Some nursing schools are beginning to offer doctorate level degrees. So eventually we will have people who have a doctorate degree in nursing. So, a nurse could introduce herself as "Dr. Jones."
Now, that sounds pretty weird. I am not sure what a doctorate in nursing allows you to do, but it sure sounds weird.
"Hi, I'm Dr. Jenny, I'll be the nurse that will be taking care of you."
It seems that more and more of health care is being handled by "mid-level practioners" or "mid-levels." These are Nurse Practioners and Physicians Assistants. I don't mind this at all for staffing quick clinics and walk-in type centers for sniffles and Z-packs. They are good at that. And it isn't very hard to do. Any one can treat the sniffles with a Z-pack. You don't have to wait 8 weeks for your family practice doctor to be able to see you.
Mid-levels are also good at extremely complicated and highly specialized stuff. Cardiothoracic surgeons and orthopedic surgeons and rheumatologists routinely use them in their highly specialized fields, and they are well trained and really know what they are doing. I don't mind that at all. Especially for follow-up visits and following routine stuff in their respective specialty.
I will be offended, however, if I send a patient to a cardiologist because there is an issue that I can't understand or I can't handle, and they are seen by the PA or NP on their first visit. That is offensive. I am a freaking physician! If I need help, I don't want a nurse's opinion! That is blatantly offensive, and I won't send my patients to specialists that try to pull that crap.
Last time I sent a patient to a cardiologist asking them for some advice on one simple thing, the NP saw the patient and ordered nearly every single cardiology test under the sun. No thanks! That's not a good way to practice medicine. My patients on't need dumbassedness!
I think that nurses and physicians are trained differently. Nurses go to school for many years learning how to execute orders and perform certain tasks that are asked of them. Physicians go to school for many years and are trained to critically analyze situations and figure out how to treat the patient in the right way. Sure, the nurse may carry out many of those orders, but she didn't come up with them and has no idea why some of those orders are a good idea.
Doctors Think, Nurses Do!
Reversing roles is retarded. How many doctors can start an IV or mix up a drip? How many nurses can figure out which pressor to start?
Yes, there are dumb doctors. I have met plenty of physicians who are mentally lazy, dumb asses that fail to understand simple concepts. I can't tell you how many dumb ass doctors miss simple diagnoses like DKA or Sepsis. We can't have more dumb asses running around with the authority to give orders and treat patients.
Who do you want formulating your treatment plan? A physician? Or a nurse?
I know my answer.
Unfortunately, there are some things in medicine that are complicated and require a lot of mental knowledge. If you haven't been trained in that, you won't know what to do. But a lot of people can put band aids on things.
For example, I can't tell you how many times a patient comes to see me and tells me that their former primary doctor started them on lasix for leg edema. The conversation usually goes as follows:
"So, why are you on lasix?"
"Dr. Jones started me on it when my legs started swelling."
"Why were your legs swelling?"
"I don't know."
"Did he investigate the leg swelling at all? Like what did he think was causing it?"
"No. He said it just happens and that lasix was going to help."
How idiotic is that? Someone comes in with bilateral pitting edema of the lower extremities and all you do is put them on lasix? Are you mentally retarded? No investigation of why they may be swelling? No ultrasound of the heart to look for heart failure? No liver tests or kidney and urine tests? What the hell?
DOCTORS screw this up..... so what happens if we start letting mid-levels start screwing things up? They will screw up more. BIG TIME!
But they cost our health care system less (initially, or so we think), and hence, we are going to be seeing more and more of them. They are much cheaper than physicians, and much worse.
Health care costs will end up going up eventually.
Friday, December 10, 2010
Wednesday, November 17, 2010
ER/IM Residents Suck
In my years of practice I've never met dumber residents. They suck at ER and they suck at IM. Please pick one to suck at!
In the ER they order chronic workups and forget to treat the acute issues. When they are upstairs in the ICU or floors, they treat evrything as if it is an acute issue. They have cute lil recipes for everything. Hypertensive? Esmolol drip.
Make up your minds! Suck at one or the other.
In the ER they order chronic workups and forget to treat the acute issues. When they are upstairs in the ICU or floors, they treat evrything as if it is an acute issue. They have cute lil recipes for everything. Hypertensive? Esmolol drip.
Make up your minds! Suck at one or the other.
Published with Blogger-droid v1.6.5
Central Line? Nah!
Why is it that patients that need a central line never get one. But the ones that don't need one always get it?
Can someone from the ER explain this.
Can someone from the ER explain this.
Published with Blogger-droid v1.6.5
You feel big because you are!
I'm tired of big people wondering why they feel so huge. It's because you are so huge! When you weigh 450 pounds, that bizarre unexplained feeling of being big.... is actually reality. You really are big!
Published with Blogger-droid v1.6.5
Wednesday, November 3, 2010
Yes, your knees hurt because you are fat
I remember many years ago when a patient who weighed 380 pounds, walked and asked me "My knees really hurt, do you think it's my weight?"
"Yes. I do"
"That's what I've been thinking, I know it's my weight."
"Well, even if you lose a few pounds, you will feel better. I highly recommend it."
We need to always talk to patients about weight loss and smoking cessation. EVERY VISIT! THEY NEED IT! AND IT WORKS!!!!!!!!!!!!!!!
Of course, we can always replace knees. But come on people, why get to this stage? Just lose some weight!
"Yes. I do"
"That's what I've been thinking, I know it's my weight."
"Well, even if you lose a few pounds, you will feel better. I highly recommend it."
We need to always talk to patients about weight loss and smoking cessation. EVERY VISIT! THEY NEED IT! AND IT WORKS!!!!!!!!!!!!!!!
Of course, we can always replace knees. But come on people, why get to this stage? Just lose some weight!
Tuesday, November 2, 2010
"I'm the ER Attending"
Nothing irks me more than when the ER attending gets on the phone and says, with an air of authority and condescension, "I'm the ER attending."
Well, if you are the ER attending shouldn't you know better?
A few years ago the ER called me telling me that my patient is having a STEMI (big heart attack) and that they are going to call the interventionalist on call and activate the cath lab. Fine.
The resident is talking to me and telling me the patient's story, and it really sounded more like a pneumonia case than a heart attack case. I asked the resident to tell me about the EKG and they began describing it, "Some ST elevations in the inferior leads..."
Then the ER attending got on the phone and quickly said, "The machine is reading it as an Acute MI."
"Wait, who's this?"
"This is the ER attending. And the machine is reading it as an acute MI."
"Well, I was talking to your resident, and it sounds more like pneumonia."
"I am the ER attending and it's reading it as an acute MI."
"Ok, sir. Thanks"
If you are the ER attending you should have something more intelligent to say than restating what a dumb EKG machine thinks it is. Just because the machine thinks it's an AMI, doesn't mean you have to keep saying that. Machines are wrong nearly all the time. The sensitivity is not that high. Especially in acute MI.
Stop telling people you are an attending, but that you can't read an EKG. It's not very flattering. If you are an attending you should be able to use your own brain. Don't be a dumb ass!
Otherwise, why do we have doctors? Nurses and EKG techs (heck, even janitors) can read back what the machine says. Why do we need doctors? Just fire all the doctors and let the janitors run the show.
As the federal government tightens and the economics of medicine tighten, we can't afford stupidity. We have to be smarter than the machines and morons that they are hiring to replace us and save costs. If a physician actually knew how to read an EKG or chest xray, maybe you could save the nearly $50,000 it costs to activate the cath lab and have an interventionalist come in and perform an unnecessary, and potentially harmful procedure, on an unsuspecting patient who just needs some antibiotics.
"I'm the Angry Internist!"
Well, if you are the ER attending shouldn't you know better?
A few years ago the ER called me telling me that my patient is having a STEMI (big heart attack) and that they are going to call the interventionalist on call and activate the cath lab. Fine.
The resident is talking to me and telling me the patient's story, and it really sounded more like a pneumonia case than a heart attack case. I asked the resident to tell me about the EKG and they began describing it, "Some ST elevations in the inferior leads..."
Then the ER attending got on the phone and quickly said, "The machine is reading it as an Acute MI."
"Wait, who's this?"
"This is the ER attending. And the machine is reading it as an acute MI."
"Well, I was talking to your resident, and it sounds more like pneumonia."
"I am the ER attending and it's reading it as an acute MI."
"Ok, sir. Thanks"
If you are the ER attending you should have something more intelligent to say than restating what a dumb EKG machine thinks it is. Just because the machine thinks it's an AMI, doesn't mean you have to keep saying that. Machines are wrong nearly all the time. The sensitivity is not that high. Especially in acute MI.
Stop telling people you are an attending, but that you can't read an EKG. It's not very flattering. If you are an attending you should be able to use your own brain. Don't be a dumb ass!
Otherwise, why do we have doctors? Nurses and EKG techs (heck, even janitors) can read back what the machine says. Why do we need doctors? Just fire all the doctors and let the janitors run the show.
As the federal government tightens and the economics of medicine tighten, we can't afford stupidity. We have to be smarter than the machines and morons that they are hiring to replace us and save costs. If a physician actually knew how to read an EKG or chest xray, maybe you could save the nearly $50,000 it costs to activate the cath lab and have an interventionalist come in and perform an unnecessary, and potentially harmful procedure, on an unsuspecting patient who just needs some antibiotics.
"I'm the Angry Internist!"
Saturday, October 23, 2010
Want a subclavian? Here's a pneumo!
A few months ago a rocket scientists from the ER admitted a patient for sepsis. Along the way, they attempted throwing in a subclavian central line. Needless to say, the patient ended up with a pneumothorax and a chest tube. The chest tube got dislodged and came out, so they jammed it back in. True story.
Looking back at the xrays, the subclavian entered into the skin almost right at the junction of the sternum and clavicle, very medial. Who the hell does that? Looking back through the ER chart, it turns out it was one of the "hotshot" ER residents who is cocky, overconfident, and a total ass. Figures.
What's more bizarre is that the patient wasn't even septic. They spit in his mouth, and his blood pressure came up. By "spit in his mouth", I mean they gave him a 250 mL bolus, the equivalent of adding one drop to the ocean. The blood pressure, according to the ER charting says the BP at it's lowest was 84 systolic. After that measly bolus it went up to 110. Sooooooooo septic!
In the ICU the patient was never even on a pressor! Go figure.
This irritates me to death. Be consistent. The truly septic patients never get a central line. They normal patients, get central lines.
ER residents and attendings need better training in central lines. I've put in over 2000 subclavians, and not once have I given anyone a pneumo. Why not get trained properly?
Looking back at the xrays, the subclavian entered into the skin almost right at the junction of the sternum and clavicle, very medial. Who the hell does that? Looking back through the ER chart, it turns out it was one of the "hotshot" ER residents who is cocky, overconfident, and a total ass. Figures.
What's more bizarre is that the patient wasn't even septic. They spit in his mouth, and his blood pressure came up. By "spit in his mouth", I mean they gave him a 250 mL bolus, the equivalent of adding one drop to the ocean. The blood pressure, according to the ER charting says the BP at it's lowest was 84 systolic. After that measly bolus it went up to 110. Sooooooooo septic!
In the ICU the patient was never even on a pressor! Go figure.
This irritates me to death. Be consistent. The truly septic patients never get a central line. They normal patients, get central lines.
ER residents and attendings need better training in central lines. I've put in over 2000 subclavians, and not once have I given anyone a pneumo. Why not get trained properly?
Subscribe to:
Posts (Atom)