Saturday, February 14, 2009

ER as Primary Care Clinic

I had a long day of triage yesterday, and in true Friday the 13th fashion, had some weird ones.  There was the blood pressure of 201/102 (I'm sure there is a hidden message there, but unfortunately Tom Hanks was otherwise occupied and could not decipher it for me), the chronic back paineur-frequent-flier who suddenly decided that if he announced that he has numbness in his groin, he would get back faster, the chest pain who initially told me that the pain came with deep inspiration and coughing *thank you, back of the line for you, ma'am* and then when it comes her turn for triage, says, "no, the pain is constant and I haven't been sick lately, and I'm not coughing at all.  Oh, and it radiates to my left arm."  My BS alarm was working overtime, but when a patient says that, I have to at least order up an EKG and some blood tests.  I still wasn't about to bump another patient out of a bed for that one (incidentally, not only did the EKG come back NSR, but the social worker made a trip out to see me to let me know that this patient was on "the list" at 4 other hospitals for abuse of Emergency Services and had a list of psych problems longer than my left arm.  So long, in fact, that Happy would have told her to stop smoking.*

But what really got me was how many patients I saw that were sent by their doctors.  It was probably less than 10, but it felt like every other patient.  Some of them were pretty legit, like the possible sepsis, or the asthma exacerbation (although she was speaking in full sentences and was in no apparent distress, her lungs sounded very tight and wheezeful,** and she had only previously had asthma during pregnancy).

Then there was the parade of the others, like the RLQ pain that needed a workup for R/O appy FROM 5 DAYS AGO, the high blood pressure patient that got no workup other than a blood pressure check and a trip to the ER (Dear Doctor, perhaps if you had, I don't know, TALKED TO YOUR PATIENT, you may have discovered that he was out of his blood pressure medications.  I do believe that your medical license permits for you to write for BP med refills.  Signed, Me.), or these gems (from the patient's own "reason for your visit"):

Dr C#$%^ office told me to come in for my Chronic back pain
Referred from Primary PhisicioiN to E.R. (I don't remember the actual chief complaint, but I do remember it was unimpressive enough that I dumped her back in the waiting room)

Then this one made me laugh out loud:

DR A#$%# J#@$@ up and quit on his patients and I need my meds.

Not sure of the story behind that one, but he earned himself a trip to see the PA and get a couple days' worth of meds and a referral to a new PCP.

I'm also amazed at the number of patients sent in by their dentists for antibiotics.  The Dentists know that we cannot do anything more than give a handful of Vics and some penicillin.  I'll never understand why they can't have the patient come in to the office, sit in the chair for 1 minute to have their teeth glanced at, and then walk out with a prescription and an appointment for a week or two later.***

Finally, there was the direct admit patient who was told to come to the ER to be evaluated "in case there is something I missed."  I would comment on that one, but I don't swear.

* Incidentally, I'm actually on Happy's side in the stop smoking debate, but it is still fun to joke about because he takes it so seriously and Nurse K takes her exception to him so seriously in turn.  Calm down, children.
** made-up word for the day.
*** Okay, so I do understand it, and it is spelled M-E-D-I-C-A-R-E but it is still dumb.


Nurse K said...

Asterisks are my thing. Copycatter.

If you're going to steal my asterisk gimmick, you at least have to disagree with Happy Hospitalist who thinks smoking causes obesity despite it being an appetite suppressant.

Braden said...

Using an asterix to indicate that there is a foot note is not a gimmick, it is a common literary practice wherein an unrelated remark or clarification can be made without interrupting the flow of one's thesis. Don't go pulling a Rush Limbaugh on me and assume that you are the original source of every idea. I've been using footnotes for years and years. In fact, I used footnotes in high school when the use of said notes placed you firmly in the "geek" category. In fact, I had never noticed that you even used them, though if you wish to take credit, then I will allow it, but you have to give me credit for the capital letters that I see you stealing from me.

And as for the smoking thing, I think I'll make a post on it if I get the energy.*

* I just wanted to make a footnote here because I thought it would be fun. Was it good for you?

Somenurse said...

We have had a rash of "my doctor sent me" as well. Some are legit, most are BS jarc seekers. Most of our legit ones are from the peds office for r/o dehydration, r/o pneumo, r/in RSV. Secondly one of our local docs was arrested for selling narc prescriptions so now we have a rash of chronic paineurs who are faking other illnesses to get seen. Yet somehow even with the legits the doc rarely calls to tell us the pt is coming. Then the pts get mad cause we had no idea they where coming and they have to wait. The ones that get really pissed are the ones who where "refered" for an MRI. We don't do MRI's on just anybody.