Friday, February 22, 2008

140 into 280

My favorite patient of the day presented against the following backdrop.....The hospital is full. Our minor care center's 12 beds have all been converted to holding beds for admits awaiting a room. Of our 31 main ER beds, 9 are blocked by more admits, the others full of patients being evaluated. We have 12 stretchers in the hallway (all full) and 21 patients in the waiting room bitching about how slow and uncaring we all are.

Chief Complaint: "My lips are chapped".

I couldn't believe that of all the patients waiting to be seen, this one got a bed.

I went to see her, and began my interview. "What's your emergency today?".

"My lips are chapped", she says.

"When did this start?" I ask.

"When I started dating my new boyfriend".

Rolling my eyes, I said "you'll have to be a little more specific since I don't know when you upgraded your boyfriend".

"'bout a week" was the response.

"does he have a beard?" I wondered.

"yes, he has a goatee" she volunteered.

"well, that's probably causing some irritation of your lips so give them a rest for a few days, use some Vaseline or Chapstick, and you'll be OK", I assured.

She had a very puzzled look on her face, then finally said: "it ain't my mouth lips, it's my pussy lips"!

I should have figured that out myself. Nothing is that easy. Upon further questioning, she then mentioned that she had green vaginal discharge and pelvic discomfort. GREAT! Nothing like a pelvic exam on a 280 pound 'cheezer'.

Sure, 'nuff. She had an STD.

BUT...the story doesn't end here!

3 hours later, she returns to the ED dragging her new 140 pound boyfriend. She wants him checked and treated so they can get back to business...classic.

P.S. Taxpayers....I did both of these exams for free as I am required by law. I also treated both for free. In addition, the time I spent with them kept me away from seeing paying (and certainly more urgent) patients. When we get Obama-care, your tax dollars can pay me to do this! Thanks in advance.


  1. only those who do what we do believe you doc. i believe you. i'm glad i paid for her and her man.

    right as you posted i was getting ready to post on a similar topic so i'll just add it here...

    Dr. Lwobs is now our most efficient doc. We are full. Flu is rampant. We have people leaving without being seen in droves. The chart then reads "LWOBS"- left without being seen.

  2. The paying patients leave and find their way to a minor care clinic or decide to wait a couple of days to see their PCP.

    The freebies just wait it out, no matter the trivial nature of their complaint since we can't turn 'em away.

    At my hospital, when LWBS goes up, my income goes down...and my workload increases.

  3. Fuck wads.
    I'm a teacher. I earn in the 40s after 10+ years. I have a 30 dollar copay with a 2k deductible.
    No diseases.
    If you see me in your ER, I'm probably dead already.

  4. anon: We're not talking about you, or those of you who use the ER properly. Why is this so very hard for you to understand?

    Remember while you're sitting in the waiting room for your legitimite condition...I'm frequently tied up with issues like this.

    My goodness you're off base here.

  5. Just a thought, but could you have written an Rx for the boyfriend at the time you treated the girlfriend?
    Might have saved you their return trip... or not, depending on whether they would actually have the Rx filled.

  6. ....and the boyfriend dies because he's allergic to something prescribed and '85' didn't examine him nor ask about allergies. Who knows, maybe Big Mama didn't even get it from the boyfriend. :-)

  7. As per nurse K's comment. I'm not in the habit of writing Rx's for people who aren't patients.

    I don't know his allergies, meds, history, etc. I wouldn't trust his new girlfriend to know any of this. My wife and I have been married over 23 years and she doesn't know what blood pressure med I take.

  8. dear anonymous teacher,
    is it English, sir or ma'am, that you teach? i weep for our children.

  9. Okay, you guys know that I like your cranky selves, but I have to ask...I know you aren't particularly fond of fat patients with hygiene issues (which I can understand be they fat or not, because...ew. Wash your asses, people.), but do you feel the same way about fat patients in there for legitimate concerns (not chapped nether regions.) who have good hygiene, and aren't hounding you for Demerol?

    I'm not trying to pick a fight, but as a big girl myself (I'm working on it.), it's embarrassing enough to go to the OB/GYN, and it's sort of horrifying to think that if I went to the ER that the doc would be grossed out by me.

  10. dear elizabeth,
    beauty is in the eye of the beholder. if you want to know the truth, the worst stuff i've ever heard regarding the female anatomy and the pelvic exam comes from the mouths of my female nurses. they are, well, a bit unforgiving. from someone who was terribly embarrased by tampon commercials in the 1980s i have been changed into someone who is not embarrassed by anything i see in the ER. i hope that comes accross to my patients. performing a pelvic exam on anyone is fraught with too many taboos to mention so we just do them and don't talk about it. again, the ladies on the provider side seem to approach this differently.

  11. elizabeth: no, I don't look down on fat patients. I'm a big boy myself.

    It's the hygeine issue in some large patients.

    Pelvic exams are among my least favorite things to do. Pelvic exams on patients with nasty vaginal discharges are stomach turning. And frankly, pelvic exams on 280 pound women are difficult (for both the patient and physician).

  12. Back in the day, I worked at a bank in the hood, and we had a few fragrant ladies of the night come make deposits (heh) after they got off of work. One of my more eloquent coworkers would spray copious amounts of Lysol in their direction and remark that "Them hoes need to go wash they nasty asses before they come in here."

    So, yeah, I can see why taking a peek at said nasty asses would be kind of squicky. Just checking.

  13. I've been in an emergency room once in my life, just a couple of years ago for a broke hip. Ugh. And since, I suppose, I was ferociously guarding that leg, don't know why, the EMTs gave me a shot that knocked me right out (doesn't take much to do that--that was my first time to get morphine). But as unfamiliar as I am with such things I have no problem believing the ER tales here. I do remember in the ER hearing laughter occasionally in the nurse's voice when I was answering her questions off and on...such as when she asked if I'd had any operations and I said yes, a tubal ligation (I suspect she'd seen some old records that told that I have seven kids). I liked the laughter. I really thought everyone in that hospital were simply wonderful. Truly. I considered I had one rest, eat a little, do whatever I was asked to be ready to go home two days later. I felt perfectly confident that I was getting the best of care, and thanked each medical person who came within view. But was so glad to go home that it wasn't til months later that it occurred to me that I could have sent chocolates! When I read your ER stories, it seems to me you're blowing off the misery of dealing with so much misery and sometimes meanness/stupidity. It really is all such a revelation to those of us on the outside of your profession. Thank you.

  14. "140 into 280"

    Diet Coke isn't a pleasant nasal wash. Just FYI.

  15. Ha Ha, I knew from the beginning what lips she was talking about. To this day I'd almost rather have my own prostate palpated than do a pelvic. I've always been fairly good at procedures, IVs, lines, chest tubes, but I'm a clutz at finding the cervix. My favorite chief complaint is an elderly woman who complained that her farts smelled bad. Except she wouldn't say "fart" because it was a bad word. Took me a good 15 minutes to figure that one out.

  16. I'm guessing that when the anon English teacher above said "Fuck wads", he was talking about the STD couple in the post, not you guys.

  17. People with STDs deserve treatment, too. You sound pretty jaded to be in this line of work. I'm not sure why you're taking it out on the patient that she was seen before other maybe more urgent cases---isn't that the job of the hospital, to prioritize the patients?

  18. kbab:
    1. Yes, people with STDs need treatment, however, they can easily be treated at the county health clinic or a PCP office. Since PCP offices and the county clinic require a form of payment, these patients rush to the ER for treatment of their nonemergent condition (because its "free" for them). Its "free" for these lovely people, but not free for taxpayers (like me).
    2. Expressing one's opinions on an anonymous internet blog is not "taking it out on the patient." Erdoc85 still gave the patient adequate medical care and treatment. His frustration, as expressed in the post, is because the patient was clogging the busy ER with an nonemergent complaint and has no intentions of paying him for his services (see #1).
    3. It is not the job of the "hospital" to prioritize patients, it is the job of the triage nurse and charge nurse. Erdoc85 chose not to bash his triage nurse or charge nurse in his post, most likely because he understands how difficult an ER nurse's job is under those conditions (full ER, full waiting room). Smart ER docs don't bash their nurses, as they know what an asset good ER nurses are in the ER and how difficult your life will become after pissing off a nurse.
    4. Spend a 60-80 hour workweek in a busy ER and see how compassionate, world-loving you are at the end of the week. This "line of work" is a tough job, and these docs have been putting up with the same bullshit for how many years? "Jaded" or not, I'm sure all of these docs are damn good docs. I would much rather have one of them treat me than some doc who is more concerned with world peace than medical care.

  19. dear anonymous schoolteacher.
    if you were not calling us ''fuck wads'' then i apologize for taking offense. since i actually am a fuck wad i did take offense.

  20. Unless the dudes can pay $100 ( for the uninsured) we do a MSE and send them to the health unit (only 4-5 blocks from the hospital)-my tax dollars pay for that. As for the chick, if they are draining and stinking and painin', I don't go down south. I make sure they aren't with child, then give them the Rocephin, Zmax, Flagyl combo meal and tell them to take baby's daddy to the health unit.

  21. kbab: OF COURSE WE'RE JADED! This is an example of the kind of BS that jades us.

    Thank you docdefender for making all of my points for me.

    Thank you to the anon hip person.

  22. Good God! I knew there was a reason I never dated a fat woman. I will say what the Doc didn't. "Call Jenny."

  23. since when did an STD become an emergency. Your ER and hospital is under no obligation to provide anything but a screening medical exam.

    If he wants treatment and evaluation for his STD, he needs to pull out his wallet.

  24. dear happy hospitalist.

    good question. EMTALA does not define emergency. docs are not in triage. no one wants to be the first to miss an emergency turning them away at the door. recall the death in the ER waiting room last fall?? UGI bleed. frequent flier. druge seeker. ct scanned thirty times etc... that night she was sick and she died and CNN and 8 million attorneys are on the case.

    as for STDs and emergencies here are a couple...
    1. tubovarian abscess from PID
    2. acute urinary retention due to acute HSV/GC etc... both men and women
    3. fitzhugh curtis syndrome.

    i've seen two of #1 and two of #2 and none of number 3 in ten years. i don't have an answer, i agree with you, but there is no definition of "emergency condition" and a host of triage failures every day so i think it unlikely that anyone will be turned away, ever. also, in my state, we can't triage out, even if we want to, medicaire/medicaid patients.

  25. I just have to say this. I have seen many medical professionals who are obese. My doctor is not a beanpole,and his nurse is a 300+ pound porker. In fact, I don't think anyone on his staff, has ever missed a meal. Half the nurses at the local hospital are Fat. Some of us lean guys, could get a big laugh, at their expense.
    I don't date fat women.That is a personal choice. People living in glass houses however, should not throw stones.That applies to everyone,including nurses.

  26. Zane,

    Uh... please re-read the post. You missed its real topic.

    The rant over fat people was several posts ago. We all got it out of our systems then. Scroll down.


  27. In response to Nurse K and ERDoc85, I understand your POV in having reluctance to write an Rx for a patient you haven't seen/examined. However I would like to point out, as a future pharmacist (and current pharm. technician with 8 yrs of Hx working in hospital/pharmacy), that 1- its our job to collect that information as well, before filling any Rxs and 2- the CDC actually recommends writing for STD Abx for infected sex partners.

    Just a thought. Please be gentle in response. ;)

  28. Well Amy, I have it out of my system too. I was referring to the comment about the nurses being unforgiving. I have never been fat, nor do I intend to be, but as I look into the future, I see myself in the minority.

  29. Zane,

    You have a point.
    However, the current mass hysteria against the obese has turned into some kind of fox hunting (like the one against the smokers before that).
    On a brighter side, hopefully, it will most likely bring awareness to healthier lifestyles. So maybe you won't be in the minority after all. :-)
    That's a positive.


  30. My hospital has no mechanism or policy for medical screening. They've looked at it a couple of times and dismissed the idea secondary to medico-legal concerns.

    As 911 says, EMTALA is very vague and our conservative legal counsel doesn't want to risk a mistake. The penalty is too high.

    When I did work in a 'medical screen and dismiss' facility, it took just as much time for me (if not more since I was more careful in my documentation on those patients).

    Pharmd2b: no rude response. I'll just say that I am not writing Rx for a patient with whom I have no doctor-patient relationship or medical record. That's a dangerous prescecdent.

  31. Just be happy that you didn't miss the diagnosis on account of a boyfriend whose goatee has been situated so as to chap those lips too.

  32. GROSS.

    One of our ER docs told me about a pelvic he did on a 300+ pound lady. She had different colors of toliet paper wedged up there, he said there had to be an entire roll wedged up in her folds.


  33. Well after my 415 lb pt last week, I went back to carrying frozen diet dinners...and I am 5'8" 170 #, and unable to lift even one of her legs...with help. I know I am paranoid...but I dread getting "nurse" butt...and I had a Physician's Assistant who gave me a physical for a travel assignment who kept telling me I was OBESE! I still hate him...

  34. Speaking as a 400lb+ fat woman who manages to keep herself clean, I suspect that if someone is that dirty, or "looses" a whole roll of toilet paper in their folds (which I suspect is BS), the person has bigger problems than just his or her weight.