Quick Learner

So I had a drug seeker come in the other day with her usual back pain.  Lately I have been very stingy with narcotics and after refusing to give her a shot of anything stronger than Toradol I explained that I only give narcotics for patients with fractures or obvious acute injuries and never to patients with chronic pain (which is not strictly true but I thought it would be impolite to point out in front of her family that my records showed six visits in the last two weeks to our other Emergency Departments around town).

In my discharge instructions I cautioned her to return for numbness, weakness, urinary retention, or urinary incontinence (all things that can be caused by spinal cord injury) and wouldn’t you know the next day she showed up with a normal gait, normal neurological exam, normal deep tendon reflexes but having ostentatiously wet herself, something she mentioned to me as she stumped past on the way to her room.

Nice try.

Apparently the internet is loaded with sites where drug-seekers can learn what to say and how to present themselves to Emergency Physicians to get drugs.  I’m less than impressed by a patient who endorses twenty-out-of-ten pain in the right upper quadrant brought about by eating fatty foods who I have to shake vigorously to awaken but some of them are quite good.  I’ve been burned a few times, suckered into giving Dilaudid to patients who I later discovered to be frequent fliers.  The first warning sign is usually the inability of a normal dose of Dilaudid…essentially legal, high-grade heroin…to “touch the pain.”

The Holy Grail for the seeker is, of course, being admitted for intractable pain and being put on a “pump,” or Patient Controlled Analgesia (PCA) which is like having your narcotics on tap.  Still, suckering the doctor into giving you a few hits of Dilaudid before the unamused charge nurse hands him a stack of papers detailing your last twenty visits is a major victory as is scoring a ‘scrip for Lortab.

Oh, and just a tip: If you are young, otherwise healthy, and look stoned (because you are stoned) I’m not going to give you anything but some life advice so don’t bother coming in.  Your back may or may not hurt but many people older than you with real skin in the game have survived back pain with nothing more than Motrin.

Just an aside, I write prescriptions for Motrin because it only takes one mouse click on our Electronic Medical Record system but I always hand-write on the printed prescription, “Over the Counter, Not for Prescription.”  I’m really busy so a minute saved here and there can add up to real time over the length of a shift.   I don’t care if you have Medicaid and they will pay for it.  It’s not asking a lot for you to throw down a couple of bucks for your own medical care.

I still get frantic calls from patients saying that my prescription says “600 mg” of Motrin and all they sell are 200 mg tablets.  I weep for this generation.  Have Americans always been this stupid or is this something recent?  It’s probably a recent thing.  My older patients may or may not have a college education or advanced degrees but most of them seem to have some basic common sense.

We are definitely getting less intelligent.  Apparently being a moron is not only an accepted lifestyle choice but, given the growing allure of the welfare state, it is now also a desirable survival characteristic and one that is being aggressively selected for.

Patient of the Week

“My Doctor told me to come in to be admitted for back pain.”

“I have no doubt your back hurts but as you are clearly without neurological deficits, appear comfortable, have no fever, and a negative urinalysis there is no indication to admit.  What kind of doctor is he?

“A chiropractor.”

“We have an automatic door in the department so it you move quickly it won’t hit you on the ass on your way out.”

The Crying Game

Remember that movie where, after a couple of hours it is finally revealed that the chick is a dude?  That’s kind of like President Obama.  All of his breathless supporters thought he was a beautiful, sensitive, caring girl but now 200 days into his presidency he has shown everybody his penis and, although they still want to like him, it’s hard now because the chick’s a dude, man.  Sort of changes everything.  I mean, she still sounds the same, looks the same, is wearing the same clothes but she’s a guy…and all but his most ardent followers must be squirming in their seats to think they were ever attracted.

Sure, the die-hard zealots, those who have in the dead of night surreptitiously scraped off their “Dissent is the Highest Form of Patriotism” bumper stickers still think he’s good-looking even if he has a twig and berries but the majority of Americans, those who care I mean, are catching on that the Sun God, Ra-Obama, is something of a petty dictator along the lines of Mussolini.   That and he is completely out of his element, not very smart, and well along in completely screwing up the one thing he was mistakenly elected to fix.  A silver tongue/teleprompter and charm are not a substitute for basic intelligence and some friggin’ common sense, even in the insanity that passes for American political culture.

I’m Back

As many of you know I recently finished my residency training and am now working as a real live Emergency Medicine Attending Physician, completely autonomous and completely responsible for every decision I make.  It has been an easy transition so far because, and you may read this as a defense of the need for residency training, my program trained me well to handle the full range of medical emergencies that we commonly (and uncommonly) encounter.   More importantly however, my program trained me to be comfortable with the not-so-emergent patients; the ones with a blurry constellation of mild complaints and extremely vague exam findings.  The truth is that there is a lot of general medicine in Emergency Medicine and as one of the most common presenting complaint appears to be, “I couldn’t get a quick appointment with my own doctor so I decided to come here,”  I am beginning to understand that my job is not to work up everybody all the time for everything.  While I still reflexively admit the usual patients (chest pain, elderly with unexplainable pain) I’m sending a lot of people home with instructions to follow up with their own doctor…even going so far as to call the doctor in question for patients I think are unreliable.

I mention this because I sent a patient home with vague abdominal pain who came back the next day and was diagnosed with appendicitis by one of my colleagues.   You might say I missed the diagnosis but I respectfully submit that, as the patient was given clear discharge instructions to return if not better (which he did) we can put that one in the win column.  It’s either that or we CT scan every patient with no fever, a normal white count, a benign abdominal exam and absolutely none of the classic findings for appendicitis except a very mild, intermittent pain in the lower abdomen that didn’t even localize to the right lower quadrant.

I’m also beginning to appreciate the utility of the “Likelihood Ratio” and how it applies to Emergency Medicine.  Our most excellent Program Director drummed statistics into us and we naturally resisted manfully but it is good to now have some theoretical basis upon which to justify not ordering labs or studies that will not effect treatment or disposition decisions.   I still reflexively order Basic Chemistry Panels and Complete Blood Counts but one day I’m going to get the nerve not to do it.  I wonder how much money we waste checking these things on people who look healthy?

Just file it under not wanting to know everything about every patient when usually it is enough to address the chief complaint and be done with it.  Which brings me to one of my biggest pet peeves, that is, the ordering of imaging studies and lab work in triage.  Sure, sometimes this practice speeds up disposition but not every patient, for example, with abdominal pain needs an Acute Abdominal Series; a set of four xrays at my hospital.  With a few exceptions, the Acute Abdominal Series should be reserved for, well, patients with an Acute or “Surgical” abdomen which I assure you most of my patients do not have.  Vague abdominal pain certainly does not qualify and the Acute Abdominal Series is completely useless in either ruling in or ruling out anything useful in the majority of patients for which it is automatically ordered.

If I suspect something is going on I’ll get a CT scan.

Not only is the routine ordering of unnecessary imaging wasteful but once we get the study we are now on the hook for every finding on it, even those that are incidental.  If I miss a small pulmonary nodule on an unnecessary chest film that later turns out to have been lung cancer I own it and the ensuing lawsuit.  Better not to know…especially if the guy came in for a sore throat and no other respiratory complaints and with a completely normal lung exam.

The triage clerk is killing me.

27 thoughts on “Pandamorama

  1. Panda,

    I’m glad to see you are back. And it is good to know there is life after residency. Having now spent some time in the clinical lab thinking about things like test utilization and cost containment, I can tell you that unnecessary lab tests can be quite costly. There have been some efforts to look at whether the daily CBC is really necessary in all hospitalized patients. But I think it is hard to break the habits of reflex testing.

    Another problem at one of the hospitals we rotate at was lots of orders for send-out testing from the ED, ie pt comes in with fatigue, MD orders entire panel of thyroid tests which includes send-outs for Abs. Initial TSH comes back normal, MD goes off shift, pt gets sent home. Lab still has sent out other tests, which of course come back normal days later when pt is long gone. Probably better EMRs/reqs could help w/ some of that, as would better ordering practices. There’s a long way to go.

  2. “even going so far as to call the doctor in question for patients I think are unreliable.”

    I’m not a doc, and this surprised me. My PCP’s office is incredibly busy, and I can’t imagine his staff calling me to follow up on a call from the ED. Is that common?

  3. I think it’s inconsiderate to make patients pay for medicine that is covered by their insurance, regardless of their ability to pay for it. Insurance companies rip a lot of people off. People who have insurance have the right to use it. You are stepping all over that right.

    (Whoa. People on Medicaid pay nothing for any of their care, hence the abuse of the system. As for their “right” to use it,” this is ridiculous. Medical care isn’t a right, even if you have private insurance and it is ridiculous to make the taxpayers (me) or the other customers pay twenty bucks for a cheap, over-the-counter medication…not to mention that if the majority of my ridiculous medicaideurs had any common sense or a decent regard for the hard-earned money of the people supporting them they wouldn’t throw away our four hundred bucks coming to the Emergency Department for something normal people handle with a couple of mortrin.

    On another note, isn’t that the problem with medical insurance, namely that it has gone from being something used to cover major expenses to something that people expect to pay for everything, including routine care? – PB)

  4. Time clarifies many diagnoses. The CT might not have even showed the appendicitis, and then a young person might have gotten irradiated twice in two days if they repeated it when he came back.

    Keep posting, man. You should throw in a good word or two about how you get to see your wife and kids (I hope) now that you’re not a resident.

  5. Panda, you do NOT have permission to allow so much time to elapse between your brilliant posts. A girl has…ah, “needs”, ya know? and too much time between having those needs fulfilled makes a girl “uncomfortable”. Now repeat after me; “I will blog at least weekly, I will blog at least weekly…”

  6. Bitch please.

    Obama not smart…..riiiiiight. Palin 2012, eh? All those genius Fox News talking heads can’t be wrong.

    (Dude. You are confusing political skill with knowledge and a highly contrived liberal education with intelligence and, I repeat, common sense; common sense being the foundation of intelligence. President Obama could only get elected because millions of functional retards either thought he was the Messiah or fully expected him to pay for their gas, their mortgage, and every other annoying expense of life. The proof if in the pudding. Maybe he is The Smartest Man In The Fucking World but, as he is rapdily making a hash out of everything he wants to do…well…so what?-PB)

  7. From a non-physician:
    Congrats on completing your residency. Looking forward to more frequent posts.

  8. I’m planning on entering an EP residency someday. Just curious, where did you go, and what other programs can you recommend as excellent?

  9. There’s a book review I read, where the author got the impulse for writing a book from a conversation she overheard in a NYC bar in mid-september, 2001. Two men in their late 20s and in business suits, were discussing the terror attacks: “This is like Pearl Harbour all over again”, said one. “Pearl Harbour? What’s that?”, asked the other. “You know, the one during the Vietnam War”, he replied.

    So, the author decided she’d do some research, to see if such misinformation was a just a blip, or more common. What she found was not only a disinterest in knowledge and being intelligent, but an active aversion to it. I lost the name of the author and the book, and so haven’t been able to read it.

  10. Dr. Bear:

    Wondering if you happened to see the article below, and whether or not this is evidence that at least some people are coming to their senses in the health care debate:

    In your opinion, do malpractice caps work? Or are Health Courts a viable solution…or some combination thereof, along with other options (Loser Pays, etc.)?

    Thanks for any insight you can provide. Glad to read another great post!

  11. Panda : I disagree with your assessment on Obama. My evidence is from reading transcripts of talks he has given, WITHOUT a teleprompter. The man is able to respond to questions with clear, consistent ideas that have broad support by credible experts. Yeah, yeah, maybe you don’t believe in Keynesian economics or in various theories about healthcare reform. Or in CO2 emissions/global warming. However, the people who hold the advanced degrees in these things generally do. Sometimes the experts are wrong…but in your job, you have to do the things those experts tell you to do.

    What I’m saying is that I think the man is a generally credible and competent decision maker. He appears to be trying to make major changes happen, just like he promised. Now, some of these ‘changes’ are probably going to screw things up. Congress is certainly putting it’s mark on things. But it isn’t Obama you should blame for the current hash of things.

    As for your spiteful decision to make patients pay for their motrin….not sure what to say to that. Maybe this is a liberal idea, but some patients really are poor (that’s why they are on medicaid). Moreover, they don’t have any feasible way to get an education or a decent job. If they have a job at all, they probably have to work about 3-4 hours to make $20 just to buy motrin. They probably are pretty strapped for money all of the time, due to such low incomes.

  12. Oh Panda, how good it is to have you back! How we have missed you!

    I do agree with you about the AAS being an almost unnecessary study to be ordered at triage. Much like that urine preg that just keeps getting ordered on those
    post-hysterectomy gals…

  13. SmithJohn: Go to any RiteAid, Walmart, Walgreens, you name it. They all sell store brand ibuprofin for about $5. If you have smoked a pack of cigarettes, seen a movie, or have a cell phone, you can afford some ibuprofin.

  14. Urinary incontinence can be a sign of serious spinal compression, but it is usually painless.

    I’ve gotten some indignant reactions from people who present with dramatic tremors and high level pain complaints. When I tell them “Well you know, tremors come from the brain”, they often infer I’ve just said it’s all in their heads. That’s some pretty quick defensive thinking, amigo.

  15. Pandabear –

    I’m an intern on wards this month (I’m post-call today). All I can say is you speak the truth about medicine brother. Before med school I spent four years in DC working for a POTUS. You’ve got the politics nailed too. Keep it up.

  16. Panda, I know you didn’t go into medicine for the money. Nevertheless, the biggest difference, I suspect, between a typical month at work now and before you finished residency is the size of your paycheck.

    What’s it feel like, finally having adult pay? What do you plan to do with the money? Obviously, you have a huge amount of debts and deferred expenditures…but what do you plan to do after that? You could save for retirement, I suppose…but as you know, our lives can end alarmingly quickly. If you want to do something neat in your life with your money, now’s the time to do it.

  17. Dear PB,

    I know you’ve probably thought of this already, but why not go back to the old website and start advertising and making some $$$. This way everyone wins…you get some cash for a possible article a week, we get our much needed fix of asian bear mammals, and liberals/chiropractors are given a verbal thrashing. I know we all could use your words in these dark times…so how bout it?

    p.s. – I miss you

  18. shah – advertising doesn’t pay much. He’d make more money at work than he would spending even a couple hours setting up his own site and getting advertising added to it.

  19. smithjohn – you mind giving me an idea of how much someone can make from ads? like per 1,000 views is it 5 bucks or something? (random guess)

  20. Advertising doesn’t pay much? Anyone ever heard of She makes $400,000 a year off of her blog.

  21. Hey I think you practice in La Jolla, probably in VA, Thornton, or Hillcrest. Only a conjecture (“Sun God” “La Jolla” My friend was diagnosed with appendicitis the next day he went back to Hillcrest.)

    (Not even close. In fact, where I practice could not be more different than La Jolla. In fact, I’ll wager you can’t get more different between any two places in the United States. -PB)

    Dud love your posts!

  22. To make real money from advertising, you need millions of pageviews and a large audience. (hundreds of thousands of people or more)

    There’s only 80,000 medical students in the United States.

  23. Well, son (I say that affectionately and non-patronizingly, wishing I were your age again while being so very glad that I’m not your age again and just commencing my 32 years of Emergency Medicine practice), it’s wonderful to see your attitude on the ordering of unnecessary tests. I fought with my colleagues for decades about the rote ordering of tests, thereby making myself a heretic of the first order in their minds. But, I was right, as are you. Sounds like you have the balls to stand by your convictions and your correctness. We are/were probably both a bit crazy for that matter but it does feel good doing it right, doesn’t it? There is so much to be said for skilled physical diagnosis and it’s unheralded effectiveness. Do they even teach it much anymore? In spite of my probably intemperate iconoclasm, I was *never* sued in all those years; I do wish the same for you – keep up the good fight.

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