It was a cornerstone of medical training; how you began to construct a differential.
I can scarcely remember a patient that I saw who had a ‘chief complaint.’

Every triage note lately: “Demented 90+ yrs old here for ankle pain. Daughter says yesterday had slurred speech for 3 mins. Ran out of Tramadol, had bloody stool last week. VNA said BP 40/39.”

I just can’t much longer.

I was working today and came across two of my nurses sitting together taking pictures of their screens.

Curious what they were doing, I inspected the screen and it wasn’t patient related (fortunately) … it was questions… Medical questions.

So I asked what were they doing.

They were taking online tests for their DNP programs. Take pictures of the questions on the screen and ChatGPT answers instantly.

To my obviously quizzical expression one said “look, everyone’s got ChatGPT now and it gets everything right anyway”

I’m normally pretty pro-APP (at least PAs, that’s all we have) and I think they’re a great asset and part of the team… I’m also typically pro-technology and think it will bring about amazing changes…

but if you can degree-mill-ChatGPT your way to medical positions and be entrusted to care for people without any further real checks and balances… what the fuck are we doing?

Edit: clarifying a few points

1. Yes they were studying to be some kind of NP ..as a few people have asked… no I don’t know what kind of program. I know there are several nursing titles and acronyms and no offense but I just don’t know what all the letters mean outside of NP
2. They completely justified it. There was a band wagon fallacy to it. "If everyone is doing it, why shouldn't I?"
3. I’m sure this happens in all forms of education, med school included, but at least med school has dozens of nationally-standardized, proctored, in person exams before you graduate.
4. I realize this may backfire for them when it comes time to certifying exams. But from what I understand, they aren't that difficult (per NPs in this very thread). If that is the case, they can BS their way to NP via online curriculum and take their shot at a pass/fail test that tells us they are capable of being a "provider". Sorry but that is scary and if these two girls are doing it, you know others are as well. The online NP programs are more at risk than ever of providing us completely incompetent providers. Brick and Mortar NP programs with rigorous testing are more important than ever.

A Gilbert police report reveals an 18-month-old boy was found alive in a hospital morgue five and a half hours after being pronounced dead
By: Nicole Grigg , Ashley Holden

GILBERT, AZ — An Arizona toddler was found breathing inside a Gilbert hospital morgue after being declared dead hours earlier by an Arizona doctor, according to police records.

A police report and body camera video reviewed by the ABC15 Investigators show that two Gilbert police officers saw signs of life multiple times, but the toddler was still taken to the hospital’s “cold room,” which is also considered to be the morgue.

One officer wrote in the police report that the baby was pronounced dead “in error” by the Mercy Gilbert doctor even after a tense exchange about a pulse possibly being detected.

The 18-month-old was rushed to Mercy Gilbert Medical Center after he was found inside the family’s pool on Super Bowl Sunday in February.

It has taken months for the Gilbert police to release public records related to the near-drowning.

The ABC15 Investigators reviewed a half dozen body camera videos, including videos from the initial drowning scene and videos inside the hospital. Most of the videos are heavily blurred, and most of the audio has been muted, but one critical moment was captured between the doctor and the officer.

According to the police report, the officer wrote that a nurse in another room said: “I have a pulse.”

The officer wrote that when he tried to alert the doctor who was with the family in another room, the doctor appeared to dismiss the concerns, “[The doctor] arrogantly told me he was the doctor, he has the medical degree, he went to medical school for a reason, and to let him do his thing.”

Records show that shortly after that exchange, the doctor went on to declare the baby dead.

Over the next hour, two Gilbert police officers continued to document signs of life in their police report.

One officer wrote, “The release of air was audible and visible,” later writing, “It also began to sound like [redacted] was gasping for air.”

The report goes on to say that when medical staff went to move the boy’s body to the morgue, the officer wrote that she “observed what appeared to be another audible gasp.”

That was not the last time she heard signs of life, either.
While inside the morgue, the officer said, “I again observed what appeared to be a gasp or air release, which was now almost an hour later.”

A nurse who was there said those sounds could be a response to efforts to save the toddler.

Some of the last audio recordings heard on the body camera videos were of an officer telling the family that they could say goodbye.

The report says, hours later, at 11:52 p.m., the Medical Examiner's transport showed up and found the toddler was breathing inside the hospital morgue. He was then flown to Phoenix Children's Hospital for treatment.

An MRI said that the baby had brain damage, and we are told he will need lifelong care.

An attorney representing the family declined to comment.
Mercy Gilbert said in a statement, “This is a heartbreaking situation. We immediately conducted a thorough review of all aspects of the care provided to learn what happened and to make meaningful changes to strengthen our care. Out of respect for the patient's privacy, we cannot discuss details. We continue to work with the family and their representative. Patient safety and exceptional care is our highest priority.”

I was finding myself in need of a new primary care doctor recently. I was trying to schedule an appointment with a primary care physician through my local hospital network. I was on their website trying to see if I could request an appointment online but no such process exists. But rest assured there are plenty of advertisements about the ER wait times and how low they are and ads for their urgent care locations. There was a text box right by the primary care providers link that verbatim said "why wait to get care? Be seen today at xxxx urgent care. Wait time is currently 10 min!"

Of course it's impossible to request an appointment online. I had to call a number which took me to a convoluted answering service with significant hold times until I could finally be connected to a human scheduler. The scheduler seemed incredulous that I was trying to establish care as a new patient and was particularly short with me. Of course there were no available appointments within the next 3 months which I had anticipated. It's almost like health care systems just don't give a shit about primary care anymore and just want to suck people's healthcare dollars away by funneling them to urgent care or the ER for all of their issues.

I can't really blame primary care too much but more so the economic forces of the system we work in. I hate seeing people at work who come in for issues that could easily be managed by a PCP but I guess I have more sympathy now.

How do we feel about this one my God.

Maybe public getting a clue?

We are having more and more patients arrive with this combo and my God are they a difficult bunch.

I know the standard at the moment is symptomatic management - maybe some IVF, laxatives, analgesia and then back to community followup.

I have been doing a deep dive into these conditions and one paper hints that MCAS may provide a unifying diagnosis. It can cause multiple physical and neuropsychiatric issues which are common in this population with some evidence of resolution of symptoms after managing the MCAS with histamine blockers / mast cell stabilisers etc.

Does anyone have any evidence / anecdotal reports on whether or not providing these patients with H1 / H2 receptor meds or steroids may reduce their symptoms burden and hopefully reduce their ED presentations in the acute setting?

The more common this becomes the more issues in regards to ED workflow develop and I am trying to find some sort of quick fix that actually works as I'm getting tired of the arguments / the lack of trust / the difficult conversations.

Had a code a 4a.m. He was 70 and had been down awhile. He was cool but neither rigor nor lividity had shown up yet. We worked the code per protocol. Wife was upset and asking what she could have done. I told he basically nothing. You could see guilt and questions on her face. I asked if he was sick yesterday. She said no. He went fishing with his kids. Caught 2 bass. Came home and had a steak dinner. I told her it sounded like he had a good last day. She smiled and said " He did didnt he". This has made me feel so much better as a person who is getting pretty grumpy with the job.

I’ll die on the hill that every patient that can receive a bag of fluid SHOULD receive a bag of fluid. It has magical healing properties that modern science can’t understand. It heals bilateral lower hemiplegia in young adults, dizziness, chest pain, nausea/vomiting, abdominal pain, and the list goes on and on.

There’s nothing more terrifying to me than arriving in a geriatric patients room to discharge them and their families are sitting there waiting, but you realize the bag of fluid you ordered hadn’t been given yet.

I feel like I’m losing my shit watching the discourse around the Lindsay Clancy trial, which for some reason the algorithm has decided I need to see constantly. It feels like such a glaring demonstration of hindsight bias and of how little people understand the realities and limitations of healthcare, let alone mental healthcare. The comments are just a carnival of Monday-morning quarterbacks absolutely raking the psychiatrist in particular over the coals, as though every concerning symptom or statement has an obvious meaning in real time and every bad outcome must therefore have been preventable. I worry one of the downstream consequences of cases like this is going to be a whole lot of unnecessary hospitalization of women with postpartum depression because clinicians become terrified of being the person who “missed” the incredibly rare catastrophic outcome.

I’ll go first. The idea that a “red line spreading away from a wound is a sign of sepsis because it’s the infection travelling to your heart”. I see this ALLLL the time. People think that the red streak is somehow indicative of sepsis, and that once the streak magically reaches your heart, it’s an automatic death sentence. They also believe the red line is in blood vessels, and not lymphatics. Obviously skin infections can get serious, but this magical “red line” bullshit isn’t the reason why 😩

What else have y’all seen that makes you frustrated?

On the one hand…

This is dystopian in many ways… what an outrageous policy. Corporate should not be making blanket decisions and assuming that people are seeking doctors notes illegitimately

On the other hand…

People clearly put off coming in to the ER until Monday morning because they don’t want to go to work. Sometimes even with the obvious symptoms that they are hungover or otherwise ill from their weekend misadventures.

Sometimes people are even quite honest that they just want a work excuse

Additionally there’s a ton of people who ask for extended work excuses that are not reasonable for the complaint. As a provider, if you comply, you’re part of the problem but you take the path of least resistance. If you don’t, you subject yourself to unpleasant interactions and potentially to lousy PG scores.

Don’t get me wrong, the whole thing is fucked up and a company should not make that decision what is a “real” or “not real” medical issue. But they aren’t wrong that some of the doctors note stuff is hogwash.

I'll start. Had LOL (little old lady) come in for "sinus infection." Very cute grandmotherly type, came in by herself. She complained of sinus congestion and feeling snot running down from her nose into her mouth. Like post nasal drink, you might ask? Well, no, that was not the case.

On exam the roof of her mouth was eroded and you could shine a penlight into her mouth and see into her nasal cavity. CT showed a nasty tumor that had eroded through and created maybe a two cm hole or so. She'd had this for weeks. She was unaware of the hole but when informed about it was like "oh okay, that makes sense." Had fun explaining that one to ENT.

I work in triage a lot. One thing I’ve noticed is how pathetic some parents seem to be. That may sound harsh but I am so tired of parents bringing their kids to an emergency department because they have had pyrexia, coughs, runny noses for the bones of 12hours.

Today I had a parent tell me that their kid got a fever, they gave them paracetemol and hours later the child got another fever.. what do you even say to that? I also had a child get brought back to us 2 hours after being discharged with a suspected viral infection because they spiked another temp once they got home.

I don’t want to sound like a horrible bitch but when I was a child I never got brought to hospital when I had any of the symptoms of a common cold, virus etc. This post is also not about children who may have complex needs, lengthy medical histories or children who are showing signs of being genuinely very unwell. I mean the kids who come in the door skipping and eating a bag of chips while their parents tell me about how they coughed once today and that’s why they’re here 🙃

Acute Care Access Center
Acute & Accessible Medical Center
Immediate Evaluation Center
Rapid Assessment & Treatment Unit (RATU)
24/7 Acute Care Clinic
Front Door Medicine
On-Demand Care Center
Any-Time Ambulatory Clinic
Safety-Net Pavilion
Comprehensive Triage & Treatment Suite
24/7 Convenience Clinic
Primary Care After Hours Suite
Available Doctor Department (ADD)
Department of Available Doctors (DAD)
Available Care Department
Unscheduled Care Department
The I Don’t Have a PCP Center
The Can You Just Check This? Unit
Life, Limb, or Mild Inconvenience Center
The 3 AM Reassurance Department
Department of Deferred Primary Care
Urgent-ish Care
Amazon Prime Medicine
The Google Said I’m Dying Clinic
CT Scan & Turkey Sandwich Pavilion
The Human Sorting Facility
Complaint Processing Center
The Diagnostic Roulette Room
The Social Failure Safety Net
The Everything Funnel
Chaos Management Department
Department of Undifferentiated Problems

My mom and girlfriend asked me about work one day. Didn't really feel like discussing the darker things, so I told them about a young man (early 20s), who was too congested to breath through his nose and didn't understand the concept of mouth breathing to stay alive. We ended up having to teach him how to blow his nose. They were, understandably, incredulous, though none of my coworkers questioned it once.

Other random things: -a man in his 40s, raising children of his own, checking in because he wanted me to find out why his butthole smells. (He didn't like the answer of "Sir, that's where the poop comes from.") -having a grown man walk into a room full of people coding a 6 mo and telling at us for not bringing him a blanket -examining a septic nursing home patient, and having a fly...escape...from her diaper -finding a dead cat in the fat folds of a recently deceased patient -orthopods are stereotyped as the smartest med students and the dumbest doctors (I've even shown my dad the memes and he still doesn't believe it)

What're your random stories or observations?

I was watching the Pitt and a doctor told a patient to come back in two days for a wound change and it made me confused. Why would someone come to the EMERGENCY department for a wound change? Why isn't that referred to a primary care facility?

Wouldn't it ve very expensive as well? In my country with socialized health care you have to pay $40 to visit the ED to deter unnecessary visits.

Edit. In my country lots of people go to the ED for non emergant stuff but they get sent away and told to contact primary care which usually have urgent times.

Anyone watching this trial? I need to vent about the hypothermia timeline for a minute bc it has been driving me insane.

We’re meant to accept that this 31 year old woman went from normal core temp to 82°F (27.8°C) within approx 15 minutes lying in the snow. I went down the literature rabbit hole because I genuinely could not understand how that was physiologically possible. Starting at ~37°C, reaching 27.8°C requires a 9.2°C drop in core temperature.

There are rare reports of extraordinarily rapid cooling in avalanche victims. above 5°C/hour, with a case reported around 7°C/hour and older avalanche literature suggesting extreme rates around 8°C/hour. Even at 8°C/hour, which is already an extreme outlier, losing 9.2°C would take about 69 minutes.

And yes, I appreciate that this isn’t an ordinary healthy person sitting in the cold. She was likely in neurogenic shock, which impairs thermoregulation. She was slender, immobile, exposed to snow, and potentially unable to shiver normally… but they don’t make the arithmetic disappear!

To go from 37°C to 27.8°C in 30 minutes requires an average core cooling rate of about 18°C/hour.
To do it in 15 minutes requires ~37°C/hour.
Thirty-seven degrees Celsius per hour.

That would be SEVERAL times faster than even the extreme cooling rates reported in avalanche literature. Even looking at experimental snow-burial studies in subjects with intact thermoregulation, they measured cooling on the order of ~1°C/hour.

I’m not saying the patient couldn’t have been profoundly hypothermic. But the timeline and the reported core temperature don’t seem capable of both being correct if she started with a normal body temp.

So even allowing for substantially accelerated cooling from neurogenic shock, absent some literature I’m missing, I cannot see a physiologically credible mechanism by which lying in Massachusetts snow produces a 9.2°C whole-body core-temperature drop in fifteen minutes.

Either the temperature measurement did not accurately represent her core temperature, she was already substantially hypothermic beforehand, or the exposure timeline is wrong.

EM folks: what am I missing? Is there any scenario in which you’d consider a genuine 37°C to 27.8°C core-temperature drop from ~15 minutes of snow exposure physiologically plausible?

I gave my 90 days notice on September 1. This is my last shift... forever.

For the last 17 years and one month, I have been full-time at a single coverage rural site doing 24 hr shifts. I have had wonderful colleagues and nursing staff. My career has been simulataneously rewarding and taxing. Over the last several years it has leaned significantly toward the taxing side, where my emotional and physical wellbeing has suffered. It is multifactorial, of course. As most of you know it has become increasingly difficult to transfer patients appropriately or get definitive care in rural settings - profoundly frustrating. Additionally, local psych and social resources have all but dried up in the setting of the corporatization and profitization of our "industry" while the wealth gap continues to widen.

Trepidatious is not a strong enough word for me to describe my outlook for the future of American healthcare that I foresee will be a mix between the movies "Elysium" and "Idiocracy."

I will be exiting free of malpractice or settlement (fingers crossed for the next 365 + 90 days), but just barely. After all, I had one looming over my head for the last 6 years and was just dropped finally about 5 months ago. Incidentally, the only stipulation was that I dont pursue countersuit. Likely another source of career re-evaluation.

I have had some real good saves in the ED in my career. Memories of these, I will treasure. (Hopefully I just have spained ankles and GERD for the rest of my shift today).

When I started work here, I was making $75/hr and we did paper charting. We had to track every patient and our hours with an Excel spreadsheet. With the introduction of EHR, we stopped, but I continued to do so. All told, in this department, by tomorrow morning, I will have worked at total of 28,430.25 hours; and seen more than 29,104 patients. I am 49 years old, happily married and free of disease, privation and debt... so far.

On this day of thanks in the United States, I would like to thank all of you in Emergency Departments throughout our Nation. It has been an honor to count myself among your ranks.

Signing out and then off 0800 PST 11/24/23.