How about primaries abusing the ED? As though the ED is some branch of their private practice. I am so sick of people coming in saying, "I saw my MD, Dr. Big Douche and he said to come here for x,y, and z." ARRRRGH!!!!
My first question is always and "When do you plan on finding a new MD?" TO THE GENERAL PUBLIC: Your doctor should never send you away from his office after having made an appointment with him to go to the ED for:
1) A pelvic exam. As in "he said I needed to come here because I need a pelvic exam. He sent these cups..." Are you sh#tting me? It's time to find a new doctor!
2) "He said to come in here because I need blood work." No, you may think this means go to the lab with your order for blood work, but alas, no. It should read, "Just go to the ED to see a real Dr. because I don't have a f#cking clue."
3) An EKG. This is self explanatory.
4) Because you're wheezing. Please see #3.
5) Because you need medical advice. When you call the doctor to ask medical advice, you'll never speak to the MD personally. The CLERK (please note, not the nurse) wil say, "You should go to the ED." Why? Not because you're sick but because the doctor is tired of being sued. You wore a tshirt advertising your town's local ambulance chaser to your last appt, what do you expect?
In summation, the only time you should leave your PCP's office to go to the ED is when the ambulance is called. If your doctor doesn't feel you need to go by ambulance, you probably don't need to go. Also, I don't care what your doctor told you. We're not "holding" a room for you. If he cared, you would have orders in your hand. You do know he's not really "meeting you here," right?
The only thing worse is when the God-doctor actually shows up and expects you to be at his beckon call. "Sorry, I have an emergent pt, you'll just have to replace that peg tube without me holding your hand. Maybe your office nurse who you pay to do your bidding personally can lend you a hand."
Mom4 not being able to get in to see the doc is one thing,.but actually going to the doc to be told to go to ER is another. Obviously if your child is wheezing and needs a breathing tx you should at least go to urgent care. Imagine going to your reg doc and being told you need to go to ER for a breathing tx! Although in my opinion, unless it's in the middle of the night and can't wait until morning, your reg doc should be able to see your wheezing child ASAP!
Totally agree! I've had children going to the same pediatric practice for over 20 years and I've never had them tell me they couldn't see my sick child. Mind you I didn't wait until the noon to call, I was on the phone as soon as their office opened letting them know what was going on and this small office only has 1 pediatrician in the office (rotate out with larger office in larger town nearby).
I only help in the ER when I need/have to and it is shameful how the same practitioners abuse the ER while others take care of their patients. I'll never understand why folks don't see that their primary is dumping them, some act like their primary has called ahead for reservations so they can be seen quicker. Makes it hard on the ER staff and the hospital gets the complaints, not the doctor.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
Nope, Sorry TraumaNurseRN... not everyone is seen/tx'd by the ER doc. We have many pt's sent in by one of the Staff attending/teaching MD's that has seen a pt in their office/clinic and they call ahead to tell us what resident service to come see the pt when they arrive (surgery, vascular, OB, Peds, Ortho etc....)
Additionally, we have several smaller "feeder" hospitals in the area and many times we get transfers to us from them and the attending on-call specialist lot's of times "calls in" to tell us that a certain pt is "on the way" from said outside hospital and to page resident x-y-z on arrival.
Point is, not everyone is here to see the ER MD and sometimes, those "call in's" actually do serve a use for us. ESPECIALLY our nephrologists! They will almost always see their own pt's and admit them before we (the ER MD/NPs) even get a chart made up!
-MB
Exactly...They don't call ahead unless you should be seen in the ER. And most of the time it's a brief history and a verbal to be seen and treated by the ER doc. (Hello...everyone who comes to the ER is seen and treated by the ER doc) Primary's do abuse the system as well, and that's because they schedule patients for 10 minutes of their time in their office and always end up going over that 10 min. They dbl book apointments just like the airlines overbook flights.
For the most part I'm right there with you but on few occasions my MD may feel there may be an acute problem that needs to be evaluated quickly by a surgical (or some other) specialist. Getting in to see a surgeon in the office is impossible on short notice- they are in OR, or seeing thier own patients, or new in-house consults. I can picture a very competent family practice MD saying " I don't know if your appendix is hot or not- you are sick enough to make me very concerned, I want you seen by a surgeon as soon as possible to assess the problem so I want you to go to the ER- if you family is with you I don't see why they can't drive you in but I want you seen as soon as you can safely get there" I have the utmost respect for my doctor mostly because he knows his limits and will err on the side of caution with getting me evaluated by a specialist, but calling 911 and taking up paramedic time or a private ambulance when all the patient needs is an safe ride is a waste of $ and recources.
mwboswell I'm curious how that works. I work nights, so our out pt dept is closed, maybe things are different during the day. We frequently get pts arriving at triage, "Dr Smith sent us here,.he thinks Johnny needs to have his appendix removed. Dr Smith is supposed to meet us here." My first questions is to ask if they have orders in hand, and then to check with admitting to see if direct admit orders have been received. Sometimes admitting will have orders and tell me the pt is going to 620-2 and off they go.
More often than not,.what Dr Smith really meant is that the pt had all the s/s of a hot appy, he doesn't have access to at CT and the pt should go to ER. In my hospital the ER docs don't admit pts. They do the work up and if the pt needs to be admitted they call the appropriate doc. They also don't see pts outside of the ER,.they are strictly ER docs. This means that if Johnny needs a CT, even if Dr Smith writes that he needs the CT, I have to order a CT with an ER docs name and an ER doc must take responsibility for that pt. The ER doc will do his/her work up and call Dr Smith to let him know what he finds. At this point Dr Smith can choose to admit the pt, find a surgeon etc.
I understand the pts frustration when they come from a docs office, labs drawn, pain meds given and are under the impression that they are going to be admitted and sent to surgery. If those labs weren't drawn in our system, and show up on our computer we have to repeat the labs, the ER doc must repeat the assessment of the pt, and essentially start over. I think the point here is that if Dr Smith would have just written admit orders, sent the pt to the floor for the CT etc we could skip the whole ER! Of course then you have to figure out what to do if the CT comes back normal. Is the pt really sick enough to stay in the hospital? Is this something that could have waited until morning?
I think a big issue here is that pts/family want answers and they want them now. They want something done now! Parents especially don't want to hear "This doesn't look like anything surgical, lets watch him/her a day or two and see what happens".
When the family doc has exhausted his resources and found nothing, the answer is to send them to the ER. So many times the ER repeats many of the same diagnostics, still finds nothing and pts/family members are very upset. Occasionally the family doc will admit the pt for obs, to watch the pt or do further (non emergent) diagnostics and then the family is asking why we didn't just do that from the beginning, rather than have the pt spend 2hrs at the docs office, 4 hrs or more in ER and still have no answers.
I'm obviously not talking about pts with chest pain, stroke like sx etc who need the ER work up and need it now. I think many family docs are "forced" into sending pts to the ER to make them happy. Then they are really ticked when we work them up over hours, tell them "yes grandma probably needs to have her gallbladder removed, here is a doc for you to follow up with tomorrow"!
People don't seem to understand that the ER is there for EMERGENCIES, things that if put off will cause you to die/lose a limb/cause permanent disability or otherwise negatively affect the quality of your life if not treated NOW. It isn't there for convenience, it isn't a free clinic, it isn't meant to treat chronic medical problems. I do understand the docs frustration when a pt refuses to wait until tomorrow for their CT/Xray/strep screen etc, but you would think the doc would tell the pt that the other option is ER but I can't guarantee they do what you want done and you'll probably be there for hours placed behind the emergencies.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
I don't think it's outright manipulation by patients/families expecting their MD to "see them there".... I think it's a difference between what message was told them versus what they actually heard....
Example:
Jane Smith calls her MD's office.
Jane gets the office LPN.
Jane says "I need to come in to be seen, I'm sick".
LPN: "what problem are you having?"
Jane: "my stomach is hurting and I had a bit of a fever today"
LPN: (who thinks this is the WORST CASE SCENARIO)..."let me check w/the MD/NP"
LPN: "Dr so-and-so says go to the ER it may be your appendix"
Jane later shows up to triage saying "my doctor said to come here".
Of couse there are permutations of this.
Some of which give the "subtle" appearance of that their primary MD WILL meet them there; others are implied. But what the patient HEARS is that "my doctor is supposed to see me here".....
I have found in my "personal observation" (non-scientific and this is my opinion only) that
1) A LOT of Dr office staff (LPNs, MAs etc) think that "MOST" every "sick call" is the worst-case-scenario and that you are DYING!!!!
2) A LOT of ER staff (RN's) think that "MOST" every patient that comes in is NOT SICK AT ALL!!!
Interesting opposite ends of the spectrum!!!
Again, just my personal observations over 15 years from small 5 bed ER to a 120+ bed ER University Hospital.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
To your point below...
I ESPECIALLY always try to explain it like this....
I tell them that although we cannot find a cause for their pain/problem tonight, that doesn't mean it is not real. I explain that our system is designed to look for/rule out EMERGENT conditions for which I would...
1) Admit you to the hospital
2) Consult a surgeon for surgery within the next 24 hours
3) Call a specialist in from home/office/sleeping to admit you
4) or can d/c you home for further workup and feel reasonably confident that you will not progressively deteriorate and die.
I will also tell them that "although I can't tell you what 'IS' the problem, I can reassure you and tell you what 'IS NOT' the prolbem".......
I also frame it in a time perspective. I tell them, "all the work we've done here at this ER visit [4,5,6+ hours] is the equivalent to maybe 5-10 days worth of your primary doctor doing some tests (go to this test, come back to office to decide what to do next....REPEAT this 3 or more times)...so in that case a lot of times they actually appear greatful and reassured.
-mb
People don't seem to understand that the ER is there for EMERGENCIES, things that if put off will cause you to die/lose a limb/cause permanent disability or otherwise negatively affect the quality of your life if not treated NOW. It isn't there for convenience, it isn't a free clinic, it isn't meant to treat chronic medical problems. I do understand the docs frustration when a pt refuses to wait until tomorrow for their CT/Xray/strep screen etc, but you would think the doc would tell the pt that the other option is ER but I can't guarantee they do what you want done and you'll probably be there for hours placed behind the emergencies.
The whole problem with Dr.'s sending the pt to the ED because it sounds like an emergent appy is that everyone sounds sick on the phone. That's why the triage nurse triages face to face. The nurse actually speaks to the pt face to face, takes vitals and history, and actually lays eyes and even some times hands on the pt during an assessment. I kind of find that important to decide if it is emergent. It would be nice if the primary md would "emergently" get the pt in the office and do the same. He may find out the abd pain and fever doesn't have a temp and is having abd pain from menstral cramps during a quick assessment. It goes back to sending them to the ED to cover their own behinds. Can't really blame them for that but it's still aggravating.....
Sorry -- should have been clearer. When I send a pt to the hospital with a script in hand for tests - they are to go to admitting, not the ER. However, some of my pts, just like everyone's don't always follow directions - lol.
They don't realize I'm just trying to save them some time.
nurseshepherd
108 Posts
Totally agree! I've had children going to the same pediatric practice for over 20 years and I've never had them tell me they couldn't see my sick child. Mind you I didn't wait until the noon to call, I was on the phone as soon as their office opened letting them know what was going on and this small office only has 1 pediatrician in the office (rotate out with larger office in larger town nearby).
I only help in the ER when I need/have to and it is shameful how the same practitioners abuse the ER while others take care of their patients. I'll never understand why folks don't see that their primary is dumping them, some act like their primary has called ahead for reservations so they can be seen quicker. Makes it hard on the ER staff and the hospital gets the complaints, not the doctor.