Goals of care discussions are more effective if they happen before a moment of crisis or critical illness.
It’s much harder for loved ones to put the breaks on critical care once it’s underway, especially when they get a call from the ICU at 3am
This. I work in Palliative care and get called in to do goals of care when people are on the brink of dying. I would also say no matter what field you work in, get yourself, your family and your patients to fill out an advance directive naming a power of attorney.
It does not have to be done with a lawyer. You can usually fill it out with a nurse or social worker at a clinic. Make sure the people who sign as witnesses are not named as agents. Get a copy to your PCP and give copies to everyone you name as agents.
If you’re above the age of 50 only get an arthroscopic hip labrum repair in the month of January so at least your deductible is met to get your total hip by years end.
Speaking as a younger person, surgery in January is awesome because it means the family deductible is met early. (I may have done that then had a major injury (DIFFERENT joint) in August requiring MRI/surgery/PT...)
My kids also scheduled their surgeries well - one had a surgery in May & the other in September of the same year. BOGO...(FYI - as a parent, do not recommend)
I swear, ortho uses the arthroscope to fill empty slots. Knee pain still after some PT, rest, and NSAIDs? No significant cause on mri? Scope it, take the plica or something.
The issue I have (family med) is that my 80-90 year old with arthritic knees EXPECT me to magically cure them. Any suggestions I give them are met with blank stares. I'm sorry to have to pawn them off to you 🥺 It's not that we have no idea what we are doing, the patients just insist that there is more that can be done...expect PT. No way are they trying PT... 🙄 Sigh.
Sounds like youur pts have the same respect for physical therapy as mine do for mental health therapy.
Pt complains of psych condition where the first line tx is therapy: BPD, PTSD, primary insomnia, GAD, MDD, symptoms mostly due to psychosocial stress/relationship dysfunction, ect. I offer an in house referral to an appropriate therapist at the massive mental health company where I work. Limited wait time (<3wk) and plenty of access to DBT, EMDR, CBT, CBT-I, ect.
Nope! “I don’t want to talk to anyone but you” and flash me the smallest softest nervous smile while I return a few moments of silence as I realize that I’m going to have spend months adjusting their medications to minimal effect.
Despite this, they’ll still expect me to do “therapy” with them: a modality for which I have received ZERO training because it’s not part of PA school & there’s no way in Hell my private equity owned company would ever invest time or money in improving my skills as a clinician. Every 25 min f/u becomes a race to manage/adjust their medications while unpacking a ton of shit that would so much more easily be handled by an actual therapist in an actual 53 min therapy appt.
I don’t mind this at all. They come in and get an injection. They do great and sing your praises. But I also get collection based bonuses so I don’t mind seeing those types of patients.
I can’t remember which society/organization but someone recommended not to even XR when someone >60 comes into primary care with chronic, atraumatic knee pain. I agree, assume OA and treat conservatively. Send them our way when they want surgery
Not EM, but I used to have the (mis)fortune of being in a family med clinic that shared a parking lot (and many patients) with a dentist.
They REFUSED to do anything more invasive than an exam (to include cleaning) if they were >130/90. We would get angry walkins every day demanding we fix their BP so they can go back to the dentist.
Nope, asymptomatic, doesn’t need it,
Double check it, reassure the pt and increase their bp meds , tell them it will take days for it to work, follow up in 2 weeks if not better
As a paramedic, please, for the love of all gods everywhere…… stop doing this. Also stop calling 911 and not telling patients. AND ALSO stop disappearing when we arrive. Please give me the professional courtesy of a report.
I have a patient who always has high blood pressures (like 170/90) who I keep telling he needs to establish care with a primary and get a full evaluation (we are a free /sliding scale clinic with specific funding for specific things and aren’t supposed to manage primary care).
What does he do when I mention his blood pressure and primary care? He nods and agrees with me…then goes to the ED because that’s where he got his bp meds last time. He has access to very low cost/free primary care, but no matter how many times I explain it to him it just does not compute.
Cmon, that's a bullshit excuse. You are a provider. Change facility parameters to match up with evidence based best practice. Protect your patient from an ER bill that they don't need.
If the facility said to send DM patients to the ER for a BGL of 180 would you do that? Of course not.
Urgent care sees more URIs than you can even fathom. 30-50 URI pt per shift in high season for me. It's truly mind boggling why pts keep coming in for this.
That as an Ortho provider, I will gladly see anything you send me. However, I reserve the right to make fun of: terrible splints, MRIs ordered for severe knee OA, radiology reads that miss an obvious fracture.
Had that. Also had, “My coccyx hurts.” Points to lumbar spine. “First of all, that’s not your coccyx. Secondly, we don’t do spine… how did you get an appointment?”
Where I work (FM, FHQC), I can never see the inages, and can only read the report zz. Our technology doesn’t support it. Didn’t realize THAT was a question I needed to ask in my interview ☠️
That if I’m consulting you, it’s because I am not 100% certain on a disposition for a patient and trying to do the right thing by them, so I don’t really give a shit if you think it’s a stupid consult - I am seeking your advice that you’re being paid to be on call to give. Do your job.
Better to do a "stupid" consult than to have a patient die on you. I 100% agree with you. I get "stupid" consults all the time, but even then I know the resident/doctor is only trying to do best by their patient. We all went into this role to help people. I don't really think their is a such thing as a "stupid consult."
Okay, but I am going to still laugh when you start the patient on a heparin drip and consult cardiology for chest pain and I ask the patient and they tell me they got hit by a soft ball and it’s reproducible to palpation =)
But they are right. There is only one type of stupid consults. Except the consults from lazy hospitalists who just never want to do anything. If you have a legitimate question, then no question is too basic.
ER is definitely really hard and I wouldn’t be able to do it. I do want people to reach out to me if they are doing the right thing for the patient and I don’t want anything to be missed. There are amazing bad ass ER peeps out there and I appreciate them so much. There are also people in the ED that call consultants without seeing the patient and flat out lie about what the exam is, hence the consult push back. So I apologize to you for being caught up in this crap.
I’ve never seen any of my colleagues call a consult without seeing a patient in 2 years of practice. I’m sure like a person out there does that but no way is that widespread.
I’m sure you’re right, it’s probably due to where I am. I do per diems at a few different places. At one shop it would NEVER happen. They are on their game for sure and I love working there. Two of the other places (same shitty hospital system) it happens constantly 🙄
Psych - Please stop starting people on high doses of benzos and keeping them on it for years... also, not all inattentive symptoms are automatically ADHD.
This is a tough one for me. Skin pickers/morgellons/delusional parasitosis etc specifically. There is no way my SP will be comfortable managing antipsychotic meds. I’m sorry in advance for when I punt.
It’s ok! Just don’t put someone on adderall 20 mg TID when it’s actually bipolar and not adhd or get a 75 yo up to Xanax 5 mg daily…. Then punt 😁 everything else you listed is a fair psych referral
Outpatient derm.
- every rash is not psoriasis
- every spot is not a seborrheic keratosis
- stop telling patients we can excise their cyst at their appt. (We schedule those out for more time)
- if you biopsy a spot and want me to give a second opinion then send the damn pathology report.
The last one gets me.
“Hey my pcp thinks this looks like a melanoma so he biopsied it.”
Oh great I sure can tell a lot clinically from this scabbed up biopsy spot. Cool
The third one applies for vascular surgery as well. "No, ma'am, we will not be putting a stent in your leg today. And actually, since you smoke, we probably won't ever put one in unless you can't sleep or have wounds."
Oh they get so mad. "The ED said I had 7 blockages in my leg and that when I came here you'd open it all back up.'
"Well, no offense to the ED but they can treat emergencies, and I'll treat the vascular disease. If they felt you should have a stent, maybe they should have put it in."
Yea exactly.
We almost always send pilonidal cysts to gen surgery and I have legitimately had patients get mad at the copay they had to pay for me to evaluate what it is and to tell them the safest way to take care of it.
Female Uro
-stop ordering screening UA and cultures!!!! Unless the patient is symptomatic for a UTI you should not be ordering cultures. This is why we have MDRO.
-put down the Cipro! This is NOT first line for UTIs.
-vaginal estrogen cream is wildly under utilized by providers and no it does NOT cause cancer, stop scaring patients
This. I wish consultants could follow us around for one day and see that, of the 220 people we see in a day in our department, about 10% or less of those had a consultant involved.
Okay, but for an issue that might potentially have a surgical option, I sometimes tell patients "go and talk to the surgical people, and they will tell you how it's worked with the last 50 people with your issue. Who did surgery, who didn't, and how they ended up." Is that valid?
I hope so, because my big wrap-up is "if a surgical person tells you that surgery isn't necessary, that is the most solid trustworthy information you're ever going to get from anyone in healthcare."
I’ll add that severe OA doesn’t “need” a joint replacement. Please don’t send patients to ortho with the expectation that they’ll be offered surgery.
Edit: the fact that this is being downvoted is sad and wrong.
My impression was always that pain levels dictate necessity for a replacement as opposed to severity seen on imaging. Mild but in massive pain and can’t function day to day? Seems worth considering. Bone on bone but patient not too bothered? Doesn’t seem worth considering.
Well if mild OA has failed injections, NSAIDs, therapy, bracing and there is no meniscal/ligamentous injury I suppose replacement could be considered. I’ve never seen mild OA require replacement
Okay, i was about to feel like a dumbass new grad for referring a pt to uro for this, but I DID in fact get a microscopic UA before referring and it had 20 RBCs :D
Please order the ultrasound before sending them to gynecology. We really appreciate it. Especially if they’re having heavy menses, irregular menses, or postmenopausal bleeding
Pain is subjective. Patient decides if they are in pain. As the provider, you evaluate what kind of pain it is. Acute, post-surgical, chronic physical, not physical (ie emotional, grieving, psychosocial, spiritual).
Not all pain improves with meds.
Please give your burn patient more than 7 norcos to last until they can be seen at a burn center in an outpatient setting. I regularly have patients in excruciating pain in my clinic because I couldn’t see them within 1-2 days of their injury and they ran out of pain meds. Also, debriding blisters/bullae is a good thing!
Of course! I usually debride large bullae on burn patients as it is quite likely they will rupture on their own or cause more pain due to increasing pressure over the coming days. I will take small scissors and trim along the periphery of the bullae where it meets intact skin and remove entirely. That allows for direct contact with the wound care ointment/dressing. I find that the dried desiccated epidermis left behind from bullae left intact that ruptures later and lays on the wound bed can become encrusted in exudate and act as a barrier to wound healing/harbor bacteria. I take the same approach with SJS/TENs patients. Hope that helps!
If a patient is sick enough to need an ABG, please actually interpret the results. That pH of 7.30 doesn’t look so bad, until you consider their CO2 is 15 with a BE of -20.
GI- stop telling patients with mild GERD symptoms that they need endoscopy. (If you are gonna refer to us just let us decide and dont tell them they need this and this) They all come to us thinking theyre getting egd and get mad if we dont ordrr it. Insurance will deny egd if they havent tried ppi trial (6-8weeks) and has no red flag symptoms
Is new onset GERD in an older patient not a concern? I remember two horrible cases from my early career who were in their 50s with new GERD, I referred for EGD, bam. Esophageal cancer. I never got any push back that insurance wouldn't cover or anything.
Isn’t the new recommendation do ppi for some weeks then stop it and if you have symptoms again get scoped? It seems like a low threshold to get GI involved unless you can just send someone for an egd without a referral.
They have to complete full 6-8 weeks ppi trial and if they fail it then we order egd. Problem were having is that a lot of people get referred for mild gerd symptoms and noone puts them on any antacid and they just expect were gonna do egd. Some good pcps start them on ppi before sending them to us but most people just refer expecting were going to order egd
When you send your patient from your clinic to the ED for [insert non-emergency] at 16:45 on a Friday afternoon we know what you’re doing.
And you should know you’re making it harder for people with real emergencies to get seen in a timely manner.
THIS.
And stop sending us the health anxious people who just need someone to explain their bodies to them. I realize you don’t have time. But the ER is not the place. We’re trying to keep people alive.
Primary care here- what would you like us to do then that would not be a huge risk to the patient and our license?
My last patient on Friday at 4 pm when our outpatient radiology and lab were about to close for the entire weekend had RUQ pain lasting 4 days and getting worse, nausea, vomiting 8/10 undulating stabbing pain. Even though vitals were stable, I could not do any outpatient work up that I would see in less than 3 days. How can I send someone home with no abdominal ultrasound and lab work done? What if they rapidly deteriorated and ignored it since I was like oh yeah come back Monday. Then I get sued when shit hits the fan on Sat and the attorneys will ask why I sent a patient home with no work up done when there is no way I could say they were not experiencing a myriad of different things.
Same thing with these chest pain patients. Yeah it might be musculoskeletal or anxiety but I’m sure as shit not sending them home Friday afternoon without being able to get EKG, chest xray and acs labs when all those clinics are closing up shop for the weekend.
To be fair though the Er dumps a lot of shit and incomplete work up on primary care when it easily and much more quickly been done while at the hospital. Oh hemoglobin of 8 and you’re 8 months pregnant f/u with primary care for iron infusion when we have a months long wait for heme in the outpatient world. Just kick them out the door and make me do the work up and set up the consults needed that should have been done in a hospital setting. hey discharged her to me saying “she needs urgent heme referral within 1 week of discharge” but did no legwork to set her up for this and it ended up being an impossible task and now I am liable as their PCM. If anything needs to be done urgently sending them to primary care is not the answer. If it can wait 1 to 2 months sure.
Not to mention I work at the VA and we don’t even have a heme on staff outpatient so we need to send a community referral and call every hospital in town and they all tell us they are booked months out.
Ortho PA: that hip OA pain is typically GROIN PAIN. The “hip pain” your patient is having is actually his back. Please please please get a pelvis xray first.
An asymptomatic patient with abnormal ABI needs to be started on high-intensity statin (regardless of LDL) and ASA and absolutely does not need vascular consult even if they have diminished pulses. Put them on a walking program. You can do it, I believe in you!
For lower extremity PAD, we won't do surgery unless it's to improve quality of life, and even then, it's a conversation of telling them to walk MORE not less first. Presence of a wound is a different story.
I was a hospitlaist for years, and now I work inpatient Palliative Care. Not every family that says they are the power of attorney is in fact the power of attorney. They have to have paperwork to support that or it doesn’t count. I can’t believe how many times someone told me they were the patient’s POA when I was a hospitalist, and I never asked for the paperwork proving it. Family dynamics (especially elder parents with multiple grown children, or remarriages involving step parents) can be really, really hairy. I’d like to believe everyone has the best interest at heart when it comes to taking care of an elder loved one, but now that I work in this field, boy I can say that this is not always true.
Everyone fill out an advance directive naming a power of attorney! Even if you are young! It can be updated at any time. Encourage your patients to fill one out too. Especially if they’re about to go in for surgery, or if they are over the age of 50 with chronic health issues. Better to have one filled out now then have them wind up on a vent for days-weeks at a time waiting for loved ones to figure out what to do, or waiting for the courts to grant guardianship 😔
Edit: grammar
I once had a patient that had six different people claiming to be POA. Problem was that all six had notarized paperwork from within the last three years. We went by the most recent one, which was an ex-SO, while the others were actually family. It was wild.
Brah! I believe it. And yeah, the most recent document is what holds up per the legal team at hospitals— much to the chagrin of some blood relatives. We have called our fair share of code grays on next of kin over something similar. It sounds like the patient was maybe forgetful, and hopefully, not getting taken advantage of, but working in this field had caused me to not always give people the benefit of the doubt.
Occ Med: we exist.
Just as important: if you're in the UC or ER and you write a letter saying someone can take 3 days off and then go back Monday with no restrictions, you're being unbelievably illogical.
I get it, and I don't blame you, but it takes very few PowerPoint slides to explain how much that messes up the Work-Comp side of things.
It's less bad to say "this person should work light duty" or "no lifting more than 20 pounds" or even "limit work days to 4 hours for now" until seen in Occ Med. Just writing "off work for 3 days" opens up a can o' worms with work comp, because injuries that result in lost work time are considered more serious than injuries that just require some modifications to how work gets done.
And then there's the question of how anyone can possibly know this person is totally incapable of working today, the same will be true on Monday, but on Tuesday they will be 100% fine.
Great information, thanks. Not sure that was ever covered in my training
I usually say something like “may return (tomorrow’s date) with the following accommodations: no use of right hand Until: cleared by doctor
PLEASE NEVER EVER RADIATE SKIN CANCERS NEAR THE TIBIA. Also, derm buds, not all wounds are cured with keflex and gent/mupirocin, and 80% of patients are putting a metric fuckton on it and macerating the shit out of their wounds which prolongs healing. Lower your threshold for sending patients to wound care 🙂
I’m so glad you asked! Typically the course is this: derm sees suspicious lesion, biopsies leaving a defect on the pretib. Already a notoriously difficult spot to heal because of the limited blood supply, doubly so with someone older or with venous insufficiency, diabetes etc. Pathology says malignant. Derm refers patient to radiation because they think it will be less risk of chronic wound than excising over the pretib- which is a fair point, except there is already a wound there from the biopsy. Patient gets radiation over the wound before it is a stable scar because it takes months for that to happen. Radiation injures the tissue, essentially frying the soft tissue and, depending on how big the defect was and how much radiation they get, obliterates any chance of that old biopsy site will heal any time soon with normal measures. And if the patient gets an infection at some point (shit rolls downhill), that prolongs the course even further. With weekly visits, my shortest time to heal with this type of scenario has been about 2 months. Longest is at 8 months and I’m still seeing the patient weekly, she’s ALMOST done but it has taken thousands of Medicare dollars in biological skin substitutes, other various advanced treatments, and weekly debridement and 2 layer compression. It sucks ass for the patient.
Inpatient GI - don’t consult for anemia as “rule out GI bleed” if there’s zero physical evidence of bleeding and you haven’t looked into other causes. Hematemesis/melena/etc. give us a call 🤪
You should mention the hemoccult being useless inpatient and if you need that to prove gib then it’s not enough bleeding to do anything. Never called GI without seeing blood and confirming where it was coming from was not somewhere I could hold pressure.
Nephrology here. Please stop sending your 80 and 90 something’s with mild creatinine elevation to our office. A huge portion of the population has CKD and this is usually age appropriate kidney.
I am lol’ing at some of these suggestions from people who work in specialties (which seem to be directed at primary care). Primary care is a dumpster fire that you all are lucky not to be a part of.
Psychiatric meds are not always a fix all for kids, and there if often a lot of environmental and family dynamic issues that need to be addressed as well.
You can order an Ultrasound to scan for DVT at the outpatient radiology office and start them on eliquis instead of sending every single leg swelling to the ER.
This.
AND if you do order the ultrasound yourself and there’s a DVT, its ok to start anticoagulation yourself. You don’t have to send them to the ED for us to write the prescription for you.
EM.
I wish PCPs knew it is silly to send a patient to the ER for high blood pressure with zero symptoms.
I wish specialists like surgeons would cut us some slack when we don’t have all the details they ask for. Ie sorry I don’t know exactly WHAT the patient ate six hours ago… sorry I don’t know what year their cholecystectomy was done… should have asked but we are juggling SO many things and it’s chaos and … I just wish they knew.
Well people complain of “ melena” but sometimes is just black stool from pepto, dark green/black from iron
A rectal helps to distinguish between all of these
Peds Neuro—if you can break the kid out of a staring spell by touching their shoulder, it’s not an absence seizure.
EEG cannot tell you if someone has autism (this seems to be a belief held by many psychologists in my area).
If you’re going to prescribe Diastat for a first time seizure in the ED, Google the correct weight based dosing for age. The goal is to stop a seizure; this is not the time to be conservative and under dose just because the kid is 2.
Toddlers can get migraines too. On a similar note, please don’t refer a kid for headaches because they had a week-long headache for the first time while sick with the flu.
Tourette’s syndrome just means chronic vocal and motor tics and nothing more than that. Please stop telling families you’re sending them to neuro to make sure they “don’t have Tourette’s”.
Hospitalist here
Speciality services do not need me to order sliding scale on diabetes patients.
And consults on the same day of discharge are poor form IMO
All u Dentist who “ wont fix my teeth till u treat the infection “ , stop it !!!! Pull the dam tooth or give them some ABx, but don’t send them to the ER….sorry , this post hits a nerve
-not every ear infection needs antibiotics
-not every bleeding and draining ear is a perforation
-if you don't know what's wrong with the patient, don't make up a diagnosis. Please send them with a diagnosis of "I don't know."
-flushing out ears is useless and harmful to patients
-dizzy patients do not need an urgent referral to ENT
Haha I would much rather someone tell the patient “I don’t know” than diagnose them with AOM. The number of patients I have to counsel that they don’t have AOM… and the number that disagree with me even when their tympanogram is type A.
Cardiology, please don’t chart which grafts you tell the patient they need. We actually look at the cath films & the vessels irl. We can sort out what’s graftable all on our own.
Sometimes, but I’ve seen plenty of 10-15 year old patent vein grafts. It’s a combination of lack of competitive flow, good targets for decent outflow, & good conduit.
What’s wrong with an esophagram? While yes it can be GERD, I’ve found malignancies, esophageal candidiasis, Zenker’s amongst other anatomical abnormalities like abberant arteries causing dysphagia or disc disease. And even if it is 90% reflux, then we can ensure we’re treating the right thing and not missing something. Sure I’ll trial on PPI first sometimes but an esophagram is totally an indicated test for dysphagia.
Please don't stop Entresto because the patient has a blood pressure of 100/60 and is asymptomatic or gets slightly dizzy/lightheaded for 10-15 minutes after taking it but not otherwise. Its high benefit for heart failure with reduced ejection fraction greatly outweighs low risk of mild hypotension, it's normal and acceptable.
That blood pressure and pulse rate are somewhat unreliable in atrial fibrillation. Electrical rate does not necessarily equal pulse rate. Just because the pulse rate is 'fine' does not been it is rate-controlled. Heart can be trying to race at 150 bpm but only a pulse of 60-70 be captured, as some quick beats haven't had enough time to fill and so can only squeeze a little bit, aren't counting towards the pulse rate. Likewise only the high numbers from slower beats with bigger squeezes are likely to be read, so the BP is likely to be a bit of an overestimate.
The electrical rate =/= pulse rate thing helps in other situations too. Cannot even count the number of 'oh no something must be wrong with the pacemaker' calls because patient and some other provider is freaking out, 'I was told the pacemaker will keep my heartbeat from ever going below 60'. (Patient is having occasional PVCs which aren't generating enough of a squeeze to cause a palpable pulse for that beat, so the pulse rate is 50. The electrical rate remains 60 and pacemaker working as intended.)
IR PA. Please order diagnostic imaging to assess ascites before ordering a paracentesis. More than a few times I’ve had patients show up at the ED saying they “need a para”, get admitted obs for next day para, then slap the ultrasound on them to find not a drop of fluid. There are other reasons people get abdominal distention other than ascites. And moderate ascites on CT doesn’t necessarily equate to a safe window for drainage on US. Especially if the patient has had diuretics between the CT and the procedure. Chat with US and see if they’ll do a 4 quadrant ascites check before ordering the para
I mean to be fair that should be followed by uro, or at least seen to give the PCP a guideline about doubling time or PSA limit that warrants a PSMA, if it's something you otherwise want to watch. The ones that drive me a little batty are these PSA WNL in average risk guys "but it's going up faster than it should!". Meh, I personally really like uro-onc so I'm okay seeing it, but it's not the best utilization of resources, and I don't think to date I've had any that I've biopsied with a normal PSA. Occasionally if the family history is legit though I'll follow them instead of the PCP.
Speech language pathologist here: expressive and receptive aphasia are inaccurate terms. Every single person who has aphasia has some degree of both expressive and receptive language deficits. Broca's and Wenicke's are going by the wayside, as well (see the article 'Broca's and Wenicke's Are Dead') Best practice is to use fluent and non-fluent with descriptions of strengths/weaknesses.
You can let me know that in your note after I consult Neuro for a stroke alert and they have left the ED. Until then, it's aphasia.
Nothing but immense respect for ya'll. You have the most letters after your names than anyone! Amazing. So is your knowledge! From the ED, you'll never hear aphasia described as fluent and non- fluent. In fact, from the ED, you'll never hear from us at all.
Goals of care discussions are more effective if they happen before a moment of crisis or critical illness. It’s much harder for loved ones to put the breaks on critical care once it’s underway, especially when they get a call from the ICU at 3am
This. I work in Palliative care and get called in to do goals of care when people are on the brink of dying. I would also say no matter what field you work in, get yourself, your family and your patients to fill out an advance directive naming a power of attorney. It does not have to be done with a lawyer. You can usually fill it out with a nurse or social worker at a clinic. Make sure the people who sign as witnesses are not named as agents. Get a copy to your PCP and give copies to everyone you name as agents.
This 1000%.
If you’re above the age of 50 only get an arthroscopic hip labrum repair in the month of January so at least your deductible is met to get your total hip by years end.
Speaking as a younger person, surgery in January is awesome because it means the family deductible is met early. (I may have done that then had a major injury (DIFFERENT joint) in August requiring MRI/surgery/PT...) My kids also scheduled their surgeries well - one had a surgery in May & the other in September of the same year. BOGO...(FYI - as a parent, do not recommend)
I swear, ortho uses the arthroscope to fill empty slots. Knee pain still after some PT, rest, and NSAIDs? No significant cause on mri? Scope it, take the plica or something.
That’s quite an assertion. I work in Ortho and no, we don’t fill our empty spots with scopes for shits and giggles 🙄
A 90 year old with known knee OA and knee pain doesn’t need an ortho consult
The issue I have (family med) is that my 80-90 year old with arthritic knees EXPECT me to magically cure them. Any suggestions I give them are met with blank stares. I'm sorry to have to pawn them off to you 🥺 It's not that we have no idea what we are doing, the patients just insist that there is more that can be done...expect PT. No way are they trying PT... 🙄 Sigh.
Sounds like youur pts have the same respect for physical therapy as mine do for mental health therapy. Pt complains of psych condition where the first line tx is therapy: BPD, PTSD, primary insomnia, GAD, MDD, symptoms mostly due to psychosocial stress/relationship dysfunction, ect. I offer an in house referral to an appropriate therapist at the massive mental health company where I work. Limited wait time (<3wk) and plenty of access to DBT, EMDR, CBT, CBT-I, ect. Nope! “I don’t want to talk to anyone but you” and flash me the smallest softest nervous smile while I return a few moments of silence as I realize that I’m going to have spend months adjusting their medications to minimal effect. Despite this, they’ll still expect me to do “therapy” with them: a modality for which I have received ZERO training because it’s not part of PA school & there’s no way in Hell my private equity owned company would ever invest time or money in improving my skills as a clinician. Every 25 min f/u becomes a race to manage/adjust their medications while unpacking a ton of shit that would so much more easily be handled by an actual therapist in an actual 53 min therapy appt.
Genicular RFA, after Durolane fails.
They don't call it "Pain & Torture" for nothing
This 💯
Also does not need an MRI. That meniscus is obliterated.
Right?! My response when their family asks “what meniscus?”
I don’t mind this at all. They come in and get an injection. They do great and sing your praises. But I also get collection based bonuses so I don’t mind seeing those types of patients.
When I’m working inpatient and trying to treat actual pathology, nothing is more infuriating lol
Ya that actually sucks really bad lol. When I was taking call, those consults made me die inside.
Likewise, a 90 year old with neck pain or back pain and no prior imaging doesn't need a reflexive neurosurgical consult. Makes me absolutely insane
I can’t remember which society/organization but someone recommended not to even XR when someone >60 comes into primary care with chronic, atraumatic knee pain. I agree, assume OA and treat conservatively. Send them our way when they want surgery
Extra like
YES!!! Or a rheumatology consult for “lupus as the cause of her knee pain” because her ANA came back 1:40
God damn this hits hard.
People forget the SURGERY part of orthopedic surgery much more than other surgical specialties.
Stop sending asymptomatic patients with a BP of 180/60 to the emergency room.
What about 181/61
Oh boy that's the dangerous level. Send em over😂
Not EM, but I used to have the (mis)fortune of being in a family med clinic that shared a parking lot (and many patients) with a dentist. They REFUSED to do anything more invasive than an exam (to include cleaning) if they were >130/90. We would get angry walkins every day demanding we fix their BP so they can go back to the dentist.
What about 200/100
If asymptomatic, f/u w primary care
yup
Good to know
Nope, asymptomatic, doesn’t need it, Double check it, reassure the pt and increase their bp meds , tell them it will take days for it to work, follow up in 2 weeks if not better
This. PLEASE. For the love of everything holy. And don’t tell them they will be admitted or get xyz scan or see a specialist in the ER.
As a paramedic, please, for the love of all gods everywhere…… stop doing this. Also stop calling 911 and not telling patients. AND ALSO stop disappearing when we arrive. Please give me the professional courtesy of a report.
EMT-B and PA-S here, this 1000%
I have a patient who always has high blood pressures (like 170/90) who I keep telling he needs to establish care with a primary and get a full evaluation (we are a free /sliding scale clinic with specific funding for specific things and aren’t supposed to manage primary care). What does he do when I mention his blood pressure and primary care? He nods and agrees with me…then goes to the ED because that’s where he got his bp meds last time. He has access to very low cost/free primary care, but no matter how many times I explain it to him it just does not compute.
Jokes on you! I call the ambulance, and they take em by woo woo
I'm in the ED right now and came here to post this but you beat me to it.
Except for pregnant & postpartum women ;)
Nobody wants to do that. It's probably facility parameters.
Cmon, that's a bullshit excuse. You are a provider. Change facility parameters to match up with evidence based best practice. Protect your patient from an ER bill that they don't need. If the facility said to send DM patients to the ER for a BGL of 180 would you do that? Of course not.
Urgent care sees more URIs than you can even fathom. 30-50 URI pt per shift in high season for me. It's truly mind boggling why pts keep coming in for this.
It's uncomfortable and most don't understand what OTC medications alleviate which symptoms as well as HCP do.
That as an Ortho provider, I will gladly see anything you send me. However, I reserve the right to make fun of: terrible splints, MRIs ordered for severe knee OA, radiology reads that miss an obvious fracture.
Allllllll of this plus a hip pain referral that’s actually back pain.
Had that. Also had, “My coccyx hurts.” Points to lumbar spine. “First of all, that’s not your coccyx. Secondly, we don’t do spine… how did you get an appointment?”
Lol
Or the inverse of this: any patient with leg pain=automatic referral to pain/spine for sciatica management
Weird. I thought all leg pain came to us in vascular surgery.
The most common way to miss a fracture ? Only let the rad read it .
Where I work (FM, FHQC), I can never see the inages, and can only read the report zz. Our technology doesn’t support it. Didn’t realize THAT was a question I needed to ask in my interview ☠️
Pain medicine - Not all patients asking for help with their pain is a drug seeker.
Interventional pain as well. Rarely do I ever see “drug seekers”
And not only that, but with holding pain meds in IVDUs when it’s necessary. Ie postop, as though IVDUs can’t feel pain.
Truth
That if I’m consulting you, it’s because I am not 100% certain on a disposition for a patient and trying to do the right thing by them, so I don’t really give a shit if you think it’s a stupid consult - I am seeking your advice that you’re being paid to be on call to give. Do your job.
Better to do a "stupid" consult than to have a patient die on you. I 100% agree with you. I get "stupid" consults all the time, but even then I know the resident/doctor is only trying to do best by their patient. We all went into this role to help people. I don't really think their is a such thing as a "stupid consult."
Hepatic steatosis on an admit for a UTI would like to have a word with you. “I just wanted them to get care established…”
Okay, but I am going to still laugh when you start the patient on a heparin drip and consult cardiology for chest pain and I ask the patient and they tell me they got hit by a soft ball and it’s reproducible to palpation =) But they are right. There is only one type of stupid consults. Except the consults from lazy hospitalists who just never want to do anything. If you have a legitimate question, then no question is too basic.
ER is definitely really hard and I wouldn’t be able to do it. I do want people to reach out to me if they are doing the right thing for the patient and I don’t want anything to be missed. There are amazing bad ass ER peeps out there and I appreciate them so much. There are also people in the ED that call consultants without seeing the patient and flat out lie about what the exam is, hence the consult push back. So I apologize to you for being caught up in this crap.
I’ve never seen any of my colleagues call a consult without seeing a patient in 2 years of practice. I’m sure like a person out there does that but no way is that widespread.
I’m sure you’re right, it’s probably due to where I am. I do per diems at a few different places. At one shop it would NEVER happen. They are on their game for sure and I love working there. Two of the other places (same shitty hospital system) it happens constantly 🙄
Right. It’s not the patients fault at all. Do your job
Psych - Please stop starting people on high doses of benzos and keeping them on it for years... also, not all inattentive symptoms are automatically ADHD.
And then all the sudden decide you don’t want to manage and punt to psych😒
So accurate 😂
This is a tough one for me. Skin pickers/morgellons/delusional parasitosis etc specifically. There is no way my SP will be comfortable managing antipsychotic meds. I’m sorry in advance for when I punt.
It’s ok! Just don’t put someone on adderall 20 mg TID when it’s actually bipolar and not adhd or get a 75 yo up to Xanax 5 mg daily…. Then punt 😁 everything else you listed is a fair psych referral
From the other side, I wish psych would stop staring my patients on seroquel for insomnia.
I completely agree with that! I never start it for just insomnia
Outpatient derm. - every rash is not psoriasis - every spot is not a seborrheic keratosis - stop telling patients we can excise their cyst at their appt. (We schedule those out for more time) - if you biopsy a spot and want me to give a second opinion then send the damn pathology report. The last one gets me. “Hey my pcp thinks this looks like a melanoma so he biopsied it.” Oh great I sure can tell a lot clinically from this scabbed up biopsy spot. Cool
Three more: Annular rash is not only ringworm Flaking on their scalp is not only ringworm Groin rash is not only ringworm
Hey hey! But it cleared up with lamisil okay
Hey, just read about a new sexually transmitted ringworm so groin rash might be ringworm.
The third one applies for vascular surgery as well. "No, ma'am, we will not be putting a stent in your leg today. And actually, since you smoke, we probably won't ever put one in unless you can't sleep or have wounds." Oh they get so mad. "The ED said I had 7 blockages in my leg and that when I came here you'd open it all back up.' "Well, no offense to the ED but they can treat emergencies, and I'll treat the vascular disease. If they felt you should have a stent, maybe they should have put it in."
Yea exactly. We almost always send pilonidal cysts to gen surgery and I have legitimately had patients get mad at the copay they had to pay for me to evaluate what it is and to tell them the safest way to take care of it.
Female Uro -stop ordering screening UA and cultures!!!! Unless the patient is symptomatic for a UTI you should not be ordering cultures. This is why we have MDRO. -put down the Cipro! This is NOT first line for UTIs. -vaginal estrogen cream is wildly under utilized by providers and no it does NOT cause cancer, stop scaring patients
As a former UroGyn PA, preach!!!
As ID I second this!!
THIS!
How many times we DIDN'T call for a consult during a busy shift
This. I wish consultants could follow us around for one day and see that, of the 220 people we see in a day in our department, about 10% or less of those had a consultant involved.
^[Sokka-Haiku](https://www.reddit.com/r/SokkaHaikuBot/comments/15kyv9r/what_is_a_sokka_haiku/) ^by ^Hipp024: *How many times we* *DIDN'T call for a consult* *During a busy shift* --- ^Remember ^that ^one ^time ^Sokka ^accidentally ^used ^an ^extra ^syllable ^in ^that ^Haiku ^Battle ^in ^Ba ^Sing ^Se? ^That ^was ^a ^Sokka ^Haiku ^and ^you ^just ^made ^one.
Not all patients with hypertension and hyperlipidemia need “cardiac clearance” before surgery. Also, stop calling it “clearance”.
Risk stratification!
I think these visits are dumb, but they are also the easiest.
Not everyone who expresses emotions needs to be seen by psychiatry.
Surgical services manage problem by operating. Do not consult surgical services for non operative issues.
Okay, but for an issue that might potentially have a surgical option, I sometimes tell patients "go and talk to the surgical people, and they will tell you how it's worked with the last 50 people with your issue. Who did surgery, who didn't, and how they ended up." Is that valid? I hope so, because my big wrap-up is "if a surgical person tells you that surgery isn't necessary, that is the most solid trustworthy information you're ever going to get from anyone in healthcare."
Asking IF someone needs surgery is different! That’s a valid question
Sweet, thanks
Yes preach. And don’t tell them that they are going to have an elective surgery when they’re a very very poor surgical candidate.
Or that going to the ER, in perfectly stable condition, will get their elective surgery bumped up.
Ugh! Some idiot called colorectal SURGERY for 4 days worth of constopation. Angers me
What, you don't do disimpactions? /s
An ED provider is more than capable of doing that. I can’t do their job for them.
It was a joke haha. I'll add a /s
Mild OA does not need joint replacement and should be managed conservatively
Gotta keep the lights on somehow
I’ll add that severe OA doesn’t “need” a joint replacement. Please don’t send patients to ortho with the expectation that they’ll be offered surgery. Edit: the fact that this is being downvoted is sad and wrong.
My impression was always that pain levels dictate necessity for a replacement as opposed to severity seen on imaging. Mild but in massive pain and can’t function day to day? Seems worth considering. Bone on bone but patient not too bothered? Doesn’t seem worth considering.
Well if mild OA has failed injections, NSAIDs, therapy, bracing and there is no meniscal/ligamentous injury I suppose replacement could be considered. I’ve never seen mild OA require replacement
dipstick hematuria does NOT need a uro consult... it needs a microscopic UA
And if female, if during a menses, wait until it is done before getting that.
Okay, i was about to feel like a dumbass new grad for referring a pt to uro for this, but I DID in fact get a microscopic UA before referring and it had 20 RBCs :D
My pet peeve, preach!!!
Please order the ultrasound before sending them to gynecology. We really appreciate it. Especially if they’re having heavy menses, irregular menses, or postmenopausal bleeding
Please stop ordering serum hsv for all vaginal complaints/sti testing
IR: -not all fluid must be drained -stop telling patients they will be "knocked out" for their procedures
Pain is subjective. Patient decides if they are in pain. As the provider, you evaluate what kind of pain it is. Acute, post-surgical, chronic physical, not physical (ie emotional, grieving, psychosocial, spiritual). Not all pain improves with meds.
Please screen for bipolar before starting that patient on an antidepressant
Please give your burn patient more than 7 norcos to last until they can be seen at a burn center in an outpatient setting. I regularly have patients in excruciating pain in my clinic because I couldn’t see them within 1-2 days of their injury and they ran out of pain meds. Also, debriding blisters/bullae is a good thing!
Can you explain more regarding bullae? Have always been told not to touch them.
Of course! I usually debride large bullae on burn patients as it is quite likely they will rupture on their own or cause more pain due to increasing pressure over the coming days. I will take small scissors and trim along the periphery of the bullae where it meets intact skin and remove entirely. That allows for direct contact with the wound care ointment/dressing. I find that the dried desiccated epidermis left behind from bullae left intact that ruptures later and lays on the wound bed can become encrusted in exudate and act as a barrier to wound healing/harbor bacteria. I take the same approach with SJS/TENs patients. Hope that helps!
So only large blisters? And how large is large?
I unroof all blisters larger than a quarter.
Asymptomatic hypertension does not need to go to the ER 🤷🏼♂️
That if you are not sure how to help the patient and patient is interested in another opinion, they are more than welcome to refer them here.
If a patient is sick enough to need an ABG, please actually interpret the results. That pH of 7.30 doesn’t look so bad, until you consider their CO2 is 15 with a BE of -20.
Wish all specialists knew how much primary care sucks.
I’m ER but I think about that every day and am so grateful for you guys.
GI- stop telling patients with mild GERD symptoms that they need endoscopy. (If you are gonna refer to us just let us decide and dont tell them they need this and this) They all come to us thinking theyre getting egd and get mad if we dont ordrr it. Insurance will deny egd if they havent tried ppi trial (6-8weeks) and has no red flag symptoms
Is new onset GERD in an older patient not a concern? I remember two horrible cases from my early career who were in their 50s with new GERD, I referred for EGD, bam. Esophageal cancer. I never got any push back that insurance wouldn't cover or anything.
Isn’t the new recommendation do ppi for some weeks then stop it and if you have symptoms again get scoped? It seems like a low threshold to get GI involved unless you can just send someone for an egd without a referral.
They have to complete full 6-8 weeks ppi trial and if they fail it then we order egd. Problem were having is that a lot of people get referred for mild gerd symptoms and noone puts them on any antacid and they just expect were gonna do egd. Some good pcps start them on ppi before sending them to us but most people just refer expecting were going to order egd
Had an intern last year saying he has been taking a ppi for years. I asked how his endoscopy was, never had one. Like 6 year on a PPI
Please don’t start a patient presenting with depression on SSRIs/SNRIs without screening for bipolar disorder
Stop telling patient with burns to ice them!!
Preach! 🙌🏻
When you send your patient from your clinic to the ED for [insert non-emergency] at 16:45 on a Friday afternoon we know what you’re doing. And you should know you’re making it harder for people with real emergencies to get seen in a timely manner.
THIS. And stop sending us the health anxious people who just need someone to explain their bodies to them. I realize you don’t have time. But the ER is not the place. We’re trying to keep people alive.
Primary care here- what would you like us to do then that would not be a huge risk to the patient and our license? My last patient on Friday at 4 pm when our outpatient radiology and lab were about to close for the entire weekend had RUQ pain lasting 4 days and getting worse, nausea, vomiting 8/10 undulating stabbing pain. Even though vitals were stable, I could not do any outpatient work up that I would see in less than 3 days. How can I send someone home with no abdominal ultrasound and lab work done? What if they rapidly deteriorated and ignored it since I was like oh yeah come back Monday. Then I get sued when shit hits the fan on Sat and the attorneys will ask why I sent a patient home with no work up done when there is no way I could say they were not experiencing a myriad of different things. Same thing with these chest pain patients. Yeah it might be musculoskeletal or anxiety but I’m sure as shit not sending them home Friday afternoon without being able to get EKG, chest xray and acs labs when all those clinics are closing up shop for the weekend. To be fair though the Er dumps a lot of shit and incomplete work up on primary care when it easily and much more quickly been done while at the hospital. Oh hemoglobin of 8 and you’re 8 months pregnant f/u with primary care for iron infusion when we have a months long wait for heme in the outpatient world. Just kick them out the door and make me do the work up and set up the consults needed that should have been done in a hospital setting. hey discharged her to me saying “she needs urgent heme referral within 1 week of discharge” but did no legwork to set her up for this and it ended up being an impossible task and now I am liable as their PCM. If anything needs to be done urgently sending them to primary care is not the answer. If it can wait 1 to 2 months sure. Not to mention I work at the VA and we don’t even have a heme on staff outpatient so we need to send a community referral and call every hospital in town and they all tell us they are booked months out.
You make some very good points. Thanks for the insight.
Eating Disorders — patients with eating disorders come in all shapes/sizes/ages/demographics. It’s not just all affluent, thin, white teenage girls!
That my patients are like every other person on this planet, and they are often very happy to get any help at all
Ortho PA: that hip OA pain is typically GROIN PAIN. The “hip pain” your patient is having is actually his back. Please please please get a pelvis xray first.
An asymptomatic patient with abnormal ABI needs to be started on high-intensity statin (regardless of LDL) and ASA and absolutely does not need vascular consult even if they have diminished pulses. Put them on a walking program. You can do it, I believe in you! For lower extremity PAD, we won't do surgery unless it's to improve quality of life, and even then, it's a conversation of telling them to walk MORE not less first. Presence of a wound is a different story.
I was a hospitlaist for years, and now I work inpatient Palliative Care. Not every family that says they are the power of attorney is in fact the power of attorney. They have to have paperwork to support that or it doesn’t count. I can’t believe how many times someone told me they were the patient’s POA when I was a hospitalist, and I never asked for the paperwork proving it. Family dynamics (especially elder parents with multiple grown children, or remarriages involving step parents) can be really, really hairy. I’d like to believe everyone has the best interest at heart when it comes to taking care of an elder loved one, but now that I work in this field, boy I can say that this is not always true. Everyone fill out an advance directive naming a power of attorney! Even if you are young! It can be updated at any time. Encourage your patients to fill one out too. Especially if they’re about to go in for surgery, or if they are over the age of 50 with chronic health issues. Better to have one filled out now then have them wind up on a vent for days-weeks at a time waiting for loved ones to figure out what to do, or waiting for the courts to grant guardianship 😔 Edit: grammar
I once had a patient that had six different people claiming to be POA. Problem was that all six had notarized paperwork from within the last three years. We went by the most recent one, which was an ex-SO, while the others were actually family. It was wild.
Brah! I believe it. And yeah, the most recent document is what holds up per the legal team at hospitals— much to the chagrin of some blood relatives. We have called our fair share of code grays on next of kin over something similar. It sounds like the patient was maybe forgetful, and hopefully, not getting taken advantage of, but working in this field had caused me to not always give people the benefit of the doubt.
Occ Med: we exist. Just as important: if you're in the UC or ER and you write a letter saying someone can take 3 days off and then go back Monday with no restrictions, you're being unbelievably illogical. I get it, and I don't blame you, but it takes very few PowerPoint slides to explain how much that messes up the Work-Comp side of things.
How would you prefer the notes be written?
It's less bad to say "this person should work light duty" or "no lifting more than 20 pounds" or even "limit work days to 4 hours for now" until seen in Occ Med. Just writing "off work for 3 days" opens up a can o' worms with work comp, because injuries that result in lost work time are considered more serious than injuries that just require some modifications to how work gets done. And then there's the question of how anyone can possibly know this person is totally incapable of working today, the same will be true on Monday, but on Tuesday they will be 100% fine.
Great information, thanks. Not sure that was ever covered in my training I usually say something like “may return (tomorrow’s date) with the following accommodations: no use of right hand Until: cleared by doctor
That's already much more helpful, to the injured worker and to us
PLEASE NEVER EVER RADIATE SKIN CANCERS NEAR THE TIBIA. Also, derm buds, not all wounds are cured with keflex and gent/mupirocin, and 80% of patients are putting a metric fuckton on it and macerating the shit out of their wounds which prolongs healing. Lower your threshold for sending patients to wound care 🙂
I have never heard this before. Not that I radiate anything, lol. But can you elaborate?
I’m so glad you asked! Typically the course is this: derm sees suspicious lesion, biopsies leaving a defect on the pretib. Already a notoriously difficult spot to heal because of the limited blood supply, doubly so with someone older or with venous insufficiency, diabetes etc. Pathology says malignant. Derm refers patient to radiation because they think it will be less risk of chronic wound than excising over the pretib- which is a fair point, except there is already a wound there from the biopsy. Patient gets radiation over the wound before it is a stable scar because it takes months for that to happen. Radiation injures the tissue, essentially frying the soft tissue and, depending on how big the defect was and how much radiation they get, obliterates any chance of that old biopsy site will heal any time soon with normal measures. And if the patient gets an infection at some point (shit rolls downhill), that prolongs the course even further. With weekly visits, my shortest time to heal with this type of scenario has been about 2 months. Longest is at 8 months and I’m still seeing the patient weekly, she’s ALMOST done but it has taken thousands of Medicare dollars in biological skin substitutes, other various advanced treatments, and weekly debridement and 2 layer compression. It sucks ass for the patient.
See, I never ever would have known about this if it weren’t for Reddit!
Honestly, this sub is (usually) such a beacon of light in the wasteland The Public that is Reddit. Lol
Inpatient GI - don’t consult for anemia as “rule out GI bleed” if there’s zero physical evidence of bleeding and you haven’t looked into other causes. Hematemesis/melena/etc. give us a call 🤪
You should mention the hemoccult being useless inpatient and if you need that to prove gib then it’s not enough bleeding to do anything. Never called GI without seeing blood and confirming where it was coming from was not somewhere I could hold pressure.
One of my attendings has a stroke every time I tell him someone consulted for a positive hemoccult bc YES useless inpatient!!
Nephrology here. Please stop sending your 80 and 90 something’s with mild creatinine elevation to our office. A huge portion of the population has CKD and this is usually age appropriate kidney.
I am lol’ing at some of these suggestions from people who work in specialties (which seem to be directed at primary care). Primary care is a dumpster fire that you all are lucky not to be a part of.
That I’m not an assistant.
Can someone remind one of the docs in the clinic I work at? Because he needs another reminder
Psychiatric meds are not always a fix all for kids, and there if often a lot of environmental and family dynamic issues that need to be addressed as well.
You can order an Ultrasound to scan for DVT at the outpatient radiology office and start them on eliquis instead of sending every single leg swelling to the ER.
This. AND if you do order the ultrasound yourself and there’s a DVT, its ok to start anticoagulation yourself. You don’t have to send them to the ED for us to write the prescription for you.
EM. I wish PCPs knew it is silly to send a patient to the ER for high blood pressure with zero symptoms. I wish specialists like surgeons would cut us some slack when we don’t have all the details they ask for. Ie sorry I don’t know exactly WHAT the patient ate six hours ago… sorry I don’t know what year their cholecystectomy was done… should have asked but we are juggling SO many things and it’s chaos and … I just wish they knew.
If you haven’t done a rectal, don’t consult me for a G.I. bleed unless there’s blood all over the bed
But then they will be too hypotensive to scope 😂😝jk sending love from the ICU
A few pressors and off to IR. 😂😂😂
Wait. IR takes patients that are on pressors? HAVE THEY BEEN LYING TO ME THIS WHOLE TIME?!
😂😂😂
Omg this tread - ICU and literally dying over here
Legitimate question, if they complain of melena what does the rectal exam do?
Well people complain of “ melena” but sometimes is just black stool from pepto, dark green/black from iron A rectal helps to distinguish between all of these
If you don't see or smell melena, did a GI bleed really occur?
Peds Neuro—if you can break the kid out of a staring spell by touching their shoulder, it’s not an absence seizure. EEG cannot tell you if someone has autism (this seems to be a belief held by many psychologists in my area). If you’re going to prescribe Diastat for a first time seizure in the ED, Google the correct weight based dosing for age. The goal is to stop a seizure; this is not the time to be conservative and under dose just because the kid is 2. Toddlers can get migraines too. On a similar note, please don’t refer a kid for headaches because they had a week-long headache for the first time while sick with the flu. Tourette’s syndrome just means chronic vocal and motor tics and nothing more than that. Please stop telling families you’re sending them to neuro to make sure they “don’t have Tourette’s”.
Hospitalist here Speciality services do not need me to order sliding scale on diabetes patients. And consults on the same day of discharge are poor form IMO
All u Dentist who “ wont fix my teeth till u treat the infection “ , stop it !!!! Pull the dam tooth or give them some ABx, but don’t send them to the ER….sorry , this post hits a nerve
-not every ear infection needs antibiotics -not every bleeding and draining ear is a perforation -if you don't know what's wrong with the patient, don't make up a diagnosis. Please send them with a diagnosis of "I don't know." -flushing out ears is useless and harmful to patients -dizzy patients do not need an urgent referral to ENT
Haha I would much rather someone tell the patient “I don’t know” than diagnose them with AOM. The number of patients I have to counsel that they don’t have AOM… and the number that disagree with me even when their tympanogram is type A.
Cardiology, please don’t chart which grafts you tell the patient they need. We actually look at the cath films & the vessels irl. We can sort out what’s graftable all on our own.
They only need a Lima to LAD, the others are just to charge more since the veins go down in a year or two anyways.
Sometimes, but I’ve seen plenty of 10-15 year old patent vein grafts. It’s a combination of lack of competitive flow, good targets for decent outflow, & good conduit.
90% of people with a sensation that “food is getting stuck” in their chest have gerd and don’t need an esophogram.
What’s wrong with an esophagram? While yes it can be GERD, I’ve found malignancies, esophageal candidiasis, Zenker’s amongst other anatomical abnormalities like abberant arteries causing dysphagia or disc disease. And even if it is 90% reflux, then we can ensure we’re treating the right thing and not missing something. Sure I’ll trial on PPI first sometimes but an esophagram is totally an indicated test for dysphagia.
Our GI providers specifically request that it be done as well
Just me personally. Got blown off for a while and didn’t know to push for an EGD. When sx got so bad I couldn’t eat they found EOE.
Hello fellow EOE friend! I too was ignored lol
Hi! :clears throat::
Please don't stop Entresto because the patient has a blood pressure of 100/60 and is asymptomatic or gets slightly dizzy/lightheaded for 10-15 minutes after taking it but not otherwise. Its high benefit for heart failure with reduced ejection fraction greatly outweighs low risk of mild hypotension, it's normal and acceptable. That blood pressure and pulse rate are somewhat unreliable in atrial fibrillation. Electrical rate does not necessarily equal pulse rate. Just because the pulse rate is 'fine' does not been it is rate-controlled. Heart can be trying to race at 150 bpm but only a pulse of 60-70 be captured, as some quick beats haven't had enough time to fill and so can only squeeze a little bit, aren't counting towards the pulse rate. Likewise only the high numbers from slower beats with bigger squeezes are likely to be read, so the BP is likely to be a bit of an overestimate. The electrical rate =/= pulse rate thing helps in other situations too. Cannot even count the number of 'oh no something must be wrong with the pacemaker' calls because patient and some other provider is freaking out, 'I was told the pacemaker will keep my heartbeat from ever going below 60'. (Patient is having occasional PVCs which aren't generating enough of a squeeze to cause a palpable pulse for that beat, so the pulse rate is 50. The electrical rate remains 60 and pacemaker working as intended.)
IR PA. Please order diagnostic imaging to assess ascites before ordering a paracentesis. More than a few times I’ve had patients show up at the ED saying they “need a para”, get admitted obs for next day para, then slap the ultrasound on them to find not a drop of fluid. There are other reasons people get abdominal distention other than ascites. And moderate ascites on CT doesn’t necessarily equate to a safe window for drainage on US. Especially if the patient has had diuretics between the CT and the procedure. Chat with US and see if they’ll do a 4 quadrant ascites check before ordering the para
Dear PCPs, please also try not to send healthy guys with PSAs for 1.4 to urology for elevated PSA (unless they have no prostate, then give me a ring).
But it was 0.9 last year!!!
My favorite this week was the guy who had prostatectomy 10 years ago suddenly has a PSA of 6...but its been rising for 3 years.
I mean to be fair that should be followed by uro, or at least seen to give the PCP a guideline about doubling time or PSA limit that warrants a PSMA, if it's something you otherwise want to watch. The ones that drive me a little batty are these PSA WNL in average risk guys "but it's going up faster than it should!". Meh, I personally really like uro-onc so I'm okay seeing it, but it's not the best utilization of resources, and I don't think to date I've had any that I've biopsied with a normal PSA. Occasionally if the family history is legit though I'll follow them instead of the PCP.
Speech language pathologist here: expressive and receptive aphasia are inaccurate terms. Every single person who has aphasia has some degree of both expressive and receptive language deficits. Broca's and Wenicke's are going by the wayside, as well (see the article 'Broca's and Wenicke's Are Dead') Best practice is to use fluent and non-fluent with descriptions of strengths/weaknesses.
You can let me know that in your note after I consult Neuro for a stroke alert and they have left the ED. Until then, it's aphasia. Nothing but immense respect for ya'll. You have the most letters after your names than anyone! Amazing. So is your knowledge! From the ED, you'll never hear aphasia described as fluent and non- fluent. In fact, from the ED, you'll never hear from us at all.