Tuesday, September 04, 2007

I've Got to Say This Sooner or Later

OK, I'm old and tired and maybe burnt, but not burnt out..Never been sued in 30+ years..As I mentioned before, I'm leaving my current position to start up a new EM residency in a Big City..Working in Small City USA today...

Saw a neurotic LOL(little old lady, not laugh out loud)today who was just neurotic about having a pacer put in 4 mos ago and still having chest pain, blah, blah..Took me, oh, 2 minutes to figure out this was no cardiac problem and we go on and have a "non satisfying" encounter. She wants a cardiologist to come see her, etc..I tell her I'm the cardiologist dejur and I'll figure it out,etc..We've all been there..She wants a new doc and luckily we're triple covered so I pass it off to 1 of my colleagues (who just to have been one of my ex-residents!)...

Anyway, she doesn't like this doc, a female by the way for you gals out there, but my bud does her thing and after about 6 hours all is proven benign and she goes home...

There was much wailing and moaning and gnashing of teeth..Many accusations of I'm mean (actually called my friend "evil" because she talked too fast)... God I wanted to stop them as they left and tell them I was right in the first 2 minutes and she was a little old POS.. But I somehow refrained...

Where is it written that we, ER docs, have to take this kind of abuse? That any other doc would tell them to take a hike as soon as they asked for another doc... Why do we put up with this crap? Yes, it's because we don't want another complaint, I know, I know. Why do we let that decide on many of our courses of action?

Further, why would I, as old and experienced as I am, let this bother me so much?? Why did we let the passengers start driving the bus? And would I be such a bad guy if I just started telling all of my pts what they didn't have wrong with them in the first 5 minutes and kicking their ass out the door? Should I cause my group, who I dearly love, that hassle purely for self gratification? Would I be mentally more healthy?(I think so) I don't know the answer, just seeking your intelligent input..

.Thanks, OF


  1. There's a lot of shades of gray -- when a patient tells me they're unhappy and want a new doc, they are almost always unhappy with the proposed course of treatment, which is a polite way of saying that they wanted narcotics and I declinded to provide.

    In those cases, I tend to tell them that they do not have an emergency condition, and having satisfied EMTALA, I discharge them, with the assistance of security, if needed.

    It's harder when the issue is medical/anxiety-driven. Sometimes you can start over and win their trust (or at least their acceptance), soemtimes you sort of realize they don't believe a word you are saying but gloss it over by talking fast. Doesn't matter -- it most always ruins my day.

    Good luck with residency.

  2. Ah, we have one of these too. But she is only 1 wk post pacer implant. And we have to follow her chronically.
    I made sure she wasn't in my clinic for her f/u wound check!

    I think that if we had the luxury of spending more time with the pt, then we could alleviate the anxiety without having to do the million dollar work up. In clinic I have been able to do this and have the pt agree to clinical f/u to reassess sx and not do a bunch of unnecessary tests. Certainly in the ER there is not that luxury.

    Don't have any answers for you.
    But bet it would be fun to adopt the tell 'em where to go behavior the last week that you worked.


  3. I know I would feel a lot better if i could just say what I really feel like. I am pretty blunt in real life, but can't be in proffessional life and that SUCKS! I feel for you. I feel for all of us this way.

  4. I think that it is very hard to work through a difficult patient like that. Obviously, she is frustrated with other factors that have nothing to do with her heart, and while it's unfair for her to take it out on you most certainly, it is difficult to tell a patient with that kind of chip on their shoulder what is/isn't wrong with her. You do have 2 choices, 1. is to gloss over everything in a hurry regardless of whether she listens or not and 2. is to try and hit a 'human' factor with her so she doesn't think you're some cold doc who thinks she's just a pain in the ass- regardless of whether she is or not. Getting your patients to believe that you care about them, regardless of whether they are sick or not- goes a long way in diffusing the cantankerous or hostile patient

  5. Old fart,

    Haven't done this as long as you, but after over 47,000 patient encounters, it does build up. On my last day of work (in 12 years or when I hit the lottery whichever comes first) I am going to let it fly. I hope I have each of the following:

    Nervous ninny, with hovering family: Get a f**king grip and get the f**k out.

    16 year old with 3 kids by 3 dads (actually had this this week): Shut your f**king legs.

    Drug seeker: For the last time, you POS, no drugs from the ED.

    Gang banger with crooked hat and saggy pants: you are not cool, you sack of shit, straighten your hat and pull up your pants, and sell that grill to buy some soap for your kid.

    There are more, but I thinks that is a good start.

  6. Kick her ass to the curb. The EMERGENCY room is for, yes, you guessed it, EMERGENCIES! If we let patients treat our ERs as a psych clinic / drug distributor then that's exactly what patients will use it for.

    I really don't think the ER is the place to indulge patient's neuroses. "Ma'am, you have chest pain that is non-emergent... GET THE FUCK OUT."

    I'm semi-kidding. We can be polite and humane and "compassionate" without being a doormat. Now when people come in for TRUE emergent care, more time will be available to them. Everyone wins, except the annoying old bag.

  7. Cat, just saw your post...
    As always, more elegantly said than me.

  8. Having experienced a "neurotic LOL" for the past several weeks, I think nothing you could have done would have made her feel better.

    How hard is it to get a psych consult and tranquilizers?

  9. knitalot3

    it's been two years since i have been able to get a psychiatrist into the ER and that was only a fluke.

    it's not so hard to get a 'psychiatric extender' (someone with special training in basic psychiatric diagnosis) to see someone.

    we can easily give 'tranquilizers' but not to this patient. first, she would take offense. second, she had real problems with her heart, and even though Oldfart was next to certain her problems were not cardiac she still succeeded in getting what she wanted, a million dollar workup, and still was unhappy.

  10. I think alot of doctors are incompetent; so do many other people. I have a girlfriend who was having ocular migrain headaches. She had them for over a course of a year without diagnosis, no help, and 3 different doctors. Finnaly the fourth doctor correctly diagnosed it, within 6 months of treatment she only gets one headache every 6 months now. Her problem was almost terminal, no eating, crashing and sleeping on floors etc.

    Too many textbook dumb doctors. If you don't fit the textbook or the flow chart no treatment for you. Oh, so you do have some fungus on your toe? Here take this medicine that has a 1 in 20 chance of destroying your liver. Then we can makes some big bucks finding you a another liver. Nevermind its better just to use some bleach or just live with the toe fungus.

  11. I am a premedical student with absolutely no experience from which to speak, so feel free to rightfully ignore the following text, but I'd think that you have to find some way to say what you mean, even if you have to tone it down a bit for the sake of not racking up a complaint count as high as your patient count.

  12. anonymous

    I don't speak for the others, but I am incompetant and just do this for the cash. I know for sure I would have misdiagnosed your "I have a girlfriend" (? you have more than one? How about "my girlfriend") and I would also have missed her fibromyalgia, sciatica, chronic fatigue, reflex sympathetic dystrophy, phantom penis pain and who knows what else. But as long as she pays the bill, I'm happy.

  13. whoops

    I'm so imcompetent I typed "incompetant".

  14. You tell him, Cat. I'm all for a lively discussion, but to come into someone's "house" and be insulting just violates my sense of decorum. I was raised in a gentler time.

  15. OF,
    you know, I think some people actually NEED a dose of reality now and then. If your partners are as sick of ED abuse as you are, maybe they wouldn't mind as much as you think they would if you gave some abusive patients that "Reality Check" during your time left. Can't hurt to ask 'em.
    Then again, I could be full of it.

  16. dear anonymous,

    i know who you are and i know your blog. here it is right here and i've linked your page on my site.

    keep rockin' dude!


  17. Maybe I could get a psych consult for my LOL and the tranquilizers for me. I don't have a heart condition, yet.

    Love the blog guys!

  18. That's a good idea! Why not put only phsychologists in the ER?

    Only patients that are comatose or rational enough can get past them to treatement.

    A great triage solution.