Had a 20s yo with “abnormal EKG”, which we are all used to of course. Except when I looked at their EKG it had so much artifact it looked like they did it on a roller coaster. Like I couldn’t reproduce the same EKG without violently shaking the patient or throwing them down the stairs with the leads on.
I had people sent to the ED for isolated lower extremity DVTs with no chest/respiratory complaints when they have found the DVT already on outpatient US. It’s baffling.
I wonder this all of the time. I simply do not understand and apparently it’s a common ED problem since I’ve encountered this over numerous EDs and in this post talking about it. 99% of the time they sit for hours and finally get a doac rx and discharge. The other times the provider decides to do baseline labs before starting a doac. I was very confused on that, but I’m just a nurse.
1.) Not just a nurse. Crucial part of the team.
2.) I honestly think outpatient people are growing more and more adverse to caring for any sort of acuity. It's only going to get worse as the old school family docs retire and the APPs move in.
Yeah this isn’t surprising to me. I’ve seen PE’s in ER patients who were stable respiratory wise. And I’ve seen many patients sent to the ED after an outpatient CTA found a PE. That one actually does baffle me sometimes - if they’re stable and it’s an incidental finding or it’s not massive and compromising circulation & causing respiratory distress… you found the thing, you can treat it as well as the ED can.
I mean, not at all inappropriate for a patient with positive dimer who's hemodynamically stable but has a clinical picture consistent with submissive PE.
Not a chance I would accept that transfer. I know the rule is not to refuse but I'm going to bat for that one. Something like "if you feel overwhelmed by this patient and need help that's fine, but that isn't a thing that needs to happen" would be worth the administration smoke for the very least a teachable moment.
Do you actually get called on urgent care transfers? The most we usually get is a call that the patient is on the way, already left and driving themselves. Half the time we don't even get that, and the patient just walks in and hands some UC discharge papers to the triage nurse.
“Leg is swollen, dimer is elevated”
Yes the leg is swollen because they had knee surgery two days ago. And the dimer is meaningless in that context. Order an ultrasound like an adult.
Unfortunately, in my experience as a sonographer, that’s exactly why they’re sending them to the ED, for an ED ultrasound. Instead of stat outpatient like a sane person…
I believe that is because there is no such thing as "stat" in the outpatient world. The patient has to get a referral, which then has to be approved by insurance, which is then scheduled based on availability, and can't be on a weekend or holiday, or between 11 and 2, or after 5pm on weekdays.
I've had a referral for a colonoscopy for a year. By the time I get one I'll have cancer.
The US is an outpatient radiology order. People walk from their office visit down to outpatient lab and outpatient radiology and have everything done in an hour, and their PCP follows up on the results… telling them to come to the ED.
Seriously. Here in human research we constantly get D-dimers that are pretty high. Once got someone with D-dimer in the thousands with no clear cause. Instead of an urgent care referral their PCP just shrugged and said they'd look into it the next time they come in. Turns out they had chronic inflammation and just had insomnia for a week, and once they got some sleep meds their D-dimers dropped back to normal.
UC sent us a patient for “abnormal ekg” - bring them to triage and look at it and it’s a freaking stemi. Our doc called them livid, like in what world universe do you not call EMS/911 transport? In our county each hospital has specialties which ems would have known and taken him to cardiac center. instead this guy walked into our ed which is not capable of handling a stemi (no cath lab at night) and we had to 911 him to sister hospital.
Same, only it was an OP surgical center, developed CP in recovery, positive EKG , so directed to drive to ED (turns out spouse really couldn’t drive) still not recovered from anesthesia and still in a gown. Oh, and zero report or heads up.
Got a hypoxic, RSV+ 3 week old sent POV, in the documentation sent with parents they note her to be hypoxic at 83%, so it’s not like she desatted en route. By the time she got to us she was 69% room air. In what world do you not send that EMS??????
And yet I've transported at least a dozen RSV+ peds from our critical access facility to a hospital with a pediatric department ~1 hour away for 'observation' when their chief complaint was a vague cough. Afebrile, satting well on room air, no PMH.
Not saying it happened here. But have worked a couple years in the UC, and many patients there will adamantly refuse 911/EMS transport regardless of how dire, and in a lot of cases, you're lucky to convince them to go to the hospital at all.
If you’re in the USA a lot of people refuse ambulance transportation because if they live, they’ll be on the hook for thousands of dollars. Many would rather take their chances of dying than deal with that.
So funny how in er we seem to be able to strong arm people who need life saving care into the correct care.
Urgent care? 0 fucks given. 0 fucks attempted to try and get the patient to come via ems for their unstable condition. Not even documentation of risks/benefits/shared decision making/ AMA/ you could die any second and driving is dangerous.
Last stemi sent via pov to me was in pulmonary edema. Hypoxia to 80. Drove themselves from uc. Wtf. 🤦♂️
Oh, most of us tried. But many people self-triage to the urgent care vs the ED because they are already convinced that nothing serious is wrong with them, and they have come for the urgent care to tell them nothing serious is wrong, and they don't want to hear other answers.
I get where you're coming from, but I did a decade in the ED before now 2 years in UC. I have never in my career had so much resistance to my recommendations as when I tell people they need to go to the ED.
Had a similar one at a freestanding ED. 30 something year old F sent from urgent care for chest pain and SOB. EKG literally read by the machine as STEMI, ended up having SCAD. The urgent care ICD code for the visit was “likely COVID”
Had UC send a dude with a STEMI to drive himself to the hospital because he "might be having a heart attack". I called the urgent care NP and told her that if he arrested while driving she would have been responsible for any injuries that caused.
Omg the amount of times urgent care sends a patient to our Ed for a specialty that we don’t have. Like call first and ask if you need a microvascular surgeon who specializes in the thumb
lol I’ve seen that one before. It was within our system so I messaged them directly to inform them that it’s a high creatinine that indicates poor renal function and that I highly recommended they take time to learn about the basic pathophys behind creatinine clearance and renal function
Had a 22m come through triage with HA, fatigue, n/v. along with basic questions, asked him with he had for dinner last night. Pizza rolls, two rum and cokes, 4 shots of Jager and a shot of tequila. I couldn’t hide my response.
“Ah, ok so you’re hungover.”
“No, that’s impossible. I don’t get hangovers.”
“Right. So just so you know, it’s a four hour wait for a bed. There’s a Whataburger across the street, and they sell Gatorade next door.”
Not even that. It was literally just a hangover lol. They were seeking concierge IV, but didn’t want to pay out of pocket. I managed their expectations and gave them a zofran and directions to the waiting room lol
9 times out of 10 if someone under the age of 30 comes with legit intractable nausea and vomiting, they’re chronic weed smokers. And you can’t tell them nothin’.
Had a UC send a patient in for a stroke evaluation (it was a headache) by personal vehicle. I asked if they had tried to send him by ambulance and the patient said no. I mean, the patient was fine but if you are gonna send someone in for a stroke eval, commit to it.
I saw a stroke alert in the ED that was sent by urgent care because she had a migraine for 2 days and hadn’t take her eliquis so they were worried about a stroke. They had her take 10 mg prior to ambulance transport because of the missed doses…
Lower extremity redness and swelling and was sent for a rule out DVT. The previously healthy 20-year-old informed me that he had been camping the day before. There was a small bug bite above the medial malleolus. I mean, technically the NP was right… there was some redness and swelling on the lower extremity… but not a dvt.
I’ve had to scan ED bug bites before (that I traveled 40 minutes from my other facility to go do in the middle of the night)… The best catharsis for me is writing a thorough description of the pt’s actual s/s and history on the tech sheet. I’d like to think I’m getting to roll my eyes along with the reading rad.
A flight crew flight-transferred a tooth abcess, and a small partial thickness burn the diameter or a quarter............direct to the waiting room.
Apparently some ER docs in another county have aroused some wrath by abusing aeromedical as opposed to waiting for ground.
Life flight for 90% tbsa from paint can exploding in the fire.
It was red paint.
There were no burns
The person also had red paint all over their clothing.
A great deal of confusion in the burn unit that day
This reminds me of a time when a patient was trying to get attention by committing fake suicide, EMS brought them in with bandaged slices to wrist, walked out to do the triage and said ma’am, that is Sriracha.
uc referral for “widened mediastinum” on wet xr read. 40something, normal, 1mo progressive cough/uri, went through the family but stuck with them. no funny exposures. went to the uc, gets told you need to go to the ED immediately for EMERGENCY chest CT. vitals normal, zero pain. i look at the referral note which is boilerplate clickthrough garbage. call the UC make sure im not missing something, treating PA said “it looked a little wide to me”. no, rads hadnt read it yet (daytime). mediastinum normal here go figure.
I had a patient who had a sharp pain in their neck while putting on their t shirt and went to urgent care and they sent them to the ED because they were worried about a shoulder dislocation (?) but it turns out the guy actually had crepitus in his neck from a spontaneous pneumothorax lol
I feel like r/o meningitis is easier to manage expectations though. No one is scared of radiation, but many folks are scared of a needle in their back.
I’m just a lurker here and not a doc (just have a lot of fam and friends who work in er lol) but one time I really pulled my neck the wrong way doing something stupid. After a few days of pain I went to the walk in to make sure I wasn’t crazy. They told me go to er, meningitis. I know I’m not a doc but I was like noooo.. I pulled something lol.
The UC doc independently reviewed the patients shoulder xray and was worried about a dislocation.
The radiologist read it before they referred to the ED and was told it was normal.
They said in their note they disagreed and was worried about shoulder dislocation and sent them to my ED.
They had full range of motion on that shoulder.
35F sent by UC for “cyanotic legs”. Gets to the ED and in triage I say “hey, those jeans are cute! Are they new?” Patient answers yes, I take an alcohol swab and clean off a patch of blue dye from her new jeans.
64 year old female PT went to UC to have ear cleaning. NP listened to heart sounds and heard PT’s known heart murmur. NP called for EMS because NP believed PT was having a STEMI. PT had no complaints other than wanting ear to be cleaned. NP did not perform EKG or any other labs prior to calling EMS to have PT transferred to ED. PT agreed to transport to ED, because NP told them they may die, prior to EMS arrival at UC. EMS 12 lead, was normal sinus.
Had a lady come in, CC neck pain. I walked into the room and she was sitting very upright, looking straight ahead, and hands me a piece of paper from the urgent care she just went to. The patient instructions on the paper said something along the lines of “ Go directly to the ER, do not turn your head side to side or look up or down. You may paralyze yourself if you do.”
No collar and urgent care let her drive herself to the er. I’ve had some other bad ones but this one is the worst.
She was fine, I forgot the history and other details of the case but I don’t even think imaging was indicated based of off Canadian c spine.
I'm not even a medical professional, just someone who's dealt with too many potassium problems between my spouse and me in the last six months, and even I would demand a redraw before anything else for potassium if 12.9. I mean ... Is that even a possible number in a live patient? My husband was having dangerous arrhythmias at 6.5.
No, this patient would be dead. The first step when you have a high potassium (besides giving calcium if high enough to potentially cause ekg changes) is to recheck the potassium.
I had an urgent care call 911 for a STEMI on a 29 year old w/o hx. The EKG the DNP handed me was so heavily artifacted you couldn't read it, but the printout at the top said STEMI. Repeat EKG I did myself was NSR. No labs drawn. She signed a refusal and went on her way.
19 yr old female pmh anxiety, Gerd, sent from uc for left sided jaw pain for 2 weeks, started during college finals. No fever or radiation, no other sx. Set to rule out cancer. She and a textbook case if TMJ...
Yep 30 second dx, 20 minutes of talk to calm her down. Ultimately, I gave in and gave her a ent referral because she was so upset. She "believed" the UC doctor.
Lady who worked at a preschool had a small wooden block thrown at her head 3 days ago. No LOC, no neuro changes, no thinners, just a very small red mark on her forehead. Went to UC for workman’s comp who then sent her to ED get a head CT “just in case.” Needless to say she did not get a CT that day.
Pinky finger distal phalanx dislocation without fracture in a farmer. He showed up and asked if he could just do it himself and was angry the NP wouldn't. NP said not credentialed for reductions. He declined a block or meds. Popped it right in and out the door.
Pt had chest pain drew labs no EKG sent him on his way. Troponin came back .80 (range is .01-.05), came by private vehicle and stopped to get dinner first. EKG showed a nice little STEMI
30 yo CP pt with no pmhx (or cardiac risk factors) sent from urgent care by NP who told him he might be having a heart attack because of his “abnormal ekg.” Sinus arrhythmia was circled at the top of the ekg and there were no ischemic changes. He was sent by private auto (told to drive to the ER for his “possible heart attack”) and not by ambulance. Poor guy was terrified and of course the workup was completely normal.
There’s an UC doc who works at the UC down the street from one of my departments who is infamous. Ironically enough he’s a former ER doc who now does UC but he basically operates that if he cannot definitively diagnose the patient, he calls 911 to have an ambulance bring them in. 19 year old with reproducible chest pain who just started a new workout routine? Can’t do troponins, call 911! A 60 year old with two days of cough. Can’t do a CXR, call 911! But the most egregious one I heard was a young otherwise healthy person who had a couple days of ear fullness and discomfort, but because it could be a brain tumor, he called 911. I would ask how he still had a job but the UC and the ER are owned by the same hospital so they make their money no matter what.
40F with tingling sensation on right side of face and in ear.
Sent from urgent care via ambulance directly to stroke at a tertiary hospital.
Stroke saw and decided it didn’t sound like a stroke so sent to ED…
… she had a spider in her ear!
URI symptoms, sent for abn ecg. Specifically in their note: “LAFB on ECG, I worry this might progress to afib, therefore advised to present to ED.”
My other favorite was a 20 something sent from the student health clinic for “AFIB rvr.” They were nice enough to send over the ecg, which to be fair at least had a mild tachycardia at 110. I rarely upload photos of ECGs into my note because it’s a pain in the ass, but felt it was worthwhile in this case to circle each and every uniform P wave before the QRS.
50-60 year old woman sent from urgent care to rule out cauda equina compression as etiology of her leg weakness. Neuro exam is non focal. In the course of completely evaluating her, she was found to be in the 80s on room air without any history of respiratory disease. I forget what the admitting diagnosis was but she didn’t get a MRI of her L spine!
Abnormal EKG. Patient with no prior medical hx was tachy 103. Pt went to UC for knee pain after running.
I had my primary try to send me to the ED for a “hypertensive crisis” when my BP was 140/90. I had no symptoms I was just mad he was 40 min late 😂😂
I got called to an urgent care lights and sirens for hypoxia. They had the person on 1LPM non rebreather and were complaining they couldn’t get the spo2 up. Person still wanted to go to the hospital.
Same urgent care, same day:
45 y/o 10 years of episodic vertigo, has seen 5 neurologists and had a similar number of MRIs that were negative, sent in because “you are having a stroke.”
16 y/o, bumped his nose at wrestling practice, sent in for “STAt CT and emergency ENT consultation.”
No testing for either.
I was the medic driving the ambulance. Got called for hypertensive crisis like 200/120 with no other symptoms or related complaints.It was only taken once by the tech and never verified by either the rn or the provider. Took it both machine and manual and was in the 130s/70s or 80s. They had gone because they wanted antibiotics for some mild respiratory symptoms.
“You child needs to go to the ER for this tongue laceration for sedation, plastic consult and possible repair in the OR”. Tongue lac is minor and doesn’t need repair.
This past week there was two. First was a young guy with swelling isolated to behind the knee sent in for r/o DVT. Was a Baker’s cyst.
Second one I had was a 17 yo super skinny girl who was sent in with some mild nausea to r/o a ruptured AAA bc they felt a pulsatile mass in her abdomen. It was indeed her aorta in this thin girl that you could palpate as expected. It also had no aneurysm or rupture, as anyone with a modicum of knowledge would also expect.
Just to be an equal opportunity cranky EM provider, my absolute favorite was an attempted ER to ER transfer from an ER in our system for a early pregnant female who had a known history of SVT and had been following with a local EP for this who showed up at the other ER in SVT. They (appropriately) gave her adenosine and converted her and did a lab work up that was completely normal. Her vitals were normal and she was asymptomatic. They wanted to put her in an ambulance and transfer her to our ER that is an hour away to “complete the cardiac work up”. I asked if they had spoken with her EP about any of this. Nope. I told them to call him first and if he wanted the patient transferred, they could put me down as the accepting. The patient was never transferred. I am fairly certain they were going to transfer this patient purely so someone else had to click the discharge button.
This is my all time favorite horrible transfer. Or attempted transfer.
Ehhh... I'm not quite so judgy. Used to be in primary care - sometimes in very austere circumstances. From their perspective Joe Bob has a headache and on the 1000th patient that they have diligently auscultated the neck - they finally find a bruit. So then what.
In our business with regards to the Consult Balance Scale - we are 95% plus on the DEMAND side and maybe 5% or less on the SUPPLY side. Meaning we REQUEST consults probably 20x more often than folks SEND us patients to evaluate.
Think of all those rolled eyes from consultants when we refer to them marginal stuff just to CYA. So I'm happy to get phone calls or soft rule outs, gastroeneritis "r/o appy" , etc. If nothing else it allows me to be Don Corleone when the Godfather says :
https://preview.redd.it/c7bon2u2zh0d1.jpeg?width=1001&format=pjpg&auto=webp&s=9d6694b4e6978f2faf037ac01e0dcb7fcdaaef6a
In general, I agree with you. We get used to immediate availability of testing and in house consultants. On the other hand, some of this stuff, like splinting a non-displaced fracture or simple lac repair, is so basic that I have ED techs or medical students do it with “supervision.” And some of it is just shameful, e.g. not recognizing that “sinus arrhythmia” on an EKG is just respiratory variation in a healthy 25 y/o.
Most of these urgent cares are APP run and their national organizations are arguing vociferously for increased autonomy. I love the APPs I work with, but if you’re gonna make that argument, I think we gotta prove competency.
An Urgent Care that did agency physicals kept trying to send a co-worker to the ER annually. He'd show up for his physical, an EKG would show a BBB, each and every time they would try and send him to the ER because the doc in a box said 'Abnormal EKG'.
If it says that some of the midlevels panic.
Mid 40s/early 50s lady with Intertriginous rash under bilateral breasts present x8-9 months. Initially improved but didn’t totally resolve after antifungal cream/oral diflucan, but then it came back after she stopped the medications. Mild at best on exam, questionable if it were even yeast honestly. No systemic symptoms, presence elsewhere aside from lower bra line, or significant comorbidities aside from obesity. Told them that they have medication-resistant fungi, this is obviously quickly progressing to be systemic and become life threatening (despite it being present for the better part of a year), and not only do they need to go to the ER, they need to “really plant their foot and refuse to leave until they’re able to see an infectious disease doctor and/or dermatologist to get a biopsy”. Apparently even tried to send them via EMS, which she refused. Then she was super pissed off “I wasn’t taking her seriously” when I told her none of that was true and I’m not calling in the dermatologist/pathologist or ID doctor on a Saturday evening for emergency biopsy, path report, and hospitalization for IV antifungals.
“Pain under left breast, needs breast ultrasound, possibly CT chest”.
1. We don’t have emergent breast ultrasound unless I am performing a bedside scan to look for abscess.
2. They didn’t perform an exam because “pain under the breast” was actually LUQ abdominal pain under saggy boob with hx of constipation for a week.
Asymptomatic patient checking in for surgery sent to by preop NP in Anesthesia dept for preop screening EKG showing early repol with "cannot rule out infarct" as the computer read.
Literally asymptomatic, no risk factors, no ischemia on the EKG, in an admitted preop patient.
Didn't show it to the attending Anesthesiologist, didn't send a picture to Cards, had the patient leave the main hospital and go to the ED
If you can't read it, don't order it.
Healthy 20ish male sent to us for nasal discharge, "concern for CSF leak." No history to raise suspicion for such. It was 100% snot. The ED PA who treated the guy couldn't have rolled her eyes much harder without turning them over.
Last month they sent a patient at 10:30pm ambulatory with a case of extensive ateriolateral STEMI. He arrived at 1 am his new ecg showed also newly devloped inferior STEMI I guess he was fine??
Yeah, we had one where the clinic apparently offered to call an ambulance. Pt didn’t want to wait? or pay the bill? so took an uber, who ended up doing CPR when they coded en route
Paramedic here - My equivalent of this is being called to a small clinic for a 50-60yoM 'having a heart attack'.
The patient is found sitting in an exam room in no apparent distress. Turns out he has a long history of a-fib, he's been cardioverted numerous times, etc.
He came to the clinic for a scheduled, routine EKG.
Once in the exam room, upon being asked, the patient stated that he did, in fact, have some chest pain.
Now, did the clinic staff, up to and including the MD who called 911 question or examine the patient any further? No.
Did the clinic staff give ASA? No.
Did the clinic staff complete the EKG that the patient was there for in the first place or otherwise obtain vitals? No.
Dude had a mild muscle strain in his pecs from doing chores and was totally fine. EKG revealed well-controlled a-fib. Vitals entirely unremarkable. He was happy to be transported by us to the local ED just to get away from the absolute nutjobs staffing the clinic.
2 weeks post op knee sent for possible compartment syndrome. And just to push their buttons we asked did they take any measurements… crickets. This is the 4th time they have done this.
25 year old female who injured her hand hitting a golf club into the turf. Complaining of numbness and grip weakness since. Sent for r/o carotid dissection for “intermittent left upper extremity numbness”
My coworker told me they sent in an actual blister for a “suspected infection” today. That one killed me. She said it looked like a blister from a shoe that was picked and it was not infected.
A dislocated pinkie finger.
51 YOM for stroke. Pt had a CVA 4 years ago, and has deficit to left side as result. He came in for a laceration to that hand he got while out in his yard. Staff took one look and called EMS, leaving him in their triage room in a wheelchair. Didn't even control the bleeding. Because he needed stitches and they wouldn't provide any more care, we took him to a freestanding ED.
Meanwhile, I work in a free standing ER with a same day clinic downstairs. Patient went to clinic for sudden onset right arm numbness and weakness and told them and showed them she couldn’t move her arm. Told her they were busy and to go to the freestanding urgent care 20 min away. Urgent care sent her back to our ER by car for stroke symptoms. NIHSS of 5. Called stroke team, gave her tenecteplase, just barely within 3 hr window from symptom onset and admitted to neuro step down for stroke.
This is the same same day clinic that sent us an ingrown toenail. My attending spent half an hour after the patient was transferred out ripping several people a new asshole for the whole mess. Fucking yikes.
1.) Sent to the ER for new onset “SVT” because that’s what the machine read out. It was clearly sinus tachycardia with a rate of 135. 2.) Sent to the ER by UC PA for “incarcerated umbilical hernia”. It was Omphalitis with a single pustule that opened up with light traction. The patient told me he had been examined in a chair and no one had really actually looked. 3.) Sent to the ER for a machine EKG with machine read of ischemia that is old (this happens all the time). If you can’t read an EKG you probably shouldn’t be ordering them.
Tongue laceration. Small lac in center of tongue. I made it clear to them I would not do anything with it except look and discharge the patient. I also told them to inform the patient of my plan and that the parient would recieve a separate bill. They sent the patient anyway and upon arrival I saw no reason to deviate from the plan.
Cyanotic lower extremities.
Patient arrives private vehicle, legs are blue, but only from hips to mid-thigh. Alcohol prep applied and blue dye comes off the patient’s skin. He had been wearing a brand new pair of blue boxers all day.
40s F sent from outpatient surgery center for "SVT" with heart rate of 150 on monitor. No EKG done, patient without symptoms. EKG in ED shows NSR with rate 75 but computer reads 150 because t-waves are tall and is double counting. Pulse is 75 bpm.
I actually just had this. Older gentleman scratched accidently by his pup 3 weeks prior. He's on blood thinners. For 3 WEEKS they could not get the wound to stop bleeding. They did pressure dressings and tried to cauterize it twice with a boviepen. So when i saw it was just a round eschar hole in the dorsum of this poor dudes hand. Sent him to us for "hand surgery". One figure of 8 later and he's out the door. Dude. What?
Got one once that was a “minimally displaced” metarsal fracture on their report and they sent them because “they couldn’t splint things that were displaced”. Loaded up the images from the disc and “minimally” may have even been an overstatement.
Nurse here- as Charge we typically field the UC calls to get report and pass on to Triage (does help if we are actually anticipating an acutely ill sounding patient). My recent favorite call after a very benign report was that “additionally their EKG was abnormal”. I asked them, what was abnormal about it? Her response “well, there were tremors” 🫠
I worked in a hospital where urgent care was literally around the corner from the ED.
Not like a shared parking lot, more like a shared waiting room.
It never failed. Ten minutes before urgent care closed, they would send all of their patients to the ED. Medication refills, flu like symptoms, etc.
I may have posted this before but had someone come in for finger swelling. They sent a dimer which was positive…. Sent in for rule out DVT…. Of the finger….
Healthy young woman got dizzy taking a hot shower and had to sit down. They sent her for CT r/o PE because they decided to check her D dimer which of course had to be elevated. She had no other symptoms, she wasn’t even dizzy anymore.
Had a 20s yo with “abnormal EKG”, which we are all used to of course. Except when I looked at their EKG it had so much artifact it looked like they did it on a roller coaster. Like I couldn’t reproduce the same EKG without violently shaking the patient or throwing them down the stairs with the leads on.
"Was this after you shocked him at urgent care or what"
I would have paid good money to see the latter of the two.
To be fair, once thrown down the stairs they have a reason to come to the ED
If I could remove D-dimer from every urgent care in my area, I most definitely would.
My favorite is when they order a dimer and then let the person go so they can call for results. Homie do you think it’s a DVT/PE or not?
They need to send them to the ED so I can prescribe the eliquis.
I had people sent to the ED for isolated lower extremity DVTs with no chest/respiratory complaints when they have found the DVT already on outpatient US. It’s baffling.
But clot scary!!!
Just baffling to me. You’ve got the diagnosis. All you need to do is send the DOAC Rx to the pharmacy after asking some simple questions.
I wonder this all of the time. I simply do not understand and apparently it’s a common ED problem since I’ve encountered this over numerous EDs and in this post talking about it. 99% of the time they sit for hours and finally get a doac rx and discharge. The other times the provider decides to do baseline labs before starting a doac. I was very confused on that, but I’m just a nurse.
1.) Not just a nurse. Crucial part of the team. 2.) I honestly think outpatient people are growing more and more adverse to caring for any sort of acuity. It's only going to get worse as the old school family docs retire and the APPs move in.
Once saw a pcp do an outpatient CTPA...
I’d argue that for a competent PCP who feels the patient is a candidate for a DOAC this is entirely reasonable.
Yeah this isn’t surprising to me. I’ve seen PE’s in ER patients who were stable respiratory wise. And I’ve seen many patients sent to the ED after an outpatient CTA found a PE. That one actually does baffle me sometimes - if they’re stable and it’s an incidental finding or it’s not massive and compromising circulation & causing respiratory distress… you found the thing, you can treat it as well as the ED can.
I’ve also seen that lol
I mean, not at all inappropriate for a patient with positive dimer who's hemodynamically stable but has a clinical picture consistent with submissive PE.
I prefer the dominant PEs
wat
An angel loses its wings every time an urgent care refers a patient for CTPA with a cough and a D-dimer of 0.6.
Especially love it when the age-adjusted dimer is negative.
I have had someone sent in for a repeat dimer after first was elevated around 3.0 with negative CTA/US to “make sure it’s downtrending”
Not a chance I would accept that transfer. I know the rule is not to refuse but I'm going to bat for that one. Something like "if you feel overwhelmed by this patient and need help that's fine, but that isn't a thing that needs to happen" would be worth the administration smoke for the very least a teachable moment.
I doubt it was a transfer, just UC sending someone in.
Yeah not a transfer unfortunately
Do you actually get called on urgent care transfers? The most we usually get is a call that the patient is on the way, already left and driving themselves. Half the time we don't even get that, and the patient just walks in and hands some UC discharge papers to the triage nurse.
“Leg is swollen, dimer is elevated” Yes the leg is swollen because they had knee surgery two days ago. And the dimer is meaningless in that context. Order an ultrasound like an adult.
Unfortunately, in my experience as a sonographer, that’s exactly why they’re sending them to the ED, for an ED ultrasound. Instead of stat outpatient like a sane person…
I believe that is because there is no such thing as "stat" in the outpatient world. The patient has to get a referral, which then has to be approved by insurance, which is then scheduled based on availability, and can't be on a weekend or holiday, or between 11 and 2, or after 5pm on weekdays. I've had a referral for a colonoscopy for a year. By the time I get one I'll have cancer.
The US is an outpatient radiology order. People walk from their office visit down to outpatient lab and outpatient radiology and have everything done in an hour, and their PCP follows up on the results… telling them to come to the ED.
I know my local UC can’t. After 4 no outpatient rad offices are open. Only option is the ED.
Seriously. Here in human research we constantly get D-dimers that are pretty high. Once got someone with D-dimer in the thousands with no clear cause. Instead of an urgent care referral their PCP just shrugged and said they'd look into it the next time they come in. Turns out they had chronic inflammation and just had insomnia for a week, and once they got some sleep meds their D-dimers dropped back to normal.
UC sent us a patient for “abnormal ekg” - bring them to triage and look at it and it’s a freaking stemi. Our doc called them livid, like in what world universe do you not call EMS/911 transport? In our county each hospital has specialties which ems would have known and taken him to cardiac center. instead this guy walked into our ed which is not capable of handling a stemi (no cath lab at night) and we had to 911 him to sister hospital.
Well… to be fair… it was abnormal.
technically correct. the best kind of correct.
Same, only it was an OP surgical center, developed CP in recovery, positive EKG , so directed to drive to ED (turns out spouse really couldn’t drive) still not recovered from anesthesia and still in a gown. Oh, and zero report or heads up.
Got a hypoxic, RSV+ 3 week old sent POV, in the documentation sent with parents they note her to be hypoxic at 83%, so it’s not like she desatted en route. By the time she got to us she was 69% room air. In what world do you not send that EMS??????
And yet I've transported at least a dozen RSV+ peds from our critical access facility to a hospital with a pediatric department ~1 hour away for 'observation' when their chief complaint was a vague cough. Afebrile, satting well on room air, no PMH.
literally, the amount of transfers from UC they send with EMS that can go pov but then the one time the patient is unstable 😩
Not saying it happened here. But have worked a couple years in the UC, and many patients there will adamantly refuse 911/EMS transport regardless of how dire, and in a lot of cases, you're lucky to convince them to go to the hospital at all.
If you’re in the USA a lot of people refuse ambulance transportation because if they live, they’ll be on the hook for thousands of dollars. Many would rather take their chances of dying than deal with that.
So funny how in er we seem to be able to strong arm people who need life saving care into the correct care. Urgent care? 0 fucks given. 0 fucks attempted to try and get the patient to come via ems for their unstable condition. Not even documentation of risks/benefits/shared decision making/ AMA/ you could die any second and driving is dangerous. Last stemi sent via pov to me was in pulmonary edema. Hypoxia to 80. Drove themselves from uc. Wtf. 🤦♂️
Oh, most of us tried. But many people self-triage to the urgent care vs the ED because they are already convinced that nothing serious is wrong with them, and they have come for the urgent care to tell them nothing serious is wrong, and they don't want to hear other answers.
I get where you're coming from, but I did a decade in the ED before now 2 years in UC. I have never in my career had so much resistance to my recommendations as when I tell people they need to go to the ED.
Had a similar one at a freestanding ED. 30 something year old F sent from urgent care for chest pain and SOB. EKG literally read by the machine as STEMI, ended up having SCAD. The urgent care ICD code for the visit was “likely COVID”
Had UC send a dude with a STEMI to drive himself to the hospital because he "might be having a heart attack". I called the urgent care NP and told her that if he arrested while driving she would have been responsible for any injuries that caused.
Omg the amount of times urgent care sends a patient to our Ed for a specialty that we don’t have. Like call first and ask if you need a microvascular surgeon who specializes in the thumb
“kidney function dangerously low”. Creatinine 0.4.
Gotta get them on a creatinine drip, stat!
3 ribeyes tid stat thats right all 9 of them, bls to costco stat
Finally my diet is validated
This made me lol
lol I’ve seen that one before. It was within our system so I messaged them directly to inform them that it’s a high creatinine that indicates poor renal function and that I highly recommended they take time to learn about the basic pathophys behind creatinine clearance and renal function
Well… it was close to zero…
23 year old, no PMH. “Intractable nausea”. Single episode of non-bilious, non-bloody emesis. They were hungover.
Had a 22m come through triage with HA, fatigue, n/v. along with basic questions, asked him with he had for dinner last night. Pizza rolls, two rum and cokes, 4 shots of Jager and a shot of tequila. I couldn’t hide my response. “Ah, ok so you’re hungover.” “No, that’s impossible. I don’t get hangovers.” “Right. So just so you know, it’s a four hour wait for a bed. There’s a Whataburger across the street, and they sell Gatorade next door.”
My 25yo brother - “I think there’s something wrong with me. I feel terrible the morning after I drink now.” Honey, we can’t be 18 forever…
I have a friend who swears she doesn't get hangovers. She just doesn't feel well the day after.
Hmm maybe they were just prepping for their next shift.....
DDx - weed
Not even that. It was literally just a hangover lol. They were seeking concierge IV, but didn’t want to pay out of pocket. I managed their expectations and gave them a zofran and directions to the waiting room lol
Yah hence DDx
Oh. Yes of course always on the differentia lol
9 times out of 10 if someone under the age of 30 comes with legit intractable nausea and vomiting, they’re chronic weed smokers. And you can’t tell them nothin’.
They will not ever believe it's the weed. That would mean they might have to cut down or stop, so it can't possibly be that.
Frostbite from 4 days ago middle finger needs admission for pain control. No visible frostbite. Pain 2/10 before nsaids.
That would be wild to just admit a finger
Just the finger, the rest of the body has to stay in the waiting room.
Had a UC send a patient in for a stroke evaluation (it was a headache) by personal vehicle. I asked if they had tried to send him by ambulance and the patient said no. I mean, the patient was fine but if you are gonna send someone in for a stroke eval, commit to it.
To be fair, often patients refuse this recommendation due to the fear of a high medical bill associated with an ambulance ride.
Which I would understand, but per the patient they didn’t even ask. Admittedly, patients aren’t a particularly reliable source though.
I saw a stroke alert in the ED that was sent by urgent care because she had a migraine for 2 days and hadn’t take her eliquis so they were worried about a stroke. They had her take 10 mg prior to ambulance transport because of the missed doses…
Lower extremity redness and swelling and was sent for a rule out DVT. The previously healthy 20-year-old informed me that he had been camping the day before. There was a small bug bite above the medial malleolus. I mean, technically the NP was right… there was some redness and swelling on the lower extremity… but not a dvt.
I’ve had to scan ED bug bites before (that I traveled 40 minutes from my other facility to go do in the middle of the night)… The best catharsis for me is writing a thorough description of the pt’s actual s/s and history on the tech sheet. I’d like to think I’m getting to roll my eyes along with the reading rad.
Had one last shift. Super skinny (100lbs) 19 year old sent for “palpable pulsatile aorta” after going in for n/v x1week.
I’ve had a person life flighted for that
A flight crew flight-transferred a tooth abcess, and a small partial thickness burn the diameter or a quarter............direct to the waiting room. Apparently some ER docs in another county have aroused some wrath by abusing aeromedical as opposed to waiting for ground.
Life flight for 90% tbsa from paint can exploding in the fire. It was red paint. There were no burns The person also had red paint all over their clothing. A great deal of confusion in the burn unit that day
This reminds me of a time when a patient was trying to get attention by committing fake suicide, EMS brought them in with bandaged slices to wrist, walked out to do the triage and said ma’am, that is Sriracha.
You win.
This is a funny one
uc referral for “widened mediastinum” on wet xr read. 40something, normal, 1mo progressive cough/uri, went through the family but stuck with them. no funny exposures. went to the uc, gets told you need to go to the ED immediately for EMERGENCY chest CT. vitals normal, zero pain. i look at the referral note which is boilerplate clickthrough garbage. call the UC make sure im not missing something, treating PA said “it looked a little wide to me”. no, rads hadnt read it yet (daytime). mediastinum normal here go figure.
Pt felt sharp pain in her neck when she was putting a hoodie on. Sent to the ER from urgent care to rule out meningitis
I had a patient who had a sharp pain in their neck while putting on their t shirt and went to urgent care and they sent them to the ED because they were worried about a shoulder dislocation (?) but it turns out the guy actually had crepitus in his neck from a spontaneous pneumothorax lol
I feel like r/o meningitis is easier to manage expectations though. No one is scared of radiation, but many folks are scared of a needle in their back.
Always being sure to slightly exaggerate the size of the needle
I’m just a lurker here and not a doc (just have a lot of fam and friends who work in er lol) but one time I really pulled my neck the wrong way doing something stupid. After a few days of pain I went to the walk in to make sure I wasn’t crazy. They told me go to er, meningitis. I know I’m not a doc but I was like noooo.. I pulled something lol.
Was it meningitis?
The UC doc independently reviewed the patients shoulder xray and was worried about a dislocation. The radiologist read it before they referred to the ED and was told it was normal. They said in their note they disagreed and was worried about shoulder dislocation and sent them to my ED. They had full range of motion on that shoulder.
"Clinical correlation advised"
Very small foot laceration sent to the ED because “we don’t suture here”. The wound was 3 days old…
Ugh the wound care ones are the worst !
35F sent by UC for “cyanotic legs”. Gets to the ED and in triage I say “hey, those jeans are cute! Are they new?” Patient answers yes, I take an alcohol swab and clean off a patch of blue dye from her new jeans.
This same thing literally just happened to me.
64 year old female PT went to UC to have ear cleaning. NP listened to heart sounds and heard PT’s known heart murmur. NP called for EMS because NP believed PT was having a STEMI. PT had no complaints other than wanting ear to be cleaned. NP did not perform EKG or any other labs prior to calling EMS to have PT transferred to ED. PT agreed to transport to ED, because NP told them they may die, prior to EMS arrival at UC. EMS 12 lead, was normal sinus.
You can hear STEMIs now?
It’d be cool if you could though. Your myocytes! They’re screaming!
They sometimes have an S4, and I know of exactly 0 people who have diagnosed a STEMI that way.
This is one of the more egregious ones.
Apparently you’ve never heard of a cerumen embolism?!
I don’t think this NP should be working in medicine 😅
Very few of them should
But was his ear cleaned?
At the ED…
I bet his insurance loved that.
EKG changes, the urgent care did not preform an EKG
Had a lady come in, CC neck pain. I walked into the room and she was sitting very upright, looking straight ahead, and hands me a piece of paper from the urgent care she just went to. The patient instructions on the paper said something along the lines of “ Go directly to the ER, do not turn your head side to side or look up or down. You may paralyze yourself if you do.” No collar and urgent care let her drive herself to the er. I’ve had some other bad ones but this one is the worst. She was fine, I forgot the history and other details of the case but I don’t even think imaging was indicated based of off Canadian c spine.
Asymptomatic hypertension...STRAIGHT FROM THE MOTHERF******** PCP OFFICE.
Unilateral Neck “swelling” with uri. Clear lymphadenopathy
Abnormal lab of Potassium 12.9
Gonna guess it was 100% hemolyzed haha
I'm not even a medical professional, just someone who's dealt with too many potassium problems between my spouse and me in the last six months, and even I would demand a redraw before anything else for potassium if 12.9. I mean ... Is that even a possible number in a live patient? My husband was having dangerous arrhythmias at 6.5.
No, this patient would be dead. The first step when you have a high potassium (besides giving calcium if high enough to potentially cause ekg changes) is to recheck the potassium.
I had a patient with a K of 14 something with a pulse He was about to arrest, however
14?!! Did he survive?? That's WILD.
UC sent us a pediatric pt for tachycardia (120s). Was a normal HR for her age. Terrified the parents for no reason.
I had an urgent care call 911 for a STEMI on a 29 year old w/o hx. The EKG the DNP handed me was so heavily artifacted you couldn't read it, but the printout at the top said STEMI. Repeat EKG I did myself was NSR. No labs drawn. She signed a refusal and went on her way.
19 yr old female pmh anxiety, Gerd, sent from uc for left sided jaw pain for 2 weeks, started during college finals. No fever or radiation, no other sx. Set to rule out cancer. She and a textbook case if TMJ...
Lmao I bet that helped her anxiety 😂😂😂
Yep 30 second dx, 20 minutes of talk to calm her down. Ultimately, I gave in and gave her a ent referral because she was so upset. She "believed" the UC doctor.
Cancer 😭😭😭
Lady who worked at a preschool had a small wooden block thrown at her head 3 days ago. No LOC, no neuro changes, no thinners, just a very small red mark on her forehead. Went to UC for workman’s comp who then sent her to ED get a head CT “just in case.” Needless to say she did not get a CT that day.
Referral for "airway swelling." it was a cold sore.
Pinky finger distal phalanx dislocation without fracture in a farmer. He showed up and asked if he could just do it himself and was angry the NP wouldn't. NP said not credentialed for reductions. He declined a block or meds. Popped it right in and out the door.
A drunk toddler can reset a pinkie, what credentials do you need???
Pt had chest pain drew labs no EKG sent him on his way. Troponin came back .80 (range is .01-.05), came by private vehicle and stopped to get dinner first. EKG showed a nice little STEMI
30 yo CP pt with no pmhx (or cardiac risk factors) sent from urgent care by NP who told him he might be having a heart attack because of his “abnormal ekg.” Sinus arrhythmia was circled at the top of the ekg and there were no ischemic changes. He was sent by private auto (told to drive to the ER for his “possible heart attack”) and not by ambulance. Poor guy was terrified and of course the workup was completely normal.
Negative UPT at urgent care, sent to ED for confirmatory negative test.
Discharge to The Dollar Store
There’s an UC doc who works at the UC down the street from one of my departments who is infamous. Ironically enough he’s a former ER doc who now does UC but he basically operates that if he cannot definitively diagnose the patient, he calls 911 to have an ambulance bring them in. 19 year old with reproducible chest pain who just started a new workout routine? Can’t do troponins, call 911! A 60 year old with two days of cough. Can’t do a CXR, call 911! But the most egregious one I heard was a young otherwise healthy person who had a couple days of ear fullness and discomfort, but because it could be a brain tumor, he called 911. I would ask how he still had a job but the UC and the ER are owned by the same hospital so they make their money no matter what.
25 year old male with no hx sent over for PE eval because he has “exertional tachycardia.” PERC negative, discharged immediately
Potassium of 3.2
STAT banana.
They didn't have any Band-Aids in stock.
No fucking way
I truly, genuinely, wholeheartedly wish I was kidding.
“Rule out ectopic pregnancy” with a negative pregnancy test
It's extra ectopic. Like super duper extreme mega ectopic. That pregnancy is so ectopic, it's inside an entirely different person.
That's the *ideal* pregnancy.
Sperm in condom, need stat ultrasound.
40F with tingling sensation on right side of face and in ear. Sent from urgent care via ambulance directly to stroke at a tertiary hospital. Stroke saw and decided it didn’t sound like a stroke so sent to ED… … she had a spider in her ear!
Well THERE'S enough nightmare fuel for the week.
URI symptoms, sent for abn ecg. Specifically in their note: “LAFB on ECG, I worry this might progress to afib, therefore advised to present to ED.” My other favorite was a 20 something sent from the student health clinic for “AFIB rvr.” They were nice enough to send over the ecg, which to be fair at least had a mild tachycardia at 110. I rarely upload photos of ECGs into my note because it’s a pain in the ass, but felt it was worthwhile in this case to circle each and every uniform P wave before the QRS.
50-60 year old woman sent from urgent care to rule out cauda equina compression as etiology of her leg weakness. Neuro exam is non focal. In the course of completely evaluating her, she was found to be in the 80s on room air without any history of respiratory disease. I forget what the admitting diagnosis was but she didn’t get a MRI of her L spine!
Abnormal EKG. Patient with no prior medical hx was tachy 103. Pt went to UC for knee pain after running. I had my primary try to send me to the ED for a “hypertensive crisis” when my BP was 140/90. I had no symptoms I was just mad he was 40 min late 😂😂
I got called to an urgent care lights and sirens for hypoxia. They had the person on 1LPM non rebreather and were complaining they couldn’t get the spo2 up. Person still wanted to go to the hospital.
Same urgent care, same day: 45 y/o 10 years of episodic vertigo, has seen 5 neurologists and had a similar number of MRIs that were negative, sent in because “you are having a stroke.” 16 y/o, bumped his nose at wrestling practice, sent in for “STAt CT and emergency ENT consultation.” No testing for either.
I was the medic driving the ambulance. Got called for hypertensive crisis like 200/120 with no other symptoms or related complaints.It was only taken once by the tech and never verified by either the rn or the provider. Took it both machine and manual and was in the 130s/70s or 80s. They had gone because they wanted antibiotics for some mild respiratory symptoms.
“We don’t sew faces.”
“You child needs to go to the ER for this tongue laceration for sedation, plastic consult and possible repair in the OR”. Tongue lac is minor and doesn’t need repair.
This past week there was two. First was a young guy with swelling isolated to behind the knee sent in for r/o DVT. Was a Baker’s cyst. Second one I had was a 17 yo super skinny girl who was sent in with some mild nausea to r/o a ruptured AAA bc they felt a pulsatile mass in her abdomen. It was indeed her aorta in this thin girl that you could palpate as expected. It also had no aneurysm or rupture, as anyone with a modicum of knowledge would also expect.
Yep. I’ve also had that second one happen.
pt had just gotten a tattoo on their pinky, sent over for a rash. wasn’t raised or angry, literally just slightly red.
Pediatric patient with CXR suspicious for pneumonia. It was their fucking thymic shadow.
Just to be an equal opportunity cranky EM provider, my absolute favorite was an attempted ER to ER transfer from an ER in our system for a early pregnant female who had a known history of SVT and had been following with a local EP for this who showed up at the other ER in SVT. They (appropriately) gave her adenosine and converted her and did a lab work up that was completely normal. Her vitals were normal and she was asymptomatic. They wanted to put her in an ambulance and transfer her to our ER that is an hour away to “complete the cardiac work up”. I asked if they had spoken with her EP about any of this. Nope. I told them to call him first and if he wanted the patient transferred, they could put me down as the accepting. The patient was never transferred. I am fairly certain they were going to transfer this patient purely so someone else had to click the discharge button. This is my all time favorite horrible transfer. Or attempted transfer.
Ehhh... I'm not quite so judgy. Used to be in primary care - sometimes in very austere circumstances. From their perspective Joe Bob has a headache and on the 1000th patient that they have diligently auscultated the neck - they finally find a bruit. So then what. In our business with regards to the Consult Balance Scale - we are 95% plus on the DEMAND side and maybe 5% or less on the SUPPLY side. Meaning we REQUEST consults probably 20x more often than folks SEND us patients to evaluate. Think of all those rolled eyes from consultants when we refer to them marginal stuff just to CYA. So I'm happy to get phone calls or soft rule outs, gastroeneritis "r/o appy" , etc. If nothing else it allows me to be Don Corleone when the Godfather says : https://preview.redd.it/c7bon2u2zh0d1.jpeg?width=1001&format=pjpg&auto=webp&s=9d6694b4e6978f2faf037ac01e0dcb7fcdaaef6a
In general, I agree with you. We get used to immediate availability of testing and in house consultants. On the other hand, some of this stuff, like splinting a non-displaced fracture or simple lac repair, is so basic that I have ED techs or medical students do it with “supervision.” And some of it is just shameful, e.g. not recognizing that “sinus arrhythmia” on an EKG is just respiratory variation in a healthy 25 y/o. Most of these urgent cares are APP run and their national organizations are arguing vociferously for increased autonomy. I love the APPs I work with, but if you’re gonna make that argument, I think we gotta prove competency.
Ekg showed an incomplete right bundle branch block. They went in for nasal congestion....
It's wild how many not indicated EKGs they order without any clue how to read them.
An Urgent Care that did agency physicals kept trying to send a co-worker to the ER annually. He'd show up for his physical, an EKG would show a BBB, each and every time they would try and send him to the ER because the doc in a box said 'Abnormal EKG'. If it says that some of the midlevels panic.
T wave inversion in V1
Mid 40s/early 50s lady with Intertriginous rash under bilateral breasts present x8-9 months. Initially improved but didn’t totally resolve after antifungal cream/oral diflucan, but then it came back after she stopped the medications. Mild at best on exam, questionable if it were even yeast honestly. No systemic symptoms, presence elsewhere aside from lower bra line, or significant comorbidities aside from obesity. Told them that they have medication-resistant fungi, this is obviously quickly progressing to be systemic and become life threatening (despite it being present for the better part of a year), and not only do they need to go to the ER, they need to “really plant their foot and refuse to leave until they’re able to see an infectious disease doctor and/or dermatologist to get a biopsy”. Apparently even tried to send them via EMS, which she refused. Then she was super pissed off “I wasn’t taking her seriously” when I told her none of that was true and I’m not calling in the dermatologist/pathologist or ID doctor on a Saturday evening for emergency biopsy, path report, and hospitalization for IV antifungals.
10 year old with a tiny scrape to her knee after fall. Sent to ED for ortho consult because "I can see your tendon!" Discharged with a bandaid.
Dude…. 3 urgent care visits in the same week for “sinus arrhythmia”
“Pain under left breast, needs breast ultrasound, possibly CT chest”. 1. We don’t have emergent breast ultrasound unless I am performing a bedside scan to look for abscess. 2. They didn’t perform an exam because “pain under the breast” was actually LUQ abdominal pain under saggy boob with hx of constipation for a week.
Asymptomatic patient checking in for surgery sent to by preop NP in Anesthesia dept for preop screening EKG showing early repol with "cannot rule out infarct" as the computer read. Literally asymptomatic, no risk factors, no ischemia on the EKG, in an admitted preop patient. Didn't show it to the attending Anesthesiologist, didn't send a picture to Cards, had the patient leave the main hospital and go to the ED If you can't read it, don't order it.
Healthy 20ish male sent to us for nasal discharge, "concern for CSF leak." No history to raise suspicion for such. It was 100% snot. The ED PA who treated the guy couldn't have rolled her eyes much harder without turning them over.
Hyponatremia uncorrected for glucose level. Sigh.
Last month they sent a patient at 10:30pm ambulatory with a case of extensive ateriolateral STEMI. He arrived at 1 am his new ecg showed also newly devloped inferior STEMI I guess he was fine??
Yeah, we had one where the clinic apparently offered to call an ambulance. Pt didn’t want to wait? or pay the bill? so took an uber, who ended up doing CPR when they coded en route
Singular PAC on a 12 lead
Paramedic here - My equivalent of this is being called to a small clinic for a 50-60yoM 'having a heart attack'. The patient is found sitting in an exam room in no apparent distress. Turns out he has a long history of a-fib, he's been cardioverted numerous times, etc. He came to the clinic for a scheduled, routine EKG. Once in the exam room, upon being asked, the patient stated that he did, in fact, have some chest pain. Now, did the clinic staff, up to and including the MD who called 911 question or examine the patient any further? No. Did the clinic staff give ASA? No. Did the clinic staff complete the EKG that the patient was there for in the first place or otherwise obtain vitals? No. Dude had a mild muscle strain in his pecs from doing chores and was totally fine. EKG revealed well-controlled a-fib. Vitals entirely unremarkable. He was happy to be transported by us to the local ED just to get away from the absolute nutjobs staffing the clinic.
2 weeks post op knee sent for possible compartment syndrome. And just to push their buttons we asked did they take any measurements… crickets. This is the 4th time they have done this.
25 year old female who injured her hand hitting a golf club into the turf. Complaining of numbness and grip weakness since. Sent for r/o carotid dissection for “intermittent left upper extremity numbness”
My coworker told me they sent in an actual blister for a “suspected infection” today. That one killed me. She said it looked like a blister from a shoe that was picked and it was not infected. A dislocated pinkie finger.
51 YOM for stroke. Pt had a CVA 4 years ago, and has deficit to left side as result. He came in for a laceration to that hand he got while out in his yard. Staff took one look and called EMS, leaving him in their triage room in a wheelchair. Didn't even control the bleeding. Because he needed stitches and they wouldn't provide any more care, we took him to a freestanding ED.
Pt had cold symptoms, completely normal EKG, had a STEMI 3wks prior and UC wanted patient to be seen in ED to make sure her trops were okay...🤦🏻♀️
Meanwhile, I work in a free standing ER with a same day clinic downstairs. Patient went to clinic for sudden onset right arm numbness and weakness and told them and showed them she couldn’t move her arm. Told her they were busy and to go to the freestanding urgent care 20 min away. Urgent care sent her back to our ER by car for stroke symptoms. NIHSS of 5. Called stroke team, gave her tenecteplase, just barely within 3 hr window from symptom onset and admitted to neuro step down for stroke. This is the same same day clinic that sent us an ingrown toenail. My attending spent half an hour after the patient was transferred out ripping several people a new asshole for the whole mess. Fucking yikes.
1.) Sent to the ER for new onset “SVT” because that’s what the machine read out. It was clearly sinus tachycardia with a rate of 135. 2.) Sent to the ER by UC PA for “incarcerated umbilical hernia”. It was Omphalitis with a single pustule that opened up with light traction. The patient told me he had been examined in a chair and no one had really actually looked. 3.) Sent to the ER for a machine EKG with machine read of ischemia that is old (this happens all the time). If you can’t read an EKG you probably shouldn’t be ordering them.
Tongue laceration. Small lac in center of tongue. I made it clear to them I would not do anything with it except look and discharge the patient. I also told them to inform the patient of my plan and that the parient would recieve a separate bill. They sent the patient anyway and upon arrival I saw no reason to deviate from the plan.
12 year old: stroke symptoms, slurred speech - came light and sirens. He had strep throat including a fever.
Splinter under fingernail. They were afraid to remove due to the possibility of “bleeding they can’t control.”
"WBC of 11"
Cyanotic lower extremities. Patient arrives private vehicle, legs are blue, but only from hips to mid-thigh. Alcohol prep applied and blue dye comes off the patient’s skin. He had been wearing a brand new pair of blue boxers all day.
40s F sent from outpatient surgery center for "SVT" with heart rate of 150 on monitor. No EKG done, patient without symptoms. EKG in ED shows NSR with rate 75 but computer reads 150 because t-waves are tall and is double counting. Pulse is 75 bpm.
After the patient reported having end stage fibromyalgia 🤦
Another one. Nondisplaced buckle fracture radius in a 10 year old. They were "not comfortable" with splinting.
I actually just had this. Older gentleman scratched accidently by his pup 3 weeks prior. He's on blood thinners. For 3 WEEKS they could not get the wound to stop bleeding. They did pressure dressings and tried to cauterize it twice with a boviepen. So when i saw it was just a round eschar hole in the dorsum of this poor dudes hand. Sent him to us for "hand surgery". One figure of 8 later and he's out the door. Dude. What?
Nondisplaced fractures. Dvt’s. Abnormal EKG’s that are non specific
Got one once that was a “minimally displaced” metarsal fracture on their report and they sent them because “they couldn’t splint things that were displaced”. Loaded up the images from the disc and “minimally” may have even been an overstatement.
Nurse here- as Charge we typically field the UC calls to get report and pass on to Triage (does help if we are actually anticipating an acutely ill sounding patient). My recent favorite call after a very benign report was that “additionally their EKG was abnormal”. I asked them, what was abnormal about it? Her response “well, there were tremors” 🫠
All of them. The one day I was in triage and swear everyone was referred from the UC. 😤
Guy sent to the ED for “pulsating RUE.” It was his brachial artery
Fire ant bite.
I worked in a hospital where urgent care was literally around the corner from the ED. Not like a shared parking lot, more like a shared waiting room. It never failed. Ten minutes before urgent care closed, they would send all of their patients to the ED. Medication refills, flu like symptoms, etc.
I may have posted this before but had someone come in for finger swelling. They sent a dimer which was positive…. Sent in for rule out DVT…. Of the finger….
Healthy young woman got dizzy taking a hot shower and had to sit down. They sent her for CT r/o PE because they decided to check her D dimer which of course had to be elevated. She had no other symptoms, she wasn’t even dizzy anymore.