Saturday, March 20, 2010

blank check

In my anesthesia group, the second call doc is known as the "Rover," which sort of means that they are the out of OR everyman. Aside from administering anesthesia in the endoscopy suite (11 cases yesterday, thank you very much) we are also the doc that gets called for all new pain consults and central line placement requests, as well as anything else that people may need. The pain consults are mostly what you'd expect--post-surgical pain management, acute on chronic pain, oral conversions of IV narcotics, what have you. But now, twice, I've gotten called from services that want me to write narcotic prescriptions for patients being discharged from the hospital. Let me be clear: they are not asking for advice on what oral pain meds to discharge the patients on, or recommendations about conversions or tapering or dosing. They just want me to show up and write a prescription for the patient to take home with them.

NURSE: Dr. XYZ said to call you guys to come write the morphine prescription. She's supposed to be discharged right after.

MICHELLE: Wait, but I've never even met this patient before. I've never even heard of her. And I'm never going to see her again. I don't think it's really appropriate for me to be writing a morphine prescription for this person. Who's the primary doctor in charge of her care?


MICHELLE: So why doesn't Dr. XYZ write the prescription?

NURSE: He says he can't.

MICHELLE: He "can't"? He's...not a doctor? He doesn't have a DEA number?

NURSE: He just told me to call you and for you to do it.

MICHELLE: Look, I want to help you, but I'm not going to do that. I can't just come and write narcotics for a patient that I've never taken care of, know nothing about, and am never going to see again. That's just completely inappropriate. Someone who is responsible for that patient needs to take it on themselves to write that prescription. Either the primary doctor on service or her primary doctor outside of the hospital. Someone who is going to follow up with her. Someone who is going to see her again, ever.

NURSE: But Dr. XYZ wanted you to do it.

MICHELLE: I'm not trying to pass the buck here, or give you a hard time, I know you're just following orders. But...look, if he wants advice on what narcotic to send her out on, or wants me to help him calculate the appropriate dose, that's fine. But I'm not going to come and just write a prescription for someone I never met. Frankly, I'm an anesthesiologist in the OR. I don't even carry a prescription pad.

NURSE: (Pause)'re not going to do it?

Any doctor with a DEA number can write a prescription for narcotics for patients that need it. Whether or not they want to take responsibility for writing those prescriptions is a whole other thing. Which begs the question...if they as the primary physician don't feel comfortable taking the responsibility, why would I?

Here's one for the comments section: What's the most inappropriate thing you ever got called for in the hospital?


  1. Nurse: I tried to give the patient Tylenol for his 'joint pain' and he said, "Tell that doctor to get her head out of her her ass. I can't take Tylenol because of my liver. I have to have Percocet."

    P.S. I'm good PCP - I write my own narc scripts for my patients.
    P.P.S. That guy had normal transaminases.
    P.P.P.S. I've also been called for 'patient's visitor wants something for anxiety.'

  2. When I was a medical assistant I was asked to take a patient's call because the PA was tired of taking their phone calls because the patient needed to see psych and wouldn't go. I was successful in getting them to go. w00t

    Don't know if that was that inappropriate but it's all I got.

  3. As an Ob/Gyn Intern - ED consult for pelvic organ prolapse in a 30ish year old woman.
    When I go to see her, turns out she is psychotic with the unflappable idea that "things are falling out" when in fact, she has a completely normal pelvic exam. The ER PA had done a pelvic exam and knew it was normal, but thought she might believe the "expert". Yeah...that's what psychotic patients are known for...being reasoned with.

  4. Anonymous12:59 AM

    I'm an anesthesiologist. Once, I got a 911 call to see a kid in the Phase II portion of recovery because she appeared ashen and somewhat cyanotic with bluish lips. Vital signs were all normal. After questioning mom and the nurses, the patient just had blue and green popsicles.

  5. Anonymous3:25 AM

    I am a 4th yr medstudent who is friends with an osteopathic intern. A nurse paged her at 4am to get a neck adjustment for HERSELF, not even for a patient. I'm glad she said NO and went back to sleep.

  6. Naomi6:29 AM

    At 2am while doing night cover for General Medicine - "Pt's urea level is low, please review urgently" - this for bloods that were taken at 9am the previous morning!!

  7. Stella7:35 AM

    A woman called the OB/Gyn emergency answering service at 3am to get advice on what she should to for her BOYFRIEND's cough. I told her he should go see his doctor.

    I've also been called to consult on patients for vaginal bleeding when they were just having their period-- it was clear that the primary team didn't ask the patient.

  8. Anonymous8:37 AM

    Holy Crap_this happens to me allllll the time_the sad thing is-we are expected to HONOR it for certain surgeons ( ! )- I am a resident. See also:

    1. Hospitalist attending wants orders for morphine drip for end stage lung CA patient as he is " not comfortable " writing it.

    2.Floor orthopaedic RN decides to stop patient controlled epidural s/p total knee replacement because of "change in neuro exam" ( the patient was FINE ) and demands an order for PCA.

    3. RNs calling for pain consult because they think the " patient needs it ".

    4. Orthopaedics thinks that I am their curbside medicine consult for all of their floor patients pre op no matter how healthy, because they are " bone doctors " and somehow have lost all medical acumen.

    Yep-I'm an anesthesiologist too.

  9. Anonymous9:14 AM

    'NFR order please' (NFR is our equivalent to your DNRs) written on the board regarding multiple geriatric patients while on night shift.

  10. I was on psych consult service this fall when I got my favorite consult ever:

    "[the patient] seems lonely and needs someone to talk to".

    My least favorite:
    A nurse calls me to order an antipsychotic on a patient AFTER giving her an inappropriately high dose of said med because the patient was awake when the nurse wanted her to sleep. Nurse was eventually, but not instantly, fired.

  11. Anonymous11:54 AM

    I've got a few that happened to me or colleges in neurology:
    1. A call to the consult pager from a physician in an outside ED about how to prescribe narcotics in a child with a non-neurologic reason for pain and no neurologic history. Ummm, whatever you would usually do...
    2. Leg numbness in an ortho patient. On exam the patient has an epidural. Talk to the team: "oh, we thought we DCed that two days ago..."
    3. "Focal vaginal seizures" in an oby-gyn patient. She was mentally retarded, masturbating, and then getting upset about the end result of said activity.
    4. Dysarthria in a patient with no tongue.
    5. Concern for "rigor mortis" in a patient who was not dead.

  12. Anonymous12:31 PM

    As the pain consult I have gotten the call for "can we reduced the amount of pain meds the patient is on because I am uncomfortable writing a prescription for this much." The pt needed that much and had excellent out pt follow up with his PCP of 20 yrs. The resident had never thought of writing a script for 1 week (during which the PCP would take over opioid prescribing responsibilities) instead of 30 days.

  13. Anonymous12:57 PM

    Patient's daughter (in the office): My mom can only be on 5 meds. 5. No more than 5. I'm not a doctor or anything, but we have to d/c some of these meds.

    Me (thinking): (looking over list of 20 meds) - Well, what do you want her to die from?

  14. Anonymous2:10 PM

    A dying patient's family member asked me to write a percocet prescription for him (the family member, not the patient) because his PMD wouldn't.

  15. I'm an anesthesiology resident and I get called all the time to write opioid prescriptions for patients I don't know. Obviously, I refuse.

    Also I get called to put in IV's on the floor if they seem "difficult".

    One time a nurse was very upset with me because I didn't put a line in a competent patient who refused the procedure. She didn't seem to understand that it would be illegal to do so and thought that I didn't "convince him hard enough" !!!

  16. One call, I admitted a girl with chest pain. The ED had ordered cardiac enzymes which were normal.
    That night I got woken up to a page - her nurse asks me, concerned, "have you seen the patient's troponin?" me: yes.....? it was okay. nurse: but it's LOW. me:.........
    turn's out our computer system reports that value as "low." maybe the nurse wanted me to give the patient some extra troponin to make it normal?

  17. Anonymous3:35 PM

    "pt congested, can I have order for Vicks vaporub?"--3am page when I was intern on trauma service for pt with rib fractures.

  18. A 30 year-old patient has appendicitis. BhcG comes back positive, and oops, she realizes she's 8 weeks pregnant. When Ob/Gyn evaluates her pre-operatively, she asks if they could just "take care of it" after general surgery is done with the appy.

  19. Anonymous4:18 PM

    We had a pt who had OD'ed on tylenol in the MICU in liver failure with little hope of transplant and we were pulling for her to recover when she spiked a fever. The patient's nurse then asked for a tylenol order to get the temperature down.

    I was once asked by the surgery team at 3am to turn back on an ICD for a patient who had coded intra-op and was now comfort care, on a morphine gtt, and DNR.

  20. Anonymous4:55 PM

    Got called at 3 AM for some ativan for a patient known for insomnia ... When I asked for his vitals, the nurse said "I didn't take them, he was sleeping..."

    Also got called at 4 AM for a "medical word" the nurse didn't know in the crosswords...

  21. This comment has been removed by the author.

  22. Personally I always hate to page a physician with some lame-@ss request from a patient (i.e. more pain meds when they're taking everything under the sun already, or some non-essential fish oil pill that's not formulary and can wait until morning rounds to be ordered, but which the patient insists they can't live with and wants *now* at some equally lame time of night, like 11p.m.)

    Just a thought: a few of the idiotic pages physicians receive are a result of nurses having to pander to a "customer service" driven model of healthcare and the resultant amplification of self-entitlement in some of our patients. Trust me, we nurses don't relish paging you guys for stuff like that, but if the patient makes a big stink about it and you aren't on the floor to consult directly, we don't have much of a choice.

    And I'm sure I don't need to point out--as some of these anecdotes attest--that nurses are not the only ones who make moronic, life threatening mistakes or lapses in judgment; it happens to everybody who rides the often-not-so-happy fun train that is health care.

  23. Anonymous6:01 PM

    Jamie, where did this unprovoked defensiveness come from? I didn't see anything in the post or in the comments that suggested any broad-sweeping conclusions about the nursing profession or any other group in health care.

  24. Anonymous6:41 PM

    1) paged while on trauma service for patient with acute on chronic leg pain for order for ketamine... patient was on a non-monitored floor bed

    2) paged (while on trauma again) for patient with "altered mental status" who was actually just sleeping and then NOT called later the same day for patient in cardiac arrest

    3) called by freaked out med student to evaluate a patient "STAT" for seizures who was in the bed shaking and saying "i'm having a seizure" (i carefully explained to him that if he was talking, he most likely was not seizing)

    i am an emergency resident, and most of our "inappropriate consults" are from patients requesting narcs for minor injuries. i usually try to prescribe a dose of suck-it-up

  25. I got a General Medicine consult from a surgical step down unit about large orthostatic blood pressure changes. When I got there, the BP was being measure through an art line, even while the patient was standing with no adjustments to the level.

  26. Anonymous7:32 PM

    Consult for "vaginal bleeding" in a patient who had had a hysterectomy (including cervix) 10 yrs ago and had massive bleeding from the bladder that was known --- internal medicine resident "didn't feel comfortable" doing an exam and wanted OB to do it. Oh well, easy consult, just silly.

  27. Vascular consulted me when I was a med student on heme/one for a hypercoagulability consult on a psychotic, non-adherent patient who was *supposed* to be on warfarin, who had just thrombosed her graft. INR = 1.0.

    It was my first consult on that service and I was so flummoxed because I thought there *must* be something else going on, that it took me twice as long as necessary.

  28. Anonymous10:46 PM

    I got called once to prescribe SC morphine for a post-thyroidectomy.

    "What did the anaethetist prescribe?" I asked.

    "Endone." She said.

    "Have you given it?"

    "No. I don't think its strong enough. She's in a lot of pain."

    "Ok. Try giving it and see how she goes."

    Go up to that same ward 30min later for another issue.

    Sister comes bustling out and demands the order for SC morphine. I ask if she's given the endone. She hasn't.

    I ask why.

    "I don't think she can swallow it."

    Run into room to find patient going blue around the lips and stridoring. Bleeding into thyroidectomy scar.

    And in the middle of attempting to intubate the patient who had a respiratory arrest - she came over with an order for SC morphine she'd written up for me to sign.

    Needless to say - I didn't :p


  29. Anonymous10:53 PM

    Page from a nurse at 1am about a patient admitted at 9pm whose H&P and admission orders had been in the chart since then: "Doctor, about patient in room XX, what is the plan of care?"
    Me, sleepily: "The plan is xxx. Why do you ask; is there something wrong with the patient?"
    Nurse: "No, I just wanted to know what to tell the morning nurse in report."

    Also, I've gotten middle of the night pages for Miralax and diaper rash cream, and been asked to clarify days-old orders that the night nurse was diligently reviewing at 3am.

  30. Anonymous1:15 AM

    A nurse paged me (then med student) to tell me she had mistakenly given 10 times the dose of a medication, and wanted me to write an order saying that it was ok.

  31. Anonymous1:41 AM

    paged to evaluate patient with hemiparesis and aphasia but negative CT and "normal" labs. The stroke fellow and I assessed the patient and ran her into the MRI scanner. While she was being scanned I checked her labs - serum glucose was 20. A little D50 and she was back to baseline. I'm glad she got thousands of dollars of imaging done when they could have saved time and $$ with a simple finger stick or even a cursory glance at her bloodwork.

  32. Anonymous3:44 AM

    'we'd like imaging-guided LP pls'
    'have you tried on the ward? was it unsuccessful?'
    'no we are worried the patient has increased ICP and dont want them to cone'

    because us radiologists have magic hands that wont let them cone??

  33. Anonymous12:48 PM

    At our institution, the Orthopedic folks will try to find any excuse at all to dump post-operative patients on any other service. On the one hand, if they're that disinterested in taking care of patients, I'd rather be doing it. On the other hand, there is really no excuse to transfer a patient for things like diabetes management when we have a diabetes consult service . . .

  34. Call from a pt (emergency line) at 3 am: "I was just wondering if this vaginal discharge that I've had for many years should be anything to worry about?"

    Consult from medicine for vaginal spotting (not even heavy bleeding) in a 92-year-old woman, DNR for multiple other terminal medical problems, hemoglobin normal.

  35. Anonymous10:06 PM

    I am a med student still and had to point out to a PGY 2 that maybe keeping that patient with uncontrolled epistaxis (even a balloon foley wasn't working) on heparin may not be such a bright idea. She told me to basically "shut up and color" morning she was lamblasted at morning report and the patient had to recieve 2 units of FFP.

  36. Anonymous11:43 PM

    On call for psychiatry, I was asked to sing "amazing grace" to psychotic patient because her family didn't want her to get Haldol (they just didn't like the sound of it) and "sometimes that song calms her down."
    I tried it. It didn't work.

  37. Anonymous3:01 AM

    ER - 10yo girl presents with bright red tongue. on interval history, had red popsicle for lunch. intern removed red discoloration with a paper towel. mother then proceeded to demand IV benadryl for this "allergic reaction."

  38. Anonymous7:14 AM

    during my 2nd year ob/gyn residency, consult from the ICU to remove a "retained" tampon....thank goodness for all that medical training

  39. Anonymous8:27 AM

    On an out-of hours shift as a house officer in the UK (i.e. intern) I was asked to "please rewrite this patient's drug chart as it has gotten lost between pharmacy and the ward and we have nothing to double check the discharge medication script against before we can send this patient home".

    My response was, "Hang on, you want me to back-copy a patient's discharge presciption onto a drug chart so you can double check the prescription against the drug chart I've just copied?"

    Response was "Oh."

  40. Internal medicine resident4:06 PM

    Got paged at 3:30 AM when I was an intern covering the general medicine service:

    Nurse: "You need to call a psych consult for Mr. X. Right now."
    Me: "Why?? What's going on?" (thinking patient has become acutely psychotic or needs restraints or something)
    Nurse: "Well, he is very depressed right now."
    Me: "How so?" (is he acutely suicidal? out on a ledge?)
    Nurse: "He looks sad."
    Me: "He looks sad? Well, I can come talk to him..."
    Nurse: "No, don't come now. He's sleeping."
    Me: "So he looks sad ... in his sleep? And you want a psych consult?"
    Nurse: "Yes, and not 'want,' 'NEED,' and we NEED it now."

    I did my psychiatry colleagues a favor and did not wake them up at 3 in the morning to evaluate a sad sleeping face. He denied any 'sadness' the next morning on pre-rounds.

  41. Anonymous8:12 PM

    I just got back from seeing a patient as an ER consult for a completely non-displaced fracture of a metacarpal. I need to cope with my bitterness better.

  42. ER attending from an outside hospital called me (on-call OB intern) and said, "Hi, this is Dr. X, one of the attendings at Hospital Y. We have one of your patients who delivered 6 days ago, and I think she has pre-eclampsia. What should I do?"

    Me: "Um, what makes you think she has pre-eclampsia?"
    Attending: "Well, she has a headache and she just delivered 6 days ago, and her blood pressure is 205/113. I called [Other outside hospital with similar name to mine] because I thought she delivered there, and they told me to send labs. So the labs are pending."
    Me [Imagining patient stroking out]: ...
    Attending: "So can we just transfer her to you, because we don't do OB here?"
    Me: "Can you fix her blood pressure first?"
    Attending: "Sure. What do you want me to use? She's not breast feeding."
    Me, thinking: a non-pregnant woman who is not breast feeding has a blood pressure of 200/100. Use any freaking medicine you want!
    Me, out loud: "Anything will be fine."
    Attending: "OK, what is your goal BP?"
    Me, thinking: um, I'm the intern, since when do I give advice to the attending?

  43. As an anesthesia resident, I was paged to start the IV for an elderly lady in the observation unit (should have 1:1 nursing care). I arrived, but the intern and nurse were busy discussing issues at the desk, so I wandered over to the bed # that was mentioned on the phone.
    Behind the curtain sits a family member (obviously uncertain what to do) and her poor dead mother. (Q sign, no pulse, DNR order).
    I go back and ask the intern and nurse who exactly they wanted the IV in and they indicate the bed I had just come from. I reply, " That patient needs an IV? That patient is dead and does NOT need an IV!"

    Seriously? Review your DNR orders and don't call anesthesia for IVs on DEAD people.

  44. Anonymous11:26 PM

    Me (when first term as intern) - to certify a patient as dead in another hospital (request came thru admin who'd been asked). I don't think I had a good reputation for certifying pt's...

    My sister as trauma resident - asked to urgenty review bad fracture on an ED patient. When she got there, couldn't pick it so asked the referring dr who pointed to that long black line between tibia and fibula...

  45. Anonymous8:55 AM

    92 y.o. who lived with her daughter was a new admit for abdominal pain. upon exam the resident noted vaginal bleeding. She questioned the fsmily, "is the vaginal bleeding new?".

    Daughter: "oh I think she is having her period."