A Real Question From A Real Reader: Panda, Can I Hack It?

(Another real question from a real reader, really sent to my real email address. -PB)

Ian writes: “You’ve described what Emergency Medicine is like but what would you say are the ideal qualities of Emergency Medicine doctors? (I seem to handle stress and emotions very well and can easily remain calm in pressing moments)”

Let me back into this question but not without first stressing that I am a resident, not a board certified Emergency Medicine physician, so you have to look at what I say from that perpective. Gruntdoc or Scalpel, both of whom have excellent blogs, can probably give you a better perspective of what it’s like to be habituated to the trenches of Emergency Medicine. I’ll give you my opinion, for what it’s worth, but I am perfectly willing to defer to superior wisdom and experience on this topic.

With this in mind, let’s consider five random patients of one of my latest shifts. They were, in no particular order, the following:

1. A chronic pain patient on 180 mg of MS-contin per day (enough to render comatose a small Cuban village), admitted to the hospital across town for a surgical consultation, put on a luxurious inpatient analgesic regimen by his admitting physician (3 mg of dilaudid IV every four hours as needed), and pretty much living the drug-seeker’s dream who nevertheless had such a desire for a smoke and a beer that he checked out against medical advice and then, when they wouldn’t take him back, decided to try our establishment. While it is true that we sometimes have trouble coordinating information, I happen to work at that other hospital too so it’s not like I couldn’t call my colleagues over there and ask what in the hell was going on.  His several hour stay in our department under my care was characterized by whining, constant demands for narcotics, and several reassessments on my part where I had to wake him from a deep sleep to ellicit symptoms of 20/10 pain all over.

“Does your back hurt?”


Do your legs hurt?”


Does your face hurt?”


‘How about your left eyebrow, does that hurt?”


I refused to give him anything stronger than Toradol before I could talk to his doctor. He slept, whined, and finally called his sister who, when she showed up, constantly asked the nurses to talk to me, accused them of being lazy and became irate when I said, in no uncertain terms, that her opinion of the nurses was absolutely wrong and that she had no idea how hard they work.  They both eventually left in a fit of anger, muttering dark threats that I would be hearing from their lawyer…and they later showed up at the Emergency Room across town for the same complaint.

2. An 89-year-old severely demented woman in the advanced stages of Alzheimer’s disease and with a past medical history that, if you added a few multiple choice questions to it, could have done decent service as a pathology exam. She was dumped from a nursing home with a chief complaint of (imperceptible) “Altered Mental Status.”  I suspected an accidental overdose of her nightly sedative (not that I had any idea of her baseline mental status, you understand) because on the transfer Medication Administration Record (MAR) from the nursing home, the section listing dosages and time of administration was physically cut out of the copied page, likely done to keep us from discovering that she may have gotten an extra dose or two of this or that.  I can only imagine the emotional turmoil of the nurse at the home. Should she pretend nothing happened and possibly have the lady die on her shift or risk having her shoddy nursing skill exposed by calling the paramedics? Eventually she must have decided to compromise and send the patient but cut out the important parts of her medication history, no doubt assuming that the doctors and nurses in the Emergency Department are a pack of morons.

Veterinary medicine at its finest. Patient alert, calm, but totally incoherent. Vitals normal and stable. Vitals of a seventeen-year-old Lithuanian virgin in fact. Nothing really wrong with her except that, and this may be a shock to many of you, she was 89, demented, and none of her many impressive medical problems went away or were cured as a result of our humble efforts. We sent her back after a relatively cheap four-thousand-dollar work-up no worse for the wear, with nothing to show for it but a few more cross-sectional images of her moth-eaten brain mouldering on a server somewhere in cyberspace.

3. Nine-month-old boy brought by his mother at three-in-the by-God-morning because he usually drinks five ounces of formula before bedtime but tonight, oh the horror, only drank three ounces before falling into the blissful sleep in whose gentle embrace I found him when I opened the door. Completely normal physical exam and negative review of systems.  And I mean completely negative. No fever, no coughing, no diarrhea, no nothing. I spent more time than you might imagine with this patient because I didn’t want to believe that anyone could possibly haul their baby out of bed in the dead of night, sit in a crowded waiting room with drug addicts and hookers, and then wait for three hours to tell a guy with 14 years of higher education that her baby was two ounces short of his usual daily formula intake.

She left angry because I was able to give her the good news that her baby was clean, well-fed, healthy, happy, and perfectly normal in every respect and that the CT scan she requested was definitely not necessary.

4. A 22-year-old-woman, eight weeks pregnant by date of last menstrual period, complaining of pelvic pain but eating fast food in her room and exhorting me to hurry up with the preliminaries and get to the ultrasound. Refused a pelvic exam (and I don’t care what some people say, a pelvic is important to work up pelvic pain), left several times to smoke outside, had a beta-HCG consistent with her estimated gestational age, and no real history or physical exam findings that would suggest she wanted anything other than a nice ultrasound picture of her baby to paste in her scrapbook. Putative father soon thrown out for rifling the IV cart for butterfly needles and syringes. Mother professing ignorance of babydaddy’s hyperkleptoremia and finally leaving without so much as a thank you after a perfectly normal eight-hundred-dollar ultrasound, on the taxpayer’s tab, of a perfectly normal eight week intrauterine pregnancy.

And no, I did not give her a picture to take home. Not unless she coughed up eight hundred bucks. All of our imaging is on a computer anyway. Grief all around. She had waited seven hours and almost had a total stranger stick his hands in her kooter fer’ nothing (which is what I heard her tearfully relate to her mamma on her cell phone).

5. 34-year-old women with a chief complaint of “knee pain.” slipped on the ice two weeks ago. Did not seek medical attention at the time. Gait normal. Exam unremarkable. Clinically no indication whatsoever for any imaging studies or for anything at all except a heartfelt, “Life sucks and you occasionally bang your knee,” which of course you can’t write on discharge instructions. Patient angry. Very angry. Storms out in an attempted elopement. In a demonstration in miniature of everythig that is wrong with the American health care system, I was sent to convince her to stay, eventually mollifying her with a completely normal three-view plain film of her offending knee. Reassurance all around. Motrin. Hasta la Vista. Come back if the pain gets worse or for the love of Mohammed, go see you primary care doctor, would ya’? (Can’t write that on discharge instructions either).

Fifteen minutes later, accosted by customer service representative.

“Can you give her a work excuse?”

“Sure. I guess it would be okay for her to rest today.”

“She want’s it for the last two weeks. She missed work and says her boss will fire her if she doesn’t get a doctor’s note.”

“Absolutely not.”

“Are you sure? Come on. All you have to do is sign it.”

“That’s called fraud where I come from…and I’m not going to get sucked into some worker’s comp scam.”

Consider these five of what I assure you are extremely typical patients. Each one with a totally bogus complaint which in a world ruled by common sense would have garnered nothing but laughter and a hearty, “You want to see the doctor for that? When pigs fly, buddy.”  And yet each one was duly triaged, sent back, given serious consideration, was worked up as if money were no object, and perhaps worst of all from the perspective of a resident or attending, required as much if not more paperwork and documentation than a patient with a legitimate complaint. The patient who had eloped from the hospital across town, for example, did not just leave but drew us into the usual Kabuki drama where we pretend he is a legitimate patient and exhort him to stay while he pretends to be a responsible citizen who is just exploring his health care options. Once again, in a perfect world we would have said, “Look, you stupid motherfucker. You were admitted to a perfectly decent hospital for your bogus complaint and they took you as seriously as if you weren’t just some hopped up dope addict. You took up a scarce bed, one that could have been filled by somebody who was really sick, and by eloping you spit in the face of both the overworked resident who admitted you and the busy attending who in laying hands on you assumed complete responsibility for your welfare in the hospital. You had it made. 47 million uninsured my ass. You and your shrew of a sister have never paid a dime for any of your extensive utilization of our health care system but you are such connoisseurs of our product that you act like you are bankrolling the entire shooting match.”

But you can’t say that. Each of these patients must be met with the same grim determination to diagnose and treat as any other.

Consider also that while these five patients represent obvious misuse of Emergency Services, most of the legitimate patients you will see, those with sincere medical complaints, will end up with a completely negative work-up or an embarrassingly weak admission leading to a work-up by someone else which is either negative or tells you exactly what you already knew and which may have been demonstrated several dozen times in the previous few years. I can’t tell you how many patients, for example, brought in for an exacerbation of their congestive heart failure whose symptoms were completely reversed after a few hours in the department (diuretics, oxygen) who are admitted and discharged a day or two later with a diagnosis of congestive heart failure exacerbation.

If you decide on Emergency Medicine, oh my gentle readers, scholars and adventurers all, you will see plenty of seriously injured and critically ill patients. But they will be intermixed with a huge volume of mundane medical complaints, some perfectly reasonable and some sublimely ridiculous, all of which you must wade through to get at the interesting cases. The stress of the job is not going to come from intubating the difficult airway or deciphering the mystery of an inexplicably decompensating patient whose life hangs from a thread passing through your hands. If you don’t like this kind of thing it would be criminally foolish to match into emergency medicine anyway, not to mention that at most Emergency Rooms these patient do not come in huge volumes but are an occasional treat to keep you interested and sharp.  The stress of the job comes from the sure knowledge that while you are in the trauma bay resuscitating the critical patient your backlog of drug seekers and vague abdominal complaints is inexorably growing and, as these are the financial bread and butter of our profession, they may not be ignored.

21 thoughts on “A Real Question From A Real Reader: Panda, Can I Hack It?

  1. Thanks. I live in England and I’ve always wondered why our National Health Service sucks up more and more money every year. I suspect the type of patients you describe are less common here but the drain must be measurable.

  2. I just got off a shift on our critical care side and even on that side where everyone is “sicker” I think I saw all five of these people! What a mess. I laughed out loud and feel better now after reading your blog – thanks panda! Oh and the beer i just finished helped me as well!

  3. Hmm…so I suppose thick skin and a high tolerance for ignorance are two valued qualities for this profession. I wondered how I would fair in that environment because I have an above average compassion for people which gives me tolerance, even for idiots. But still, that kind of shit that you described would easily get to anyone. I think I’d have to shadow someone in EM for a lengthy amount of time to truly know if it’s still something I’d do for a living.

    Thanks for answering my question Panda.

    On another note, do you know of any trauma surgeons with good blogs? I’m interested in that specialty as well.

  4. Just came over from a couple of ER Nurse blogs and read 4 or 5 of your posts. After being out of nursing for ten years, I love reading really good blogs about the wide world of medicine. The misuse of ED’s by Medicade/ welfare folks is apparently only understood by doctors, not politicians. You should run for something — cover, perhaps?
    Anyway, thanks for the interesting reading.

  5. Panda, Patients are not the only ones who abuse the ER system. I have a little quip my colorectal surgeon. (I have prolapsed internal hemmorhoids, so having a stapled hemmorhoidectomy). So, I get the “paperwork” from his office and it says I have to have an EKG. No big deal. I understand, but the catcher was that I was to go to any hospital between 8a and 4p on a “walk in basis” and have an EKG (with interpretation) done. Is this a crock of shit or what? How fucking lazy can you get? Jeez, if you thought I was a candidate for surgery, shouldn’t you have performed an EKG in your office when I went for a consult? What kind of looks would I get if I actually went to the ER? I suppose I’d be waiting for hours and hours only to find out that I have NSR, let alone tying up a precious resource for somebody who may actually need it. Who would have paid for it? My ER copay is high and probably would have rejected payment for a non-emergent use of ER. (I have, of course, made an appointment with my PCP to have an EKG done). Have you heard of other physician’s doing something like this? (I’ve certainly heard many a story of the PCP who just tells pts to go to ER after his office hours are over because he doesn’t want to deal with it).

  6. “Just walk in, tell ’em your pregnant and that your belly hurts.”

    Olan Mills would at least require a credit card.

    I like the fact that the imaging doesn’t get printed.

    Dave G Pharm D:

    Are you trying to embarrass yourself? So your colorectal surgeon doesn’t do EKGs in his office; why would you expect him to anyway? Maybe you could call your internist or family doctor and ask whether they could do your preop medical clearance and EKG for you, and save you the trip to the hospital. If you don’t have a family doctor who has that capability, then calling the hospital to ask whether there is an outpatient services clinic that can provide an EKG that you need.

    >>”What kind of looks would I get if I actually went to the ER? ”

    Maybe the look someone who ought to have more of a clue would get for doing something that didn’t make the best sense.

    >>”Is this a crock of shit or what? How fucking lazy can you get? ”

    I was wondering that about you.

  7. Hi PB.

    1. You are the man. I mean a fucking Marlboro Man.

    2. How in GOD’S NAME do you deal with this shit? I would quit. It’s one thing to work your ass off, get little sleep, little respect, and little paychecks if you’re saving some kid’s life, but it’s a whole nother world of shit if you’re going through all of this to help out 80% B.S. complaints. Even 25% B.S. complaints would be too many. But this is a serious question: HOW do you keep your head up? Military training is good, but not THAT good, is it?

    3. When you run for office, I will be the Anvil to your Hammer of Truth. Let’s take take over this country and force people not to be dumbasses. HA HA HA! (an even cackle)

    (Actually, I get plenty of sleep now that I am done with the off-service rotations.  I also want to add that I don’t really mind all of the minor complaints, I’m just pointing out that what people think is stressful about Emergency Medicine is not what I believe most of us in the specialty get stressed out about.  I know what to do when I get a cardiac arrest, a serious trauma, or a critically ill patient.  It’s the minor things that make you worry.  Is, for example, the lady with the vague abdominal pains just having a little gas or is it an ectopic pregnancy?  Does the kid with the fever just have a little touch of the “flu” or does he have meningitis? Will we miss something in a discharged patient that will come back to bite us in the ass?

    In fact, the number of images and tests ordered by our attendings, or rather the frequency with which they might add a CT of the abdomen where I think it is unnecessary, seems proportional to the number of times they’ve been sued.   And since Emergency Medicine physicians seem to be sued a lot for missing something that wasn’t even part of the chief complaint, you can see how the temptation is to say, “Fuck it, I know this CT has one chance in a thousand of being positive but it ain’t my money I’m spending and I’m tired of explaining to a jury that we can’t catch everything in a fifteen minute Emergency Room encounter.  As I will explain in an upcoming article, as a resident I am learninfg to throw money away with both hands and a big shovel…and this is not just confined to Emergency Medicine although we are big offenders because we have effortless access to all the expensive toys. -PB)

  8. Yeah, if the surgeon said “Go to the ER to get an EKG,” that would be dumb. If you just misunderstood him, and he really meant “go to the hospital’s outpatient clinic”, that would make sense.

  9. That was truly a wonderful post. I think you coined Emergency Medicine very well.
    We had someone bring on a DOG last night to be resuscitated. It was dead, the owners were hysterical! A nurse actually started CPR on it. I don’t think I would have done anything.
    Thank god it wasn’t busy. Ridiculous.
    I think what keeps Emergency nurses, doctors,techs heads up are things like this, in the grand scheme of things, you really never know what kind of stuff you’ll see at work that day. I love that. Great post.

  10. Dave G Pharm D: I don’t have a nurse in my sleep clinic and send several patients a week to the local hospital’s outpatient lab (or their pcp) for a blood draw or occasionally an EKG. I don’t send them to the ER and I don’t ask for an interp.

  11. As a first year I had the chance to shadow a few
    ER docs and within an hour of being in the ER I had people asking me for percosets.

    What can you do for the drug seekers? My naive heart hopes that there is a social worker they can see and perhaps pursue rehab options.

    Most interesting to me is what keeps you motivated and energized when coming into work each day?

  12. Thank you! Thank you for this post. I work in radiology and sometimes wonder if the doctors realize that 1/2 the imaging they order is a waste of time. #2 and #5 are in our ER at least once a week.

  13. “So Panda, do ya feel stupid choosing your profession? Sure glad all my patients are nice, perfectly healthy human beings with more money than brains, lol!”

    Fixed that for you.

  14. I have to agree that it is not just patients who abuse the ER. Following a total knee at about 5 weeks post op, I experienced sever pain, swelling and redness. The swelling was so bad I wnet from a 110 degree bend to less than 50 in one days time. I called my OS who tald me to go to ER and tell them he sent me to have an ultrasound of my leg. If I didn’t have a blood clot then don’t let them admit you just go back home and come see me tomorrow.

    Do you know how well this goes over when you translate that for the ER Doc? So, bottom line was I get admitted and told by the ER Doc. that no way she is letting me leave there and that if my OS wants me to be discharged then he can bring himself in and discharge me. No ultrasound done in ER. In fact no ultrasound done for the next 24 hours. Then my OS gets mad at me and tells me “I told you not to let them admit you and to demand an ultrasound”?

    Why didn’t we hear about any of these while you are trashing patients? Also, your 3 view x-rays are laughable when it comes to knee pain and I know that you know this. It took an MRI to show that my carliage was torn in two and that my knee had end stage arthritis and all the while my x-rays were clean. You send these people home telling them they are FAKING and wasting your time when you know you haven’t done the right tests to document what is really happening. But, if you can get a clean x-rays then that gives the right to do so.


    (Whoa.  A torn cartilage or any knee injury in a patient who has been walking normally for two weeks and is neurovascularly intact is not, repeat not, a medical emergency and part of my discharge instructions were for her to follow-up with her primary care doctor (which she had) for further evaluation if the knee continued to bother her.  I did not send her home “telling her she was faking” (which she was) but only that we had found no emergent cause of her knee pain that we could address at 4 AM.  There is no way I am going to send this patient for an MRI.  Our MRI is booked solid almost 24-hours-per day and although many patients and primary care physicians think we should do it, we don’t often usurp the process just because it’s the Emergency Department.  I wouldn’t even send her if she showed up the by ambulance and I really believed she had torn cartilage unless the orthopedic surgeon who I would consult asked me to.  He’d probably just have us put her in a knee brace and follow up with him during the week where he would send her from his office to one of many out-patient imaging centers in the area.

    Xray?  Quick n’ cheap.  MRI?  Slow and expensive. An MRI of the knee, for example, takes about 30 minutes in the machine and costs two thousand bucks.  A lot of bling for someone looking for a work excuse. -PB)

  15. I was just thinking that in the hospital where I am 1/3 people comes in half dead whether from home or from one of dozens of NH’s around that area, hardly more than 1/20 are there seeking narcotics.

  16. It strikes me that many people have lost perspective on what is an EMERGENCY. To me, EMERGENCY means a situation in which your life is in danger or permanent damage to your body is imminent. If you go to the ER with “severe pain, swelling, and redness” and the docs tell you that your life is not in danger and you need to follow up with your OS or PCP, this is not laziness on their part, it is called triage.

  17. I started out nursing life in the ER. I have to admit I loved it. It was a tiny ER that serviced a very large holiday interstate and a small town.
    We just didn’t get too many drug seekers and because we kept a book with a list of our regulars we had a bit of prep before they came back.
    I had some great ER docs who were not afraid to tell everyone they were not getting any drugs before a complete exam was done.
    Strangely our most non compliant irritating patients were the Amish.
    They came in and acted like it was their very own pharmacy. They refused exams and demanded antibiotics and pain meds for coughs, it was always for a cough…it was bizarre..we found out later most of the drugs they got they used on their livestock. They had a wonderful cough they used too..or they all had TB..who will ever know?
    The hospital had an attached pharmacy so they didn’t pay for the drugs..you have to pay the veterinarian up front..the doc? It’s free.

  18. I’m starting to talk myself out of EM. I have enjoyed my years in EMS, but as I get ready to start third year, I don’t think I want to handle those people past the front door of the ER.


    (Whoa.  You have to deal with this kind of patient in every specialty.  Trust me.  -PB)

  19. I always felt bad for the docs and others staffing the ER when we would get the people after the ER coming in with their narc scripts and complaining how slow the ER was and how we need to hurry up and get their meds when you can clearly see that the script was altered from maybe 6 vicoden to 60 with refills listed as “prn” or “10”. At least usually in the pharmacy we can get rid of them quickly. The state laws where I am say no refills on CII and as one person from our state’s bureau of narcotics said “if it’s an ER script with refills for narcotics, its probably a forgery.”

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