The Quickie
Toward the end of a shift, an enterprising ER doc sometimes looks to take one last uncomplicated patient before going home. We call these patients "quickies."
Sometimes, what looks like a quickie really isn't, so one has to be careful.
PATIENT 1
Chief Complaint: sprained ankle (Great, send them
back!)
Nurses note: pt c/o twisted ankle and vaginal discharge for one week. (Never mind.)
PATIENT 2
Chief complaint: UTI (perfect!)
Nurses note: pt c/o burning with urination, lower abdominal pain, and vaginal discharge for one week. (Never mind.)
PATIENT 3
Chief complaint: migraine (Hmmm...migraine or pelvic, tough call)
Allergies: Toradol, Compazine, Reglan, Haldol, DHE, NSAIDS, etc. (Ka-CHUNK! back in the rack!)
PATIENT 4
Chief complaint: 6 weeks old, feverish (Maybe just a worried mom, lets look at the vitals)
Initial vital signs: Temp 98.4 (Winner!)
I enter the room to find a sick kid with a repeat temp of 102 who required a sepsis workup and a transfer to another facility, causing me to stay an hour after my shift ended. Oh well, at least the right patient got seen first.
In reality, quickies are generally not worth the effort. They aren't financially rewarding for us because of their low acuity, they aren't medically satisfying because they usually don't really need to be seen in the ER anyway, and they don't do much to decompress the waiting room since they are just as quick for the next guy. I've become more a fan of leaving on time than seeing another sore throat.
Sometimes, what looks like a quickie really isn't, so one has to be careful.
PATIENT 1
Chief Complaint: sprained ankle (Great, send them
back!)
Nurses note: pt c/o twisted ankle and vaginal discharge for one week. (Never mind.)
PATIENT 2
Chief complaint: UTI (perfect!)
Nurses note: pt c/o burning with urination, lower abdominal pain, and vaginal discharge for one week. (Never mind.)
PATIENT 3
Chief complaint: migraine (Hmmm...migraine or pelvic, tough call)
Allergies: Toradol, Compazine, Reglan, Haldol, DHE, NSAIDS, etc. (Ka-CHUNK! back in the rack!)
PATIENT 4
Chief complaint: 6 weeks old, feverish (Maybe just a worried mom, lets look at the vitals)
Initial vital signs: Temp 98.4 (Winner!)
I enter the room to find a sick kid with a repeat temp of 102 who required a sepsis workup and a transfer to another facility, causing me to stay an hour after my shift ended. Oh well, at least the right patient got seen first.
In reality, quickies are generally not worth the effort. They aren't financially rewarding for us because of their low acuity, they aren't medically satisfying because they usually don't really need to be seen in the ER anyway, and they don't do much to decompress the waiting room since they are just as quick for the next guy. I've become more a fan of leaving on time than seeing another sore throat.
posted by scalpel at 4:22 PM
23 Comments:
I'm curious. I've asked my own doctor this question. I'm diagnosed with being both obese and alcoholic dependent. I also have high AST & ALT, both in the 300 range. I am completely cognitively aware of the risk factors associated with both obesity and alcoholism. I am acutely aware.
I would like to be prescribed a course of Topiramate. From my research I would like to start with 25mg daily increasing weekly until 100mg daily. I believe this to be an ideal treatment for my situation.
I've tried diets, detox, rehab, and exercise. As well as cognitive-behavioral therapy.
I recognize you're probably very uncomfortable in offering any medical advise in this forum. Perhaps you could suggest, at least, papers on the topic or general suggestions. I can't seem to properly represent to my physicians the importance of this treatment. I am 25 and 6"1' 405 lbs. I am a college graduate and have an IQ of 136. I am very successful in my career, married and a very involved and a socially involved family person.
Anyway, I'm mostly curious about your understanding of Topiramate.
Hey Scalpel, it seems that you have a very cleverly disguised free advertisement on your site (see anonymous comment at 0706). I have the sudden urge to ask my doctor if Topiramate is right for me
Anyway, we had a patient like that in our ER today: a quick ear pain that turned out to be bell's palsy. 9 hours later...
In our department there is nothing to be gained from taking the OTH (other chief complaint) in the hallway as the last patient. It will be neither quick nor painless and will likely involved insects or discharge. OR worse, both.
I'm not familiar with that indication for Topamax, sorry.
Another quickie: Ear ache.
Nurses note: Pt c/o radio tracking device implanted in ear by KGB.
99% guaranteed quickie: Suture removal.
Lately, it seems every female patient under age 40 has "vaginal discharge" tacked on to their primary chief complaint.
The best "quickie" (other than suture removal) is a male with non-radiating back pain.
Male with non-radiating back pain is fairly quick UNTIL... allergy list: see migraine patient above; or:
fever? yes
weight loss? yes
h/o prostate CA? yes
In other words, any complaint can become complicated. The long-tail as DBMedRants calls it.
What do you you low acuity? Every patient in the ED can be billed a level 5. Remember? It's the ED where anything can happen and full workups ensue with an excellent and thorough crew of well documenting nurses typing away on a fancy EMR.
I have seen stubbed toes carry the documentation of level 5 ED visits. Because even stubbed toes can present in uncommon ways.
The nice thing about primary care? I can always bring them back for the second problem. I can also say that I don't to GYN and let my PA do that stuff. I guess there is a bright side to not getting paid much - there isn't enough difference b/w level 3 and 4 visit to motivate longer visits.
I am prepping for my colonoscopy procedure tomorrow, I am on my way to the pedicurist to get my calouses removed, I don't want to scratch the staff with my severley dry and scratchy feet! (: then I am coming back home to drink that awfull drink and remain in the bathroom for the rest of my night! wish me good news, Stacy.....
If they are touching your feet, they're doing it wrong.
Good luck.
Just a reminder, twisted ankle and vaginal discharge is Shmitty's syndrome until proven otherwise. Classic Shmitty's diad. Also, it's an automatic level 5.
Rob,
The difference between a lvl 3 and lvl 4 visit with Medicare payment is about $27 where I am(NC). Asking about their allergies, or HTN, or whatever along with whatever else they are there for(assuming medically necessary-ie haven't been in for it since Dr. Dino was a hatchling) gets you from a 3 to a 4 for about 2 minutes work. And that two minutes spent on their HTN is probably more important than the cold or acne or whatever they came in for anyway.
LOL Scalpel ! oohhh they did it right today! wasn,t that bad,except for the sedation,I was pretty awake and still nervous,I am allergic to Demerol( found out at 9rs old during tonsillectomy,ooo I still remember it, fever,rash,hives,it was pretty bad, mom said I could have died.soo today,instead, they gave me some fentynal? and versed?(spelling?)it was to me very uncomfortable and alot of pressure,Thank God everything was "perfect,no polyps,problems.etc.. for I will NEVER undergo that procedure again, unless its thru my toes!!!! Thank You for making me smile today" I needed that! Have a great week, Stacy...
When I saw the title of this post, I thought it was about something completely different ... like a closet rendezvous a la Grey's Anatomy.
Oh Stacy! Don't say never! They make that stuff in several "great tasting flavors"! You don't want to miss out!!
Does anyone actually go back to the ED (or anyplace else) to get their s t i c h e s out? C'mon.
LOL I don't care if they made it with chocolate, I still would puke it all up !! No Thanks, No Way, absolutley NEVER AGAIN!! from the prep to the procedure, NEVER ! LOL
Really, Tracy. I've always picked out my own stitches. What's the big deal? Staples might be a different story, tho.
Oh, and ime Topamax can cause serious cognitive difficulties. But this isn't medical advice; just an observation.
Marcia You're so right about staples...different story. Although...the hospital a l m o s t sent me home with a staple remover kit because they thought my doctor might not have one...what??? He's a physican, for God's sake! (Looking back, i should have taken the kit...Ha!) However, i did get to see my "Pre-Hospitalist" to get them out and he's a sweetheart, so i guess it was worth it...!
This is a really weird comment string.
Indeed.
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