Sunday, November 04, 2007

Second Opinions

What's the deal with the ED being used for second opinions?

Friday night, almost 50% of the patients I saw had been seen for their problem within a week of their ED visit. I didn't find or change any treatments on any of these folks.

One was a guy had months of abdominal pains. He had been admitted by GI to the hospital next door and had all of the appropriate labs plus an ultrasound, CT scan, MRI scan, EGD, and ERCP...all of which were negative. He came wanting a "different doctor" and "Demerol" plus a repeat of all of his tests!

Another patient was a child with otitis externa. He had been seen by his PCP that morning and started on oral antibiotics AND Floxin drops, but within 12 hours he just "wasn't better" and had "severe pain" (he was asleep at the time of exam). The parents seemed completely shocked that I told them that it might take him a couple of days to get better! They wanted him admitted until he was well.

It was so fun and interesting to be the "second opinion doctor" that I didn't have time to see the football player who was injured.

What a pain! Thank God for EMTALA to insure that these people could be evaluated in the ED whenever they wanted.


  1. EMTALA sucks with the force of a thousand high power OREK vacuums.

    here's another thing that sucks and was an issue for two patients tonight, both brought in by ambulance, both from the same nursing home, both with falls.

    some legislator, no doubt with the help of the ACLU, passed a law which forbids physical restraints of patients anywhere without approval of the lord judge magistrate of the world. or, barring her signature, i can order restraints, with two forms with about thirty check boxes, not to exceed 24 hours.

    in the nursing homes this means that bedrails can not even be raised on alzheimer's patients who wander around at night and fall. you can't put a posey vest on them anymore, and you certainly can not restrain their exrtremities even to prevent known wanderers from hurting themselves.

    second opinion? government solutions suck with all the sucking power... (see above).

  2. You mean, you didn't know? Doctor of Medicine=Magician. Let us know when you start playing Las Vegas, please.

    This reminds me of when I was an OB nurse, and pts would come to L&D, and we would have to explain to them in kind words that coming to L&D does NOT make you go into labor. There were no magic hormones in the air. You come to L&D AFTER you are in labor, not before. *sigh*

  3. I can't count the number of poor old demented folks that fall all of the time, and we can't restrain them because it "sounds cruel" to some legislator who's never been involved in patient care. These families are usually devastated that more can't be done to keep their Mom or Pop from jumping the rails and testing the law of gravity. I always tell them: "I know this sucks and makes no sense....don't vote for Democrats".

    Kiki: I have actually asked the staff to call SPD to get me "a magic wand, 11 inches, willow, unicorn hair core, not too swishy". I figured it was the only thing that would make the patient immediate cure. I don't know the spell, but I could experiment...that should be fun anyway. To date they haven't been able to find my wand (one tech actually called). But I'll keep trying.

  4. perhaps you mean this magic wand??

  5. what? the E.R. isn't the place you go when your PCP won't give you percosets? awww.

    don't even get me started on restraints. The laws are retardiculous. They'd rather have confused people running down the middle of the road in front of the nursing home than put a posey vest on someone.

  6. And even Poseys don't work sometimes.When I worked on the floor, I had a uremic patient waiting for emergent dialysis--a big, late-middle-aged man. He was so disoriented and confused from the uremia that he kept pumping up his penile implant and sprinting down the hall naked with a humungous hard-on yelling, "YEAH BAYBEEEEEE" like Austin Powers.

    We put a Posey on him (which was slightly too small) to try to keep him in bed. At one point, the nurse aide came running out of the room screaming, "he's getting loose!!" I ran in there; the guy was sitting up in bed, ripping the posey with both hands like David Banner turning into the Hullk and yelling, "ARRRRRRRRGH!" He got up out of the bed and promptly yanked out his femoral central line catheter that had been placed for his dialysis.

    THAT was a fun clean-up.

    P.S. boys: I love you guys--I've added youse to my blogroll!

  7. When I was an aide on the Alzheimer's NH unit (AKA "the most difficult job in the world"), we used the Merry Walkers for the wandering, falling patients (they could sit on the chair or if they fell, they wouldn't fall all the way to the ground). One patient wasn't into the merry walker idea, so he'd basically taught himself the Fosbury Flop, and would do that to jump out of the walker and onto a bed (not necessarily his bed, of course). For being an 80-year-old demented Alzheimer's patient, he was pretty damn good at the high jump.

  8. 911: That's the wand...what's the spell you use? I've tried "Wingardium Leviosa", "Expelliarmus", "Alohomora", but none of these seem to work. The only success I've had is with this dangerous spell I borrowed from the dark side: "getthefuckouttahere".

  9. hmmmm... i think something like "normosaleeketorolacanarcaneeyeevee" might do wonders.

  10. Second Opinions. One time my Dad who is 84yrs old was having his prostrate checked, while the Dr had his finger up his bum my Dad said "could you put another finger in there"the Dr said "WHAT" my Dad said"yeah I would like a second opinion" They both got a good chuckle.

  11. my favorite are the fuckers who send in their patients to the ER because they can't figure out what's wrong with their whiny bastard patients.

    we had a girl come in with reflux symptomatology today, and when we asked her why she was here, the mom said "because dr. gotmydegreeinforeignland said he didn't know what was wrong, and figured that you guys could figure it out".....needless to say, we couldn't, and when we called him to tell him we tested every orifice and internal organ in her body, and couldn't find anything wrong, and were sending her home on zantac and a bland diet, he said "well, that's what I thought to do, but thanks for doing the testing".

    bastard FP's......wasting my valuable time

  12. B&J: I've had enough of this behavior. I tell people that their doc basically "dumped" them to the ED due to laziness. I tell the patient that their doc could have ordered the workup on his/her own, but they were too lazy to do so.

    Since we have hospitalists with contracts to admit patients from certain docs, these docs now just send their patients to the ED for admission. I see these people and many of them truly don't need to be admitted (they just need a competant PCP). But I'm lazy too. I just admit these folks. As far as I'm concerned, the beef is between the PCP and the hospitalist. I'm not going to enter the argument, I don't have time.

    I tell these patients too that their PCP could have called ahead and arranged a direct admission for them to save them time and a $1500 ED bill. But he/she didn't want to argue with the hospitalist over such a BS they just want me to do it.

    I'm tired of covering for these assholes. I just tell the patient the truth: "Your doctor is lazy and really doesn't care, so he/she sent you here to get rid of you. I'm sorry about that, and if you'd like a referral to another doc, I'll be happy to give you the name and number of a doctor that takes care of his/her patients".

  13. I have noticed an increase in 2nd opinion people too only it doesn't present with those specific words. Its a lot more of the, "I was at so and so ER last week and they didn't do anything". Sometimes they have been to 2 ERs and they are so dumb that they tell us they have.
    Office docs especially dump narc seekers on the ER. I think they or their partner should be called and asked what they want us to do with the patient.....