Circus of Chief Complaints (Your Tax Dollars at Work): Part 1

Actual Patient Interaction Number One:

“So Mrs. Smith, how’s your pain?”

“Oh doctor, it be paining me real bad. Can I get some Dilaudid.”

“How about we start with some Nubain?”

“What’s that?”

“It’s a synthetic narcotic, kind of like Demerol.”

“Is it any good?”

“Sure, it works great and doesn’t give people the rush they get from other narcotics.”

“Oh, I’m allergic to it.”

Actual Patient Interaction Number 2:

“I felt sick, doc. At work.”

“When did it start?”

“About twelve hours ago. But it’s gone now.”

“Really, how are you feeling?”

“Great. I didn’t feel that sick but I thought I’d better come in.”

“So you don’t feel sick now?”

“Naw, I feel like a million bucks. It only lasted about an hour and it’s gone now.”

“So let me get this straight…you sat in the waiting room for upwards of ten hours to be seen by me, it’s two in the morning, you feel fine, and there’s nothing that I can help you with?”

“Well, I need a note for work.”

“You said you weren’t that sick, why didn’t you just finish the work day and go home? I mean, you could have been asleep at home instead of hanging out here watching late-night television.”

“I don’t like my job that much.”

“You realize that your non-problem is still going to cost close to five hundred bucks, right?”

“Well, I really don’t like my job…”

Actual Patient Interaction Number Three:

“What do you mean there’s nothing wrong with my kid?”

“I didn’t say that. I said he had a cold which will get better on its own and there’s nothing you need to do about it except give him some Tylenol or Motrin for his fever.”

“How do you know he ain’t got pneumonia?”

“He doesn’t. He looks great.”

“I want a cat scan.”

“I’m not going to get a CT on a kid with a cold, ma’am.”

“My sister said he needs a CT.”

“He doesn’t.”

“We waited five hours.”

“I’m sorry. He has a cold. Drive home carefully, they tell me it’s snowing tonight.”

“We came by ambulance…can I get a taxi voucher?”


Actual Patient Interaction Number Four:

“So, what brings you in Mr. Jones?”

“I’m constipated.”

“How long has it been going on.”

“Almost three years.”

“Uh…okay…what do you expect us to do about it?”

“I need help getting the shit out.”

“There is a fine selection of fiber and other laxatives at Wal Mart. In the pharmacy section…and just like us, they never close. Have you tried any of those things?”


“Uh…Okay, well, there you go. I can give you some Colace right now and by the time you get home things should start moving.”

“My mother said you’d scoop it out for me.”

“Not in this lifetime.”

Actual Patient Interaction Number Five:

“I’m going to sue all y’all.”

“We’re doing everthing we can for your mom.”

“You’re not. Can’t you see she’s suffering?”

“I’m trying to make her comfortable.”

“You just don’t care. She’s in a lot of pain.”

“Well, she’s had a lot of muscle and tissue breakdown from laying on the floor in her room in your house for three days. Tell me, does your mother have any health problems?”

“She’s been falling a lot lately.”

32 thoughts on “Circus of Chief Complaints (Your Tax Dollars at Work): Part 1

  1. Run into #1 all the time.

    Multiple analgesic allergies on a patient’s chart (e.g. acetaminophen, ibuprofen, codeine, tramadol) are virtually pathognomic for opioid dependence.

  2. I had a conversation with one of my [black, female, med student] friends the other day regarding Obama running for the democratic ticket (Please, no one get offended). She was trying to tell me that the lower socioeconomic classes (specifically in reference to S.Carolina) didn’t vote for Obama because he is black– but because he stood for good issues (nb. she supports him too).
    To the point– I think those in the medical field (myself included) sometimes get caught up in what we are surrounded by (some of the brightest crayons in the box)– and forget that simply by graduating college, we are a [vast] minority. This is by no means an excuse for addiction or trying to get out of work… but it helps to understand why the majority may not be living up to our standards (even though to us, our standards seem like a minimum). Imagine talking about Nietzsche to a toddler.
    In the end, we are not at all representative (for the most part) of the US population. Makes for good comedy though.

  3. Just finished another nonacute side shift. Couldn’t wait to hit the road, grab a beer and see the family. Saw all of the above and a new one:

    “What brings you in tonight”
    ‘I called 911’
    “what for?”
    “help with the house work”
    ‘what did you need EMS / Ambulance for?”
    ‘to change my sheets and help me with the housework’

    (Pt is elderly, lives alone, and had a cast put on her ankle today and decided that EMS could help her around the house – they stuck her in the truck and dumped her in a room. LMAO 🙂

  4. My God, what did I sign up for when I came to medical school? There’s a reason I try to only read your blog at night – there’s no way I could sit inside all day and suffer through pathology and histology and assology if I were reminded how shitty patients are. I am going to drop out and become a full-time alcoholic.

    See ya soon!

  5. Pt: I’m sick, I have a fever.

    Nurse K: Your temperature is 97.8. Did you check your temperature at home?

    Pt: No, but that’s high for me.

    Nurse K: Did you take Tylenol or ibuprofen to try to feel better?

    Pt: No.

    Nurse K: Did you just drink something cold?

    Pt: No.

    Nurse K: So what are you here for today?

    Pt: My fever.

    Nurse K: Alright, the doctor will be in!

  6. I’m probably revealing my naivety here BUT, why don’t they use NP’s in ED’s so you don’t have to waste your time on colds and constipation?

  7. So, for the folks who work in these settings (all healthcare???), do you have just as many sane, reasonable patients who you enjoying helping? Because I would quickly stop giving a shit if every patient interaction went like the ones given here…

  8. I am actually allergic to Nsaids. I developed the allergy after being given a long acting NSAID for my Ankylosing Spondylitis. I swell, itch, puff up, wheez. But got forbid I inform an ER doc of this when I break my ankle – OOOOOOH, I’m drug seeking.

    FWIW, my teenaged son developed the same allergy following surgery. Couldn’t possibly be real, now, could it.


    (Whoa. If you break your ankle I will be more than happy to prescribe a short course of narcotics for you, any time, any day.  Broken ankle: Legitimate emergency complaint, acutely painful, unanticipated, low probability of narcotic seeking behavior or narcotic abuse.  Ankylosing Spondylitis: Not a legitimate Emergency complaint and you need to see your own doctor for your pain meds because many, many people, even those who have this condition, are addicted to narcotics whether they want to admit it or not.-PB)

  9. “I am actually allergic to Nsaids. I developed the allergy after being given a long acting NSAID for my Ankylosing Spondylitis. I swell, itch, puff up, wheez. But got forbid I inform an ER doc of this when I break my ankle – OOOOOOH, I’m drug seeking.

    FWIW, my teenaged son developed the same allergy following surgery. Couldn’t possibly be real, now, could it.”

    Do you actually read Panda’s blog or did you just want to post how offended you are? Of course there are people allergic to NSAIDs, but there are probably even more people who feign an allergy to NSAIDs. There are other painkillers between the spectrum of NSAIDs and morphine, but if someone comes in and says they’re allergic to NSAIDs and need morphine, they probably are lying.

    And duh, breaking your ankle actually hurts. Pretending your back hurts does not actually hurt.

  10. Kim: NPs and PAs i know are TOO GOOD to only see colds and constipation.

    Don’t you get it? Nurse K will even leave the non-fever “fever” for the doc.

    Phaedrus: get out while you can…it only gets worse from here…Peace!


    (We have PAs.  They work the “urgent care” side…which kind of shows you how many bullshit complaints innundate our department that we see so many of them on the “acute” side.  The PAs work under an attending who makes most of the discharge decisions.   Don’t get me started on mid-levels.  I will say that about the only people in the medical profession who have a respect for the limits of their knowledge are doctors. -PB)

  11. A couple of weeks ago I actually had to take my wheelchair-bound son to the ED for a non-emergent “emergency”. It was at the behest of the school nurse, who insisted he had a dislocated elbow. He’d gotten his arm caught under his chair’s armrest and was in considerable pain. The responding EMT thought he had a dislocated shoulder. I declined the ambulance and drove him to the ED myself, and from triage we were sensibly shunted to urgent care.

    (Actually, I went straight to an urgent care clinic that was much closer to home than the hospital, only to discover that they couldn’t take my insurance! What the hell’s the point of a place like that?)

    After a set of X-rays it turned out he didn’t have a dislocated anything. He’d gotten his arm caught under the chair’s armrest, and probably pulled a muscle trying to get it out. This only happened in the first place because he had a substitute aide for that day, who almost certainly had left him with his arm trapped for more than the “couple of minutes” she claimed. I can hardly wait for the subrogation form to come in from the insurance co. Yes, the school has insurance that will cover most of my $150 ER copay, but I suspect they’ll be hit up for just a wee bit more.

    The point of all this rambling is to confirm PB’s note that one does in fact see PAs on the urgent care side. We’d seen this same one before as it happens, and he seems to know his stuff. Whether or not he oversteps the limits of his knowledge I can’t say, although it was very quiet and therefore easy to overhear him consulting with the attending over the phone. But I gathered none of the cases he was following were very complex.

    An ambulance for a cold? What’s wrong with these people? And what’s wrong with the ambulance company that they gave them a ride? That’s one expensive taxi!


    (A typical Emergency Physician makes around $130/hour.  A PA might make a half to to a third of that.  So PAs aren’t cheap.  They may save a little money but only a small part of the bill in the ED is physician or “providor” charge so the differential is not that great. -PB)

  12. Believe me, some of us would LOVE to stay out of the ER. Why do the urgent care centers close at midnight (5 pm around my inlaws’ house, we once found out)? We need them more when the regular MD offices are closed. A couple of nights ago my 3 year old, who had gone to bed with no sign of any illness, woke at 2 am retracting, sticking his tongue out to ease his breathing, and barking in that lovely classic croupy fashion. 15 minutes in the bathroom running the shower, and he was still seriously distressed. No choice but to go to the ER–he was sticking his tongue out and so on, not just coughing uncomfortably. Of course, the ride in the night air did him good, so he wasn’t nearly so ill by the time we got there. Still he was reading 73-80 on the pulse ox (the nurse managed to get it to read 97 for quite literally 2 seconds by squeezing it on his finger and waiting, even though it immediately fell back to 74 while he still held it there, but he wrote “97” in the chart). One dose of decadron and we went home. I would happily have gone to the urgent care center for that and knew it would have been preferable, but at 2 in the morning what am I supposed to do with a 3 year old whose lips are starting to turn blue? If I had waited, it could have been life-threatening, but by the time we got to the ER doctor he was presented with a fairly calm toddler with no signs of so much as a viral infection (though apparently ds still sounded croupy on exam with stethoscope). During the day obviously I’d have taken him right in to the pediatrician’s office but where do I go at night when I’m genuinely concerned? I’m not trying to be snarky, I’m seriously asking your opinion and advice.

    (It’s highly unlikely that your three-year-olds oxygen saturation was 73 percent and many, many times more likely that the pulsoximeter wasn’t gettng an accurate reading.  We regularly intubate people who can’t keep their saturation above 88 percent or so.  The nurse squeezed it on your kids finger to make good “contact” and a 97 percent is a 97 percent.  A child with a sustained oxygen saturation of anyting under 90 percent is a serious medical emergency and not something we play around with.  On the other hand, if your child was, with the exception of the cough, looking well, alert, and not lethargic or extremely agitated he’s probably all right.

    Keeping in mind that the mortality in otherwise healthy children from “croup” is almost zero, I still have no objection at all to you bringing your chid in at any hour for something like this.  It is distressing, it is uncomfortable for the kid, and it could be something else other than croup.  I do not mind minor complaints.  Have I not been clear about that?  I’m just pointing out that some complaints are ridiculous, and that a parent who will drag their otherwise healthy child in at 3 AM for a little cough, the sniffles, a bout of diarrhea, or even a little vomiting  should be arrested for child abuse. -PB)

  13. Liesele –

    You tell a common story here in the PB comments section, the one where your experience counters Panda’s stories. Well, there are plenty of GREAT reasons to take your kid to the ER. It sounds like you had genuine reasons to be concerned about something that incidentally turned out mild. That’s an ER success story, so why do you feel offended? Is there something in the above article that reminds you of yourself? Did Panda Bear, MD, point you out specifically as somebody who abused the ER?

    Can you not see that in this article and others, the author uses some anecdotes that OBVIOUSLY can’t be generalized to the ENTIRE population, but make good points about a statistically (and financially) significant subset of the ER visits in the country. In no way did he try to characterize your specific visit.

    He writes to a general audience about some general trends, so when you respond to a specific author about your specific experiences, you kind of missed the boat.

    Your fancy words (retracting, pulse ox, decadron, presented, ds, etc) imply some health care experience and a basic level of intelligence that probably allows you to distinguish urgent from nonurgent- how could you possibly think that this article described you ?

  14. Jobe, I didn’t and I’m not offended, nor am I trying to contradict Panda; I’m trying to get a handle on how providers would like us to use the system, for everyone’s benefit–so that the practitioners aren’t overwhelmed by cases that should never come to them, while at the same time the public which is not composed of medical professionals is adequately educated to make good decisions about health service use. I’m a medical librarian, only tangentially related to the true medical fields, and I absolutely respect those of you on the ground caring for us. I’m just trying to feel out how you want us to make these decisions. Obviously some people are horribly abusing and mis-using the system and I know that’s who you’re trying to single out. I want to know if there’s a way I can make sure I’m not one of the abusers for your sake and for mine. I don’t believe that Panda allows or encourages only practitionersto read or comment here, and I would suggest that dialogue between the providers and the resource users would be valuable in initiating change and improvement.

  15. If you think you have an emergency, then don’t hesitate to come to see us. We don’t mind, really. Our job is to determine if you have an emergency or not. But if you really don’t have an emergency (which our triage nurse can usually determine in about 2 seconds), then don’t get upset when you have to wait a long time to be seen, and don’t get upset with the staff when you are discharged with little more than a pat on the back and a “fare-thee-well.”

  16. “An ambulance for a cold? What’s wrong with these people? And what’s wrong with the ambulance company that they gave them a ride? That’s one expensive taxi!”

    The EMTs aren’t exactly qualified to tell people “No, you don’t need to go to the hospital.” Sure, if it’s something REALLY minor, like a papercut, but I can just envision the lawyer saying to the EMT, “At what point in your lengthy 3-month training were you taught to diagnose pneumonia in the field?” Besides, the ambulance company makes money regardless of how trivial the complaint is, which is why the fire department turfs the lame calls onto the private companies. The FD wants the good calls.

  17. Prowler: No, an EMT isn’t necessarily qualified to diagnose pneumonia. That a mother might want a doctor to look at her child’s cold isn’t the point, even if the need for an ED visit is debatable. (i.e. unnecessary for any parent with two brain cells to rub together.) In what kind of situation does a patient with cold symptoms require an ambulance ride?

    It’s the mother who called 911 for a cold. It’s the mother who decided to take the ambulance. It’s the mother who thought it worthwhile to wait 5 hours. The EMTs had little to do with any of that. They are not “these people”. That would be the mother, and her sister who thought a CT scan was indicated. To be blunt about it, they’re idiots.

    I’m speaking as someone who’s actually taken a kid to the ED in an ambulance for genuine pneumonia far more often than he’d have liked.

    And no, the ambulance company doesn’t get paid. Why should someone who’s won’t pay for primary care, who probably won’t pay for the ED visit, and who’s too cheap to pay her own way home, dig into her pockets to pay for the ambulance? They’re getting soaked too. Or are ambulances paid for by the government where you live?

    At least in my area, the VFD are the first responders in all cases, but don’t operate any ambulances. All ambulance service is contracted to a private company, which bills separately just like the EM doctors, radiologists, etc. If the county pays them when they can’t collect on a bill, I’ve never heard tell of it. (I’m not counting Medicaid here. If a family has that in my area, they ought to have primary care.)

  18. Liesele: If you’re the kind of person to ask these questions of yourself, IMO you’re not the kind of person who’s going to abuse the system.

  19. Liesele –

    It’s just that you and I both know that YOUR situation isn’t what Panda was writing about. When your 3yr-old has blue lips at 2AM, you definitely go to the ER. Your post only asks what to do in YOUR situation- but everybody reading this blog is smart enough to tell you you made the right call with your kid. Note that in your first comment, you don’t ask how the general public should make decisions, you as what YOU should have done in YOUR specific situation.

    Your second comment finally asks the question I guess you meant to ask in your first post: How do untrained people (and mothers!) make decisions about ER visits in the heat of the moment? That’s one of the major themes of the whole blog… WITH SOME freakin’ COMMON SENSE!

    Back before our current “insurance” system completely erased incentives for critical decision-making, people used more common sense because they got bit in the ass (wallet) when they didn’t. Now that the bill is somebody else’s problem, it’s actually not that surprising that people abuse the ER. (The only real surprising thing is the people that are stupid enough to come in with a very minor complaint that doesn’t warrant emergency treatment in the face of huge temporal costs- namely, they get bumped to the back of the line and spend 10 hrs waiting to get some free tylenol).

    The whole theme of the last few posts has been something along the lines of “We would like you to be a little more discriminatory in your ER decisions because you are using up valuable community resource- but there’s something in it for you to: you can save a lot of time and hassle.”

    The overriding principle remains that when you are in doubt, you should go to the ER. BUT DON’T BE IN DOUBT ABOUT A SIMPLE COLD.

  20. “An ambulance for a cold? What’s wrong with these people? And what’s wrong with the ambulance company that they gave them a ride? That’s one expensive taxi!”

    People who call an ambulance for complaints like this never have any intention of paying the bill. Yes, it’s an expensive taxi ride, but hey, if the taxpayers are footing the bill, who cares right? I’m waiting for the day someone dies because the only remaining ambulance in the area is doing a taxi ride.

    However, we as medics are not there to determine if the call is ‘bullshit’ or not. Even when it clearly is.
    We are required by law to take anyone who calls. For any stupid reason.

    For all those slight fever calls at 2 in the morning for which no tylenol has been given by the parent, for all the drunks, drug seekers, and dumbasses out there… We get em first, and we HAVE TO bring them to you. We have no choice.

    911 abuse is no different from ER abuse.

  21. Don’t worry, it will all get fixed when Single Payer herself comes to sweep away all of Medicine’s misfortunes!

  22. Hey Panda, off topic a little here- but wondering if you have any thoughts on the Ritter case. Was reading today on Yahoo about how Henry Winkler was testifying about what a great guy/entertainer he was- seems relevant to the malpractice case I thought. Anyway, they are trying to hang the radiologist and cardiologist for mis-diagnosis. He had a whole body CT scan two years prior- must of sucked to be dissecting your aorta for two years.

  23. “And no, the ambulance company doesn’t get paid. Why should someone who’s won’t pay for primary care, who probably won’t pay for the ED visit, and who’s too cheap to pay her own way home, dig into her pockets to pay for the ambulance? They’re getting soaked too. Or are ambulances paid for by the government where you live?”

    Oh, the government pays for it, otherwise my employer would have gone out of business a looong time ago. Title 19/Medicaid pays fairly well for an ambulance ride, so those who are covered by it are more than willing to make good use of it.

  24. While I am very forthright about getting prompt medical attention for genuine medical emergencies, due to your information and preaching, I will call a nurse or doc before I head to the ER. Many of the hover-parents around me (mine and the SO’s, aunts, etc) usually question my judgement on why I would hesitate.

    Then they take the kiddies in at 9pm, and I see them getting home dreary eyed on my way out to work in the morning; “the doctor said to give ______ plenty of fluids and rest, and to just wait it out.”

    Hooray for sleep!

  25. Saw a patient today that illustrates my point perfectly, even too perfectly.

    Patient is a thirty-something year old woman with two very young children who presents to our hospital with an abscess in the gluteal region. She has multiple medical problems, most of which are secondary to her being medication non-compliant. In fact, she has been seen for this abscess many times in the last month at our hospital and by her admission, across the street.

    So, after cleaning, draining and inserting a iodine strip into her abscess she asks for pain meds. She reports allergies to codeine, refuses acetaminophen and tramadol and demands narcotics. This, despite the fact that she is wearing an ankle bracelet as she is on home probation for failing a drug test. She claims that a histamine blocker caused it to show amphetamine positive.

    Prior to seeing the patient, I noted on her chart that she had recently tried to establish a new PCP relationships at one of our satellite clinics which ended with her leaving the clinic swearing at the attending that she was going to report him to the medical board as he did not refill her narcotics (she had quite a supply of oxycodone written by a mid-level two days prior to seeing the attending.)

    So, I gave her 12 pills of oxycodone just so I could get rid of her.

    Now, who do you think pays for the medical care of this narcotic addicted felon who takes no responsibility for her health and uses medical resources without any regard to cost?

    If you pay taxes, you guessed it, you do.

    She’s covered by medicaid.

  26. I’m personally a big fan of the lidocaine patch. Whatever patient comes in with complaints of joint pain, stating that needs medication, I always recommend the lidocaine patch because it does not cause systemic effects. Patients hate it.

  27. “I’m just pointing out that some complaints are ridiculous, and that a parent who will drag their otherwise healthy child in at 3 AM for a little cough, the sniffles, a bout of diarrhea, or even a little vomiting should be arrested for child abuse.”

    Hey, thanks!

    Before I entered into nursing school and had a complete grasp of medicine, I had a panicked mom moment where I took my 3 week old son to the ER in the wee hours of the morning for vomiting. Now mind you, he was born caesarian and had aspirated meconium and was in the NICU for a week after he was born, so of course I was a nervious wreck running on no sleep and a deployed husband. And so with my limited knowledge of medicine I freaked out that he threw up so much (twice, my god! lol) and went to the ER.

    My point is, we aren’t all idiots. Some of us are truly convinced that a visit to the ER is suitable. Now that I know better from having a clue I’m not nearly so paranoid and easily freaked out by throwing up, but I certainly wouldn’t be so quick to judge a parent bringing in their kid because you never know, they might be having a panicked mom moment too.

    PS I’m hoping to be
    an ER nurse. Even after reading your blog, which is awesome by the way. 🙂


  28. You know what I really hate? That this is usually a doctor’s expectations when they see their patients, which ends up including me. Kinda sick of it, honestly.

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