| A Little Press Ganey Secret |
[21 Dec 2009|11:14am] |
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http://erstories.net/archives/1513 
So, my hospital, as well an many others I suppose, have certain criteria as to whom they send their Press Ganey patient satisfaction scores to. The policy is (and should be) that they do not send them to patients who present with psychiatric symptoms and/or alcohol or substance abuse related complaints. It does not have to do with what the ultimate diagnosis is (ie, it would easy if you could just make the dx of someone who presented for abdominal pain and demanded narcotics with “personality disorder”), but what the complaint is. The complaint is whatever the non-medically trained “greeter” writes into the computer when the patient presents. Often it is completely wrong - meaning the real reason the person is there is something completely different. Therefore, I frequently change it (or correct glaring misspellings) to the correct reason they are there. This gave me an idea. I personally find it perfectly appropriate to change “migraine” or “med refill” to ” requests Dilaudid” or “Ran out of Percocets” after I interview and examine the patient and realise the only reason they are there is to score narcs. Of if they are drunk and making whatever unrealistic demands, I change the presenting complaint to “intoxicated” or something else that makes it clear the main reason the person is there is because they had too much to drink. I mean, I am not going to be judged and have my administration rate me based upon when or not I hooked some seeker up with drugs.
Thus, when I had a recent patient storm out when I would not give her Dilaudid and Ativan for her chronic abdominal pain, and offer threats of “I am going to trash you on your satisfaction score!!!!”, I simply smiled and thought to myself, “well, you ain’t getting no STINKING form!”
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| You’re Scaring Me |
[20 Dec 2009|10:56am] |
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http://erstories.net/archives/1512 Sir, the grimacing I see on your face is frightening me. The reason is that with every face contorting expression of pain, I notice the ST elevations on the monitor! Here, have a nitro. There, better. Pain down to 2/10, ST’s down 50%. (Taps fingers impatiently for cardiologist to call back) - Nurse, can you put another call out to Dr Angioplasty? You just did 5 min ago? Sorry, well, call him again in 5 if he does not call back. OK, Sir, how are we…… there is that grimace again. Shit, those ST’s are back up again. Your pain level? 9/10. What’s your BP? 170 systolic? Good. We have a lot of room to play. Lets give you another under the tongue while you work on chewing up that Plavix tablet I gave you. Good, you look better now. OK, Nurse, lets just take this guy over to the cath lab and meet Dr Angio over there. This guy is making me sweat. Yeah, the monitor is hooked up and I have the bottle of Nitro. Lets rock. (please don’t code, please don’t code)
Damn, this new ER is further away from the cath lab. Hurry up, the patient is grimacing again. You steer the stretcher while I give him another sublingual. Oops, excuse me Sir, (random man bumps into me) the radiology dept is down there - sorry, I hope the wheels did not crush your feet. I have a sick patient here. What? The monitor leads have come off? Balls across the nose, don’t worry about it we are almost there. We can tell if his ST’s are going up by looking at his face. Next right? Oh, yeah. Been a while since I was over here. Room 4? Thanks. Lets get him onto the table. Wait, there is his facial contortion again. Let me give him another nitro. Good. Now lets all pull on three. One, two, three! Ok, Sir, there ya go. What? Dr Angio just arrived? WHEW! Good job guys. Good luck Sir.
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| Which of These Cases was Appropriate? |
[19 Dec 2009|11:49am] |
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http://erstories.net/archives/1510 
Lets see. I had a nice mix of patients that came in during my latest night shift over about a 2 hour period from 2 am to 4am.
A 21 year old woman with “hot flashes” (see last post).
A 35 year old man with a keloid on his shoulder that he had for three years.
A 10 year old boy with ear “itching” for three weeks.
A 16 year old boy who twisted his ankle two weeks prior and was not really having any trouble walking on it.
A 19 year old withdrawing from Oxycontin.
A 41 year old looking to get more Dilaudid and Ativan for her chronic abdominal pain.
NONE OF THEM WERE. They all wasted my time.
I was ready to throw myself under a bus until a nice man came with a STEMI!
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| Critical Lab Values |
[17 Dec 2009|10:29am] |
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http://erstories.net/archives/1507 Why is it that the informing of the staff of critical lab values is so difficult? Why can’t the lab just remember that secretaries, techs, and registrars are NOT medically trained enough to understand the importance (or relative unimportance) of an abnormal value?!?! I know why, they just want to get the name of someone (anyone) who they can document that they told about the HgB of 5! They don’t care who it is - hell, it could be the cleaning guy. Just anyone that they can put down as having “been informed” about the critical value. Please, people - please, please tell the RN or MD involved with the case (well, I prefer the RN so that he or she can filter out all the “urine glucose greater than 1000″ in the chronic diabetic (yawn!)). If you tell the secretary, she is not going to know that a Ca level of 7 does not usually matter for hill of beans but a sodium of 107 does! She is going to forget to tell anyone - or just write it down somewhere for us eventually to see, and we won’t know about it til the patient with the hyponatraemia seizes!!
We’ve been through this. Lab - only tell and RN or an MD. Secretaries, REFUSE to accept the info and just patch them through to someone who can!
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| Time To Retire |
[16 Dec 2009|11:13am] |
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http://erstories.net/archives/1505 
I honestly respect old doctors - they have years of experience and often a great rapport with their patients. However, some of them need to hang up the stethoscope. Even with completing CME requirements, some do not not ever seen to change their 20-30 year old practise patterns. Case in point. A pediatrician who is generally revered by his patients’ parents (they seem to think he is like some Doctor Spock or something), is completely living in the past with his management of febrile children and infants. Typical patient he sends in:
1) A 9 month old girl with fever of 102 for one day and the sniffles. Vitals normal except the fever. He wants urine cath cultures, blood cultures, chest X-ray, and CBC. When the white count is .1 (!!!) over the limit of “normal” he wants Rocephin injection daily until the culture results come back.
Duh. Ummmmm NO. Luckily the family saw how silly this was and refused all but the blood and urine (which was normal by the way as well)
2). A 21 month old boy with fever of 103 for two days, some vomiting (but still able to hold down fluids and making urine and tears), and diarrhea. He wants Blood, urine, and stool cultures, electrolytes, and a 20cc/kilo fluid bolus.
We could not get the IV and he was screaming bloody murder, so instead I gave him an orally dissolving Zofran tablet, some juice and some Motrin. Family was happy. Pediatrician was not when he called to ask about all the results only to find I had discharge the kid.
Sorry Bud. Hang it up or repeat a residency!!!!
BTW, the answer to yesterday’s quiz was #3, but all the other options were bantered around the MD’s charting area with plenty of laughter.
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| Multiple Choice Questionaire |
[15 Dec 2009|05:11pm] |
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http://erstories.net/archives/1270 OK, quick multiple choice test. Answer tomorrow.
An Elderly Lady presented with a fall and fractured wrist which happened while she was “Chasing after her husband”. Which choice correctly describes the circumstances of this situation:
1. She was chasing him with a frying pan after discovering him to have had a Tiger Woods-style harmem of girlfriends
2. They were having a bit of role playing prior to sex and she was a “cop” and he was a “robber”
3. He was demented and after getting out of the house, was heading down the street into traffic
4. A diehard Repulican, she was upset that husband expressed support in the “public option”
5. He startled her out of sleep with a “dick tag”
*Definition of Dick Tag
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| I Couldn’t Have Said it Better Myself |
[14 Dec 2009|12:53pm] |
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http://erstories.net/archives/1501
Upon my return from the Caribbean (which was awesome by the way), I read the latest issue of EP Monthly - and what struck me as a great truism was an “In my Opinion” piece by Thomas Doyle, MD entitled “Treating a Nation of Anxious Wimps”. He makes a great case describing that what we do is just help the body to heal itself (most of the time) and that the big problem with health reform is that we as a nation just don’t get it! We don’t understand that much of what we have happen to us will get better on its own! But heck, GO TO THE DOCTOR just in case! Obviously, the biggest portion of health care expenditures are with the elderly and chronically ill (who unfortunately ARE sick) but I agree that the rest of the country is full of over-utilisers as well! As he says “Tincture of Time” and “Elixir of Neglect” cures colds, bronchitis, most headaches, sinusitis, and aches, pains, and sprains!
* I am sure this wimp in the picture went to the ER after the game just to get checked out!
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