Read this for a laugh.. and a sigh

[kadiah]

Hey everyone! I'm a long time lurker. I'm posting for the laughs and honestly I just need to vent. I work at an Urgent Care in the NE operated by a large hospital system. Usually, I love seeing tick bites pop up on the schedule - they're easy to remove, take 5 minutes of patient education, and we have a great smart set that takes about 2 minutes of documentation, boom done. Well, Wednesday was a day from hell in our UC. On top of our 50+ patients with normal cough, sore throat, sprains we had a new onset CHF with angina, symptomatic bradycardia, and new onset a. fib. It's frequent for us to see have to triage, stabilize, and ship the higher acuity stuff because we're right outside the ER so they stop here on their way because "they didn't want to wait." About 20 minutes before we close, this lady comes in with a tick bite, my nurse rooms her, but she comes out with a "nope nope nope" face. She says "see what you think, but I don't see anything there." 

 

There was no tick. If anything it looked like there was a tick that might have been removed, but honestly it looked like she was pricked with a thorn or pricker bush. She said she "felt it bite her" while working in the garden. She said that "on her skin" the ticks always "bury into her body completely" and she has previously had to have ticks "surgically removed and have CHUNKS OF HER SKIN cut out" (it sounded like she meant someone made an elliptical cut into her skin and sewed it.) No matter what I did to convince her, no matter how much I talked about CDC guidelines and everything, this woman would not budge, she was demanding I dig for the tick, which I would not do. I also have the gift/curse of having a baby face, and while I am young (*gasp* 28, so obviously I know absolutely nothing), it drives me nuts that people treat me as if I have zero authority. I offered to get the other provider working in the clinic for a "second opinion." She is a NP who has practiced for about 25 years in multiple different ERs around the country, so she seems "more authoritative". She of course backed me up, saying there is nothing there, and we tried to convince this patient, pulling up the CDC guidelines, pictures, anything - but we could not calm her down. She stormed out, saying she's going the the ER for a second (actually third) opinion.

 

I just brushed it off as normal crazy and went home. I also worked the next day. Well, the minute we took our phones off service, doesn't this woman call. She's angry, demanding my name, my SP's name, the NPs, name, the nurses name - I'm surprised she didn't ask for my DOB and SS number she was so livid. So I'm like, oh god what happened when she left. I pull up the chart, saw she was discharged from the ER, obviously. The ER triage PA basically said "there is no tick, bye." Okay, good. Well this woman went to another UC, operated by our system that is open later. She saw an NP there, who of course diagnosed her as a "tick bite" and documented she "removed the tick forcibly with forceps with great difficulty." What did she remove- skin? I know this NP, she used to work for our UC group and she has a reputation for giving patients anything they want. So it doesn't shock me, but oh god does it make me angry.

 

I have a very understanding boss, who I just wrote an email to explaining the situation and he says he'll handle any complaints. Thank god the ER PA also documented no tick bite, or else I'd look like an idiot. It's so frustrating and I don't understand why other providers feel the need to cater to people like this.

 

Anyone else have any good stories like it?  

 

 

[KMD16]

Welcomed to UC where most complaints are essentially a total BS :) I said this with a smile. Gets use to it. Only in America!

[dmdpac]

Based only on information contained in the OP it sounds like the patient in question may benefit from a psych consult.  Delusional parasitosis is a real thing.  It's hard to tell if that's really what's going on based on the limited information and format of this particular discussion.  However, it would certainly be something to keep in the back of your mind as part of your differential.

 

I've encountered what I suspected was a case of delusional parasitosis once.  She was absolutely convinced she had bugs in her skin.  Her arms were covered with open wounds from where she would dig out said "bugs" with her fingernail.  It was, overall, a pretty sad case.

[Reality Check 2]

Look up Morgellon's Disease and have fun with that one.

 

I have had several patients over many years insist they have it.

 

I think the last NP probably dug a hole - which is so not advisable - made it bleed, produced the "tick" - likely subcutaneous fat - and made it all up.

 

Not a good practice as infection, scarring, just bad judgement all come to mind.

 

The patient is obviously mentally disturbed.

[ventana]

Ugh

 

I read with interest an article some 10 + years ago about why PA, MD and NP's sometimes throw each other under the bus on bad decisions and second guessing.... figured I would never do that

 

 

Now 10 years later and seeing what some other providers have done, I have a tough time keeping my mouth shut.... sometimes what people will do is is just insane...... and it comes from a provider so it must be true!

 

Most recently an new grad provider told a patient some advice that was just plain wrong..... I did what that article stated, and corrected the patient on what the true medical literature stated and advised them that sometimes people don't stay up to date.....

 

Oh well

[ajnelson]

Being in the ED, we get a lot of patients 'referred' to us. Its always a treat trying to explain to a patient why the doctor they just saw over reacted, or was incorrect, etc.

I always try to give the other provider the benefit of the doubt and I try not to make it seem like they did anything wrong. We all know how stories change or our prior experiences can effect how we practice.

[GetMeOuttaThisMess]

Playing devil's advocate, be careful about being too high and mighty because one never knows when you'll be the one to take it in the shorts on something missed. It happens to all of us if you play this game long enough.

[rev ronin]

Playing devil's advocate, be careful about being too high and mighty because one never knows when you'll be the one to take it in the shorts on something missed. It happens to all of us if you play this game long enough.

I'm going to have to disagree.  Screwing up and missing something is NOT the same as doing something dangerous and pointless just to get the patient to go away.

[ajnelson]

Playing devil's advocate, be careful about being too high and mighty because one never knows when you'll be the one to take it in the shorts on something missed. It happens to all of us if you play this game long enough.

In my setting, its more about certain providers sending EVERYTHING to the ED, way over reacting to certain things, scaring patients about their results, or telling the patient I need to do a specific test in the ED.

I had our urgent care send a back pain with sciatica patient to the ED yesterday for 'pain control' and also implied we'd do an MRI. They didn't attempt pain control at all (he had been using only Flexeril for pain). And never even did plain films. He didn't need an emergent MRI...And he needed real pain medications. Dose of anti-inflammatory, lidocaine patch and narcotic, was comfortable and wanted to go home (and our urgent care has access to all of that)

[LoRezSkyline]

Textbook Morgellon's/delusional parasitosis as others have suggested - have had similar patients in the ED convinced there was something sub-q that needed to be dug out or (even better still!) bring in ziploc bags/envelopes of said mysterious substance to be "analyzed" - makes for an interesting conversation when you tell them that isn't exactly possible...

[Guest UVAPAC]

In my setting, its more about certain providers sending EVERYTHING to the ED, way over reacting to certain things, scaring patients about their results, or telling the patient I need to do a specific test in the ED.

I had our urgent care send a back pain with sciatica patient to the ED yesterday for 'pain control' and also implied we'd do an MRI. They didn't attempt pain control at all (he had been using only Flexeril for pain). And never even did plain films. He didn't need an emergent MRI...And he needed real pain medications. Dose of anti-inflammatory, lidocaine patch and narcotic, was comfortable and wanted to go home (and our urgent care has access to all of that)

 

 

1.  I see a lot of patients with lower back pain both acute/chronic and hardly ever (if ever) prescribe a narcotic for pain.  99.9% of the guidelines suggest this is inappropriate and not efficacious.  I would think that people with true sciatica would do better off on a neuropathic medication such as neurontin.

 

2.  On a very rare occasion we get a patient who complains of progressive lower extremity weakness, loss of sensation in lower extremity, fecal/urinay incontinence/retention.  In a case such as these we have referred to the emergency room for MRI, as obviously that is just about the only way to obtain a stat MRI.  Obviously if the provider in the ED feels comfortable telling them it is not necessary and discharging them, that is the providers decision.  I believe the very few we have sent to the ED, have all had an MRI done.

 

3.  On a side note nearly every new guideline I have read on acute lower back pain suggests NSAIDs and if you want to get really wild, adding a muscle relaxer.  They are very straight forward that opioids/narcotics simply are not indicated, and if anything  contraindicated.  They suggest that physical therapy can help, but often is not necessary.  They encourage patient's to stay active and progressively increase activity levels.  

 

The other thing I have told patients is that studies show that NSAID + extra strength tylenol has been shown to be as efficacious as vicodin or percocet without the harmful risks/side effects.  

[GetMeOuttaThisMess]

1.  I see a lot of patients with lower back pain both acute/chronic and hardly ever (if ever) prescribe a narcotic for pain.  99.9% of the guidelines suggest this is inappropriate and not efficacious.  I would think that people with true sciatica would do better off on a neuropathic medication such as neurontin.

 

2.  On a very rare occasion we get a patient who complains of progressive lower extremity weakness, loss of sensation in lower extremity, fecal/urinay incontinence/retention.  In a case such as these we have referred to the emergency room for MRI, as obviously that is just about the only way to obtain a stat MRI.  Obviously if the provider in the ED feels comfortable telling them it is not necessary and discharging them, that is the providers decision.  I believe the very few we have sent to the ED, have all had an MRI done.

 

3.  On a side note nearly every new guideline I have read on acute lower back pain suggests NSAIDs and if you want to get really wild, adding a muscle relaxer.  They are very straight forward that opioids/narcotics simply are not indicated, and if anything  contraindicated.  They suggest that physical therapy can help, but often is not necessary.  They encourage patient's to stay active and progressively increase activity levels.  

 

The other thing I have told patients is that studies show that NSAID + extra strength tylenol has been shown to be as efficacious as vicodin or percocet without the harmful risks/side effects.  

 

 

Said very nicely.  Back to my looking for retirement property.

[sk732]

1.  I see a lot of patients with lower back pain both acute/chronic and hardly ever (if ever) prescribe a narcotic for pain.  99.9% of the guidelines suggest this is inappropriate and not efficacious.  I would think that people with true sciatica would do better off on a neuropathic medication such as neurontin.

 

2.  On a very rare occasion we get a patient who complains of progressive lower extremity weakness, loss of sensation in lower extremity, fecal/urinay incontinence/retention.  In a case such as these we have referred to the emergency room for MRI, as obviously that is just about the only way to obtain a stat MRI.  Obviously if the provider in the ED feels comfortable telling them it is not necessary and discharging them, that is the providers decision.  I believe the very few we have sent to the ED, have all had an MRI done.

 

3.  On a side note nearly every new guideline I have read on acute lower back pain suggests NSAIDs and if you want to get really wild, adding a muscle relaxer.  They are very straight forward that opioids/narcotics simply are not indicated, and if anything  contraindicated.  They suggest that physical therapy can help, but often is not necessary.  They encourage patient's to stay active and progressively increase activity levels.  

 

The other thing I have told patients is that studies show that NSAID + extra strength tylenol has been shown to be as efficacious as vicodin or percocet without the harmful risks/side effects.  

 

And imaging isn't necessary...unless red flags are present. 

 

Gone are the days of 3 days on your back with 800 of tid Motrin, 5-10mg of qid Valium and q4-6h Demerol or T#3's.  Having been used as a training aid for a McKenzie Back Care course, I'm a big proponent of physio...and if he person has Dunlap's Disease*, I point it out and tell them to do something about it if they want their pain to stay away.

 

* ​Dunlap's Disease is where the belly Dunlaps over the belt.

 

​​​SK

[ajnelson]

1. I see a lot of patients with lower back pain both acute/chronic and hardly ever (if ever) prescribe a narcotic for pain. 99.9% of the guidelines suggest this is inappropriate and not efficacious. I would think that people with true sciatica would do better off on a neuropathic medication such as neurontin.

 

2. On a very rare occasion we get a patient who complains of progressive lower extremity weakness, loss of sensation in lower extremity, fecal/urinay incontinence/retention. In a case such as these we have referred to the emergency room for MRI, as obviously that is just about the only way to obtain a stat MRI. Obviously if the provider in the ED feels comfortable telling them it is not necessary and discharging them, that is the providers decision. I believe the very few we have sent to the ED, have all had an MRI done.

 

3. On a side note nearly every new guideline I have read on acute lower back pain suggests NSAIDs and if you want to get really wild, adding a muscle relaxer. They are very straight forward that opioids/narcotics simply are not indicated, and if anything contraindicated. They suggest that physical therapy can help, but often is not necessary. They encourage patient's to stay active and progressively increase activity levels.

 

The other thing I have told patients is that studies show that NSAID + extra strength tylenol has been shown to be as efficacious as vicodin or percocet without the harmful risks/side effects.

This was a reasonable guy who tried Flexeril for 5-6 days without much improvement. He had been using a bit of Tylenol on and off, but it didn't provide any improvement so he didn't continue it. He can't take NSAIDs regularly because of other medications he is on. And has to be cautious of Tylenol use because he's had his LFTs be adversely affected by it. (All of which I had access to, not just his word). It had been over a year since he's had any controlled substance prescribed (post Ortho surgery).

This was an acute injury and really, he just needed adequate pain control and physical therapy (which I also helped arrange). I'm a huge proponent of alternatives to narcotics. Tylenol and ibuprofen are good medications. But, they have their limitations as well. And sometimes a small amount of something stronger is needed. I also prescribed (and gave) a lidoderm patch. I find that these help a good majority of people, and are a great adjunct, no matter what route we need to go with treatment. I, too, encourage remaining as active as possible. And explain to my patients why it is important, usually using the example that they are really stiff when they first get up, but once they are up, feeling better. Sitting, laying just allow muscles to keep tightening, which is what we are trying to treat/prevent. Not all of my back pain patients get pain medication. But I'm also not afraid of treating someone so they are comfortable enough to get up and do their ADLs...

He did not meet criteria for an emergent MRI. The urgent care doctor that saw him sent him for an MRI because his pain wasn't getting better. (This provider sends 25-50% of his patients to the ED, most of which are not justified). Right buttocks pain radiating into leg. Intact strength and neuro exam. No numbness or even tingling. There was nothing about his story or exam that was concerning enough to warrant an emergent MRI. Maybe for persistent pain after conservative treatment has failed. But he's been shortchanged on the conservative treatment as it is.

[Katera]

In my setting, its more about certain providers sending EVERYTHING to the ED, way over reacting to certain things, scaring patients about their results, or telling the patient I need to do a specific test in the ED.

I had our urgent care send a back pain with sciatica patient to the ED yesterday for 'pain control' and also implied we'd do an MRI. They didn't attempt pain control at all (he had been using only Flexeril for pain). And never even did plain films. He didn't need an emergent MRI...And he needed real pain medications. Dose of anti-inflammatory, lidocaine patch and narcotic, was comfortable and wanted to go home (and our urgent care has access to all of that)

 

 

 

Most UC's I work at:

 

a.)  Have no narcotics onsite, only Toradol.

 

b.)  Have strict practice guidelines forbidding giving any oral narcotics for back pain, period.

 

 

This is what 75% of corporate UC's I have worked at do.  That is why you see the ER dumps.  I'm not saying it's right, but it's a fact.

[d2305]

I used to use gabapentin until they abused it too. Back to decadron which works as well as anything. I love it when they bring their MRIs with them. I've seen the bugs under the skin patients too. Legitimate larva migrans kids with mothers demanding treatment.

[Reality Check 2]

As for the OP and the mystery bug or foreign body.....

 

I refuse to potentiate mentally unstable behavior at this point in my career or life. Enabling the thought processes and allowing for bad medical choices isn't smart or useful.

 

Press Ganey be damned - folks need to own up to doing the RIGHT thing at the right time for the right reasons and stand tall.

[sas5814]

Prescient post about back pain and ER dumps! I am doing a 12 in the UC today. We are a big hospital system and most of our UCs are co-located with FP clinics. The doc next door fell ill and had to go home so his schedule was cancelled. One patient just showed up for a follow up on her chronic low back pain, chronic cough (smoker) and to get a wart frozen off none of which we do in the UC. I did the best I could do with her cough and told her she needed to follow up with her PCP and may need to see a spine specialist or a pain specialist (she has an appointment pending for the end of June) and no I wouldn't refill her opioids. She says to me "they told me next door to come over here because you do the same thing they do." After she left here bawling and went next door the nurse has stones enough to come over here and (try) to fuss at me.

Oh and the patient said "so I should go to the ER?" I told her I couldn't tell her not to but there was a 99% likelihood she would sit in the lobby for hours and then be told essentially the same thing.

*sigh* first day back from vacation....