BS in the ED

The Surviving BS Campaign: Early Detection of BS in the ED

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ST. LOUIS, MO – A groundbreaking new multicenter study shows that early detection of BS in the ED leads to significant overall improvement in patient mortality, as well as improvement of ED physician and nursing job efficacy.  This study was performed at over 200 emergency departments in the US and over 500,000 patients were enrolled.

ER halt BS
New groundbreaking protocal

Upon evaluation in the ED, the participating physicians and nurses were asked to assess the patient for having Spewing Obvious BS (SOBS) Criteria.

To meet SOBS criteria, the patient required four or more of the following:

01) Allergy list greater than 8 items
02) More than 20 visits to the ED within the past month with similar complaints and discharge
03) The exact statement “I usually have a really high pain tolerance.”
04) Inquiring if a particular ED physician is on shift
05) Patient having stable BP, HR, RR, Temp, O2 sat, but reporting pain greater than 9 on a 10-point pain scale
06) Patient unable to recall non-narcotic home medications, but are able to recall specific doses, pharmacology, texture, and apparent inefficacy of their home narcotic medications
07) Patient verbalizing “I think it’s called…” then stating various articulations of the word “Dilaudid” despite not being prompted to mention the medication
08) Witnessing the patient taking a selfie of themselves at any point during their ED visit
09) Fast-food bag in hand while chief complaint is GI-related
10) The patient presenting with another family member having separate and more concerning symptoms, but the patient stating he/she “just wanted to be seen too, since I’m here anyway”

Four or more of the SOBS criteria with a pain scale greater than 10 on a 10-point pain scale will classify the patient as severe BS.

The goal of this study was to identify BS early in the ED workup, and apply aggressive exit door directed therapy (EDDT).  The physicians and nurses involved were instructed to initiate the BS protocol when four of the BS criteria were met.  This activates the entire hospital system of a possible BS situation.  These patients are immediately seen by the hospital’s BS Intervention Team, who come down to re-assess the patient.  If BS is suspected, the patient may then be given a lengthy lecture about the purpose of an emergency department, the dangers of ED misuse, and discussion about the critically-sick patients who will receive less attention and care secondary to other patients’ BS behaviors.

The results of the study are intriguing.  After the implementation of the Surviving BS Campaign, out of about 500,000 enrolled patients, about 100,000 met BS criteria.  Among these patients, over 80,000 had severe BS, and 5,000 patients went on to develop BS shock.  BS shock is identified if patient develops a pseudoseizure at any point during this process.

After early identification of BS in the Emergency Department and subsequent activation of the BS Intervention Team, the physicians and nurses were then free to attend to non-BS patients.

Over the course of this study, the efficacy and mood of the emergency department increased dramatically.  Most importantly, the mortality and all adverse outcomes decreased for non-BS patients.  The study authors contribute this mostly to EM doctors and nurses being able to do real Medicine instead of spending time managing BS.

If you liked this article, find more ED articles by its author at a great new blog, Emergency Department on Cruise Control.

ED BS detector
“The patient’s still running high on the BS monitor, even after a bolus of intelligent conversation.”


  • Show Comments

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    OMG, thought this just happened in Australia! Further study should be undertaken to include the patient who is FB +ve though. (Facebook, not foreign body!)

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    Our ED flags BS patients with a “care plan”, which displays an icon alerting providers of their particular proclivity after they are triaged. Enormously helpful!

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    Gabriel Cade

    The exception, of course, is “end-stage fibromyalgia.” Which can initially be treated with di-di-di-diphenhydramine, until the patient catches on, or does not fall asleep.

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    Astrid Flores

    I always say I wear a BS radar at work. Some pts. are so skilled though that they slip through my radar. With this tool, I can detect each and every one of them. Thanks Gomerblog!

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    Kimiko Kimura Williams


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    Sarah Bledig Portugal

    Love this!! Thank you. So great

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    Rissa Stackhouse

    “If you don’t give me my Norco’s, I’m going to go out and kill myself because I can’t take this pain…” SHAZAAM… instant 5150. :D

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    Rebecca Gage

    Unfortunately, our ER’s BS ‘o meter keeps breaking from overuse. So I’ve proposed we re-purpose that bad boy into the ER version of candy crush (replace candy with images of narcs, of course) to improve patient satisfaction & subsequent irritability during long wait times. Jury is still out that.

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    Robin Fahringer Mitchell Machajewski

    Again I say of Gomer blog: isn’t this supposed to be satire? Wow! Nailed it!

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    Julie Hoover Quintanilla

    I think this study is bogus. The BS ratio should be way higher than 2%. It’s AT LEAST 25%, AT LEAST!

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    Sherry Anne Barredo

    I would like to be a part of the BS Intervention Team..

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    Helen Aanstoos

    Posting a sign on the admitting/registration window “We are out of Dilaudid. Sorry for the inconvenience.” Would help cut down on the wasted time, maybe even boost employee morale, due to actually maybe getting lunch breaks.

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    Mike Phillips

    Saying you are having a seizure while actively “seizing”.

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    Stefan Nissen

    AKA Culture Related Anxiety Phenomena (CRAP).

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    Stefan Nissen

    I’m kind of upset that the study did not study the corrolary to this disease “status hispanicus”.

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    Christine Hartley

    OMG I read this at the beginning of my UC shift. And my first patient has gotten 1080 lortab since 2/14. And states she is allergic to lortab AND only takes pain medicine “now and then”. Severe BS!!!!!!

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    Rikki SchonFeldman

    “Halt BS” – new groundbreaking protocol. hahaha!!!

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    Mónica Godrid

    Worse than Ebola….

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    Sonrisa Holmes

    This makes me happy

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    Heidi Barney


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    Dottie McBrien

    Nurses everywhere please read! Ground breaking study: a must read, esp #9!

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    Debbie Preston


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    Victoria Morgan

    Number 9 needs to be expanded to include vending machine items in hand when complaining of gi sx.

    Also, the math works out to 2% of ed patients. This is obviously wrong. We obviously need further study. The number would have to be closer to 10%, if not more.

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    Ashling Barr

    Tears, always with the tears

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    James M Wilson

    “Among these patients, over 8000 had Severe BS, and 500 patients went on to develop BS Shock. BS shock is identified if patient develops a pseudoseizure at any point during this process.”
    Ryan Hutchinson
    Ben Abo

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    Karen Schmidt

    or a sticker for the pt chart for the known BS pt

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    Drew Warmath

    “I can only take Norco 10’s, the 5’s give me a rash….”

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    Belinda Smith

    Another acronym to add Raechal Stoops

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    Heather Hendricks Bliss

    Brooke Chantay, Cynthia King

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    Kimberly Henderson Hastings

    Robert Stone blah ha ha

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    SaraKate Tillman

    Love it

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    Elena Clifford

    Agree. Need no bullshit button

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    Kathleen Grint

    I don’t need a KUB to know they’re FOS.

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    Kim Rockway Marple

    Sonrisa Holmes
    Janie Jones

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    Paula Hamilton

    Maybe if we would just give every patient the tiniest dose of dilaudid everything would be fine! ;)

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    Emily Strohecker Samuelson

    OMG! Pseudoseizures FTW!

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    Heather Harris

    Add “empty threats to leave AMA” on the criteria list!

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    Tracy Goodman

    That covers it!

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    Joan Cunningham Adams

    I would like the no bull shit pic as a sticker or button for my badge

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