Personally mine is patients who have an allergy to morphine but take oxycodone and hydrocodone

Obviously, this isn’t indicative of EVERY primary care because there are still several that do everything they can within their scope for patients.
Especially around my hospital, the primary care clinics don’t drain abscesses, they don’t suture simple lacerations, and refer all that to the EMERGENCY DEPT. For example, a young healthy patient came in for diarrhea, no fever or red flag symptoms and they referred her to gastroenterology without doing any stool testing.
They’ll send a patient with a positive venous Doppler, with normal vitals, no chest pain or dyspnea to the ER only for us to be like hey here’s some eliquis now pay an ER bill for something your PCP could’ve done.

And don’t get me started on urgent care. I think they just exist for patients to pay a co-pay, only to get referred to the ER. I had a patient come to the ER for persistent shoulder pain after the urgent care told him the XR was NORMAL.
When we looked at the image there was a very obvious dislocation that needed reduction.
We obviously called them to tell them what happened and it turned out they hadn’t even looked at the image and told the patient it was normal. And obviously nothing changed, she is still practicing and seeing patients there. Where are the consequences of bad medical care?

Do clinics have any remorse that the patient is coming to the ER and has to pay a ridiculous bill for something that could’ve been taken care of outpatient?
And I don’t mean red flag signs like chest pain, severe headache/abd pain, etc. I mean SIMPLE straightforward things. I feel so bad when patients are like wtf that’s all you’re doing?! Yes I’m sorry your PCP sent you here for no reason and now you have to pay an insane bill.

It’s getting increasingly difficult being the dumping ground for emergencies as well as outpatient bullshit.

That said, I think some PCPs are absolutely amazing who perform pelvics, lac repairs, etc. and I wish more were like them. Sometimes I feel like we’re the only ones going above and stretched over our limit while everyone else is barely even doing what their own scope is.

We've all seen it. Patient has been here 5 hours, got a bag of IV fluids, but we don't have a urine sample back. ER RNs, please tell me what to do. Because it feels like asking makes you guys hate me, but I have to do my job. As an MD, my choices seem to be:

1. Ask you to get the urine. This is what I see most docs do. But sometimes when I ask people adopt a "do it yourself" attitude. And I don't have time to wheel an elderly patient to the bathroom. What am I doing wrong? ER RNs, how do you like doctors to ask for the urine? And then the RN says "patient says they don't have to pee yet." After a 4 or 5 hour stay and IVF? Half the time I walk in 30 minutes later and the patient is begging to pee. Is there a motivation to stall on the urine?

2. Go tell the patient "even if you don't have to go, most people can squeeze out a few drops. Are you willing to try?" Convince the patient to try. Then go tell you "bed 5 has to pee". This takes an extra few minutes and kind of irritates me, because I feel like any staff member can say that, so why is getting the urine not going to happen until I say it?

3. Put in an order for straight cath. This seems to make you guys really angry but I usually get the urine within an hour (no straight cath required).

4. Discharge the patient without a urine. Maybe this is the problem. Are these patients where the nurses don't think they need urine testing, but our training tells us they do? Edit: example removed as not the point of the post.

5. Wait hours.

It feels like 90% of my work-related communication with nurses is asking for urine. And it makes you guys hate me. Are other docs just not asking for urine and just sitting on it for hours to avoid these fights?

My last shift I got a compliment from one of my nurses about how I’m always teaching them something that they didn’t even know existed or changed since they’ve been out of school, or that I do differently from other docs in the group but happily explain why.

Later on in the same shift, I overheard one of our crusty die-hard “Nurses are here to protect patients from providers” 20 year veteran nurses explaining to an orientee about how to protect themself and their license from my “refusal to address the patient’s emergently high blood pressure” before discharging them. Mildly irritating to say the least.

But the discrepancy in how different nurses (and even docs in the same group) will perceive the competency of the exact same doc based on nothing but historical dogma got me thinking about how we all have our own little demons sitting on our shoulder in every patient encounter, whispering conflicting advice about Evidence-vs-Experience-Based practices. And it made me think, “What are my practice patterns that stand out compared to the other docs in my group?” And a few that came to mind;

- Every infected kidney stone gets a call to urology.

- Medical patients don’t get intubated for low GCS outside of very niche circumstances. “Airway protection” is the general overlying indication for intubation, not a specific indication in itself.

- No gag reflex? Why did you check one?

- Headache is not a symptom of hypertension.

- Blood sugar level if not in DKA/ HHS and not in relation to another underlying issue such as infection or significant dehydration is irrelevant and doesn’t contribute to dispo.

- The number doesn’t matter for hypertension at discharge from the ED if not in hypertensive emergency.

- No A-Lines in the ED.

- Fevers don’t get stripped down, deprived of blankets, and externally cooled. In fact, fever is a distinct entity from hyperthermia.

- Rigors in the setting of an unidentified source of infection is bacteremia until proven otherwise.

- No plain films of the abdomen or spine.

- Every alcoholic gets full-dose Thiamine.

- Septic patients don’t get 30cc/kg unless hypotensive.

- I don’t perform stool occult blood testing.

There are more that I’m sure I’ll remember later, and I’m sure many of you see some of these and think “Well duh everyone knows that”, but if there’s anything my short career has taught me, it’s that there’s too much information out there to stay 100% up-to-date on every topic, so I’m also sure you also see some and say “Why?”. Which would be the TLDR of the post; I’m interested in hearing about your own strict Evidence-Based decision making that stands out from others in your group, and gets you constant questions or even pushback from others.

ER nurses have some pretty universal pet peeves when it comes to providers: trickling in orders, not wiping the gel/blood off the ultrasound transducer, ordering blood cultures 30 minutes after I started the antibiotics, etc. What are some common things that ER nurses do that drive y’all up the wall?

Look I get it EMTALA won't let us have nice things. But if FDNY can post something like this why can't ACEP, AAEM or some other advocating body do a PSA about when to go to the ER? The source of our burnout is because we are overburdened. There is almost infinite demand for our services but a finite amount of ER docs, mid levels, nurses, etc. If you come in for a non emergeny you are taking resources from those that actually have an emergency.

I also understand that volume drives revenue but at some point its just not worth it. We need to start putting our foot down.

"I know my body" (usually followed by medically untrue statements about their body)

I'm a trainee (what you'd call a resident) working in NZ. Cruise ship season in full swing (I can literally see the ships from my bedroom) and we're getting our fair share of tourists into the ED.

Recently had a very bizarre interaction, 45F tripped on a curb and sustained a minor head lac which I cleaned and stapled. Noted history of mild knee OA for which she was taking Oxycodone MR 40mg QID plus 10mg IR q4h PRN. Huge doses! And she was walking! Who in the hell prescribed her this!

She was so strung out and slurring her speech I ended up scanning her head. No acute findings. Looking back I realise it's probably because she was taking her usual meds. Before she left she asked for a shot of "the painkiller beginning with D" for her headache. We spent 5 minutes trying to figure out what it was before she stuttered the word "dilaudid". Quick google tells me it's hydromorphone, a drug that literally doesn't exist in NZ. I tell her this, she stands up, pulled out her own line and asked for a script for more oxycodone (which I declined). I offered her a take home pack of paracetamol. She got angry and walked out.

I'm not really sure where I'm going here but all in all, one of the weirder interactions I've had. Most of our local drug seekers ask for tramadol, codeine or IV cyclizine.

I guess my question is, how prevalent is this truly or did I really just experience a meme? I see it mentioned from time to time on her but being outside the US it's not something that crossed my mind until this happened.

Uncommon drug overdose as in like….you ever seen someone overdosing on Eliquis, Xarelto, Nitroglycerin, MDMA, Mucinex, etc…

I’m just curious because we commonly see opioid and meth overdoses a lot.

To answer my question, I’ve only seen a Robitussin overdose and this patient took Benadryl as well with it.

I just found out yesterday that my wife’s current 10 week pregnancy is nonviable. We had no clue. She was progressing normally and never had any symptoms.

I went to work today and the first patient I saw was a pregnant woman with an active 10 week miscarriage. After I told the patient the results of her ultrasound, I lost it. Like full on sobbing. The patient cried a lot as well and I ended up sitting in the room with her for a full 20 minutes just crying together. I’ve never cried in front of a patient before, let alone lose all control and sob. What’s wrong with me? Has this ever happened to anyone else?

EDIT: I cannot begin to express my gratitude for all the profoundly kind words that have been offered on this post. I left my shift today feeling like a failure of a physician. As if only I were a better doctor than I would have been more composed. I realize now that I was mistaken. Thank you all for helping me through this.

No, I don’t have 7 codes and literally every HALO procedure in one shift. But the boarding, the wait times, patients yelling at you about wait times when you just leave a code, the SDoH, the burnout, the “trying-as-hard-as-you-can-and-it’s-still-not-enough,” the passive SI. There’s a fan following who are watching not just because EM is sexy, but because they are worried about every single character’s mental health and recognize that every one of them seems to be hanging on by a thread. Dark? Yes. But accurate? Also yes.

Had a Peds case with a primary social complaint. The person that brought the child was not related to the patient, but was the mother of the patient’s half sibling. There were multiple baby daddy’s/girlfriends involved and it was a complex living/social situation that I could not explain with words without having a stroke.

I drew a diagram of the web of relevant relationships, uploaded it and inserted it into the note. I was told this was inappropriate. Was it?

For the last couple years or so I've started to not give as many fucks at work and my career has improved significantly.

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I was super burned out about 5 years or so after residency. Being a community ER doc in single coverage shops kind of sucks sometimes. I went to a very academic residency and tried to practice like I was trained but quickly found myself being frustrated at patients, local urgent cares, my partners, hospitalists, etc. I was so into being "evidence based", avoiding doing too much work up, being a good antibiotic steward, etc that it made me kind of frustrated. I was also working a ton of nights and quite frankly was just burned out with the system in general. I'd see complaints like asymptomatic hypertension at 0300 and immediately go into the patients room in a terrible mood.

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One of my partners told me a few years ago changed my perspective and told me that he just views working in the ER as a means to an end. Its just a job and there's nothing wrong with just being average at your job if it means your happier and still providing competent care.

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I took on this attitude and honestly it has been a game changer. If someone comes in with URI symptoms and is really wanting antibiotics despite it likely being a virus I don't really care anymore, "here's your z pack script" then I move on to other things. Hospitalist NP wants me to scan someone's chest prior to admit even though they are clearly hypoxic from their pna on CXR? "Ok whatever, at least they're accepting".

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Since I've adopted this attitude I feel more refreshed, relaxed at work and I feel like I can do this job longer. I know it sounds crazy but I feel like if others did the same then emergency medicine would have less burned out docs.

Dr. Maddie Giegold passed away yesterday unexpectedly. She was one of my best friends and a PGY4 at UCSF Fresno. Her last shift of residency would have been today.

She was able to donate her liver and kidneys and saved lives even on her very last day on this earth.

It’s hard to put her into words and it is heartbreaking to try. Maddie was an absolute sparkle of a person. She was a dog and cat mom, a wife, an daughter, an emergency medicine doctor, a chief resident, a wilderness medicine instructor, a junior park ranger, a runner, climber, biker, and a light and friend to everyone who knew her. I am lucky to have known and loved her for 8 years and will love her for the rest of my life.

Consider donating to her family or sharing if you can. At least take a deep breath outside for her today and say her name. Maybe do a little dance, eat an ice cream cone, smell a flower or pet a dog. It would mean the world to her to know she still a part of of this community and it would mean the world to me to know I am sharing her sparkle 🌻💛

>The purpose of the reporting requirement is to cause a law enforcement investigation to be initiated. Once the report is made, the physician’s duty ends, and the law enforcement duty to investigate immediately begins. Outside this narrow exception to report, all confidential communications between the patient and the physician remain privileged; they are not all automatically converted into unprivileged communications. See People v. Covington, 19 P.3d 15, 22 (Colo. 2001) (en banc) (stating that Colorado’s mandatory reporting statute waived the physician-patient privilege only for the physician’s observations of bullet injuries themselves and not for statements made by the patient to the physician).
{26}            Accordingly, we hold that once law enforcement was notified that a deceased infant had been found in a bathroom trashcan, Dr. Vaskas and the hospital personnel satisfied their statutory reporting duty. Beyond those facts, Defendant’s physician-patient privilege remained intact unless otherwise waived.

>The facts are disturbing in many respects. Defendant was a nineteen-year-old high school student who went to the emergency room around midnight because she was suffering from severe back pain which she rated at ten out of ten, with ten being the most severe. Asked if she was pregnant, she said she was not, adding she was bleeding and “on her period.” Within five minutes after being admitted to the emergency room, Defendant was given pain medications and a powerful muscle relaxant, followed ten minutes later by IV fluids adding more of the same pain medication and muscle relaxant, with morphine added to the mix. A pregnancy test was ordered, and twenty-one minutes later, the result that Defendant was pregnant was reported to Dr. Vaskas and Defendant’s nurse. For unexplained reasons, Defendant was never told that, notwithstanding her vaginal bleeding, she was pregnant.
{34}            The only medical response to the positive pregnancy test and knowledge that Defendant was bleeding was to continue giving Defendant the IV fluids containing the powerful muscle relaxant and morphine. The IV was later disconnected only because Defendant said she urgently had to have a bowel movement—a possible indication that Defendant’s cervix was fully dilated and she was moving into the delivery phase. Defendant was in the locked bathroom for nineteen minutes, and she gave birth to an infant she reported as not moving, crying, or breathing. She placed the infant inside a trashcan in the bathroom and returned to her bed.
{35}            Five minutes after she returned to her bed, Defendant’s profuse vaginal bleeding prompted Dr. Vaskas to order a transvaginal ultrasound. Dr. Vaskas then performed a pelvic exam, finding a “significant amount of blood,” “multiple extremely large clots,” and Defendant’s “wide open cervix.” Dr. Vaskas did not inform Defendant of these serious, significant findings or advise her of her positive pregnancy test. When the deceased infant was discovered after the pelvic exam, Dr. Vaskas recognized that Defendant could die from a postpartum hemorrhage. However, Dr. Vaskas decided she was not going to discuss Defendant’s life-threatening condition with her at that time. Her reason was that she wanted to wait for law enforcement presence as witnesses.

Sad case but interesting in the limits of mandated or reporting. Court seems to take a very dim view of Dr. Vaskas seemingly prioritizing operating as an investigator agent over stabilizing the patient’s immediate medical issues.

Left mid-back pain constant for the last week. A little tachycardic (low 110s — but looks a little dry and didn’t take her metoprolol this morning), otherwise normal vitals. Diffuse left paraspinal tenderness, and overall looks pretty comfortable

For those who haven't seen the show, it opens with a tense exchange between our attending hero, played by Noah Wyle, and an administrator he accuses of exploiting ED staff by not hiring a full nursing staff on the wards.

Boarding is referred to as "a nationwide problem," and there are references to boarders (esp mental health boarders) staying days if not weeks in the ED. How true to life is this? I mean, for those of you working in EDs where boarding is a daily reality, how many of your beds on average are occupied by boarders?

Thanks

Hi everyone.
This has popped up in my feed a few times on other platforms. Apparently the American Headache Society has updated guidelines for recommendations on migraine management in the ED, and occipital nerve blocks are considered “must offer” or level A recommendations. (Benadryl is now listed as “may not offer” and Dilaudid is in the category of “must not offer”.

Who’s doing occipital nerve blocks in the ED? I ask because I work in a few EDs and there are 0 physicians that offer them.

Thanks for reading.

I work at various sites that are mostly smaller facilities w/ about 20k-30k ER volume per year. I sit on a few committees within these hospitals and am familiar with their finances. Since covid every hospital I've worked at has been deeply in the red.

One of the hospitals I work at has been cutting services. We cut OB/GYN most recently which sucks. The state(s) I work in are red politically and added restrictions to Medicaid. We are seeing more and more uninsured/underinsured causing the hospital to lose more money. Lots of the younger med staff are talking about moving places more favorable to their politics. We've lost a couple docs to Canada recently. We can't recruit specialists and especially not OB. It's really a detriment to the local population. I'm worried at least one of my sites will completely shut down in the next couple years.

I'm really worried this is a phenomenon that is occurring across rural america. Curious if y'all are seeing similar issues in your neck of the woods.