Post your boring, nonsense shifts!
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First, you are a stud. Seeing all of that in a standard 8-12 hr shift is impressive. You had several sick patients. And you can’t even dispo them properly because your hospital is overwhelmed.
You legit had 15 sick patients and an additional 5 of them was totally reasonable to be evaled in the ER.
Our health care system is so f’ing terrible. We are known to give free health care to everyone who shows up!!! Just somehow get into our country and make a beeline to the closest hospital. You’re all set.
Some of those guys you took care of sure play a risky game of personal health brinkmanship. Sometimes you wonder if they waited one more day they would just be dead. 6 hours even.
Man you did a lot of good work that shift. I really wonder if there were any patients who will positively benefit from that. Or will it just give them another month before ending up in the hospital again.
14) lol.
16) why even do the LP? 3 months?
16) I would throw that GI under the bus in the note
Your population is hella sick.
16) why even do the LP? 3 months?
16) I would throw that GI under the bus in the note
Your population is hella sick.
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What major academic hospital has an NP gatekeeper to their ICU? What the actual f? Nothing against NPs I’m married to one but that’s ridiculous.
It is not unusual to provide emergency care to patients who need it in civilized world
What the hell are u talking about allantois?
I think he's trying to justify spending millions on uninsured foreigners here for free healthcare. Otherwise we wouldn't be nice.
I feel like there are some shifts that are “good scary” and some that are “bad scary”. That shift was bad scary.
Why is a NP denying an obvious ICU Admission?
Because they have been given the power to do so without the knowledge required to use said power appropriately?
That’s obvious, but why have they been that power when a residency trained, board certified physician says they need to be in the ICU.
Haven't contributed since I became an attending. Here's a snapshot of my last 12 hr night shift. Our PCP's admit their own, we have no hospitalists except for the NP at night that does all the orders and H&P's
69 M, Pyelonephritis in solitary kidney, admit urology
73 M, Hearing aid part stuck in ear, removed in triage and D/C'd
66 F, Chest Pain s/p stent, admit to her cardiologist
43 F, Chest Pain/Anxiety after ETOH, D/C
23 M, Bronchitis X2 months with multiple unsuccessful outpatient treatments, sent by PCP, Observation
54 M, N/V/D, weakness; Admit for Hypokalemia and Hypomagnesemia
4 M, Fever; fluids, correctly dosed tylenol/motrin and D/C
49 M, N/V/D Abd Pain, Neg w/u and D/C
52 F, Chest Pain, Neg workup and D/C
38 M, "Not Feeling right" after smoking weed laced with meth trying to fix insomnia, Metabolize to freedom after sleeping it off and breakfast
63 F, COPD Exacerbation (again), observation
3 M, Came in with PD after parents arrested for arson and drugs, found in car alone at local gas station covered in soot, D/C with CPS approved family
28 M, "trouble breathing & chest pain" X 2 months, pectoral muscle spasm, D/C
83 F, yet another octogenarian belly pain w/N/V/D, admit due to concerns for recurrent C. Diff colitis
86 M, Orthopnea, due to multifocal PVC's, admit
68 M, Trach, PEG, feed, water, turn 2/2 brain bleed, cardiac arrest, etc. From home with aspiration PNA from tube feed, Admit
63 M, 3rd visit in 24 hours, at least the 10th in the last 60 days, with foley cath problems, observation with consult to urology (tired of him coming in twice a day because they can't seem to troubleshoot the foley at home after being educated multiple times)
5 M, Viral URI, correct dose tylenol/motrin and D/C
50 M, SI after getting in fight with spouse, medically cleared and still waiting placement
21 M, "Cat Scratch" after messing with a stray, Here's your azithromycin and D/C from triage
61 M, Right sided weakness and deficits for 2 weeks, NIH 5, has been driving and hobbling to physical therapy for a hip injury, they told him 3 days before coming in "You look like you've had a stroke, go to the ER" Negative Head CT and MRI, but total occlusion of bilateral ICA's, admit
And the one that had me leaving 90 minutes late...
58 M, Hx of prolonged ICU stay for original COVID with trach/PEG, ESRD on dialysis. EMS brought him in for altered LOC, hypoxic, hypotensive, Intubated, can't keep the sats up, hard to sedate, Admit ICU
69 M, Pyelonephritis in solitary kidney, admit urology
73 M, Hearing aid part stuck in ear, removed in triage and D/C'd
66 F, Chest Pain s/p stent, admit to her cardiologist
43 F, Chest Pain/Anxiety after ETOH, D/C
23 M, Bronchitis X2 months with multiple unsuccessful outpatient treatments, sent by PCP, Observation
54 M, N/V/D, weakness; Admit for Hypokalemia and Hypomagnesemia
4 M, Fever; fluids, correctly dosed tylenol/motrin and D/C
49 M, N/V/D Abd Pain, Neg w/u and D/C
52 F, Chest Pain, Neg workup and D/C
38 M, "Not Feeling right" after smoking weed laced with meth trying to fix insomnia, Metabolize to freedom after sleeping it off and breakfast
63 F, COPD Exacerbation (again), observation
3 M, Came in with PD after parents arrested for arson and drugs, found in car alone at local gas station covered in soot, D/C with CPS approved family
28 M, "trouble breathing & chest pain" X 2 months, pectoral muscle spasm, D/C
83 F, yet another octogenarian belly pain w/N/V/D, admit due to concerns for recurrent C. Diff colitis
86 M, Orthopnea, due to multifocal PVC's, admit
68 M, Trach, PEG, feed, water, turn 2/2 brain bleed, cardiac arrest, etc. From home with aspiration PNA from tube feed, Admit
63 M, 3rd visit in 24 hours, at least the 10th in the last 60 days, with foley cath problems, observation with consult to urology (tired of him coming in twice a day because they can't seem to troubleshoot the foley at home after being educated multiple times)
5 M, Viral URI, correct dose tylenol/motrin and D/C
50 M, SI after getting in fight with spouse, medically cleared and still waiting placement
21 M, "Cat Scratch" after messing with a stray, Here's your azithromycin and D/C from triage
61 M, Right sided weakness and deficits for 2 weeks, NIH 5, has been driving and hobbling to physical therapy for a hip injury, they told him 3 days before coming in "You look like you've had a stroke, go to the ER" Negative Head CT and MRI, but total occlusion of bilateral ICA's, admit
And the one that had me leaving 90 minutes late...
58 M, Hx of prolonged ICU stay for original COVID with trach/PEG, ESRD on dialysis. EMS brought him in for altered LOC, hypoxic, hypotensive, Intubated, can't keep the sats up, hard to sedate, Admit ICU
Sometimes we get really lucky. My overnight shift last night, and I'm paid hourly at this job:
1. 14 yo M with fever and other random symptoms. + COVID. discharge
2. 21 yo F with abd pain, brought in by father for possible appy. Not tender, not scanned. Labs ok, d/c
3. 75 yo M with fever and dysuria, WBC 17, +UA. Not septic, d/c with abx
4. 38 yo F with face pain and wanted 2nd opinion on why her dentist, who saw her earlier in the day, didn't want her to have antibiotics. I said follow your dentist's advice. d/c.
5. 72 yo F with 2 weeks CP, today worse. Labs, EKG, CT PE, trop x2 all neg. has good f/u, d/c
6. 62 yo M from jail p/w covered in poop, literally. hypotensive, tachycardic, UGIB. Hg 4.5. 4U pRBC, protonix, CaGlu, admit to ICU.
THAT'S IT
1. 14 yo M with fever and other random symptoms. + COVID. discharge
2. 21 yo F with abd pain, brought in by father for possible appy. Not tender, not scanned. Labs ok, d/c
3. 75 yo M with fever and dysuria, WBC 17, +UA. Not septic, d/c with abx
4. 38 yo F with face pain and wanted 2nd opinion on why her dentist, who saw her earlier in the day, didn't want her to have antibiotics. I said follow your dentist's advice. d/c.
5. 72 yo F with 2 weeks CP, today worse. Labs, EKG, CT PE, trop x2 all neg. has good f/u, d/c
6. 62 yo M from jail p/w covered in poop, literally. hypotensive, tachycardic, UGIB. Hg 4.5. 4U pRBC, protonix, CaGlu, admit to ICU.
THAT'S IT
Everyone is too far out for Paxlovid when I see them.
Yeah, I worked overnight last night and primaried 27 in 9 hrs. Not relaxing or fun. Also not paid hourly (thank God) but still. F that noise.
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Why the CaGlu? I’d never heard of this? (Sorry if a dumb Q)
Ca gluc has more Ca per unit than CaCl.
Oh, ok! It's been a LONG time. There was some advantage to gluconate. I can't recall what it was, though.
Yep, unless you are unvaccinated and high risk, you are always too far out, even if you got sick five minutes ago. So much hype and pressure for a treatment with zero high quality evidence to support its use.
Gluc has less sclerotic effects on veins and has much lower risk of tissue necrosis with extrav, which is why it's used almost exclusively outside of code situations despite the lower calcium content.
My understanding wasn't so much that there is no calcium in transfused blood, but rather that the PRBCs contain citrate which chelates calcium. Not enough to require replacement in most cases, but in massive transfusion the effect becomes notable and so you should be giving some calcium for every 4 or so units of blood you give.
Also giving blood tends to increase the K, especially if it's an older unit and calcium helps with that.
Ca chloride should be given in a central line although I have given it peripherally without any issues.
If they have close PCP follow up, I would prefer y'all do nothing and let me handle it.
I give calcium chloride through good peripheral access on occasion in which I think it's truly appropriate.
Oh, I see your problem here. Don't check an A1c from the ED.
This pt also happened to get 3L crystalloid (combo NS and LR, 1L by EMS, 2 by me) while waiting for labs. So he already received 3L when I got the Hg of 4.5. So now I figured he was super dilute. I gave him 1U ONeg while they were crossing 3 more, and due to having persistent hypotension I gave CaGlu just assuming that his electrolytes were all F-ed up and pts who get a lot of blood should get IV calcium due to the reasons stated above by others. I wanted to do anything to augment the BP. I also started him on levophed, which is probably not evidenced based...but he's alive now and doesn't have AKI. Endoscopy showed a huge duodenal bulb ulcer with a clot on it.
Had I had to do it all over again..I would have just activated massive transfusion...or perhaps given him 2U Oneg immediately. I dunno.
His first repeat Hg was 10 after 4U...so something good happened during the resus.
There is roughly zero % chance that I am starting a pt on insulin and discharging them from the ER. There’s a whole lotta education that needs to be done, lab follow up, outpatient monitoring, that is all outside of my job as en ER doc. I don’t even love starting pts on metformin from the ED and sending them, but I do bc benefits > risk. But a brand new initiation of insulin rx and dc from from the ED… nope nope nope not me.
NO!
Two reasons:
1) The amount of training and teaching someone requires typically exceeds 5 minutes. I literally don't have the time.
2) we are not trained on this at all...potential malpractice.
3) we have to draw the line somewhere between primary care and emergency care. If the nation wants primary care when they go to emergency departments, then they should rename it Primary Care Department and staff it with IM folks.
Lol if they have good pcp follow up they would get diagnosed before their A1C is 13 .. in my comically poor area I start metformin 500 bid if their sugar is > 350ish .. if I think they truly need insulin initiated immediately(rare) I admit them for new DM … most can be chilled out to around 350 with IVF then I start metformin. That said, I don’t order A1C in the ED, it doesn’t result timely and doesn’t affect my mgmt.
I would prefer the pcp handle it too but I hear a lot of “I called for an appointment and they gave me one in {3 months from now}” in my comically poor area.
Yea I hear a lot of that too....frustrating. Still I don't ever admit hyperglycemia and I'll titrate their meds up and up, but I won't start insulin. I'll send A1Cs to help the other docs, I don't care if it 7 or 14.
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That's one of the unique things about where I work. We have no hospitalists during the day, their PCP admits them. After we've done the workup, we can often get them to come see them in the ED and admit them, start meds then D/C, or arrange for quicker follow up
What do you do for people who don’t have a PCP?
Yeah, when you said this last time we talked - it blew my mind.
They rotate taking unassigned patients
Fastrack shift at one of my hospitals. I'm only supposed to see "treat and street" patients. It's like a UC but technically they came to the ER. 8 hours total:
1. 62 yo man with non-descript globus sensation with no concerning features. No tests. d/c
2. 19 yo man traumatic thumb pain, xr neg. d/c
3. 79 yo woman with finger pain for 2 months. There is a super tiny paronychia. I poked it. pus came out. d/c and no abx.
4. 13 yo boy traumatic thumb pain, xr neg. d/c
5. 15 yo boy elbow sprain, xr neg. d/c
6. 73 yo woman with cough for 10 days. xr neg. d/c with zpack and T3
7. 29 yo man here for wound check. lip repaired a few days ago, thinks infected and in fact it looks great. d/c
8. 54 yo woman with ear pain for 1 month. otitis media. d/c with abx
9. 5 mo girl with viral gastro. no meds, no tests, d/c
10. 3 yo with left wrist trauma pain, xr neg, d/c
11. 16 yo boy with left elbow pain, has anterior fat pad sign with no fx. treated as radial head rx. splint/sling and d/c
12. 18 yo M/F with viral gastro and heartburn, d/c with famotidine and zofran
13. 46 yo F with muscular LBP exacerbated by obesity, toradol IM and d/c
14. 34 yo M with pain for months after skateboard accident. no access to health care. ordered xrays largely just to help, not because i thought they were indicated. d/c
15. 21 mo F with elbow pain after mom picked her up, might be nursemaids? but it's fine now. no xrays, d/c
16. 30 yo man used Etoh, acid, ecstasy, cocaine, weed, and mushrooms all last night. He is surprisingly normal. Wanted to get checked out. He was checked out. d/c
17. 17 mo girl fell hit head, no concerning features, d/c
18. 63 yo man with bee sting and allergic reaction. gave benadryl/pepcid, d/c
19. 58 yo man with "my BP is high and I'm dizzy". 135 - 160 SBPs. d/c with no testing.
20. 73 yo man with toe pain, might be gout or cellulitis, treated for both. d/c with abx and prednisone.
21. 72 yo man with left leg lac, 10 stitches, d/c.
22. 22 yo man drunk wants rehab. Real jerk and was kicking medical equipment. Told him to come back tomorrow to see substance abuse navigator.
23. 21 yo F with swollen L mandible, already on penV because she was seen 4 days ago. Either abscess or adenopathy, and US showed adenopathy. Phew. No I&D needed now. Switched her to clindamycin, d/c
24. 49 yo woman burned her R hand, 2nd degree partial thickness burn. baci, wound care, d/c
1. 62 yo man with non-descript globus sensation with no concerning features. No tests. d/c
2. 19 yo man traumatic thumb pain, xr neg. d/c
3. 79 yo woman with finger pain for 2 months. There is a super tiny paronychia. I poked it. pus came out. d/c and no abx.
4. 13 yo boy traumatic thumb pain, xr neg. d/c
5. 15 yo boy elbow sprain, xr neg. d/c
6. 73 yo woman with cough for 10 days. xr neg. d/c with zpack and T3
7. 29 yo man here for wound check. lip repaired a few days ago, thinks infected and in fact it looks great. d/c
8. 54 yo woman with ear pain for 1 month. otitis media. d/c with abx
9. 5 mo girl with viral gastro. no meds, no tests, d/c
10. 3 yo with left wrist trauma pain, xr neg, d/c
11. 16 yo boy with left elbow pain, has anterior fat pad sign with no fx. treated as radial head rx. splint/sling and d/c
12. 18 yo M/F with viral gastro and heartburn, d/c with famotidine and zofran
13. 46 yo F with muscular LBP exacerbated by obesity, toradol IM and d/c
14. 34 yo M with pain for months after skateboard accident. no access to health care. ordered xrays largely just to help, not because i thought they were indicated. d/c
15. 21 mo F with elbow pain after mom picked her up, might be nursemaids? but it's fine now. no xrays, d/c
16. 30 yo man used Etoh, acid, ecstasy, cocaine, weed, and mushrooms all last night. He is surprisingly normal. Wanted to get checked out. He was checked out. d/c
17. 17 mo girl fell hit head, no concerning features, d/c
18. 63 yo man with bee sting and allergic reaction. gave benadryl/pepcid, d/c
19. 58 yo man with "my BP is high and I'm dizzy". 135 - 160 SBPs. d/c with no testing.
20. 73 yo man with toe pain, might be gout or cellulitis, treated for both. d/c with abx and prednisone.
21. 72 yo man with left leg lac, 10 stitches, d/c.
22. 22 yo man drunk wants rehab. Real jerk and was kicking medical equipment. Told him to come back tomorrow to see substance abuse navigator.
23. 21 yo F with swollen L mandible, already on penV because she was seen 4 days ago. Either abscess or adenopathy, and US showed adenopathy. Phew. No I&D needed now. Switched her to clindamycin, d/c
24. 49 yo woman burned her R hand, 2nd degree partial thickness burn. baci, wound care, d/c
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You got a laugh because of #16. But, what is this? Two-fer, or androgyne?
Yea a gender change I believe.
