Your 5 least favorite chief complaints in your ED

[winterallsummer]

Yep just as bad as the problematic patient presenting to ED, is the problematic patient then following up with the FM PA.  Lucky for the latter, so few of our patients follow up.

[Evolute]

Paula,

 

dental pain should be referred to a dentist. Seem strange that you would get these pts.

 

If you don't like ED/UC sending you pts for f/u why are you in FM? Isn't one of the jobs of FM to coordinate pt care, and to determine if they need referral to a specialist? IE: pain clinic. the ED does not/cannot make referrals to pain clinics. As I'm sure you know, most (if not all) pain clinics require a pt to have a full workup prior to being seen by them.  So are we just suppose to discharge these pts with no ongoing plan and wait for them to come back to the ED? these pts need long term help/care. isn't that what FM does? If you don't want to treat chronic pain pts on an on going basis (I know I wouldn't) FM can at least refer to pain clinics, or other appropriate specialties.

 

So anyway, ED/UC will keep sending you these pts for f/u. You can treat them as you see fit...... and if yo get tired of treating chronic Dz, there's always ortho.     

[sk732]

In Paula's defence, when I was in FM, I had a number of folks with ongoing dental pain that either couldn't afford a dentist or were going through their dental procedures.  A frequent visit would be because their dentist wouldn't see them until antibiotics were initiated...though why they couldn't call in the Rx escapes me.  The other issue in FM is the people with poor oral health also had poor general health as a result - the circle of life as it were.

 

SK

[MrsGPAC]

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. 

Well, the ED is certainly not the appropriate place to have chronic pain managed. If this is your patient, I feel as though it is not unreasonable to ask you to take part in their follow up care.  Am I wrong here? I personally don't tell patients what their PCP will or will not do for them, just tell them that no further meds will come from the ED.  And I send dental pain to dentists…because you have no more training than I do in being a dentist.  But I agree with the above.  You can see dental pain and write antibiotics for your patients just as easily as I can.  Even on Friday afternoons.    

[Guest Paula]

Most of the patients are not my patients.  I have about 40 patients on my panel, if you want to call it that.  I am seeing every MD/DO/NPs patients in my group since none of them seem to have open appointments to see their own patients.  It takes a long time to build a practice.  

 

Of course I will see the patient and I don't mind seeing ones who have true pain.  The one pain clinic we refer to won't take our referrals much anymore.  They do not require a full work up before the referral either. 

 

The problem is the drug seekers.  I would like to see the UC/ED practitioners to offer them a service such as getting into a treatment program but no one even seems to address the issue.  Then the patient (if they show for their appt. with me) gets a thorough PMH and I am reading all the chart notes I can find, examine them and then attempt to get the ones with the opiate dependence into a treatment program.  SO far, no takers.  I guess they find Kratom and are happy.  

 

I am getting burned out doing the coordination of care with the reams and reams of paperwork and it really irritates me that the UC providers can't (or won't) even fill out an initial workman's comp paperwork.  I get the joy of filling it out even tho the UC was the first ones who see the pt.  Can't they do their part of the process?  I don't get that at all.  Is that some kind of rule now that UC/ER can't do referrals?  When I worked there I did referrals all the time directly to ortho, PT, for example.  Do you guys not know how to do paperwork?

 

I would quit before ever applying for an ortho job, yuk.  Or surgery, double yuk.   The more and more we do in FP for less and less pay is driving me to look towards early retirement.  Maybe I will have to go back to UC so I can avoid all the paperwork and get paid a heck of a lot more for less work.  I do enjoy figuring out what the patients diagnosis is when the  ER couldn't figure.  Had one of those today.  Made it worth it.  

 

However, I did  get a patient complaint today since I didn't prescribe an antibiotic for her cold and she rated me a 0, would not recommend me to anyone, so now my satisfaction scores are in the pits (so will probably eventually get a pay cut for that one bad survey) all others have been great surveys.  This is what we face in PC and the suits that control us.  Kind of like that song lyric: I owe my soul to the company store. 

 

DO you lose pay for a bad patient satisfaction score?  

 

I've had a bad day and now I feel better a little.  Rant over but you touched a nerve, Evolute.  (Can I come see you for my nerve pain?) It's an emergency, btw. 

[GetMeOuttaThisMess]

Very well said Paula. I'm right there with you.

 

 

Sent from my iPad using Tapatalk

[sk732]

Paula, doesn't say much for your administration if you're getting a pay cut because you did your job properly and they didn't properly investigate why you got that goose egg...maybe you should look for something else.  I got out of FM because I was paid for an 8 hour day, but, since I was sole provider for my practice (my SP was 35km away) and had a 4 digit patient list, work was done when it was done, which was often on my own time.  I got really tired of over paid management (nurses/social workers) telling me I wasn't entitled to overtime.  Now in the ER, I go to work, do my shift, and go home.  If I incur reasonable overtime (we were getting slammed or a pile of last minute admission orders and such), I get paid for my time.  I leave work at work now - no charting from home.  And I made sure my patients knew it was the system, not them, as to why I left.

 

SK

 

Edited for a grammar oopee.

[Evolute]

Paula,

 

I agree, drug seekers are a problem. As far as the  treatment option, that's not really an option for the pts I see in the ED. the nearest treatment centers are >80 miles away. Drug seekers sure aren't going to drive those distances (unless its to get to another ED for more drugs). Further more I work in 2 of the top 5 poorest counties in the state. most of my pts have to find a ride to the ED b/c they don't drive, cant afford the gas, don't have a car. So the ones with "true pain" most certainly cant afford to get to the pain centers. We are such a rural state that most chronic pain is managed by FP/FM. So that's where I send them.

 

As far as coordination of care goes....isn't that hat FP/FM does? Personally, I fill out work comp claims every time a work com pt presents to the ED. Even if the paperwork comes in several days later. So I don't know why other ED providers are not doing this. I'll give you this one.

 

I (and I think most ED providers) do make referral when appropriate. the example The example I gave above about the female with a humerus Fx. I referred her directly to ortho. No need for FP/FM to get involved. But honesty, how many pts with joint sprain/strain need ortho or PT? not many. But they do need f/u to be sure they are healing. b/c they may have an injury not picked up in the ED. IE: twisted ankle with normal PE( other than tenderness and swelling), negative XR. Could have tendon, ligament, cartilage injury. I don't have MR available (and if I did I wouldn't MR every joint that comes through the door). And I'm  certainly not going to CT them. How about chest pain with negative work up? Should I call cardiology at 0200 (when FP/FM folks are nicely tucked into their beds) and tell them I have xxx pt who presented with CP, negative PE, negative EKG(s), negative serial troponins, can I have them f/u with you? is that appropriate? Maybe we should start calling their FP/FM provider at O dark thirty for f/u. I'm sure you guys would love that. Again, it goes back to coordination of care.    

 

As far as paperwork goes, it sucks no matter the specialty. thou FP/FM seems to have more then most.....one reason I don't work FP/FM

 

I agree with ortho and surgery....couldn't do it.

 

More pay for less work? As the solo ED provider working I 2 EDs I think its safe to say that my liability is much higher then that of FP/FM. When was the last time A FP/FM/UC provider treated (and made a disposition) on a pt with CP? or worked up an acute abdomen? or treated a multi system trauma? intubated? placed a chest tube? treated a traumatic aortic arch rupture? or had to tell family members their loved one died? Me? all of the above within the last 6 weeks. Less work? I don't think so. we all know FP/FM pay sucks. If I could change it I would. But again, specialty is a choice.

 

If I had to take a pay cut every time a pt (or their family) wasn't happy i'd be in the poor house. IE: drug seeker not getting the scripts filled, kiddo not getting the abx mom wants/expects, family that want grandma/grandpa admitted b/c they want to go out of town for the weekend. as far as your salary being tied to pt satisfaction? that's complete BS. we all pi$$ off pts ( and their family) from time to time. for f#&ks sake, we are not selling insurance!!!!

 

Paula, im glad you feel better, and yes you can come see me for your "emergent" nerve pain. however I have to tell you the same thing I tell my other colleagues/friends. if dyou show up in my ED its a tube in every orifice. lol 

 

btw, thanks for all our hard work, we in ED truly appreciate it.

 

Evolute 

[True Anomaly]

for folks with chronic back pain, there is nothing that says you have to treat with narcotircs.......... is there?

 

No there isn't- on the contrary, there is growing objective evidence that you shouldn't treat with short-term opiates, and never start on long-acting opiates in the ED.

 

HOWEVER....saying "no" to a chronic pain patient, whether legit or not, almost always leads to an argument and a confrontation.  I don't mind saying "no" when appropriate, but the ensuing fight is always draining.  Yeah yeah, woe is me, blah blah blah....but what doesn't help is when you have colleagues, either other PA's/NP's/physicians who will give them "just a few" to avoid the confrontation- making it that much tougher to say no and stand your ground because you feel it's the right thing to do, instead of kicking the can down the road by giving them "just a few more".  

[True Anomaly]

Dental pain is easy - put in a block :-D

 

How many blocks do we need to treat these people with before they finally go to the dentist for definitive care?  The block lasts 12 hours at the most- and yes, I've had patients bounce back the next day because, guess what, the block wore off.  Then what?  You're right back at square one because "it won't stop hurting" and now you tell them no and go follow up with dental and you've done them no favors for the long-term because ultimately it's up to them to see dental.  

 

If I can talk to dental or OMFS and know they will be seen later that day or the next day for an acute problem, I have no issue with doing a dental block.  It's the chronic dental pain that putting in a block for becomes a way for them to avoid going to the dentist for another day, but puts them right back at square one eventually. 

[db_pavnp]

As the solo ED provider working I 2 EDs I think its safe to say that my liability is much higher then that of FP/FM.

 

Is it as safe to say as you think?

[sk732]

The trick lies in telling them that (a) their problem isn't going away without seeing a tooth fairy and (b) it is only to get ahead of the pain control curve.  I get them started on 600mg of Ibuprofen before they leave the dept and tell them they need to take it regularly.  If they bounce back, I document them as non-compliant, tell them they're at risk of developing lidocaine toxicity (a bit of a fib) and that while I'm comfortable with me extracting teeth, they won't be when I'm done with them...especially if they just needed a root canal.  Oh, and it's not something that's routinely done in the ER.  

 

You touched on a BIG problem - most ED's don't have on call dentistry.  I can call for OMF (in the large tertiary centre), but getting emergency dentists in many places is like pulling hens' teeth (pun intended).  Issue I have is, in Canada, despite there being "universal health care", that doesn't extend to oral health - it costs nothing (except in taxes) to go to the ER, but you pay through your ass to go to the dentist unless you have extra health insurance (or are on a government assistance or Treaty Status Aboriginal)...and even then you still do.  I'm sure the same happens in the US - tooth fairies make WAY more money than a lot of MD's do.

 

Another issue of course is that most normal humans at least hate (if they aren't outright shyte scared of) dentists...which, second only to cost, is why most people avoid going.

 

SK

[Boatswain2PA]

Taking this conversation in a slightly different direction (but back to topic).  Here are the five least favorite chief complaints I have had.  

 

1:  Unresponsive infant, CPR in progress

 

2.  Child pulled from water, CPR in progress

 

3.  Child versus adult non-biological-father, CPR in progress

 

4.  Child run over by SUV (this one somehow ended okay despite being very, very bad at the beginning)

 

5. Multi-car MVA, multiple code red traumas enroute.  

Dental pain?  Headache?  Back pain?  My job is to ensure it's not badness (Ludwig's, subarachnoid, spinal abscess), give emergent treatment (abx, compazine, toradol & lidocaine patch), and have them follow up with primary care.

 

90 year old weak & dizzy?  Rule out emergent badness (dysrhythmias, bad anemia, etc) and admit to obs.

 

Non-toxic kid with a fever?  Apap or ibuprofen and they're feeling better by the time I'm done fighting with the EMR, reassure parents, give them the dosing sheet and they're out the door.  

 

Barfing kid?  Same as above, but with zofran.  Document that they are eating before they go out the door.  

I am very, very lucky in the environment that I practice in has good primary care, and the PC docs are also the hospitalists and never push back against admissions.  

[CAdamsPAC]

Whats so bad about seeing kids with fevers?

Especially when they don't have a thermometer at home, and they start adding complaints even siblings to the mixture!

[CAdamsPAC]

Taking this conversation in a slightly different direction (but back to topic).  Here are the five least favorite chief complaints I have had.  

 

1:  Unresponsive infant, CPR in progress

 

2.  Child pulled from water, CPR in progress

 

3.  Child versus adult non-biological-father, CPR in progress

 

4.  Child run over by SUV (this one somehow ended okay despite being very, very bad at the beginning)

 

5. Multi-car MVA, multiple code red traumas enroute.  

 

Dental pain?  Headache?  Back pain?  My job is to ensure it's not badness (Ludwig's, subarachnoid, spinal abscess), give emergent treatment (abx, compazine, toradol & lidocaine patch), and have them follow up with primary care.

 

90 year old weak & dizzy?  Rule out emergent badness (dysrhythmias, bad anemia, etc) and admit to obs.

 

Non-toxic kid with a fever?  Apap or ibuprofen and they're feeling better by the time I'm done fighting with the EMR, reassure parents, give them the dosing sheet and they're out the door.  

 

Barfing kid?  Same as above, but with zofran.  Document that they are eating before they go out the door.  

 

I am very, very lucky in the environment that I practice in has good primary care, and the PC docs are also the hospitalists and never push back against admissions.  

Top 5 I can deal with.......the rest not so much. Thank God for healthy adult oilfield workers out on the edge of the world.

[CAdamsPAC]

The trick lies in telling them that (a) their problem isn't going away without seeing a tooth fairy and (b) it is only to get ahead of the pain control curve.  I get them started on 600mg of Ibuprofen before they leave the dept and tell them they need to take it regularly.  If they bounce back, I document them as non-compliant, tell them they're at risk of developing lidocaine toxicity (a bit of a fib) and that while I'm comfortable with me extracting teeth, they won't be when I'm done with them...especially if they just needed a root canal.  Oh, and it's not something that's routinely done in the ER.  

 

You touched on a BIG problem - most ED's don't have on call dentistry.  I can call for OMF (in the large tertiary centre), but getting emergency dentists in many places is like pulling hens' teeth (pun intended).  Issue I have is, in Canada, despite there being "universal health care", that doesn't extend to oral health - it costs nothing (except in taxes) to go to the ER, but you pay through your ass to go to the dentist unless you have extra health insurance (or are on a government assistance or Treaty Status Aboriginal)...and even then you still do.  I'm sure the same happens in the US - tooth fairies make WAY more money than a lot of MD's do.

 

Another issue of course is that most normal humans at least hate (if they aren't outright shyte scared of) dentists...which, second only to cost, is why most people avoid going.

 

SK

A Dentist who covered the ER I worked in, taught me that Facial Swelling, Fever, fracture involving the teeth are "Dental Emergencies" , pain isn't on the list. Feeding stray cats will get you more cats visiting . I've wondered what the Dental Board or Medical Board would do if someone I treated for  dental complaints had a bad outcome, since Dentistry isn't in my scope of practice.

[sk732]

Oddly enough, I had to do a 2 week dental course in school (my program was military - in some places I've been, I was doc, tooth fairy, padre, addictions counsellor, preventative medicine tech, head crusher, etc, ad nauseum) and pain, especially acute onset pain, was considered a dental emergency until cause was proven. I've done a lot of blocks, have done temporary restorations/crowns/fillings as well.  A lot of those blocks are great for facial suturing incidentally.  Last PA conference I was at actually had a really good seminar of dental issues, including blocks, in primary and emergency care.

 

Back on track, got another new ER Dx today that had my head shaking...Plantar Wart ::).

 

SK

[LT_Oneal_PAC]

I will say my favorite CC that I've ever seen and had me giggling the rest of my rotation: chest pain s/p burrito.

[jen0508]

5 least fav:

 

dizziness

old person with weakness 

bartholins cyst

big lip lacerations on kids - hard to suture when they are screaming and crying 

old demented person with nothing really wrong with them but their family decided they cant take care of them anymore so they bring them to the ER

[RetNavyPAC]

Here's my fave!  From about 2 months ago on an overnight shift

 

CC: "Test for everything"

 

 

. . . gotta love EM.  :-)

 

 

I'd love to upload the screen shot but why are we limited to 46 lousy KB?!

[EMEDPA]

5 least fav:

 

dizziness

old person with weakness 

bartholins cyst

big lip lacerations on kids - hard to suture when they are screaming and crying 

old demented person with nothing really wrong with them but their family decided they cant take care of them anymore so they bring them to the ER

this is why ketamine was invented...

[winterallsummer]

I just got another one to add to this list: "here from [well known walk in clinic aka McD's of medicine], needs head CT."  What was the injury?  Someone accidentally bumped the patient in the occipital region of the head with a stack of dishes while cleaning the kitchen.  No LOC, emesis, amnesia.  Headache.  And this occurred... two days ago.

 

I really wanted to call the UC PA (unfortunately it was a PA) and inform them that 1) any CT rule ever would show you this patient does not need a head CT, 2) as would common sense, and 3) if the patient really did need a head CT (which is why she was sent to my ER), you probably shouldn't have given 60 mg of IV toradol!!!

 

Can't make this up folks.

[True Anomaly]

I just got another one to add to this list: "here from [well known walk in clinic aka McD's of medicine], needs head CT."  What was the injury?  Someone accidentally bumped the patient in the occipital region of the head with a stack of dishes while cleaning the kitchen.  No LOC, emesis, amnesia.  Headache.  And this occurred... two days ago.

 

I really wanted to call the UC PA (unfortunately it was a PA) and inform them that 1) any CT rule ever would show you this patient does not need a head CT, 2) as would common sense, and 3) if the patient really did need a head CT (which is why she was sent to my ER), you probably shouldn't have given 60 mg of IV toradol!!!

 

Can't make this up folks.

That's just embarrassing 

[CAdamsPAC]

No there isn't- on the contrary, there is growing objective evidence that you shouldn't treat with short-term opiates, and never start on long-acting opiates in the ED.

 

HOWEVER....saying "no" to a chronic pain patient, whether legit or not, almost always leads to an argument and a confrontation.  I don't mind saying "no" when appropriate, but the ensuing fight is always draining.  Yeah yeah, woe is me, blah blah blah....but what doesn't help is when you have colleagues, either other PA's/NP's/physicians who will give them "just a few" to avoid the confrontation- making it that much tougher to say no and stand your ground because you feel it's the right thing to do, instead of kicking the can down the road by giving them "just a few more".  

Which is why when I get to a new locum position I meet with every provider and let them know that I do not treat chronic pain or refill narcotics written by others.

[EMEDPA]

I just got another one to add to this list: "here from [well known walk in clinic aka McD's of medicine], needs head CT."  What was the injury?  Someone accidentally bumped the patient in the occipital region of the head with a stack of dishes while cleaning the kitchen.  No LOC, emesis, amnesia.  Headache.  And this occurred... two days ago.

 

I really wanted to call the UC PA (unfortunately it was a PA) and inform them that 1) any CT rule ever would show you this patient does not need a head CT, 2) as would common sense, and 3) if the patient really did need a head CT (which is why she was sent to my ER), you probably shouldn't have given 60 mg of IV toradol!!!

 

Can't make this up folks.

as a side note 60 mg is never an acceptable IV dose! that is the IM dose for a really big person....personally I never use more than 30 by any route due to studies saying 60 is no more effective than 30 but significantly increases the risk for renal failure. I tell  my students 60 mg is the renal failure dose of toradol(as in the dose causing renal failure....)