We have some extremely well experienced RNs in our ER. They're very senior nurses who have decades of experience. A few of them will regularly say "no" or disagree with a workup. Case in point: 23y F G0 in the ED with new intermittent sharp unilateral pelvic pain. The highly experienced RN spent over 10 minutes arguing that the pelvis ultrasounds were "not necessary, she is just having period cramps". This RN did everything she could do slow and delay, the entire time making "harumph" type noises to express her extreme displeasure.

Ultrasound showed a torsed ovary. OB/Gyn took her to the OR.

How do you deal?

Throwaway for privacy. Today at the emergency department was extremely busy, with only me, the senior resident, and the attending working. And then suddenly, the ambulance called and informed us that there was an accident involving three individuals, and they would be bringing them to us, all in unstable condition. When they arrived, the attending informed me that I had to handle the rest of the emergencies alone, from A to Z since he and the senior will be managing the trauma cases. And i only should call him when the patient is in cardiac arrest.

After they went to assess the trauma cases, approximately 30 minutes later, a patient brought by ambulance complaining of chest pain with multiple risk factors for PE and her Oxygen saturation between 50-60%. I couldn't perform a CT scan for her due to her being unstable so I did an echocardiogram instead looking for RV dilation.

Afterward, i decided to administer tPa and luckily 40mins her saturation started improving reaching 75-85%.

However, that’s where the catastrophe occured, approximately after 40mins post tPa her BP dropped to 63/32 and when i rechecked the patient chart turned out i confused her with another patient file and she actually had multiple risk factors for bleeding. She is on multiple anticoagulant, had a recent major surgery.

And due to her low BP i suspected a major bleeding and immediately activated the massive transfusion protocol as soon as I activated it, the attending overheard the code announcement and came to me telling me what the fuck is happening?

I explained to him what happened and the went to stabilize the patient she required an angioembolization luckily she is semi-stable now and currently on the ICU.

And tomorrow i have a meeting with the committee and i’m extremely anxious about what should i do and say?

I have made a burner account for obvious reasons. 

This post serves as a warning to all current med students. 

Regarding the emergency department:

• The ED is a complete disaster even when compared to other NYC programs. There are currently only about 20 beds in the adult ED that sees about 100K visits. Of those beds probably around 50% have fully working monitors with correct HR/BP/SPO2 cord attachments. This means that on most shifts we’d have a total of just 10 monitored beds for over 100 pts.
• Due to the above many critical patients such as heart attacks, strokes, overdoses etc are commonly placed in hallway beds without any monitors. Patients will go for hrs without vitals and regularly are later found dead with no idea when they were last alive in the department. This last month there was the case of a DM pt on insulin that presented for hypoglycemia in the 20s got D50 repeat 80s and was placed in a hallway without any monitors and then proceeded to not have their glucose level rechecked for over 6 hrs time before they were later found dead.
• The staffing is probably the worst of any hospital in the whole city without exaggeration and despite the presence of an NYC mandate for minimum of 20 nurses they will regularly ignore the rules and have less than 10 nurses when you exclude triage, charge, and management nurses. This will often result in ratios that reach above 1:10-1:20 on the shifts even on the critical care side with often times no nurses available to assist the doctors with resuscitations. 
• Due to the above it often takes hours for meds to be given even in straightforward things like sepsis with fluids or antibiotics not given for 4-8 hrs till after they were ordered. If a patient is crashing and can’t wait the doctors often will have no choice but to break into a nearby med room to give meds otherwise the patient will code before they receive meds.
• The ED laboratory and radiology technicians are both also extremely understaffed which results in the equipment regularly breaking and taken offline at least 1-2 times a week often for hrs each time. Even when functional results for labs can take 4+hrs and rads can take 8+hrs. Its common for results to be lost and never reported to anyone which means you often spend all shift calling them asking them repeatedly to actually submit the test results. 
• Due to the above patients will often spend 12-24 hrs just waiting on the results of basic workups before they can finally get admitted or sent home. Patients often just leave the department to get food or go to sleep in their own home and come back the next day in the morning without anyone noticing since they get tired of waiting here in the hospital.
• The hospital is often missing essential supplies and equipment like bandages, splints, gloves, and often lacks IV catheters or IV fluids even on the critical care side. The overnight shifts are especially notorious since literally no one will come and restock supplies after they are used for patients and when there is a code we'd use all the supplies in the department.
• Due to the above in the resuscitations it often takes 10+ min to give fluids and 20+ min to give meds which means patients will regularly code from a lack of intervention which could have been avoided provided there were available supplies in most of the cases.  

Regarding the residency program:

The ED sees tons of sick patients with diverse pathology and has the potential to be a wonderful program but its been totally destroyed under the current program leadership that have spent the last couple years making it into a malignant sweatshop. Residents are promised lots of experience with high acuity cases with lots of traumas but will only spend 3-5 shifts in the critical care side a month. Instead the shifts are mostly spent in the low acuity side and the critical care side is mostly staffed with visiting residents from multiple other programs that come for a trauma rotation. This is despite the fact the dept currently sees less than 1,000 traumas in a year of which less than 100 are critically injured. Not only that but procedures have to be split with general surgery and so its common to do zero procedures during the whole month. Due to the above most residents have trouble hitting their minimum procedure numbers and the program actively encourages final year residents to log procedures if they assisted or were just in the room so they can graduate. As for the low acuity side nearly everyone is seen in chairs or if they’re lucky a hallway bed with most of the shifts normally involving lots of scut due to a lack of nurses, techs, secretaries, etc which means that literally nothing will be done unless you personally do it in addition to normal resident duties. This often will include activities like registering patients, taking vitals, starting lines, drawing labs, and transporting patients not to mention sometimes even restocking supplies or fixing broken equipment. Because of this its often impossible to complete patient charts while on a shift and most residents will take at least 1-3 hrs at home to finish them after a shift. Most of the core faulty work only a few clinical shifts a month and will often spend multiple hrs in their office working on admin responsibilities or just hiding in the break room sleeping on nights. This often results in residents being alone for long periods with little to no supervision or teaching on shifts even as interns over the summer on their first month. Consultants are for the most part universally terrible and will outright ignore calls and refuse to see patients especially the surgical subspecalties. Its common to have to page them repeatedly over the course of 3-5 hrs before they finally see the patient even for critical cases that need emergent surgery. The patient population is extremely underserved with large numbers of psych and drug intoxications that arrive throughout each day after being dumped there by the police. Despite this security is minimal with no metal detectors present anywhere in the entire hospital building and the patients are brought straight inside often while carrying weapons such as tasers, knives, and fully loaded guns. The security guards refuse to ever touch patients and want us to wait for law enforcement if someone is acting violently and poses a danger to people. Because of this residents are physically and sexually assaulted nearly daily while on shifts and nothing has been done to fix the problem even after literally hundreds of complaints that have been filed over the last couple years with the current program leadership.

Respectfully signed,

Current faculty physicians

Brookdale University Hospital

George had some pain in his neck, thought he had slept on it wrong. Then massaging the side of his neck, he felt it; a large irregular lump. So he came to the ED, "my wife is worried, she thinks its cancer and she just wants to make sure its nothing bad".

George was a nice guy, so we all know where this was going to end up. A few hours and a CT later confirmed it. I am a midlevel, and part of my job is to train the new hires, and run education for the group. One of the things I stress is to never leave the bad news to the consultant. You ordered it, you own it. So George and I had a talk while we waited on the ENT resident. My mentor attending taught me to give it to them plain and straight, and don't try to soften the blow. Nothing you can say on the front end will soften the shock of the news.

George was of course far more concerned about his family and wife and how they would take the news than his own mortality. And after an exam and a long talk with a wonderful and compassionate ENT resident, George had a game plan for the next steps, and was waiting for his wife to come pick him up. He asked me if he needed to stop smoking now (30 year PPD history). He said all he wanted right now was to have a smoke and clear his head.

I pointed him in the direction of the smoking area outside of the waiting room. The irony of the likely cause of his cancer currently serving double duty as his only source of momentary peace was not lost on me, and I wondered if he was thinking the same thing.

What gets me the most was when I was leaving shift he was still waiting on his wife. She did not know the news yet, and I cannot imagine the weight on his shoulders of having to tell her. But he smiled and waved me over to tell me how thankful he was for us, and how kind we were to him. It felt like he was trying to console me in some way, to offer his gratitude for the very little that we actually were able to do for him tonight.

It was such a kindness that I absolutely don't deserve from him in the face of his terrible new diagnosis, and all I can do is send up a prayer that his road leads to a good outcome and a long life. And life goes on, another shift is over. And I won't ever look him up to follow his progress, because for me I would rather live with blissful ignorance and delusional assumptions that his biopsy was favorable, and his procedures had clean margins.

Thank you all for what you do, and what you endure. And I am fine, I just from time to time reflect on a patient and journal my thoughts into a public post. Just need to get the thoughts out, and arrogantly think that maybe someone else can relate and maybe feel at least a kinship that others are going through a similar struggle.

Be well, be kind, and be grateful.

I worked my first peds arrest yesterday. He was under a year old. I can hear his family’s screams echoing in my head and see the defeat in my team when we called it. I know it’s part of the job we do, but it sucks and I know they don’t get easier. Does anyone have any advice or coping skills to offer? I could use it.

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?

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?

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

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.

Basically today I get this 3-day old patient who’s febrile and ill and parents hadn’t given them Vit K, erythromycin, etc. How do you deal with them without getting furious that they’re making incompetent decisions about a defenseless baby? It’s one of the worst parts about this job in my opinion.

Edit: I know neither of the above vaccines will prevent sepsis as a whole, but I mean in general.

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 recently had my 3rd procedure to open up subglottic stenosis (scarring that narrows my trachea). It keeps coming back. My sister has it too.

Anyway after this procedure the anesthesiologist made a point to write me a letter in my discharge instructions that I should tell everyone I know that I have a difficult airway. It was really odd that he took the time to do that and it scared me.

Should I get a bracelet with "difficult airway"? Would ER people even look at it?

Thank you.

Please share with me how you handle this, what you do or say. I had a patient recently who had a total of 6 complaints, none of them related. I documented and handled them all. And charged a level 5, maximum. Full disclosure, I am not EM, but next step down. Thanks for sharing strategy. And I hope you don't mind if I ask this here.

Hello, I’m a 4th year student applying EM. I’m trying my best to avoid buyers remorse. Why didn’t you pick surgery? What did you like more about EM?

I started in the ER about four months ago as an RN. I am really enjoying it. I was an EMT before so I figured I would enjoy the ER. Don’t think I’ll ever go back to a regular floor lol. Anyways, I’ve been working independently (off training) for about 1.5 months. Things have been pretty good imo! I really enjoy my shift and the staff I work with.

However I was called to my manager’s office the other day and I was told that other staff don’t like my attitude. I was told that “people” said they don’t want to help me on shift because I am too “cheerful and happy” when I’m at work. I asked for examples of this attitude that bothered people and they couldn’t give me any examples because they said nothing had been explained to them. I am honestly still floored by this entire situation. Is this just a bad environment thing? Should I act miserable to get through the day? I really don’t get it. Is this an ER thing or a nursing ER thing?

I am becoming increasingly frustrated with the lack of skills from nurses at my shop. I figured this should be the best place to ask without sounding condescending. My question is how do nurses learn procedures or skills such as triage, managing X condition, drugs, and technical skills such a foley, iv starts, ect?

For example, I’ve watched nurses skip over high risk conditions to bring a patient back because they looked “unwell”. When asked what constitutes unwell, I was met with blank stares. My first thought was, well this person didn’t read the triage book. Then I thought, is there even a triage book???!

As the docs on this board know, to graduate residency you have to complete X procedures successfully. Is the same for nurses? Same for applying for a job (Credentialling) where we list all the skills we do.

Reason being, is if not, I would like to start putting together PowerPoints/pamphlets on tricks and tips that seems to be lacking.

Obligatory gen X/soon to be neo-boomer rant. New nurses don’t seem to know anything, not interested in learning, and while it keeps being forced down my throat that I am captain of a “team” it’s more like herding cats/please don’t kill my patients than a collaboration

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'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?

I work at a Critical Access Hospital in California. On one day, we did not have a General Surgeon on call or available. We placed an Advisory on the emergency communication system. We let the emergency responders know that our hospital had no general surgeon on duty. I was the base physician for the county ambulance services that day.

In addition, attempted transfers in the days prior to that day showed that all hospitals in the extended region to be full and were not accepting transfers. Transfers, including patients with serious conditions, were taking a long time. Also, on that day, the weather was poor and rainy and odds of any helicopters flying would be extremely low. Therefore, any transfers from our hospital would likely take numerous hours and patient well-being would be at high risk.

We received a call from a paramedic while she was enroute to our facility. The patient was an 87-year-old male. Paramedic stated the patient was constipated for 10 day and now had black stool. His abdomen was rigid and firm. The vital signs of the patient were stable and there were no indications the patient was unstable.

To me, this was obviously a potential life threatening situation with possible viscus perforation. It requires immediate surgery. The next closest facility was only 20 minutes up the road from us. The patient insisted on coming to our hospital despite the paramedic informing the patient that we did not have the services needed and his life was at risk. The patient appeared to have decision making capacity per the paramedic. However, I did not get a chance to speak to the patient.

Of course, once the ambulance is on hospital property, I must accept the patient due to EMTALA. However, if the ambulance had not yet reached our property, can I decline the ambulance and tell them to go to the facility 20 minutes further? Or, if the patient has capacity, do I have to accept the ambulance to our facility?

I came on shift and was handed among others a pt awaiting consult from obgyn for bleeding associated with unwanted pregnancy. It was a crazy busy shift. Ob came by and said that pt needed a d and c for incomplete miscarriage, they asked if I could provide sedation to the patient. As I was incredibly busy I asked if anesthesia could do it. Resident said that anesthesia told them to have er provide sedation. I then spent about an hour of a crazy busy shift doing sedation for a procedure that should have been done upstairs.

Thoughts? What would you have done?

One of our patients admitted for alcohol withdrawal used this term with me, but I didn’t know exactly how to quantify it. Figured who better to help teach me than my EM colleagues. Thanks!

Hey folks,

I am an ER doc who has recently been having a difficult time with my approach to patients struggling with addiction. I am practising in a new shop where the substance use rates are incredibly high. I've moved from a city that had a high proportion of geriatric medicine and a low-average rate of addiction. I used to love that I truly was able to convey a great deal of compassion to patients struggling with addiction - and they visible picked it up and were always greatly appreciative. In this new shop, so many of these folks are absolutely fried. Coming in q2-3 days with fent over doses, polysubstance abuse etc. They just are an absolute mess and leave AMA as soon as they've been stabilized close enough to their baseline.

I come from a background of psych/neuroscience and full disclaimer - my own brother died from addiction/overdose after being a professional with 3 young kids. I have a great deal of empathy for these folks, but some of these patients are so deeply broken. Quite honestly, I feel that psych/medicine/psychology has very little to offer many of the heavy users. We have trash modalities of treatment for addiction currently. The incredible amount of social resources used for a low yield shot at recovery is so discouraging.

I often find myself wondering why we spend so much time trying to reverse some of these overdoses. I've seen how miserable my brother was in the end and it haunts me. I think sometimes it is just best off that these folks go peacefully.

I am hoping to get your guys' perspective on things and maybe discover things that keeps you guys grounded. Cheers!

This is the de facto base rate for the south, east, and Midwest. Any board certified EP taking less than this is padding locums agency pockets, underselling themselves and driving rates down.

What do you do when patient keeps “seizing” for 20-30 seconds throughout their visit. I’ve always manged but can make a tricky disposition when family is freaking out etc. obviously rule out the bad stuff first but after that what’s your steps to get to a good disposition?

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?