The Flow Stopper
Often when starting a shift, I'll find the waiting room packed with patients and several new patients already in rooms waiting to be seen. Sadly, there's no time to chit-chat with the nurses or surf the internet for the latest sports scores. In a situation like that, I've got to hit the ground running. My goal is to disposition and clear out the first few patients as quickly as I can. On a good night, if the stars line up properly, I hope to turn over most of the rooms once or twice before I can even think about slowing down.With fairly straightforward patients who can communicate well, this is an achievable goal. Tell me your problem and I'll fix it, or I'll find someone who can. That's what I do.
Unfortunately, far too often traffic jams occur. One slow driver in the left lane, a poorly-timed trainwreck, or someone giving grandpa a phenergan will all have the same effect. The laminar flow trickles to a halt, and once it stops it takes a while to get it started again.
These flow stoppers may present in various forms which have been well-described previously on this blog and many others. Any patient who requires an interpreter, any time-consuming procedure, patients who are overly demanding, patients with numerous concerned and annoying relatives, patients who want to be admitted but don't need to be, patients who need to be admitted but don't want to be, patients requiring more than one or two calls to other physicians, and so on.
The challenge is to deal with the traffic jam and resume the previous pace, which is easier said than done (for me anyway).
I sometimes wish I had a REJECT button to use once per shift in a situation that is unnecessarily slowing me down. When Mrs. Jones asks me to talk to her (Pediatric resident) nephew in Iowa to discuss her current condition, I could just press the button and move on to the next patient.Before I spend a painful 20 minutes on the interpreter phone trying to get a history from Mrs. Xiang, who is almost as deaf as the interpreter, I could just hit REJECT and see three other patients instead.
When I've already arranged an admission for Mr. Stewart's chest pain, and then he wants me to talk to his son's Cardiologist across town and try to transfer him to another facility, I'd be all over that button like I was on Jeopardy and the category was The Human Body.
If grandma's feeling a little bloated because she can't poop, I'd be hitting that button like a fibromyalgia patient on a PCA pump.
Labels: ER, rejects, traffic jams
posted by scalpel at 6:49 PM
29 Comments:
Yeah, I like that idea---it's kind of like that machine in Willy Wonka's factory that rejected the "Bad Eggs". Down they went.....
But I'll tell you when I want that "Reject" button---and it's for my pet peeve:
It's when I go to a patient's home to review their recent doctor visit and they unexpectedly thrust a med-applicator tube into my hand (which feels suspiciously sticky on the outside) and then explains: "Here's the medicine the doctor gave me for my vaginal infection..." YECK!
But then they completely neglect to tell me that the doctor ALSO gave them a prescription for Coumadin/Lasix/KCL/Amiodarone. Why don't they hand me those damn med bottles?
(Ooops---sorry for the rant---but I need that "Reject" button, too....)
Uh-oh, you're fixing to get all the fibro freaks decrying your insensitivity.
Interpreters...When we lived in Hawaii & I was awaiting my ultrasound, I had the time to peruse the list of extensions for translators. There were over a dozen. I imagine it can be hard sometimes to figure out which interpreter you need; I find Portuguese hard to recognize in print. Must be exponentially worse in person.
Patients who want to be transferred:
"You're too unstable to be transferred at this time. Maybe in the morning after your XYZ has stabilized, your internist can arrange it."
Annoying relatives:
"Our policy is to only have 2 visitors in the room..."
Don't want to be admitted:
"Here is the AMA form. If you sign this, you can leave against medical advice, but, unfortunately, most insurance companies will make you pay for this emergency visit out of pocket if you don't wish to comply with my recommendation for treatment, which includes admission."
Interpreter:
You're screwed, sorry.
"Patients who want to be transferred:
"You're too unstable to be transferred at this time. Maybe in the morning after your XYZ has stabilized, your internist can arrange it."
Even when there not too unstable to be transferred? You are saying you will lie and dump on the floor staff? Nurse K if you really feel this way than I strongly suggest you get out of ER nursing and I am a heck of a lot more experienced than you are.
The only people that have asked to be transferred were VA patients (because the VA doesn't accept 911 ambulance calls), and if a VA patient is calling 911, it's because something baaaad is going on...like COPDers in resp distress or they're having chest pain. VA patients are very frugal with their use of the 911 system.
There aren't many other people willing to pay the several thousand dollar fee for a facility preference transfer that is not otherwise medically necessary.
Doctors insensitive to "fibro-freaks?" Naaaah, couldn't happen. I really do like the idea of an eject button for patients, though. Arrogant, ignorant doctor? BOOF! Up and out he goes like an F-16 pilot on a really bad day. Thinks chronic pain is a psych issue? KABANG! and damned if that chute didn't open this time, leaving our subject with firsthand experience of what pain feels like.
10th ER visit of the year for an adult migraine patient whose mother is shreaking in the hallway in front of the nurse's station "MY DAUGHTER IS IN PAIN!!! SHE'S BEEN WAITING TWO HOURS! WHY AREN'T YOU DOING ANYTHING FOR HER!?!
I'd be hitting that REJECT button like she was hitting the call light before she finally came out in the hall. Heh.
ouch, scalpel...looks like you hit a nerve there! Or was it one of the 18 specific tender points needed to diagnose fibromyalgia?
I think you might need to xray it...wait, that doesn't show you nerves?
Then maybe you need an MRI!
(sorry for the insensitivity...just venting)
As for chronic pain in the ED:
If one truly has a chronic pain syndrome, then one surely has a doctor who prescribes his/her medicines, correct? And quite often, those are "pain specialists" with whom one has a contract about where one gets said medicines, correct? And the condition has been worked up over and over again by physicians attempting to discover an organic cause, correct?
If all above are correct, then why use the ED for your refills, for your continued negative workups?
(wow, I'm in a sarcastic mood tonight...)
All you need to do in order to diagnose fibromyalgia is to look at the patient's medication list and their allergy to medication list.
It's called the public. They aren't all the same. Welcome to the real world most other professionals deal with. Imagine having to collect money from these people, if you can.
“If all above are correct, then why use the ED for your refills, for your continued negative workups?”
If you can’t figure out why all of the above might not be correct or applicable, I fear you’re beyond anyone’s ability to educate you. But even if we assume all of the above are true, which in the majority of cases it is not, it is possible for people with an ongoing chronic pain problem to have an acute exacerbation of that pain and not be able to reach their regular pain doctor and have no choice but to suffer or go the the ER looking for “help,” if you could call what happens to chronic pain patients in the ER helpful.
There is another thing that happens, and I know this is difficult for doctors to understand so I’ll type it real slow, but the patient might actually have something else wrong with them that is causing a new pain. And get this, they might not have had an X-ray, MRI or tarot reading to determine the cause! Of course, not that any of that would stop you from dismissing their concerns with a wave of your mighty hand, but you might want to maybe get the facts straight before getting out your tattoo gun and scribbling “drug seeker” on their foreheads. After all, ignorance is available for free on the streets, why would anyone want to pay for it?
As for how people use the ER, the president of this country seems to feel it is a great place for ordinary folks without insurance to go when they have the flu or an ingrown toenail, so why do you expect anyone else to think differently, particularly when they are dealing with something as horrific as severe pain?
"All you need to do in order to diagnose fibromyalgia is to look at the patient's medication list and their allergy to medication list."
I should think the omniscient wouldn't need even that much, but I guess they don't make gods like they used to.
For those lacking omniscience, you might note that food and drug intolerances are relatively common and very pronounced in many people with fibromayglia, so you should not be surprised at patients reporting them. There are also a number of illnesses that can mimic fibromyalgia, such as hypothryroidism or polymyalgia rheumatica, but few doctors screen for them. Far easier to use the rubber stamp than to use reason, logic or science.
redhawk is this you?
25th visit so far this year (at this ER only) for pain, multiple mri's, ct's, neuro consults, and "fired doctors"
nah, I don't think I am missing anything. maybe modern medicine can't figure it out and does not have answer. for that I am sorry. and sorry for you that many are just looking to get a "buzz"
One time in triage, a patient w/hx fibro told me: "I'm allergic to those things....oh, you know what they're called...um, N-something. N...sssss. What is it that starts with an N?
I replied: "NSAIDS?"
Her: "Yeah! That's it!!!! NSAIDS!!! I'm allergic to them."
Me: "Which particular NSAIDs are you allergic to?"
Her: "I don't know---ALL of them, I suppose."
Me: "What happens to you if you take an NSAID? What is the specific type of allergic reaction that occurs?"
Her: "Oh...um...I think I get sick. I just can't tolerate them."
Me: "Which pain med are you NOT allergic to?"
Her: "Morphine."
C'mon folks...that last statement of the post was obviously made up. Nobody would ever put a fibromyalgia patient on a PCA pump.
And no, redhawk, I'm never surprised about the numerous allergies of fibro patients. Except that they never seem to be allergic to "the good stuff."
Weird, that.
“And no, redhawk, I'm never surprised about the numerous allergies of fibro patients. Except that they never seem to be allergic to "the good stuff."
Weird, that.”
Not weird at all. There is no class of meds that causes adverse reactions as frequently as NSAIDs do, so it shouldn’t be supririsng to anyone that people often can’t tolerate them. This is particularly true for people with fibromyalgia, as NSAIDs can severely exacerbate the irritable bowel syndrome that often accompanies it, and this in turn can cause a flare up of other fibro symptoms including cramping, spasming and pain. In fact, some fibro experts believe that irritable bowel may be the cause of the high rate of drug and food intolerances in people with fibro, and some go as far as stating it may be a contributing if not causative factor in fibromyalgia itself, and not just a symptom.
Since NSAIDs are useless for fibro pain and symptoms, they really shouldn’t be used to treat it. In my own case, taking just 2 200mg ibuprofen can cause whole body cramping in just 4 or 5 hours, as can many other things like high fiber vegetables or fiber-con tablets. It is not a fun illness and unfortunately very poorly understood and accepted.
Narcotics, on the other hand, are well tolerated by the majority of people, including people with fibro, as they mimic the body’s own endorphins. They can help to counteract the severe diarrhea people with fibro often experience, which is a problem in its own right. In my own case, I can’t take narcotics in an adequate dosage because I can’t tolerate the laxatives and stool softeners I have to take with them, but the narcotics themselves are not a problem. I do love to go down the list of stuff I can’t tolerate, and then see the look on the doctor’s face when I mention that narcotics aren’t an option for me either. Watching the expression change from dubious to shocked is always amusing. And sad.
"I do love to go down the list of stuff I can’t tolerate, and then see the look on the doctor’s face when I mention that narcotics aren’t an option for me either"
what do you want?
I TOTALLY understand where you are coming from! I think we all need a reject button to help us get through. I just LOVE your blog -- you have inspired me to start blogging....thank you!
Let's see. The problem is pain. Can't take NSAIDS, and they don't work. Don't want narcotics, which work great but constipate. I guess you just want to talk, and have a sympathetic listener. Why in the name of Einstein would you go to an ED? Get a life!
Chronic pain? Chronic means its been there a long time. Emergency means a sudden and unexpected event or condition that may represent a threat to life or limb. Which one belongs in an ED?
"Let's see. The problem is pain. Can't take NSAIDS, and they don't work. Don't want narcotics, which work great but constipate. I guess you just want to talk, and have a sympathetic listener."
Literally the last place on the planet I would go to if I wanted a "sympathetic listener" would be to an ER doctor, especially if I wanted sympathy for my pain. Frankly, what I and many people with CP want is to not have to deal with your "profession" at all, but to go back to the way things were in the 19th Century where you could walk into any drug store and buy whatever you needed for your pain without having to justify your existence to anyone. What we have to live with instead is an unspeakably barbaric form of tyranny and exploitation where millions of Americans with chronic pain have to writhe in agony for months and years and pay out the ass for "treatments" that rarely work when there is a cheaper, better and more humane alternative if we could just get it out of the hands of the drug companies, doctors and government.
"Why in the name of Einstein would you go to an ED? Get a life!"
Get a clue. Where did I say I want to go to the ER? I am trying to impress upon you the fact that not everyone who says they have an allergy to meds—even many allergies—is a drug seeker, and with fibro in particular, this is almost a defining characteristic of the illness, it is so frequent . As for going to the ER for pain, chronic or otherwise, I have said it before but I wouldn't send a dog I didn't like to the ER for pain, let alone a human being.
"Chronic pain? Chronic means its been there a long time. Emergency means a sudden and unexpected event or condition that may represent a threat to life or limb. Which one belongs in an ED?"
Chronic pain doesn't just stay at one level. For Christ's own sake how hard is that to understand? There are times acute exacerbations so extreme they can lead many people to commit suicide. What do you want from people, that they should stay home and writhe in agony or kill themselves to avoid inconveniencing you? If you don't want to treat pain, why did you become a doctor? You do realize that untreated pain is also a threat to life and limb, don't you?
"Frankly, what I and many people with CP want is to not have to deal with your "profession" at all, but to go back to the way things were in the 19th Century where you could walk into any drug store and buy whatever you needed for your pain without having to justify your existence to anyone."
Back then, all they had was opium and snake oil. And all a suicide threat will get you is a psych eval and possibly an involuntary hospitalization. But usually not, because it's obvious that someone making such a threat is just being manipulative.
"...there is a cheaper, better and more humane alternative if we could just get it out of the hands of the drug companies, doctors and government."
And that magic bullet is.....?
"Back then, all they had was opium and snake oil."
Back then, and now, opium and its derivatives were all you needed to allow 95 percent of people with pain to get their pain under control. Snake oil was also a powerful anti-inflammatory, and good for that kind of pain.
Pain treatment is an aspect of 19th Century medicine that was in fact superior to what we have today. This is because anybody with half a day's wages could walk into any general store and buy whatever he needed to treat his pain. Nowadays, you need a permission slip from a doctor and that can take years, thousands of dollars, repeated invasive and useless treatments, and a boatload of abuse and humiliation to get, by which time the damage is already done and there is often little prospect for improvement.
"And all a suicide threat will get you is a psych eval and possibly an involuntary hospitalization."
Who said anything about a suicide threat? I am talking about the reality that as many as half of all suicides are due to undertreated physical pain, and that the rate of suicide among people with CP is over 10 times that of the general population.
"But usually not, because it's obvious that someone making such a threat is just being manipulative."
"Obvious" to you, perhaps, but no so obvious to people who actually know something about suicide. There are very often quite a few warnings before someone finally does it, and to regard every threat as a form of manipulation is backward beyond belief.
"...there is a cheaper, better and more humane alternative if we could just get it out of the hands of the drug companies, doctors and government."
"And that magic bullet is.....?"
Prevent acute pain from becoming chronic by treating it aggressively from the word go, and the only way to accomplish that is to allow people to purchase what they need over the counter without a script as we did in the past, and to open the drug market to competition so that the prices of these drugs will reflect their natural rate.
"Prevent acute pain from becoming chronic by treating it aggressively from the word go."
That is quite a hypothesis you have there. You seem to suggest that patients with chronic back pain or fibromyalgia, for example, are simply victims of the medical establishment and that their chronic conditions are essentially CAUSED by the medical establishment not treating their initially presenting (sentinel) episodes aggressively enough. If only their pain would have been treated aggressively from the beginning, they wouldn't HAVE chronic pain, and their "condition" wouldn't exist at all.
But wait, I thought there were supposed to be specific neurotransmitter deficiencies in fibromyalgia patients. Maybe those biochemical changes are really caused by mean physicians who don't prescribe adequate amounts of narcotics. Maybe uncaring doctors are responsible for spinal stenosis and intervertebral disc disease too. Or maybe your hypothesis needs further study.
Or maybe you REALLY meant that making opium derivatives available OTC again would prevent chronic pain from becoming more acute (instead of the other way around).
Or something.
There is a current society in which those drugs are available without a prescription. It's our local high school. Three of the students have died from drugs since January. Expanding that to society in general would tend to improve the quality of the gene pool, without a significant impact on the tax base, if you catch my drift.
I admit to being clueless, but Redhawk, you need to understand my perspective. This is an ER blog, written by Scalpel, an ER doc, and this thread is on flow stoppers in the ER. Because you are trolling here, it was natural that I thought you might be someone who might clog up an ER. By your response, I now know that you would never do that. And the reason that you wouldn't is that you have done it so much you have finally given up. Good for you! Now get a life.
Joints, I think your rarely-mentioned perspective as someone who has personally suffered from chronic pain for many years and yet continued to be not only a productive member of society but one of its leaders gives you more credibility than anything I could say.
Perhaps its easier for someone like you (who actually has structurally identifiable causes of pain) than someone with fibromyalgia (who is widely considered to have simply a psychiatric problem) to cope with pain. But I doubt it.
I think that pain is like many other neuropsychophysiological conditions that test the human will and our ability to persevere. Some people forge ahead despite their handicaps, and some people curl up into a ball and blame society for their ills.
But yeah, narcotics are controlled for a very good reason.
"That is quite a hypothesis you have there. You seem to suggest that patients with chronic back pain or fibromyalgia, for example, are simply victims of the medical establishment and that their chronic conditions are essentially CAUSED by the medical establishment not treating their initially presenting (sentinel) episodes aggressively enough. If only their pain would have been treated aggressively from the beginning, they wouldn't HAVE chronic pain, and their "condition" wouldn't exist at all."
That isn't just my opinion, it is the opinion of many pain specialists as well. The latest theories are that chronic pain is believed to be caused or exacerbated by CNS sensitization, and this sensitization can be dramatically reduced in frequency and severity by aggressive pain management up front, and even pre-emptively, in the case of surgical pain. Even where there is a direct and continuous nociceptive cause, CNS senitization can exacerbate the pain. That it is so difficult to get pain treatment is almost entirely the fault of doctors, the government, and the drug companies who monopolize these meds, and thus it can and should be called a largely iatorgenic disorder. BTW, why do certain doctors always put the word "condition" in quotes?
http://www.smw.ch/docs/archive200x/2002/21/smw-09913.html
http://www.cpmission.com/main/painthekiller.html
"But wait, I thought there were supposed to be specific neurotransmitter deficiencies in fibromyalgia patients."
There are. Whether these are a cause or effect is uncertain.
"Maybe those biochemical changes are really caused by mean physicians who don't prescribe adequate amounts of narcotics."
There is no doubt that untreated pain can cause biochemical changes that can cause or exacerbate pain and its attendant problems like depression. If nothing else, they can cause loss of sleep which is believed to be a key driver for fibromyalgia.
"Maybe uncaring doctors are responsible for spinal stenosis and intervertebral disc disease too. Or maybe your hypothesis needs further study."
I didn't make such a claim, you did. What I am saying, is even where there is a direct physiological cause for the pain, such as with spinal stenosis, central sensitization can still occur making the pain worse than it would be if it were treated promptly and aggressively. The medical monopoly on these drugs coupled with medievel attitudes towards people with pain are the primary reasons it is not.
"Or maybe you REALLY meant that making opium derivatives available OTC again would prevent chronic pain from becoming more acute (instead of the other way around)."
Actually, it would do both. It would reduce the incidence and severity of chronic pain, and where chronic pain does exists it would reduce the llikelihood of acute exacerbations. There are legitimate problems with opiates, but there is little to justify the extreme paranoia and demonization of this class of drugs and those who are forced to use them.
Your first article repeats the hypothesis but offers no evidence to support it (from my quick review...sorry, I have another engagement tonight, but I'll look at it in more detail later). Your second article just looks like a chronic painer advocacy site.
I would agree that chronic painers tend to be hypersensitive to stimuli and that the expectation of pain can make even a mild painful stimulus seem disproportionally more intense than it would be otherwise. But it seems unlikely to me that these patients' chronic pain would go away if only they had unrestricted availability of narcotics.
Not that it matters, because it simply isn't going to happen.
"There is a current society in which those drugs are available without a prescription. It's our local high school. Three of the students have died from drugs since January."
The old "we are doing this to save the kids" standby. People die from taking prescription drugs every day, as well, over 100,000 a year, in fact. But what drugs were these kids taking, and why were they taking them? I'll bet dollars to doughnuts one of the drugs they were using was alcohol, which kills far more people every year than narcotics do but you'lll never hear of an "alcohol overdose." Why is that?
"Expanding that to society in general would tend to improve the quality of the gene pool, without a significant impact on the tax base, if you catch my drift."
Your drift is that you think people who do drugs deserve to die. So much for your pseudo-concern for the kiddies. This isn't about protecting society, but about control.
"I admit to being clueless, but Redhawk, you need to understand my perspective. This is an ER blog, written by Scalpel, an ER doc, and this thread is on flow stoppers in the ER. Because you are trolling here, it was natural that I thought you might be someone who might clog up an ER. By your response, I now know that you would never do that. And the reason that you wouldn't is that you have done it so much you have finally given up. Good for you! Now get a life."
Like many doctors, you are extremely presumptious, and like many doctors, your presumptions are wrong. I am not here to "troll" as you put it, but to challenge some of the bigoted streotypes and medievelist treatment of CP patients I see on display on this and other blogs.
I have never, nor will ever, go to an ER for pain treatment. I'd as soon burn my money in the sink and save myself a trip. I have been there for chest pain and palpitations, thinking it was something worse, and I have been there for abdominal pain accompanied by fever, thinking it might be appendicitis. The first words out of my mouth are "I am not here for pain meds" before I say anything else, because I know from the horror stories of countless others and my personal experience outside the ER of what happens when yoou mention the "P" word around the whitecoats. If you don't know what happens when you mention the "P" word, watch this short video if you have the time for a typical example of what happens in the ER when you do.
http://www.youtube.com/watch?v=x9jPvPMVfn4&watch_response
or
http://tinyurl.com/yqqfp9
"Perhaps its easier for someone like you (who actually has structurally identifiable causes of pain) than someone with fibromyalgia (who is widely considered to have simply a psychiatric problem) to cope with pain. But I doubt it."
At one point, both MS and diabetes were "widely considered" to be psychiatirc problems. In another time, all illness was "widely considered" to be the work of the devil, or witches, or "bad humors." The ignorance hasn't changed, all that has changed is the presumptions underlying it. There is quite a bit of evidence for a phyiological basis for fibro as well as for most forms of CP, and little evidence, if any, for psychogenic pain. This article form the Canadian Pain Society addresses this mindset:
(quote)There is also impressive evidence of significant biochemical abnormalities in disorders such as fibromyalgia; three independent studies demonstrated levels of substance P in the cerebral spinal fluid that were two to three times those in controls (10-12). As well, we know that, based on animal data, there is significant evidence of neuroplasticity in the spinal cord in response to pain stimuli, which could account for the clinical picture of regional pain syndromes (3,13). In these conditions, neurotransmitters such as substance P have also been implicated. More recently, altered regional cerebral bloodflow has offered opportunities to document a physiological concomitant of the patient’s pain experience (14). Despite this impressive collection of physiological evidence about pain, the scientific evidence does not appear to be reaching legislators or clinicians who seem determined, based on ideology, to impose draconian alternative paradigms to deal with chronic pain and, in particular, its associated disability....
...To justify such an approach, psychosocial factors are often implicated as causative. However, a wave of recent research has demonstrated that psychological factors are more secondary to pain than causative (7,15-17)... Psychological difficulties occurring as a consequence of the pain and subsequent disability are often misinterpreted as causative.(end quote)
http://www.pulsus.com/Pain/02_02/teas_ed.htm
"I think that pain is like many other neuropsychophysiological conditions that test the human will and our ability to persevere. Some people forge ahead despite their handicaps, and some people curl up into a ball and blame society for their ills."
Kind of like doctors who like to blame "drug seekers" for their nasty and bigoted attitudes towards people in pain.
The majority of society wants to legalize drugs, so I wouldn't blame "society." But I will lay the blame squarely on the medical profession for its barbaric refusal to treat pain humanely and justly in far too many instances, and for the primitive mentality that anyone who wants to take a drug for pain, as opposed to taking a drug for anything else, is weak and cowardly. You have no idea of the gargantuan struggles people with pain endure in their efforts to overcome their problems, and to make snap assumptions like this based neither on reason, science, or even first-hand experience is truly appalling.
"But yeah, narcotics are controlled for a very good reason."
Which is what, so doctors and drug companies can charge monopoly rents? There was a time in our history when these drugs weren't controlled and we didn't see the sort of problems that are "widely considered" to occur in the absence of prohibition.
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