WhiteCoat

I’m Just The Dumb ER Doc

I get along well with most of the docs on our medical staff. There are still a couple that talk down to me and act condescending as if I’m some idiot. He who laughs last …

One of said docs personally accompanied one of his patients to our ED while I was working. The patient was dizzy and having chest pressure. He wanted to manage her himself. He didn’t need any help from the ED physician.

Nurses got the vital signs. Initial blood pressure was 66/palp. Initial heart rate was SVT at 190-200. The patient was sweating like Chinese officials trying to verify Jiang Yuyuan’s age.

The staff doc ordered thrombolytics — STAT. The nurse came out of the room, grabbed me by the arm, and pulled me toward the room.
“Need any help, doc?” I asked.
“No, we’re fine.”
“Why are we giving thrombolytics to someone whose EKG doesn’t show an MI?”
“Not giving them – just having them ready.”
“No problem. Call me if you need any help.”

When we got out of the room, I told the nurse to suggest that the doctor cardiovert the patient.
She did. No go.
There is no way that the doc would give a shock without knowing what the patient’s coagulation status was.

The doc ordered Adenosine. No change.
The doc ordered Amiodarone. No change.
Then the doc ordered Dopamine drip. Still no change.
I’m sitting at the nurse’s station listening to the monitor clipping along like a metronome on crystal meth.
Beepbeepbeepbeepbeepbeepbeepbeepbeepbeepbeepbeep

Then I hear a stat page for the cardiologist to come to the ED.
I mozy back over to the room.
“Everything OK?”
“Yes. everything is fine” says the doc – holding the monitor paper and rifling through it like he was reading a ticker tape.

The cardiologist arrived in no time.
As he was walking by, I loudly asked the nurse “they called the cardiologist because they’re going to SHOCK the patient, right?”
I caught the tails of his white coat as he whisked through the door of the room.
Then the family doc shouted “Someone call the lab and find out what’s taking them so long with those coag studies!”

Then the nurse walked out of the room and threw her hands up in the air.
The patient’s blood pressure hit 72/palp and the cardiologist wanted to give 4mg of Morphine IV push. The nurse refused.

Then the cardiologist set off a flurry of activity throughout the hospital by asking for something that no one could find. Nurses looked through drawers in the ED. They called the ICU and no one could find it up there, either. The floor nurses didn’t have it, either.

With the medical metronome still beeping away, a nursing student who was eating lunch in the cafeteria came running up to me and handed me the item with a sigh of relief.

The item that the cardiologist desperately needed was the 2008 ACLS protocol.

I had a good half dozen pithy comments to make to the doc as I walked into the room with the book. But I didn’t. I’m such a chickenshit sometimes.

Instead, I opened the page to the “Tachycardia” algorithm and told the nursing student to go in the room and tell the cardiologist that it looks like the patient needs to be shocked. That way she could look like the star.

Even us dumb ER docs have our moments.

Or as one of my professors used to say … “even blind squirrels find nuts once in a while.”

27 Responses to “I’m Just The Dumb ER Doc”

  1. rlbates says:

    Good for you! How’s the patient?

    She ended up doing fine. They transferred her to the ICU and then cardioverted her into a normal rhythm – after getting her coagulation studies back.

  2. Marilyn says:

    That was my first question too…did the patient survive?

  3. Patrick says:

    The patient would have been in far safer hands in the back of the local ambulance, most likely.

  4. TK says:

    Holy friggin’ crap. Those docs are totally pathetic – and I mean Pathetic with a capital P. I assume they are not ACLS trained. I have had my share of arrogant primary MD’s talk down to me but in a case like that I have never had one not ask me for help – sure the cardiologist might be called but by then I would have shocked the patient – you could have told the dolt that if he was THAT worried about the patient stroking out, he could have given the patient a blast of Heparin before the shock. It’s bunglers like that that give malpractise lawyers something to do.

  5. hashmd says:

    Hey, as a PCP, I resemble that last remark!

    I guess they forgot what they taught me in 3rd and 4th year Med School rotations—when all else fails, treat the patient, not the labs!

    Family docs get to be good by knowing what they DON’T know. And I don’t know 2008 ACLS.

    With an unstable BP and SVT, I’ll take any help in a hurry. The ER belongs to you guys. I only come at your bequest after you’ve done your magic. I see myself as a humble guest in the land of CRAZY stuff.

  6. I am surprised you could hear the cardiac monitor over the LOUD RINGING OF THE GONG!!!!!!

    Sheesh.

    What a story. I would have been scratching my eyes out with the dopamine order.

  7. ladyk73 says:

    Hm hmmmm…Hmmmm. Why are you letting another doctor waltz into your office and treat your patients? I know it is more complicated than that, but my god! But would you ever walk into this physician’s office and start treating his patients?

    It sounds like YOU should be in charge of the ER (at that time) and what ever happens in that ER is YOUR responsibility!

    I get common courtesy, but geez. If he wanted to treat the patient, he should have a direct admit. This just sounds totally weird to me… Am I missing something?


    We definitely try to keep an eye on everything, but the staff docs still consider the patients “theirs” – even when the patients come to the ED. Some of the docs just don’t think the ED physicians are very smare.
    I think it has something to do with the perception that ED physicians are not really “experts” in anything and therefore have inferior knowledge to the internists and consultants.

  8. ladyk73 says:

    And why do I look like a chicken bug?

    Chicken monster. Actually it looks more like a crab monster. Those are just the avatars that WordPress randomly assigns to people not affiliated with WordPress.

  9. BFG says:

    This may be a dumb question, but why were they so concerned about coag studies prior to electrical cardioversion? (??hx of AF/risk of throwing a clot – wanting to know the pt was anticoagulated?)

    I have no idea. That was part of the frustration.

  10. Cynic says:

    Lady73:

    I do not want to put words into WC mouth, but I have done the same as he has. Dealing with arrogant schmucks on a daily basis is a reality.

    Sometimes it more enjoyable to watch, and I use this term loosely a “colleague” flounder about. For those that have been good to us we will back up in a heartbeat. (Sorry for the pun). For those who have dumped on us, or just have poor attitudes, karma is a bitch.

    All that said, if the patient was in dire need of help I would have stepped in. WC I feel would have also done the same. I myself don’t get excited over SVT, stable or not.

    Some bathroom reading if you are bored.
    http://www.emedicine.com/MED/topic1762.htm

    I was a little nervous about this lady. This is one of those times that I wanted to step in, but neither the cardiologist nor the internist was very receptive to my suggestions. So what do I do? If I stop what they are doing, take over, and there is a bad outcome, both of them would lambaste me for what I did. If I let them keep putzing around, things could deteriorate. One of those positions where you are damned if you do and damned if you don’t.

  11. shadowfax says:

    Next time you renew your hospital contract, suggest that your group have an “exclusivity” clause — this is geared to prevent exactly such situations as this. When your group is the exclusive ED service provider, then you will have the standing to take control in these cases. It’ll be unpopular with the other medical staff, so you have to have and be willing to spend some political capital with hospital administration to get it. The most successful strategy is to present this as a timeliness issue — patients who wait around for X time waiting for the private doc to get there a) slow down the rest of the ER, b) are at risk for deterioration, and c) represent an EMTALA liability if they are not screened and stabilized promptly. So you offer to be “helpful” and “work with” the privates, of course, to improve patient care and expedite the flow.

    My experience is that once you have asserted your control over your turf, it actually is a lot easier to work with the privates, since clear lines of authority are established, and you almost never need to “pull rank.” And it generally is just fine to be collegial and let the PCPs who want to take an active hand in their patients.


    This is a good point.
    Unfortunately it becomes a fine line between being helpful and ticking off the staff physicians. Relationships with the ED staff are already strained with several of them.
    We allow the staff docs to use one of the ED rooms as a “courtesy” so that they can see their patients and get testing done before the patients are admitted. Some take advantage of it by using all the hospital supplies and then discharging their patients from the ED. Others use the policy as a way to keep the ED physician from seeing the patient – which can sometimes have less than optimal outcomes.

  12. Chrys says:

    I don’t know how you held yourself back. You really need that exclusivity clause. That person should have had to step aside, while you aided the patient.

  13. TK says:

    We tried to get an exclusivity clause and the privates shot it down like a Kamakazi over the Marianas. Luckily, most of the docs that see their patients in the ER know what they are doing and are not afraid to ask for help if it is outside their realm of practise.

  14. HyperAl says:

    I wonder if his insurance carrier knows that he is doing ER work? A friendly call to the carrier might jack up his insurance premium 3 folds. Ouch, that would really hurt, don’t you think?

  15. That’s Shocking!

    Ooooh. You’re good.

  16. arrrr says:

    How many stories about dumb ER docs who misinterpret SVTwAC as VT do you think the cardiologist tells? Or the internist when you miss a Wegener’s? These little pissing contests are sadly endemic to medicine and all of its fiefdoms and usually reveal as much about the teller as the subject.

  17. Jeff says:

    You do realize that some day, that arrogant doc may end up as your patient, and be dependant on YOUR decision. SOMETIMES there is justice in this world….

  18. Not sure where you practice but it sounds like some of the 3rd world antics that occur in south Florida. Coming from the Midwest I was appalled at what was allowed to occur in south Florida. By the way, I’ve always worked best with all of my ER docs.

  19. cathy627 says:

    My OS once sent me to the ER and told me to tell them I was there because he sent me there to have an u/s of my leg to r/o clot after TKR. ER doc. almost laughed at me and told me I was being admitted and then my OS could order an u/s if he wanted one, but she thought I had an infection in my new joint and was treating me as though I did. Next day os comes to my hospital room bitching me out for allowing them to admit me and for the ER doc. not doing an u/s.

    These things really shed a bad light on the medical professionals as a whole. By the time I left, I was mad at all of them. But it was the ER Doc. who was right. I had an infection.

  20. [...] – Medical Weblog When in the emergency department, sometimes it’s best to let the people who normally work there handle the job. Rating:  (Not Rated)   Loading … Share This [...]

  21. psychiatrist says:

    ER docs have much more experience than I do at managing an acute panic attack. I would imagine an emergency doc sees more acute panic attacks in one shift than I have seen in 10 years of psychiatric practice. There must be many medical problems that you see the acute presentation of much more often than other physicians.

    When I was doing my internal medicine rotation, one of the other psych interns was assigned to the ICU for his medicine rotation. When the code alarm went off and we ran to the ICU, I was surprised to see the patient was still able to talk. Later, I asked my resident why a code was called. He said the nurses called it when the psych intern pulled out a handbook to figure out how to handle tachycardia of 180. Not the poor psych intern’s fault, he should not have been assigned to the ICU.(those were the days…)

  22. SeaSpray says:

    The lay person asks…Does the saying saying “time is tissue” have any relevance with tachycardia? Could it have deteriorated to an MI?

    In the best interest of the patient… that stuff just should not happen.

  23. [...] is about to occur but some recent events at our hospital have pushed me over the edge. The case the White Coat describes of being talked down to by an internist who doesn’t know his ass from a hole in the [...]

  24. greenb02 says:

    What year did this occur? I thought this stopped years ago. I have to agree with Shadowfax.

    This occurred about 2 weeks ago. Wish Shadowfax’s solution were that simple, but politics are politics.

  25. Liz says:

    I love that you sent the nursing student in to alert the doc. I am a medical student, and sometimes I feel even worse than the interns, who at least get yelled at daily (we are ignored, pushed over, talked around and stepped on). It makes all the difference in the WORLD when anybody takes 60 seconds to teach me something, or let me do a minor procedure, or asks me a question. I always thank anyone who does so, and they usually look at me like I’m crazy, but it’s so nice to be acknowledged and treated respectfully. I can’t quite figure out how some docs get their egos about them after being on the bottom of the pile for so long…how can they forget how it feels?

  26. JS says:

    Liz,

    I just started my 3rd year rotations also. I feel the same and think it is a shame that medicine has these types of people in it. Do they get their rocks off on inflicting pain on medical students? It is so weird, but these physicians are suppose to be “caring” for patients, and they don’t even care about the people they work with. I’m 35 yo and seen more shit than than most 65 y.o.’s but I have to swallow my pride, smile, and silently bemoan the state of medicine that creates these type of sadistic physicians. I can’t wait till I am a physician and I can defend med students and nurses from the antics and tirades of my colleagues and don’t have some evaluation hanging over my head like the Sword of Damocles.

    Anyway, I’m venting after a miserable day of presenting and rounding in pediatrics and getting ridiculed for my presentation skills and filling out a discharge summary.

  27. Spook, RN says:

    That was funny Doc. :-)

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