WhiteCoat

Open Mic Weekend

Back by popular request …

All weekend everyone is welcome to post any medically-related comments, questions, observations in the comments section.

Only rules are that there are no personal attacks and that the comments are medically-related.

Will try to respond Monday or Tuesday with answers.

Stay cool over the weekend.

17 Responses to “Open Mic Weekend”

  1. Long Time ED doc says:

    Someone please tell us the secret for having E.D nurses consistently undress patients prior to the physician’s exam. The physicians in my E.D. have tried “education,” bribes, threats, appeals to good clinical care, and as well as a few more creative attempts that probably shouldn’t be listed in a polite mixed-gender forum such as this. I’d pay a royalty fee to the E.D. physician who can knock this one out of the park with a good answer…

    Have at it!

    • Steve says:

      I have had the same frustration (not where I work now but at previous institutions I have been at). Patients with chest pain, abdominal pain, and complaints “in the box” who aren’t undressed…it is frustrating and time consuming to work around it.

      One possible solution- can you make it part of the ED tech’s responsibilities? When patients get in the room, it’s the tech’s job to make sure they get undressed and to help if needed. This may take some pressure off of the nursing staff by delegating it to the techs.

      Otherwise I think it has to be addressed from the top down- the nursing supervisors need to be on board that this is an expectation for every patient. You could make reasonable exceptions for isolated extremity complaints, stubbed toes, etc. but at a minimum, any complaint “in the box” = undressed.

      • Long Time ED doc says:

        I am in agreement with your ideas battling the ongoing undress the patient problem. We tried the tech’s doing it along with each and every of your other comments but it still doesn’t get done.

        I suggested an “undress the patient” specialist permanently assigned to the E.D. but it didn’t fly. I have even written a formal medical order such as “undress the patient.”

        The nursing top down approach didn’t quite work either. Lots of memos were generated and placed into impressive 3 ring binders, which were placed on shelves in our E.D. Hard for the staff to be motivated by their nursing supervisors in the suits and heels directing them from afar.

        Sorry to sound frustrated. We as Emergency physicians are continually pressed to increase productivity and do more with less. The least we can get done is having the patient undressed so we can do a decent exam.

    • Dina says:

      I’m not an ED doc, but I’ll take a stab at it. How about a sign over every bed, “Please remove your clothes and put on a gown (found in X). All patients must be in gowns to be seen by physician. If you are having trouble undressing, please let nurse know.”

      Or something like that.

      • Long Time E.D. Doc says:

        Yep, another very good suggestion that was tried and didn’t work like we had hoped, or anything close to it…Sounds like the kinda think that would work in a physician’s private office where the patient’s are literate, cooperative and have to pay their bill or be kicked out of the practice.

      • Dina says:

        Busted. That’s me. A doc in private practice. Since I’m in a low paying specialty, I was kinda counting on that royalty….

    • AnERNurse says:

      VERY simple…..make it so I only have to see 3 patients at a time. I know ENA and blah blah blah say 4 is the optimal number, but when I have 4 pt’s, it’s like a never ending merry go round of bull shit where I’m lucky if I chart 1/2 of what I need to.
      Seriously, when I have 4 rooms, all the pt care is pretty doable- if I don’t chart at all. And when I have 4 rooms, it’s not abnormal be given 2 pt’s at the same time. And since we’re tight for beds, often BOTH of those pt’s are ESI 2. So if I get a chest pain at the same time as a pale, sweaty, abdominal pain (happened last night)- by policy I only have 10 minutes to get an EKG on BOTH of those pts. Maybe the charge nurse or tech can help, maybe not. SO, on granny with chest pain (whom it would probably take me at least 5 minutes alone to undress), I throw the 12 lead on under the clothes, so I can at least get the EKG completed, while I run in and quick EKG/ line/ lab pale, sweaty abdo pain.
      Now, I do this with, every intention of getting them undressed after I’ve at least run the 12 lead. But, oh wait, I NEED to call report on my admit, so they can go upstairs, so the incoming ambulance can have that room. Then, oh yeah, I better get pain meds on board for abdo pain, and oh granny with chest pain needs her labs drawn (oh, phew the tech is gonna do that). Oh man, I haven’t seen my fourth patient, in like an hour and a half- better go at least pop my head in, make sure VS are okay. Oh, they need to go to the bathroom, and some pain meds- *sigh*, alright. Oh, now my new ambulance is here, gotta settle them.
      NEVER ENDING merry go round of shit that HAS to be done- that my dear doctors is why my pt ends up still dressed with the 12 lead snaking under their shirt. Believe me, I prefer them undressed too.
      I’d say it needs to be the triage nurse or tech’s responsibility, but they’re on the same merry go round with their own patients.

      • Nurse K says:

        ER doc walks into a room, a patient isn’t undressed. Hand them a gown and tell them what you want them to do. Return to room in 2 minutes.

        Same theory works for urinals. Instead of spending five minutes finding someone to hand an old guy a urinal, hand the old guy the urinal yourself.

        That being said, whoever puts the patient in a room should have them undress. Easy as that.

      • Long Time E.D. Doc says:

        Huge thanks for a great reply! No resources=Less efficient/suboptimal care. Nurses and ancillary support drive the efficiency of the system. Ask any E.D. doc.

      • Nurse K says:

        Haha, ask any ER nurse and we’ll say the slow vs. fast docs drive the efficiency. Ask the fast doc working with the slow doc on the other side of the ER and they’ll say the same thing. One horrendous shift recently, Doc #1 saw 33 patients in 12 hours (a lot) and Doc #2 (slowest doc) saw 15 in the same timeframe. I doubt the nurses were any slower on slow doc’s side vs. fast doc’s side.

        All I’m saying is…hand the people a gown. Sometimes we’re stuck doing slow doc’s huge set of orders.

    • WhiteCoat says:

      My vote is that it starts out as teamwork, then progressively gets more assertive if people take advantage of the situation.
      Absolutely agree with AnEDNurse that when excrement hits the spinning blades, everyone pitches in to get the job done – regardless of the “title” or what needs to be done.

      It’s common sense for a patient to be undressed once they get into an exam room and if it isn’t crazy busy, I don’t think it’s something that should have to be prompted any more than I think getting an EKG on a patient with chest pain needs to be prompted.

      My approach is to first ask nicely a few times and explain why it has to happen.
      If that doesn’t work, then I will tell the patients in a loud voice that unfortunately I can’t examine them until they’re undressed and that I’ll be back once someone helps them get on the bed and into a gown.
      If that doesn’t work, then I’m the jerk who will write “please undress patient” and “please chart vital signs” as orders and I’ll make copies of the charts to show the nurse and/or the nursing supervisor if it’s repeatedly the same offender.

      If that makes me a jerk, so be it. I’m not going to run my ass off doing everyone else’s work so that they can play Words With Friends and surf the internet.

      It’s a team sport.

  2. Long Time ED doc says:

    Hey Dr. Whitecoat!

    Any chance for a heading called “Best Of” where the most read articles, columns, most obnoxious and/or funny comments can be posted so they don’t get pushed so far to the back of the pile that they don’t get read by visitors who are new to the EP Monthly website?

    Even Craig’s List has a Best Of. Consider this merely a random suggestion.

    (Hoping I am not missing this idea if it already exists here, although it might be fun to see number of “out-raged” people online pointing out what a douche bag I am overlooking it.)

  3. Emily says:

    Seconding AnERNurse. I promise, nurses don’t undress patients just to be jackasses. We actually do want to undress them the vast majority of the time – we like to see what we’re looking at, too. It just isn’t always as simple as it seems. Also, a “Hey, Em, can you get Room 4 undressed? I need to look at his back.” will probably get you a lot farther than a written order to undress the patient. That only makes you look like Doctor Jerk and makes me hate you. It’s sort of like the guy who actually writes “Give Patient A Drink of Water” and “Give Patient A Blanket”. I have worked with that guy, and he was the Worst.

  4. Jennifer says:

    I realize Open Mike weekend has passed, but just checked in and had a question. As a patient with excellent private insurance, I had occasion a few weeks ago to visit a local for-profit “Emergency Room.” I was treated by a PA, never saw a physician, and the “treatment” was an x-ray that I was told was negative for a fracture and I was sent on my way with some antibiotics (of course). I followed up with my own physician on Monday where I received yet another set of xrays which did indicate a fracture. I also received sutures and follow up treatment. the cost for my “Emergency Room” visit was almost $2,000, fully covered by my health insurance.

    What is the emergency care physicians’ take on with these entities that are popping up like mushrooms all over town? And, in a true medical emergency, is it best to go to a “real” hospital or would I expect the same level of care, given my injury was non-life threatening? What is an informed (and INSURED) consumer to do?

    • WhiteCoat says:

      Reminds me of the old saying that “the last doc is always the smartest.” Even if you got appropriate treatment the first time around, the subsequent treating doc has the benefit of seeing whatever the problem was and the effects of the initial treatment.

      The problem with emergency departments is that you can’t base the quality of care on the location. Many docs work at more than one facility, so the “bad” doc that you saw at the freestanding emergency department may be the same one you see the next day at the “real” hospital.

      By the way, if you’re not comfortable having a physician assistant treat you, then you have the right to request that a physician treat you. May have to wait a little longer, but it’s your option.

      • Jennifer says:

        Got it – thank you!

        I imagine these stand alone EDs must be real money makers – I wonder if they siphon the insured patients away, and leave the hospitals (both for and non-profit) left holding the bag with the non or under-insured.

        And no issue with being treated by a PA (other than the fact that she was wearing flip flops and her very long hair was down, eew), but I imagine she earns a lot less than than the MD on duty, but my bill didn’t reflect that. Profit! Winning!

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