Wednesday, July 4, 2007


I'm probably beating a dead hrose with the whole ER thread I wrote last week, but I just want to quote PandaBear. He writes a post about drug addicts, and says that one tried to fake his way through a chief complaint of rectal bleeding. He syas:

"It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit."

So even before he checks the guy's labs, he is saying he doesn't believe he's having a significant bleed. Probably what any sane internist/primary care doc would surmise.

But Panda also says this:

"And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry"

So he drew a stat hemoglobin and hematocrit, EVEN THOUGH he figured the guy was full of garbage. Why didn't he just kick the guy out of the ER if he was so sure? Why did he send the stat labs???

Because, my friends, even the Panda knows that liability is key, and just in case the guy is NOT full of it, he has protected himself. And he's in the ER, so he has access to those stat labs when he needs them.

So for those ER-heads out there who would laugh if an internist sent such a patient to the ER (or any other patient who could use a stat lab to rule out a life threatening condition), please reflect if you would have acted any differently had you recieved the call or lab result or whatever at your office or home. Clearly, the PandaBear is making the same mistakes the primary care guys are making.

I promise this is my last post on the topic. Until I get angry again, that is.


scalpel said...

Umm, in your previous post, you were discussing sending someone to the ER when you ALREADY HAD lab data (that was minimally abnormal, no less). Not only that, but you generalized your point to state that ALL such patients should be sent to the ER, no matter what their demographic characteristics were, and whether they were symptomatic or not.

If you don't want to bother with your partners' patients and don't give a damn how long they have to wait unnecessarily in the ER, why can't you just admit that? But don't try to justify your laziness with the idea that you are just being cautious, because you aren't fooling anyone who knows anything about Medicine.

Anonymous said...

Mike, your commentary, as scalpel pointed out, was about sending all patients to the ER when you received labs or history that could potentially be abnormal. the 3.3 K level (minimally abnormal) in an asymptomatic patient deserved a stat lab in your opinion. You can see that very few of your colleagues are with you on this one.

Your commentary about rectal bleeding and PandaBear's posts reflects a misunderstanding of the issue and his post. First and foremost, a person who presents to the ER requires a medical screening exam to rule out life threatening emergencies. A drug seeker who presents with rectal bleeding and abdominal pain will get a workup to minimally include a hgb/hct. If anyone calls you complaining of abdominal pain and rectal bleeding, please send them to the ER immediately. I wholeheartedly support that decision as prudent medicine.

If they call complaining of painless rectal bleeding, no abdominal pain, dizziness, weekness or other significant symptoms, see them in clinic some other time. According to you, that guy could have inflammatory bowel disease and die. A guy calling in with painless rectal bleeding, and otherwise asymptomatic does NOT need to be sent to the ER for an emergency colonoscopy.

If there are any GI docs out there who would endorse performing emergency colonoscopy on such a patient, please write to this blog...


any one???

Nope... see...

Please blog about relevant examples. PandaBear's example is one to demonstrate how he can efficiently extricate these people from the ER without over-utilizing resources. Your lesson here.. listen carefully.. is to understand NOT to over-utilize resources such as the ER.

Anonymous said...

Jeez. Enough of it. The petty bitching is silly. Your last few posts are very pathetic.

I truly love Internists and am glad they are there to do what they do.

If you refer someone to the ER to address test results, or minor complaints just prepare them for what it is -- which may be a 2-10 hr wait from triage to the doctor, and maybe a 24 hr or more wait in the ER until they recieve hospital be for their "direct admission".

Every IM resident has spent a month or two in the ER or moonlighted in some VA or podunk ER so think they are completely qualified to criticize everything that happens in an ER.

The IM residents rotating through the ER seemed to do ok if:

1. They were not asked to see more than 1 pt/hr.
2. Saw no one less 16 years old.
3. Were able to avoid any chief complaint that included blood.
4. Weren't asked to see someone really sick that needed to be immediately stabilized.
5. Saw no one that was batshit crazy.
6. Saw no one with a pregnancy related issue.
7. Saw no one with a deformed limb
8. Saw no one brought in on a backboard.
9. Saw no one that required any type of procedure.
10. Were in no way in charge of managing the overall flow of in the department and presenting to triage.

In large part they are completely oblivous to the fact that the EM residents are seeing 2-3 times as many patients, doing resuscitations, and running traumas before a chart is even made to make it to the "to be seen rack".

On the other hand my hat is off to anyone who chooses to grind through primary care practice and manage chronic conditions over years, and hospital round daily on admissions. This is what I did for 4 years before going back to do an EM residency. I couldn't take it any longer. Perhaps that is why you are so angry.

Mike said...

I love how all anyone got from three posts was that a K was 3.3 It was one part of a longer riff on how ER docs are whiners and have little concept of office reality. And also how nothing 911doc said backed up his claim that "something has happened to general medicine".

The point about Panda Bear is valid. He did exactly what an office doc would do... IF that office doc had a stat lab and time and a place for a patient to wait being monitored. But we arent so lucky in the office. He has the luxury of knowing in the back of his mind that on that slim chance he's wrong, at least the guy was in the ER at the time.

Office docs have no such luxury, and I wish the ER heads would stop being so disingenuous and just accept that ER visits are not always traumas or fun for you guys.

I agree with the last anon post... I was not exposed to detached limbs and I probably got sheilded from a lot of stuff. But I also know that the signouts from ER to IM lacked much. There's enough hard work betwixt both specialties. But ER heads seem to whine much more about it then the IM heads.

Finally.. I am unchanged about potassium. Once you've had a patient code and die on you for it, you will also disagree with your colleagues.

Anonymous said...


I challenge you to find any medical literature that describes a mildly decreased K causing cardiac arrest. I also challenge you to prove that you have coded more patients than even a senior EM resident. You will find that you don't even come close. most attendings in their first year will code a patient nearly every day, and the vast majority of them have K levels exceeding 6 or more.

The prior post was trying to illustrate very clearly that your "experience and expertise" in emergency care is so limited and narrow-minded that you haven't a clue how the department really works. Most docs will see between 2-4 patients per hour, some even more. Trauma is not the most exciting part of EM, actually, we are typically on the hunt for the most significant disease to affect our patient population and those that will kill in a relatively short period of time. Ectopic pregnancy (you haven't a clue), Aortic dissection, Pneumothorax, MI, and the list goes on. It is a very different mindset, and one that does its very best to protect the population.

Your very willingness to send a cellulitis patient in for "direct admission" to "speed things up", or to reflexively send your stress to the ER only undermines it. You should really try to revisit that policy in the midst of the myriad of commentary you have received.

"ER heads" spend far less time complaining about things than you do ruminating on how emergent a K of 3.3 is. Once P4P starts, you'll probably spend even more time whining.

Anonymous said...

I really don't whine about any visit. I don't care. I am there anyway and it is just another patient. I think the main reason ER docs are "whining" on this topic is because we often bear the brunt of patient whining because "they were sent to to the ER" for legitimate and unneeded reasons.

Where I work there is only a handful of IM, FPs that still do the clinic thing AND take care of their patients in the hospital. 95% have relegated the role of taking care of sick patients to the hospitalist. I think that is 911's main point.

Everyone has their hangups often colored by past experiences. Yours might be a potassium of 3.3. Mine might be a low risk chest pain as an example. I send home probably 200-300 home a year. Considering that it is estimated that 1-3% of MI's are missed from the ER I am guaranteed to be burned sometime. So if I get an uneasy gut feeling on some low risk chest pain that I want to admit what is the big grief?

I had an office pracitice and admitted all my own patients for 4 years. My work now in the ER minute by minute, hour by hour, is 10 times harder, more stressful, prone to error, prone to the retrospectoscope, etc than my previous practice. But I would not trade back in for the pager. It is just a different animal.

Don't delude yourself that whining is limited to ER docs. Your own posts prove that we have not cornered that market.

Anonymous said...
This comment has been removed by a blog administrator.
Anonymous said...

What happened to direct admits? Show me a PCP that carries a pager today and I'll show you a dedicated Doctor. My own PCP gives all his Pt.'s his cell number which thank god I haven't had to use.

If you were so worried about the status of your Pt. why didn't you send them to the hospital via ambulance as a direct admit?

Case in point my elderly mothers PCP had her drive herself to the ED with SOB, dizziness and thready pulse. Turns out she was experiencing heart failure due to 2 medications (blood pressure and diabetes) prescribed by said PCP that were negatively interacting with one another.

Fortunately the "Whining ED" Doc was able to look at her list of medications and diagnose/determine her problem. All the while her PCP and a cardiologist were advocating for a pacemaker. 24 hours off her blood pressure medication put all vitals back to normal.

Now if she had died on the drive to the ED and taken out a family on their way to Disneyland you can bet that I and the other family members would have sued the pants off the PCP for their failure (read laziness) in calling for an ambulance, following the ambulance to the hospital and doing the admission herself.

It all comes down to paperwork, admit through the ED = less paperwork. You're shirking your responsibility to your Pt.'s. Then again you probably were much too busy to alter your 0800-1700 schedule.

This 20 year ED Tech sure misses the old school Docs who truly cared more about their Pt.'s then their office hours.

Go ahead flame on the lowly ED Tech, I know I'm the bottom of the barrel but, I'll put my basic emergency skills up against your MCAT skills any day. Remember passing a test does not give you knowledge and experience, it simply proves you have test taking skills

Happyman said...

"Now if she had died on the drive to the ED and taken out a family on their way to Disneyland you can bet that I and the other family members would have sued the pants off the PCP "

and you wonder why PCPs don't want to take care of very ill (ie. hospitalizable) people.

the descent schedule (although necessity of a pager) is all that is left in primary care, and for the crappy money nobody is going to give that up nowadays, especially with the sue-happy mentality that even pervades pseudo-medical folks (ED tech). Ever hear of the phrase "a little knowledge is a dangerous thing"?

Mike said...

" challenge you to find any medical literature that describes a mildly decreased K causing cardiac arrest."

Misses the point. Just because it is 3.3 when I get called, doesnt mean its 3.3 anymore. Why can I not get anyone to understand this point?

"I also challenge you to prove that you have coded more patients than even a senior EM resident"

You are all that is man. Seriously, does this have anything to do with anything I've said?

" Ectopic pregnancy (you haven't a clue), "

A clue about what?

"we are typically on the hunt for the most significant disease to affect our patient population and those that will kill in a relatively short period of time"

So screw anyone else who will die more slowly??

." You should really try to revisit that policy in the midst of the myriad of commentary you have received."

None of the cokmmentary changes one thing I've said. And any PCP or ER doc who was a PCP for a day would do the same.

"...on how emergent a K of 3.3 is."

Getting a repeat stat K is indicated. Tell me how it isn't?

Anonymous said...

"Getting a repeat stat K is indicated. Tell me how it isn't?"

Your whole fixation on this thing invalidates just about anything you have to say. Should we check it every nanosecond? Hey it is back to 3.5 but it could be dropping again -- let's check again

A VERY HIGH PERCENTAGE of ER patients have a K of 3.3 or less. A little anxiety leads to a little respiratory alkalosis leads some K into cells leads to a meaningless low reading. This is very very normal in trauma, miscairrage, panic attack, and a myriad of other things seen in the ED.

Do we recheck it before discharge?
NO. I think I will try it out though.

"Hey friendly hospitalist, I have this 17 year old female who broke up with her boyfriend and started hyperventilating and was dizzy and numb all over. Her K was 3.1. Will you admit her and check hourly stat K's until it is normal?"

Mike said...

You make that statement as a joke. For me it was reality.

Let's not even broach the subject of inappropriate ER admits cause the patient "just didn't look right" I ALWAYS give the ER the benefit of the doubt, cause I wasn't there, as I've said. But god forbid the ER heads who blog returned the favor for PCP's.

And no more posts about how many codes someone has done, or how many ER shifts/clinic they did. Its so off topic and uninteresting, I can't bear to see any more.

Anyway, if I had simply said a K of 6, (which is a much more common phone call) then I wouldn't have had to hear all this dreck.

Mike said...

"Do we recheck it before discharge?
NO. I think I will try it out though"

Anyway, you've already had your repeat K, and you've observed the patient, so you already had an unfair advantage over an OFFICE!! Thus, it is not an apt analogy.

scalpel said...

Fact is, you've got to lose a lot of potassium (~160mEq) to drop from 3.5 to 2.5 (2.5 = the value that is truly an emergency requiring cardiac monitoring and aggressive replacement, and above which is usually nonemergent).

Potassium doesn't just evaporate or disintegrate. In order to drop that much, potassium must leave the body. If the patient isn't vomiting, actively diuresing, or suffering from copious watery diarrhea, the potassium just isn't going to suddenly plummet overnight from 3.3 to 2.5.


And all of those caveats can be easily ascertained via a quick history by telephone, and the problem stabilized by a simple prescription called into any pharmacy. A repeat stat K just isn't indicated, certainly not in EVERY CASE, a distinction you seem to be unwilling to admit.

I don't mind your dumping these patients on us nearly as much as I am disturbed by your lack of knowledge regarding this important and common electrolyte disturbance. The fact that you consider mild hypokalemia to be just as dangerous as mild hyperkalemia is shocking.

Just admit that you're wrong and we'll move on.

Mike said...

scalpel... how can I be wrong when you have no idea what the situation is. Did the patient have a lab done on Friday and the lab calls but no one hears about the K for a day or two? Because this is a dnagerous situation. And it happens all the time. And if they are on lasix, then no vomiting required. And many office patients are on lasix (or another diuretic)

Your obsession with this one point, I'm guessing, is a way to ignore the other cases, and many more I could posit, where an ER doc would say "Damn dumb PCP's dumping again", hence 911doc's "Whither the Generalist" tripe.

But feel free to perseverate more on the K of 3.3 and my bad clinical judgement if you like.

scalpel said...

No, I pretty much agree with the other cases, except the INR one of course (and even that one I'll cut you some slack on). I'm only arguing the one that you are wrong about.


Mike said...


Nurse K said...

Okay, let's hug it out now, guys.

Anonymous said...

Er tech dude is a class one ass! he/she is part of whats wrong with medicine today. I guess suing someone would have made them feel real big and nobel.

Anonymous said...

Mike, I'm more than happy to drop the issue regarding differences in training.

You can pervert the hypokalemia example into many things... "Uhhh I forgot to mention he said he was having palpitations and dizziness, chest pain and right eye vision loss." Perhaps you were just uninformed enough to actually believe that a K of 3.3 would be universally recognized as an emergency. Doh! Scalpel is absolutely correct in his post regarding hypokalemia and how PCP's can help by not reflexively dumping patients, patient phone callers, annoying family members with patient and patient requests, overbearing family members with nursing home patients and "he isn't eating as much" complaints, and so on and so forth. I know we all live and work in a litiginous environment...

ERTECHDUDE you typify that statement

... but spending a few more moments on the phone with the hypokalemia patient could avert most REASONABLE internists and FP's from dumping them on the ER.

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