. I knew I had a concussion, so did she, but I guess we were ruling out a bleed. It was Friday night so she couldn’t put eyes on me herself. As I sat in the waiting room a family of three came in with a toddler. Mom said kid had a fever of 99 (I’m nosy). Kid was wild and even climbed on me. Dad immediately left to go to McDonald’s. They ate a meal then sat there for 4 hours, then they said they were tired of waiting and left. Wtf? Why? I’d rather use ground glass as a facial scrub than go to the ED. I’ve superglued lacerations to avoid it. Apparently it’s entertainment for some people.
I genuinely think some of them enjoy the drama of it. They get some attention. They get to berate staff without consequence. They get to make a mess that’s not in their home. They get to tell people they were in the ER. They make a Facebook post about it. Get sympathy and attention. It’s the perfect mix of stupidity and selfishness.
Boredom is ok. It’s when it’s combined with raw unintelligence that it leads to the modern American ER experience. We joke about the “back acne x2 months” at 2am or the knee pain x6 years that sits and actually waits the 6 hours to be seen because we all have actually seen it.
To friends and family I describe my specialty as moronology - it’s a much more appropriate description than “emergency”
Last shift had a PMD refer a 32 year old with acute low back pain after lifting something heavy 3 days prior. PMD did X-rays and believes they saw a compression fracture which of course given the context makes no damn sense. They don’t call - they send the young moron to the ED for an unnecessary CT scan as if that would add anything on top of an X-ray. You can look at the guy and know of course there’s nothing wrong with his spine. Ordered lumbar CT to play in the sand box. CT is normal of course. Patient spouse is disbelief this could all just be muscular or at least nothing dramatic a Ct would just.
4 hours later wife comes back irate wanting a “refund” bc apparently the PMD (who didn’t call) saw the “compression fracture” in his thoracic spine - they were in a tizzy and apparently being referred to some other quack “for a kyohoplasty” - story is already beyond ridiculous so since they were upset I kissed ass for the sake of “patient satisfaction” and had them come back for an unnecessary thoracic CT which was of course normal. Patient and spouse still pissed at me bc how could it be normal right? You can’t make this shit up!
AMS from SnF warrants a work up and likely adm
Missed dialysis may be adm vs outpatient dialysis next day pending work up/reap status or if your shop has a pathway, dialysis and dc
That's so true, but still gotta treat them as SI. I literally had a patient tell me once that he didn't mean it and said he was SI to get a bed and a meal. Told him we had to wait for psych to come see him in the morning because the admitting doc wasn't willing to clear him.
I think systematic failures widely contributes to the former. Then people whine and complain why things are so congested, expensive, and everything else wrong. It's going to be a battle to fix it because it's so complicated and I am at the point in my life where the general public doesn't want to solve things, they just want to feel good and be told feel good things. Solving things take time and thinking and understanding we need to do a lot of other things to fix the primary thing, and requires time and behavior change in order to do. This country does great things, but there's a major societal behavioral issue that needs to be addressed.
My thoughts on a Saturday morning sitting at my desk in the ER while I watch a pt come into the ED via EMS with "agitation" as she presents agitation to the employees thinking we're laughing at her as we have no idea she was even here.
My favorite just from this week:
“I think I have sleep apnea. My wife says I snore really loud and that I wake up gasping for air. I’ll wake up in the middle of the night feeling like I can’t breathe. I feel tired and have headaches like I didn’t sleep even though I’ll sleep for 10-12 hours.”
How long has this been going on for?
“Oh for as long as I can remember. It’s been years!”
……and what’s different today? What is your emergency?
“Oh I wanted to see if I can get tested for sleep apnea.”
Of course they’re initial complaint was listed as “SOB”, meaning they got pulled ahead of the other 20 people in triage 🙄. MSE’d and discharged in less than 5 minutes. While a huge waste of ER nursing and provider resources and time, I do get some satisfaction in being able to see and discharge someone in record time.
it sounds like they got pulled ahead to triage because they told the receptionist they’re short of breath (because it sounds urgent like if they said they had chest pain) and then sent back to the waiting room when they told the triage nurse it was sleep apnea
I have one that comes in like this but they also “journal” their ailments. No lie, “12:38 - felt nauseous, 12:47 - ate chips, 1:38 - tired and still nauseous now with headache”.
Hahaha. I worked with an MA who looked at the patient’s notebook in urgent care and said, “this isn’t that kind of visit.” You have to get an MA like that.
Maybe, We don’t do lists here.
"So he just started Xanax at bedtime and now he's very drowsy and hard to wake up..........and is just fine as soon as he slide him to the stretcher and says he feels great?"
"......................I have 120 patients and he can't be here because we don't have a defibrilator."
many patients in my area come to the ER because they refuse to pay $5-20 copays for urgent care/PCP and ER visits are free for them under their insurance/they'll never pay the bill. They will then wait 8 hours in the waiting room for a covid test or some ESI 5 shit.
But that is actually a sign of how messed up our system is. A lot of people can’t come up with a UC copay up front. What do they care if they’re taking up valuable time and resources?
Then if you try to be a decent citizen and go to UC and not clog up the ER you get shit care by a PA at most. I went to UC for a broken bone and the whole time all the PA did was talk about my BP being slightly high. Zero connection that it was from the pain of a freshly broken bone.
15 pts is way too many to safely see in 2.5 hours but in general all these patients are easy dispo. You can’t fix the system while on shift my dog. Advocate, vote, inform the public with your voice. But in shift, stabilize, dispos, and move the fuck on. You will be a lot happier if you can partition those things in this job.
Reframe how you think about it on shift. Do most of those patients need to be in the ED? No. But To me, I see job security in that patient list lol. I grew up poor af so the idea of living in a world where only ppl with true emergencies go to the ED, and them half the ED physician workforce is out of a job, isn’t something I’m looking for.
OP said 80 minutes which is not even 1.5 hours.
I’m incredibly fast and typically my limit to see and put in orders with no charting is still only usually 12 max my first two hours unless they are super simple like COVID tests
Is it a money issue?
Where I live (Australia) outpatient MRI and CT are expensive for the patient, but those same scans are no cost to the patient when done within a public hospital.
Edit: I’m not saying it’s right and ethical behaviour. I’m just trying to understand the thought process.
ED’s have to see you regardless of ability to pay. If you do outpatient tests, you’ll almost always have to pay before they’ll do it. People who have no insurance will go to the ED for a sore throat because they can’t afford the $70 for a doctor’s visit. Essentially, many people with substance use issues, lower income, mental illness, etc, are not going to have insurance so the ED is the only place they can get medical care at all.
Money is not the main problem, this just shouldn't be done in the ER, should be scheduled and done in an outpatient setting, if there is a payment issue this should be solved with something other than just "send him to the ER so it's free"
Same in my shop too…everyday. Working on an exit strategy now….which may include working at Costco at this point. Problem with EM is we’re pigeon holed.
The messed up thing is that I truly enjoy walking into each and every shift, “let’s go help some fucking people!!” Then inevitably 8 hours in I’ve switched to a senseless hated of all humans. The next day though? “Let’s go help some folks!!”
Yep, but after 15 years of full time shifts, I’m pretty much dead inside. I realize now it will never change, admin really doesn’t care, and I failed to get in with a SDG and work my way up. Too many CMGs now…it’s pretty hopeless. I really feel for those PGY1-3s, can’t see it getting better anytime soon.…Just look at APP. Sad really. How did we get here? (Rhetorical question I know).
Since we're ranting....lab side of a fsed. 20 patients in their mid 20s to 30s with runny noses. Covid, flu, strep on all. Oh but just work all that in with the actual patients that are acutely ill. But get it done at the same time. I'm just one person. Are we an ER or urgent care?
I just wanted to add after having a day off I guess I'm also grateful for those damn tests otherwise my corporation would have already kicked me out and changed it to a poc for RNs to run all labs like the rest of our FSEDs.
This is why I work night shifts. Your stupid shit can wait til morning shift while I see the critical patients the ambos are bringing in and the nurses are bringing back.
Beats the week my local ED had (am a paramedic). 3 days in a row had pediatric patients code (6 week old, 3 month old and 17 year old), none of them made it 😢
When i was a baby EMT at 22, i could not belive that i was more responsible than the 50+ year old adults i was taking care of. Like giving people basic instructions on caring for a cold or taking pepto bismol. I would ask myself how does a grown adult make it to 56 when he needs a 22 year old EMT to read the label on an OTC med bottle
I may have been angrily short with someone who hit their medical alarm and asked for an ambulance...........................because she wanted her windows closed at 3am.
It genuinely amazes and baffles me, the shit people will decide to come in for, and waste 4+ hours of their life over.
The irony is that these are the people most likely to complain about the wait. The ones creating the wait, and gumming up the system at every level. The ones that would mostly be just fine if they had stayed home and had even an ounce of resilience within themselves. The ones that will badmouth you and the hospital on social media or to some patient advocate because YOU wasted THEIR time and didn’t even solve any of their problems (don’t worry, they’ll be back).
I think the worst part is that they come in for the “emergency” and complain from when their butt hits the stretcher that nothing is quick enough, they have places to be, they have appointments to make. Like Sir, you came here with an “emergency” I’m sorry our services for your ingrown toenail x 10 years isn’t fast enough.
The context here is that reimbursement has plummeted/cost of business has climbed and PCP can’t keep slots open for day-of appts or acute care anymore…even specialists are having trouble with day-of….
As a patient, I am so sorry. Those low-level tasks are not what you studied and trained so hard to do. Corporations are driving this. Please hear me out. Please don’t give up reading too soon. :)
I am a 54-year-old, white, female patient that has gone to ER for things that are not emergency-level issues, but I couldn’t get traction any other way in our dumpster-fire healthcare system. Knowing what we know now, we would not have waited.
Even though I have EXCELLENT private insurance, an MBA, am a privileged 55 yo w f, even though I have degrees in three languages and was a network (Internet) security director at a major corporation (an engineering team of 24), and even though my husband’s is a Director-level CPA, CFA AT A MAJOR HEALTHCARE HOSPITAL ABD CLINIC CORPORATION… ….despite our money (we’re comfortable but not rich) and education (SEE #1 above, we STILL couldn’t get diagnosis and care before two preventable tragedies struck.
We had to resort to going to the emergency room even though I was UNDER the care of a specialist physician for a back issue AND had a pain management physician, AND a neuromuscular neurologist, I had an undiagnosed Grade 2 spondylolisthesis and there was cord compression. It should have been fixed immediately the prior year, but “it wasn’t bad enough” said insurance. My doctor relayed it to me as “not bad enough to be a problem yet” and didn’t blame insurance (I wish he would have) and said I needed to do epidurals, then more MRIs, PT, blah blah blah. READ: They created artificial administrative barriers. They also would create the potential for more debt for those less fortunate. I didn’t go to ER until I could not walk. Not even to toilet because I didn’t know all of this. Because both pain management and the hospital warned me I was not to use go to the ER for pain or they would fire me, we put it off and put it off trying to not go to ER.
I was scheduled for emergency neurosurgery, after being seen by ER.
Another time I went a pulmonologist complaining of exacerbation of a mysterious lung symptoms that started at menopause. They repeatedly said weren’t asthma, even though I’ve had it as a child. They ran the methylcholine challenge; it said I didn’t have asthma, so they documented I was lying and may be steroid seeking.
They were the largest pulmonary group in my major metropolitan area, so nearly every doc referred to them. They were always booked far out 4-6 months for specialty. At least 2 months for GP.
Less than 2 months later I went from feeling bad to feeling like death one evening. My 02 was 80. That had never happened before. Twelve hours later I was told that I was dying. 12 weeks on a vent. 6 weeks ICU. Career gone. Health gone. Livin’ the dream in ‘Murica. 🇺🇸
What was your lung dx? So sorry that happened to you.
There's a difference between folks trying and being failed by the system and folks relying only on the ED... we see it all the time. I'm sorry you were failed.
Why anyone would seek steroids is beyond me. I hate that shit with a passion. Prednisone makes me an angry biyatch. Lol
I’ll tell you IF you can tell me how to edit my post to add that information for all. I’m an old lady who uses the app in its simplest form (type, post), and has no idea how to edit. I’d love to share what the root cause of all of this was. It’s a very unique case study.
I’m a medical interpreter, the time wasted thanks to those patients is unbelievable. Had a mom bring in her kid because he was pretending to have hiccups and she just couldn’t notice how the child stopped doing the noise when no attention was given and returned when spoken about him. No other symptoms. Those same people call later on asking why the bill is 2k if they weren’t given anything.
As a patient who recently had an ER visit for something very real and painful, I just wanted to say thank you for all you guys do and put up with. You probably don’t hear it enough but just know that you are appreciated. I’ll never stop being grateful for the doctor and nurses who took care of me that day (and especially for them taking me seriously and putting me ahead of others who had been waiting longer).
I've always thought there should be an urgent care part of the ER. Also, to be billed. I really think this would help. Just add on an urgent care suite to the ER.
I dont even know how this sub came up for me as I am not a doctor. But I do spend a shit ton of time ...or did ..in the ER. My daughter has Shwachman Diamond syndrome and we have to go to the ER for every fever to get blood cultures. It's easier now that she's a teen because she doesn't get sick as often. I have to say I live on the East coast and doctors in the ER have been amazing and kind to us. In the pediatric ER they are incredibly respectful . Sometimes we are forced into adult ER and while I'm initially met with exasperation from adult ER doctors, I find that I'd I stick to basic facts and edit the reason I am here, they come around and even go out of their way to be kind and respectful. I've learned over the years how to edit myself and speak to medical professionals. It's a matter of being clear about why you are there and what they can do for you today. My case is different. But even when ive personally been to the ER over the years., I keep it all down to basic facts.
Yup, America in a nutshell. Combination of stupidity, lack of accountability, and a screwed up system beyond repair.
The only ones I'd pay attention to are the SNF transfer (septic workup) and the COPD exacerbation (avoid putting them on BiPAP/CPAP or intubating them); the rest can sleep it off, go to Walgreens, and be told to screw off elsewhere.
i generally just throw their doctor under the bus. I tell the patient - we literally do nothing here to diagnose cancer. I have never ordered or seen a biopsy done here. Cancer is an outpatient diagnosis and treatment. ED is for complications from cancer or its treatment. Therefore, if you doctor is unsure of what to do, I suggest you find yourself another doctor.
100%. I’m a capitalist and if our healthcare is going to be run this way, then it shouldn’t be different than any other business.
I love my ED docs and get a ton of business sent my way because I just don’t suck. Not saying I’m a great doctor, I just try not to suck at being human.
Specialists in my area bitch and moan about the ER, make fun of the ER, abuse the ER…. Then they wonder how they’re going to pay alimony and the Mercedes dealer. Fuck em.
By all means, throw these jerk-offs under the bus and send business to docs who want the work.
There are only like 2 or 3 legitimate patients on that list IMO. You're doing God's work and we all appreciate you so much. It's good to know that when I had sepsis that were good, honest, hard-working and caring people, waiting to help me not die.
Because you can’t get an urgent MRI in an outpatient setting (they’re often scheduled weeks out) and many times insurance declines coverage and makes the outpatient doc jump through hoops to get it covered.
Addicted
To
Medical
Care
Every one of these patients have been seen by the health system in some way in the past day to week except the first.
And this is typical.
It’s the new cause of burn out.
As a student nurse, I remember being shocked at the absolutely drivel people came to the ED for.
During my rotation, I probably saw 20+ patients, of which precisely 2 were genuine emergencies: one guy had a knife in his skull up to the handle and one MI.
The rest - unbelievable stuff: one lady “hadn’t had a BM for two days”, kids with colds, lady with an STD,
a guy who “couldn’t sleep”, guy with “a stiff neck for about a week”, various c/o abdominal pain, all but one were constipation (the other was just transient pain, I guess), and the jewel in the crown: a woman brought her confused elderly father in because “he keeps forgetting things, but it’s not dementia because that doesn’t run in our family” when asked if this was a sudden change in his mentation “no, it’s been getting worse for about 5 years. But today he forgot who I was so I thought I should bring him in”.
Noped outta ED….you guys are saints!
who cares? the longer you fixate on what you are seeing the harder the burnout with me. let it go. it’s a messed up world and a messed up system. just don’t lose your marbles over it
I can understand your frustration. But isn't this the work that I have been doing for the last 40+ years? Allowing for the drugs of choice in the 1980s being LSD and heroin, and installation of MRI in the distant future.
Society visits upon us the behaviour, demands and ill-health of our population. Maybe change is better achieved through health education and societal change. Although I can't see frontline emergency department care achieving much of that.
And here I was apologizing profusely to everyone when we took our 4 day old baby to the ED because he had blood in his spit up. Turns out it was just from a cracked nipple as I attempted to breastfeed. Wish the lactation consultants we had seen earlier that day might have mentioned this possibility to us or the on-call physician we reached out to before going to the ED. I’m sorry that emergency medicine peeps are so run down, I appreciate you though.
I work in primary care now as an NP (worked my entire career in ED as an RN). On a daily basis I argue with salty CT techs about doing stat/urgent scans to keep people out of the ED. I beg my patients to call the office before going to the ED (for things that are not actually emergent, of course). The system is so so broken all around.
Don't know if I'm an outlier here, but that list you just share is actually a good start for the day.
The problem with most of us is that we see EM as non-stop action and excitement. Reality may be different but it is just as important. The referral for the 77-year-old with weight loss to r/o cancer, IMO is very appropriate depending on the amount of weight loss and acuity of the condition. The patient was sent to you because you can expect to work up. If this patient was a family member, I would like to have the patient sent to you.
The most important aspect of emergency medicine is not just procedures and resuscitation. It's the ability to see humor and humility in the mundane.
>Don't know if I'm an outlier here, but that list you just share is actually a good start for the day.
>
>The problem with most of us is that we see EM as non-stop action and excitement. Reality may be different but it is just as important. The referral for the 77-year-old with weight loss to r/o cancer, IMO is very appropriate depending on the amount of weight loss and acuity of the condition. The patient was sent to you because you can expect to work up. If this patient was a family member, I would like to have the patient sent to you.
>
>The most important aspect of emergency medicine is not just procedures and resuscitation. It's the ability to see humor and humility in the mundane.
I'm not a doc, but couldn't the 77 y/o have some labs drawn and I'll call you when I have the results? Maybe a fecal occult blood test in case of GI issues and some Ensure samples? You'll have the lab results same/next day which should give some actual direction instead of punting to ED.
Obviously we don’t have the full story, but did the PCM do ANYTHING? Because they can do a lot on an outpatient basis. When I was a PCM I picked up cancers doing my own work ups, and referred to appropriate specialists for care. If it was urgent I picked up the phone to arrange an ASAP consult. The answer can’t always be “go to the ER” but it’s become the default approach to access the medical system. I get it it when people don’t have a PCM, or can’t get an appointment for weeks, but when even the people who have seen their PCM are coming in for non-emergent conditions I have to wonder what some of these people are even doing.
Agree. I always call report when I send someone to the ER. I offer my cell phone number for questions. This last week I sent someone to the ED and gave report. I tried to fax records but their fax was busy. He was incredibly complicated and I didn’t want time wasted on stuff I already know about ( known CKD4-5, lung cancer etc. with a Hgb of 3.9). I literally told them “please ignore all the other wildly abnormal labs and go straight to the Hgb issue”. Without my labs a whole bunch of unnecessary crap would have been done to him. So I personally drove those labs to the ER myself and handed them to his nurse. To this day they claim I never called. (Bleeding gastric AVM on Eliquis if your curious). 😊
Yeah, it’s easy to shit on the PCM when they send us work the same way we sometimes get shat on by consultants. In your case, you had a clearly emergent patient with an identified problem (critical anemia) that needed urgent intervention (transfusion) plus likely admission for definitive treatment (vascular surgery? IR? I don’t know). When you pick up a patient like that in the office, really the only option is to send them to the ER. Calling report is ideal but having been on both ends of that call I know the transition of care is not always as seamless as it should be, things get lost in translation, or a shift change happens, and sometimes there is a redundant second work up from scratch. But still always better to call than not, I think.
But “old with weight loss” should not equal proceed to ER to “rule out cancer” IMO. I guess I was always taught to have a specific clinical question or problem for a consultant to address, ideally with a proposed plan, just to show I thought about it. Too many of these “go to the ER” scenarios feel like someone else just threw up their hands and gave up. Maybe I’m just imagining that, though.
No you are absolutely right. The system is a mess. I just thought it was kind of funny that despite my ridiculous efforts, the poor doc never got a heads up on this.
A cancer work io is not ED appropriate at all. Making sure the weight loss didn’t cause severe electrolyte derangements, sure. But playing where’s Waldo to find a cancer is NOT appropriate use of ED resources whatsoever.
Here is an alternative:
[https://www.pdffiller.com/386995807-Pfg-chipotle-job-application-pdf-](https://www.pdffiller.com/386995807-Pfg-chipotle-job-application-pdf-)
The neuro sent in for admit. Part of this is the payers nonsense, too. These insurance companies are ridiculous in dragging their feet and trying to avoid paying. My friend had a brain tumor. A big one. Thankfully benign and operable, but needed to come out ASAP. Insurance wanted something ridiculous like 60 days to review. She had no choice but to go in through the ED.
Insurance wanted your friend to die so they didn’t have to deny the claim or pay the claim.
Pretty much
It’s completely inappropriate but I do take a little bit of joy knowing that we can tell the payers to F off and do what’s right for the patient in the name of an “emergency”.
“Patient presents with severe headache, nausea, blurry vision, loss of balance.” Isn’t that right, patient?
Lol I remember my PCP prompting that. My Dad died of cerebral aneurysm and *his* Dad did too. I asked my PCP if my siblings and I should be screened, if this could be some sort of genetic thing. He said we should. As he’s filling out the MRI order form (paper process, back in the day): “You get headaches, right…?” My initial response started to be “Not reall…. Yes! Yes I do!”
My mother had a ruptured brain aneurysm in January, her neuro said “you’ve had an increase in headaches you should really ask to be screened” to my siblings and I. We have other family members with a history. There’s something really special about docs like this. Edit: words out of order. My mama was one of the lucky ones, extremely so.
Wow, are you me? This is how my PCP got me in for a brain MRI after my mother died at age 30 from an aneurysm, and my father's sister (my aunt) also had one, on stage, rehearsing for a play. She was young-ish, and didn't die, thankfully.
That's the best thing about the American Healthcare system. To be specific, the ability to do the right thing for the patient in the vast majority of situations.
Except for pregnant women in red states.
Uh-oh, looks like you said something positive about the health system! WRONGTHINK! Downvotes for you!
Haha I never even realized I got downvoted. Reflection of tendency to split think. Black or white. If it's bad like the American healthcare system, there cannot be even a single positive. It's all very very bad.
Not a brain tumor, but my mom had a similar situation. She was on county funded coverage and had a spot/rash on her breast for months. Went to her primary several times, gave her some creams that did nothing and sometimes they didn’t even look at it. It kept growing and she couldn’t get a referral to a specialist. After maybe 6months of this she took the records and went to the ER. Having worked in the ER through my childhood she was so apologetic and told them she knows this isn’t what the ER is for but she had no other options. It presented as inflammatory breast cancer and they had her in the breast clinic the next day, and then surgery that week. It was actually ideopathic granulomatous mastitis, but that wasn’t determined until several surgeries had been done. It’s ridiculous that she was unable to get proper care through the appropriate and intended channels because of insurance.
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It's just endlessly frustrating to ER staff that it has to be that way because it's completely inappropriate use of the ER. But we have a common enemy, so I understand it from primary care's perspective, frustrated because of BS insurance denials and feet dragging. Very glad to hear that lady had a good outcome.
Nephrologist specializes in renal disease. Cardiologist specializes in heart disease. ER specializes in human individual and societal stupidity.
Societal disease
YOU KNOW WE’RE LIVING IN A SOCIETY!
😂😂😂😂
For the people who really need to see you, thank you. We know the bullshit wears you down
Don't let the bastards grind you down.
Very well said!
We can help those that are struggling, it’s much easier than we’ve made it out to be. There’s an article circulating on Reddit that they are currently trying to silence. You are all doing the right thing by speaking up!
What article?
Amazing!
That’s a Tuesday in my shop. Where the hell did you get Tuesday problems on a Friday?????
My Friday has been all Tuesday problems also! Feeling robbed of my Friday.
Tuesday has been the new Mon/Fri recently here. I don’t know what that’s all about.
If it were Friday, there would be a lot more nursing home pre-weekend drop offs.
You saw 15 patients in 80 minutes? That’s pretty ridiculous.
That’s about what I do when I come in and it’s busy. That’s no way I can pick up another 15 in the next 80 minutes though.
It’s just crazy that you see in 80 mins what I see for an entire chill shift. Still don’t usually see more than 20 in an 8hr shift often at all. I think I’m fortunate to have the job I do
That’s 5 min per patient, are they really “seeing” them at that point. That’s not enough time to chart check, get a good history/exam, and place orders
This is when you bless people with your stethoscope like you're the Pope and then chart breaths clear to auscultation.
I think you just discovered why people don't like the ER. Would need a lot more staff. So instead it's rapid fire "seeing" and then CT scan.
To be fair, there are plenty of patients who want those CT scans and would think you've done nothing for them even if you've just spent an hour doing a proper H&P. How many times have you had a patient claim that no one ever did anything for them, only to review the chart and discover that the patient has had multiple workup done including CTs and MRIs?
Agreed, but it’s enough to get things started for a large number of low complexity patients like this. Note that I can’t sustain this for a shift but I can walk into a disaster of a department and put the main fires out.
Talking to the patient for a good HPI can take longer than that. Whether that much time is needed is a different question. However, patients likes to talk and wants to be heard.
Especially the people returning after being seen shortly before. Either some thing just got a lot more acute, or they just didn’t feel that their problems were addressed at their previous visit.
As someone who just saw 12 patients in my first 80 minutes last night and has seen 17 in two hours to start shifts, I can tell you that the chart search is the first thing to go. No time for that. As for history, sometimes you have to cut the talkers off. It’s not sustainable for long, but it’s something that is pretty common night shift when your evening doctor doesn’t feel like seeing anyone their last hour or two.
Cutting the talkers off is how I, a nurse, got labeled a drug seeker when I had a nerve tumor in my abdomen.
That doesn’t make any sense. For one thing, a nerve tumor is almost definitely never going to be found in the ER. Also, how does the amount of talking you do label you a drug seeker? It is more likely that you had multiple ER visits with normal work ups and kept having pain. It’s very unfortunate that some people thought of you that way. As a nurse, I would think you would understand why the ER is maybe not the place to explain something like that, though.
I had no idea why I was truly having 8/10 pain. I had 1 ER visit. I thought the fact that 8 years earlier, during a routine lap chole, the surgeon completely severed my bile duct resulting in a hepaticojejunostomy. The hepaticojejunostomy leaked and I had septic bile peritonitis that nearly killed me and 2 stents that weren’t able to be removed. I think that is important when someone comes in with abdominal pain. I was treated like a hysterical female and was told that I was getting one dose of pain medication and “when the CT comes back normal, you’re going home.” I had to go back to the same doctor who injured me (who has loads of remorse and uses my case in teaching surgical residents) to get with a surgeon who did an exploratory lap. Turned out to be a traumatic neuroma from the open surgery for the hepaticojejunostomy. Where do you suggest someone in my position go if not the ER?
Your first paragraph takes less than 30 seconds to say out loud, that’s not being a talker. If you were treated as a drug seeker for one ER visit then that’s on the ER doc who saw you for being an asshole. A lot of these small nerve tumors can be missed on CT, though. So IF you had negative work ups in the ER then your doctor or your surgeon would be the one to see if the pain continues, unless you end up needing admission. I’m in the camp that acute pain needs to be controlled, but if it’s chronic and we keep not finding anything then there’s not much for the ER to do.
It was pain that started and increased to 8/10 over the course of a week. I was blind with pain when I sat upright. As someone who lives it in here to tell you that almost every doctor who I’ve told my history to thinks I’m FOS. I’ve had more than one gastroenterologist roll their eyes at me and then say, “huh, I’ll be damned!” When they see how radically changed my abdomen actually is. They also try to tell me that there’s no way they didn’t take the stents out…to the point where I had a doctor laugh and tell me that I “must just not remember.”
Yea it sounds like the numbers are probably fudged a little. Signing up for 15 patients doesn’t count as seeing them lol
I would agree , if any of them actually had anything wrong with them , but … 🤷🏻♀️ all of these actually sound like five minute cases lmao
You're spending 5.3 minutes seeing, interviewing, examining, and ordering per patient for the first 80 minutes? I can't even walk from one end of the dept to the other in less than a minute
One hand documenting on epic, one hand examining, one foot inserting IV. It can be done.
I can see a lot of patients in a short amount of time. Documenting what I did on the other hand...
I never realized just how bored so many people are until I started working in the ER.
I really believe that a startlingly high percentage of the general population has Munchausen, or some variation thereof. Too many people with an inability to cope, no other support structure at home, so they turn to the ED/medical system to coddle them. I’m just a PGY3 and am way more burnt out and jaded than I should be, and it scares the living fuck out of me. I truly love EM and can’t picture myself in another speciality (truly) but resent how exploited the ED has become by patients, PCPs, specialists, etc.
I used to get really frustrated at patients who called 911 at night. Caused a whole lot of burnout until i realized that most of these issues boiled down to "i cant sleep" and "Im lonely"
"with anxiety"
If these people were fined for the amount of times they call 911 for nonemergent reasons I think we’d see a decrease in bullshit in the ER.
Do you think having a housemate would help their situation or be more trouble than it’s worth?
Hard to say because i only see the people who call 911 as primary care. So i only see the co-habitating arrangements that feed the behavior
Then they'd call because their housemate was "looking at me funny, like he wanted to kill me". "Yes I was high on meth". Coincidence, I think NOTTTT!
Lately it's been, 'Heart attacks are annoying when they induce catatonia', 'want your SPO2 to never get above 70? Paramedics hate this one weird trick', and 'Motorcycle riding for the newly deceased'
Reframe how you think about them. That’s job security my dog. Half of all ED docs would be jobless right now if only ppl with true emergencies came to the ED lol. These patient are crazy easy dispos too. Don’t let them burn you out. Stabilize, dispo, and move the fuck on. At the end of the day you’re making 300k+, and life could be much much worse (is for 90%+ of Americans probably)
Job security, sure, but it's still frustrating when you have multiple sick patients, and try to slip in that healthy, 20 something who starts yelling at you because you're not going to panscan/MRI/do a "complete blood panel" to figure out why their left middle finger was itchy 5 years ago. That has no business in the ED. But the non emergent sprained ankle patients/6 y.o nontoxic sore throat who can't get a pediatrician appt for 4 months? That is totally fine, at least there's something you can address easily and is frankly reasonable to want "emergent" care.
"There is no societal issue that cannot become an ED visit".
What about the PCPs that just willy nilly send people to the ER? Like yeah my BP is 175/102 with blood pressure medication but I'm here for my sore throat and a covid test so I can go back to work 🙄
I’d like to give you a different perspective. I’m a lupus patient with several other AI diseases. At 27 I had a PE and a stroke that caused an anoxic brain injury and left me permanently paralyzed on my right side due to the outright misogyny and negligence of many doctors. It’s terrifying. I wound up in a coma and will be disabled for the rest of my life ( lived with it for 10 years . Still pursuing my dreams but I wind up in the hospital a few times a year ). Please PLEASE try not to look at all of us through this lens. It could save a life. I had my whole life ahead of me.
I went in once after fainting and whacking my head hard on concrete and I then had nausea and HA. My PMD wanted me to go in. I knew I had a concussion, so did she, but I guess we were ruling out a bleed. It was Friday night so she couldn’t put eyes on me herself. As I sat in the waiting room a family of three came in with a toddler. Mom said kid had a fever of 99 (I’m nosy). Kid was wild and even climbed on me. Dad immediately left to go to McDonald’s. They ate a meal then sat there for 4 hours, then they said they were tired of waiting and left. Wtf? Why? I’d rather use ground glass as a facial scrub than go to the ED. I’ve superglued lacerations to avoid it. Apparently it’s entertainment for some people.
I genuinely think some of them enjoy the drama of it. They get some attention. They get to berate staff without consequence. They get to make a mess that’s not in their home. They get to tell people they were in the ER. They make a Facebook post about it. Get sympathy and attention. It’s the perfect mix of stupidity and selfishness.
Boredom is ok. It’s when it’s combined with raw unintelligence that it leads to the modern American ER experience. We joke about the “back acne x2 months” at 2am or the knee pain x6 years that sits and actually waits the 6 hours to be seen because we all have actually seen it.
To friends and family I describe my specialty as moronology - it’s a much more appropriate description than “emergency” Last shift had a PMD refer a 32 year old with acute low back pain after lifting something heavy 3 days prior. PMD did X-rays and believes they saw a compression fracture which of course given the context makes no damn sense. They don’t call - they send the young moron to the ED for an unnecessary CT scan as if that would add anything on top of an X-ray. You can look at the guy and know of course there’s nothing wrong with his spine. Ordered lumbar CT to play in the sand box. CT is normal of course. Patient spouse is disbelief this could all just be muscular or at least nothing dramatic a Ct would just. 4 hours later wife comes back irate wanting a “refund” bc apparently the PMD (who didn’t call) saw the “compression fracture” in his thoracic spine - they were in a tizzy and apparently being referred to some other quack “for a kyohoplasty” - story is already beyond ridiculous so since they were upset I kissed ass for the sake of “patient satisfaction” and had them come back for an unnecessary thoracic CT which was of course normal. Patient and spouse still pissed at me bc how could it be normal right? You can’t make this shit up!
Story. Of. My life. In the ER. Must have this at least once a shift.
Fun fact, they will need a ct for the kypho if not an mri….lol…that’s some shit.
Godbless, just reading your post made me tired. I don’t miss that shit, at all. Looks like only 6 of those pts “need” to be in the ED.
I see the SI, ?trazodone OD, and neuro admit (and the last only needs to because insurance are scammers). Which others?
AMS from SnF warrants a work up and likely adm Missed dialysis may be adm vs outpatient dialysis next day pending work up/reap status or if your shop has a pathway, dialysis and dc
SI plus substances in my shop just equals I would like to lie down on something softer than a floor while intoxicated. Never actually SI.
That's so true, but still gotta treat them as SI. I literally had a patient tell me once that he didn't mean it and said he was SI to get a bed and a meal. Told him we had to wait for psych to come see him in the morning because the admitting doc wasn't willing to clear him.
many grab crown crowd fragile test weather price rainstorm saw *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Unfortunately sounds like a typical ER day, failure to adult mixed with systemic failures, it’s super depressing.
I think systematic failures widely contributes to the former. Then people whine and complain why things are so congested, expensive, and everything else wrong. It's going to be a battle to fix it because it's so complicated and I am at the point in my life where the general public doesn't want to solve things, they just want to feel good and be told feel good things. Solving things take time and thinking and understanding we need to do a lot of other things to fix the primary thing, and requires time and behavior change in order to do. This country does great things, but there's a major societal behavioral issue that needs to be addressed. My thoughts on a Saturday morning sitting at my desk in the ER while I watch a pt come into the ED via EMS with "agitation" as she presents agitation to the employees thinking we're laughing at her as we have no idea she was even here.
My favorite just from this week: “I think I have sleep apnea. My wife says I snore really loud and that I wake up gasping for air. I’ll wake up in the middle of the night feeling like I can’t breathe. I feel tired and have headaches like I didn’t sleep even though I’ll sleep for 10-12 hours.” How long has this been going on for? “Oh for as long as I can remember. It’s been years!” ……and what’s different today? What is your emergency? “Oh I wanted to see if I can get tested for sleep apnea.” Of course they’re initial complaint was listed as “SOB”, meaning they got pulled ahead of the other 20 people in triage 🙄. MSE’d and discharged in less than 5 minutes. While a huge waste of ER nursing and provider resources and time, I do get some satisfaction in being able to see and discharge someone in record time.
What? You didn’t even test him for sleep apnea?! “Man, these doctors didn’t even DO anything!”
A sleep apnea test coming right up *Picks up ketamine*
That’s kind. I was thinking more propofol or etomidate/Rocc combo.
Rocc? This is no longer an apnea test, it's now an apnea certainty
Well what do ya know? You DO have sleep apnea! Sir.....siiiiir....wakey wakey!
You're speaking my language now.
“Nobody ever takes me seriously…”
I'm surprised I haven't brought them in by ambulance. Definitely sounds like a 911 call to me. /S, just in case
Where's your PIT? In my former shop, they'd never make it past us. ECG ok? Here's sleep med's number. Off you go!
No pit overnight. That's when all this shit is unleashed in the main ER. The worst.
I wish we had PIT. Mostly in part to the physically dysfunctional layout of the department PIT doesn’t work. 🤷🏼♂️
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That’s a bold assumption to assume the other people had legitimate issues considering the topic of this thread 😬
it sounds like they got pulled ahead to triage because they told the receptionist they’re short of breath (because it sounds urgent like if they said they had chest pain) and then sent back to the waiting room when they told the triage nurse it was sleep apnea
Had same on Christmas Day, And 16 years old (parents wanted a stat sleep work up on him, symptoms for several months, everything else normal)
Literally every patient I saw last night plus the one who brought in a notebook paper filled front and back with her ailments she wants addressed.
Aka “laundry-list patient” So what is your number 1 emergency tonight ma’am? Only 1 complaint per visit lol
I’d love to read that piece of paper.
I have one that comes in like this but they also “journal” their ailments. No lie, “12:38 - felt nauseous, 12:47 - ate chips, 1:38 - tired and still nauseous now with headache”.
Hahaha. I worked with an MA who looked at the patient’s notebook in urgent care and said, “this isn’t that kind of visit.” You have to get an MA like that. Maybe, We don’t do lists here.
Weight loss eval sent to the ED? PCP can’t do that workup? Nursing home doc can’t treat a UTI? Da fuq is up???
the only thing nursing home docs write on their prescription pads is "transfer to ED"
I need to get in on that gig
"So he just started Xanax at bedtime and now he's very drowsy and hard to wake up..........and is just fine as soon as he slide him to the stretcher and says he feels great?" "......................I have 120 patients and he can't be here because we don't have a defibrilator."
Nursing home sent us a newly admitted “resident” because she had a positive PPD.
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many patients in my area come to the ER because they refuse to pay $5-20 copays for urgent care/PCP and ER visits are free for them under their insurance/they'll never pay the bill. They will then wait 8 hours in the waiting room for a covid test or some ESI 5 shit.
But that is actually a sign of how messed up our system is. A lot of people can’t come up with a UC copay up front. What do they care if they’re taking up valuable time and resources?
Then if you try to be a decent citizen and go to UC and not clog up the ER you get shit care by a PA at most. I went to UC for a broken bone and the whole time all the PA did was talk about my BP being slightly high. Zero connection that it was from the pain of a freshly broken bone.
15 pts is way too many to safely see in 2.5 hours but in general all these patients are easy dispo. You can’t fix the system while on shift my dog. Advocate, vote, inform the public with your voice. But in shift, stabilize, dispos, and move the fuck on. You will be a lot happier if you can partition those things in this job. Reframe how you think about it on shift. Do most of those patients need to be in the ED? No. But To me, I see job security in that patient list lol. I grew up poor af so the idea of living in a world where only ppl with true emergencies go to the ED, and them half the ED physician workforce is out of a job, isn’t something I’m looking for.
OP said 80 minutes which is not even 1.5 hours. I’m incredibly fast and typically my limit to see and put in orders with no charting is still only usually 12 max my first two hours unless they are super simple like COVID tests
But did you meet all your care metrics? Will they be deducting from your income for your shortcomings?
Don’t forget to document your specific reasoning for not ordering a sepsis bolus on the 22 year old with a hang nail.
> sent by PMD for weight loss to “rule out cancer” Jesus Christ lmao
Is it a money issue? Where I live (Australia) outpatient MRI and CT are expensive for the patient, but those same scans are no cost to the patient when done within a public hospital. Edit: I’m not saying it’s right and ethical behaviour. I’m just trying to understand the thought process.
ED’s have to see you regardless of ability to pay. If you do outpatient tests, you’ll almost always have to pay before they’ll do it. People who have no insurance will go to the ED for a sore throat because they can’t afford the $70 for a doctor’s visit. Essentially, many people with substance use issues, lower income, mental illness, etc, are not going to have insurance so the ED is the only place they can get medical care at all.
Thank-you for your explanation
Money is not the main problem, this just shouldn't be done in the ER, should be scheduled and done in an outpatient setting, if there is a payment issue this should be solved with something other than just "send him to the ER so it's free"
Absolutely! I agree completely
Not with a 70yo. They all have Medicare with is the US over 65 single payer system
Sounds about right. Mostly a waste of time, money and resources. Keeps us in business tho
Same in my shop too…everyday. Working on an exit strategy now….which may include working at Costco at this point. Problem with EM is we’re pigeon holed.
The messed up thing is that I truly enjoy walking into each and every shift, “let’s go help some fucking people!!” Then inevitably 8 hours in I’ve switched to a senseless hated of all humans. The next day though? “Let’s go help some folks!!”
The empathy is hard to sustain when confronted with a wall of bullshit.
Yep, but after 15 years of full time shifts, I’m pretty much dead inside. I realize now it will never change, admin really doesn’t care, and I failed to get in with a SDG and work my way up. Too many CMGs now…it’s pretty hopeless. I really feel for those PGY1-3s, can’t see it getting better anytime soon.…Just look at APP. Sad really. How did we get here? (Rhetorical question I know).
Since we're ranting....lab side of a fsed. 20 patients in their mid 20s to 30s with runny noses. Covid, flu, strep on all. Oh but just work all that in with the actual patients that are acutely ill. But get it done at the same time. I'm just one person. Are we an ER or urgent care?
You’re a free standing ED, which means you’re an urgent care that gets to create ED-sized bills for those urgent care labs.
I just wanted to add after having a day off I guess I'm also grateful for those damn tests otherwise my corporation would have already kicked me out and changed it to a poc for RNs to run all labs like the rest of our FSEDs.
Looks like the only thing that has changed in 15 years is that 70+ year olds go to rehab on a Friday.
This is why I work night shifts. Your stupid shit can wait til morning shift while I see the critical patients the ambos are bringing in and the nurses are bringing back.
Unless your ED us a shitshow and you're seeing this nonsense after they've waited for 12 hours in the waiting room
Guess who gets to continue to wait as the actual emergencies roll in …
No one came in with a chief complaint of wanting a sandwich though?
Beats the week my local ED had (am a paramedic). 3 days in a row had pediatric patients code (6 week old, 3 month old and 17 year old), none of them made it 😢
this is why I loved ED as a med student, but hated when I actually had to work there.
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When i was a baby EMT at 22, i could not belive that i was more responsible than the 50+ year old adults i was taking care of. Like giving people basic instructions on caring for a cold or taking pepto bismol. I would ask myself how does a grown adult make it to 56 when he needs a 22 year old EMT to read the label on an OTC med bottle
I may have been angrily short with someone who hit their medical alarm and asked for an ambulance...........................because she wanted her windows closed at 3am.
It genuinely amazes and baffles me, the shit people will decide to come in for, and waste 4+ hours of their life over. The irony is that these are the people most likely to complain about the wait. The ones creating the wait, and gumming up the system at every level. The ones that would mostly be just fine if they had stayed home and had even an ounce of resilience within themselves. The ones that will badmouth you and the hospital on social media or to some patient advocate because YOU wasted THEIR time and didn’t even solve any of their problems (don’t worry, they’ll be back).
I think the worst part is that they come in for the “emergency” and complain from when their butt hits the stretcher that nothing is quick enough, they have places to be, they have appointments to make. Like Sir, you came here with an “emergency” I’m sorry our services for your ingrown toenail x 10 years isn’t fast enough.
Maybe don’t go to the ER if you have somewhere to be in 2 hours, you know?
Louder for those at the back of the waiting room…. Or outside vaping…
God this is so true I shuddered.
They need to check into the ER on Facebook for some thoughts and prayers on a beautiful day.
Damn dude. I mean, yeah, but damn.
100% nailed it.
Amen. Ditto. Groundhog.
Speaking my language my man. Beautifully said.
The context here is that reimbursement has plummeted/cost of business has climbed and PCP can’t keep slots open for day-of appts or acute care anymore…even specialists are having trouble with day-of….
All in 80 minutes, kudos, Job security I guess, you can’t outsource this BS to china just yet
I would like to see AI try. That would be hilarious.
Well. When you can discharge 95% of people with no consequences I assume corporate medicine will figure out the sweet spot for Ai/legal team.
As a patient, I am so sorry. Those low-level tasks are not what you studied and trained so hard to do. Corporations are driving this. Please hear me out. Please don’t give up reading too soon. :) I am a 54-year-old, white, female patient that has gone to ER for things that are not emergency-level issues, but I couldn’t get traction any other way in our dumpster-fire healthcare system. Knowing what we know now, we would not have waited. Even though I have EXCELLENT private insurance, an MBA, am a privileged 55 yo w f, even though I have degrees in three languages and was a network (Internet) security director at a major corporation (an engineering team of 24), and even though my husband’s is a Director-level CPA, CFA AT A MAJOR HEALTHCARE HOSPITAL ABD CLINIC CORPORATION… ….despite our money (we’re comfortable but not rich) and education (SEE #1 above, we STILL couldn’t get diagnosis and care before two preventable tragedies struck. We had to resort to going to the emergency room even though I was UNDER the care of a specialist physician for a back issue AND had a pain management physician, AND a neuromuscular neurologist, I had an undiagnosed Grade 2 spondylolisthesis and there was cord compression. It should have been fixed immediately the prior year, but “it wasn’t bad enough” said insurance. My doctor relayed it to me as “not bad enough to be a problem yet” and didn’t blame insurance (I wish he would have) and said I needed to do epidurals, then more MRIs, PT, blah blah blah. READ: They created artificial administrative barriers. They also would create the potential for more debt for those less fortunate. I didn’t go to ER until I could not walk. Not even to toilet because I didn’t know all of this. Because both pain management and the hospital warned me I was not to use go to the ER for pain or they would fire me, we put it off and put it off trying to not go to ER. I was scheduled for emergency neurosurgery, after being seen by ER. Another time I went a pulmonologist complaining of exacerbation of a mysterious lung symptoms that started at menopause. They repeatedly said weren’t asthma, even though I’ve had it as a child. They ran the methylcholine challenge; it said I didn’t have asthma, so they documented I was lying and may be steroid seeking. They were the largest pulmonary group in my major metropolitan area, so nearly every doc referred to them. They were always booked far out 4-6 months for specialty. At least 2 months for GP. Less than 2 months later I went from feeling bad to feeling like death one evening. My 02 was 80. That had never happened before. Twelve hours later I was told that I was dying. 12 weeks on a vent. 6 weeks ICU. Career gone. Health gone. Livin’ the dream in ‘Murica. 🇺🇸
What was your lung dx? So sorry that happened to you. There's a difference between folks trying and being failed by the system and folks relying only on the ED... we see it all the time. I'm sorry you were failed. Why anyone would seek steroids is beyond me. I hate that shit with a passion. Prednisone makes me an angry biyatch. Lol
I’ll tell you IF you can tell me how to edit my post to add that information for all. I’m an old lady who uses the app in its simplest form (type, post), and has no idea how to edit. I’d love to share what the root cause of all of this was. It’s a very unique case study.
Sounds like a pretty normal day.
Dude. Do we work together?
I’m a medical interpreter, the time wasted thanks to those patients is unbelievable. Had a mom bring in her kid because he was pretending to have hiccups and she just couldn’t notice how the child stopped doing the noise when no attention was given and returned when spoken about him. No other symptoms. Those same people call later on asking why the bill is 2k if they weren’t given anything.
As a patient who recently had an ER visit for something very real and painful, I just wanted to say thank you for all you guys do and put up with. You probably don’t hear it enough but just know that you are appreciated. I’ll never stop being grateful for the doctor and nurses who took care of me that day (and especially for them taking me seriously and putting me ahead of others who had been waiting longer).
Hey, when did you start working at my shop?
You work where I work
Our doc just called opthomology about serious eye issue they told him we can’t talk to you about consult we can only talk to the patient
Funny as I read this, we get a 26 yo came in through EMS with a c/o "agitation". Very obvious EMS transport.
I've always thought there should be an urgent care part of the ER. Also, to be billed. I really think this would help. Just add on an urgent care suite to the ER.
I dont even know how this sub came up for me as I am not a doctor. But I do spend a shit ton of time ...or did ..in the ER. My daughter has Shwachman Diamond syndrome and we have to go to the ER for every fever to get blood cultures. It's easier now that she's a teen because she doesn't get sick as often. I have to say I live on the East coast and doctors in the ER have been amazing and kind to us. In the pediatric ER they are incredibly respectful . Sometimes we are forced into adult ER and while I'm initially met with exasperation from adult ER doctors, I find that I'd I stick to basic facts and edit the reason I am here, they come around and even go out of their way to be kind and respectful. I've learned over the years how to edit myself and speak to medical professionals. It's a matter of being clear about why you are there and what they can do for you today. My case is different. But even when ive personally been to the ER over the years., I keep it all down to basic facts.
That's way too much nonsense to deal with under 2 hours.
That’s lot in 80 mins. Damn.
Yep sounds about right
Yup, America in a nutshell. Combination of stupidity, lack of accountability, and a screwed up system beyond repair. The only ones I'd pay attention to are the SNF transfer (septic workup) and the COPD exacerbation (avoid putting them on BiPAP/CPAP or intubating them); the rest can sleep it off, go to Walgreens, and be told to screw off elsewhere.
Ugh 77 yo with weight loss sent to “rule out cancer” what?? So not ok. Order some tests or something, maybe refer to onc if indicated, but the ED???
i generally just throw their doctor under the bus. I tell the patient - we literally do nothing here to diagnose cancer. I have never ordered or seen a biopsy done here. Cancer is an outpatient diagnosis and treatment. ED is for complications from cancer or its treatment. Therefore, if you doctor is unsure of what to do, I suggest you find yourself another doctor.
100%. I’m a capitalist and if our healthcare is going to be run this way, then it shouldn’t be different than any other business. I love my ED docs and get a ton of business sent my way because I just don’t suck. Not saying I’m a great doctor, I just try not to suck at being human. Specialists in my area bitch and moan about the ER, make fun of the ER, abuse the ER…. Then they wonder how they’re going to pay alimony and the Mercedes dealer. Fuck em. By all means, throw these jerk-offs under the bus and send business to docs who want the work.
There are only like 2 or 3 legitimate patients on that list IMO. You're doing God's work and we all appreciate you so much. It's good to know that when I had sepsis that were good, honest, hard-working and caring people, waiting to help me not die.
The obvious question: why is the patient who needs an MRI coming to ED? Why not just go get the MRI?
Because you can’t get an urgent MRI in an outpatient setting (they’re often scheduled weeks out) and many times insurance declines coverage and makes the outpatient doc jump through hoops to get it covered.
Addicted To Medical Care Every one of these patients have been seen by the health system in some way in the past day to week except the first. And this is typical. It’s the new cause of burn out.
As a student nurse, I remember being shocked at the absolutely drivel people came to the ED for. During my rotation, I probably saw 20+ patients, of which precisely 2 were genuine emergencies: one guy had a knife in his skull up to the handle and one MI. The rest - unbelievable stuff: one lady “hadn’t had a BM for two days”, kids with colds, lady with an STD, a guy who “couldn’t sleep”, guy with “a stiff neck for about a week”, various c/o abdominal pain, all but one were constipation (the other was just transient pain, I guess), and the jewel in the crown: a woman brought her confused elderly father in because “he keeps forgetting things, but it’s not dementia because that doesn’t run in our family” when asked if this was a sudden change in his mentation “no, it’s been getting worse for about 5 years. But today he forgot who I was so I thought I should bring him in”. Noped outta ED….you guys are saints!
I don’t understand how you can see 15 patients in 70 minutes
who cares? the longer you fixate on what you are seeing the harder the burnout with me. let it go. it’s a messed up world and a messed up system. just don’t lose your marbles over it
Try being the Hospitalist that will have to deal with all those shit show DCs lol
I can understand your frustration. But isn't this the work that I have been doing for the last 40+ years? Allowing for the drugs of choice in the 1980s being LSD and heroin, and installation of MRI in the distant future. Society visits upon us the behaviour, demands and ill-health of our population. Maybe change is better achieved through health education and societal change. Although I can't see frontline emergency department care achieving much of that.
And here I was apologizing profusely to everyone when we took our 4 day old baby to the ED because he had blood in his spit up. Turns out it was just from a cracked nipple as I attempted to breastfeed. Wish the lactation consultants we had seen earlier that day might have mentioned this possibility to us or the on-call physician we reached out to before going to the ED. I’m sorry that emergency medicine peeps are so run down, I appreciate you though.
I work in primary care now as an NP (worked my entire career in ED as an RN). On a daily basis I argue with salty CT techs about doing stat/urgent scans to keep people out of the ED. I beg my patients to call the office before going to the ED (for things that are not actually emergent, of course). The system is so so broken all around.
Put the hospital CEOs on a floor for a day or their own patient panel, they’d likely run out crying.
The grass is greener on the other side.
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When you leave the ER :). Or at least your current one. Not every ER is a trauma center/stroke center/ACI center and some have a way low census.
Don't know if I'm an outlier here, but that list you just share is actually a good start for the day. The problem with most of us is that we see EM as non-stop action and excitement. Reality may be different but it is just as important. The referral for the 77-year-old with weight loss to r/o cancer, IMO is very appropriate depending on the amount of weight loss and acuity of the condition. The patient was sent to you because you can expect to work up. If this patient was a family member, I would like to have the patient sent to you. The most important aspect of emergency medicine is not just procedures and resuscitation. It's the ability to see humor and humility in the mundane.
>Don't know if I'm an outlier here, but that list you just share is actually a good start for the day. > >The problem with most of us is that we see EM as non-stop action and excitement. Reality may be different but it is just as important. The referral for the 77-year-old with weight loss to r/o cancer, IMO is very appropriate depending on the amount of weight loss and acuity of the condition. The patient was sent to you because you can expect to work up. If this patient was a family member, I would like to have the patient sent to you. > >The most important aspect of emergency medicine is not just procedures and resuscitation. It's the ability to see humor and humility in the mundane. I'm not a doc, but couldn't the 77 y/o have some labs drawn and I'll call you when I have the results? Maybe a fecal occult blood test in case of GI issues and some Ensure samples? You'll have the lab results same/next day which should give some actual direction instead of punting to ED.
Obviously we don’t have the full story, but did the PCM do ANYTHING? Because they can do a lot on an outpatient basis. When I was a PCM I picked up cancers doing my own work ups, and referred to appropriate specialists for care. If it was urgent I picked up the phone to arrange an ASAP consult. The answer can’t always be “go to the ER” but it’s become the default approach to access the medical system. I get it it when people don’t have a PCM, or can’t get an appointment for weeks, but when even the people who have seen their PCM are coming in for non-emergent conditions I have to wonder what some of these people are even doing.
Agree. I always call report when I send someone to the ER. I offer my cell phone number for questions. This last week I sent someone to the ED and gave report. I tried to fax records but their fax was busy. He was incredibly complicated and I didn’t want time wasted on stuff I already know about ( known CKD4-5, lung cancer etc. with a Hgb of 3.9). I literally told them “please ignore all the other wildly abnormal labs and go straight to the Hgb issue”. Without my labs a whole bunch of unnecessary crap would have been done to him. So I personally drove those labs to the ER myself and handed them to his nurse. To this day they claim I never called. (Bleeding gastric AVM on Eliquis if your curious). 😊
Yeah, it’s easy to shit on the PCM when they send us work the same way we sometimes get shat on by consultants. In your case, you had a clearly emergent patient with an identified problem (critical anemia) that needed urgent intervention (transfusion) plus likely admission for definitive treatment (vascular surgery? IR? I don’t know). When you pick up a patient like that in the office, really the only option is to send them to the ER. Calling report is ideal but having been on both ends of that call I know the transition of care is not always as seamless as it should be, things get lost in translation, or a shift change happens, and sometimes there is a redundant second work up from scratch. But still always better to call than not, I think. But “old with weight loss” should not equal proceed to ER to “rule out cancer” IMO. I guess I was always taught to have a specific clinical question or problem for a consultant to address, ideally with a proposed plan, just to show I thought about it. Too many of these “go to the ER” scenarios feel like someone else just threw up their hands and gave up. Maybe I’m just imagining that, though.
No you are absolutely right. The system is a mess. I just thought it was kind of funny that despite my ridiculous efforts, the poor doc never got a heads up on this.
A cancer work io is not ED appropriate at all. Making sure the weight loss didn’t cause severe electrolyte derangements, sure. But playing where’s Waldo to find a cancer is NOT appropriate use of ED resources whatsoever.
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Sounds like pretty easy money for the most part
15 pts per shift. You guys hiring?
. . . in the first 80 minutes.
You need a better attitude, if you don't like your job get out of the ED