Surviving Night Shift

[RustedFox]

I sedate patients for perianal abscesses.

I sedate patients for breathing too loudly.

---

Members don't see this ad.

 

[Jabbed]

I'll do the PTA aspirations only if they are over 2cm. If less, then I don't even bother and will DC with abx and ENT f/u instructions. I used to do CTAs on all of these to visualize and delineate abscess size but nowadays I can often judge if it's less than 2cm based entirely on exam and I won't even bother with imaging. I have found that I do more of these since working with residents as I do think they need to know how to do them at the bedside.

I never do paracentesis anymore, especially after reading some of that iatrogenic SBP data. What a low yield procedure and most of the time completely impractical in a busy ED, plus it conditions that pt population to perpetually abuse the system and show up over and over again for taps. I might do a diagnostic aspiration if I'm feeling really nice but most of the time I don't even do those anymore. If they are blown up like a balloon and having some mild respiratory compromise then I just stick them in and have GI or IR do it as inpatient. I can't believe I used to sit there for half an hour with vacuum bottles or working up a sweat manually pumping that stuff into a bucket. I won't touch these unless I've got an intern that needs to learn the procedure and "put in their time".

I punt most perianal abscess to surgery unless it's clearly gluteal. I used to try to do some of these in the ED earlier in my career which is why I probably have hearing loss. It's like performing medieval torture. The screams that come out of the room... If I ever come in with one of these please for the love of God let surgery explore under anesthesia so I'm asleep.

I haven't done a thoracentesis since residency I don't think... Completely unnecessary in the ED.

Joint aspirations...usually not. Again, iatrogenic seeding of the joint is not exactly statistically insignificant and I'm much better these days of gauging a true septic joint vs tenosynovitis. Most of those traumatic hemarthrosis knees are going to fill up with blood within 24 hours of you tapping it. If it's a post op knee fogetaboutit. Ortho would count their lucky stars it if you poked a needle in there so they can finger you as the culprit in the lawsuit.

I kind of miss doing some of those cervical injections, trigger point injections, occipital nerve blocks, etc.. but damn...who has the time these days. I almost never have a slow shift where I can do some of those. I used to do intercostal nerve blocks for rib fractures or bad shingles lol...man those residency days seem like ages ago.

I’ll do PTAs if the stars align (resolved cellulitis, cooperative healthy patient). I’ll do native joint aspirations as well and have occasionally been surprised by what would otherwise have been an occult septic joint. I’ll do this as a fully sterile procedure though and the risk of infection/reaccumulation is emphasized verbally, in the consent, and on my chart. This all seems within scope of practice and standard of care.

Paras/thoras: almost never. I did one last shift because it was a slow day and I kind of just wanted to do it. I connected to wall suction and had the tech go in to change the cannisters. Ended up being a 5 hour dispo between work-up, drainage, and albumin for like 2 RVUs. So… not worth it. But at least I wasn’t sterile for 45 minutes manually pumping out 6 liters of peritoneal fluid 😅

Regional anesthesia is probably the most rewarding thing that I’ll do on a semi-regular basis. Taking away someone’s pain entirely is so rewarding. Every time it works I feel like I should’ve gone into pain medicine.

Yes, doing most procedures is rarely as lucrative as seeing another patient and, depending on your practice setting, there will generally be someone turf it to. I still find them rewarding at times though and like knowing that I still have your proficiency if need be.

 

[sloh]

Ended up being a 5 hour dispo between work-up, drainage, and albumin for like 2 RVUs. So… not worth it. But at least I wasn’t sterile for 45 minutes manually pumping out 6 liters of peritoneal fluid 😅

Wow haha, felt these were so cool to do as a medical student

Regional anesthesia is probably the most rewarding thing that I’ll do on a semi-regular basis. Taking away someone’s pain entirely is so rewarding. Every time it works I feel like I should’ve gone into pain medicine.

If only pain medicine procedures were actually that effective—or even close to it

 

[Rekt]

If I didn't do procedures, no idea how I could last in EM. It's really the only "fun" part. Imo it actually speeds up discharge. Most procedures take minutes. Couldn't imagine turfing a PTA. They're incredibly simple if it's set up safely. I left Residency with double digit drainage of PTAs. Who's doing your joint taps? That's insane. It takes like 90 seconds to do one. I love LPs, do them all despite most other docs turfing out to IR. I'll do diagnostic Thora/para but not therapeutic. Scrotal and perirectal depends on case by case. If there's a lot to go after that I can see I'll do it. Usually after imaging. Chest tubes I'm not calling anyone else to do. Same for tubes and c lines.

Mid levels can take the lacs.

 

[RoyBasch]

Joint aspirations...usually not. Again, iatrogenic seeding of the joint is not exactly statistically insignificant and I'm much better these days of gauging a true septic joint vs tenosynovitis. Most of those traumatic hemarthrosis knees are going to fill up with blood within 24 hours of you tapping it. If it's a post op knee fogetaboutit. Ortho would count their lucky stars it if you poked a needle in there so they can finger you as the culprit in the lawsuit.

Is doing a diagnostic arthrocentesis of a native easily accessible (such as knee) joint not considered firmly in the ER wheel house? I think my local practice pattern is pretty conservative with procedures (I have partners who haven't placed a central line in a decade) but I don't know anyone who wouldn't do a diagnostic arthrocentesis on a native knee where acute septic arthritis is suspected.

 

[RustedFox]

If I didn't do procedures, no idea how I could last in EM. It's really the only "fun" part. Imo it actually speeds up discharge. Most procedures take minutes. Couldn't imagine turfing a PTA. They're incredibly simple if it's set up safely. I left Residency with double digit drainage of PTAs. Who's doing your joint taps? That's insane. It takes like 90 seconds to do one. I love LPs, do them all despite most other docs turfing out to IR. I'll do diagnostic Thora/para but not therapeutic. Scrotal and perirectal depends on case by case. If there's a lot to go after that I can see I'll do it. Usually after imaging. Chest tubes I'm not calling anyone else to do. Same for tubes and c lines.

Mid levels can take the lacs.

I used to love LPs. Then, I moved to Florida.

 

[Groove]

Is doing a diagnostic arthrocentesis of a native easily accessible (such as knee) joint not considered firmly in the ER wheel house? I think my local practice pattern is pretty conservative with procedures (I have partners who haven't placed a central line in a decade) but I don't know anyone who wouldn't do a diagnostic arthrocentesis on a native knee where acute septic arthritis is suspected.

I don't have a problem tapping native joints if I'm suspicious of SA. Most of the times...I'm not though. I don't ever touch periprosthetic or post op joints nor has any orthopod ever asked me to. I don't tap traumatic joints. It's kind of hard to miss a septic joint. I used to tap symptomatic knees all the time after residency but don't anymore. It's like bacterial meningitis...most of those cases kind of slap you in the face. Hard to miss, not all..but most of them are pretty obvious. I don't LP nearly as much as I used to...

I'll send for fluid analysis if I need to but it grinds my pt's to a halt because our micro lab takes so long.

 

[Groove]

I’ll do PTAs if the stars align (resolved cellulitis, cooperative healthy patient). I’ll do native joint aspirations as well and have occasionally been surprised by what would otherwise have been an occult septic joint. I’ll do this as a fully sterile procedure though and the risk of infection/reaccumulation is emphasized verbally, in the consent, and on my chart. This all seems within scope of practice and standard of care.

Paras/thoras: almost never. I did one last shift because it was a slow day and I kind of just wanted to do it. I connected to wall suction and had the tech go in to change the cannisters. Ended up being a 5 hour dispo between work-up, drainage, and albumin for like 2 RVUs. So… not worth it. But at least I wasn’t sterile for 45 minutes manually pumping out 6 liters of peritoneal fluid 😅

Regional anesthesia is probably the most rewarding thing that I’ll do on a semi-regular basis. Taking away someone’s pain entirely is so rewarding. Every time it works I feel like I should’ve gone into pain medicine.

Yes, doing most procedures is rarely as lucrative as seeing another patient and, depending on your practice setting, there will generally be someone turf it to. I still find them rewarding at times though and like knowing that I still have your proficiency if need be.

Agree with you about regional. So satisfying and I try to teach the residents blocks when I have the time. I had a guy start crying from relief when I was in the middle of an intersalene for a dislocated shoulder. I didn't even have the needle out before he lets out a huge sigh of relief and was like "thank you!"

LOL @ the wall suction paracentesis. That's creative, I'll have to try that one sometime.

 

[Groove]

I sedate patients for perianal abscesses.

How on earth??? Moderate sedation? What positioning do you have them in? Lithotomy? Reverse lithotomy? Prone Jacknife? I can't imagine monitoring sedation safely while having my face pressed against someone's bunghole to thoroughly EUA, Cx and drain in the ED while taking care of all my other patients. Describe your technique. Are you just whacking them with the ketamine hammer long enough to do the I&D or what? Why not just hand all these perianal cases to general surgery or colorectal? I can't count the OR notes where they've been surprised at how deep these things go or run into unforeseen complication and/or think it's early Crohn's, etc.. I'd hate to inadequately drain of these and have someone develop a fistula from my poor technique in the ER. That's ballsy man. Maybe I'm lucky where I'm practicing but I've actually never had any pushback from surgery on these cases.

 

[emergentmd]

I will do a quick perianal I&D on pts that doesn't want to go the hospital, surgeon willing to see them in 2 dys, and they are cooperative.

 

[southerndoc]

I sedate patients for breathing too loudly.

Droperidol = vitamin D

Very very helpful when the N:E (noise:emesis) ratio is >1. Had someone the other day with cannabinoid hyperemesis syndrome who had a N:E of about 25. I think I heard them wretching 25 times before they were able to place some saliva in the emesis bag. No true emesis, so I guess the N:E is approaching infinity still.

 

[Dr Mantis Toboggan]

Droperidol = vitamin D

Very very helpful when the N:E (noise:emesis) ratio is >1. Had someone the other day with cannabinoid hyperemesis syndrome who had a N:E of about 25. I think I heard them wretching 25 times before they were able to place some saliva in the emesis bag. No true emesis, so I guess the N:E is approaching infinity still.

The #1 reason I don’t want the devil’s lettuce legalized in my state. I hate taking care of CHS.

 

[RustedFox]

The #1 reason I don’t want the devil’s lettuce legalized in my state. I hate taking care of CHS.

Dude, it's so agitating here in FL.
It's not even "legalized" or "decriminalized" or whatever nonsenseword that stoners use.
Everyone who complains of "anxiety" can go and get their "Medical THC Card" and it's legal.
But now, you can't go anywhere without obnoxious, smelly, cognitively-delayed stoners everywhere.

I went to an arcade two nights ago. An actual arcade; no bar. You could get some sodas as long as they stayed in the front, because the pinball machines (which was my big reason for going; I'll argue that I'm tournament-level good on a few tables) are vintage and kept in tournament condition.

So, I rack up a 1B+ point game on "Theater of Magic" and Shaggy walkes up and pushes start on the table to my right, reeking of stoner-piss and "mom's basement"-caliber body odor. And he just stares at the table with his glassy, injected eyes. Unclear on what to do next.

I really, really wanted to punch him in the mouth.

And then there was StonerDad in his "Pantera" tee shirt, with StonerMom and her 10/10 whitetrash tattoos. No bra under a Hanes wifebeater shirt. Both are mindless while their kid screams, running up and down the aisles of tables. Its 10pm; your kid does not belong here. I almost elbowed the kid in the skull once or twice when I pulled back the plunger for my next ball launch.

I hate stoners. A lot.

 

[WilcoWorld]

The #1 reason I don’t want the devil’s lettuce legalized in my state. I hate taking care of CHS.

Dude, it's so agitating here in FL.
It's not even "legalized" or "decriminalized" or whatever nonsenseword that stoners use.
Everyone who complains of "anxiety" can go and get their "Medical THC Card" and it's legal.
But now, you can't go anywhere without obnoxious, smelly, cognitively-delayed stoners everywhere.

I went to an arcade two nights ago. An actual arcade; no bar. You could get some sodas as long as they stayed in the front, because the pinball machines (which was my big reason for going; I'll argue that I'm tournament-level good on a few tables) are vintage and kept in tournament condition.

So, I rack up a 1B+ point game on "Theater of Magic" and Shaggy walkes up and pushes start on the table to my right, reeking of stoner-piss and "mom's basement"-caliber body odor. And he just stares at the table with his glassy, injected eyes. Unclear on what to do next.

I really, really wanted to punch him in the mouth.

And then there was StonerDad in his "Pantera" tee shirt, with StonerMom and her 10/10 whitetrash tattoos. No bra under a Hanes wifebeater shirt. Both are mindless while their kid screams, running up and down the aisles of tables. Its 10pm; your kid does not belong here. I almost elbowed the kid in the skull once or twice when I pulled back the plunger for my next ball launch.

I hate stoners. A lot.

I hope you two are also in favor of making alcohol illegal, because it's caused me 1000x more headaches than weed ever has.

 

[RustedFox]

I hope you two are also in favor of making alcohol illegal, because it's caused me 1000x more headaches than weed ever has.

I haven't had a drink in almost 2 years now.
Although I agree that drunks are obnoxious and nasty (and often need the ICU), they tend to not interfere with a good evening out with their terrific odor.

 

[bravotwozero]

I hope you two are also in favor of making alcohol illegal, because it's caused me 1000x more headaches than weed ever has.

I’m in favor of people belonging to either category get sent to jail instead of the ED for public intoxication. For some reason, cops seem to forget that still IS a crime in this country.

 

[WildEMDoc]

Going into my 4th year as a nocturnist.

Definitely stopped doing therapeutic paras (will do diagnostics if I am starting antibiotics), thoracentesis (if they need me to do it they need a pigtail). Don't really touch peri-anal stuff though, fortunately have surgeons more than happy to take care of butt pus. Will do PTA's if I can see them plain as day, don't go chasing anymore.

I'll also not infrequently knee injections (steroid+local) in people with gout or arthritic knee pain. Yes I know its a little bit overkill and enabling, I always tell them "your PCP can probably do this for you and not very many ER doctors will", but I'll tell you it is damn satisfying having a patient who has had such bad knee pain from arthritis, cant afford a replacement/no insurance, get some relief in the ED and probably for the coming months.

Dreading legal weed here but sometimes I'm not sure what is worse; the weird synthetic stuff people are buying from these head shops that take them to at best meth, at worse PCP. One of my shops doesn't have droperidol and gets really weird about haldol IV which makes it painful.

 

[Dr Mantis Toboggan]

I hope you two are also in favor of making alcohol illegal, because it's caused me 1000x more headaches than weed ever has.

I’m from WV. I can quit this **** and be a bootlegger.

 

[WilcoWorld]

I haven't had a drink in almost 2 years now.
Although I agree that drunks are obnoxious and nasty (and often need the ICU), they tend to not interfere with a good evening out with their terrific odor.

Ha! We meet different drunks.

 

[WilcoWorld]

I’m in favor of people belonging to either category get sent to jail instead of the ED for public intoxication. For some reason, cops seem to forget that still IS a crime in this country.

"jail clearance" more like "liability transplant"

At least it's an easy dispo in most cases.

 

[RustedFox]

Ha! We meet different drunks.

I mean; you have a good point.
If I'm going out; I tend to go to places where drunks don't congregate en masse.
I sure as hell stay away from motorcycle bars and other strange places.
Drunks tend to get policed by their friends better than stoners, because somehow - the friends of a stoner think "they're just fiiine".
Stoner-logic.
The friends of a drunk know when he/she is gonna generally be an ass, and they keep a weather eye out.
A drunk can walk into a place (say, an arcade), and the whole place doesn't immediately smell like *drunk*.

 

[BoardingDoc]

The #1 reason I don’t want the devil’s lettuce legalized in my state. I hate taking care of CHS.

Do you not have droperidol? I see a lot of CHS in my shop (at least one a week, frequently much more) and it's always an easy fix. 2.5mg IV drop +/- fluids and labs. DC once the drop makes their brain chemistry close enough to normal that they realize that they can have a tummy ache and not scromit everywhere.

I frequently DC them with an Rx for capsaicin cream as well as it keeps some of them from bouncing back. Plus it adds complexity to their chart and might bump up reimbursment a bit.

Drop doesn't work? It's like ketamine in this case. Just give them more. Eventually it works or they lose consciousness (I still consider that "it works") and then you DC them when they're awake enough to walk but not enough to whine.

That said, I did get one guy who had 8 ED visits in 4 days for CHS and I had seen him twice in 3 days for it. On that second visit I simply told him that he needed to stop smoking and that we would no longer be doing any tests or giving him meds in the ER for this. It worked. Now he only shows up for other stupid crap.

 

[GonnaBeADoc2222]

Dude, it's so agitating here in FL.
It's not even "legalized" or "decriminalized" or whatever nonsenseword that stoners use.
Everyone who complains of "anxiety" can go and get their "Medical THC Card" and it's legal.
But now, you can't go anywhere without obnoxious, smelly, cognitively-delayed stoners everywhere.

I went to an arcade two nights ago. An actual arcade; no bar. You could get some sodas as long as they stayed in the front, because the pinball machines (which was my big reason for going; I'll argue that I'm tournament-level good on a few tables) are vintage and kept in tournament condition.

So, I rack up a 1B+ point game on "Theater of Magic" and Shaggy walkes up and pushes start on the table to my right, reeking of stoner-piss and "mom's basement"-caliber body odor. And he just stares at the table with his glassy, injected eyes. Unclear on what to do next.

I really, really wanted to punch him in the mouth.

And then there was StonerDad in his "Pantera" tee shirt, with StonerMom and her 10/10 whitetrash tattoos. No bra under a Hanes wifebeater shirt. Both are mindless while their kid screams, running up and down the aisles of tables. Its 10pm; your kid does not belong here. I almost elbowed the kid in the skull once or twice when I pulled back the plunger for my next ball launch.

I hate stoners. A lot.

Whoa how does one get this good at pinball?

I feel like when I play the ball goes straight down the hole.

 

[RustedFox]

Whoa how does one get this good at pinball?

I feel like when I play the ball goes straight down the hole.

1. Know the ruleset for the table.
2. Understand 3 critical techniques

- the dead pass
- the post pass
- the drop shot

3. Practice.
4. Stop cradling (catching and holding) the ball on the flipper. Resist the urge to do this. Resist the urge to do this. Resist the urge to do this.

 

[CoolDoc1729]

I haven't had a drink in almost 2 years now.
Although I agree that drunks are obnoxious and nasty (and often need the ICU), they tend to not interfere with a good evening out with their terrific odor.

Also most people with problems related to alcohol acknowledge that’s the problem. The hyperemesis patients with the endless racket and drama are usually not interested in that being the cause because it’s “natural,” you know, like ricin. So it never gets better, not because it is addictive , but because it can’t possibly cause any problems.

 

[RustedFox]

Also most people with problems related to alcohol acknowledge that’s the problem. The hyperemesis patients with the endless racket and drama are usually not interested in that being the cause because it’s “natural,” you know, like ricin. So it never gets better, not because it is addictive , but because it can’t possibly cause any problems.

"BuT iTs aLL nAtUrAL..."

Christ, the number of times I have heard this.

 

[southerndoc]

The #1 reason I don’t want the devil’s lettuce legalized in my state. I hate taking care of CHS.

It's not even legal in my state. I've heard that edibles are usually the reason why people develop CHS. After they develop it, even second hand smoke can trigger it.

A few months ago I had some guy who had CHS so bad that his creatinine was 7, CO2 <5, pH 6.9, a BHB >5. When I asked him when the last time he smoked, he said "I smoked in the car right before being dropped off. I thought it would help with my nausea."

 

[WilcoWorld]

It's not even legal in my state. I've heard that edibles are usually the reason why people develop CHS. After they develop it, even second hand smoke can trigger it.

A few months ago I had some guy who had CHS so bad that his creatinine was 7, CO2 <5, pH 6.9, a BHB >5. When I asked him when the last time he smoked, he said "I smoked in the car right before being dropped off. I thought it would help with my nausea."

How can you smoke with a pH<7?!?!?

 

[CoolDoc1729]

How can you smoke with a pH<7?!?!?

I saw a (older, 70ish, not dialysis-dependent) lady Sunday night with BUN 150, Creat 19, pH of 7.08 but would have been sub 7 if she wasn’t as tachpneic.. looking back at the records she’s left from our waiting room a few times after getting labs showing creat 2-5-9-12. So she’s probably been functioning for a couple weeks around 7… 😳

 

[Dred Pirate]

The nights are killing me man. Currently i do a run of 5 and a run of 3 every month. 20 shifts total.

I’m a PGY3 so I know it should be hard but damn if I don’t feel like a pile of used diapers after a run of 5 overnights.

I did 7 on 7 off for several years- finally it just hit me "I feel like ****" - well actually it was after taking 3 weeks off, and I was like "Damn, I feel so much better" obviously not being at work helped, but just living normal made a huge difference.

An old timer told me, "its ok to do nights for a few years, but don't stick around too long. You will get used to being unhealthy, and you will also will mentailly not be able to deal with the daytime BS (mgmt, etc) on days because you have been away so long - and you will feel stuck

 

[southerndoc]

How can you smoke with a pH<7?!?!?

He wasn't mentating the best, but he had it together enough to smoke. I'm surprised he wasn't comatose. That same shift I had someone talking to me with a glucose of 16. Explained their dizziness!

 

[RustedFox]

He wasn't mentating the best, but he had it together enough to smoke. I'm surprised he wasn't comatose. That same shift I had someone talking to me with a glucose of 16. Explained their dizziness!

"Had it together enough to smoke".
That's the only function that stoners are generally capable of even with a pH of 7.35-7.45.

So... baseline.

 

[thegenius]

It's not even legal in my state. I've heard that edibles are usually the reason why people develop CHS. After they develop it, even second hand smoke can trigger it.

A few months ago I had some guy who had CHS so bad that his creatinine was 7, CO2 <5, pH 6.9, a BHB >5. When I asked him when the last time he smoked, he said "I smoked in the car right before being dropped off. I thought it would help with my nausea."

BHB?

 

[BoardingDoc]

BHB?

Beta HydroxyButyrate