14 Emergency Medicine Laws for New Trainees

[u/PraiseBe2TheSalt]

1. Sensitivity > Specificity

Your job isn’t to figure out what’s wrong. Your job is to make sure the patient doesn’t have something life-threatening. That’s it. No more, no less. Trainees struggle with this because they’re always trying to land the perfect diagnosis. But it doesn’t matter what’s causing the belly pain if it isn’t dangerous. That’s not your job. That’s internal medicine’s job. Patients will get frustrated when you “don’t find anything” because they’re still in pain. That’s part of the game. You’re not saying nothing’s wrong, you’re saying it’s not something that’s going to kill them.

You don’t need to dig down into every subtlety or obsess over tiny lab differences to figure out if this is Condition A or Condition B. That’s not your lane. If you’re only satisfied when you’ve explored every possible path, switch to internal medicine. In EM, once you know they’re safe and you know their dispo, you move on. Admit or discharge. It doesn't always feel like closure, which sometimes sucks. The hospital will hate it too because they treat the ED like a walk-in clinic where patients can get every answer instantly. And maybe that’s fine when things are slow, but when it’s busy on a Monday night, you’re not playing primary care.

It’s not about whether you truly believe the patient has appendicitis, it’s about whether the possibility has crossed the threshold where it now needs to be actively ruled out. If you tell me you think it’s a 5% chance, that might still be enough. Your job is not to be right. Your job is to not be wrong. No one cares when you’re right, but everyone cares when you miss. FM/IM deals with the most likely cause, you deal with the most dangerous. The 27-year-old with a fever, URI symptoms, and a heart rate of 130 probably has a generic viral URI... No one cares about that. One of them will eventually have severe myocarditis. So when your attending says the patient can’t go home until the HR comes down, and you argue it’s “just a virus,” the burden is now on you to prove that. If the HR doesn’t drop after your typical treatments, your theory just failed. Now you need to rule out danger, maybe that means pulling a troponin or bedside echo or whatever. And when it’s negative, don’t be smug about it. Try to figure out what red flags your attending saw. Figure out what made them escalate the workup. Most residents miss this. They’re too busy being happy that the test was negative to realize the test wasn’t about proving the expected diagnosis, it was about not missing the thing that actually kills someone.

This is one of the most important concepts in emergency medicine. It should be in your head all the time: what’s the worst thing this could be? Not the most likely…the worst. So when you present a patient with URI symptoms and start listing a differential of allergies, sinusitis, post-nasal drip, you’ve told me nothing. This isn’t a family medicine clinic. I want to hear why it’s not myocarditis, RPA, PTA, meningitis, or cavernous sinus thrombosis. That tells me you’re thinking like an emergency physician. You should be overly sensitive to danger. That means your early workups will be mostly negative, and that’s exactly what should happen. If you’re not seeing normal labs and normal CTs, you’re not casting a wide enough net. Eventually you’ll refine it and develop the gut instinct and know who doesn’t need a scan. But until then, scan. Check the labs. Be aggressive. That’s how you keep people alive.

 

2. Stop Double-Thinking About Ordering a Test and Just Order It

If you’re at home making dinner and your mind keeps circling back to one patient you discharged, wondering if you missed something, hoping they’re okay, thinking maybe you should’ve checked one more thing, then you should’ve ordered that damn test. That nagging feeling is your “gut.” What people call gut just is subconscious pattern recognition, your brain picking up on something it hasn’t fully processed yet. You need to listen to it. As an aside, that feeling exists for a reason and if it’s bad enough to keep you thinking about that patient, then you need to call them and tell them to come back to the ED or at least check on them. You think they’ll see you as unsure or incompetent, but the opposite is usually true. They see a doctor who gives a shit. One who’s still thinking about them even after they’ve left.

Recognition is the most important skill you have. It’s what separates you from everyone else in medicine. The ICU can tune up a critical patient better, Family med is better at preventive care, Cards knows heart failure management down cold, OB can deliver a baby without flinching, Ophtho owns the slit lamp, and Peds can probably examine a kid better than you. But none of them can regularly find a needle in a haystack on purpose. None of them can understand when someone is having a real problem hidden in a common complaint. They cant see from the doorway that someone is about to code or look at a WR board of 64 patients and know which 2 are the most important.

Now imagine how the rest of the world would function if they lived like we do. What if someone in their neighborhood died from a lightning strike every week? What if every April, half the street got audited? Or once a year, someone they knew went down in a commercial plane crash? It would change how they thought, how they lived, and what they paid attention to. That’s what this job does to you. It rewires your brain. You see improbable events so often that they stop being improbable, they just become normal.

Other specialties will look at us and say all we do is “order tests.” Yeah, we do. Because we’re the ones who actually seethe 1-in-500,000 cases. That’s the job. And the most terrifying patient in the ED, the one that keeps experienced docs up at night, is the one who looks fine but isn’t. The well-appearing but sick patient is where people get burned. If you can’t spot that patient yet, you will. And when you do, you’ll understand exactly why you never, ever ignore the “gut.”

 

3. Never let someone with less experience than you talk you OUT of a workup 

 

4. If the Patient or Family Is Extremely Pushy About a Test or Task, Just Order It and Move On. Every Once in a While, They’re Right.

Every patient encounter is really an analysis of probability and risk. With patients who are less likely to be litigious, both you and they are more tolerant of uncertainty. You don’t need to chase the 1-in-1,000,000 condition when you already know in your gut it’s not there. That’s why in medical missions or resource-limited settings, you aren’t ordering D-dimers and CTAs for super low-risk patients. You’re making decisions based on clinical judgment and probability, not fear of litigation. 

But when a patient or family demands testing, they’re not engaging in probability-based reasoning. These are the litigious ones. They will not tolerate missing a 1-in-a-million case, no matter how unreasonable that expectation is. They don’t want your opinion. They want a test. You need to recognize that mindset. If something is missed, they may pursue litigation or at least a strong complaint, not because it’s fair or likely to win, but because that’s how they operate. And sure, maybe you’ll win the case or it gets dropped, but you’ll still go through the stress, anxiety, and time of depositions and investigation. See Law 9.

 

5. Do Not Trust Old People

You were taught that the history and physical are the foundation of your differential, and that’s true. But it’s only reliable when the patient is young. In pediatrics, the H&P is extremely accurate. That’s why you can work an entire shift in the Peds ED full of belly pain and vomiting, and not place a single IV or spin a single CT. Kids, despite being harder to examine and less precise with their symptoms, actually have reliable exams. (Yes, they’ll make you more anxious because they can’t describe their pain like adults can, and yes, the stakes feel higher because it’s a child and not an 89-year-old with a DNR. But rest assured: kids rarely have serious pathology, and their physical exam is trustworthy.)

Now flip that completely once they hit about 65. Honestly, even a rough 50. The reliability of the history and physical collapses. If they’ve got diabetes and some neuropathy on top of it, the exam is useless. Just order labs and a CT from triage with the radiology favorite indication of “pain.” A stable, elderly patient might casually mention some vague nausea and have light RUQ tenderness but also have no distress, no fever, vitals are fine, doesn’t want pain meds. And then the CT shows a ruptured AAA, perfed diverticulitis, or obstructing stone with urosepsis, etc. Zero pain. Zero classical exam findings. It will happen. These patients don’t read the textbook. They won’t be febrile, they won’t be tachycardic, they won’t act sick.

You have to over-workup older adults. Not because you’re paranoid, but because your other tools, history and physical, don’t work on them. Radiology will complain that you’re scanning every patient. Good. That’s their job. Your job is to keep the mortality curve flat, not to win popularity contests with CT techs. Don’t skip the test because you’re worried what your colleagues will think, or because admin is tracking your CT utilization, or because throughput metrics are tight. None of those people will be there when you're pulled into a QA review. And I’m not just talking about lawsuits. I’m talking about you, lying in bed at 2 a.m., staring at the ceiling, knowing you saw something but didn’t pursue the imaging or workup. Knowing you thought about it and didn’t test. And now that patient is dead. Maybe they were going to die anyway… maybe they weren’t. 

That’s the weight of this job. And that responsibility belongs to you. Not family med, not internal med, not the CT tech, not the scribes, not the nurse manager, not the CEO. You. You’re the one who has to live with the decision. Read Law 3 again.

And this doesn’t just apply to elderly patients. Anyone with a compromised ability to give a reliable history or physical falls into this same category. That includes patients with language barriers, cognitive disabilities, psychiatric illness, or those under arrest. If you can’t trust the story or the exam, then you’ve lost your most basic tools. Now you need labs, imaging, and an extra level of caution. Because when the H&P fails, it’s only a matter of time before something slips through and that miss is going to be yours.

 

6. Always watch patients when they don’t know you’re watching them. 

You are constantly trying to separate what’s real from what’s performative. One of the best tools you have is observation when the patient thinks no one is paying attention. That’s when the truth leaks out.

The patient may grimace and clutch their stomach the second you walk in, but sit upright and scroll their phone when they think they’re alone. Or they may breathe like they’re dying until you leave the room, then go right back to casual conversation with their visitor. These small, unscripted moments matter.

This is your real physical exam. Not just what they say or how they act in front of you, but how they move, how they sit, how they breathe when they forget they're being evaluated. You're not just reading vitals or pressing on bellies. You're reading behavior. Because that’s where the truth lives. And when what you observe doesn’t line up with what they’re telling you, that’s your red flag. See law 7 and 12.

 

7. If They Walk In, They Need to Walk Out. They Cannot Be Discharged in a Wheelchair.

This is not about mobility, it’s about clinical trajectory. If the patient shuffled into the ED under their own power, they sure as hell shouldn’t be discharged in worse shape than they arrived. If someone comes in with back pain and they don’t improve with Toradol and Valium, it’s time to escalate. Drop the PO meds. Start an IV, order an ESR, and consider a CT or MRI. Think SEA. At that point, it's no longer "just a spasm." It’s a workup.

There’s a weird trend that seasoned ED docs know well: patients love to wait until just before they crash to show up. They’ll sit on back pain, chest pain, or weakness for weeks, then roll in at 9 p.m. and code at 9:45. That’s the pattern. So when someone comes in under their own steam but still looks like trash, and especially if they’re worse after treatment, take it seriously. If they walked in but can’t walk out… stop. That’s where SEAs, aortic dissections, or silent ACS with a “normal” workups hide. And yeah, nine out of ten times, it’ll still be nothing. That’s fine. But the one time it isn’t, you’ll only catch it because you paid attention to this red flag. Read Law 1 and 2 again.

And remember: in this context, pain control isn’t just symptom management, it’s now a diagnostic. So, if the pain doesn’t respond the way it should, something is wrong. So a single 325 mg Tylenol tab isn’t going to cut it for a chronic opioid user if you’re trying to assess a legit response. Treat the pain.  You already use this “pain treatment then reassess” logic when checking for occult fractures so apply it here too. 

 

8. Droperidol Is the Most Useful Drug You Have

Migraines, Agitation, Pain augmentation, Drug-seeking, Psychosis. Droperidol hits all of it. No other drug in your toolbox works on such a wide spectrum of ED complaints this efficiently.

It disrupts the dopamine reward loop. Droperidol (and other dopamine antagonists) effectively shut down the patient’s drive to chase something like attention, drugs, admission, validation. That “reward” they get from being in the ED? Gone. They don’t want the meds. They don’t want the admission. They don’t even want the drama anymore. It just evaporates.

You need to be an expert on this drug. Know the dose ranges, black box warnings, QT risks, side effects, and pharmacology inside and out. Be able to quote the literature. You’ll run into attendings who flinch, pharmacists who want to block your dose and nurses who say, “But this patient isn’t psychotic, why are you using it?” They don’t know, you do. Be able to cite the Lexicomp page from memory and walk them through it. Understand why it left the market, why the FDA black boxed it, and why it came back. You have to be the one who knows what you’re doing when the pushback hits.

Here’s what makes Droperidol unique: it doesn’t just take away pain, it removes suffering. Chronic belly pain? Crying, frustrated, hasn’t eaten, marriage stressed, missed work. Give them droperidol, and they’ll tell you they still feel the pain, but they don’t care about it anymore. The suffering is what brought them in, not the physical pain sensation. Same with someone who broke their wrist. The pain may still be there, but the fear? The panic? The dread about not working, driving, or helping their kids? All gone. That’s what this drug does. It turns down the spiral.

If Droperidol doesn’t work, if they’re still acting out, still in pain, still agitated, that’s a red flag. This drug is so broadly effective that a failure to respond should immediately raise your concern. 

 

9. Figure Out Why They’re Really Here and Address It Early

If a patient comes in with a mild cough for three weeks, nothing new, nothing alarming, you should be asking yourself one thing: Why today? If the symptoms haven’t changed, then something else brought them in. Just ask them: “What’s got you worried?” or “What are you hoping we can help with today?” Most of the time, they’ll tell you. They want a chest X-ray. Or a note for work. Or cough medicine. Or antibiotics. Once you know what they came for, you can focus your time on that instead of spinning your wheels for 30 minutes and then realizing they just wanted Z-Pak for a viral URI. And now you’ve wasted time, and you still have to now undo an expectation you could’ve handled upfront in two minutes.

You’ll start to recognize patterns. Parents of young kids often want a CT after a head bump, patients with a cough want antibiotics, etc. Certain patient populations don’t want tests, they just need to hear, “You’re okay.” Others need the exact opposite: they want tests so they can see proof. Once you know the pattern, you can walk into the room and address the concern before they even voice it. That’s what experienced attendings do. They walk in, make a statement that hits the core fear, and walk out with five-star reviews, not because they solved a complex case, but because they answered the real question the patient had without wasting anyone’s time.

If the patient is a nurse, a tech, a doctor, just ask: “What are you worried about?” They’re not here for reassurance. They’ve already done a basic eval. They want something they can’t do themselves: a CBC, a UA, a chest X-ray. 

Other times, the patient isn’t worried at all, but someone in their life is. The guy with a swollen leg for a month doesn’t care, but his friend panicked about a DVT. The college kid with a bug bite isn’t concerned, but his mom is blowing up his phone. Ask directly: “Why did you come in today, not yesterday or last week?” or “Who told you to come?” Then call the mom. Tell the friend. Reassure the real audience.

Sometimes they just need a work note. They don’t have a PCP, their job requires documentation, and now they’re sitting in your ED. Skip the imaging and unnecessary testing, get them what they need and move on. Same with the patient who has a GI appointment in five days but came in for chronic abdominal pain with no change in symptoms. They’re not here for a diagnosis, they’re here to make sure it’s still safe to wait 5 days. That’s the actual chief complaint: Is it safe to wait until I see the specialist? Say it out loud: “Sounds like you're here because you're not sure if it's still safe to even wait five days. Let’s figure that out together.” That line alone will calm half the room.

Same thing with asymptomatic hypertension. The patient doesn’t feel bad, but their mom just had a stroke and now they’re terrified. Or they had a minor head bump, but their neighbor told them about a kid who died from a delayed brain bleed. That’s the fear you need to uncover and address directly. Once you do, the patient stops asking questions. Because their real one has already been answered.

Use direct language. Try:

• “What made you come in today?”
• “What are you worried about?”
• “Tell me what has you concerned.”
• “I just want to make sure it’s safe to wait for that appointment.”

This isn’t scripting, it’s clinical efficiency. Think about how you handle your spouse when you know something’s wrong. You don’t dance around it, you ask straight up, “What’s going on?” and “what has you worried right now?” Do the same with your patients.

And when it comes to pediatrics, remember: it’s all about the parents. Kids with nausea and vomiting? The parents want IV fluids. URI? They want antibiotics. Head bump? They want a CT. You already know the script, so don’t wait for the question. Preempt it. Say, “We’re going to try oral Zofran first because it works better than IV fluids, and if it doesn’t work here, it won’t work at home.” Now the parent doesn’t even ask about IVs because you already addressed the concern they walked in with. (as a side note, these Pushy Peds Moms blurr the line to overriding law 4.)

 

10. You Cannot Leave the Room Without a Plan

You don’t get to “figure it out later.” You need to give the patient something before you walk out of that room. Even if it’s not perfect. Even if it changes later. You still need a plan: labs, a med, imaging, an observation strategy...something. The patients with a wandering HPI and 13 random complaints will wreck you if you don’t learn how to anchor. And make no mistake, this is the weakest skill in almost every new trainee, resident, PA, NP, doesn’t matter. It’s a skill just like reading an EKG or running a code. You have to refine it. You have to self-critique. You have to build this on purpose.

I don’t care if a resident doesn’t know what to do or doesn’t understand the patient's condition, or even if they didn’t even think about the most obvious medical problem for the presentation… that can be learned.  But if a resident comes to me after spending the entire Memorial Day weekend in a patient's room in fast track and then comes out and tells me that they don’t know what is going on or what to do or where to go with this patient… That resident is about to get wrecked. It is not about being an asshole, it’s about training you for the worst parts of the future that you signed up for.

Flash forward to your first job. Third shift. Thursday night. You’re working solo in a 25-bed freestanding ED, and there are 45 patients in the department. You’re alone. No backup. If you’re still messing around with HPI-wanderers and going in and out of rooms with no plan, your shift is going to fall apart. The nurses will hate working with you. Your scores will drop. Your length-of-stay numbers will suck. You’ll never leave on time. Patients will get harmed. You’ll finally make it to Room 25 after 3 hours and realize they’ve been sitting on a dissection for 3 hours while you’ve been screwing around in Room 4, trying to make sense of a vague headache and intermittent chest tightness that’s been happening for two years. That’s how people die. 

This is community EM. This is what you signed up for. Get your plan, get out, and keep moving.

Read Laws 8 and 12 again. This is how you get control of the room and control of your shift.

 

11. You Might Not Be Selling Cars, But You Better Be Selling Something

If you’re admitting to internal medicine, think like internal medicine. Don’t work the patient up to death with every single test in the ED. Your job is to rule out emergencies and make sure the patient is stable, not to solve every vague complaint. If you go fishing for every obscure diagnosis and order every lab, every scan, every specialty test, you’re leaving nothing for the admitting team to do. And when that happens, the admit will get denied or fought. Rightfully so. They’re going to ask, “If you already did everything, what exactly do you want me to do?” That handoff usually sounds like: “Hey, I’m not sure what’s wrong. I checked everything from labs, CT, troponin, the works and it’s all normal. But I still don’t like it. Can you admit them?” That’s not a sell, that’s a punt. 

You also need to learn the IM docs the way you learned your own EM attendings. Know their pet peeves. Know what makes them uncomfortable. Know what makes a case fly through versus one they’ll fight back. This matters even more in community hospitals where relationships count. If you learn how to tee up the admit just right, tailor the language, the handoff, and the tone to that doc, you’ll get admits through smoothly when others won’t. This is a skill and it’ll save your ass more than once.

When you call consultants, talk like a human being. You’re not reading a SOAP note, you’re having a conversation. Use tone. Use inflection. Lead with the punchline, especially when you’re calling for an opinion rather than just offloading a task. You don’t need a speech for classic appendicitis, but if the CT shows some weird mass in the orbit and you don’t know what to do with it, you better lead with: “Hey, I’ve got something weird I want your take on…” Hook them. Don’t drone through the entire chart before you get to the point. No one is listening when you do that. Consultants are people, not checklists. And yeah, some will still be assholes. Welcome to the job. Move on.

Here’s the mindset: every single call you make is giving someone else more work. No one wants to do more work. The consultant doesn’t want to admit. Internal medicine doesn’t want the patient because they think it’s ICU’s problem. ICU doesn’t want them because they think it’s medicine’s problem. Everyone is trying to offload. So your job is to sell the story, why this patient belongs here, and not somewhere else. If you think they need to be admitted, you don’t ask for permission. You say: “I’m telling you this patient needs to come in, do you want them on your service or someone else’s?” It’s not a negotiation.

And don’t assume specialists won’t dump dangerous patients back on you just because they’re the “expert.” OB will discharge ectopics, ENT will send home post-tonsil bleeds, Cards will discharge patients with trop elevations. Especially at night. They’ll try to convince you it’s safe to send them home because they don’t want to admit. But the call is still yours. You’re the last line. If your attending says admit, or if your gut says admit, then admit. Make it easy for the consultant if you have to buy telling them you’ll put them on medicine service yourself, but don’t let the patient leave.

Sometimes you’ll call a consultant on a patient YOU think needs to be admitted and they’ll say something like, “They could be admitted or discharged, I don’t really care.” That’s your signal. When a specialist waffles like that, you proceed with your admit. Call internal medicine and tell them the consultant is recommending admission. And here’s the key: track those patients. If they end up going to the OR or stay for admitted for a week, that’s the case you were right about. That’s the patient who justified your instincts. 

Any ER doc/PA/NP worth their weight can find some false positive labs test or an exaggerated HPI to get any patient admitted with any easy sell if they feel they need to be. CRP, trop, lipase, lactate, BNP, etc.

Read law 5 again

 

12. Set Expectations from the Beginning

If a patient tells you they’ve had abdominal pain for 27 years, tell them, clearly and immediately, that you are not going to figure it out today. If they’re drug-seeking, tell them they will not be receiving any opioid medications during this visit. That may feel adversarial. You were trained in med school to be kind, to be accommodating, and you should be, but with certain patients, vague language only makes things worse. These cases require firm, definitive statements. That’s how you protect your staff, your time, and yourself.

You must lay a firm, clear foundation for these people.  If you leave them even just a little bit of wiggle room they will put all their faith and effort into just that little space that’s left.  If they are here for pain seeking and they’re being rude to the staff and you try to pacify them by saying something like, “let’s just try Tylenol and then will see how it goes” so that way they will calm down and you can move along when you already know you are not going to give them stronger pain medicine, what you just did is leave them a little window of chance.  What you really told them was that you might give them pain medicine they just need to work for it in whatever way they think is going to be best to that end point.  Whether that be violence or anger or uncontrolled pain or anger towards the nurses.

Instead, be direct: “You will not be getting Dilaudid today.” Full stop. No back-and-forth. No justification. No negotiation. Say it once and move on. These encounters go smoother when there’s nothing to debate.

Now, here’s the uncomfortable part. Your future employment metrics are going to be tied to patient satisfaction scores, whether you like it or not. But you are not going to satisfy everyone. Some patients come to the ER expecting narcotics, MRIs, or an automatic admission. And when they don’t get it, they’re going to be pissed. Their expectations and what the ER actually does are not always going to line up. You just have to take the L on some of these. Just accept it and move on. Maybe 15% of your patients will walk out angry, and yes, admin will ask what happened. Nursing leadership will mention it. Your name will show up in a one-star Google review. That’s fine. Take the L. You signed up for this job, this is part of it. And if you’re wondering where burnout starts, this is about 25% of it right here.

 

13. If They Come Covered in Feces, Find a Reason to Admit Them

This isn't about the feces, it's about what it represents. Patients who arrive like this, usually via EMS from a nursing home or dropped off by a long-lost relative, are almost always signaling something bigger. This is not hygiene. This is a marker of major functional decline, severe cognitive impairment, neglect, or all three. There’s a reason they ended up in this state, and it’s not usually benign.

Think through the logistics. What has to go wrong in someone’s life for them to be found like this? They’re either too impaired to care for themselves, or no one around them is doing it. Either way, this person is not safe at home, is likely missing medications, and absolutely is not receiving appropriate care. You don't discharge that.

And if you're looking for justification, this is a great time to lean into the hospital’s over-aggressive sepsis protocols. Drop a borderline lactate, soft vitals, and functional decline into the chart and let the order sets work for you. The system is already wired to keep them…use it.

 

14. Document the Annoying Incidental Findings Found on Imaging

If the radiologist mentions it, you mention it. Every incidental finding, no matter how irrelevant it feels, needs to go in your diagnosis list and your MDM. Pulmonary nodules, adrenal nodules, hepatic steatosis, aortic root dilation, coronary calcifications, hyperglycemia, whatever. Make a macro, or better yet, a set of macros that lets you drop this stuff in fast with customized language. It takes five seconds. 

Because here’s what’s coming: in about eight years, someone’s going to show up with metastatic cancer or a ruptured aneurysm, and they’ll pull up your old ED chart. And if that finding was on a scan and you didn’t document it, you’re going to be explaining why. You won’t remember the patient, but they’ll somehow remember you. Get in the habit now.

 

That's all I got for now!

[u/Jalford]

11yrs experience, very good post, we have incredibly similar thought processes. I would add to be nice to nurses/staff and patients. If you piss off a nurse they may not let you know the next time they notice something. If you piss off a patient and then screw up they will remember you and they won’t anything slide. If a patient feels like you were nice and genuinely cared about them they will be much more lenient.

[u/mr_meseekslookatme → u/Jalford]

I would also add to introduce yourself and involve whoever is with the patient. You win them over they will almost always be on board with your plan.

[u/Jalford → u/mr_meseekslookatme]

100%. I start every encounter with an introduction and a handshake, including kids. (I have gotten a lot of positive feedback over the years directly related to this - the doctor came in quickly introduced himself and shook my child’s hand and actually listened to them, that was impressive). Never assume you know the relationship of person at the bedside. … that’s when you refer to their spouse as their grandmother or vice versa. That is like asking someone if they are pregnant, and it is so easy to do if you aren’t careful. As me how I know. My script to start most encounters is “hi my name is Dr. xxx, what’s your name? Shake. Nice to meet you. I see there is someone here with you, how are the two of you related? It’s pretty busy today, thank you for being patient with us, we’re gonna be sure to take care of you and address your concerns, what brought you in today?

It is lazy to not know who is there with the pt. Think if there was a sex trafficking issue or a domestic abuse situation, kidnapping, you name it. See a red flag and you can try to naturally get the patient alone in imaging or whatever to make sure they are safe.

Really good discharge instructions are also critical.

The reason I love OP’s post so much is that it focuses more on the psychology of a workup and the human interaction between patient and provider…. it incorporates so much more into the encounter than just medicine. This is totally separate from the textbook medical knowledge. So many smart docs suck at this. So many mediocre docs from a strict book smart/test score standpoint) look like very smart docs because they understand this.

Also, exploding on a patient for coming in for something dumb yields little benefit. It wastes time. It pisses them off. And making them feel bad doesn’t suddenly educate the entire community and prevent others from doing the same. If it comes up in the conversation, sure, tell them this would be appropriate for a PCP office or walk-in clinic in the future. But piss them off, make them feel bad, then they get a huge bill….not a good recipe there.

Listen, determine sick/not sick, err on the side of ordering the tests, err on the side of admitting (don’t lose sleep over regrets), don’t be a dick, be an airway and other core procedures expert, shared decision-making (can’t emphasize this enough), if it doesn’t need sutures glue it and save a ton of time, and exceptionally clear discharge instructions.

[u/Megaholt → u/Jalford]

As a nurse, we’ll let you know-because we know that if we don’t, it ultimately comes down on us somehow, but we may not be very kind about it when we do let you know.

Plus, we are all here for the same reason, and it serves nobody to act like dicks to each other.

[u/boriswied → u/Megaholt]

I don't doubt that inclination, and i think OP's suggestion that "nurses wont let you know something if they dislike you" is not about nurses, but just humans in general.

I am reminded of stories, i think from a Malcom Gladwell book, about what makes airplanes crash. There are these truly harrowing recordings of first and second pilots discussing things, that show, almost better than anything i've heard, how TINY mistakes in interpersonal communication can quickly lead to huge catastrophes.

I remember reading a black-box transcript, where the first pilot giving off a "vibe" of not wanting another complaint or nuisance, is what causes a second pilot to "give up" mentioning ice on the wings of a plane about to take off. 300 or so souls dead, including those two pilots, just 2 minutes later.

When something is an obvious problem to us, all of us with any concern for patients will make sure we get that into the light. That's when something is obvious.

However when unconscious pattern recognition ("gut", as the OP called it), for which we cannot make clear, strong arguments, nags at us a little bit, then it's much more grey. That's when poor interpersonal relations can and does cause real harm for patients or others.

[u/Megaholt → u/boriswied]

Fair point-I can see that happening, and I can absolutely believe it happens in healthcare way, WAY too often-like, nurses who give that “nursing dose” to the patient that is annoying them”, or the ones who chart on restraints without ever checking that the order is actually in the chart…

[u/PraiseBe2TheSalt → u/Jalford]

I absolutely agree that not pissing off the nurses or patients is one of the top core ER laws. and there are many more not listed above too. Actually, trainees should know that I tried to focus this list on the less obvious stuff that tends to get left out of the big lessons that get hammered into you when you start training. I tried to highlight the things it usually takes years of trial and error to really figure out.

[u/AgtHoliday → u/Jalford]

Yes. It drives me crazy to see EM residents getting short with ED nurses.

Every single other specialty is annoyed by your phone call, best case scenario. More likely they think you’re incompetent for not knowing their specialty as well as they do, no matter how good you are at your job, regardless of the fact that they would absolutely drown in your shoes. Like OP said above, no one cares when you’re right, but you’d better believe they notice when you’re wrong.

The only, and I mean only, people in the hospital who give a damn about you are the nurses, techs, RTs, and PCAs who are in the trenches with you in the ED. They are your brothers and sisters in arms, and you’d better treat them well.

[u/PraiseBe2TheSalt → u/AgtHoliday]

Well said. I feel like that last paragraph is really another law on its own. It’s one of those things you only learn once you’re out on your own. In residency, your attendings usually care for and protect you, but out here, like you said, it’s your staff, and especially your nurses, that you live and die with. 

I actually remember the moment I realized/fully appreciated this. I had a super overwhelming multi‑system case that took forever to get admitted to the ICU. And of course, it was with a particularly difficult intensivist. After what felt like hours of me and my nurse slogging through this patient’s issues and procedures, I finally got him admitted. I remember thinking, man, I’m sending that guy up now whether you like it or not. I was so relieved to be done with it and to have gotten him into the ICU without catching the usual wrath from that intensivist. 

Then my nurse, who had been in the thick of it with me the whole time and was just as worn out, came walking back from the elevator after the drop‑off absolutely bawling. I immediately thought, damn this dude died in the elevator after all that??Nope. She had gotten absolutely torn apart by the ICU attending for the things I had done. And I mean lit up. She had to answer for all the things I thought I had slipped by. I was devastated. It felt like I had punched my own family member in the face. I still think about that every time I want to sneak something in before an admit. And if I’m admitting a patient for some reason that’s not obvious, I try let my homie know so they don’t look like a complete fool during their handoff. It really is just us down here.

[u/BetCommercial286 → u/AgtHoliday]

I think ED nurses and techs are the only ones who’d hid body’s for there docs if needed. (Assuming we like them) That may just be because we’re more than a tad sketch. And we like it that way.

[u/ZadabeZ]

ED attending for almost 25 years here… One of the best things I’ve read on this sub reddit yet… You should get this published!

PS: could not agree more that Droperidol is the best drug in the world

[u/n8henrie → u/ZadabeZ]

It's funny, having spoken about this with colleagues that (like me) trained during the droperidol shortage, I don't really get the fascination with this drug, and I've found very little need for it over the last few years that it's been available (in spite of looking for ways to make it another arrow in my quiver).

What would you say is your NUMBER ONE real-world "this exact common patient presentation needs dro and nothing else" indication? If you assume an otherwise healthy 70kg patient with normal QTc and no known interacting meds, what would your initial and re-dose strategy be? And for comparison, what would you begrudgingly use (and why do you think it would be inferior) if you just discovered your shop was 86'd dro?

[u/descendingdaphne → u/n8henrie]

From a nursing perspective at least, it’s worth more than its weight in gold for cannabinoid hyperemesis - how else do you stop the scromiting and get those people discharged relatively quickly?

[u/n8henrie → u/descendingdaphne]

I probably have one of the highest rates of discharge and shortest LOS among my colleagues (EDIT: for this condition), and we see a lot of these (and have for years, being in a "free care" setting and being minutes from the CO border).

IMO, CHS is at least 50% psychological, driven by anxiety and obsession / paranoia. My strategy starts with a long talk about expectations, which do not include complete relief or symptoms, lean heavily on the importance of prevention (and relative inadequacy of available treatments), and are heavily aimed at making a connection with the patient.

I warn them that haldol will probably help them feel better temporarily and may give them akathisia, and that I don't give it until they are more or less safe for discharge -- so if this happens, they are free to leave.

When needed, I tell them that scromiting is disruptive to other patients, and if they are disrupting care (and not having an emergency) I will discharge them without further treatment.

I make them NPO, take away their water bottles, and tell them they will also be discharged if they are caught drinking water in the bathroom or stealing it from other patients' rooms (happens all the time).

I start with some meds directed at the esophagitis / gastritis they all have while waiting on labs. I often do a bedside ultrasound to evaluate for biliary path as an alternative Dx; this often has the advantage of getting some extra bedside time and showing them cool stuff, which I think helps extra with the anxiety / psych side.

Once labs are back and all looks medically stable, I give 2.5 of haldol and write up some discharge instructions for ORT (usually with famotidine / zofran / ORS for Rx).

Often about 30 minutes later they are dressed and asking to go home and/or the vomiting stops and I suggest they are safe to go.

Doesn't always work, but I think it works as well as my colleagues' various approaches (often with dro, dilaudid, long naps in the ED), often has a much shorter time to discharge, and I've been very pleased with my repeat encounters with these patients (who often recall my counseling and approach in a positive light even months later).

[u/Flowerchld → u/descendingdaphne]

100% this!

[u/Comprehensive-Ebb565 → u/n8henrie]

This is my go to migraine med. 2.5IV/5IM Also works wonders for non-pathological abdominal cramping.

[u/Comprehensive-Ebb565 → u/Comprehensive-Ebb565]

And if agitated, 5mg for biting, 10mg for fighting.

[u/PraiseBe2TheSalt → u/Comprehensive-Ebb565]

That's an amazing mantra and pretty damn accurate

[u/bluejohnnyd → u/n8henrie]

Cannabis hyperemesis is probably #1. My favorite less common use is for chronic pancreatitis flares, or really any nonlocalized belly pain. Treats the nausea, kills scromiting and drama, and pairs really well with Tylenol/ofirmev +/- a half dose of your opioid of choice if indicated. Have definitely had patients whose typical MO is to be admitted for intractable pain go home after 2.5mg IV droperidol and 0.5mg Dilaudid with a bag of LR, then tolerating Tylenol and ginger ale a half hour later.

[u/ExtremisEleven → u/bluejohnnyd]

Oh I like it for the chronic pancreatitis crowd. I have one that feeds me the same story every time and he now understands I will not be giving him the dilaudid 2, Q1h that he requests. I’ve offered ketamine, but I’ll add droperidol to the menu.

[u/n8henrie → u/bluejohnnyd]

Love it. Thanks.

[u/InsomniacAcademic → u/n8henrie]

I typically use 1.25 mg droperidol for migraines, nausea/vomiting, and abdominal pain. The agitated, violent psych patient gets 5 mg droperidol. Haldol will also work for migraines, nausea/vomiting, and abdominal pain. I usually use 2/2.5 mg of haldol for those indications if I don’t have droperidol. I personally hate haldol for the violent agitated patients bc IM haldol takes so long (15-20 min) to kick in. Those patients get ketamine if I don’t have droperidol, or I need to sedate them faster than droperidol can.

[u/PraiseBe2TheSalt → u/n8henrie]

I agree with what others are saying here.

I’d say there are 4 core patient types who are getting droperidol as a first-line med:

#1: Severely agitated or aggressive patients who need control for safety.
I used to give Geodon and Ativan, but I’ve switched to droperidol and Valium years ago because of better reliability and faster onset. I usually give 5–10 mg IM droperidol with 5-10 mg IM Valium. I’ll scale the dose down for patients who are less agitated or already somewhat sedated. This is backed by ACEP’s policy on severe agitation: link. It works about 95% of the time with maybe bath salts being the main exception, and those usually get ketamine first.

#2: Severe migraine patients with a strong anxiety or suffering component.
There’s usually more going on in the room than just a migraine. Compazine works well for classic migraines and is still my go-to for straightforward cases, but when there’s an added social component or anxiety, I lean toward droperidol. I’ll give 1.25–2.5 mg with 12.5 mg Benadryl, just like I would with Compazine. In my experience, it’s more effective at relieving the suffering and anxiety component. Compazine can help that too, just to a lesser extent.

#3: Scromiters.
We all used to use Haldol and Benadryl, now it's droperidol and Benadryl—usually 2.5–5 mg IV. It’s simply more effective and tends to need fewer repeat doses than Haldol (n=1, of course). These patients also often have that same anxiety/suffering component I mentioned above.

#4: Patients with factitious disorder (and to a lesser extent, malingering or conversion disorder).
This ties closely to Law 6, you have to lean on that heavily. Once you remove the reward-seeking drive, most of these patients just want to leave. I use droperidol here as much for diagnosis as for treatment, especially in cases with dramatic, unsupported symptoms like complete lower body paralysis without a clear cause, pseudoseizures, etc. This is a select patient group.
I keep the dose low, usually 0.625 to 2.5 mg IV, depending on the level of behavior.

[u/mezotesidees → u/PraiseBe2TheSalt]

Why Valium and not versed? That policy seems to suggest dro+versed (5+5) as the fastest/safest. My understanding is midazolam is the fastest acting IM benzo.

Also, I’ve saved this post and shared with friends. I’m over 5 years out from residency and honestly this was just such a fantastic read that it made me rethink how I might approach certain situations (although I find I already do most of what you’ve so exquisitely ascribed here). Thanks for your contribution, it’s a great post and will no doubt serve many a new trainee.

[u/PraiseBe2TheSalt → u/mezotesidees]

Thanks for the kind words. As far as the Valium, I probably should have left that part out because it’s just an issue specific to where I work. I found that the nurses where I work always subconsciously associated the word Versed with sedation. There were times where I’d verbal order for an agitated patient and then come back to the room to find RT setting up for a sedation because my RN thought I was gonna sedate the guy because that’s what we typically use Versed for. Also got a few follow up emails that a consent form was not done for a sedation 🙄. So I just went to Ativan, until the shortages. Then to diazepam and it’s stuck

[u/n8henrie → u/PraiseBe2TheSalt]

Love it. Thank you!

I recognize exactly the patients you're describing in each of these scenarios, and applaud you for tailoring treatment to not just different colors but different shades of suffering.

[u/MrPBH → u/n8henrie]

There is a formal name for the practice of treating pain with an opioid and a butyrophenone: neuroleptic analgesia.

It has been suggested that the practice reduces opioid use while still providing adequate analgesia. I personally find it quite useful for abdominal pain, especially cases where there is no clear explanation for their pain.

I think that it makes sense in theory as the gut has nearly as many dopaminergic receptors as the CNS. Clearly they must be doing something and that something is probably related to pain. (I know, very scientific analysis!) Supposedly, butyrophenones also inhibit NMDA receptors and the mysterious sigma-1 receptors.

I like to give a morphine : droperidol ratio of 4 : 1.25 mg IV. You can give 8/2.5 mg IV upfront if pain is severe or patient is large.

If you don't have access to droperidol, haloperidol also works. In that case, use a 4 : 2.5 mg IV ratio.

[u/PraiseBe2TheSalt → u/MrPBH]

Ah so there is a name for this! Thank you for that. I’ve been calling it “pain augmentation”

I also use the 4:1.25 morphine:droperidol dosing, though I have found that a 0.625mg dose has been pretty indistinguishable in desired effect while slightly reducing the incidence of drowsiness. I’m not sure if the lower dose really comes with any less incidence of akathisia though. 

[u/n8henrie → u/MrPBH]

Cool, thanks!

[u/PasDeDeux → u/n8henrie]

No clue about for other indications, but I did some lit searching and I think the most parsimonious take on the available evidence is that droperidol and haloperidol are not significantly different when used for agitation.

Preemptive: That one small wake forest study from the early 90's is not sufficient to convince me that droperidol is faster acting, especially given larger, more recent studies that trend toward haloperidol being slightly faster acting. Point to any individual article and there's another one that seems to imply the opposite, marginally, when it comes to these two meds.

[u/ExtremisEleven → u/PasDeDeux]

Honestly it’s real damn hard to quantify crazy. I usually go with whatever the people getting beat up think works the fastest. There may not be a real difference but if there isn’t a difference, I’m going to go with whatever sends the message that I’m supporting them. As someone who is/was commonly in the middle of the dog pile, droperidol feels like it works faster. At least the swinging and kicking stops faster.

[u/n8henrie → u/ExtremisEleven]

Love this, excellent point.

EDIT: although, I have to admit that making sure I'm the first face in the way of a fist also goes a long way towards moral support, and towards making sure that I'm properly mitigated to making the behavior stop as soon as humanly possible

[u/PasDeDeux → u/ExtremisEleven]

I was always taught it was the benzo (if giving a 5/2/1 or similar) that was the fastest acting part of the restraint cocktail, anyway.

[u/ExtremisEleven → u/PasDeDeux]

They’re fast acting but not always appropriate. I’m using droperidol mono most of the time and only add versed if things don’t shape up fast. Most of the time I’m trying to avoid benzos all together. I also need to sedate a fair number of delirium patients and I don’t want them anywhere near a benzo. The droperidol is off faster than the versed is so I can get psych on to eval fairly quickly and I don’t have to worry about the benzo blahness afterward.

[u/PasDeDeux → u/ExtremisEleven]

That does seem like a pretty big advantage to droperidol vs haloperidol, I didn't catch the much shorter half life initially. (Have never had reason to prescribe droperidol in my line of worik.)

[u/n8henrie → u/PasDeDeux]

I came to same conclusion with lit review, and my clinical experience seems to back this up.

[u/ExtremisEleven → u/n8henrie]

As someone training in the golden age of droperidol, I put that shit on everything.

Cannabis hyperemesis is the primary use. Hands down, it’s the only thing that works reliably and the patients have started to ask for the other thing that starts with the D. You can dick around with zofran or compazine if you want to listen to them scromitting for another hour or just give the droperidol and go about your life.

It works great as part of a migraine cocktail with Toradol for the super anxious crowd. I don’t even use the Benadryl but I don’t see why you couldn’t.

Just like with zofran, you need a metric ton of it to really mess with the QT and we aren’t really playing with those doses.

The dosing is pretty flexible. 0.625 IV is the “standard” nausea dose. This is my naive LOL with anxiety and vomiting. Just get her sons phone number before you give it to her because she is not good to want to be bothered while she’s taking the best nap of her life when you’re ready to discharge her.

I start with 1.25 IV for CHS and will repeat it once PRN. Anecdotally, I almost never have to redose and have found something else is usually wrong if I’m looking for a third line.

For agitation, I’ll give 2.5 IM if they are pacing and uncooperative, 5 IM if they’re beating up the staff. It’s faster than Haldol and works nicely with versed if I find myself questioning the need for ketamine (Again, uncommon). You can go up to 10, but I will actually reach for the ketamine if we are getting zombified because my shop gets antsy above 5, mostly because the bottle has 5 in it.

[u/n8henrie → u/ExtremisEleven]

Thanks for this, very interesting!

Just a few minutes from the CO border, I'm no stranger to CHS, and I've had excellent luck with ~2.5 of haldol, while my colleagues at times struggle with dro. Wasn't there even an RCT comparing the two? I'll have to review. My issue with these meds is usually that I don't want them to sleep, I just want them to be ready for discharge; after 2.5 or haldol, I've routinely had them get themselves dressed and ask me if they can leave yet. Not always always of course.

That migraine / nausea dose is lower than I have used. In fact, I'm our EHR guy and wonder if I should lower the default (from 1.25). Very small, relatively high volume shop, we really can't have patients sleeping who are safe to take that nap at home. (I also haven't used diphenhydramine in these for ages -- usually APAP / toradol / compazine with a verbal warning beforehand that the akathesia is normal and usually means they can go home and rest with the knowledge that the migraine will continue to improve).

Also sounds interesting for agitation. My fav here is olanzapine but we don't carry IM, sounds like a good alternative to the usual suspects.

Thanks again for your time and in-depth response!

[u/ExtremisEleven → u/n8henrie]

I usually send people home within an hour of meds or as soon as they can PO challenge. There are a few I hang on to because they just put out bad vibes and I want to keep an eye on them. We don’t have good social support or follow up here so if I’m sending someone home, unless I can convince them to get someone to come get them, I assume they will be alone.

I think it would be interesting to look at the strains/doses of cannabis and see if there is any different phenotype that might respond to different meds differently. I can’t imagine the stuff we have here is anywhere near as good at the stuff in Colorado.

[u/n8henrie → u/ExtremisEleven]

Interesting points and fair speculation.

I unfairly omitted that I'm in a context that offers free care (and federal tort claim protection).

I am big on ORT and discharge with ORS. I rarely do PO trials (peds / elderly only). I am big on education that ORT is enough to keep them alive, and that humans have tolerated water-only fasting (with some vitamins) for as long as a year -- they will be fine for a day or two if taking a sip of ORS every 3-5 mins.

I am big on encouraging bounceback visits -- "I'm sorry you're still not feeling well. We've been pretty thorough today, but there's always the possibility of missing something -- I'll be here tomorrow at the same time, if you're not feeling any better please come back and let me check you again." Big on phone follow-ups, by the same token.

Agreed, never rush to discharge someone that gives you bad vibes! Definitely have an occasional presumed CHS that ends up being a necrotic gallbladder.

[u/ExtremisEleven → u/n8henrie]

My last one was PID. Apparently I need to specifically ask about vaginal odor 🤦‍♀️

[u/gasparsgirl1017 → u/ZadabeZ]

It's amazing that scrommiting is the hallmark of Cannabinoid Hyperemesis Syndrome and it truly has a very different sound than regular vomiting. When I was in Medic class, I practiced in a state where marijuana was "decriminalized", so when I picked up shifts in the ED for extra $$$, I was well aware of CHS. I also had my fair share of experience picking up patients who called EMS for it. They had to wear the "trash bag of shame" where you cut a hole in part of a biohazard bag and the patient wears it like a lobster bib because you can't trust their aim into one of those tiny emesis bags (full disclosure: this only is appropriate if you are within arms length of the patient at all times so they don't try to strangle or suffocate themselves with it).

My medic class was in a state where marijuana was illegal, full stop. None of my classmates had any experience with this disorder, and they certainly didn't know the difference between vomiting and scrommiting. I was trying to be genuinely helpful with some of the tips and tricks I had learned from dealing with these patients because my classmates had no experience with them. They could not have cared less. I still think about my classmates every now and then and wonder if they have finally heard the magical sound of scrommiting. But I'll be damned if when they get to the ED, the doc orders droperidol, and the RN drops it like its hot, everyone is happy... both those that have to listen to the scrommiting and the poor scrommiter. I wish they would let us carry it on the truck to administer with fentanyl and for its other indications after we perform a 12 lead to rule out long QT. It might be my close second favorite drug after ketamine.

[u/PraiseBe2TheSalt → u/ZadabeZ]

That's very kind, thank you!

[u/scribblesloth]

Few things. Love this list!!!

Agree that old people with vague complaints will be the bane of your existence. Just scan them. They are old and therefore won't mount that immune response, have vastly different pain tolerance, be on meds that will suppress physiological response, have multiple other comorbidities that means when they crash they'll crash quick.

Always preempt the outcome of a test. Tell them what will happen when a test is negative aka you will be going home. Never ever say there's nothing wrong, because that WILL bite you in the arse. Just say whatever is going on is not life threatening immediately but should have further investigation with your GP.

Preempt for those presenting with likely chronic problems that the search for a diagnosis could be a long process and that there may not be a diagnosis in the end and the focus may be on symptom management. Not because there's nothing wrong but medicine doesn't necessarily have the tests or names for every condition. This will help the patient feel validated and any one of your colleagues they see going forward will thank you for not making promises on their behalf.

NEVER shit talk another colleague to your patient. I do not care if you don't know this doctor or think the doctor should have done x. Or why did they send y in. Patients recall discussions with any health professional with their own biases colouring the memory. The doc may have said something like, 'I want you to go to the ED to make sure this isn't life threatening.' but the patient remembers it as their doc telling them something is killing them. You have no idea how your patient will relay what you said to them in a way that makes you look like an idiot to someone else. So give your colleagues the benefit of the doubt. Some might be idiots but most aren't.

Be kind to yourself. You will miss things. People will die. You will disagree with people. You will come to despise and despair of humanity some days. Find the thing that makes you enjoy the job. Learn to recognise burn out in yourself and others. Remember you are making someone's day.

[u/ExtremisEleven → u/scribblesloth]

Preempting the patient hearing “there’s nothing wrong” regardless of your actual discussion will save you a lot of time when delivering the bad news of a stone cold normal workup. “I’m not saying nothing is wrong, obviously something is off because you’re here, but the good news is, I did not find anything that requires you to stay in the hospital tonight. This is likely to be X, but if you don’t start feeling better in Y timeframe or you feel worse, you need to come back or see Dr Z.” has saved me a lot of arguing with people who expect to be dismissed.

[u/scribblesloth → u/ExtremisEleven]

Absolutely. My script is "unfortunately i can't give you a diagnosis today. But I can tell you that whatever is going on is not immediately life threatening. I definitely think this is something you should have follow up with your gp to consider further investigation such as x (something reasonable!!) and if it continues to be an issue your GP could consider a referral to y services. And I will put that in the discharge letter for your gp and you"

And its always consider because the gp might make a different but equally valid plan and I'm not trying to dictate their actions.

[u/ExtremisEleven]

The words “No emergent abnormality” are your best friend when documenting interpretations.

• Electrolyte panel: no emergent abnormality.

Do NOT spend 10 minutes reading mildly abnormal sodium and chloride levels into your note. No one cares if you don’t find it significant enough to fix in the ED and the admitting team should be reviewing the labs on their own anyway.

DO make a macro for “Discussed X incidental finding on CT. Patient informed that we are unable to rule out Y and they will need further outpatient evaluation with Z. Referral to Z placed. Patient agrees with plan.”

[u/tyrkhl → u/ExtremisEleven]

I also print out the radiology report and give it to them, usually with the pertinent part highlighted. And then I document that I gave the patient the radiology report.

[u/PraiseBe2TheSalt → u/tyrkhl]

Exactly. My process is tell patient briefly, put it in the diagnosis, drop the ED course macro, and print it with the AVS stuff. It's in my mental checklist at discharge time to double check the incidentals in the body of the radiology report.

[u/nateisnotadoctor]

This is so terrific. I don’t agree with all of it, but every new trainee should probably read this. Droperidol IS the best drug ever.

[u/diniefofinie → u/nateisnotadoctor]

What do you not agree with?

[u/drag99 → u/diniefofinie]

I also don’t completely agree with just ordering the test or plan that a family is demanding especially when it is clearly not indicated or regarding the litigation risk. ER physicians in general have an almost pathologic fear of litigation. About a third of ER doctors will never be sued in their career. And for the overwhelming majority of the rest, you will at most be named no more than 3 times. That is 3 patients out of 50-100k patient encounters over a career. This doesn’t mean you shouldn’t worry, at all, about litigation, but it shouldn’t really be significantly effecting clinical decision making outside of borderline cases. 

Don’t slam benzos into the nonepileptic episode patient just because a family member is demanding it. Don’t give IV narcotics to the gastroparesis patient demanding narcotics. Don’t order a CT abdomen on the patient presenting for the 30th time this year with 20 negative CTs unless there is a clear change in presentation. Don’t push TNKase on the 30 yo migrainer with 10 negative MRIs, 5 prior thrombolytic administrations, just because they are demanding thrombolytics unless there is clear objective evidence. 

You will likely have people that will respond to this with “obviously I wouldn’t do that”, but I see the way others practice, and it tends to not be obvious to the large majority of fellow ER doctors. It’s okay to use common sense in medicine. You don’t see surgeons agreeing to do major abdominal surgery on bed-bound, demented 95 yo’s just because a family member demands it. It’s okay to tell family members or patients “No”.

[u/Old_Perception → u/drag99]

I'd say I mostly don't agree with it. The better path is mastering the ability to give a firm no along with a concise, one-time explanation of your rationale. And do this without wasting time and energy on bargaining and beating around the bush and circular discussions and sheepishly letting people order a la carte off your quick pick list.

[u/Luddaite → u/diniefofinie]

I don't think I agree with the "just order the test" sentiments for new trainees. It's too early for them to do that. I totally agree with that sentiment for senior residents and attendings but definitely not for interns. They need to spend a year or two thinking a lot about the implications of ordering a test.

[u/Powderm0nkey → u/Luddaite]

I partially disagree. Think about it, but don't try to rationalize your way out of it. ESPECIALLY in the last 1-2 hours of a shift or any night shift. If you think it, order it. Your brain isn't firing right at those times. Trust your gut. How else do you build up your gestalt than by ordering a few extra tests and proving to yourself that what you were thinking (pos or neg) was right?

[u/n8henrie → u/Powderm0nkey]

Along with sibling response, I also agree here -- in particular regarding imaging.

If you're within the last hour or two of a night shift, just get that CT (and admit or hand it off if need be). Your thinking isn't sound, and it's time to be extra cautious.

[u/n8henrie → u/Luddaite]

Came to find or make this comment.

While I entirely agree with the sentiment regarding "if you're going to ruminate on this once you get home," I also routinely see patients harmed by cognitive laziness regarding testing.

The decision regarding whether or not to do a test should be similar to other interventions -- at least brief consideration of the risks, benefits, alternatives, and consequences.

[u/LuluGarou11 → u/n8henrie]

"I also routinely see patients harmed by cognitive laziness regarding testing."

Yes.

[u/nateisnotadoctor → u/Luddaite]

Yeah it was this. My current employer has an EM residency program that is not very strong and part of the reason for that is our culture shotgunning orders from triage. They learn that the right way to work up XYZ complaint is just brainless sets of land plus CT the relevant part. Not smart

[u/Cremaster_Reflex69]

As a still new ish attending (PGY7), my one tidbit of advice to add to this excellent post:

Follow up on your patients. Both the ones you admit, and the ones you send home. Keep a list of MRNs of these patients.

That patient with the weird neuro complaint that you placed in the obs unit for MRI and neuro consult? Follow up and see what neuro had to say, was your decision to admit appropriate? Did the extra imaging find anything? Did you just waste the patient’s time and leave them with a huge bill? I learn more from doing this than EMRap/UpToDate could ever teach me.

Alternatively, follow up on that patient you discharged. I tend to practice by the mentality of “if I’m going to think about this patient when I get home, just do the damn extra test / just admit them”. However sometimes there are borderline patients who truly could go either way, so you do shared decision making and they don’t want to be admitted or they want to leave without X test.

CALL THAT PATIENT BACK in a couple days. Check and see how they’re doing. Patients really appreciate it, and it could save you from a lawsuit one day. Honestly I probably only do this twice a year, but it helps put my mind to rest.

[u/ExtremisEleven → u/Cremaster_Reflex69]

The number of people I’ve admitted with a normal work up, decent story but really just put in under obs for “bad juju” that ended up having a massive CVA while inpatient is a little jarring.

[u/MzJay453 → u/Cremaster_Reflex69]

As an FM resident, when I rotate in the ED this was something that would always drive me wild lol. I rant to just follow their whole story and our EMR made tracking them tricky.

[u/FragDoc]

The droperidol part hints at a dirty secret no one wants to openly acknowledge: a lot of unexplained abdominal pain is psychiatric. It works because you’re hitting “reset” on the person’s brain. I think it’s the greatest evidence that we need to start acknowledging the role of anxiety, conversion, and other psychiatric complaints in explaining a lot of unrecognized somatic complaints. Test heavily, take people serious, but if all else fails: empiric dopamine antagonist.

[u/ReadyForDanger]

Saving this post to share with my nurses who are new to this speciality so they can understand how EM docs think and why they order (or don’t order) certain things.

On their end:

Just put in the damn standing orders and get the ball rolling as soon as you triage the patient. No sense in delaying what you know is going to get ordered anyway.

If the patient tells you in triage what they’re specifically hoping for (x-ray, work note, etc), communicate that to the doc and save everyone time.

Do go charting every little non-life threatening complaint. This isn’t House. We’re not chasing zebras. Don’t get upset when the doc doesn’t go down a rabbit hole trying to solve a mystery diagnosis that you suspect. Move the meat.

[u/PraiseBe2TheSalt → u/ReadyForDanger]

This entire list started with Law 13, coined by one of my favorite ER nurses. Many years ago he put to words that feeling I had but couldn't put my finger on. He and I then used to blurt it out anytime someone came in covered in poop. It was proven right so many times that I thought I should start writing these down lol.

[u/Loud-Principle-7922]

As a medic, I love posts that give me insight into how doctors think and why. Helps my handoffs.

[u/afreaknamedpete]

Legitimately amazing.

One thing I'll add: you got to get good at explaining things. Tons of people will just take want you say at face value and be done with it. But more and more and more that isn't the case. Gone are the days where your words will just be trusted on weight of degree alone.

I've noticed this time and time again. I'd strongly recommend having a script for explaining hypertension: I like bringing up the inherent absurdities of BP measurements from inflating bags on the arm. A script for why their dependent edema will not be immediately curable. A script for why you're not ordering the UA for chronic contamination. A script for why they need to see a cardiologist. A layman's CHF explanation.

Show them the XR. I often literally bring up a picture from Google of Lumbar anatomy for those worried well LBP. If you're going to genuinely try to deescalate care for god's sake do it right. Bring the family to the bedside, get a chaplain if you have one. Sit down, get family members on speaker. MAKE A RECOMMENDATION if you think they should be DNR or hospice actually try to convince them and don't make vague noncommittal statements. Have these conversations like ICU does.

It can be time consuming.

Treat it like a procedure. Don't bother with hostile or disinterested parties. Use it judiciously, but don't ignore it.

And honestly? It's selfish. You won't get more than a vague 'Thanks Doc' from 99% of people, especially the ones you do save. But genuine human warmth and gratitude, I've only ever gotten it after sitting down and doing the whole explanation business. It'll help keep you in the game longer.

[u/SlenderMug]

Great post. To your point about old people, I’ll never forget what one of my attendings said.

“When was the last time your grandmother threw up? And when was the last time you threw up? You can’t trust your H&P in old people. The threshold to scan is much lower.”

[u/RNing_0ut_0f_Pt5 → u/[deleted]]

Former teacher, now BSN student here, I feel the same way. It’s definitely a change, but many many parts are linear to the education side.

[u/tohsimas135]

As a PGY-10, I agree with all of these

[u/KingNobit → u/tohsimas135]

As a PGY4 non US doctor I think its a bit too liberal with tests and scans

Edit: i also work in a jurisdiction where doctors can't be sued

[u/D0ct0rSw4g]

Mostly agree, but not with point 2: "be aggressive, order that scan ,order that lab". Then you are just training defensive docs. Go with them, take part of a history and exam with them. Show them what you are looking for to clinically rule out the most dangerous thing. Discuss the case, educate them.

Dont let them swim around helplessly ordering scans for obvious migraines and whatnot.

Show, discuss, teach and educate.

[u/Ineffaboble → u/D0ct0rSw4g]

I’d soften this to “never talk yourself out of a test.” If you are disciplined and careful and evidence based and your gut is still telling you they need a test or consult or whatever, just err on the side of doing it. Sometimes your subconscious will recognize a pattern that you can’t even explain to yourself. You don’t want to ignore it.

[u/D0ct0rSw4g → u/Ineffaboble]

Oh heck yes I agree. But at least find arguments why it probably isnt, but if the gut feeling says so: do it. It sure develops that gut feeling.

But at least show the resident what you are looking for and not let them pan-scan everything "because you couldnt convince me it wasnt".

[u/Ineffaboble → u/D0ct0rSw4g]

For sure. One reason I enjoy working with trainees is that it forces me to articulate why I’m making certain decisions, and sometimes the mere act of explaining something makes me rethink it.

[u/juliacliff]

Experienced nurse (13 years) but new-ish to EM (3 years) and making the mental shift from inpatient to emergency is still a huge learning curve. Saving this to reference later, thank you.

[u/Medicinemadness]

Pharmacy here- Droperidol is amazing and I am sorry some try to stop you from using it! Most pharmacist should be open to verifying the order though if you walk them through it like you said!

[u/Adenosine01]

This is fantastic! I’m usually in the ICU but pickup in the ER PRN, so #1 is something that I struggled with. These are all great, especially # 8!

[u/ninabullets]

"Never let someone with less experience than you talk you OUT of a workup" should be on goddamn banners around the department.

[u/PraiseBe2TheSalt]

A quick summary I wanted to add:

The point of this list is to help you (trainees) see some of the subtleties you only learn with some experience. Trainees often get frustrated when an attending does one thing with one patient and the opposite with another. These laws explain some of why that happens. In the moment it’s hard to break down every reason or describe gut instincts, so it often comes out as “just do it, trust me.” But until you’ve been burned enough times and seen enough unusual cases yourself, you won’t fully develop that same sense. You know, the parts of emergency medicine that aren’t written down anywhere. These are the things you only pick up by watching attendings and working in the trenches... the non‑textbook stuff.

When I was involved in training, I noticed that some other attendings can (and do) teach the medical knowledge better than I can. That’s not my strength, and plenty of people are smarter than me. What I kept seeing, though, was trainees repeatedly struggling in the same areas that aren’t about medicine at all: social dynamics, reading a room, anticipating how an interaction will unfold just by watching small cues, like how a patient talks to the triage nurse. So I started focusing my teaching on that. These are the things that, if improved, make someone’s shift smoother and free up brain space for the actual medicine stuff.

Over time I started keeping notes on common pitfalls, grouping them, and refining them. This list comes from about five or six years of keeping tabs on these patterns, with heavier editing in the last few months. I cut a lot out to keep it usable, and I can add more to this later as I refine the rest.

I’ve also noticed differences depending on background. For example, someone who worked like service jobs before med school sometimes adapts more easily to tense social dynamics than someone who went straight through. Med school and residency rightly select for academic skill, but they often leave people unprepared for the compressed, high‑stakes social situations we face basically daily. Watching smart training residents, PAs, and NPs struggle in those moments is tough, so I wanted to offer something practical. These are just my opinions and observations. I’m glad others have found them useful. I should share more lists I have in the future like the one I have on what makes EM great and what makes it suck that I have no problem adding a little to after each terrible shift!

[u/joe_pro_astro]

This is perfect. No notes

[u/MSVPressureDrop]

Just here for some droperidol love...

Doc, I feel as though I have to have worked with you at some point! I can think of several former colleagues that could have written this set of rules.

[u/we_all_gonna_make_it]

This is an incredibly helpful post for all doctors. I’m reading this as a dermatologist and found many useful points. Thank you!

[u/swiftsnake]

Corollary to #5 - don't trust infants, especially neonates. The younger they are, the more likely they are to fool you.

[u/surfanoma]

I’m going to get this tattooed on the inside of my forearm so I can always refer to it. God tier post, thank you.

[u/emergemedicinophile]

Pgy-15. I agree with them all. I tell the newbies many of the same things.

[u/descendingdaphne]

Points #9 and #12 are the difference between a good doc and a fantastic doc when all else is equal.

[u/Ananvil]

Law 8 is my favorite law. Droperidol fixes everything

[u/Quiet-Knowledge-5828]

This is such a well written summary for brand new residents who still lack the experience and the gut feeling. That’s how you learn. I will save this excellent piece of writing and get back to it until I feel more confident in practicing medicine.

[u/Queen-gryla]

I am not a medical professional, so my knowledge is extremely limited, but is this really why old people get admitted for (ostensibly) the most basic complaints (like nausea/vomiting)? I work in a hospital and watch the bed board/ED board for my job, and I always notice that the elderly get admitted for seemingly minor things. (I’m not about to get myself fired, so I don’t look at their charts for more info.)

[u/Old_Perception → u/Queen-gryla]

Way more likely to be caused by something truly dangerous, and also way less likely to be able to cope with their symptoms at home.

[u/Queen-gryla → u/Old_Perception]

Interesting

[u/hungrygiraffe76]

#1 applies so much to my fellow paramedics. I'm not doing this EKG because I truely think its cardiac, I'm doing it to show it's not a STEMI (yes I know there's more to a stemi rule out, but you get the point). Also I don't need to ask 86 questions hopelessly trying to "diagnose" the stable abdominal pain patient who doesn't need any intervention from me.

[u/PraiseBe2TheSalt → u/hungrygiraffe76]

Law 3 right here too. Someone who doesn’t understand how all this works is trying to convince you that you don’t need to do something you’re planning on doing based on your experience. 

[u/ExtremisEleven → u/hungrygiraffe76]

This plays well with law 5.

A great medic catches a ton of STEMIs when the LOL in NAD calls for nausea.

[u/shemmy]

damn. u ever thought of writing a book?

this is some great shit just sayin. thanks

[u/AdNo2861]

Yes. Ty for wringing it down so well.

[u/urdadsfuturedoctor]

saving this

[u/strawberryfoam]

These are great. Hit the nail(s) on the head. Almost want to print this up and put it in our team rooms.

[u/mermaids_are_real_]

This is absolutely fabulous. Thank you.

[u/petitebrownie]

This is gold.

[u/AstronautCowboyMD]

Bruh this shit is money

[u/sadlerj92]

Patients can't tell if you're a shit doctor. They can tell if you're a shit person. Shitty people get complaints.

[u/flymaster99]

Graduated residency in 2020, and wow this is the greatest post I have seen on Reddit. Kudos!

[u/hokub3]

PGY 20 here. I love that list and want to share it with all the new interns. Very well said! Thank you for sharing.

[u/Walter_Malone]

I’m one week into my intern year in the ED. This is gold and held up a mirror to the things I’m doing wrong, and the few things I’m doing right. Thanks for taking the time.

[u/Temperance522]

Wow, what a comprehensive post. Well articulated.

I will echo the "Why Did you Come in TODAY?" segment. In the Psych ED that was my baseline question. Psych symptoms are often constant, the reason they come to day is important, and they probably haven't articulated that clearly in their initial description of their complaint. The patient tends to talk more generally, more globally about what's going on. But the recent escalation is the key to figuring out the real complaint, and the risk assessment.

I would add, consider suicide assessment in all patients. Especially in older male patients who present because someone else is worried. Suicidal patients can be eerily calm and complacent. That's what happens when someone has mentally articulated a plan for their demise. They calm down, they have a plan. Being male, mid age, losing a job, getting divorced, living alone are all escalate the risk of suicide. And this is the group that is suicide completers. Ask if they have formulated a plan, are they plagued by intrusive thoughts of death, do they have intent, do they have means. Evalute for Means, Method, Plan, Intent.

Sometimes, medical presentations are the result of someone slowly losing interest in caring for themselves. They won't lead with that, you have to intuit it, and pry it out of them.

[u/MrPBH]

I agree with you that droperidol punches way above it's weight for pain control, but I don't know if I agree with your purported mechanism. Interesting hypothesis, for sure! lol

With that said, good job on the whole write up. It's hard to deal the inherent contradictions in this field and everyone needs to create a coherent philosophy to make it make sense. I like the way you frame it as a balance between competing demands. Sometimes you need to order the study that isn't indicated to find a resolution to the problem. You need to be aware that consultants aren't necessarily right all the time.

In that way, I think rule #10 really unifies your thesis. You need to create a plan and commit to it. The worst sin in this profession is not knowing what to do. You don't have to be right, but you need to do something! Even if that something is discharging the patient home after reassurance or admitting the patient because you can't find anything but they are covered in feces.

[u/[deleted]]

Wow, I’ll share this with my friends.I only have Haloperidol and I’m good at #6

[u/hqbyrc]

This post is pure gold !!!

[u/This_Doughnut_4162]

You were trained well!

[u/Pitiful_Board3577]

🎤DROP! This is the most fabulous thing I’ve read on reddit. Of course, as people have already done in the comments in reference to Law 2, you can come up with an argument to support the “other side of the story” with absolutely anything mostly. But bottom line, every single one of these is a necessary part of your practice that needs to be perfected and honed in on if you want to be an efficient ED provider. I’ve heard most of these separately over time, but I’ve never seen them so put together and explained so amazingly well!! I’m secretly wondering what region you work in so maybe I can come work alongside you LOL

Just some comments on my favorite laws…

Law #8 - we no longer have droperidol in stock! There is a doc that loved to use it, mostly for all the reasons you explained. Of course the pharmacist called me when I placed the order to make sure I 1000% needed it, saying “We had 2 vials last week and Dr K used one of them. I’m pretty certain this is our last vial, and we aren’t getting any more in…” Of course, I definitely needed it. Of course I told him I’d hunt him down if he told Dr K it was me that used the last vial of his favorite medicine LOL. Jokingly of course!!!

Law #2 - I had a 33yo guy that came in with the CC of shortness of breath. Unfortunately my shop doesn’t have licensed personnel out front to receive the patients on arrival, and registration is notorious for putting in “shortness of breath” or “chest pain” for a 20-something year old with a URI/cough. Of course you typically wouldn’t think too awful hard about it being something serious in a 33yo either. He was put in one of our chair rooms, and was fairly well-appearing when I walked in to see him. He looked like he didn’t feel well of course, but it definitely didn’t strike me as anything serious. He said he was short of breath most specifically when walking or doing something, and mentioned he’d felt as if he’d had a bit of fever. No pertinent PMH, no asthma, no cardiac or pulm issues, afebrile. He was a little tachycardic but mostly in the 90s to low 100s, no outward signs of distress, but did have decreased breath sounds BL and some expiratory wheezing. I ordered a CXR and a duoneb, said I’d check back with him after the breathing treatment.

Before I was able to go back in the RN came to me and said he’d rechecked his temp and it was now around 102-103, and he asked if I wanted to do blood work. I didn’t want to drag out this guy’s visit longer than we had to, and knew his CXR should result at any second. BUT, thank goodness I listened to my GUT and went ahead and got a CBC, CMP, LA + BC. Ironically his CBC resulted before the CXR did (grrrrr), and his WBC was like 24k. Then his LA was > 4, and of course his CXR came back saying multifocal PNA. I was shocked. I did initially suspect he possibly had a viral PNA due to the way he sounded, his symptoms, and how bad he felt, but I never would’ve expected to get those kind of results when I first met this guy sitting up in a fast track chair.

He was quickly moved to the regular ED to a stretcher of course, sepsis stuff started, and I got him admitted. I finished up with him right at the end of my shift. When I went back the next day, the same RN came up to me as soon as he saw me. This patient CODED and DIED!!! He’d made it to the floor, his dyspnea had worsened, so medicine sent him for a CTA chest. He coded on the CT table and they weren’t able to get him back. I was so thankful that we’d proceeded with the blood work! I felt shear terror thinking about the what-ifs. I could’ve kept the mindset that this was just a URI and just DCd him home!

Moral of the story - Listen to your gut. And remember Law #2 and Law #4 every time you’re on the fence about ordering something. If it’s something that’s irrelevant to the patient’s complaint, something that could harm the patient, or the particular test the patient/family is requesting isn’t the correct test for what they/you are looking for - then no, probably don’t order it. But explain to them WHY you’re not ordering it, or why it’s of no use. But by all means, if there’s no harm, no foul in adding it into your work up, then just order the dang test! Always remember that the patient knows themselves the best, and their family/friends are second-best. You’ve just met them.

[u/Cozaes]

From a wannabe perspective this feels like borderline scripture, thank you for taking the time to write all of this out doc ❤️

[u/tk323232]

Marked

[u/Brilliant_Lie3941]

After the first paragraph I was already trying to figure out how to save this post so I can reference it in the future. This is a great list!

[u/TheBadDoctor13]

Amazing!

[u/OhHowIWannaGoHome]

Commenting so I can find this later

[u/HaldolSolvesAll]

This is GOLD

[u/tauredi]

Saving, thanks

[u/miamiapizzaria]

Excellent.

[u/shuks1]

This is awesome, going to cross post to r/EMresidency

[u/s-lacking]

PG 34 here. Great!

[u/athena_k]

Excellent post. Thanks for sharing this advice

[u/superb_jaguar1082]

This is amazing! MS4 aspiring EM doc doing my first EM rotation tomorrow and saving all of these! Any advice for medical students doing audition rotations? What are things you would want to see in students rotating with you (if they were to rotate with you)? 

[u/lurking2be]

Awesome.

[u/madmann122]

Long story with Droperidol .. I don't know how anyone could enjoy it. Wish it stayed gone

I went to the ER for what was the worst headache of my life .. dizzy, vomiting, fainting. Crazy stuff. After everything, they gave me a cocktail of IV medicines. Droperidol being included, plus a mess of other things. IV injected Tylenol is incredibly amazing...

What I remember: Nurse said "This is gonna make you sleepy and relaxed. It'll also help with your headache and nausea."

So I'm like wow super drug! Let's get it! Meanwhile I'm in agony in my brain and my wife just came in

Injection goes in... I immediately feel... Different

Strange

Sinking...Falling... Can't stop... I fell through my bed about five times by this point. I see my wife right next to me, feel her holding my hand. A strange small cough starts to develop.

Nurse says: "Is that cough normal? Does he do that always?"

Wife: "Yea, sometimes he has a cough"

Me in my head because I can't move or speak at this moment .. But for some reason am completely conscious saying, wait... No I don't have a cough .. what is this?

Something's... Off... Weird

Feel myself drifting away, scared. What's going on.

Somewhere in the back of my mind, like a voice on the wind I heard it. Only me, no one else. A small voice that said "Don't fall asleep"

It was like lightning, thunder... Something's wrong! I said, Or I thought I did, I tried... My wife was inches away and I couldn't tell her... HEY! Something's wrong!

I can't breathe

Then again, the lightning. Only this time it hit me, and adrenaline like I have never before felt, that could wake a corpse. That voice... "Don't fall asleep"

And with that, the biggest breath I could take, pulling my life back to me. Sat up so fast, ripping at my shirt. "Something's wrong! Please go get help!"

My poor wife ... Tears, running, yelling for help...

My heart rate jumped to 200 bpm in seconds. All that had just happened felt like eternity, but was a mere flash of time. I thought I was dying, no... I am SURE I almost died.

What followed was an hour of pure panic, shaking, freezing, and terror while my chest felt like it was going to burst open with every thud. I wanted to break things... Hurt people... Hurt myself. All to make that feeling stop.

I wanted to reach into my chest and grab my heart to squeeze it and make it stop... One of the scariest feelings to me is that of having no control over what is happening to you

When my doctor finally stopped by to brief me on my visit, all he had to say was "Woopsie Daisy, sorry you weren't supposed to have that! It's not supposed to be given via IV injection! It's meant to be on a timed drip. And they were supposed to give Benadryl.. But I'm glad you're okay!"

Came home and researched my new found kryptonite only to find out that it was pulled from the market for causing unexpected deaths... Via sudden cardiac arrest. And now is used in very small doses to help with nausea. It is banned in European countries, even today, and has a black box warning that when given, patients must be monitored on an EKG for at least two hours. The hospital I was at discharged me only 20 minutes after my heart almost stopped. Take what you will from this story, nothing was exaggerated or embellished. These types of drugs are dangerous and should not be used without serious consideration. I never want to experience that again...

[u/memedoc314]

Great summary. I’m amazed that someone who is so stellar in many areas, that you could still be so basic in your approach to “drug seekers”. You acknowledge you have to “sell something”. Have you considered being better acknowledging your concern that they have tolerance or dependence on opioids?

50% of those patients that used to leave bad reviews now get started on Buprenorphine and referred to treatment.

I hope you’ll consider adding this to your approach. Would love to discuss if it’s not something you already do.

[u/ExtremisEleven → u/memedoc314]

They’re saying you need to sell the admission plans and consult requests to other physicians, not selling the diagnosis to the patient….

This is not an exhaustive list on how to practice. I’m not sure where you got the idea that they wouldn’t also give bup. The problem I have is that by the time they end up in the ER they are too agitated to get a decent history. Droperidol is a good place to start while you figure out what exactly is going on. This is being framed as a palliative measure not the end all be all. I think you read this post with a very different lens than it was intended to have.

[u/ExtremisEleven → u/[deleted]]

I can’t say their specific motivation but ER docs are constantly shit on for doing our jobs. If you want examples head on over to R/Residency and read all about how we are apparently too stupid to order a CT pulmonary embolism study to rule out pulmonary embolism…

[u/StrongLastRunFast → u/[deleted]]

I’m an attending and agree 100%. What triggered this? And many stylistic points in here not necessarily dictated by data