Which of these statements made to me today would you find more disheartening?

[+ WilliamM]

Good. I'm glad you understand the difference between a low-life and yourself.

I certainly don't need any advice from you.

 

I would seek out @Kenny for advice and @former lurker

Edited March 26, 2021 by WilliamM

[Walker1]

The first one is painful. He may be a drug addict-but as someone with kids-that is one of the few things that can hurt. The second I will brush it off-ill mannered young ones are a dime a dozen-not important enough for me to even bother.

[+ DynamicUno]

I would have punched all of the buttons and walked off the elevator before the doors closed, let the punk take the slow ride down.

[+ purplekow]

Probably best to laugh off both of these situations. One would have to be a bit nuts to care what either of them thinks. Getting riled up over the actions of low-lifes won't do anyone any good. I'm kind of curious, though, how does one end up being admitted to the hospital for pain control of ureteral stones when one doesn't have ureteral stones? Wouldn't that be figured out easily enough before the patient is admitted (how long does a CT take, and wouldn't that be done if the pain were that excruciating)? I hope the first patient's problem list is updated to warn other healthcare personnel. These days with Epic and Care Everywhere, it's getting difficult to go tricking one hospital staff and on to the next when the gig is up.

Let me just say that it fortunate that I did not need a CT scan for a stroke based on how this case was handled. Admitted to my service when I was not on call. ER relied on a CT report on a cell phone...well there was plenty of other nonsense all compounded by his lack of cooperation to have testing done and the ER's admitting the patient with terrible information likely because he was abusive and they did not want him in the crowded ER yelling. A very experienced urologist agreed to do a cystoscopy and did it while the pieces of his story were being torn apart. When he had the cystoscopy and was told no stone no pain med is when he went on his worse of numerous tirades. He was no a kid, he was over 40.

This may have been the most obvious drug seeking attempt I have seen in a long time and everyone just was bullied or turned a blind eye.

This is not the usual level of care at this facility but it was one of the worst handled cases I have encountered.

[+ purplekow]

To reiterate, I found these things disheartening. I did not take the first remarks as anything other than the very toxic words of a manipulator. But the kind of mind that comes yp with that is disheartening and the ease with which he said it made me think that he has said these words of some version of them Ito others. .

The second was definitely not a jesting remark. I had only one floor ride with him and if the first event had not just happened I probably just would have chalked it up to his being an ass. As it was, I was just further disheartened by world in which we live.

Disheartened, not offended, but definitely saddened. I went and got an ice cream and sublimated. Almond Crunch Pop. it was delicious.

[CuriousByNature]

Both incidents were uncalled-for and unnecessary. The first seems to be an attempt to inflict pain by hitting a person where it would generally hurt the most. The second seems to be an example of the lack of respect many younger people seem to demonstrate these days. People who were taught by their parents to freely express themselves without having an awareness for anyone but themselves. Self-centred spoiled brats.

[Monarchy79]

I had a patient who became very angry that he was caught in a number of lies in trying to extract opiates. When I went to see him in the hospital this morning revealing that the tests confirmed that he did not have a kidney stone and so he would not be getting more pain medication and that he would be discharged from the hospital, he shouted at me: "hope all your kids get cancer and die in front of you, you fat sack of shit...I hope all your kids get cancer and die in your arms"

 

Leaving there to go see another patient, an nondescript young man was running for the elevator and I pushed the button to hold the door for him. His reply was "Thanks Gramps I did not think you could move that fast."

 

Im sorry that you experienced such blatant disrespect.

 

Those two assholes are part of many reasons why I’m the misanthrope that I am.

 

Fuck both of them.

[alexslaveboy]

I don't know about the second comment being "chalked up to youth ignorance"

 

I work with many 20 somethings that are downright condescending of anyone over 50......it's kind of sad how they are being brought up.

[CuriousByNature]

To reiterate, I found these things disheartening. I did not take the first remarks as anything other than the very toxic words of a manipulator. But the kind of mind that comes yp with that is disheartening and the ease with which he said it made me think that he has said these words of some version of them Ito others. .

The second was definitely not a jesting remark. I had only one floor ride with him and if the first event had not just happened I probably just would have chalked it up to his being an ass. As it was, I was just further disheartened by world in which we live.

Disheartened, not offended, but definitely saddened. I went and got an ice cream and sublimated. Almond Crunch Pop. it was delicious.

I've always considered ice cream to be a balm that can soothe many aches.

[+ purplekow]

As someone who had multiple episodes of kidney stones many years ago, including several operations to bust them up and or remove them surgically, I was often prescribed opiates in case I had an attack at home in the middle of the night. I only used them sparingly, like 1 or 2 pills during an attack and never afterwards. I rarely take even aspirin or Tylenol so the effects of the Oxycodone on me were amazing, like floating on a cloud. But I never got hooked on them. I still have about 20 of the 2 dozen pills I was last prescribed in 2007.

. Time to get rid of those pills. Potency issues after fourteen years.

[Monarchy79]

Well, I am not sure either person is a "low-life."

 

I would more sympathy for the first gentleman, having been hooked on Xanax myself

 

Both are pieces of shit. Period.

[Guest]

Let me just say that it fortunate that I did not need a CT scan for a stroke based on how this case was handled. Admitted to my service when I was not on call. ER relied on a CT report on a cell phone...well there was plenty of other nonsense all compounded by his lack of cooperation to have testing done and the ER's admitting the patient with terrible information likely because he was abusive and they did not want him in the crowded ER yelling. A very experienced urologist agreed to do a cystoscopy and did it while the pieces of his story were being torn apart...

This sounds like a probably highly mismanaged case which should be brought up for peer review by the ER and Urology departments. The appropriate imaging study would be a CT for stones, not for a stroke. The ER should not have called for admission without evaluating the problem themselves. And what's up with the urologist doing invasive urological procedures without looking at the imaging study himself? The urologist needed to ascertain for himself the size and the location of the stone before determining whether ureteroscopy, ESWL, some other procedure, or just observation was indicated at the time. I worked in urology clinic for 15 years, and the procedure is never so urgent that an imaging study can't be done, even if the stone was infected and the patient in shock, which obviously wasn't the case here.

I'm sorry you had to go through that. But the patients' behaviors, especially the 1st one, were simply the products of defective people. I would just make sure the behavior was documented in the chart for posterity, and tried to laugh it off the best I could.

[+ sniper]

This sounds like a probably highly mismanaged case which should be brought up for peer review by the ER and Urology departments. The appropriate imaging study would be a CT for stones, not for a stroke.

I think PK meant a CT scan for HIMSELF for the stroke he would have had from the outrage at what was done in the case...

[+ sniper]

That said, it sure sounds like there was room for the possibility the guy was in excurciating pain for something else that got missed, unless he's a known drug shopper.

[+ Pensant]

Gramps is decidedly not a term of endearment in American English, certainly not for a stranger.

He was being a punk.

He doesn’t know it yet; but he’ll be a gramps before he knows it.

[wsc]

Since my mid-60s, some people I've met in a professional setting have made oblique references to my age, such as a doctor that once asked, after laying eyes on me for the first time, "And how are you, today, young man?" I look like a young man in the same way that the Fat Lady at the circus looks like 300 pounds of thin, and I find such remarks condescending and irritating. But I also recognize that people often act out of surprise or discomfort, or, on occasion, simple social ineptitude. God knows, some of my attempts at humor have missed their mark, either because of my own ineptness or lack of sensitivity, or because of the other's oversensitivity. I may take some slight offense, but only slight, and try to never show any sign of irritation. I also pray others will be more forgiving of me when it's next my turn to be socially awkward.

 

The young man at the elevator would have annoyed me more than the angry miscreant seeking a fix and simply showing stupid is as stupid does. In either case, I would try as quickly as possible to shake it off and go about my otherwise quite enjoyable life. It's not worth my time to dwell on it.

Edited March 26, 2021 by wsc

[+ Charlie]

I would have to experience the entire context of the second remark to know how to take it: a condescending putdown, a juvenile attempt to be funny yet friendly, a thoughtless expression of what was occurring in his mind, etc. Tone of voice, facial expression, and body language would tell me as much as the words themselves. I had a senior professional colleague who often greeted me with, "How are you, young man?" but I could tell it was friendly banter rather than condescension.

Edited March 26, 2021 by Charlie

[Luv2play]

I would have to experience the entire context of the second remark to know how to take it: a condescending putdown, a juvenile attempt to be funny yet friendly, a thoughtless expression of what was occurring in his mind, etc. Tone of voice, facial expression, and body language would tell me as much as the words themselves. I had a senior professional colleague who often greeted me with, "How are you, young man?" but I could tell it was friendly banter rather than condescension.

 

I completely agree with the first sentence.

 

With regard to the second, I have a garrulous neignbour who is a few years older than me and has always addressed me as "young man" since I met him ten years ago. Doesn't bother me at all.

[Guest]

I would have to experience the entire context of the second remark to know how to take it: a condescending putdown, a juvenile attempt to be funny yet friendly, a thoughtless expression of what was occurring in his mind, etc. Tone of voice, facial expression, and body language would tell me as much as the words themselves. I had a senior professional colleague who often greeted me with, "How are you, young man?" but I could tell it was friendly banter rather than condescension.

I agree that tone and body language are more important than the actual words. I wouldn't often take offense at being called "young man," though, unless said with a particularly sarcastic tone. I'd much rather be called "young man" than "old man," even if the latter is closer to being the truth. I still think of myself as a young man. My "Diego" often calls me "güero," meaning "blondie," although I'm not blond. It's said with affection

The other day I was asked for ID at Target when I had a bottle of vodka among my purchases. I had to laugh out loud. Multiplying 21 by 2.5 still wouldn't reach my age. I should be thankful I can still pass for a teenager.

[Guest]

To the second one, I might have said, “oh, young man, you have no idea how fast I can move ...”

I'm guessing you're joking. Saying something like that when you're at work can get you into a lot of hot water. As a professional, one always has to behave professionally, even when being taunted or disrespected. Others' behavior doesn't give one an excuse to stoop to that level. Policemen often have the toughest job. If they stop acting professionally when they're being disrespected, tragedy can result.

[Guest]

That said, it sure sounds like there was room for the possibility the guy was in excurciating pain for something else that got missed, unless he's a known drug shopper.

I don't think so. From what we're hearing, the patient concocted the story of the kidney stone, and it sounds as if the ER evaluation may have been limited to taking a history and maybe getting a urinalysis. Pricking one's finger and letting a drop of blood into the urine cup is the oldest trick in the book, one that we hear of in medical school. Blood in the urine does require evaluation, though, not just a jump to conclusions. One has to ascertain whether it's due to infection, stone, cancer, or something else. A simple X-ray and/or ultrasound are all that's needed most of the time to evaluate for stones, although some stones, such as uric acid, can be missed by those studies. A CT for stones, however, is virtually 100% sensitive at detecting any stone that might be present, no matter what the stone is made of.

It sounds like a number of blunders were made in this man's care (not by PK, who was merely the unfortunate victim). It sounds as if the ER doctor, especially, had blinders on and didn't think things through or follow guidelines. And the urologist made the mistake of simply accepting the ER doctor's evaluation at face value instead of evaluating things himself, as a specialist should.

[+ nycman]

This sounds like a probably highly mismanaged case....

Careful. Monday morning quarterbacking is a dangerous game.

Your scenario requires that both the ED physician AND the urologist were morons.

Betting against two specialists is never wise.

 

You do know that CTs are only 95% sensitive for kidney stones...don’t you?

You do know that in a patient with intractable renal colic and no stone on CT,

a ureteroscopy can be used to r/o a kidney stone that was missed on CT....don’t you?

 

I’m not saying the case was or wasn’t mishandled. I wasn’t there and I wouldn’t dream

of jumping to conclusions and insulting my colleagues in a case I know virtually nothing about.

 

You would be wise to do the same.

[Guest]

Monday morning quarterbacking is a dangerous game.

....

You do know that CTs are only 95% sensitive for kidney stones...don’t you?

You do know that in a patient with intractable renal colic and no stone on CT,

a ureteroscopy can be used to r/o a kidney stone that was missed on CT....don’t you?

....

According to these recent guidelines from the AUA, the sensitivity of non-contrast CT is 98%, so the 95% figure you're quoting is probably out of date, and factually incorrect:

 

https://www.auanet.org/guidelines/imaging-for-ureteral-calculous-disease

 

In those rare cases, a contrasted CT will show any blockage (and if there's nothing blocked, there's neither pain nor anything clinically significant going on, except in rare cases of infection). I've never heard of blindly going in on ureteroscopy for a non-visualized stone, and I don't see that as part of the guidelines from the AUA as referenced above.

In this case, we do know that this whole situation was a sham concocted by the patient, and it sounds as if the ER staff just wanted to get this patient out of their ER. I never said I KNEW this to be the case. What I did say is that this case is probably appropriate to bring up for peer review. Peer review means that peers (people in the same department as the specialist involved) look at the records, interview the physicians involved, and ascertain whether there's something to be learned from this situation.

Peer review is an essential component towards continuing quality improvement efforts in a hospital, and, in fact, a hospital will be cited if there aren't enough cases brought up for peer review. Having a case being brought up for peer review doesn't necessarily mean substandard care was provided. I've had cases brought up for peer review, and told everything was done fine on my part (in one instance, I was told my care was "exemplary"). In most cases, it's another department which brings up the case for peer review. In general, the conclusions of the peer review committee are private, and even the person (not necessarily a physician/NP, could be a nurse) requesting the case be brought up for peer review isn't privy to the results. Often, however, when the case has teachable moments, the case is brought up to the whole department, without naming names of either the provider or the patient, so all can learn.

It's unhelpful to say "Don't judge a specialist. He knows more than you do," or "Don't Monday morning quarterback to see if it's a teachable moment." In this instance, the OP himself essentially stated the ER staff and urologist were fooled. Unlike cystoscopy, ureteroscopy is a fairly tricky procedure with a relatively high complication rate. A significant injury to the ureter can have a devastating and permanent effect on the patient's life (although if it was done on the basis of a patient's own lies, I think a jury might take a different view on how to apportion liability).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364249/#:~:text=Most recent guidelines [4] state,rare (<1 %).

 

So, in summary, I do not know that substandard care was provided and I never said so. What I did say and do believe, is that this case is highly appropriate to be brought up for peer review. And I think it represents a bad attitude to say that anyone who wasn't there at the time is in no position to question the care provided.

Edited March 27, 2021 by Unicorn

[+ purplekow]

This sounds like a probably highly mismanaged case which should be brought up for peer review by the ER and Urology departments. The appropriate imaging study would be a CT for stones, not for a stroke. The ER should not have called for admission without evaluating the problem themselves. And what's up with the urologist doing invasive urological procedures without looking at the imaging study himself? The urologist needed to ascertain for himself the size and the location of the stone before determining whether ureteroscopy, ESWL, some other procedure, or just observation was indicated at the time. I worked in urology clinic for 15 years, and the procedure is never so urgent that an imaging study can't be done, even if the stone was infected and the patient in shock, which obviously wasn't the case here.

I'm sorry you had to go through that. But the patients' behaviors, especially the 1st one, were simply the products of defective people. I would just make sure the behavior was documented in the chart for posterity, and tried to laugh it off the best I could.

Oh I quoted him in the chart in case this situation does go further. I agree it was a total horror show. I have spoken to the Chief of Medicine and have asked that the ER portion of the care be reviewed. As for myself, by the time I collected the information I called for them to cancel the case but the patient was already in the OR. Ultimately I was supervising the residents and I could have stopped delayed the case until I had all the data so I am not blameless in this matter. I think there is a whole lot of blame to go around. It started with a deceptive patient but it definitely was not the finest moment of anyone involved.

Edited March 26, 2021 by purplekow

[Guest]

Oh I quoted him in the chart in case this situation does go further. I agree it was a total horror show. I have spoken to the Chief of Medicine and have asked that the ER portion of the care be reviewed. As for myself, by the time I collected the information I called for them to cancel the case but the patient was already in the OR....

It sounds like you saved the day. By the looks of it, it appears the ER physician had the lion's share of culpability. That being said, the urologist should have done his due diligence before scheduling the procedure, and not relied on you to do his oversight. Reminds me of the time I was in the OR as a resident physician for a patient of mine in the 80s. The neurosurgeon announced he was removing a meningioma on the left side of the brain. I advised him and the staff that the tumor was on the right side. He would have cut open the wrong side of the skull had I not been there. This was in the days before required time-outs before each surgery, now a requirement. Tragedy often results when people cut corners and rely on others to do their work.

Had things gone south, such as a ureteral injury, the patient would have mostly himself to blame. That being, said, it's a-holes like this who are probably the most likely to sue when things go wrong. It would be a messy legal case, to be sure, with a lot of blame to go around, but I doubt that either the ER doc or the urologist would go away unscathed, even though it was the patient's lying that brought on the mess to begin with.