There's no exact answer here. The only thing you must do is pick up and treat the SBP, if present. But for all of you trying to determine if your work has list its "soul" and all that, think about it this way. Once a patient rolls into your ED with 10 L of fluid in his belly, he's probably got a life expectancy less than most of your cancer patients. Ever wonder why all these weird subspecialties keep popping up under EM, like Palliative Care, Pain, Sports Medicine and the like? It's because EM still has a soul, if you choose to see it. No one says you got to sit there holding vacutainers until you get 10L off someone's belly, if your department is imploding around you. But once you make the decision to stick an 18 gauge needle through a terminal liver disease patient's abdominal wall, would it hurt to draw enough fluid off so that you he can actually have some quality of life, during one of the next few of his last few weeks to live? Do you have to do it? No. Might you make a dying patient's life a little better for a few days or weeks until his next tap? Probably. If you just feel too best down most of the time, I get it, because I've been there 100 times over. But Medicine hasn't completely lost it's soul until you surrender it. Look for the "soul." It's right there in front of you more often than you might think.
