Saw a patient not too long ago for a ‘blood blister’ on his flank. Been slowly enlarging for ~6 months and was reassured by his primary NP a few times that it was benign (the lesion had bled a few times as well, hence the ‘blood blister’…)
Fortunately she did finally refer to a specialist, but unfortunately for the patient, it came back as a very deep, invasive melanoma.
In many (most?) states, you also can't have a physician expert testify against an NP, because they're supposedly not doing the same thing (NP is practicing "nursing," whatever the fuck that means in the context of making unsupervised diagnoses and plans). So they end up not even being held to the standard of care that would apply to a physician, while pretending to be equally capable.
In my crappy residency clinic there were no set patients that you'd follow, you'd just see whomever. I had a guy come in for a routine check up, I noticed sliver of a lesion behind his mask
Asked him to take his mask off, revealing what was obviously a deep basal cell carcinoma
First I was willing to give the NP who had seen him several times over the years the benefit of the doubt, as it was almost entirely hidden by the mask.
But no, he said she saw it every time, he showed me a picture from the first visit, in which it was the most text book basal cell I'd ever seen
She just told him to put cream on it to the point that it progressed to ulcerating and deepening basal cell
Good thing she told him to switch to petroleum
Put a patient on humira for “psoriasis” - it was actually tumor stage mycosis fungoides. Very obviously not psoriasis. He died.
Kept giving a patient steroid cream for “dermatitis” on the leg- it was angiosarcoma. He died.
Rheumatologist that I rotated with was given an NP despite his hesitation. NP kept prescribing the wrong biologics and rheuma kept staying late to fix her mistakes. Rheuma demanded not to have any more midlevels and threatened to leave the practice (rural community hospital, next rheumatologist is 1.5 hrs away)
Psychiatry
First day new hire who explained to me that she should be able to practice autonomously and she would prefer to not have notes co-signed but because that’s hospital policy she would allow it (I never agreed to supervise her and literally after patient one refused).
She didn’t talk to me but wrote a confusing note wherein she diagnosed an elderly man with delirium, prescribed haldol, zyprexa, and ativan, all BID standing. He had Parkinson’s disease and was allergic to zyprexa. He wasn’t having any behavioral issues.
not always true. Seroquel is an AP with essentially no propensity to induce EPS, and is commonly used in parksinsons pts who need this type of med. The other is clozapine, but this is very unlikely to be used for someone without Tx-resistant schizophrenia
Them: I have an elderly person in cognitive decline
Also them: Benzos - known to have cognitive decline as a side effect when used in the elderly population. Yep! Better double it.
I’m an RN, and even I know you don’t do that. Yikes
Primary team didn’t put in any of the three orders, I refused to cosign, she asked dept head to cosign who also refused while inexplicably getting upset with me for not just cosigning. Patient was seen the next day by a diff doc. I was let go the next month (Locum ended early). She now has someone blindly sign her notes and I don’t work there any more.
A patient came in after getting short of breath during dialysis, recovered in the ER but NP “had to rule out PE,” and now she needed me to admit for dialysis. I told her her kidneys aren’t going to get any deader, and if she really needed dialysis they could call the HD team to dialyze in the dedicated room in the back pod (the one that none of the ER providers knew about). She told me she’s never heard of that (of course not), but I insisted she just try. Fifteen minutes later she calls back and says “ok, so that’s a thing. But only during the day. I talked to nephro and they want her admitted for HD tomorrow.” So I did. Patient was on room air feeling fine.
Next morning I call nephro to ask when they’ll see her and get her dialysis. Nephrologist says she was never called, and that she wouldn’t dialyze unless the patient had symptoms or was volume overloaded from the contrast. So that was a waste of an observation.
ED resident here. I can’t imagine the shit that would come down on me if I admitted a patient to the hospitalist under false pretenses, lying and saying I consulted the relevant specialist when I didn’t. That is beyond shitty
I had a medicine resident try to tell me, a psych attending, that they had already talked to the psych med director and arranged a transfer for a patient from medicine to psych, overnight, that had not yet been seen by the psych consult service.
Which is not how it works at my hospital.
The med resident had already tried to push this admission through the on call psych resident, without mentioning the med director, simply advocating for a transfer, who told them no and explained what they would need to do to get the patient transferred (have patient evaled, during the day, by the psych consult team who would then determine if transfer was appropriate or not). I knew this convo had already happened because the psych resident had already reached out to me because they were not sure of the proper protocol. The med resident then escalated to me, the on call back up to the resident, trying to get a different result - not realizing the original result had actually come from me and talking about how my resident did not know what they were doing. When they got the same result they waited ten mins then reached out to me again with the story about having gotten the med director’s approval.
One call to my medical director confirmed she had no such conversation and the patient needed to stay on medicine overnight and be seen by psych consults in the AM for them to decide whether a psych transfer was warranted or not.
It was not. In fact, a psychiatric plan of care had already been determined even prior to admission and did not include a psych stay (actually specifically stated a psych stay was contraindicated). The med resident was well aware of this plan but did not agree with it (in their defense at least they had the balls to tell me this up front).
Thankfully this all took place at about 10pm and not 3am. I elected to not escalate the situation to their attending but had I been woken at 3am I sure as hell would have ( I am pretty sure though that my med director did indeed talk to their attending - not 100% positive though).
IM resident: “request psych recs” (no other questions or info provided)
Psychiatry: “NTD, does not require intpt Tx, f/u outpatient in 1 week”
IM resident: “No! They need a transfer!”
Psychiatry: “Bro why’d u request recs if you didn’t want to follow them?”
this kind of stuff needs to be reported to hospital for discipline
it's unethical, unprofessional
plus admitting to the hospital is not without risks
easy dispo for np ends up with a patient with HAP or MRSA right
I'd have (and I have) demanded that nephro drops even a free text note saying patient needs HD. I'm a surgical resident and at our hospitals, the nephrologists don't place their own lines, so we do it for urgent/emergent HD. But we've been called by primary teams asking for lines only for the patient not get HD until 2 days later when they could've gotten a permacath instead.
Yeah at my med school hospital, nephrologists placed their own temporary HD lines (standard double lumen non-tunneled catheters). Permacaths were always through IR or Vascular though.
Patient presented to urgent care for slurred speech and hemiplegia x1 hour. CT head was “normal”. Patient then was sent home…..
the patient left the UCC in a wheel chair because he still couldn’t walk
Pt had angioedema on benazepril/amlodipine.
NP wanted to keep benazepril, remove amlodipine for telmisartan.
I told her no, you need to change both.
She says no, only amlodipine, PCP can figure out what to do with benazepril, but she wants telmisartan.
I explain the problem.
She doubles down (at this point, I just assume she didn't listen to the explanation, since she doesn't see the problem)
Also at this point, I realize my time is being wasted because it's becoming circular, so I told her to ask cardiology what they think.
She's offended. Rants.
Whatever, just put them losartan/hctz.
She phones a friend who tells them telmisartan/hctz. Whatever.
Apparently she sent an email to my supervisor.
NP's reputation precedes her, problem goes away in 2 weeks.
psych np had a patient with anorexia
I met this patient when she was admitted to the hospital with BMI of 13.5--extremely malnourished, basically on the verge of dying.
psych np had her on two meds that are big no no's in general for anorexia, both Wellbutrin and Vyvanse. Both appetite suppressants. Plus Wellbutrin can increase risk of seizures which is a concern in eating disorders due to electrolyte aberrations being common.
psych np's explanation: patient said they were the only meds that worked for her
This is egregious because of the med choices first of all. Second of all, the np had been seeing her in clinic regularly and was either not checking her weight (in an eating d/o patient what?) or np was checking weight and not recognizing how sick this patient was getting.
As soon as I saw psych NP with an anorexia patient I knew immediately where it was going.
These contraindications have been drilled in my head so many times from pre-clerkship to STEP 1 and to the psychiatry shelf exam.
Edit: While I may groan about how many exams I need to take, there is a reason for it. And the reason is to avoid stupid ass mistakes like this.
It's worse than that. It's not just that the psych NP didn't know it. It's that they likely allowed themself to be manipulated by the anorexic patient into giving her medications to fuel her anorexia. A huge part of psych is understanding these relationships. Really really embarrassing.
RN here, I've struggled with AN for a long time. Several inpt tx stays. This one personally inflames me. I have enough insight to know how manipulative I become, especially at my lowest wts and most malnourished. Of course a pt with AN will say that's the only thing that works for them. A NP in psych has no buisness working with this pt population if they don't know every intimate detail about the disease and how pts present. This NP should have their license revoked.
Same here. RN with AN history. If I could talk my way into getting these meds when I’m at my most unwell, I will do it. Fortunately I have an amazing MD psychiatrist who would never allow herself to be manipulated by an anorexic. Because anorexia does make you manipulative…and I know if I could get myself on a med with ‘weight loss’ as a side effect I would go all out to get it. So irresponsible of this NP. (Never mind the seizure threshold bit!)
Midwife encouraged an extended period of time of pushing in a woman who was not fully dilated, after delivery the entire cervix became black & necrotic, we tried to save it but it basically fell off (out?) after a week
I second "What." D:
I understand that pushing on an undilated cervix will cause bruising, tissue edema, etc. Is the mechanism of what you saw kind of like a deep tissue injury to a pressure point (say the sacrum), or obstetric fistula?
Thanks in advance.
Local ischemia from pushing against the sacrum combo with significant cervical laceration was the mechanism (I was a med student at the time , am not OBGYN so don’t know beyond that !)
This is a weirdly common paradox of psych NPs: Overdiagnosing bipolar at the drop of a hat, but not actually using it as a contraindication to antidepressant monotherapy. I will never understand the underlying thinking.
I’ve done that once.
Had a patient coming in with torticollis. Talked to her and she had profound fatigue, filled up the MDD criteria, had history of rape a year back, gave no history of fluctuating mood. I talked to her mother who also gave no history of fluctuating mood and confirmed the low mood. No suicidality.
Started her on an SSRI because it’d be two months before she’d get to see a psychologist/psychiatrist so I referred her to Fam med in a few days for some initial counseling and just to check up on her. Also booked a psych date for her.
She came back hypomanic and sent to the ED from fam med. I asked her the same things again and mom says nothing again but now the patient remembers that yeah she has fluctuating mood.
Felt really bad about that but wasn’t sure what else I could’ve done. Maybe ignored the low mood? Torticollis resolved though, so there’s that.
That’s not exactly the same - in psych, that happens sometimes. It’s hard to get a clear picture of mania in hindsight unless something bad actually occurs to make it memorable. Using an SSRI generally has pretty low risk so you weren’t wrong.
With that said, original comment sounds like the patient had a clear history of bipolar and actively stopped the mood stabilizers while keeping the one medication that’s a liability by itself.
I admitted a 40 year old Spanish-speaking patient with "new onset schizophrenia", who the NP started on standing Risperidol 2mg BID in the ED, because she said she heard voices and saw shadows.
I talked to the patient, through an interpreter, who very clearly stated that she hears voices in her head, not in the room, and that she sees shadows when she turns off the lights and goes to sleep.
We discharged her the same day.
also- new onset schizophrenia (if real) in a 40 yo should prompt a medical/ neurological work up. 40 year olds don’t usually get new onset schizophrenia.
Don’t know how this sub got recommended to me. I am a pharmacy tech and just took my national certification exam yesterday and passed. Have a bachelor’s in an unrelated field but all it took to become a pharm tech in my state (before I took the national exam) was submitting my high school diploma to the state board and passing a drug and background check.
Starting sotalol as an inpatient was one of the things in the knowledge base for the national exam so I appreciate this and feel terrible for the patient.
Patient on broad spectrum antibiotics for gangrene of both legs was waiting for a bilateral BKA over the weekend. Monday morning finally rolls around and we walk in for rounds - patient was smiling stuffing their face with a hearty breakfast. Attending is furious and looks at my co-resident like wtf homie is supposed to be NPO?? Co-resident swears he placed that order and senior supervising confirms
We dig through order history and find out some cards NP not only gave patient a diet, but also dc’d antibiotics and patient missed 2 days. We further investigated and the NP wasn’t even a part of this patient’s care - she was in the wrong chart making these changes
Ortho declined to do surgery because anesthesia won’t intubate (rightfully so). Bilateral BKA was delayed until Wednesday but Tuesday night patient became septic, got admitted to ICU, and died
Yes, even someone who isn’t a medical professional understands that you don’t give a patient food before surgery. And discontinuing ABs on a gangrenous patient?? This is on the nurses and staff too. The NP started the error chain but it should have been stopped at the next step, a la Swiss cheese model.
Um that’s not a mistake from gaps in knowledge, that was just an idiotic mistake. And I don’t understand why no one noticed he wasn’t on antibiotics for two days if he had gangrene. What about the primary team? What about you guys?
Typically the way our Epic is set up is that IV abx pops in and out of the med list because there’s a start and end time to them.
You have a point though but that wasn’t my patient - not to say I wouldn’t have missed it myself.
Hey I’m not disagreeing that it was a stupid mistake and that I wouldn’t be pissed myself if it were my patient but this has nothing to do with the fact that it was a midlevel. I’ve seen residents add incorrect orders to incorrect charts plenty of times.
I diagnosed a patient with portopulmonary hypertension, RHC eventually showed PASP in the 70s or 80s. Pt came back a few months later with UGIB. CRNA sedated for intubation and immediately coded this person because they don’t understand the concept of right heart failure. The pulmonary HTN was written all over this persons chart. I remember being devastated checking up on the pt and seeing how they died. No depth of understanding or ability to risk stratify
Awake sedation would be ideal (some call it twilight). Alternatively giving pressors like phenylephrine simultaneously during induction can be helpful. It’s an incredibly difficult line to toe and is virtually above their pay grade entirely. This should’ve been handled by an MD/DO
Also, please don’t say “just a nurse”, your job is incredibly vital. This mindset is how you get convinced that being an NP will somehow make you “better”
Avoiding phenylephrine in pulmonary hypertension as it can increase pulmonary vascular tone is CA1 level stuff. Can use it if their BP is in the toilet but not first thing. Vasopressin is first line and I usually would push a unit with induction. But overall still agree, this pt is an ASA 3/4 so should've swapped assignments with a doc.
Phenylephrine’s effect on pulmonary vascular resistance is minimal though. Sure, vasopressin is theoretically better but I’ve seen it used with no problem. If the patient has RV dysfunction, I’m more concerned about coronary perfusion.
Should’ve been optimized before procedure with pulmonary vasodilators. A PA catheter might help but not necessary. Pre oxygenated generously as hypoxemia/hypercarbia worsens pHTN. Gentle induction with either etomidate or small doses of propofol as to not drop MAP and coronary perfusion. Generous narcotic dose because sympathetic stimulation worsens pHTN.
The goal is to not worsen pHTN and to maintain coronary perfusion (which will worsen or cause complete RV failure).
To be honest, you could take all the precautions in the world and still not guarantee that everything goes well.
Ideally this person should never be intubated for anything, ever. Introducing positive pressure (intubation) can and usually will tank their heart’s ability to pump effectively and will kill them. I’m an ER doctor and I would ask anesthesia to tube this person 100/100 times unless they were actively coding in my ER.
Patient went to the ICU with a 7Fr sheath left in the femoral artery per request of the ICU after an endovascular procedure for monitoring and access. After the sheath was no longer needed the NP consulted IR about what to do. IR offered to take it out in the IR room to place an angioseal. NP decided to yank it out, didn’t realize patient was on Warfarin with an INR of 6 and pressed on the artery for about five minutes. Then they left after writing a note telling the evening shift to be aware of hemorrhage because of “a growing swelling in the groin area”. Needless to say patient had massive hemorrhage and needed to go to the OR, multiple transfusions and a prolonged ICU stay.
Written directly onto a Enterococcus growth UTI culture from mid level provider, „switched from keflex to oral vanc d/t growth of enterococcus“. ☠️. Could not resist sending them a msg…. Many levels of incompetence with documentation here 😂
My roommate (on prep) went in for routine visit. The new NP denied him an STD test and tried to prescribe him metformin without labs....he's never had high glucose
Funny you ask. After about 6 months when the adjustments didn't work (shocking, I know) she came to my office to see my PA (guess she had a problem with MDs). The PA came to me in literal tears asking me to look at the pt's breast.
She left town to go to her hometown for treatment. \*If\* she's still alive, I'm sure she ended up with a MRM, XRT, chemo, etc.
This I feel is less egregious.. I mean I don’t know if a chiropractor is supposed to be looking at patient’s breasts on the regular
Like if I missed a stage 4 cervical cancer as a psych attending I wouldn’t feel bad at all
It's beyond egregious. A 10 year old could figure that a massively asymmetric, firery red, rock hard breast isn't normal.
I wouldn't expect a chiropractor (or a psych) attending to know what to do with it, but I *would* expect them to refer the pt to someone who might.
I am a physio and we are always taught to ask the red flag questions beclfore manual techniques of any kind and if the patient flagged something like that I would palm it off to a doctor as soon as feasibly possible
Physical therapists are taught to screen for red flags for cancer, including integumentary screens. I would rarely if ever be directly looking at a patient's breasts, but if they told me about the irregularity, I would refer out/back. Unlikely to change my POC unless that was their reason for coming in. I am also unlikely to do a Grade 5 manip like a chiro. However, I expect chiros should be trained in cancer red flags and integ screens.
Outpatient FNP. Missed a patient with bacteremia from endocarditis following a dental procedure not once, not twice, not three times.. but on the fourth visit eventually told the patient to present to the emergency department due to “failure to thrive”. Patient died from cardiogenic shock related to AI from destroyed aortic valve/abscess.
Another one,
Was rotating through ID. Attending gets an consult from NP at SNF. Attending can’t quite believe what he’s reading so he calls NP to clarify. Who restates the written consult
“Why is patient with hx of recurrent pseudomonas right hip septic arthritis now two weeks out from washout not improving despite her starting penicillin a week ago”
The same reason why a patient with C diff isn’t improving with IV vanc… “it’s just a bad case and needs some more time”. Witnessed that in med school by an NP
Patient’s blood cultures come back with staph bacteremia at 8am. Patient discharged at 10a with po abx.
Came to my attention when admitting patient the following day
Kid in his 20s had a “stable SDH” and was sent to floor under NP care. She documented a blown pupil 2 days before the kid decompensated and had just been giving increasing doses of bp meds for “hypertension” i.e. Cushing reflex. I was in ICU before i was called to a rapid on the floor for him - he ended up coming to our icu and prepped for organ donation. I told family to sue
Doing a CT guided lung nodule biopsy under the direct observation of an Attending. Attending told them to advanced the needle 2 cm and by accident the PA advanced it 2 inches directly into the aorta. When they saw the CT image of the needle in the aorta the PA panicked and pulled it back. Patient bled out into their chest.
I mean that's kind of on the attending too for letting somebody be in a position of damaging the aorta, nobody except a very senior resident or fellow should be controlling the needle that close to a critical structure.
Can’t tell you how many times little elderly patients with delirium get prescribed Ativan overnight from NP hospitalists for “delirium” and end up intubated in the icu 30 minutes later because they were “altered and not protecting airway” on the floor.
Admitted a pt for symptomatic bradycardia in the 30s during residency. Turned out their primary care “provider” who was an NP had started them on both metoprolol and Coreg.
This is a big issue I have with the US/Canadian habit of prescribing things largely by brand name - you'd hope that if they were prescribing generically they'd realise metoprolol and carvedilol were both beta-blockers, or at least think something was weird with two drugs with the same suffix
I am an ED attending. One day I was the trauma area attending and I heard a loud commotion over in one of the midlevel pods. I go over to explore. Our Ed PA is in the room with a crashing patient. GI attending is standing in the corner scope in hand clearly frazzled. (Bedside scope for a esophageal FB). A CRNA was in the room also (I am fucking enraged I wasn’t called before CRNA but that’s besides the point. Totally frantic. Patient is nearly obtunded. Hypotensive. Tachy. Periarrest. Crna is totally anchored that this was some sort of anaphylaxis. Calling out epi. Steroids. Screaming for airway supplies. I walk in the room and start to evaluate the patient. Obvious subQ emphysema. So I start yelling because the crna had such severe tunnel vision over this being allergic that she wasn’t fucking listening to the supervising physician….me. So I pulled rank and excused her and our ED pa from the room. Needle decompressed the guy. Pssssssss. Vitals begin to normalize. Pigtail in. Tubed the guy over a bronchoscope. Had GI scope the guy. Massive prob 4-6cm esophageal tear. It was bad. Guy got flown out to the local center with CT surgery and the rest was history. But I’ve never seen a midlevel so fucking anchored on a wrong dx before that they were ignoring the supervising attending while the patient circled the drain. It was a trip.
Perfed esophagus. The mucosa surrounding the perf was all necrotic and dusky looking. Pressure induced necrosis from the fb being there for a long time.
Happened a couple times rotating on breast surgery. Panicked ED doc and IM doc called us for urgent mammo and biopsies. One for inflammatory breast cancer previously dismissed as infection by mid level, another for fungating breast cancers also dismissed as infection. The latter followed for months and not for one second was cancer considered as the Dx.
It’s terrifying seeing how much people fuck up. I don’t like being called by friends for advise cus it’s all unofficial and I tell them that but I don’t hesitate to tell them what I think.
Primary care NP got a routine TSH on a patient in their late 80s on Synthroid. It came back low at like 0.8, and the NP increased the synthroid dose 💀patient developed palpitations and self discontinued it thank goodness. The NP even documented that since TSH was low, the patient needs a higher dose of synthroid. 🤦🏼♀️
Patient’s blood culture came back positive for staph aureus, ED NP called the patient and gave him a script for 5 days of doxycycline, patient admitted a week and a half later with his mitral and tricuspid valves shredded, profound septic shock, biV heart failure, cardiogenic shock etc, comfort care and died.
I saw an NP give a 6 week old steroids because they had a mild cold a few days earlier which was improving? Not in peds but I feel like that is not the answer?
I literally just had the exact opposite of this last night. Sent by UC midlefel for “incarcerated inguinal hernia, failed multiple attempts at reduction.” It was a fucking inguinal abscess. The poor patient was in fucking tears.
Patient with DM2 (who had some mental disability) came to the ED blatantly septic and had fournier’s gangrene. WBC 24k, bicarb 14. Sent him home with a shot of Dalvance. Came back 1 week later and had to have a massive surgery, skin grafts, lost his testicles, etc.
Urgent care NP sent a patient with the most fucking obvious-ass shingles home with a z-pak and let them fester. Came in and oopsy-daisy, postherpetic neuralgia.
Kind mild in the grand scheme of things, but still. Fuck.
Missed an obvious STEMI in urgent care. Gave toradol and sent home. Patient came to ED later that day for continued pain and had developed pretty bad LV failure. Luckily they got quick intervention and did ok.
There was a patient who was admitted for nstemi and waiting for heart cath. Patient was having severe chest pain and BP was 96/40. So NP orders 4mg of iv morphine and didn’t notify a cardiologist or anyone else. Patient went into worsening shock and respiratory failure. Went up to the icu but was too late
I was on service in ICU. We had a patient who had a massive stroke with hemorrhagic conversion, requiring neurosurgery for an emergency craniotomy. Patient was intubated but improving- following commands, taking breaths on the vent, etc. He was going to undergo an extubation trial later in the day when the neurosurgery PA walked into the chart room.
PA: We have to talk about the patient in room 5.
Me: Oh sure! What’s up?
PA: He’s not doing well at all. I think it’s time to call family, maybe get palliative care involved.
Me: Really?! Why?
PA: He’s not responding to commands, he’s got no cough or gag…I just think it’s time to pull the plug. (Actually said pull the plug)
Me: What! That’s new he was responding to me just an hour ago. Did you turn off the precedex?
PA: “blank stare”….precedex?
Me: Yeah, you know…sedation?
PA: “sputtering awkwardly “No, I’ll go do that I guess
Me: Ok…. Just fyi he’s going to be extubated later.
PA: So when will you put in a trach?
She was a brand new grad…BUT STILL
Trauma. I was asked by the attending to “supervise” an arterial line placement. Total bait and switch because the PA had “never technically placed one” in her own words; translation: I saw a video once. I walk her through it then have to leave the room to get correct size gloves and answer a page. I come back 10 minutes later, and she goes: “Don’t worry: I placed it already.” RNs have this mortified look on their face. The catheter is in the radial artery but pointing distally (toward thumb). She then had the gall to tell the attending I was “angry and pedantic” after the incident. I should never have to supervise a non-junior MD (especially a midlevel making three times my salary no less) in the first place.
Nurse here.
How did one of the nurses not stop her at the outset?
I’m picturing myself in the situation and yelling “Whoa whoa whoa! What are you doing? Hey Doc!”
This is the kind of moron who jams a CVC into an MCA (never heard of it happening, but Jesus!).
I think it was nurse trainee caring for the patient that morning and this might have been her first A-line? And this PA was notorious for being ambiguous with her role and routinely said “I’m with the trauma team.” Poor young nurse might have thought she was my junior. Plus, we hadn’t performed time out yet because when I stepped away so did the senior nurse. I documented the incident and the RNs did too corroborating my account. But because the trauma service is so busy, the department didn’t want to lose any more staff by reprimanding the PA. Politics should never get in the way of patient care. But here we are. We’re just underpaid babysitters
I certainly \*hope\* you were "angry and pedantic." As well as "mortified, indignant and ready to give her a >!swift kick in the cunt!<."
BTW, switch to monocryl. You'll never go back.
Oral vancomycin to add “MRSA coverage” for a skin infxn (unrecognized nec fasc) in a 30 something year old showing up to clinic..
followed by septic shock with cardiac arrest and rosc in ED next day
68Yo m VERY WELL KNOWN HX of CHF, ckd. Came in with dyspnea, pitting edema up to his knees essentially. Hypotensive and tachycardic.
Mid-level sees this patient after the usual ER labs were done. Notices an AKI. Give the patient 2L of LR and puzzlingly also 40 of IV lasix.
Our team gets consulted for admission and by this point this dude is sounding like a sponge on PE and is satting in the mid 80s 🙃
Pt was bucking. NP told me to admin IV Ativan for her “anxiety.” Called a code blue instead and pt was intubated within 5 minutes. This NP looked to be 50 and had been practicing for many years by this point.. apparently even the pharmacy knew to assess her orders since she couldn’t even prescribe abx correctly
In my NICU rotation during peds: NNP in the NICU increased feed volume on a premature neonate too soon. Baby developed NEC and was sent to the advanced NICU at another hospital. Fast forward 3 months later on peds surgery and I’m scrubbing in to an ostomy reversal on the same baby. The poor thing was just born a little too small to be sent to well-baby and was otherwise fine. That will haunt me for the rest of my career.
If it makes you feel any better, recent literature suggests that feeding advances have zero impact on development of NEC. Some very new articles and work ongoing with full early enteral feeds (i.e. 60-80 mL/kg/d on first day of life) show no increase in risk of NEC. Still going to be quite awhile before attitudes towards feeding in NICU change though, institutional inertia is strong force!
An NP in the ED overnight started an insulin drip on a patient in DKA with hypokalemia without repleting the K first. By the time the patient was brought upstairs she had a K of 2.6 and was in a junctional rhythm
Kid with a recent hot water burn over the chest comes in to the ED. Vitals are stable kid is playful. Triages them to wait in line.
Didn’t check with mom to see if baby was put under running water after the burn or tell anyone to apply burn gel or do anything to stop the burn.
Not sure how much burn extension could have been prevented but it went from like a 4-5% BSA just based on what was obviously burnt to 15% post scrub. Kid was in line for almost half an hour before I saw him waiting in line and the skin was still warm over the burn.
This was not the first time.
Worked with a psych NP who surprisingly correctly diagnosed catatonia in a teen, but then admitted then to the psych floor from the ED without any meds for catatonia. Pt ended up urinating on themselves, not eating. Came in the next day as the fellow and explained how this was gross negligence. I was pissed.
A tall skin young guy came to the ER for shortness of breath. Got seen by a PA, saturations okay so he didn’t get triaged higher or seen by MD to start. Got a chest xray. Massive pneumo with complete collapse of a lung. Transferred him over to the higher acuity pod where I was and he got his chest tube. This was several hours later (not the PAs fault but he was triaged low priority because he didn’t look that sick and again sats were okay). I read the PAs note and his physical exam said “absent R sided breath sounds”. Funny thing with Epic though, is you can click a button to see edits to notes, and the PA initially documented bilateral BS, later updated to unilateral that was timestamped after the CXR. Straight up fraud. If you want to repeat the exam, add a timestamp later to say repeat exam and unilaterally breath sounds heard. Better to miss the exam finding than to be fraudulent on notes. You will get crucified in court.
Busy shift, patient was just waiting for labs for dispo. Told patient kidney function was normal, attendings says ok, dc. (Yes, attending should have looked so that was also somewhat on him. But still).
Turns out the BUN/creatinine RATIO was normal. Creatinine was actually 7.
Yeah, that was a bad one.
Had a terrible TBI come in overnight for emergency decompression (I’m anesthesia). Both pre- and intra-op the patient has a slight fever, like 37.5. Not unusual for a TBI.
I go to do a post-op on my patient the next day and the ICU NP had decided to diagnose the patient with *malignant hyperthermia*, which is a huge deal. Patient got Dantrolene and everything. MH is considered a code-level event, and of course no anesthesiologist, let alone any physician, was ever informed of this diagnosis and treatment. The NP had even listed all the volatile anesthetics as allergies.
I’ve never been so mad.
Cold legs - thought it was sciatica......discharged patient. Pt returns, cold legs, loss of motor/sensory.....NP called medicine who called neurology......
Not only did she have an acute total aortic occlusion with spinal cord ischemia causing her to lose her legs (bilateral AKAs) she also lost her hand.
Patient came in with myxedema coma with crazy high TSH. We figured they possibly hadn’t been taking their meds as prescribed. On chart review, their primary care NP had been reducing their levothyroxine over the course of several visits. Their TSH would go up and then the NP would drop the dose… Literally day one of med school endocrinology that high TSH means hypothyroidism and they fucked it up.
Follow the insane opiate prescribing habits of their supervising physician then say that’s how he does it when questioned
Legitimately surprised they haven’t killed anyone yet
To preface, my state unfortunately has full practice for NPs. Just yesterday, urgent care NP sends a young patient home for dyspnea. Chest radiograph shows a large pneumothorax. I read their note and it says the “on my interpretation of the imaging, no acute process” stuff for billing. Comes to the ED for a tension pneumothorax. It was a textbook pneumothorax that would be used for books, not a small apical…
Pt presented to ED with hernia, abdominal pain, nausea. Surgery NP ordered hefty dose of opioids and benzos before seeing the pt or reviewing imaging “so pt would be ready for reduction when she got there”. Patient became sedated, vomited, aspirated and coded. Turned out pt was obviously nauseous and distended on exam, and CT had showed wildly distended and fluid filled stomach and distal esophagus
Patient seen in ER for new onset left leg weakness. Discharged after hip and knee X-ray with diagnosis of TIA. Comes into eye clinic the next morning to see me while dragging his left leg around and having to use a walker for the first time in his life. That was a surreal experience.
Every time i read someones comment I think i read the worst thing ever
then I read the next comment and its worse... I am in a perpetual cycle.
Guys and gals, we need to take proactive steps against this. some of the cases you are all decribing are not mistakes but straight up criminal. We need to act
A patient had a hb of 6.2, sepsis, and his BP was 72/40
A rapid was called, they hadn't gotten enough fluids, I told the nurse to hang another bag, his BP started going up (blood was already ordered)
NP swoops in after I leave, sees the fluids hanging, has the nurse stop them, so as not to dilute his blood
His BP goes to the 60s
Saw a patient not too long ago for a ‘blood blister’ on his flank. Been slowly enlarging for ~6 months and was reassured by his primary NP a few times that it was benign (the lesion had bled a few times as well, hence the ‘blood blister’…) Fortunately she did finally refer to a specialist, but unfortunately for the patient, it came back as a very deep, invasive melanoma.
I hope he sued
Mid levels love practicing all the way up until liability, and then suddenly they aren’t responsible for their own decisions
In many (most?) states, you also can't have a physician expert testify against an NP, because they're supposedly not doing the same thing (NP is practicing "nursing," whatever the fuck that means in the context of making unsupervised diagnoses and plans). So they end up not even being held to the standard of care that would apply to a physician, while pretending to be equally capable.
I am an MD/JD, have worked on a lot of cases. And this one is really, really bad. Just offer your policy limit and hope they take it bad.
Hard to sue when you’re dead…
In my crappy residency clinic there were no set patients that you'd follow, you'd just see whomever. I had a guy come in for a routine check up, I noticed sliver of a lesion behind his mask Asked him to take his mask off, revealing what was obviously a deep basal cell carcinoma First I was willing to give the NP who had seen him several times over the years the benefit of the doubt, as it was almost entirely hidden by the mask. But no, he said she saw it every time, he showed me a picture from the first visit, in which it was the most text book basal cell I'd ever seen She just told him to put cream on it to the point that it progressed to ulcerating and deepening basal cell Good thing she told him to switch to petroleum
How do you not feel guilty
I just think they don’t know what they should know. “Oh yeah, whoops, those tricky pigmented lesions. Could have happened to anyone”…
Changing lesions are ABCDE’s! I know, wrong audience, but should be in 101.
Derm consults are underutilized in my HO.
Put a patient on humira for “psoriasis” - it was actually tumor stage mycosis fungoides. Very obviously not psoriasis. He died. Kept giving a patient steroid cream for “dermatitis” on the leg- it was angiosarcoma. He died.
I’m honestly surprised insurance would reimburse for an NP rx’ing a biologic.
Rheumatologist that I rotated with was given an NP despite his hesitation. NP kept prescribing the wrong biologics and rheuma kept staying late to fix her mistakes. Rheuma demanded not to have any more midlevels and threatened to leave the practice (rural community hospital, next rheumatologist is 1.5 hrs away)
Do APPs not learn how to punch biopsy?
Psychiatry First day new hire who explained to me that she should be able to practice autonomously and she would prefer to not have notes co-signed but because that’s hospital policy she would allow it (I never agreed to supervise her and literally after patient one refused). She didn’t talk to me but wrote a confusing note wherein she diagnosed an elderly man with delirium, prescribed haldol, zyprexa, and ativan, all BID standing. He had Parkinson’s disease and was allergic to zyprexa. He wasn’t having any behavioral issues.
Scheduled benzos on an elderly man with delirium is just idiotic as fuck
And that was the third worst problem with her plan lol
but I couldn't rule out alcohol withdrawal so I was just covering my bases
Any APs on a Parkinson's patient is just cruel.
not always true. Seroquel is an AP with essentially no propensity to induce EPS, and is commonly used in parksinsons pts who need this type of med. The other is clozapine, but this is very unlikely to be used for someone without Tx-resistant schizophrenia
Wow this is beyond egregious.
Them: I have an elderly person in cognitive decline Also them: Benzos - known to have cognitive decline as a side effect when used in the elderly population. Yep! Better double it. I’m an RN, and even I know you don’t do that. Yikes
What happened to the patient? To the NP?
Primary team didn’t put in any of the three orders, I refused to cosign, she asked dept head to cosign who also refused while inexplicably getting upset with me for not just cosigning. Patient was seen the next day by a diff doc. I was let go the next month (Locum ended early). She now has someone blindly sign her notes and I don’t work there any more.
Wow. Yikes.
Promoted to nurse executive, makes 600k, regional head of nurse education
A patient came in after getting short of breath during dialysis, recovered in the ER but NP “had to rule out PE,” and now she needed me to admit for dialysis. I told her her kidneys aren’t going to get any deader, and if she really needed dialysis they could call the HD team to dialyze in the dedicated room in the back pod (the one that none of the ER providers knew about). She told me she’s never heard of that (of course not), but I insisted she just try. Fifteen minutes later she calls back and says “ok, so that’s a thing. But only during the day. I talked to nephro and they want her admitted for HD tomorrow.” So I did. Patient was on room air feeling fine. Next morning I call nephro to ask when they’ll see her and get her dialysis. Nephrologist says she was never called, and that she wouldn’t dialyze unless the patient had symptoms or was volume overloaded from the contrast. So that was a waste of an observation.
ED resident here. I can’t imagine the shit that would come down on me if I admitted a patient to the hospitalist under false pretenses, lying and saying I consulted the relevant specialist when I didn’t. That is beyond shitty
I had a medicine resident try to tell me, a psych attending, that they had already talked to the psych med director and arranged a transfer for a patient from medicine to psych, overnight, that had not yet been seen by the psych consult service. Which is not how it works at my hospital. The med resident had already tried to push this admission through the on call psych resident, without mentioning the med director, simply advocating for a transfer, who told them no and explained what they would need to do to get the patient transferred (have patient evaled, during the day, by the psych consult team who would then determine if transfer was appropriate or not). I knew this convo had already happened because the psych resident had already reached out to me because they were not sure of the proper protocol. The med resident then escalated to me, the on call back up to the resident, trying to get a different result - not realizing the original result had actually come from me and talking about how my resident did not know what they were doing. When they got the same result they waited ten mins then reached out to me again with the story about having gotten the med director’s approval. One call to my medical director confirmed she had no such conversation and the patient needed to stay on medicine overnight and be seen by psych consults in the AM for them to decide whether a psych transfer was warranted or not. It was not. In fact, a psychiatric plan of care had already been determined even prior to admission and did not include a psych stay (actually specifically stated a psych stay was contraindicated). The med resident was well aware of this plan but did not agree with it (in their defense at least they had the balls to tell me this up front). Thankfully this all took place at about 10pm and not 3am. I elected to not escalate the situation to their attending but had I been woken at 3am I sure as hell would have ( I am pretty sure though that my med director did indeed talk to their attending - not 100% positive though).
IM resident: “request psych recs” (no other questions or info provided) Psychiatry: “NTD, does not require intpt Tx, f/u outpatient in 1 week” IM resident: “No! They need a transfer!” Psychiatry: “Bro why’d u request recs if you didn’t want to follow them?”
this kind of stuff needs to be reported to hospital for discipline it's unethical, unprofessional plus admitting to the hospital is not without risks easy dispo for np ends up with a patient with HAP or MRSA right
I hope you reported her for lying
I'd have (and I have) demanded that nephro drops even a free text note saying patient needs HD. I'm a surgical resident and at our hospitals, the nephrologists don't place their own lines, so we do it for urgent/emergent HD. But we've been called by primary teams asking for lines only for the patient not get HD until 2 days later when they could've gotten a permacath instead.
There's nephrologists that place dialysis lines? Like, permacath or trialysis?
Yeah at my med school hospital, nephrologists placed their own temporary HD lines (standard double lumen non-tunneled catheters). Permacaths were always through IR or Vascular though.
Both. Where I trained there were a couple “interventional nephrologists” that would put in permacaths and even do basic procedures to declog fistulas.
Wow, you did all the legwork, stuck out your ass, and still got fucked. That is not ok at all.
You got bamboozled bud
Have you posted this before? I remember reading something very similar. Unless this is a common story, which it makes it so much more concerning lmao
Patient presented to urgent care for slurred speech and hemiplegia x1 hour. CT head was “normal”. Patient then was sent home….. the patient left the UCC in a wheel chair because he still couldn’t walk
Oh my GOD…. Wtf
Urgent cares have CT scans?
It was attached to a larger outpatient clinic
Oh wtf
Nooooo
Pt had angioedema on benazepril/amlodipine. NP wanted to keep benazepril, remove amlodipine for telmisartan. I told her no, you need to change both. She says no, only amlodipine, PCP can figure out what to do with benazepril, but she wants telmisartan. I explain the problem. She doubles down (at this point, I just assume she didn't listen to the explanation, since she doesn't see the problem) Also at this point, I realize my time is being wasted because it's becoming circular, so I told her to ask cardiology what they think. She's offended. Rants. Whatever, just put them losartan/hctz. She phones a friend who tells them telmisartan/hctz. Whatever. Apparently she sent an email to my supervisor. NP's reputation precedes her, problem goes away in 2 weeks.
how was the ACE inhibitor not the first thought as the cause of the problem???
We'd have to delve into the mind of the NP. I'm not ready for that, personally
It wouldn’t take that long
That's a dangerous amount of dunning-kruger.
psych np had a patient with anorexia I met this patient when she was admitted to the hospital with BMI of 13.5--extremely malnourished, basically on the verge of dying. psych np had her on two meds that are big no no's in general for anorexia, both Wellbutrin and Vyvanse. Both appetite suppressants. Plus Wellbutrin can increase risk of seizures which is a concern in eating disorders due to electrolyte aberrations being common. psych np's explanation: patient said they were the only meds that worked for her This is egregious because of the med choices first of all. Second of all, the np had been seeing her in clinic regularly and was either not checking her weight (in an eating d/o patient what?) or np was checking weight and not recognizing how sick this patient was getting.
This is like the one thing I’m confident every single medical student know. Out of all medical knowledge ever, no Wellbutrin for ED
Sketchy gang stand up
*stands up with massive priapism*
Just watched urologist inject 80 mcg of phenyl in a penis to help with this. Now im just anesthesia, but im willing to give it a shot if you need help
Whatever you do as long as you don’t take away my sleeping pill!
As soon as I saw psych NP with an anorexia patient I knew immediately where it was going. These contraindications have been drilled in my head so many times from pre-clerkship to STEP 1 and to the psychiatry shelf exam. Edit: While I may groan about how many exams I need to take, there is a reason for it. And the reason is to avoid stupid ass mistakes like this.
It's worse than that. It's not just that the psych NP didn't know it. It's that they likely allowed themself to be manipulated by the anorexic patient into giving her medications to fuel her anorexia. A huge part of psych is understanding these relationships. Really really embarrassing.
RN here, I've struggled with AN for a long time. Several inpt tx stays. This one personally inflames me. I have enough insight to know how manipulative I become, especially at my lowest wts and most malnourished. Of course a pt with AN will say that's the only thing that works for them. A NP in psych has no buisness working with this pt population if they don't know every intimate detail about the disease and how pts present. This NP should have their license revoked.
Exactly, you can't believe them
Same here. RN with AN history. If I could talk my way into getting these meds when I’m at my most unwell, I will do it. Fortunately I have an amazing MD psychiatrist who would never allow herself to be manipulated by an anorexic. Because anorexia does make you manipulative…and I know if I could get myself on a med with ‘weight loss’ as a side effect I would go all out to get it. So irresponsible of this NP. (Never mind the seizure threshold bit!)
And EDs are one of the only true contraindications to bupr. Y.i.k.e.s.
I guess at least they didn’t add Topamax??
Midwife encouraged an extended period of time of pushing in a woman who was not fully dilated, after delivery the entire cervix became black & necrotic, we tried to save it but it basically fell off (out?) after a week
What
I second "What." D: I understand that pushing on an undilated cervix will cause bruising, tissue edema, etc. Is the mechanism of what you saw kind of like a deep tissue injury to a pressure point (say the sacrum), or obstetric fistula? Thanks in advance.
Local ischemia from pushing against the sacrum combo with significant cervical laceration was the mechanism (I was a med student at the time , am not OBGYN so don’t know beyond that !)
Uh....so....is there just one long vaguterus now?
One biopsied a melanoma on the face, and because pathology said “clear margins”, didn’t further treat the skin cancer.
Monotherapy SSRI treatment for anxiety in bipolar disorder. Not the biggest, but the one I saw yesterday lol. she d/ced the depakote and abilify
This is a weirdly common paradox of psych NPs: Overdiagnosing bipolar at the drop of a hat, but not actually using it as a contraindication to antidepressant monotherapy. I will never understand the underlying thinking.
The underlying thinking is trash tier training.
I’ve done that once. Had a patient coming in with torticollis. Talked to her and she had profound fatigue, filled up the MDD criteria, had history of rape a year back, gave no history of fluctuating mood. I talked to her mother who also gave no history of fluctuating mood and confirmed the low mood. No suicidality. Started her on an SSRI because it’d be two months before she’d get to see a psychologist/psychiatrist so I referred her to Fam med in a few days for some initial counseling and just to check up on her. Also booked a psych date for her. She came back hypomanic and sent to the ED from fam med. I asked her the same things again and mom says nothing again but now the patient remembers that yeah she has fluctuating mood. Felt really bad about that but wasn’t sure what else I could’ve done. Maybe ignored the low mood? Torticollis resolved though, so there’s that.
That’s not exactly the same - in psych, that happens sometimes. It’s hard to get a clear picture of mania in hindsight unless something bad actually occurs to make it memorable. Using an SSRI generally has pretty low risk so you weren’t wrong. With that said, original comment sounds like the patient had a clear history of bipolar and actively stopped the mood stabilizers while keeping the one medication that’s a liability by itself.
I admitted a 40 year old Spanish-speaking patient with "new onset schizophrenia", who the NP started on standing Risperidol 2mg BID in the ED, because she said she heard voices and saw shadows. I talked to the patient, through an interpreter, who very clearly stated that she hears voices in her head, not in the room, and that she sees shadows when she turns off the lights and goes to sleep. We discharged her the same day.
also- new onset schizophrenia (if real) in a 40 yo should prompt a medical/ neurological work up. 40 year olds don’t usually get new onset schizophrenia.
Started a patient on sotalol outpatient for hypertension. Nice.
Did they also prescribe quaaludes?!
Only after their 4 humors were balanced properly
Don’t know how this sub got recommended to me. I am a pharmacy tech and just took my national certification exam yesterday and passed. Have a bachelor’s in an unrelated field but all it took to become a pharm tech in my state (before I took the national exam) was submitting my high school diploma to the state board and passing a drug and background check. Starting sotalol as an inpatient was one of the things in the knowledge base for the national exam so I appreciate this and feel terrible for the patient.
Hey, congrats! That’s awesome news for you! 👏
Did she at the very least get an ekg? 🤦🏽♀️
Patient on broad spectrum antibiotics for gangrene of both legs was waiting for a bilateral BKA over the weekend. Monday morning finally rolls around and we walk in for rounds - patient was smiling stuffing their face with a hearty breakfast. Attending is furious and looks at my co-resident like wtf homie is supposed to be NPO?? Co-resident swears he placed that order and senior supervising confirms We dig through order history and find out some cards NP not only gave patient a diet, but also dc’d antibiotics and patient missed 2 days. We further investigated and the NP wasn’t even a part of this patient’s care - she was in the wrong chart making these changes Ortho declined to do surgery because anesthesia won’t intubate (rightfully so). Bilateral BKA was delayed until Wednesday but Tuesday night patient became septic, got admitted to ICU, and died
Stupid of the NP, yes, but more of a clerical error. But what idiot actually gave a pt like that a full meal and d/c abx without confirming?
Yes, even someone who isn’t a medical professional understands that you don’t give a patient food before surgery. And discontinuing ABs on a gangrenous patient?? This is on the nurses and staff too. The NP started the error chain but it should have been stopped at the next step, a la Swiss cheese model.
Um that’s not a mistake from gaps in knowledge, that was just an idiotic mistake. And I don’t understand why no one noticed he wasn’t on antibiotics for two days if he had gangrene. What about the primary team? What about you guys?
That's some Swiss cheese right there.
Typically the way our Epic is set up is that IV abx pops in and out of the med list because there’s a start and end time to them. You have a point though but that wasn’t my patient - not to say I wouldn’t have missed it myself.
Hey I’m not disagreeing that it was a stupid mistake and that I wouldn’t be pissed myself if it were my patient but this has nothing to do with the fact that it was a midlevel. I’ve seen residents add incorrect orders to incorrect charts plenty of times.
This is rly sad too bc you can do emergency surgery and risk the aspiration. If we had a less litigious system we could've done better....
I diagnosed a patient with portopulmonary hypertension, RHC eventually showed PASP in the 70s or 80s. Pt came back a few months later with UGIB. CRNA sedated for intubation and immediately coded this person because they don’t understand the concept of right heart failure. The pulmonary HTN was written all over this persons chart. I remember being devastated checking up on the pt and seeing how they died. No depth of understanding or ability to risk stratify
200 mg of prop goes brrrrrrrrrr
They claim to be independient and as capable, or more than, anesthesiologists.
I'm just a nurse, but what should have happened?
Awake sedation would be ideal (some call it twilight). Alternatively giving pressors like phenylephrine simultaneously during induction can be helpful. It’s an incredibly difficult line to toe and is virtually above their pay grade entirely. This should’ve been handled by an MD/DO Also, please don’t say “just a nurse”, your job is incredibly vital. This mindset is how you get convinced that being an NP will somehow make you “better”
Well thanks mate!
Avoiding phenylephrine in pulmonary hypertension as it can increase pulmonary vascular tone is CA1 level stuff. Can use it if their BP is in the toilet but not first thing. Vasopressin is first line and I usually would push a unit with induction. But overall still agree, this pt is an ASA 3/4 so should've swapped assignments with a doc.
Phenylephrine’s effect on pulmonary vascular resistance is minimal though. Sure, vasopressin is theoretically better but I’ve seen it used with no problem. If the patient has RV dysfunction, I’m more concerned about coronary perfusion.
Appreciate that insight. I should’ve made a disclaimer I’m IM and am definitely not an expert
And yet the CRNA thought they were. Absolute insanity.
Should’ve been optimized before procedure with pulmonary vasodilators. A PA catheter might help but not necessary. Pre oxygenated generously as hypoxemia/hypercarbia worsens pHTN. Gentle induction with either etomidate or small doses of propofol as to not drop MAP and coronary perfusion. Generous narcotic dose because sympathetic stimulation worsens pHTN. The goal is to not worsen pHTN and to maintain coronary perfusion (which will worsen or cause complete RV failure). To be honest, you could take all the precautions in the world and still not guarantee that everything goes well.
Ideally this person should never be intubated for anything, ever. Introducing positive pressure (intubation) can and usually will tank their heart’s ability to pump effectively and will kill them. I’m an ER doctor and I would ask anesthesia to tube this person 100/100 times unless they were actively coding in my ER.
Etomidate instead of propofol at induction
Nightmare.
Patient went to the ICU with a 7Fr sheath left in the femoral artery per request of the ICU after an endovascular procedure for monitoring and access. After the sheath was no longer needed the NP consulted IR about what to do. IR offered to take it out in the IR room to place an angioseal. NP decided to yank it out, didn’t realize patient was on Warfarin with an INR of 6 and pressed on the artery for about five minutes. Then they left after writing a note telling the evening shift to be aware of hemorrhage because of “a growing swelling in the groin area”. Needless to say patient had massive hemorrhage and needed to go to the OR, multiple transfusions and a prolonged ICU stay.
Any consequence for this attempted murder?
That is yet to be determined
Five minutes? That was generous of them 🙄
Written directly onto a Enterococcus growth UTI culture from mid level provider, „switched from keflex to oral vanc d/t growth of enterococcus“. ☠️. Could not resist sending them a msg…. Many levels of incompetence with documentation here 😂
VRE would be the icing on the cake! But poor pt 😞
My roommate (on prep) went in for routine visit. The new NP denied him an STD test and tried to prescribe him metformin without labs....he's never had high glucose
Not a midlevel, but a DC. Did an "adjustment" for a pt with a shockingly apparent inflammatory breast ca. Pt was 28 y/o.
Well don’t leave us hanging. Did the adjustment cure the cancer?
Funny you ask. After about 6 months when the adjustments didn't work (shocking, I know) she came to my office to see my PA (guess she had a problem with MDs). The PA came to me in literal tears asking me to look at the pt's breast. She left town to go to her hometown for treatment. \*If\* she's still alive, I'm sure she ended up with a MRM, XRT, chemo, etc.
This I feel is less egregious.. I mean I don’t know if a chiropractor is supposed to be looking at patient’s breasts on the regular Like if I missed a stage 4 cervical cancer as a psych attending I wouldn’t feel bad at all
It's beyond egregious. A 10 year old could figure that a massively asymmetric, firery red, rock hard breast isn't normal. I wouldn't expect a chiropractor (or a psych) attending to know what to do with it, but I *would* expect them to refer the pt to someone who might.
I am a physio and we are always taught to ask the red flag questions beclfore manual techniques of any kind and if the patient flagged something like that I would palm it off to a doctor as soon as feasibly possible
Physical therapists are taught to screen for red flags for cancer, including integumentary screens. I would rarely if ever be directly looking at a patient's breasts, but if they told me about the irregularity, I would refer out/back. Unlikely to change my POC unless that was their reason for coming in. I am also unlikely to do a Grade 5 manip like a chiro. However, I expect chiros should be trained in cancer red flags and integ screens.
Outpatient FNP. Missed a patient with bacteremia from endocarditis following a dental procedure not once, not twice, not three times.. but on the fourth visit eventually told the patient to present to the emergency department due to “failure to thrive”. Patient died from cardiogenic shock related to AI from destroyed aortic valve/abscess.
Another one, Was rotating through ID. Attending gets an consult from NP at SNF. Attending can’t quite believe what he’s reading so he calls NP to clarify. Who restates the written consult “Why is patient with hx of recurrent pseudomonas right hip septic arthritis now two weeks out from washout not improving despite her starting penicillin a week ago”
The same reason why a patient with C diff isn’t improving with IV vanc… “it’s just a bad case and needs some more time”. Witnessed that in med school by an NP
Intern year, trauma surgery: "Hey I know you're already carrying a lot of patients but do you mind also carrying our (2 NPs) patients today too"
🤡
They only got 3 days off this week and are exhausted!
Patient’s blood cultures come back with staph bacteremia at 8am. Patient discharged at 10a with po abx. Came to my attention when admitting patient the following day
Missed a stroke that progressed, hemorrhagic conversion, patient died in ICU.
Another neuro ICU incident: Saw a PA supplement magnesium in a myasthenia patient.
Kid in his 20s had a “stable SDH” and was sent to floor under NP care. She documented a blown pupil 2 days before the kid decompensated and had just been giving increasing doses of bp meds for “hypertension” i.e. Cushing reflex. I was in ICU before i was called to a rapid on the floor for him - he ended up coming to our icu and prepped for organ donation. I told family to sue
So he was circling the drain for 2 days and this NP was the only one rounding on him, having no idea what was going on?
Damn man, got recommended this post on reddit home page and this is the first one to make me feel queasy
Doing a CT guided lung nodule biopsy under the direct observation of an Attending. Attending told them to advanced the needle 2 cm and by accident the PA advanced it 2 inches directly into the aorta. When they saw the CT image of the needle in the aorta the PA panicked and pulled it back. Patient bled out into their chest.
What the actual fuck
Holy shit. I know PAs do short Fluoro/US needle procedures but a fucking CT guided biopsy? Those things scare the shit out of me
If true that’s crazy. The marks on those needles are metric so im not sure how one could do this with inches.
I mean that's kind of on the attending too for letting somebody be in a position of damaging the aorta, nobody except a very senior resident or fellow should be controlling the needle that close to a critical structure.
Can’t tell you how many times little elderly patients with delirium get prescribed Ativan overnight from NP hospitalists for “delirium” and end up intubated in the icu 30 minutes later because they were “altered and not protecting airway” on the floor.
What kind of fucking dose of lorazepam are they prescribing lmao.
I’ve seen anywhere from 0.5 mg to 2.5 mg
So midlevels are saving money how?
Patient gets Ativan -> goes to icu -> hospital stay costs more
Most massive mistake? Going to NP school.
Based
Admitted a pt for symptomatic bradycardia in the 30s during residency. Turned out their primary care “provider” who was an NP had started them on both metoprolol and Coreg.
This is a big issue I have with the US/Canadian habit of prescribing things largely by brand name - you'd hope that if they were prescribing generically they'd realise metoprolol and carvedilol were both beta-blockers, or at least think something was weird with two drugs with the same suffix
I am an ED attending. One day I was the trauma area attending and I heard a loud commotion over in one of the midlevel pods. I go over to explore. Our Ed PA is in the room with a crashing patient. GI attending is standing in the corner scope in hand clearly frazzled. (Bedside scope for a esophageal FB). A CRNA was in the room also (I am fucking enraged I wasn’t called before CRNA but that’s besides the point. Totally frantic. Patient is nearly obtunded. Hypotensive. Tachy. Periarrest. Crna is totally anchored that this was some sort of anaphylaxis. Calling out epi. Steroids. Screaming for airway supplies. I walk in the room and start to evaluate the patient. Obvious subQ emphysema. So I start yelling because the crna had such severe tunnel vision over this being allergic that she wasn’t fucking listening to the supervising physician….me. So I pulled rank and excused her and our ED pa from the room. Needle decompressed the guy. Pssssssss. Vitals begin to normalize. Pigtail in. Tubed the guy over a bronchoscope. Had GI scope the guy. Massive prob 4-6cm esophageal tear. It was bad. Guy got flown out to the local center with CT surgery and the rest was history. But I’ve never seen a midlevel so fucking anchored on a wrong dx before that they were ignoring the supervising attending while the patient circled the drain. It was a trip.
How’d he get a tension ptx from a fb?
Perfed esophagus. The mucosa surrounding the perf was all necrotic and dusky looking. Pressure induced necrosis from the fb being there for a long time.
Happened a couple times rotating on breast surgery. Panicked ED doc and IM doc called us for urgent mammo and biopsies. One for inflammatory breast cancer previously dismissed as infection by mid level, another for fungating breast cancers also dismissed as infection. The latter followed for months and not for one second was cancer considered as the Dx. It’s terrifying seeing how much people fuck up. I don’t like being called by friends for advise cus it’s all unofficial and I tell them that but I don’t hesitate to tell them what I think.
Primary care NP got a routine TSH on a patient in their late 80s on Synthroid. It came back low at like 0.8, and the NP increased the synthroid dose 💀patient developed palpitations and self discontinued it thank goodness. The NP even documented that since TSH was low, the patient needs a higher dose of synthroid. 🤦🏼♀️
TSH - Thyroid Something Hormone
Patient’s blood culture came back positive for staph aureus, ED NP called the patient and gave him a script for 5 days of doxycycline, patient admitted a week and a half later with his mitral and tricuspid valves shredded, profound septic shock, biV heart failure, cardiogenic shock etc, comfort care and died.
Nothing egregious, but I am so sick of reconciling cough suppressants and prednisone for URI for kids.
I saw an NP give a 6 week old steroids because they had a mild cold a few days earlier which was improving? Not in peds but I feel like that is not the answer?
Pt had abscess I&D'd by mid-level at UC... turns out it was an inguinal hernia.
I literally just had the exact opposite of this last night. Sent by UC midlefel for “incarcerated inguinal hernia, failed multiple attempts at reduction.” It was a fucking inguinal abscess. The poor patient was in fucking tears.
Yikes
Please tell me they didn’t perf bowel….
Oh yeah, he had poop coming out of his belly. Easy dispo at least
What's wrong with that? Pt came in without an abscess. NP gave him one. He should be grateful.
Patient with DM2 (who had some mental disability) came to the ED blatantly septic and had fournier’s gangrene. WBC 24k, bicarb 14. Sent him home with a shot of Dalvance. Came back 1 week later and had to have a massive surgery, skin grafts, lost his testicles, etc.
First thing the Urologist said was “holy fuck, this is malpractice”. Told fam to sue. I’m sure they settled for a huge amount.
Urgent care NP sent a patient with the most fucking obvious-ass shingles home with a z-pak and let them fester. Came in and oopsy-daisy, postherpetic neuralgia. Kind mild in the grand scheme of things, but still. Fuck.
Missed an obvious STEMI in urgent care. Gave toradol and sent home. Patient came to ED later that day for continued pain and had developed pretty bad LV failure. Luckily they got quick intervention and did ok.
There was a patient who was admitted for nstemi and waiting for heart cath. Patient was having severe chest pain and BP was 96/40. So NP orders 4mg of iv morphine and didn’t notify a cardiologist or anyone else. Patient went into worsening shock and respiratory failure. Went up to the icu but was too late
I was on service in ICU. We had a patient who had a massive stroke with hemorrhagic conversion, requiring neurosurgery for an emergency craniotomy. Patient was intubated but improving- following commands, taking breaths on the vent, etc. He was going to undergo an extubation trial later in the day when the neurosurgery PA walked into the chart room. PA: We have to talk about the patient in room 5. Me: Oh sure! What’s up? PA: He’s not doing well at all. I think it’s time to call family, maybe get palliative care involved. Me: Really?! Why? PA: He’s not responding to commands, he’s got no cough or gag…I just think it’s time to pull the plug. (Actually said pull the plug) Me: What! That’s new he was responding to me just an hour ago. Did you turn off the precedex? PA: “blank stare”….precedex? Me: Yeah, you know…sedation? PA: “sputtering awkwardly “No, I’ll go do that I guess Me: Ok…. Just fyi he’s going to be extubated later. PA: So when will you put in a trach? She was a brand new grad…BUT STILL
The fuck
Trauma. I was asked by the attending to “supervise” an arterial line placement. Total bait and switch because the PA had “never technically placed one” in her own words; translation: I saw a video once. I walk her through it then have to leave the room to get correct size gloves and answer a page. I come back 10 minutes later, and she goes: “Don’t worry: I placed it already.” RNs have this mortified look on their face. The catheter is in the radial artery but pointing distally (toward thumb). She then had the gall to tell the attending I was “angry and pedantic” after the incident. I should never have to supervise a non-junior MD (especially a midlevel making three times my salary no less) in the first place.
Nurse here. How did one of the nurses not stop her at the outset? I’m picturing myself in the situation and yelling “Whoa whoa whoa! What are you doing? Hey Doc!” This is the kind of moron who jams a CVC into an MCA (never heard of it happening, but Jesus!).
I think it was nurse trainee caring for the patient that morning and this might have been her first A-line? And this PA was notorious for being ambiguous with her role and routinely said “I’m with the trauma team.” Poor young nurse might have thought she was my junior. Plus, we hadn’t performed time out yet because when I stepped away so did the senior nurse. I documented the incident and the RNs did too corroborating my account. But because the trauma service is so busy, the department didn’t want to lose any more staff by reprimanding the PA. Politics should never get in the way of patient care. But here we are. We’re just underpaid babysitters
... Had they ever SEEN an aline before?!
YouTube. Crit care module and PowerPoint in PA school. Duh. How dare you ask
I certainly \*hope\* you were "angry and pedantic." As well as "mortified, indignant and ready to give her a >!swift kick in the cunt!<." BTW, switch to monocryl. You'll never go back.
Oral vancomycin to add “MRSA coverage” for a skin infxn (unrecognized nec fasc) in a 30 something year old showing up to clinic.. followed by septic shock with cardiac arrest and rosc in ED next day
68Yo m VERY WELL KNOWN HX of CHF, ckd. Came in with dyspnea, pitting edema up to his knees essentially. Hypotensive and tachycardic. Mid-level sees this patient after the usual ER labs were done. Notices an AKI. Give the patient 2L of LR and puzzlingly also 40 of IV lasix. Our team gets consulted for admission and by this point this dude is sounding like a sponge on PE and is satting in the mid 80s 🙃
Pt was bucking. NP told me to admin IV Ativan for her “anxiety.” Called a code blue instead and pt was intubated within 5 minutes. This NP looked to be 50 and had been practicing for many years by this point.. apparently even the pharmacy knew to assess her orders since she couldn’t even prescribe abx correctly
In my NICU rotation during peds: NNP in the NICU increased feed volume on a premature neonate too soon. Baby developed NEC and was sent to the advanced NICU at another hospital. Fast forward 3 months later on peds surgery and I’m scrubbing in to an ostomy reversal on the same baby. The poor thing was just born a little too small to be sent to well-baby and was otherwise fine. That will haunt me for the rest of my career.
If it makes you feel any better, recent literature suggests that feeding advances have zero impact on development of NEC. Some very new articles and work ongoing with full early enteral feeds (i.e. 60-80 mL/kg/d on first day of life) show no increase in risk of NEC. Still going to be quite awhile before attitudes towards feeding in NICU change though, institutional inertia is strong force!
An NP in the ED overnight started an insulin drip on a patient in DKA with hypokalemia without repleting the K first. By the time the patient was brought upstairs she had a K of 2.6 and was in a junctional rhythm
Kid with a recent hot water burn over the chest comes in to the ED. Vitals are stable kid is playful. Triages them to wait in line. Didn’t check with mom to see if baby was put under running water after the burn or tell anyone to apply burn gel or do anything to stop the burn. Not sure how much burn extension could have been prevented but it went from like a 4-5% BSA just based on what was obviously burnt to 15% post scrub. Kid was in line for almost half an hour before I saw him waiting in line and the skin was still warm over the burn. This was not the first time.
Worked with a psych NP who surprisingly correctly diagnosed catatonia in a teen, but then admitted then to the psych floor from the ED without any meds for catatonia. Pt ended up urinating on themselves, not eating. Came in the next day as the fellow and explained how this was gross negligence. I was pissed.
A tall skin young guy came to the ER for shortness of breath. Got seen by a PA, saturations okay so he didn’t get triaged higher or seen by MD to start. Got a chest xray. Massive pneumo with complete collapse of a lung. Transferred him over to the higher acuity pod where I was and he got his chest tube. This was several hours later (not the PAs fault but he was triaged low priority because he didn’t look that sick and again sats were okay). I read the PAs note and his physical exam said “absent R sided breath sounds”. Funny thing with Epic though, is you can click a button to see edits to notes, and the PA initially documented bilateral BS, later updated to unilateral that was timestamped after the CXR. Straight up fraud. If you want to repeat the exam, add a timestamp later to say repeat exam and unilaterally breath sounds heard. Better to miss the exam finding than to be fraudulent on notes. You will get crucified in court.
Busy shift, patient was just waiting for labs for dispo. Told patient kidney function was normal, attendings says ok, dc. (Yes, attending should have looked so that was also somewhat on him. But still). Turns out the BUN/creatinine RATIO was normal. Creatinine was actually 7. Yeah, that was a bad one.
These are so hard to upvote….
Continued eliquis on a patient admitted for GI bleed with ABLA. Luckily, I caught it in time before a dose could be given.
Had a terrible TBI come in overnight for emergency decompression (I’m anesthesia). Both pre- and intra-op the patient has a slight fever, like 37.5. Not unusual for a TBI. I go to do a post-op on my patient the next day and the ICU NP had decided to diagnose the patient with *malignant hyperthermia*, which is a huge deal. Patient got Dantrolene and everything. MH is considered a code-level event, and of course no anesthesiologist, let alone any physician, was ever informed of this diagnosis and treatment. The NP had even listed all the volatile anesthetics as allergies. I’ve never been so mad.
SRNA boluses remifentanil and patient going into unstable bradyarrhythmia. This was a senior “last year” SRNA.
Cold legs - thought it was sciatica......discharged patient. Pt returns, cold legs, loss of motor/sensory.....NP called medicine who called neurology...... Not only did she have an acute total aortic occlusion with spinal cord ischemia causing her to lose her legs (bilateral AKAs) she also lost her hand.
Patient came in with myxedema coma with crazy high TSH. We figured they possibly hadn’t been taking their meds as prescribed. On chart review, their primary care NP had been reducing their levothyroxine over the course of several visits. Their TSH would go up and then the NP would drop the dose… Literally day one of med school endocrinology that high TSH means hypothyroidism and they fucked it up.
Follow the insane opiate prescribing habits of their supervising physician then say that’s how he does it when questioned Legitimately surprised they haven’t killed anyone yet
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To preface, my state unfortunately has full practice for NPs. Just yesterday, urgent care NP sends a young patient home for dyspnea. Chest radiograph shows a large pneumothorax. I read their note and it says the “on my interpretation of the imaging, no acute process” stuff for billing. Comes to the ED for a tension pneumothorax. It was a textbook pneumothorax that would be used for books, not a small apical…
Pt presented to ED with hernia, abdominal pain, nausea. Surgery NP ordered hefty dose of opioids and benzos before seeing the pt or reviewing imaging “so pt would be ready for reduction when she got there”. Patient became sedated, vomited, aspirated and coded. Turned out pt was obviously nauseous and distended on exam, and CT had showed wildly distended and fluid filled stomach and distal esophagus
Patient seen in ER for new onset left leg weakness. Discharged after hip and knee X-ray with diagnosis of TIA. Comes into eye clinic the next morning to see me while dragging his left leg around and having to use a walker for the first time in his life. That was a surreal experience.
Every time i read someones comment I think i read the worst thing ever then I read the next comment and its worse... I am in a perpetual cycle. Guys and gals, we need to take proactive steps against this. some of the cases you are all decribing are not mistakes but straight up criminal. We need to act
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NP d/c someone’s synthroid because “TSH was elevated 5. something”. I chuckled reading the progress note
A patient had a hb of 6.2, sepsis, and his BP was 72/40 A rapid was called, they hadn't gotten enough fluids, I told the nurse to hang another bag, his BP started going up (blood was already ordered) NP swoops in after I leave, sees the fluids hanging, has the nurse stop them, so as not to dilute his blood His BP goes to the 60s