I didn’t realize one of our frequent flyers who wanted to leave AMA was in the room next to the nurses station (with the door open) and I said something along the lines of “let her leave she’s here all the time”. Might of thrown a couple f bombs in there. She definitely heard me and asked for my name. I feel horrible. Not only because she heard me but because Im usually a lot more empathetic but it was a really busy day and I spoke without thinking. I’m a fairly new nurse and I feel like an a-hole.

Freshly minted attending here. In residency I was usually capping at 2 pph on efficient, busy days. I had a recent experience with my new gig where I saw 2.5 pph over the course of a 10-hour shift. Fairly low acuity (1 procedure, 4 admissions all day). During the busiest parts of the shift (when I was running department solo before swing shift arrived) I was seeing 3 pph. It was an exhausting foreshadowing of my new role as an attending.

A friend of mine who is 1 year out said they recently saw 32 pt in an 8 hr shift...

Made me curious how seasoned attendings can manage to see 3-4 pph. What types of strategic adjustments are you making to facilitate this pace and maintain safe practice?

Working at a new site, US techs are very picky, will not come in for torsion studies if pain is >12hrs. I talked her into coming in and she’s pissed af, said she knows I’m new and “I’ll learn the protocol”.

Am I in the wrong?

Edit: Does anyone support the US tech or rad protocol and do you have any studies or evidence to support this practice? I’m just wondering if they pulled this out of their ass or where they got the arbitrary 12 hour thing?

Hi! I’m an ED PA, Today I had a patient come in with a complaint of lower abdomen/pelvic pain. She says that 3 days ago her “heavy” husband jumped on her pelvis and since then she has had consistent pain in bilateral rlq & llq. I went through a thorough ROS with her, & asked her multiple times about chance of pregnancy (which she denied). She states last menstrual period was 3 months ago, and denies taking any pregnancy tests at home (multiple times). The nurse runs her urine and it is negative for pregnancy. So i ordered a CT of her lower abd/pelvis to rule out intra abdominal/pelvic and bony pathology due to mechanism of injury (her “heavy” husband). Also ordered labs, ua.

I happened to walk past patients husband and he goes “did she tell you she had 3 positive pregnancy tests”…. This being AFTER she had gotten her CT scan. I personally repeat patients bedside hcg and it is positive. I tack on a hcg quant and it results at 6500. I confront patient about lying to me and she states “i was following advice from my friends to not tell you so i can make sure you do a hospital pregnancy test, i found out about my other pregnancy through CT scan too”. At this point I order a OB US. Patient decides to elope because she has a wedding to get to…

Im so flabbergasted & i feel so guilty that I radiated this lady’s fetus. The nurse that documented the first negative test submitted a quantros report. Im not sure what to expect that could come of this long term, should i worry about repercussions from my work place, or a possible lawsuit if this lady miscarries or her child ends up with cancer?

I repleted 40 meq via central line in less than an hour, bringing it up to 1.9. The pharmacist is reporting me for dangerously fast repletion. What I can tell you is the patient was able to breath much better shortly after the potassium was given. Pretty sure the potassium was so low he was losing function of his diaphragm. Any thoughts from docs or crit care who have experience with a similar case?

I work in a very large urban ED. We’ve picked up a new regular over the past month who’s young 30s-40s and won’t stop throwing themselves on the ground. They walk with a rollator and claims that sciatica causes them to fall. They've had 8+ CT heads over the past month, xrays of everything because she purposely throws themself (somewhat convincingly) to the ground in the department. They've been admitted twice and subsequently discharged back to the homeless shelter.

In my mind, it’s clear that they are malingering to get out of the shelter, but I have no idea how to deal with this person besides admitting them at this point. I’ve tried discharging them with ems (they get brought back immediately) and I’ve tried kicking them out (they will “fall” in the entrance to the ED or just outside of it and inevitably be brought back in). I’m thinking of sending them to cpep when I see them again tonight. Thoughts?

Would you close this laceration on a 3 year old? There’s definitely a risk with the kid not letting you numb before. But does ever so slightly cross vermillion border

Was mostly by myself (with a tech) in triage today in a very busy ED today; I can’t even remember how many patients I triaged maybe 100+?
But wait times sucked today. At one point we had 5-10 ESI2s waiting for 3-5 hours and 20 ESI3s waiting upwards of 6 hours. Sometimes I’d have another nurse come up and help me protocol-lab, so we’d line and swab as many of them as we could while also trying to keep up with the never ending influx of people to triage. EKGs and CXRs all done ASAP on the ones that needed them; ESI2s got labbed right away; some ESI3s had to wait several hours while we worked through the 2s. Our docs were ordering CTs from the back but our CT techs won’t take them back from the WR “per policy”. Anyway. My question is- when it sucks like this how do y’all address such a busy and angry lobby that’s been waiting forever 😭
Do you like check on people (more than eyeballing them as you’re grabbing others) and update them on approx wait time; do you make an announcement. Idk I just feel like I could get more creative with figuring out how to deal with a crazy full lobby so I’m coming to y’all.

Right lower quadrant pain in pediatric, mother wants to leave because it’s taking me too long. I’m worried about appendicitis. Can Mom legally sign out her child AMA?

It is very rare for me to actually work on a pt with another emerge doc, save and except for sedations, codes, traumas, and shift change. There is one dr, who is very well intentioned, good bedside manner, very collegial… but he is a bad doctor.

A few days ago, needed another doc to sedate (at my shop, need two docs- one for sedation one for procedure) an anterior shoulder dislocation in a mid 20s male pt. We decided on ketofol, nurses got him set up, we go to the room and get started. The doc pushed 5mg propofol, then 5 of ketamine. Obviously, nothing happens. Then he waited a full 3 minutes. And repeated the dosing. I’m sitting there scratching my head wondering what the fuck is going on. I politely suggested a larger dose, and suggested perhaps starting with 20 k and 40 propofol. He said he wasn’t comfortable with that and likes to titrate. I was so taken aback. Another full 3 min, another 5 and 5. Then he finallly gives 10 of prop, but no more ketamine. He stopped with the ketamine at 12..5 mg. Pt never became even slightly sedated from prop due to dosing intervals. Then, very luckily nurse comes to tell him they need his help with a pt that just becamr critical. I tell him I’ve got it and he should just go. So now, 20 min after starting, I sedate and reduce, no problems.

A few weeks ago, I took handoff from him. There was a pt with one of the pts was a gi bleed. He got a ct abdo pelvis with contrast, labs on arrival were good. Said she just needed to be discharged for outpatient scope. I said ok. Once he left I looked a little harder because. I’ve definetly got trust issues with him and I see that he did not get a second hemoglobin, despite the fact she’d been there for 8hrs and had many episodes of brbpr in the Ed. Low and behold, her hemoglobin came back at 82, a drop from 159 in her arrival jn the Dept.

To those of you who have reported a colleague for incompetence rather than gross misconduct, what made you decide to dk it and do you regret it? Do you think this is worth a report to the college? Medical director? I’ve only ever reported one colleague and it was in residency, after I saw her taking a pts oxy from their room.
Any advice or Anne dotes from people who have been in this position it would be greatly appreciated

New attending. Had a gruesome death of a little boy happen in front of me the other day. I will spare the specific details but it was a penetrating trauma. Peds trauma cracked his chest, chest tubes, whole blood, blood on the floor, fingers in the wounds to stop the bleeding, the whole deal. Screaming parents and grandparents afterword. Have two sons similarly aged and I can’t get this out of my head to function normally at home. Just so happened to happen right before a week off so haven’t been back to work yet. Seen what seems like tons of deaths at this point and was never affected to this degree . Never seen a traumatic death of a healthy child though (seen pediatric codes but chronically Ill kids on borrowed time) Any tips for getting over it? How do you deal with bad deaths and making sure you don’t develop ptsd/burn out? I love what I do but if this was any weekly occurrence I would quit.

I got an admission request last night. It was for a young guy, with an “impressive” pruritic, scaly, erythematous rash “diffusely across the whole body” — with what appeared to be a superimposed cellulitis on the abdomen. This had been going on for “months” (making acute necrolysis less likely). The ER doctor ended the (text) message with, “he will need a dermatology consult on this admission.”

I said ok. And I asked — dermatology does in fact come here, inpatient, right? I have never seen them, and I know it’s classically a rare service to have.

He checked, and found out that no, dermatology does not in fact come to this hospital, to the inpatient wards. At that point, I said I did not feel it was an appropriate admission, and that the patient should be transferred to another facility with dermatology (and there is one, within 10 miles).

The ER doctor seemed to, in my opinion, backtrack. He said, you know what, the patient can just follow with a dermatologist when he leaves the hospital. You can just admit him for the cellulitis then. Keep in mind — this was at the end of both of our shifts.

I didn’t argue. I was angry, but I didn’t argue. I told him — listen, I won’t even be seeing this patient. I won’t be involved. I won’t have to do the work either way. But I don’t think it’s right for me to dump this on my colleague without the specialist support. I also don’t think it’s right for the patient.

I called my medical director. He informed me that several of the outpatient dermatologists are “happy” to help (informally), by receiving pictures, and making recommendations. He told me that it was ok for me to admit the patient, and so I accepted.

I told the ER doctor that I would accept, because of the slightly more reassuring degree of support. I then went an extra (and likely unnecessary) step, by saying I thought that this was a highly inappropriate request without confirmed dermatology support.

The ER doctor said “LOL please, you are being rediculous (sic)”

Was I being unreasonable? It’s certainly possible that the patient simply needed antibiotics for his abdominal wall cellulitis.

But WHY is an otherwise young and seemingly healthy patient having abdominal wall cellulitis, with an “impressive” whole body rash? What if he didn’t respond? What if he continued to get worse?!

I didn’t feel like the patient was a slam dunk cellulitis. There was obviously more to the story. We were BOTH in agreement that the patient would have benefitted from dermatology evaluation.

I didn’t need to say that I felt like the request was inappropriate. But I was feeling frustrated and expressing my honest opinion. And yet, I’m still ruminating over the situation.

I didn’t want to ask in the hospitalist group because I’m not looking for an echo chamber. I seek as much honesty as I like to give.

I’m an ER physician in the Rocky Mountain region. I had a patient a few days ago who came in for diarrhea and vague abdominal pain. She’s fine, went home.

Now here’s the quackery part. This patient was bitten by a tick 16 years ago. She’s being treated by a licensed DO for chronic Lyme and chronic babeziosis. She’s been on antibiotics and chloroquine as well as chronic opioids for these “conditions” for 5+ years. Lyme and babezia are not endemic to my region.

I trained in New England so I am very comfortable with tickborne illnesses. I would not fight this battle there because the chronic Lyme BS is so entrenched. However, it just seems so outlandish here that it got my hackles up.

Anyone have experience reporting something like this to the medical board? Think I should make an anonymous complaint? I know who this “doctor” is and they run a cash clinic.

I will start by saying I’m a nurse at a Level 1 Trauma center and I know I don’t know everything but I’ve seen a lot. I had a patient today come in, and arrested immediately(if not already with EMS) and he was a chronically unhealthy man, CKD on dialysis and missed his last appointment. I immediately think Hyper K. We’ve given a couple rounds of epi, bicarb, calcium, etc and I suggest insulin and D50. I over heard one resident (intern or 2nd year not entirely sure) say adamantly that’s not what he needs right now. I don’t push back much, pt goes into vtach several times, with a pulse and some without we cardiovert/ defib appropriately we get ROSC and then have to re code several times. We’ve given amio and lido to treat but then we finally give insulin and D50 then the pt comes out of vtach after. Labs come back, initial K is >10, abg after all interventions and ROSC 2nd K is 6.5 and he is finally not in vtach. Point being was me suggesting insulin and dextrose so early wrong? Or was it just not a priority? Or was the resident completely wrong? Idk I really just want to continue to learn and appropriately treat these patients because we have lots of dialysis patients and I hate feeling stupid

Edit: we coded for greater than 30 minutes and had to recode him several times were we were considering ECMO just to get him to make it so he could get dialyzed, honestly just thankful we got him back at all. post ROSC I will say the calcium was extremely high, so we definitely did that correctly. Our pharmacists was like whoops we did that. He also got epi multiple times throughout the code as well at the appropriate intervals. We did the amiodorone I suggested a little later that and eventually did IV insulin and dextrose and then finally I guess the K came down to a level he would finally stabilize and get him to the ICU for emergent dialysis.

Hi all, new attending here. I've been getting a lot of push back from midlevels recently telling me that 2 negative high sensitivity trops and normal EKG "rules out ACS". I started to hear this towards the end of my residency also. I just took a look at AHAs recent guidelines but can't find any discussion validating this. I still practice according to the HEART score and shared decision making. Any recommendations?

I've always wanted to be a doctor in EM. Long story short; shitty ex talked me out of my dream. Now I have a chance to either attend PA or MD school. I'm 37 now and by the time I finish all pre-rec's I'd be closer to 40. Would my debt of med school pay itself off? Or should I just go to PA school?

Update: thank you to everyone who commented and gave me your honest opinions, experiences and advice. I am thankful to all if you who took the time out of your day to comment. I have decided to go the MD route after I get my BA and finish up some pre rec's.

I'm a new attending, and recently in the past few months I've come across a few patients making demands prior to getting xyz test. For example -- a patient presenting with abdominal pain, demanding xanax prior to blood draws because she is afraid of needles, or a patient demanding morphine or "i won't consent to the CT" otherwise.

How do you all navigate these situations? If I don't give in to their demands, and they don't get their otherwise clinically indicated tests, what are the legal ramifications?

Hey guys, R1 EM here

Today I saw case of a middle aged female with previous breast cancer that was triple negative, she was treated almost with chemo almost 3 times and had a mastectomy, and she is waiting for a prophylactic mastectomy to the other breast. Her last chemotherapy session was like 7 months ago.

She came to the ED complaining of floaters in the Left eye for the past 2 months. It progressed into floaters with headache, that is not her usual, but it was controllable with tylenol and a nap, like it is very minimal, but a new thing to her. she went to an optometrist, she was told that this is an “eye migraine”, which was weird at the beginning, but then I understood that they were meaning “Migraine with aura”. Exam was unremarkable, no neurological deficit, good visual acuity and normal EOM and pupils are reactive with no RAPD.

It made sense, it is typical for migraine with aura, it is controllable, no neurological deficit or visual changes, the patient finished her chemotherapy 7 months ago so she is in remission, notes form her team says she is doing well. But, the patient was very stressed and crying as she was afraid that it could be recurrence. What I did is I told her that chances of getting a recurrence are very slim, but since you are in the ED, I will just check your latest CT head and consider doing one if the last one was remote, but I reassured her that most likely it is a migraine thing and I will do the CT just to facilitate her follow up with neurology later on.

I went back to her chart; last CT head was 2 years ago, so I thought I will just do this one in the ED and then outpatient neurologist follow up, easy peasy.
Results came back, shockingly a new mass with vasogenic effect in the Rt. occipital area causing all this symptoms in the Lt. eye, but no midline shift.
It was not what I expected, I was humbled. My staff was amazed that “WOW, how did you get it? This is an amazing catch!", and I got very good evaluation for it

However, I was sad inside, like, why did I just reassured her that much in the beginning? I could not even go back to her, I just called her oncologist to come and see her, I could not look at her eyes and tell her that my reassurance was BS and now you have your cancer back, good luck!

I am good at telling people that your relative is dead, because now you do not need to explain a lot, nothing more can be done, but for those patients? it is hard, especially as I fucked up with the aggressive reassurance that "meh-there is nothing", because they will have a lot of questions that I really do not know how to answer.

My take up listen today; do not underestimate even the low-chances DDx, yes I had to to reassure my patient that I will do my best, but not that nothing is wrong with them and we are doing things just as protocol, I have to be honest and sincere in my explanation.
I know I did good in catching it, but I do not like my way of the reassurance.

I just had to relieve this gelt out of my chest.
How do you guys deal with these uncertainties in terms of communication with your patients?
What would you do if you fucked up like me? :(

There’s been lots of posts especially since January of folks looking to come work in Canada.

I was inspired today when I learned that our regulating body (equivalent to state medical boards) just made it official that if you come with ABEM, you can finally get full licensure here. That means no exams, no BS… and right now the jobs are plentiful! Come join us!

As a US trained ABEM doctor, I’ve been here 10 years and I’ll tell you that as time passes, it will take a more and more compelling reason for me to return .

The pay is great, medicolegal risk negligible, patient/system expectations lower than the US., no Press Ganey garbage, minimal billing hassle with single payer. And would you believe I haven’t seen a single GSW (not even a walk in) in a decade?!?!

Hey all, looking for some advice and fielding a few personal anecdotes if anyone is willing to share. I've been working as an RN in a busy ER in a mid sized city for awhile now, and I love the environment. I'm getting the itch to go back to school (always knew I would), and I'm really considering pursuing my MD. I have a nursing degree and a bio degree, and I'm definitely not afraid of an academic challenge.

I've been considering my NP for awhile, but have had some serious encouragement from family/friends to go for my MD instead. So, I'm asking as someone who already loves the EM environment:

Do you regret becoming an ER doc? What was the experience of residency truly like? Did you feel well prepped by residency to be independent as staff? If you had to do it all again with the knowledge you have now, would you? And if you work with NPs, do you personally feel they support your position and add significantly to patient care?

Hi! i’m an ms4 and i’ll be doing my audition rotations in the ED over the next 3 months. I’m super excited and ik that students can be both helpful and another aspect of the job to have to manage, so i wanted to ask for some advice directly from y’all. obviously everyone has their own opinions, so my goal is to get a broad sense of different ones

feel free to answer any of these or just throw me some advice, i appreciate it:

what things can i do to be helpful to your workflow without overstepping or creating extra work?

what aspects of patient care can i be responsible for directly without running it by you? (asking from a place of wanting to balance keeping u updated but also not being annoying)

what would you consider to be getting in your way rather than being useful?

how/when should i update you on the plan for the patient or any changes?

what should i not do on my own volition?

what are some things med students have done in the past to help that you appreciated?

also taking suggestions on any tasks you think a med student can take on like foleys, IVs, during codes etc

thanks so much!

I’m an off-service intern rotating in the ED. Yesterday I had a patient whose wife was his legal court-appointed guardian.

He presented to the ED with his wife for fevers and worsening AMS. I picked him up and saw him. Immediately he was suspicious of my motives (claiming I was there to steal his organs) and requesting to leave. I asked him if he could tell me what would happen if he left. He said if he stayed I would steal his organs and if he left he would “avoid being detained by the government.” When I asked if there was any harm in leaving he said no. His wife talked him down and he agreed to stay for bloodwork and a UA. He was pleasant enough otherwise. I staffed him and told my attending he is suspicious of us but agrees to stay.

Then when his nurse gave him the UA cup, he stood up and said he would not be detained and that he would beat us all up. He was getting extremely angry. He walked out to the waiting room yelling profanities, and then security grabbed him.

A nurse in triage (not his nurse) said he could leave since he is not legally required to be there. I asked his wife and she said she wanted him to stay and to sedate him if needed (her words). I messaged my attending while this was happening and was going to get him from the staffing area, but security asked me what to do and they needed to know right then and there since he was wanting to leave, and I said to security “he does not have capacity, his wife is his guardian and wants him to stay, I’m going to get my attending.” The nurse got upset at me and said I was wrong, that he could leave and that I could not make him stay. She then said to get my attending because I “didn’t know what [i] was talking about.” I was already going to get my attending involved but he hadn’t seen the page. The RN’s words made me think I was missing something and that I was misunderstanding the role of a guardian and what it means if someone “has to stay” versus “can leave.”

My attending came out and convinced him back to the room, but then he threatened his nurse and me, so his wife said she would like to take him home. She understood the risks and benefits. They promptly left.

I wanted to debrief but my attending’s shift was changing and the nurse who was mad at me disappeared back to the other side of the ED. And frankly the culture here isn’t very learner-friendly lol.

Was I in the wrong for “making” him stay? As in, I asked security to help keep him in the ED since his wife is his legal guardian and wanted him to stay at the time. I said it with the intention of buying time to get my attending, not that I was going to order IM haldol and force him to be tested and treated or anything. I just felt unsure, because if I said he is okay to go when he lacked capacity and his wife as guardian wanted him to stay, then I was afraid I’d get in trouble and I’d harm the patient. But the RN with far more experience said he can leave and we cannot make him stay. And I obviously didn’t want to harm the nursing staff if he became physically threatening.

Thanks. I’m just trying to understand and be a better physician. What should I do in this situation besides get a senior/attending involved sooner? In hindsight I should’ve walked straight to the staffing area and gotten my attending instead of paging and will do that next time. But in general what is the role of a physician in this context?

Coming with good intentions but why can't paramedics be utilized more in the ED? It does not make sense to me that when I'm in an ambulance I'm allowed to perform many of the same life saving interventions that are routinely done in the ED however, hospitals seem to think medics are a liability and you'll be lucky if they will let you perform a 12 Lead when normally we are diagnosising and treating them in the field. I get there is more of hospital side of things to learn but if the ED is packed and the Physicians are struggling to keep up I dont see the problem letting medics perform the interventions they are already trained to do (codes, RSIs, cardiovertions, and so on) with an ER team that they dont have the luxury of in the field. Would love to hear other opinions but this really seems like a missed opportunity to me.

We all get those patients: they just moved, have no PCP, they come in with 7 different complaints, including a med refill. The ED provides de facto primary care. It's terrible primary care, but that's all some people get.

Are there any medications you flat out refuse to refill, even for just a few days? If so, why?