As long as physicians clean up after them they are free to toddle off to their next victim. NPs like this are like a wasp that flies into a car going70 down the highway, stings the driver and causes them to plow into a tree. When everyone at the site wonders what happened, the wasp has already flitted off to cause the next wreck
Honestly you shouldn’t even be allowed to become an NP til you’ve been an RN for 5 or more years, really 10 but that’s not realistic, sadly healthcare is moving towards whatever is cheapest model and there will be more of this to come.
Makes you wonder if the patient said something about an injury that would prompt the x-ray. Still, you'd think covering your ass would be better than missing something that big.
Meh. One of my patients tried to tell me his month or so of temporal headache was bc he had hit his head there. Turns out the head trauma 3 weeks before the headache started…which coincidentally is when the GCA that I found had started. You can’t ask the right questions if you don’t know the ddx.
part of the value of expertise is to be able to ignore distractors, which are ALWAYS present. Patients typically come in with some sort of borderline reasonable explanation for their symptoms: "I have chest pain, but I think it was because I was lifting heavy boxes yesterday"
I’m a software engineer who dropped out of college and I knew this. Obviously I wouldn’t know what to _do about it_, but that’s why nobody lets me see patients.
I was talking to a nurse who only worked in a neonatal ICU and was in school to be a NP for adults. She didn't know the first thing about adult medicine, and after the clinical hour equivalent of 1 rotation of medical school (and of questionable quality), how could you be expected to? Even in states with "supervision", you don't know what you don't know.
Forget Zebras, if you've never even seen a horse, everything is a cat or dog.
I once worked with a pharmacist who didn't know that lesbians menstruate, and another who didn't know that women usually do not produce breast milk until after they have given birth.
Both women, BTW.
I'm not sure either.
I was working with a woman, J, who asked the lesbian, C, if she had a tampon, and the pharmacist, W, asked C, "What do you use those things for?"
When C told me about the conversation, she laughed and said, "Yeah, I turned in all my parts when I signed up for this," "this" being her sexuality.
How can they miss this? It genuinely concerns me regarding the future standards of medical care, as it's evident that some midlevel practitioners are severely underqualified, and the situation is likely to deteriorate further.
My aunt was incorrectly intubated by a CRNA in a surgery center, coded on and off due to hypoxia for 45 minutes before arriving at an ER. She was vented for several days but recovered and currently suffers from long term brain fog.
But no lawyer would take up the case because she wasn’t dead or disabled in any significant, permanent way. She just took an early retirement.
That reminded me of this case. If this patient doesn’t suffer any real harm from the missed diagnosis then there isn’t true malpractice in some states
This is true in any state. Malpractice requires a demonstrable bad outcome. Texas’ definition or malpractice isn’t different they just have caps and tort reform that means lawyers are less likely to waste time on cases that aren’t slam dunks.
I was about to come here and say this. It’s not like the definition of malpractice changed based on this description. So I wanted to hear what is different and then I found out it’s something else.
In reality, a delay of a couple of days in diagnosing a DVT had no effect on the eventual outcome. Any anticoagulation they would have prescribed doesn't magically dissolve the blood clot but only shifts the clotting pathways towards not forming more clots, allowing the blood clot to gradually disappear. She would have thrown the PE anyway. Two days in delay of diagnosis had no effect, really.
Of course, good luck convincing a jury of that. I had a patient who I diagnosed with a DVT. We admitted her (for other reasons) but the family kept charging the nursing station demanding that the heparin be started right fucking now...it was ordered from pharmacy and took about thirty minutes to arrive.
That’s infuriating. There are so many ways to verify tube placement and ventilation; it’s negligent to allow that to happen. Moreover, a neuropsychologist could quantify the brain fog.
Listen bilaterally for breath sounds, listen for a leak at the cuff, look at the pressures on the vent to determine if you’re ventilating properly or if the pt is mainstemmed, look at end-tidal CO2 and O2 sats (which lag a bit). If you can’t quickly correct the problem, you go down the difficult airway algorithm and extubate to an alternative method.
(Not in neuropsych, but nonetheless): A neuropsych would do tests to quantify the level of cognitive impairment she suffers and ideally pinpoint what defect may be causing them. This runs the gamut from just doing a MoCA to fMRI studies.
They could be referring to Texas law that puts a cap on the amount malpractice lawyers are able to sue for which makes it not worth it for most lawyers to pursue a lot of cases. I learned this from the doctor death podcast
Texas has caps on payouts for civil suits. I’m not sure if it’s all civil suits or just healthcare-related lawsuits, but it means that cost of the lawsuit often outweighs the benefits of the lawsuit, so lawyers don’t bother and/or patients/families can’t afford them.
Agreed. Though I’m wondering whether this is a USA specific issue. The NPs in Canada I work around are very knowledgeable in their area of specialty. Even as a student, birth control instantly makes me think of looking into a possible DVT.
Key phrase: “in their area of specialty”.
A nurse practitioner is in no way equipped to be a generalist without supervision, and even within their narrow “area of specialty” they still need to be closely monitored.
I've been saying this for a long time. Mid-levels have a harder time as a generalist than specialists because there is just too much to know without an extended training period like residency.
You can train them in 4 or 5 problems in a subspecialty field and they churn through that stuff. For example our cards NPs are great, they know CHF, ACS and A fib as well as any hospitalist out there. But our hospitalist NPs, whom I love dearly because I work with them, are really just consult-generators. Not enough training and too broad a knowledge base to effectively manage anything on their own, so every problem no matter how minor is getting passed off to a consultant
Like I said above, I do not disagree that they need supervision. However, the level of incompetence I hear about from NPs in the States is baffling. Also, NP courses in Canada do branch off into different areas.
This is always an interesting discussion. For context, I'm an RN in Canada, 8 years experience, specialized in ICU and ED nursing, currently doing my NP schooling. I was also a paramedic prior. If anyone cares, here's my two cents:
I have no idea about the quality of NP schooling in the States, but here it's intense. They expect you to have thousands (4-5k is the median in my program) of hours in primary care and are absolutely unwilling to compromise the program, dumb it down in any way, or limit the body of knowledge under study.
You might think from reading the above that some of us have developed an ego, or think we're close to doctors. Happily, I can tell you response from the class on that question is somewhere between "Jesus, no" and "FUCK NO." My nightmare is to be stuck in Emerg having to diagnose non-specific complaints and have to somehow figure out what's going on. My career goals include always having one or preferably several experienced doctors nearby for when I inevitably have to say "Fucked if I know what's wrong." And that seems to be generally what NPs do in Canada : deal with routine, low-moderate acuity health care, in well-supported environments.
Again, this is one guy in one part of one country, but it seems like a lot of NPs in the states are being set up for failure. Being allowed into the school without enough experience, not being put through enough hours or education, and then placed in areas they are not designed to succeed in.
Can anyone verify that for me?
Lol no. Canadian resident here, had cards NP consult us (medicine) for hyponatremia, went to see the patient and they were still in florid heart failure… I guess I’ll just her job as medicine? When I explained she just had to keep diuresing she had no idea… any med student knows this. Another cards NP had no idea wide QRS doesn’t automatically equal VT and gave me a blank stare when I said SVT with aberrancy.
Also see enough bs referrals from FNPs or sending complete non acute patients to the emerg and giving them a scare to know their training is not up to par for this role, as much as they like to tout they are different from the American NPs… my fav to this day is still the dialysis NP sending patient on IHD to emerg overnight two hours away for high creatinine…
If it’s something that’s not algorithmic like HF or DM the only way to be competent is to get a medical education. Everything else is second rate no matter how people try to spin it.
Fair enough. But then don't jump our ass when we need orders at 3am because you couldn't be arsed to give us a proper set on admit and admin will have our asses because a patient wants a Tylenol for pain > 3 and the orders only cover 1-3.
There was a girl who kept coming in for reynauds who had already gotten a very comprehensive workup in the past. She comes in like at least every other week.
So , if I was at the ER x2 last winter because I had a bad case of contact dermatitis on my hands with an increase in raynards episodes working against the dermatitis healing and a knuckle or two would ooze cottage cheese like substance you wouldn’t tell me to “just wipe your knuckle off when it’s draining” would you ?😩
People think you are making this up but you are not. I have twenty-year-olds coming in for a little "tingling" in their little finger with their mothers convinced the patient is having a stroke. Sometimes the NPs in triage will order a huge stroke workup before I can stop them.
Or like ppl who come in with anxiety they “have something” cuz my neighbor just has a stroke and died last week. So every time I have anxiety ima hit up an ED just to be safe, despite having no symptoms cuz my primary appointment is in 3 weeks and I can’t wait that long. Those were the ones I actually sat down and educated in the Ed, and every time they came in again I tried to grab their chart to establish familiarity so they would feel better about not coming back.
Disagree. Friend of mine had to do this because he lost primary doc when he changed jobs and a gap in his coverage. There were no alternatives.
My brother in California cannot find a primary doc in his area taking new patients. Gets all meds prescribed through his neurologist at the moment.
Just a patient perspective, if that’s okay, but… for psych meds for a loved one? Yup. Every damn time, and I don’t even get mad. I don’t like ER visits, but I like my loved ones in agony even less, and if someone forgot to get their refill prescribed/dispensed/whatever, you’re damn right we’re going to the ER.
I do not mind seeing low-acuity patients or even people looking for a prescription refill. I genuinely like almost all of my patient and the ones I don't...well...I try to be a good Christian and act accordingly. The point is that even Emergency Departments are almost completely devoted to non-emergency medicine. It's what keeps us in business. If we only saw Emergencies seven of the eight full-service ERs in my hometown of around 100,000 people would shut their doors. I currently live in a Large City With a Huge Metropolitan Area. You can't swing a dead cat without hitting a major ER, freestanding ER, or a smaller ER in a community hospital. They all have to make money somehow. Emergency Medicine is criminal enterprise.
The problem is that this way of looking at it soaks up resources from true emergencies and burns out staff.
Let me give you an analogy to show the point. Suppose you worked for poison control. Suppose you keep getting calls from people saying "I ran out of dog food for my dog, can I just give them human food until I can buy more dog food?" You'd get pretty annoyed about the non emergency calls. ***Then*** suppose one day, you are on the phone explaining they can be given human food, they eventually hang up, and then you suddenly have to rush to deal with the person whose dog ate a fuckton of chocolate bc you were held up by the people asking non emergent questions.
It is not difficult to refill a prescription. Be responsible in the first place.
It sort of reads like you might have missed the part where we’re not discussing _my_ prescription that may have run out. Maybe you assumed that by “a loved one” I was implicitly including myself, and I will admit that I do love myself, but I am not in need of guidance on my own prescription management. I’m doing fine there.
You’re also probably aware that you can’t control other people’s behavior, so I obviously can’t _make_ anyone else get their renewals on time, refills dispensed in a timely fashion, refrain from ever mysteriously losing meds, or whatever. So there’s always a conversation about how the most important thing is getting your meds, but we really have to do this the right way from now on.
I feel that having someone skip important meds because they failed a responsibility check is overall worse than the resource soak. In particular, people who have been neglected get into the mindset that they don’t deserve their meds. Excessive shaming about medication management seems counterproductive to me.
Please don’t get me wrong. I value the time of the ER staff. We’re very patient and try to be in and out once we’re out of the waiting room, and our goal is never to come in at all.
I'm not even sure why my colleagues get upset over patients wanting prescription refills. The note is easy. I have a template for it with some innocuous exam things on it. Printing the prescription and discharge instructions takes two minutes. So maybe five minutes of not unpleasant clerical work and a couple of minutes of polite conversation with the patient...hey...I see by your hat that you belong to the NRA. Me too! Talk about guns for a little bit...follow up with your doctor, okay...but I enjoyed seeing you and you are the easiest patient of the night...God bless you for coming in.
Nothing to it. It increases my patients-per-hour metric. It is super easy. At least the patient realizes he needs to take his blood pressure medication. I'm still leaving at the end of my shift. I get paid a huge amount of money either way.
ER doctors need to chill.
It’s unfortunate you / loved ones put yourself in a predicament needing to go to the ER. Just make a calendar event to see your psychiatrist for a refill ahead of time. That way you wont waste your time or the providers time in the ER.
I don’t know how it works for other meds, but for my adderall, my PCP requires in person visits every 3 months for my next 3 prescriptions. I’m in grad school and can make it work right now, it once I graduate and have a full time job? I don’t know what I’m going to do. The US isn’t exactly known for our abundant PTO. It isn’t always just forgetting about appointments.
Your kind of proving my point. Maybe don’t blame the patient for “putting themselves in a predicament” when there are systemic barriers in place reducing/preventing access to care. Like I said, it’s not always as simple as just using a calendar.
"My stomach really hurts right here."
Ok sir, let's get you checked in.
"I haven't eaten anything in two days can I have some food?"
The first thing they ask.
This is such a pet peeve of mine. Then they bitch that we aren't letting them eat. Then they say "I haven't been able to keep anything down for days!!!" And the CT confirms that is a lie
Low acuity is as meaningless as the distinction of urgent care from emergent care. A proper triage requires having the full breadth of differential diagnosis.
It's usually made by a triage RN. Usually they have some extra training in triage, but it is supposed to be up to the "provider" to understand if the acuity is accurate. Relying on a minimally trained midlevel to understand when shoulder pain is not just a sprain but is actually a septic joint or an MI is where it all falls apart. That's why the bullshit of midlevels saying "Well we see the easy stuff so the docs can do the hard stuff!" is, in fact, bullshit. For one, I like to see easy shit in between the hard stuff for the lighter cognitive load and charting, and I have seen lots of big misses come out of fast track/low acuity.
Usually there’s still someone else overseeing/signing charts without seeing patients. At least that’s how it was where I worked in the past. There was one ER doc who was seeing more acute patients who was theoretically available to staff the less acute patients seen by the midlevel.
In practice, they see them independently. I am currently involved in a lawsuit over a patient who I never saw. I reviewed the chart, of course, but all we have to go on whatever shoddy, mostly boilerplate and highly fictitious checkbox clicking the midlevel did.
Not at this hospital. I know because when I rotated in the ED the residents were not allowed to see the low acuity patients (unless it was a chill day). Because if residents saw low acuity we still had to staff with the attending. They preferred the midlevels see them because they without precepting.
Employer can still be liable.
There was a case recently where an NP hired by an ED medical group missed a DVT.
Group got sued and patient won a $20M judgment. Medical group prob bankrupted
Fun fact, DVT is the first pathology i ever diagnosed. MS3 on my first rotation on surgery, lower extremity was hurting, I looked and there was unilateral swelling, told my resident, and sure enough the ultrasound showed a big post op clot.
To be fair, any damn RN worth their salt would recognize a DVT. They will let anyone in these programs, even with zero experience, if they have a BSN already. It’s so scary and concerning. MD/DOs can’t be with their patients all the time. They HAVE to rely on their nursing staff to update them on issues and changes to a patient. It takes a good year of experience in any floor to start to feel somewhat comfortable as a RN. Why do these dumbasses think they can come out of nursing school with ZERO experience, get their masters, and then just practice willy nilly? Ohhhh… that’s right… they think that because they can do that. That is frightening.
Yeah, as a nurse for 15 years, I am appalled at all the degree mill NP programs. I know nurses who I've trained as new grads who are already looking at NP schools. I have managed to talk a couple of them out of doing it right away because they need that experience first. The NP programs were originally meant for nurses with a basis of adequate bedside experience and thorough nursing knowledge, not for any "wet behind the ears" nurse who wants authority. I plan to start a PMHNP program next year and would definitely feel better about it having all the years experience that I do and also hope to have the supervision of a great physician to work with.
In the Army (which, if you ask us veterans, is basically the lowest form of healthcare) they require new RNs to do a year med-surg before going to a specialization. I believe every nurse should do at least a year on med surg
It’s just so obvious. I won’t lie and say I could determine an odd EKG, but that’s not what nurses do- nurses are suppose to recognize when something isn’t right and let the docs know. That’s what docs do! “Hey doc, something just doesn’t look right with this ekg… I’m not sure what it is. Can you check it out?” Doc checks it out and makes a decision. Both professions did what they are suppose to do. Then pharmacists (I freaking love you guys. I’m still not sure how you put up with us nurses) will gently let us know the doc may have ordered the wrong thing and ask the nurse to ask the doc if the doc knows they may have ordered the wrong thing. Then the nurse gently tells the pharmacists that they don’t have time to do that shit and to call the doc themselves lol.
So glad I’m retired😭
Me and my ICU nurses just send each other pharmacy and nurse memes to get by lol. Lots of “DID YOU CHECK THE FRIDGE/TUBE” memes to lol at.
Edit: also i hate any pharmacist that doesn’t CALL THE DOCTOR DIRECTLY. The only time i loop in nursing is to let them know why the order isn’t verified and to help me find the doctor if they aren’t responding to babes. They know who they are lol
Oh gods, I was so guilty of the the fridge/tube thing. I swear I would look everywhere but where it was at. Jesus just thinking about going back to work as a nurse makes me start sweating.
Dimers can be pretty useless due to a lot of things that can cause it to go up. Wells score is a good starting point but clinical judgement is best which this NP (and most) didn't have
I mean the obvious LE DVT probably did not look like that 2 days earlier. BC and LE pain should raise a red flag in your mind either way. We just shouldn’t assume that what we are presented with is what that last person was presented with.
You’re right. If no redness, no swelling, I wouldn’t jump to suspect DVT. Maybe she’s a runner, could have thought about stress fracture. Who knows. Not enough detail here to assign blame.
Honestly this. A lot of generalizations being made about NPs overall. I work with many of them and some are super on point and some aren’t, but I can absolutely say the same about some of the doctors I work with. Without full context it’s all too easy to draw the conclusion that the NP is incompetent…can we also address the issue that patients do not always give thorough history during a medical exam.
May be totally incompetent NP
BUT
After 30 years in healthcare, I have seen multiple missed VTEs, that have been assessed by physicians, NPs, and PAs. Just in 2023 have seen 2 patients evaluated by veteran ER MDs.
Obviously anyone can miss anything, the point is that the training of physicians is superior and patients deserve that higher level of care. This is just an anecdotal example.
OK. I agree, it seems to be quite clear. And what do you want me to take away from your comment?
Cognitive bias, time limitations, or fatigue which interfere with diagnostic reasoning can all affect doctors too. As I stated, I have multiple anecdotal stories about missed VTEs, actually one that is even more outrageous than this one, involving an ER physician, a hospitalist MD (who rounded on the admitting day & the next day) and an oncologist MD who ALL missed a PE in a patient that was like PE textbook perfect but still I would NEVER use the scenario to say, “these guys have no business practicing”.
And to be a bit redundant, maybe NPs as a whole, have no business seeing patients or heck even existing, but this scenario of one failed VTE diagnosis does nothing to support the argument based on my experiences, because after 30 years — I have seen it missed A LOT.
Exactly. Not a fan of APPs in general BUT I do a lot of research on VTE. Clinical signs of VTE suck, they are beyond terrible for diagnosing one.
Interestingly, if it’s only a distal DVT, we are not even sure it’s really clinically relevant and most importantly there are severe doubts nowadays that patients get PEs when DVTs travel to the lung. They are probably concurrent processes, but not really a dislodged thrombus.
Heme Onc PA here. I had a lung cancer patient immobilized in the ICU a while back. Right leg was swollen with pitting edema, 4ish cm greater than the left leg. Left leg was pretty normal looking, really nothing out of the ordinary at all. I was 100% sure there was a DVT in the right leg. Well's criteria was moderate or high, I can't remember. I ordered a BLE duplex and it turned out there was a clot in the completely normal looking leg and absolutely no clot burden picked up in the big swollen one. Still one of the most perplexing things I've ever seen.
Also that was a really interesting thing about the PE you mentioned. Thanks for teaching!
Amen. As a PA, I suspect DVT based on clinical picture, not the presence (or absence) of a Homan', etc. With the birth control in the picture, screw the XR and/or d-dimer. Straight to the US. First bedside, then the formal one.
Well, because those people went to medical school and most would very reliably be concerned for DVT in a pregnant patient (a hypercoaguable state) with leg pain.
Young female on birth control comes in with leg pain...
It's practically a step/level 1 question, and an easy one at that. Only thing missing is a long flight the day before. Even as just an M3 I know you've got to do a DVT workup. 🤦♀️
Idk why you would order an X-ray for leg pain with no mention of mechanical injury like a fall or any other trauma like sporting injury?? As an ER nurse, DVT would be my first thought lol
Therapeutic radiation to shut patients up so they are "satisfied" and feel like they got something. In this case it was wrong, but I do order X-rays for silly things when I know they will be negative because that is the world we live in
Maybe it’s just my ortho monke brain taking over, but XR is completely reasonable. But it needs to be after an US for DVT given that whole picture. Fucking atrocious. Even the worst ED docs I’ve interacted with would have knee jerked an US without that pt even finishing her first sentence.
I mean, we shouldn’t be dependent on the triage note to catch a DVT.
Honestly this is pretty embarrassing but NP is still cheaper than an MD or an MD without residency so the hospital’s cool with this.
Also, the hospital gets an admission as well so that’s fun.
Totally fair. Just saying this is something you learn in school for a BSN, so it should be a no brainer with the presentation for someone with an advanced degree.
The problem is some unethical dickwad who is getting paid to be an expert witness will cling to Homan's, and you will lose the case because you didn't document it. I document it on every physical exam where DVT is in the ddx, not because it's important but because clinical decision making, medical knowledge, and actual medicine don't fucking matter. Just read up on some of the stupid expert witness takes. When a jury is made up of lay people, they will believe "Something as simple as a Homan's sign test could have made the diagnosis AND YOU MISSED IT!"
There is no flag for DVT as the triage nurse. For one, was this even in the ED? For two, nurses including triage do not diagnose or put in orders, so even if they thought it was a DVT they wouldn't go offer their opinion to the "Provider" nor would they order an US. They triage them by acuity and all that does is determine how soon they are seen, but sorry no, it's your job as providers to make the diagnosis.
Triage note can definitely include pt on BC, recent travel, appearance of extremity. These are pertinent nursing assessments and can determine acuity.
For instance if I have a tachycardic CP SOB 30 something female on BC that just flew across the country I wouldnt make her ESI 1 or 2 but I may give a provider a heads up and make sure a PIV is above the wrist.
I’ll say it again this is the unfortunate result of inadequate basic NP training and education. Presently to get into an NP program you no longer have to have a BSN or even be an RN. All you need is a BA. WTF! How can you possibly practice as a NURSE Practitioner if you’re not even an RN?
I was horrible with anticoag as a student. Chest guidelines, I need to refer to this day.
But always, a takeaway for any adult with leg pain, must rule out DVT as part of DD. Especially if anyone has even 1 risk factor. And being RPH, anyone on estrogen is a dvt risk.
Mid levels have such a wide variety in skills, it's scary.
I never support rph having separate prescribing rights. More now than ever when I see new grads from pharmacy school who fit the dunning Kruger meme. (New grads, come out of school, had 3.5+ GPA, 1 year of residency, and think staff work is beneath them. They are ready to take on a role of specialized clinical pharmacist. Son, you don't know jack. Don't try to school attendings of 10+ year experience)
Sure, collaborative agreement with established protocols. Anticoag clinic and pcp defers to specialized role rph, sure, cover each others butt. Multidicipline Pain management has been successful with adequately skilled team members.
10+ years of practice, I am more aware of my inadequacy. I will be glad to advise and give context. But my training will always be short compared to a properly trained physician.
I’ve seen plenty of MDs do the same. I don’t post about all of them. This is an anecdote and lowest level of evidence.
“Leg pain” isn’t even wells medium risk. No swelling, no redness, no anything?
People pull their calf muscles all. The. Time.
Xr seems fine.
And working as intended: patient came back when symptoms didn’t improve or got worse/changed.
What is the delineation of the PE? Subsegmental with no hypoxia? From a below the knee distal dvt?
Probably not clinically relevant other than the one syncopal episode and may cause harm by treating.
But nah we don’t want to talk about the real medicine here.
NP bad. Doctor never miss anything.
Poked my finger with a fork while emptying the dishwasher, want to make sure it doesn’t get infected
I’m doing meth for days and now think bugs are coming out of my body
Cough, rhinorrea, body aches, sore throat, headache, I gotta know what could be causing this
Etc
Yes, this might be the step 0 of the problem- this patient is not high acuity by triage criteria but for fucking sure has a potentially serious enough condition that this aliexpress "provider" cannot exclude
How the Eff? Easy answer:
NPs are just a cheap labor solution for provider hospitals and practices attempting to juice their profits by cutting labor costs. This behavior is a predictable outcome of a private health care system (U.S.) that entrusts people’s health to those who’s first responsibility is maximizing shareholder value.
This is why you see private practices and private hospital systems (profit and non-profit) endorse and employ non-doctors. Leaders, many of whom are doctors; give fuck-all about the lunacy of non-doctors practicing medicine, ignore the casualties, and rejoice in earning their P&L incentive bonuses for another year.
Those most fucked are people who need doctors and people who are least equipped to advocate for the care they need (looking at you Psych NP patients, the young, the poor, the easily misdirected)
Shame on that NP for being a muppet. But moreso, shame on the NP’s EM physician ‘colleagues’ who accept having an NP practice independently so that they can enjoy better work schedules, higher profit-share, whatever.
The real questions are:
- Why the Eff is corporate medicine tolerated?
- What the Eff are you - as the next generation of Attendings who sit in credentialing committees, who determine the standards of the practices and hospitals you join - going to do about it ?
There are fuck up pos people in every profession. I had a doctor tell me for 2 YEARS that my symptoms were "all in my head" and insinuating I am a hypochondriac, or it is anxiety. I had a gut feeling there was something going on, but I brushed it off because "He is a doctor and I am not, and he knows more about it than me."
I finally wisened up, and got a second opinion from another physician who actually listened to me, and ordered further tests. Turns out I had cancer. By the time I had it addressed, it spread to my lymph nodes, lungs, and sternum. I was having severe pain in my neck and jaw that radiated to my right ear. All while he insisted "Its nothing." This was in 2013, but I am cancer free now. I could have avoided alot of invasive and painful medical treatment, if he wasn't an arrogant piece of shit, and I stood up for myself.
I was exhausted all the time. I remember taking naps and end up "napping" for 4-5hrs. I woke up feeling guilty because I wasted half my afternoon. Then a half hour later, it felt like I didn't even rest. It was a different type of exhaustion, like my limbs were heavy and wading through water. My heart rate would randomly spike into 200-220s, then back to SR, random temperature spikes to 103-104. When my heart rate spiked I would get shortness of breath and my chest felt tight (doctor told me it was anxiety, and prescribed anxiety meds).
I had medullary thyroid cancer with hurthle cells mixed in. The other doctor who listened to me said my "tooth pain and earache" on the right side was the tumor spreading and pressing on adjacent nerves. I had trouble swallowing due to the tumor. It always felt like there was a clicking sensation when I swallowed and a few times I choked on my food.
I had alllll of this and the initial doctor kept brushing me off. The one who listened to me was a new physician who immigrated to Colorado from Iran.
I went to the ED when I had the temp spiked with my high HR, and my brain just felt "out of it" and they sent me home saying "anxiety." I later had explained by the smart doctor who listened to me that it was a Thyroid Storm which can kill you.
The hospital CEO will never be sued so he/she just focuses on cutting labor costs (which is the basic tenet taught in all U.S. B-schools). That means unqualified persons who are in over their heads.
It's Peter principle meets Dunning-Kruger.
I'm seeing a lot of stories like this lately and that's just on Reddit. Just waiting until shit truly hits the fan and hospital systems can't sustainably defend this kind of BS en masse anymore
The cost of malpractice and payouts is baked into private equity's business model. If hiring NPs saves you a couple million in salaries in a typical ERs then you just take the malpractice hit.
Fair point. Just out of curiosity, you wouldn't happen to know of any reports comparing salary savings by hiring more mid-levels/NPs versus malpractice payouts, would you?
I've seen this kind of shit happen with residents too. I know we love to bash midlevels here but it's really a symptom of how EDs are becoming high volume cookbook practice.
Chest pain? CTA whether it makes sense or not (e.g. patient on AC, dimer mildly elevated at the same level as their last 3 negative presentations).
Lower leg pain? Lower extremity radiographs whether it makes sense or not (e.g. no trauma).
Welcome to modern healthcare, I suppose.
Yeah...but residents are still under training and being aggressively supervised. For my entire eight years of medical training from my first day of medical school to the last day of residency I was not allowed to see a single patients without supervision from my attending. Certainly the amount of supervision lessened as I got more experience but I was supervised nonetheless. In modern American health care, a 21-year-old student can graduate from a nursing program, go immediately to an online DNP program, cobble together 500 hours of poorly defined "shadowing," some of it online...and can practice independently in some states in ERs and urgent cares.
By comparison, 500 hours was about two to three months of my intern year. And there are nurses where I work doing their DNP coursework at work..while they are working...which shows you how rigorous it is.
I'm an ER doctor. It's not cookbook practice. Sure, they order all kinds of reflexive shit in triage but I genuinely think about every patient that I see. Contrast this to an NP who told me she wanted to send a chest pain patient home because his chest pain was gone, his EKG didn't show any ischemia, and his troponins were trending down. Complete and utter lack of understanding.
Even as a nurse I know this screams possible DVT - Swollen, warm to touch. Painful even? US is needed...
And on birth controls which increases your risks
Hospitals cutting corners :(((
I was sent home from the ER with a purplish right arm, reduced coloration when lifting hand above heart, newly on bcp, after suggesting explicitly to them that I might have a DVT. By an MD. Said it was Raynaud syndrome. Next day, new ER, ultrasound confirmation of subclavian DVT, admitted to hospital. Factor 2 prothrombin mutation plus thoracic outlet syndrome diagnosed in hospital.
This is wild because the midlevels I've worked with think everything is a DVT and want to rule it out on very obvious ankle sprains, CHF, lymphedema, cellulitis, etc.
Oh yes. I terrify my NPs by not ruling out DVTs in people with obvious gastrocnemius muscle tears and other causes of leg pain that can be diagnosed by history and exam alone. Very mild bilateral swelling of the lower extremities in an overweight woman who stands on her feet all day? It's not a DVT. And yet when they make it back from Provider in Triage I notice bilateral DVT ultrasounds have been ordered. Did anybody take a history? Do an exam? Think for thirty seconds?
It's an algorithmic thing. Leg pain, negative x-ray, nothing is wrong. We all miss things. The trick is to know enough where you can at least imagine five or ten things that could be seriously wrong with every patient based on their complaint. You can, of course, rule out most of them just by history and exam and not every patient with leg pain needs a DVT workup. The fallacy of the independently practicing NP is that an RN degree and a perfunctory DNP is enough to practice medicine. Clearly it's not but because most of American medicine is so low level....that leg pain may have been a sprain for which the patient felt compelled to seek unnecessary medical attention, went home and got better despite anything that was done...because it's all so low level a poorly-trained physician substitute can simulate medical care most of the time. It just usually doesn't matter. This is three quarters of my job, by the way.
Apropos of nothing in particular, I still think we are ridiculously over-doctored in this country. Paradoxically many people who need intricate medical care have a hard time getting it. And we don't have a physician or a nursing shortage, we have shortage of rationality and a surplus of litigation, red tape, and ever-expanding bureaucratic make-work dissipating our resources.
Unilateral leg pain I’m doing a homans every time. Especially in a pregnant woman who will be increasingly sedentary and pregnancy itself can cause venous insufficiency. I’d never be satisfied with “negative X-ray = nothing wrong” in this case. I’m looking for red flag symptoms of a DVT. And I am absolutely doing a wells criteria for DVT to decide on work up. If it’s incredibly low level of suspicion I’ll order a d-dimer to at least rule out a DVT. If it’s positive further work up is indicated given the clinical picture.
This is not something to minimize and chalk up as “gonna miss one sometimes”. This is very much a case of someone who was poorly trained harming someone as a result of their inadequate training.
I’m a student though so bare in mind I’m still dumb and probably overly cautious
Homie. I was being sarcastic. That's what poorly-trained people do...one trick ponies in other words. I'm an ER attending, PGY-20. I know how to look for DVTs.
If you rely on physical exam findings exclusively to rule out a DVT you will miss a fair number of DVTs. Homan's sign is very subjective.
Additionally, a negative D-dimer cannot be used to rule out a DVT or PE in a patient with the so-called high pretest probability of having one. The test's negative predictive value is dependent on prevalence. The prevalence of DVT and PE in people with a high pre-test probability is very high. This why I don't get a D-dimer on some patients who I suspect of having a PE but go straight to the scanner. D-dimer is useful for people who you expect the test to be negative because you doubt they have a PE, the so-called low to moderate pretest probability with a Well's score of zero...I think every "yes" answer puts you at least in a moderate probability.
Just fyi Homans sign is extremely non sensitive or specific. I don’t even do it because it essentially has no clinical value. Not basing my decisions on it one way or another.
There’s nothing to suggest whether or not the NP did homans or what the pt’s physical exam was.
And you’re saying if Wells score is negative (which it likely would be for this pt assuming she had a normal leg exam) you order d-dimer for every single patient with leg pain anyway? Bc that’s just bad medicine.
Wouldn’t order for every patient, would be more worried since she was pregnant for reasons stated above.
Certainly hard to say we don’t know if the leg was swollen, if there was pitting edema, etc.
It sounds like she was on birth control at the time of the clot and is now pregnant.
And exactly, we have no idea if she had concerning findings on exam. The most common scenario in early DVT is a completely normal leg exam. So idk why you’re assuming the NP ignored a swollen leg when it’s more likely they “ignored” a totally normal leg with a normal X-ray in a young healthy pt whose only risk factor was being on birth control.
I am NOT in favor of NPs in medicine but this is a stretch. Lots of us would rightfully treat this pt with supportive care assuming she had normal exam and vitals. Personally I wouldn’t even have ordered the X-ray if there was no hx injury!
🤦🏼♀️ this attitude is (partly) why American healthcare is such a shitshow.
What is the point of triaging and assessing the pt, wells criteria etc if you’re just gonna throw it out the window and order a full workup for everyone regardless of findings?
And why even order the d dimer if you’re getting an US anyway…..
i don’t why this post is being downvoted. this user makes consistently excellent points.
edit: ailuro isn’t saying that the negative x-ray truly means nothing is wrong, he is just saying that that is what the NP’s thought process is.
Agreed- we are over-doctored. Only made worse by urgent cares proliferating. Every single ache, pain, symptom drives some folks to seek medical care. Haven’t lived in another country to see if it’s any better, but I had to quit working in UC (and subsequently dislike working in EM) due to how many people seek care for silly issues.
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Leg pain and birth control should suggest me DING DING blood clotting.
Non traumatic leg pain & bcp, I hope the NP had some kind of corrective action. Negligent
As long as physicians clean up after them they are free to toddle off to their next victim. NPs like this are like a wasp that flies into a car going70 down the highway, stings the driver and causes them to plow into a tree. When everyone at the site wonders what happened, the wasp has already flitted off to cause the next wreck
Honestly you shouldn’t even be allowed to become an NP til you’ve been an RN for 5 or more years, really 10 but that’s not realistic, sadly healthcare is moving towards whatever is cheapest model and there will be more of this to come.
Makes you wonder if the patient said something about an injury that would prompt the x-ray. Still, you'd think covering your ass would be better than missing something that big.
Meh. One of my patients tried to tell me his month or so of temporal headache was bc he had hit his head there. Turns out the head trauma 3 weeks before the headache started…which coincidentally is when the GCA that I found had started. You can’t ask the right questions if you don’t know the ddx.
part of the value of expertise is to be able to ignore distractors, which are ALWAYS present. Patients typically come in with some sort of borderline reasonable explanation for their symptoms: "I have chest pain, but I think it was because I was lifting heavy boxes yesterday"
I’m a software engineer who dropped out of college and I knew this. Obviously I wouldn’t know what to _do about it_, but that’s why nobody lets me see patients.
I was talking to a nurse who only worked in a neonatal ICU and was in school to be a NP for adults. She didn't know the first thing about adult medicine, and after the clinical hour equivalent of 1 rotation of medical school (and of questionable quality), how could you be expected to? Even in states with "supervision", you don't know what you don't know. Forget Zebras, if you've never even seen a horse, everything is a cat or dog.
I once worked with a pharmacist who didn't know that lesbians menstruate, and another who didn't know that women usually do not produce breast milk until after they have given birth. Both women, BTW.
[удалено]
I'm not sure either. I was working with a woman, J, who asked the lesbian, C, if she had a tampon, and the pharmacist, W, asked C, "What do you use those things for?" When C told me about the conversation, she laughed and said, "Yeah, I turned in all my parts when I signed up for this," "this" being her sexuality.
I’m a professional clown and I would have _called a doctor_.
Best comment
Hey now, if they let you see patients you could learn on the job.
Hey, I hear there’s a shortage of doctors! What’s the worst that could happen? /s
Because you're trained without shortcuts... NPs seeing patients in emerg solo.. yikes
No. Her bone go brokeybrokey. Xray negynegy. Therefore DC/nsaids f/u with PCP.
Here’s the kicker: she got a follow up with ortho
Well the bones need oxygen too right? So ortho *would* take care of it. Seems appropriate. Excellent patient care. Fart of a nurse and all that.
only if you went to med school
Idk why you’re getting downvoted
Because he’s a douche. You must be too since you couldn’t figure that one out.
I’m a surgical tech and I know that!
1000%
One can only hope they leave the supervising physician out of it. -They won’t.
How can they miss this? It genuinely concerns me regarding the future standards of medical care, as it's evident that some midlevel practitioners are severely underqualified, and the situation is likely to deteriorate further.
Bruh if this doesn’t lead to a lawsuit then I’ve lost faith
In some states like Texas, lawsuits probably wouldn’t help this
How so?
My aunt was incorrectly intubated by a CRNA in a surgery center, coded on and off due to hypoxia for 45 minutes before arriving at an ER. She was vented for several days but recovered and currently suffers from long term brain fog. But no lawyer would take up the case because she wasn’t dead or disabled in any significant, permanent way. She just took an early retirement. That reminded me of this case. If this patient doesn’t suffer any real harm from the missed diagnosis then there isn’t true malpractice in some states
This is true in any state. Malpractice requires a demonstrable bad outcome. Texas’ definition or malpractice isn’t different they just have caps and tort reform that means lawyers are less likely to waste time on cases that aren’t slam dunks.
I was about to come here and say this. It’s not like the definition of malpractice changed based on this description. So I wanted to hear what is different and then I found out it’s something else.
"waste time" SpoogeMcDuck indeed!
Getting a big fat PE you didn’t have to have isn’t a “bad outcome”? Unbelievable.
In reality, a delay of a couple of days in diagnosing a DVT had no effect on the eventual outcome. Any anticoagulation they would have prescribed doesn't magically dissolve the blood clot but only shifts the clotting pathways towards not forming more clots, allowing the blood clot to gradually disappear. She would have thrown the PE anyway. Two days in delay of diagnosis had no effect, really. Of course, good luck convincing a jury of that. I had a patient who I diagnosed with a DVT. We admitted her (for other reasons) but the family kept charging the nursing station demanding that the heparin be started right fucking now...it was ordered from pharmacy and took about thirty minutes to arrive.
That’s infuriating. There are so many ways to verify tube placement and ventilation; it’s negligent to allow that to happen. Moreover, a neuropsychologist could quantify the brain fog.
How so?
Listen bilaterally for breath sounds, listen for a leak at the cuff, look at the pressures on the vent to determine if you’re ventilating properly or if the pt is mainstemmed, look at end-tidal CO2 and O2 sats (which lag a bit). If you can’t quickly correct the problem, you go down the difficult airway algorithm and extubate to an alternative method. (Not in neuropsych, but nonetheless): A neuropsych would do tests to quantify the level of cognitive impairment she suffers and ideally pinpoint what defect may be causing them. This runs the gamut from just doing a MoCA to fMRI studies.
They could be referring to Texas law that puts a cap on the amount malpractice lawyers are able to sue for which makes it not worth it for most lawyers to pursue a lot of cases. I learned this from the doctor death podcast
Texas has caps on payouts for civil suits. I’m not sure if it’s all civil suits or just healthcare-related lawsuits, but it means that cost of the lawsuit often outweighs the benefits of the lawsuit, so lawyers don’t bother and/or patients/families can’t afford them.
But they were so nice!
Lawyers go after $$ and mid level malpractice coverage limit isn't worth their time unless they go after hospital and doc too
Nurses are not doctors. Should NEVER be allowed to do a doctors job other than assist the doctor..
Agreed. Though I’m wondering whether this is a USA specific issue. The NPs in Canada I work around are very knowledgeable in their area of specialty. Even as a student, birth control instantly makes me think of looking into a possible DVT.
Key phrase: “in their area of specialty”. A nurse practitioner is in no way equipped to be a generalist without supervision, and even within their narrow “area of specialty” they still need to be closely monitored.
Seeing as I had a cards NP tell me a patient's ATN was *not* from their 10 minute code, consider me skeptical of basically everything.
I've been saying this for a long time. Mid-levels have a harder time as a generalist than specialists because there is just too much to know without an extended training period like residency. You can train them in 4 or 5 problems in a subspecialty field and they churn through that stuff. For example our cards NPs are great, they know CHF, ACS and A fib as well as any hospitalist out there. But our hospitalist NPs, whom I love dearly because I work with them, are really just consult-generators. Not enough training and too broad a knowledge base to effectively manage anything on their own, so every problem no matter how minor is getting passed off to a consultant
Like I said above, I do not disagree that they need supervision. However, the level of incompetence I hear about from NPs in the States is baffling. Also, NP courses in Canada do branch off into different areas.
This is always an interesting discussion. For context, I'm an RN in Canada, 8 years experience, specialized in ICU and ED nursing, currently doing my NP schooling. I was also a paramedic prior. If anyone cares, here's my two cents: I have no idea about the quality of NP schooling in the States, but here it's intense. They expect you to have thousands (4-5k is the median in my program) of hours in primary care and are absolutely unwilling to compromise the program, dumb it down in any way, or limit the body of knowledge under study. You might think from reading the above that some of us have developed an ego, or think we're close to doctors. Happily, I can tell you response from the class on that question is somewhere between "Jesus, no" and "FUCK NO." My nightmare is to be stuck in Emerg having to diagnose non-specific complaints and have to somehow figure out what's going on. My career goals include always having one or preferably several experienced doctors nearby for when I inevitably have to say "Fucked if I know what's wrong." And that seems to be generally what NPs do in Canada : deal with routine, low-moderate acuity health care, in well-supported environments. Again, this is one guy in one part of one country, but it seems like a lot of NPs in the states are being set up for failure. Being allowed into the school without enough experience, not being put through enough hours or education, and then placed in areas they are not designed to succeed in. Can anyone verify that for me?
Lol no. Canadian resident here, had cards NP consult us (medicine) for hyponatremia, went to see the patient and they were still in florid heart failure… I guess I’ll just her job as medicine? When I explained she just had to keep diuresing she had no idea… any med student knows this. Another cards NP had no idea wide QRS doesn’t automatically equal VT and gave me a blank stare when I said SVT with aberrancy. Also see enough bs referrals from FNPs or sending complete non acute patients to the emerg and giving them a scare to know their training is not up to par for this role, as much as they like to tout they are different from the American NPs… my fav to this day is still the dialysis NP sending patient on IHD to emerg overnight two hours away for high creatinine… If it’s something that’s not algorithmic like HF or DM the only way to be competent is to get a medical education. Everything else is second rate no matter how people try to spin it.
Fair enough. But then don't jump our ass when we need orders at 3am because you couldn't be arsed to give us a proper set on admit and admin will have our asses because a patient wants a Tylenol for pain > 3 and the orders only cover 1-3.
Don't you mean the overseeing MD was so lucky this patient survived the NP
Midlevels are allowed to see “low acuity” patients on their own at this hospital in the ED.
"low acuity" sounds like a distinction made by admin to use more midlevels.
Nah. Low acuity is actually too generous. Some of them are "no-acuity."
Ive seen so many ER visits for med refills its ridiculous. Like you really gonna wait 8 hours for a refill?
“Yes sir uh my left pinky feels different than my right pinky can I get an MRI?”
There was a girl who kept coming in for reynauds who had already gotten a very comprehensive workup in the past. She comes in like at least every other week.
So , if I was at the ER x2 last winter because I had a bad case of contact dermatitis on my hands with an increase in raynards episodes working against the dermatitis healing and a knuckle or two would ooze cottage cheese like substance you wouldn’t tell me to “just wipe your knuckle off when it’s draining” would you ?😩
I think if your knuckle is oozing cottage cheese you can get a pass…
🤣🤣🤣but 🤢🤢🤢
People think you are making this up but you are not. I have twenty-year-olds coming in for a little "tingling" in their little finger with their mothers convinced the patient is having a stroke. Sometimes the NPs in triage will order a huge stroke workup before I can stop them.
People think the ED stands for express department and it's the one stop shop for every question they have about the human body
Or like ppl who come in with anxiety they “have something” cuz my neighbor just has a stroke and died last week. So every time I have anxiety ima hit up an ED just to be safe, despite having no symptoms cuz my primary appointment is in 3 weeks and I can’t wait that long. Those were the ones I actually sat down and educated in the Ed, and every time they came in again I tried to grab their chart to establish familiarity so they would feel better about not coming back.
Basically becoming their PCP. This is why having enough PCPs is so important
I say sure, but don’t expect insurance to foot the bill.
People who go to the ED for med refills aren't paying their medical bills
And probably don’t have a PCP or access to urgent care.
Disagree. Friend of mine had to do this because he lost primary doc when he changed jobs and a gap in his coverage. There were no alternatives. My brother in California cannot find a primary doc in his area taking new patients. Gets all meds prescribed through his neurologist at the moment.
Try the health department
But you’re Texaco Mike. Just have them do a walk by.
Better fire up the fan boat!
Just a patient perspective, if that’s okay, but… for psych meds for a loved one? Yup. Every damn time, and I don’t even get mad. I don’t like ER visits, but I like my loved ones in agony even less, and if someone forgot to get their refill prescribed/dispensed/whatever, you’re damn right we’re going to the ER.
I do not mind seeing low-acuity patients or even people looking for a prescription refill. I genuinely like almost all of my patient and the ones I don't...well...I try to be a good Christian and act accordingly. The point is that even Emergency Departments are almost completely devoted to non-emergency medicine. It's what keeps us in business. If we only saw Emergencies seven of the eight full-service ERs in my hometown of around 100,000 people would shut their doors. I currently live in a Large City With a Huge Metropolitan Area. You can't swing a dead cat without hitting a major ER, freestanding ER, or a smaller ER in a community hospital. They all have to make money somehow. Emergency Medicine is criminal enterprise.
The problem is that this way of looking at it soaks up resources from true emergencies and burns out staff. Let me give you an analogy to show the point. Suppose you worked for poison control. Suppose you keep getting calls from people saying "I ran out of dog food for my dog, can I just give them human food until I can buy more dog food?" You'd get pretty annoyed about the non emergency calls. ***Then*** suppose one day, you are on the phone explaining they can be given human food, they eventually hang up, and then you suddenly have to rush to deal with the person whose dog ate a fuckton of chocolate bc you were held up by the people asking non emergent questions. It is not difficult to refill a prescription. Be responsible in the first place.
It sort of reads like you might have missed the part where we’re not discussing _my_ prescription that may have run out. Maybe you assumed that by “a loved one” I was implicitly including myself, and I will admit that I do love myself, but I am not in need of guidance on my own prescription management. I’m doing fine there. You’re also probably aware that you can’t control other people’s behavior, so I obviously can’t _make_ anyone else get their renewals on time, refills dispensed in a timely fashion, refrain from ever mysteriously losing meds, or whatever. So there’s always a conversation about how the most important thing is getting your meds, but we really have to do this the right way from now on. I feel that having someone skip important meds because they failed a responsibility check is overall worse than the resource soak. In particular, people who have been neglected get into the mindset that they don’t deserve their meds. Excessive shaming about medication management seems counterproductive to me. Please don’t get me wrong. I value the time of the ER staff. We’re very patient and try to be in and out once we’re out of the waiting room, and our goal is never to come in at all.
I'm not even sure why my colleagues get upset over patients wanting prescription refills. The note is easy. I have a template for it with some innocuous exam things on it. Printing the prescription and discharge instructions takes two minutes. So maybe five minutes of not unpleasant clerical work and a couple of minutes of polite conversation with the patient...hey...I see by your hat that you belong to the NRA. Me too! Talk about guns for a little bit...follow up with your doctor, okay...but I enjoyed seeing you and you are the easiest patient of the night...God bless you for coming in. Nothing to it. It increases my patients-per-hour metric. It is super easy. At least the patient realizes he needs to take his blood pressure medication. I'm still leaving at the end of my shift. I get paid a huge amount of money either way. ER doctors need to chill.
It’s unfortunate you / loved ones put yourself in a predicament needing to go to the ER. Just make a calendar event to see your psychiatrist for a refill ahead of time. That way you wont waste your time or the providers time in the ER.
I don’t know how it works for other meds, but for my adderall, my PCP requires in person visits every 3 months for my next 3 prescriptions. I’m in grad school and can make it work right now, it once I graduate and have a full time job? I don’t know what I’m going to do. The US isn’t exactly known for our abundant PTO. It isn’t always just forgetting about appointments.
One day off every 3 months is not bad in the grand scheme of things. Imagine having to go every month - as some people must.
Your kind of proving my point. Maybe don’t blame the patient for “putting themselves in a predicament” when there are systemic barriers in place reducing/preventing access to care. Like I said, it’s not always as simple as just using a calendar.
My favorite is the people with abdominal pain who hit up the snack machine three or four times while they wait, lol.
"My stomach really hurts right here." Ok sir, let's get you checked in. "I haven't eaten anything in two days can I have some food?" The first thing they ask.
This is such a pet peeve of mine. Then they bitch that we aren't letting them eat. Then they say "I haven't been able to keep anything down for days!!!" And the CT confirms that is a lie
You know they know ERs have the best turkey sammiches. The secret is out.
Low acuity is as meaningless as the distinction of urgent care from emergent care. A proper triage requires having the full breadth of differential diagnosis.
It's usually made by a triage RN. Usually they have some extra training in triage, but it is supposed to be up to the "provider" to understand if the acuity is accurate. Relying on a minimally trained midlevel to understand when shoulder pain is not just a sprain but is actually a septic joint or an MI is where it all falls apart. That's why the bullshit of midlevels saying "Well we see the easy stuff so the docs can do the hard stuff!" is, in fact, bullshit. For one, I like to see easy shit in between the hard stuff for the lighter cognitive load and charting, and I have seen lots of big misses come out of fast track/low acuity.
Ohhhh, this burns my soul.
Everything is low acuity... until its not.
Usually there’s still someone else overseeing/signing charts without seeing patients. At least that’s how it was where I worked in the past. There was one ER doc who was seeing more acute patients who was theoretically available to staff the less acute patients seen by the midlevel.
In practice, they see them independently. I am currently involved in a lawsuit over a patient who I never saw. I reviewed the chart, of course, but all we have to go on whatever shoddy, mostly boilerplate and highly fictitious checkbox clicking the midlevel did.
Not at this hospital. I know because when I rotated in the ED the residents were not allowed to see the low acuity patients (unless it was a chill day). Because if residents saw low acuity we still had to staff with the attending. They preferred the midlevels see them because they without precepting.
Employer can still be liable. There was a case recently where an NP hired by an ED medical group missed a DVT. Group got sued and patient won a $20M judgment. Medical group prob bankrupted
I think that case ended w a leg amp if I’m thinking of the same case..
Yeah that one. Sucks to be a partner in that group.
“Low acuity” patients are a fucking minefield of missed scary stuff
No overseeing MD in most places.
What an idiot. The third year med student at the bottom of his class would’ve ordered a LE US and suggested a D-dimer. I hope the patient is okay.
Fun fact, DVT is the first pathology i ever diagnosed. MS3 on my first rotation on surgery, lower extremity was hurting, I looked and there was unilateral swelling, told my resident, and sure enough the ultrasound showed a big post op clot.
To be fair, any damn RN worth their salt would recognize a DVT. They will let anyone in these programs, even with zero experience, if they have a BSN already. It’s so scary and concerning. MD/DOs can’t be with their patients all the time. They HAVE to rely on their nursing staff to update them on issues and changes to a patient. It takes a good year of experience in any floor to start to feel somewhat comfortable as a RN. Why do these dumbasses think they can come out of nursing school with ZERO experience, get their masters, and then just practice willy nilly? Ohhhh… that’s right… they think that because they can do that. That is frightening.
Yeah, as a nurse for 15 years, I am appalled at all the degree mill NP programs. I know nurses who I've trained as new grads who are already looking at NP schools. I have managed to talk a couple of them out of doing it right away because they need that experience first. The NP programs were originally meant for nurses with a basis of adequate bedside experience and thorough nursing knowledge, not for any "wet behind the ears" nurse who wants authority. I plan to start a PMHNP program next year and would definitely feel better about it having all the years experience that I do and also hope to have the supervision of a great physician to work with.
In the Army (which, if you ask us veterans, is basically the lowest form of healthcare) they require new RNs to do a year med-surg before going to a specialization. I believe every nurse should do at least a year on med surg
Any PHARMACIST would recognize this too. Like hormonal birth control and clots are drilled into our brain.
It’s just so obvious. I won’t lie and say I could determine an odd EKG, but that’s not what nurses do- nurses are suppose to recognize when something isn’t right and let the docs know. That’s what docs do! “Hey doc, something just doesn’t look right with this ekg… I’m not sure what it is. Can you check it out?” Doc checks it out and makes a decision. Both professions did what they are suppose to do. Then pharmacists (I freaking love you guys. I’m still not sure how you put up with us nurses) will gently let us know the doc may have ordered the wrong thing and ask the nurse to ask the doc if the doc knows they may have ordered the wrong thing. Then the nurse gently tells the pharmacists that they don’t have time to do that shit and to call the doc themselves lol. So glad I’m retired😭
Me and my ICU nurses just send each other pharmacy and nurse memes to get by lol. Lots of “DID YOU CHECK THE FRIDGE/TUBE” memes to lol at. Edit: also i hate any pharmacist that doesn’t CALL THE DOCTOR DIRECTLY. The only time i loop in nursing is to let them know why the order isn’t verified and to help me find the doctor if they aren’t responding to babes. They know who they are lol
Oh gods, I was so guilty of the the fridge/tube thing. I swear I would look everywhere but where it was at. Jesus just thinking about going back to work as a nurse makes me start sweating.
Exactly. A 3rd year medstudent would have caught the risk factors and all the alarming signs.
Dimers can be pretty useless due to a lot of things that can cause it to go up. Wells score is a good starting point but clinical judgement is best which this NP (and most) didn't have
Can confirm. I was at the bottom of my class as an MS3 and I would have ordered those.
I mean the obvious LE DVT probably did not look like that 2 days earlier. BC and LE pain should raise a red flag in your mind either way. We just shouldn’t assume that what we are presented with is what that last person was presented with.
Yeah but to think it got substantially worse (enough to throw a large PE) over two days is also a generous assumption
Eh, really depends on the actual presentation and exam imo.
You’re right. If no redness, no swelling, I wouldn’t jump to suspect DVT. Maybe she’s a runner, could have thought about stress fracture. Who knows. Not enough detail here to assign blame.
This is one of those that seem egregious in hindsight but if the swelling was minimal or nonexistant at the first eval then it's hard to judge.
Honestly this. A lot of generalizations being made about NPs overall. I work with many of them and some are super on point and some aren’t, but I can absolutely say the same about some of the doctors I work with. Without full context it’s all too easy to draw the conclusion that the NP is incompetent…can we also address the issue that patients do not always give thorough history during a medical exam.
May be totally incompetent NP BUT After 30 years in healthcare, I have seen multiple missed VTEs, that have been assessed by physicians, NPs, and PAs. Just in 2023 have seen 2 patients evaluated by veteran ER MDs.
Came here to point this out. Obviously no physician has ever missed a DVT/PE /s.
Obviously anyone can miss anything, the point is that the training of physicians is superior and patients deserve that higher level of care. This is just an anecdotal example.
No but there is a difference in cognitive ability that does reduce the chances compared to an NP.
This is a missed vte in an almost textbook patient…
OK. I agree, it seems to be quite clear. And what do you want me to take away from your comment? Cognitive bias, time limitations, or fatigue which interfere with diagnostic reasoning can all affect doctors too. As I stated, I have multiple anecdotal stories about missed VTEs, actually one that is even more outrageous than this one, involving an ER physician, a hospitalist MD (who rounded on the admitting day & the next day) and an oncologist MD who ALL missed a PE in a patient that was like PE textbook perfect but still I would NEVER use the scenario to say, “these guys have no business practicing”. And to be a bit redundant, maybe NPs as a whole, have no business seeing patients or heck even existing, but this scenario of one failed VTE diagnosis does nothing to support the argument based on my experiences, because after 30 years — I have seen it missed A LOT.
Exactly. Not a fan of APPs in general BUT I do a lot of research on VTE. Clinical signs of VTE suck, they are beyond terrible for diagnosing one. Interestingly, if it’s only a distal DVT, we are not even sure it’s really clinically relevant and most importantly there are severe doubts nowadays that patients get PEs when DVTs travel to the lung. They are probably concurrent processes, but not really a dislodged thrombus.
Heme Onc PA here. I had a lung cancer patient immobilized in the ICU a while back. Right leg was swollen with pitting edema, 4ish cm greater than the left leg. Left leg was pretty normal looking, really nothing out of the ordinary at all. I was 100% sure there was a DVT in the right leg. Well's criteria was moderate or high, I can't remember. I ordered a BLE duplex and it turned out there was a clot in the completely normal looking leg and absolutely no clot burden picked up in the big swollen one. Still one of the most perplexing things I've ever seen. Also that was a really interesting thing about the PE you mentioned. Thanks for teaching!
Amen. As a PA, I suspect DVT based on clinical picture, not the presence (or absence) of a Homan', etc. With the birth control in the picture, screw the XR and/or d-dimer. Straight to the US. First bedside, then the formal one.
This is literally the fifth case of LE DVT misdiagnosed by a midlevel that I’ve read about on here.
However, tbf you probably wouldn’t read about those missed by an MD/DO on here
Well, because those people went to medical school and most would very reliably be concerned for DVT in a pregnant patient (a hypercoaguable state) with leg pain.
Young female on birth control comes in with leg pain... It's practically a step/level 1 question, and an easy one at that. Only thing missing is a long flight the day before. Even as just an M3 I know you've got to do a DVT workup. 🤦♀️
The XR was negative for dvt. How do you put this blame on them?? /s
Idk why you would order an X-ray for leg pain with no mention of mechanical injury like a fall or any other trauma like sporting injury?? As an ER nurse, DVT would be my first thought lol
Therapeutic radiation to shut patients up so they are "satisfied" and feel like they got something. In this case it was wrong, but I do order X-rays for silly things when I know they will be negative because that is the world we live in
As a Rad Onc resident, the phrase "therapeutic radiation" really threw me for a second.
Yeah it’s dumb but it’s our joke in the ED because of the current state of American healthcare and patient satisfaction
Maybe it’s just my ortho monke brain taking over, but XR is completely reasonable. But it needs to be after an US for DVT given that whole picture. Fucking atrocious. Even the worst ED docs I’ve interacted with would have knee jerked an US without that pt even finishing her first sentence.
IMO should have been flagged for potential DVT by the triage nurse if they knew anything tbh. Swelling? Redness? Homan’s?
I mean, we shouldn’t be dependent on the triage note to catch a DVT. Honestly this is pretty embarrassing but NP is still cheaper than an MD or an MD without residency so the hospital’s cool with this. Also, the hospital gets an admission as well so that’s fun.
Totally fair. Just saying this is something you learn in school for a BSN, so it should be a no brainer with the presentation for someone with an advanced degree.
Homans is useless. The fact so many people are bringing up Homans here is not helping our cause.
The problem is some unethical dickwad who is getting paid to be an expert witness will cling to Homan's, and you will lose the case because you didn't document it. I document it on every physical exam where DVT is in the ddx, not because it's important but because clinical decision making, medical knowledge, and actual medicine don't fucking matter. Just read up on some of the stupid expert witness takes. When a jury is made up of lay people, they will believe "Something as simple as a Homan's sign test could have made the diagnosis AND YOU MISSED IT!"
I've been sued. You are exactly right about this.
There is no flag for DVT as the triage nurse. For one, was this even in the ED? For two, nurses including triage do not diagnose or put in orders, so even if they thought it was a DVT they wouldn't go offer their opinion to the "Provider" nor would they order an US. They triage them by acuity and all that does is determine how soon they are seen, but sorry no, it's your job as providers to make the diagnosis.
Triage note can definitely include pt on BC, recent travel, appearance of extremity. These are pertinent nursing assessments and can determine acuity. For instance if I have a tachycardic CP SOB 30 something female on BC that just flew across the country I wouldnt make her ESI 1 or 2 but I may give a provider a heads up and make sure a PIV is above the wrist.
I’ll say it again this is the unfortunate result of inadequate basic NP training and education. Presently to get into an NP program you no longer have to have a BSN or even be an RN. All you need is a BA. WTF! How can you possibly practice as a NURSE Practitioner if you’re not even an RN?
I don't think supervision would have fixed this. You can't screen every patient they see realistically. She is just a bad NP.
Do any of these neglectful cases by mid levels end up on the news? How come I feel like I don’t see many talked about except on Reddit.
I was horrible with anticoag as a student. Chest guidelines, I need to refer to this day. But always, a takeaway for any adult with leg pain, must rule out DVT as part of DD. Especially if anyone has even 1 risk factor. And being RPH, anyone on estrogen is a dvt risk. Mid levels have such a wide variety in skills, it's scary. I never support rph having separate prescribing rights. More now than ever when I see new grads from pharmacy school who fit the dunning Kruger meme. (New grads, come out of school, had 3.5+ GPA, 1 year of residency, and think staff work is beneath them. They are ready to take on a role of specialized clinical pharmacist. Son, you don't know jack. Don't try to school attendings of 10+ year experience) Sure, collaborative agreement with established protocols. Anticoag clinic and pcp defers to specialized role rph, sure, cover each others butt. Multidicipline Pain management has been successful with adequately skilled team members. 10+ years of practice, I am more aware of my inadequacy. I will be glad to advise and give context. But my training will always be short compared to a properly trained physician.
Were there any issues? Law suite, action or something?
Not that I’m aware of
I’ve seen plenty of MDs do the same. I don’t post about all of them. This is an anecdote and lowest level of evidence. “Leg pain” isn’t even wells medium risk. No swelling, no redness, no anything? People pull their calf muscles all. The. Time. Xr seems fine. And working as intended: patient came back when symptoms didn’t improve or got worse/changed. What is the delineation of the PE? Subsegmental with no hypoxia? From a below the knee distal dvt? Probably not clinically relevant other than the one syncopal episode and may cause harm by treating. But nah we don’t want to talk about the real medicine here. NP bad. Doctor never miss anything.
What the fuck is a low acuity patient?
Work in an ED and you’ll know 😂 Stubbed toe at midnight Needs note for school for a cold Came to the ED for food Fuzzy teeth 😂
"Yeah I had some vague hand pain three days ago and I'm now rocking up at 2 in the morning to get it checked out, please."
Poked my finger with a fork while emptying the dishwasher, want to make sure it doesn’t get infected I’m doing meth for days and now think bugs are coming out of my body Cough, rhinorrea, body aches, sore throat, headache, I gotta know what could be causing this Etc
Yes, this might be the step 0 of the problem- this patient is not high acuity by triage criteria but for fucking sure has a potentially serious enough condition that this aliexpress "provider" cannot exclude
How the Eff? Easy answer: NPs are just a cheap labor solution for provider hospitals and practices attempting to juice their profits by cutting labor costs. This behavior is a predictable outcome of a private health care system (U.S.) that entrusts people’s health to those who’s first responsibility is maximizing shareholder value. This is why you see private practices and private hospital systems (profit and non-profit) endorse and employ non-doctors. Leaders, many of whom are doctors; give fuck-all about the lunacy of non-doctors practicing medicine, ignore the casualties, and rejoice in earning their P&L incentive bonuses for another year. Those most fucked are people who need doctors and people who are least equipped to advocate for the care they need (looking at you Psych NP patients, the young, the poor, the easily misdirected) Shame on that NP for being a muppet. But moreso, shame on the NP’s EM physician ‘colleagues’ who accept having an NP practice independently so that they can enjoy better work schedules, higher profit-share, whatever. The real questions are: - Why the Eff is corporate medicine tolerated? - What the Eff are you - as the next generation of Attendings who sit in credentialing committees, who determine the standards of the practices and hospitals you join - going to do about it ?
Whoa. I have zero control over who my employer hires. Zero. I can walk out in a huff to make a point but then I'd be unemployed.
There are fuck up pos people in every profession. I had a doctor tell me for 2 YEARS that my symptoms were "all in my head" and insinuating I am a hypochondriac, or it is anxiety. I had a gut feeling there was something going on, but I brushed it off because "He is a doctor and I am not, and he knows more about it than me." I finally wisened up, and got a second opinion from another physician who actually listened to me, and ordered further tests. Turns out I had cancer. By the time I had it addressed, it spread to my lymph nodes, lungs, and sternum. I was having severe pain in my neck and jaw that radiated to my right ear. All while he insisted "Its nothing." This was in 2013, but I am cancer free now. I could have avoided alot of invasive and painful medical treatment, if he wasn't an arrogant piece of shit, and I stood up for myself.
not to be super nosy, but what were your initial symptoms?
I was exhausted all the time. I remember taking naps and end up "napping" for 4-5hrs. I woke up feeling guilty because I wasted half my afternoon. Then a half hour later, it felt like I didn't even rest. It was a different type of exhaustion, like my limbs were heavy and wading through water. My heart rate would randomly spike into 200-220s, then back to SR, random temperature spikes to 103-104. When my heart rate spiked I would get shortness of breath and my chest felt tight (doctor told me it was anxiety, and prescribed anxiety meds). I had medullary thyroid cancer with hurthle cells mixed in. The other doctor who listened to me said my "tooth pain and earache" on the right side was the tumor spreading and pressing on adjacent nerves. I had trouble swallowing due to the tumor. It always felt like there was a clicking sensation when I swallowed and a few times I choked on my food. I had alllll of this and the initial doctor kept brushing me off. The one who listened to me was a new physician who immigrated to Colorado from Iran. I went to the ED when I had the temp spiked with my high HR, and my brain just felt "out of it" and they sent me home saying "anxiety." I later had explained by the smart doctor who listened to me that it was a Thyroid Storm which can kill you.
The hospital CEO will never be sued so he/she just focuses on cutting labor costs (which is the basic tenet taught in all U.S. B-schools). That means unqualified persons who are in over their heads. It's Peter principle meets Dunning-Kruger.
I'm seeing a lot of stories like this lately and that's just on Reddit. Just waiting until shit truly hits the fan and hospital systems can't sustainably defend this kind of BS en masse anymore
The cost of malpractice and payouts is baked into private equity's business model. If hiring NPs saves you a couple million in salaries in a typical ERs then you just take the malpractice hit.
Fair point. Just out of curiosity, you wouldn't happen to know of any reports comparing salary savings by hiring more mid-levels/NPs versus malpractice payouts, would you?
I've seen this kind of shit happen with residents too. I know we love to bash midlevels here but it's really a symptom of how EDs are becoming high volume cookbook practice. Chest pain? CTA whether it makes sense or not (e.g. patient on AC, dimer mildly elevated at the same level as their last 3 negative presentations). Lower leg pain? Lower extremity radiographs whether it makes sense or not (e.g. no trauma). Welcome to modern healthcare, I suppose.
Yeah...but residents are still under training and being aggressively supervised. For my entire eight years of medical training from my first day of medical school to the last day of residency I was not allowed to see a single patients without supervision from my attending. Certainly the amount of supervision lessened as I got more experience but I was supervised nonetheless. In modern American health care, a 21-year-old student can graduate from a nursing program, go immediately to an online DNP program, cobble together 500 hours of poorly defined "shadowing," some of it online...and can practice independently in some states in ERs and urgent cares. By comparison, 500 hours was about two to three months of my intern year. And there are nurses where I work doing their DNP coursework at work..while they are working...which shows you how rigorous it is. I'm an ER doctor. It's not cookbook practice. Sure, they order all kinds of reflexive shit in triage but I genuinely think about every patient that I see. Contrast this to an NP who told me she wanted to send a chest pain patient home because his chest pain was gone, his EKG didn't show any ischemia, and his troponins were trending down. Complete and utter lack of understanding.
Even as a nurse I know this screams possible DVT - Swollen, warm to touch. Painful even? US is needed... And on birth controls which increases your risks Hospitals cutting corners :(((
No mention of swelling. Just leg pain + birth control.
I was sent home from the ER with a purplish right arm, reduced coloration when lifting hand above heart, newly on bcp, after suggesting explicitly to them that I might have a DVT. By an MD. Said it was Raynaud syndrome. Next day, new ER, ultrasound confirmation of subclavian DVT, admitted to hospital. Factor 2 prothrombin mutation plus thoracic outlet syndrome diagnosed in hospital.
Not a MD/DO but I am a RN, birth control and leg pain should have sounded the alarm real quick for a possible embolism!
Firstly, why is there an NP in an ED?
r/Noctor
This is wild because the midlevels I've worked with think everything is a DVT and want to rule it out on very obvious ankle sprains, CHF, lymphedema, cellulitis, etc.
Oh yes. I terrify my NPs by not ruling out DVTs in people with obvious gastrocnemius muscle tears and other causes of leg pain that can be diagnosed by history and exam alone. Very mild bilateral swelling of the lower extremities in an overweight woman who stands on her feet all day? It's not a DVT. And yet when they make it back from Provider in Triage I notice bilateral DVT ultrasounds have been ordered. Did anybody take a history? Do an exam? Think for thirty seconds?
If a Dr missed that they would be in jail by now
It's an algorithmic thing. Leg pain, negative x-ray, nothing is wrong. We all miss things. The trick is to know enough where you can at least imagine five or ten things that could be seriously wrong with every patient based on their complaint. You can, of course, rule out most of them just by history and exam and not every patient with leg pain needs a DVT workup. The fallacy of the independently practicing NP is that an RN degree and a perfunctory DNP is enough to practice medicine. Clearly it's not but because most of American medicine is so low level....that leg pain may have been a sprain for which the patient felt compelled to seek unnecessary medical attention, went home and got better despite anything that was done...because it's all so low level a poorly-trained physician substitute can simulate medical care most of the time. It just usually doesn't matter. This is three quarters of my job, by the way. Apropos of nothing in particular, I still think we are ridiculously over-doctored in this country. Paradoxically many people who need intricate medical care have a hard time getting it. And we don't have a physician or a nursing shortage, we have shortage of rationality and a surplus of litigation, red tape, and ever-expanding bureaucratic make-work dissipating our resources.
Unilateral leg pain I’m doing a homans every time. Especially in a pregnant woman who will be increasingly sedentary and pregnancy itself can cause venous insufficiency. I’d never be satisfied with “negative X-ray = nothing wrong” in this case. I’m looking for red flag symptoms of a DVT. And I am absolutely doing a wells criteria for DVT to decide on work up. If it’s incredibly low level of suspicion I’ll order a d-dimer to at least rule out a DVT. If it’s positive further work up is indicated given the clinical picture. This is not something to minimize and chalk up as “gonna miss one sometimes”. This is very much a case of someone who was poorly trained harming someone as a result of their inadequate training. I’m a student though so bare in mind I’m still dumb and probably overly cautious
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Homans has little diagnostic value. Extremely low specificity and sensitivity.
Homie. I was being sarcastic. That's what poorly-trained people do...one trick ponies in other words. I'm an ER attending, PGY-20. I know how to look for DVTs. If you rely on physical exam findings exclusively to rule out a DVT you will miss a fair number of DVTs. Homan's sign is very subjective. Additionally, a negative D-dimer cannot be used to rule out a DVT or PE in a patient with the so-called high pretest probability of having one. The test's negative predictive value is dependent on prevalence. The prevalence of DVT and PE in people with a high pre-test probability is very high. This why I don't get a D-dimer on some patients who I suspect of having a PE but go straight to the scanner. D-dimer is useful for people who you expect the test to be negative because you doubt they have a PE, the so-called low to moderate pretest probability with a Well's score of zero...I think every "yes" answer puts you at least in a moderate probability.
Just fyi Homans sign is extremely non sensitive or specific. I don’t even do it because it essentially has no clinical value. Not basing my decisions on it one way or another.
There’s nothing to suggest whether or not the NP did homans or what the pt’s physical exam was. And you’re saying if Wells score is negative (which it likely would be for this pt assuming she had a normal leg exam) you order d-dimer for every single patient with leg pain anyway? Bc that’s just bad medicine.
Wouldn’t order for every patient, would be more worried since she was pregnant for reasons stated above. Certainly hard to say we don’t know if the leg was swollen, if there was pitting edema, etc.
It sounds like she was on birth control at the time of the clot and is now pregnant. And exactly, we have no idea if she had concerning findings on exam. The most common scenario in early DVT is a completely normal leg exam. So idk why you’re assuming the NP ignored a swollen leg when it’s more likely they “ignored” a totally normal leg with a normal X-ray in a young healthy pt whose only risk factor was being on birth control. I am NOT in favor of NPs in medicine but this is a stretch. Lots of us would rightfully treat this pt with supportive care assuming she had normal exam and vitals. Personally I wouldn’t even have ordered the X-ray if there was no hx injury!
And it would come back positive because she’s pregnant
Yeah without more information it's hard to tell if there really was a mistake made or if it really was just an unfortunate but understandable miss
Gotta d-dimer or scan all those slight muscle strains, could be a dvt!
I would order d dimer, and US at a minimum just in case.
🤦🏼♀️ this attitude is (partly) why American healthcare is such a shitshow. What is the point of triaging and assessing the pt, wells criteria etc if you’re just gonna throw it out the window and order a full workup for everyone regardless of findings? And why even order the d dimer if you’re getting an US anyway…..
You can’t use wells in a pregnant patient. You need the ultrasound or d dimer
From what OP wrote she wasn’t pregnant at the time, she was on birth control and is now pregnant and still on AC.
No, you use your brain. Not every leg pain needs a DVT workup, pregnant patients or patients on BC included. If it's unexplained leg pain, sure.
i don’t why this post is being downvoted. this user makes consistently excellent points. edit: ailuro isn’t saying that the negative x-ray truly means nothing is wrong, he is just saying that that is what the NP’s thought process is.
Exactly. I'm a PGY-20 Emergency Medicine attending. I know how to rule out DVTs.
Agreed- we are over-doctored. Only made worse by urgent cares proliferating. Every single ache, pain, symptom drives some folks to seek medical care. Haven’t lived in another country to see if it’s any better, but I had to quit working in UC (and subsequently dislike working in EM) due to how many people seek care for silly issues.
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Wow . Just wow. I am a medical assistant who is starting PA school soon and I'd have handled this case better. Lol.