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ral last won the day on December 10

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  1. My wife is a nurse at one of the local high schools. She calls me from time to time, to ask a question about this or that. She calls me just now and asks, "If a patient has mono, how long before they can come back to school once they have started antibiotics?" Apparently, she just had a teen come in from a practitioner, with comfirmed positive test (have no idea whether doc, PA, NP). I calmly remind her of the viral etiology, no antibiotics needed, splenic precautions. She says, "Well, the student said she also had bronchitis, so maybe that's why she was given antibiotics." I laughed. She knows why. Big face palm.
  2. So, the fact that it has been explained by many ER providers in this thread, that we do not do referrals from the ER, obviously means absolutely nothing to you. This will be my last post to this particular thread. I'm starting to feel like Bill Murray in Groundhog Day.
  3. ^^This makes your case. You made a judgement call at the time, that you felt was warranted. My apologies to rev ronin, if I offended.
  4. I just walked a brisk pace to the kitchen to grab a beer. A bit of chest pain and some mild dizziness when I got back to the couch but, this too shall pass.
  5. Quoting rev, as to show what I am seeing about the hx of his patient. He saw her, started a work up, referred to neurology, wasn't happy with what they didn't do, so sent her to the ER, and is unhappy because they didn't do what he thought should have been done either. If I had seen the patient in the ER, I would have done the workup, similar to what EMEDPA posted. Why? Because it is now my job to make sure that I am confident that I have covered the bases, just as I explained in an earlier post: make sure there is nothing showing up as a cause for concern of immediate threat to life. BUT, I am once again left with asking myself if the patient NEEDED to come to the ER in the first place. A problem going on for six weeks, that had a neuro consult, that was not acutely symptomatic (or at least rev didn't infer such on the day he sent her to ER). Let me get this out there right now: I applaud rev for being such a strong patient advocate. I am only questioning the "send it to the ER" fallback that too many folks use, when frustrated with a system that makes us all want to poke our eyes out at times. So, that brings us back around to the "referral" thing. I guess I will direct the question to EMEDPA. When you are working at your rural ER gig, with possibly limited services and specialties (I did a lot of work at a CAH that had one family practice doc in the town, and a general surgeon that visited once a week to do consults) did you actually arrange the referral prior to discharge of non-emergent patients with negative workups? I'm not talking about calling up ortho in the town 30 miles away, discussing a pediatric supracondylar fracture, and having the guy on call say, "Yeah, have them call the office tomorrow morning and set up an appointment." I mean an actual referral: paperwork, insurance information, confirmation of appointment time, forwarding all pertinent chart info and visit history, everybody on board. It doesn't happen where I have hung my hat, big or small hospital. If it's that urgent, the specialty, if available, is consulted to see the patient in the ER, or I am transferring the patient to a hospital that has those capabilities. Maybe I am not understanding what we are talking about. Wouldn't be the first time that I am reading things wrong.
  6. Respectfully, everything that EMEDPA listed can be ordered on an outpatient basis by primary care. The number of patients that get sent home after big workups for chest pain, seizures, syncope, PSVT, abdominal pain, pelvic pain, etc., without specialty consult or referral would astound many people (both patients and providers). I can't count the number of times over the years, that I have had new onset seizures for example. They get extensive labs, a CT, a dilantin or cerebyx load, a script, and a pat on the back, with instructions to follow up with someone. No admit, no in ER neuro consult or referral. The caveat is that I have never worked at a large teaching hospital, where interns, residents, and the like are just clamoring to get their hands on any case, so I cannot say how many consults are done then and there at those facilities. Our discharge paperwork (Medhost) at one ER where I work specifically covers the "We don't knows". After extensive testing for let's say pelvic pain, where I have done CT, US, multiple labs, and come up empty handed (and me even insisting that the SP go in and examine the patient to make sure I wasn't having a brain fart) the patient gets discharge instructions stating, "We are not sure what is causing your abdominal/pelvic pain at this time but, it does not appear to be a medical or surgical emergency." The usual red flag discussion follows. Again, it's not a question of whether or not a patient needs a workup. You are certainly right on that front. It would stand to reason that if a patient has a syncopal episode right there in front of me in a primary care setting, that I would send the patient to the ER for a workup. If they made an appointment, and came in telling me that they have been passing out lately, I would begin an appropriate outpatient workup. I'm simply saying that the ED is not the blanket answer, when the same level of non emergent care and testing can be obtained elsewhere. Much peace.
  7. Rev, While I understand your frustration, (and I am also very quick to point out all that is wrong with the "system" of healthcare too) what were your expectations of an emergency department visit for her periodic syncope? I am being very sincere because, I can tell you how I would work that up, and the probable disposition of the patient before her even being seen. Does she need the expertise of specialty services? I believe she does, just like you. Is she likely to receive those services at an ED? Nope. Maybe some of the other ER guys will chime in.
  8. That is crazy, and you have every right to be ticked about it. The only time this has been up for debate is with stupid HMO and Medicaid crap. When I tell the patient to follow up with ortho, (because let's face it: I fully agree with you that a stop at the PCP is costly and a waste of time for all involved) and they tell me they are not allowed to just go to a specialist; that they are required to get their primary to coordinate the referral. It ties everyone's hands.
  9. Exactly. My discharge discussion is typically, "Good news. It's not this, that, or the other thing that we worry about needing to fix immediately here in the ER. Having said that, I am not telling you there is nothing wrong. Just that there is no pressing need to get to the bottom of it here and now. It is something that your primary care provider can usually provide care for or, if they feel you need to see some type of specialist, they will make that decision." This is different than me providing the office phone number for the ortho on call, to give a ring in the morning and make yourself an appointment for your broken ankle. I would never tell a patient to follow up with primary care for an ortho referral.
  10. Sorry the conversation has taken this turn but, since it has, I feel compelled to answer the question as to why the ED cannot do referrals. EMERGENCY. Perhaps some of you haven't worked in emergency medicine, others may be ignorant to the definition, the remainder I can only guess have become as brainwashed as the general public, that the ED is the catch all for shit. Your chronic headaches which you have been discussing with your PCP, that have encouraged three to four CT scans, at two different hospitals, over the past five years, does not need me to wake up Dr. Meningioma at 0100hrs. My job in the ED is to make sure that there is very little likelihood that something is acutely occurring or brewing right here, right now, or in the very foreseeable future (like hours away) that would be a threat to life, limb, or eyesight. To saddle me with making sure your patient gets a referral to the appropriate specialty service, on a non-emergent basis is ridiculous. Your inability to get the patient to the appropriate service as an outpatient does not warrant an ED visit. I don't bitch when primary care sends over a 57 year old with numerous risk factors, complaining of chest pain, for me work up to rule out an ACS. That makes perfect sense. Don't bitch when I send him back, having ruled it out, for you to finish off the work up with appropriate care and referral, because that also makes perfect sense.
  11. Meh, not sure what the board will say. Wrong move? Yes. Should you be hung, drawn, and quartered? Negative. Honestly though, whether you are seeing it or not (and I am not saying you are not) it boils down to integrity. Do I want someone on my team who is willing to forge a document, rather than explain why they missed the deadline? "Boss, I showed up at the class, and they told me they didn't receive my registration. I am in the process of remedying the situation." versus "I figured I could get one over on you and well, you caught me." That being said, Ral's argument: "Ma'am, I'm sorry we couldn't save your husband. I saw him collapse, and ran to him right away but, just as I was placing my hands on top of his sternum, I realized my BLS card had expired and completely forgot what I was supposed to do." Certifications/Recertifications are important for three reasons: 1. To INITIALLY prove you have acquired the knowledge and skills. 2. To prove that you are aware of changes associated with NEW methods or NEW thinking on a particular matter, that can't be proven by other means such as reading, working for a living, or living outside of a cave. (Yes, that means 'nothing new, nothing needed' to me.) 3. To line the pockets of people or groups who have personally expended ZERO dollars of their own money, to bring new information to the table.
  12. If I have determined that your condition doesn't require a narcotic rx, you will not talk me into it. Throwing a tantrum will just make matters worse for you.
  13. "She had a CT scan of the brain, which was normal." Would they not see a clot sign? (if it was a CVST, along with the duration) I am asking, as I am not well versed in these.
  14. "had some transient right face numbness for a few days" Makes me consider varicella/herpes virus infection, or trigeminal neuralgia variant. I did have an interesting case about ten years ago, with a young female (late 20's) who presented to our ER with a persistent headache, and hers turned out to be an internal carotid dissection. Considering your patient delivered a baby, a prolonged/repeated valsalva could certainly result in such.