winterallsummer Posted June 11, 2015 Share Posted June 11, 2015 What are your 5 least favorite CC's that you see pop up on the charts of your ED patients? Thought this would pass some time if others can add theirs. 1. "Fever and ear ache" in a 5 year old with a temp of 97 2. "Abnormal labs, sent from PCP" who gets there at 5:05 pm, does not know what the abnormal lab was, and has a completely normal CBC/CMP 3. "Insect bite" which always is a massive abscess in an uncontrolled diabetic. Those damn insects! 4. "Belly pain" in the totally healthy 30 year old female with 10 negative CTAPs on file, in your ER alone. This one has to tie with "back pain x 10 yrs" in the 60 year old who decided to come to the ED because he didn't want to wait 4 days to see his PCP. And no, he's not out of his meds (norco, of course), but he has seen six doctors for this back pain but decided you must be the one to turn his life around! 5. And a real CC I got "brown stool" in a 90 something, severely demented patient whose child thought that brown stool means blood (I am not kidding) because she decided to check the stool for the first time and thought this was an emergency, meanwhile absolutely no changed in demented grandma. Paging all medical students... Any others? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 11, 2015 Moderator Share Posted June 11, 2015 rectal/vaginal FB or d/c fever in any child under 5 anything involving vague eye pain or headache perirectal or bartholin's abscess anything that starts " I called the nurse hotline and they told me to come right in". (because that is all the nurse hotline ever says. I've had r elbow pain for 36 years. "it needs to get seen in the er right now". Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 12, 2015 Moderator Share Posted June 12, 2015 just about anything with a head ache.... ugh I hate head aches.... Link to comment Share on other sites More sharing options...
moy505 Posted June 12, 2015 Share Posted June 12, 2015 just about anything with a head ache.... ugh I hate head aches.... why? do you guys just give them pain meds n send em on their way? Link to comment Share on other sites More sharing options...
moy505 Posted June 12, 2015 Share Posted June 12, 2015 rectal/vaginal FB or d/c fever in any child under 5 anything involving vague eye pain or headache perirectal or bartholin's abscess anything that starts " I called the nurse hotline and they told me to come right in". (because that is all the nurse hotline ever says. I've had r elbow pain for 36 years. "it needs to get seen in the er right now". Whats so bad about seeing kids with fevers? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 12, 2015 Moderator Share Posted June 12, 2015 Whats so bad about seeing kids with fevers? the parents always want a huge workup when they really are not that sick for the most part. many parents today lack common sense and bring their kid in for a temp of 99.1 at 2 am and want blood work, etc when the kid obviously just has a cold. then they think every cold requires abx... Link to comment Share on other sites More sharing options...
jmj11 Posted June 12, 2015 Share Posted June 12, 2015 why? do you guys just give them pain meds n send em on their way? Or send them to us and we will find a better way than the ER to manage their headaches. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 12, 2015 Moderator Share Posted June 12, 2015 Or send them to us and we will find a better way than the ER to manage their headaches. I've taken that option several times now... Link to comment Share on other sites More sharing options...
Nonlegit Posted June 12, 2015 Share Posted June 12, 2015 I'm gonna go with "wants admitted" simply because from my perspective, these folks (who usually do end up admitted for something valid) have been sold a red carpet by the docs office and show up and lose their mind that they are not a direct admit, and have to sit in the lobby for 8 hours (waiting for the bed the hospital doesnt have for an MRI that will come 20 hours later). Since I work near a college campus, honorable mention - "someone spiked my drink" from every 20 something drunk girl that clearly was on the losing end of the fireball bottle. Always upping the ante with "I don't know" when asked sexual assault questions...buying SANE exam... and on and on. Usually seen laughing and rehashing the night on their phones with their besties. Link to comment Share on other sites More sharing options...
primadonna22274 Posted June 13, 2015 Share Posted June 13, 2015 1. I feel weak (and I'm 85, with every degenerative disease under the sun including dementia and a poor historian and no family with them sent in from the nursing home at 2am). 2. I feel dizzy (and I'm on 28 meds and dialysis which I missed last week cuz I was too dizzy to get out of bed). 3. I feel bad (and I'm 30, or 55, or 42, or pregnant, or haven't seen a doctor in 25 years). 4. We haven't seen momma in 2 years but it's it's the holidays so we came to surprise her and she looks like hell and her house is a hot mess and fix her already (at 5pm on a holiday weekend and there's zero chance of placing her anywhere until Tuesday at the earliest...and that's pretty durn optimistic). 5. My kid ain't actin' right. I demand a drug test /psych eval/ exotic lab workup, also at 2 am on a Saturday night. As you can see after a year of FM residency I have a decidedly inpatient bent to my "least favorite ED" complaints lol. Sent from my SAMSUNG-SM-N910A using Tapatalk Link to comment Share on other sites More sharing options...
jmj11 Posted June 13, 2015 Share Posted June 13, 2015 It has been awhile since I worked ER, so I only have one. 1)" My Attorney wanted me to come to the ER once a week to document my pain in my eye, which was caused by the fireworks display on July 4th. I am suing the city because they should have known that fireworks produce ash a a piece went into my eye." Link to comment Share on other sites More sharing options...
Evolute Posted June 13, 2015 Share Posted June 13, 2015 moy505, "why do you guys just give them pain meds n send em on their way?" First we don't "just give them pain meds". I (and the many other providers I currently work with, or have worked with in the ED) very, very rarely give narcotic pain medication for a HA. Narcotic s are not recommended as a first line agent to treat HA's. This practice has been shown to increase recidivism. Second, every pt admitted to the ED does get a workup. The workup is symptom and pt dependent. It may be limited or very extensive, again situation dependent. Not every pt with a HA needs a CT. Third, What would you have us do? We can't admit every pt that presents to the ED. In the ED our job is not long term care of pt's (though some times it seems that way). our job is to treat the immediate need/problem(s) of said pt and make the appropriate intervention, then disposition of said pt. That may be a transfer, an admit, or yes the pt may be discharged. In the case of HA, most times after a negative workup with adequate relief of symptoms the pt will be discharged with f/u. Will said pt need further workup? Most likely, but that's the job of FM, neuro, HA clinics, and maybe other specialties, but its not the job of the ED. So yes we may very well "send em on their way". Just like I did last night with the 65 yo female with a non displaced humorous Fx (I did sent her with pain meds thou), or the guy with CP and negative workup, or the 2 kiddos with fever, or the guy with abd. pain. or the...... well you guys get it... just sayin' Link to comment Share on other sites More sharing options...
jmj11 Posted June 13, 2015 Share Posted June 13, 2015 Here is a dumb trend by insurance companies that forces headache patients to the ED for less cost effective care. We have many bags of tricks for keeping patients out of the ER from anti-emetic + hydromorphone suppositories, to self injection of DHE 45, to self-injection of ketorolac, to Walgreens coming to their house and doing an IV infusion of valproate + magnesium, etc. However, each of those forementioned treatments I had rejected by insurance companies this week for 4-5 different patients. I always tell the insurance company that if they prefer to pay for a patient to go to the ED rather than using one of our home treatments, that is their choice. But it makes no rational sense. These people are getting caught up in the big net of insurances rejecting everything . . . but then forced to pay for ED visits because they are considered emergent. Someone needs to hit one of these people at the insurance company in the head with a hammer. There is an assumption that headache = drug seeker. We have had drug seekers. But, though a very careful program, I can honestly say that of our present 2,000 headache patients, I cannot think of single one that is a drug seeker. Some are on a limited supply of narcotics as rescue when their abortives fail. None are on narcotics more than two days a week and none push for more. Link to comment Share on other sites More sharing options...
Guest Paula Posted June 14, 2015 Share Posted June 14, 2015 I don't work ED anymore either but here is my worst CC: Follow up ER. "I hit my head on an electric fence and the ED did nothing for me" Review of ER note, tests, scan,EKG etc. say to f/u with PCP for medication management. Recommended naproxen. Pt. wants refills of hydrocodone. Link to comment Share on other sites More sharing options...
winterallsummer Posted June 14, 2015 Author Share Posted June 14, 2015 I'm gonna go with "wants admitted" simply because from my perspective, these folks (who usually do end up admitted for something valid) have been sold a red carpet by the docs office and show up and lose their mind that they are not a direct admit, and have to sit in the lobby for 8 hours (waiting for the bed the hospital doesnt have for an MRI that will come 20 hours later). Yes, I had one sent over via PCP "needs blood transfusion" because her CBC from the doc's office an a hemoglobin of 9 and MCV of 70, and not taking her iron pills because they constipate her, of course. And it goes without saying she was not on colace, miralax, etc. Since urgent care centers have been popping up, if they get anything but a virus that they perscribe ZPak and steroids for, they are totally clueless to what to do (with a few notable exceptions perhaps). So we get their cellulitis "needs DVT r/o" in a 25 year old with an abscess (that they didn't drain), leukocytosis and fever. We get their "needs head CT" for headache with dizziness. And their "needs CTA" for the PERC negative patient with dyspnea that didn't improve with ZPak and steroids. And yes, these patients are somehow under the impression that ED PAs and physicians take orders from the McDonald's, er I mean urgent cares, that sent them. ((sorry for those working in UC, had to vent)). To answer why we don't like seeing kids with fevers... because we would prefer to be dealing with a real emergency, 90% of the kids just have a viral illness (don't believe me? how many times do new parents bring in febrile kids... all the time. how many times does grandma with 5 kids and 10 grandbabies bring in the febrile kid? only if they are damn near septic!!), and whose parents sometimes get upset that we tell them to go home and give the kid tylenol, because they were expecting an antibiotic that we are not willing to give. To answer why we don't like seeing headaches... because 1) sometimes the patient exagerates about the sudden onset, thunderclap, worst HA of my life and we feel pressured into getting CT and sometimes LP, a huge drain of hospital resources, and 2) they often come in demanding dilaudid and are unwilling to try indicated treatment, just bothering us for narcotics, and they have had fifteen prior visits for the same thing yet refused to ever follow up with neurology like we ask them. Overall, though, I don't mind febrile infants too much, except when I have a ton of sick patients and then have to waste ten minutes explaining to a parent who will never understand why little Johnny just isn't getting a Zpack for his noravirus (next time they should go to urgent care), but many are actually reasonable. Headaches I don't mind unless they are actually drug addicts in which case they get compazine +/- haldol and discharged out the door. Link to comment Share on other sites More sharing options...
Marinejiujitsu Posted June 14, 2015 Share Posted June 14, 2015 I came in for mri on my knee. Young dramatic dizziness and weak. Anxiety-feel anxiety is a Russian roulette game Vaginal bleed and not pregnant but needs to be on ocps but we don't prescribe Dysuria in 20 yr old with negative urine The I brought a list pt. The 100 complaints. When asked, what's most important, they say "everything" Link to comment Share on other sites More sharing options...
SHU-CH Posted June 14, 2015 Share Posted June 14, 2015 the parents always want a huge workup when they really are not that sick for the most part. Same thing with barfing kids. It always amazes me that parents will drag a kid to the ED after they barf once. Kid gets an earache, they barf. Sore throat, they barf. Cold, they barf. Look at them funny, they barf. Kids need to come with an owner's manual. My second least favorite are patients referred from their PMD "just in case." They usually just want a stat CBC & BMP. I did always think it was kind of funny that a PA would be serving as the backup to cover a physician in cases where they felt uncomfortable arriving at a disposition. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 14, 2015 Share Posted June 14, 2015 Kid barfs and then either or both parents barf. Had one this week. Kid comes in for a fever and while patient is being examined mom decided she needs to be looked at as well. Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
sk732 Posted June 14, 2015 Share Posted June 14, 2015 Pet peeves in the ER - (1) The "Oh, BTW, while I'm here with my cold, could you check up what's really been bugging me for upteen years?" folks. (2) Adult children (or older teens) brought in by Mommy and or Daddy for a minor complaint and you have to literally tell the parent(s) to leave or at least shut the hole under their nose and let Jimmy Bob or Bobby Sue speak for themselves. (3) Elderly folks brought in by the same helicopter parents (now adult children) mentioned in (2) with a positive Suit Case Sign, expecting admission for something that really doesn't need it, but it's interfering with their trip to Vegas this weekend. (4) The folks that don't understand the concept that "Tincture of Time" is in fact a part of treating conditions of all kinds and show up a day later worried that they're not improving an iota...you know, the one's that don't get that a "Silver Bullet" is actually used only for putting down a werewolf OR for loading into an automatic pistol for Redneck Russian Roulette. (5) Extended care facilities that send palliative patients to the ER to die, because the charge doesn't want anyone dying on their shift...in the same vein, same facilities sending residents to the ER, by ambulance, for IV Abx because Long Term Care facilities don't do IV's, even though the RN's there get paid the same as our ER RN's but for some reason aren't required to maintain their IV certs. Hated both of those when I looked after a rural LTC facility and hate it more that I'm full time ER. Despite what I sound like, I'm actually quite outgoing, humourous and polite to ALL my patients...though I can get quite firm with a few. The folks in (2) will get a firm "STOP" if it looks like it's turning into a Jeff Duhnam show :-D. SK Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted June 15, 2015 Moderator Share Posted June 15, 2015 1. Chronic back pain 2. Chronic back pain 3. Chronic back pain 4. Chronic dental pain 5. Chronic back pain Link to comment Share on other sites More sharing options...
treejay Posted June 15, 2015 Share Posted June 15, 2015 for folks with chronic back pain, there is nothing that says you have to treat with narcotircs.......... is there? Link to comment Share on other sites More sharing options...
sk732 Posted June 15, 2015 Share Posted June 15, 2015 Dental pain is easy - put in a block :-D Link to comment Share on other sites More sharing options...
medic25 Posted June 15, 2015 Share Posted June 15, 2015 1) Anxiety. Never a satisfactory conclusion 2) Elderly dizzy. So many pathways for badness 3) Febrile, too young to talk to me. 4) The family 2-fer/3-fer/4-fer. 4 patients with the same last name, all triaged to the same room; typically a URI or a bogus MVC 5) Chronic.....fill in the rest Link to comment Share on other sites More sharing options...
Evolute Posted June 16, 2015 Share Posted June 16, 2015 1. anything psyc. Not b/c of the pts, but b/c the/our mental health system is broken! First, it takes several hours to just get a mental health eval (not so bad, I get it, they are busy also) Second, (and most importantly)I can't admit a psyc pt b/c we are not an "approved/credentialed/ accepted psyc facility, yet there is no psyc facility within 200 miles that has "beds". So I keep them in the ED..... without the help they need.... until I can get them transferred to an approved/credentialed/accepted facility....We have MHP's on staff, but cant call on them b/c we have a contract with the public health folks. So we (and the pt) waits. wtf? 2. chronic pain. how many times do I have to tell you people that I do not refill chronic pain meds in the ed? f&*k me!!!! 3. anything vaginal. vag discharge, vag bleed, little person coming out, etc.... 4. weakness for xxxx months 5. every other pt that presents to the ED........just kidding, lol Link to comment Share on other sites More sharing options...
Guest Paula Posted June 16, 2015 Share Posted June 16, 2015 Ok, I am the one who sees all these ED/UC patients in follow up. Please stop sending your chronic dental pain, back pain, neck pain, back pain to me for follow up. If you do , make sure you tell the patients that I will not renew or write a prescription for them UNLESS they have an active case of cancer or a seriously broken bone. Link to comment Share on other sites More sharing options...
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