The crap we have to deal with…

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southerndoc said:
Had a 23 year old the other day who was dizzy. I was tied up with a transfer center issue. Resident ordered an MRI. I asked him why when I finally got off this long TC call and his justification was the patient was dizzy when lying flat, didn't seem positional, and had brief trouble ambulating. In all fairness, this resident is the top in his class.

I always let residents order a lot of CTs and other tests that I normally wouldn't order. It's always been my feeling that a resident needs a certain number of negative studies to feel comfortable with their own judgement. Sure, an attending can say "you don't need to order that" but it doesn't sink in as much as a negative study.

At any rate, end of story was he had 2 small cerebellar infarcts. 23!
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I think in the age of minimally symptomatic COVID that the risk factors for CVA in young people have never been more common. I'm not a huge advocate of CYA medicine but the consequences for a 20-30 yr patient with a missed CVA that progresses to a bigger stroke are pretty damn high. If that means our electricity bill is a little higher from running the magnet, that seems like a decent trade-off.
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southerndoc said:
Had a 23 year old the other day who was dizzy. I was tied up with a transfer center issue. Resident ordered an MRI. I asked him why when I finally got off this long TC call and his justification was the patient was dizzy when lying flat, didn't seem positional, and had brief trouble ambulating. In all fairness, this resident is the top in his class.

I always let residents order a lot of CTs and other tests that I normally wouldn't order. It's always been my feeling that a resident needs a certain number of negative studies to feel comfortable with their own judgement. Sure, an attending can say "you don't need to order that" but it doesn't sink in as much as a negative study.

At any rate, end of story was he had 2 small cerebellar infarcts. 23!
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Patient have a history of nitrous oxide abuse?
 
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Arcan57 said:
I think in the age of minimally symptomatic COVID that the risk factors for CVA in young people have never been more common. I'm not a huge advocate of CYA medicine but the consequences for a 20-30 yr patient with a missed CVA that progresses to a bigger stroke are pretty damn high. If that means our electricity bill is a little higher from running the magnet, that seems like a decent trade-off.
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Magnet is running constantly anyay
 
Unfortunately commonly abused. Illicit
bravotwozero said:
How would one do that? Inhale the gas directly? Where from?

Or is consuming nutritional supplements with NOS enough to do this
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bravotwozero said:
How would one do that? Inhale the gas directly? Where from?

Or is consuming nutritional supplements with NOS enough to do this?
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Unfortunately when there is a will (cravings etc) there is a way ($$$)
See Steve O and whippets.
 
rickylafleur said:
Unfortunately commonly abused. Illicit


Unfortunately when there is a will (cravings etc) there is a way ($$$)
See Steve O and whippets.
Click to expand...

The Zappos CEO Tony Hsieh was another nitrous casualty story. It's rare but people do get addicted to this stuff. Some will divert tanks of it successfully or otherwise they'll just have these massive piles of the little cartridges, it's pretty crazy.

I've probably seen this as the etiology of neuropathy 3-4 times in my short career though the west coast / Bay may be a little more nitrous-y than other parts of the country. This is a good tox pearl and something to think about when people come in walking all funny because they can't feel their feet or with what seems like a GBS-type of presentation. If you don't ask or think of it, you'll never diagnose it.
 
DrDrummer said:
The Zappos CEO Tony Hsieh was another nitrous casualty story. It's rare but people do get addicted to this stuff. Some will divert tanks of it successfully or otherwise they'll just have these massive piles of the little cartridges, it's pretty crazy.

I've probably seen this as the etiology of neuropathy 3-4 times in my short career though the west coast / Bay may be a little more nitrous-y than other parts of the country. This is a good tox pearl and something to think about when people come in walking all funny because they can't feel their feet or with what seems like a GBS-type of presentation. If you don't ask or think of it, you'll never diagnose it.
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Yep. Only seen a couple but they're definitely out there. It generally causes a B12 deficiency which can solely explain their symptoms. Cerebral infarcts are also a possible side effect as well.
 
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My last one this morning was a doozy, I got to witness the birth of a new troll. I'm taking my last lap around the department, wishing my relief was there, when EMS is checking in a patient in a wheelchair. The patient has all their luggage with them with fresh Greyhound baggage tags. I pull the medic off to the side and get the story: Patient decided to leave Illinois for greener pastures and decided on our state ("Wanted to see what John Denver was always singing about"). Tried to pull this stunt in another bigger city on the way to us, but EMS there refused transport, so they got back on the bus. Chief Complaint: All of them. "My knee's been hurting since 1994, I've been coughing for years, I need this bump on my side checked, I need to see social work and public aid for Medicaid and a place to stay. I won't go back to the VA"; ad infinitum, ad nauseam.
Exam negative, vitals better than mine. Got a CXR and a Knee XR to make sure there was nothing acute. No social work or financial people in house on the weekend. Gets wheeled to the waiting room where they promptly start walking around, goes to the snack machine and gets breakfast and is blasting Sinatra from their phone. Negative workup, here's a sheet of shelters and the address to the free clinic, and 20cc of GTFO. Wonder how many times they'll show up before I'm done?
 
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CajunMedic said:
My last one this morning was a doozy, I got to witness the birth of a new troll. I'm taking my last lap around the department, wishing my relief was there, when EMS is checking in a patient in a wheelchair. The patient has all their luggage with them with fresh Greyhound baggage tags. I pull the medic off to the side and get the story: Patient decided to leave Illinois for greener pastures and decided on our state ("Wanted to see what John Denver was always singing about"). Tried to pull this stunt in another bigger city on the way to us, but EMS there refused transport, so they got back on the bus. Chief Complaint: All of them. "My knee's been hurting since 1994, I've been coughing for years, I need this bump on my side checked, I need to see social work and public aid for Medicaid and a place to stay. I won't go back to the VA"; ad infinitum, ad nauseam.
Exam negative, vitals better than mine. Got a CXR and a Knee XR to make sure there was nothing acute. No social work or financial people in house on the weekend. Gets wheeled to the waiting room where they promptly start walking around, goes to the snack machine and gets breakfast and is blasting Sinatra from their phone. Negative workup, here's a sheet of shelters and the address to the free clinic, and 20cc of GTFO. Wonder how many times they'll show up before I'm done?
Click to expand...
Start a tally, amigo.
 
CajunMedic said:
My last one this morning was a doozy, I got to witness the birth of a new troll. I'm taking my last lap around the department, wishing my relief was there, when EMS is checking in a patient in a wheelchair. The patient has all their luggage with them with fresh Greyhound baggage tags. I pull the medic off to the side and get the story: Patient decided to leave Illinois for greener pastures and decided on our state ("Wanted to see what John Denver was always singing about"). Tried to pull this stunt in another bigger city on the way to us, but EMS there refused transport, so they got back on the bus. Chief Complaint: All of them. "My knee's been hurting since 1994, I've been coughing for years, I need this bump on my side checked, I need to see social work and public aid for Medicaid and a place to stay. I won't go back to the VA"; ad infinitum, ad nauseam.
Exam negative, vitals better than mine. Got a CXR and a Knee XR to make sure there was nothing acute. No social work or financial people in house on the weekend. Gets wheeled to the waiting room where they promptly start walking around, goes to the snack machine and gets breakfast and is blasting Sinatra from their phone. Negative workup, here's a sheet of shelters and the address to the free clinic, and 20cc of GTFO. Wonder how many times they'll show up before I'm done?
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I think I’d get greyhound tickets of my own after that interaction.
 
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I have so few Fs left to give. I had a horrible, verbally abusive 71 yr old woman escorted out by security last night. Seeing security holding one arm while she used her cane with the other made me almost feel guilty for a minute. Then she apparently called the cops from the waiting room because, again, she is horrible.
 
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GassYous said:
Magnet is running constantly anyay
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Magnet may be constantly on, but power consumption increases during scanning.

1655645117631.png

Bottom figure is most relevant, shows power consumption during different scanning modes.
 
Arcan57 said:
Magnet may be constantly on, but power consumption increases during scanning.

View attachment 356378
Bottom figure is most relevant, shows power consumption during different scanning modes.
Click to expand...
Interesting graphic.

Hard to gauge from that diagram exactly how much juice is flowing over time. The peak spike in the 1hour graph is denoted at 47kw. That would seem to indicate that longer scans like the SSFP are probably somewhere around 25kw. Eyeballing the peaks and troughs, I'd estimate peaks make up about 25% of the total hour shown. Assume that 25kw is the average juice when it's peaked like that. That means it takes about 6.25kwh to run a scan that takes an hr. Even in Hawaii (most expensive electricity in the US with an avg rate of 34.3 c/kwh per google), that means that the electricity to perform one scan likely only costs about 6.25kwh * 34.3 cents/kwh = $2.14.

Even if I'm off by an order of magnitude, the cost of electricity seems trivial.
 
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maxxor said:
I have literally never in my radiology career heard anyone care about the energy cost of a scan lmao.

Rad techs get paid $50+ an hour. The electricity cost is negligible.
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That was kind of my original point, which was the cost of using the machine for a particular patient is low compared to the cost of a missed CVA in a young person. Then you mentioned that the magnet is always on, which I was aware of. I thought that using the magnet took more energy then just maintaining the field at rest but realized I probably needed to show some proof of that statement which is why I pulled a Figure from an article talking about CT and MRI electricity usage in a Swedish hospital. Which led directly to @thegenius 's completely understandable befuddlement. As a fun fact, the Swedish hospital in question actually does turn their MRI off at the end of the day which I hadn't encountered in any of my hospitals.
 
Arcan57 said:
That was kind of my original point, which was the cost of using the machine for a particular patient is low compared to the cost of a missed CVA in a young person. Then you mentioned that the magnet is always on, which I was aware of. I thought that using the magnet took more energy then just maintaining the field at rest but realized I probably needed to show some proof of that statement which is why I pulled a Figure from an article talking about CT and MRI electricity usage in a Swedish hospital. Which led directly to @thegenius 's completely understandable befuddlement. As a fun fact, the Swedish hospital in question actually does turn their MRI off at the end of the day which I hadn't encountered in any of my hospitals.
Click to expand...

Unplug it. Plug it back in.
That's how you fix all electronics.
 
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CajunMedic said:
My last one this morning was a doozy, I got to witness the birth of a new troll. I'm taking my last lap around the department, wishing my relief was there, when EMS is checking in a patient in a wheelchair. The patient has all their luggage with them with fresh Greyhound baggage tags. I pull the medic off to the side and get the story: Patient decided to leave Illinois for greener pastures and decided on our state ("Wanted to see what John Denver was always singing about"). Tried to pull this stunt in another bigger city on the way to us, but EMS there refused transport, so they got back on the bus. Chief Complaint: All of them. "My knee's been hurting since 1994, I've been coughing for years, I need this bump on my side checked, I need to see social work and public aid for Medicaid and a place to stay. I won't go back to the VA"; ad infinitum, ad nauseam.
Exam negative, vitals better than mine. Got a CXR and a Knee XR to make sure there was nothing acute. No social work or financial people in house on the weekend. Gets wheeled to the waiting room where they promptly start walking around, goes to the snack machine and gets breakfast and is blasting Sinatra from their phone. Negative workup, here's a sheet of shelters and the address to the free clinic, and 20cc of GTFO. Wonder how many times they'll show up before I'm done?
Click to expand...

Here in Illinois, this is funny, as we just had one, just like your case.
Except she was from a "western mountain state" coming east for greener pastures.
 
Arcan57 said:
That was kind of my original point, which was the cost of using the machine for a particular patient is low compared to the cost of a missed CVA in a young person. Then you mentioned that the magnet is always on, which I was aware of. I thought that using the magnet took more energy then just maintaining the field at rest but realized I probably needed to show some proof of that statement which is why I pulled a Figure from an article talking about CT and MRI electricity usage in a Swedish hospital. Which led directly to @thegenius 's completely understandable befuddlement. As a fun fact, the Swedish hospital in question actually does turn their MRI off at the end of the day which I hadn't encountered in any of my hospitals.
Click to expand...

If you turn it off you quench the magnet and it can take days/thousands of dollars to restart
 
Kuratz said:
It makes me genuinely very sad and upset to hear what clinical medicine has become, with EM and mid level dominated primary care being the canaries in the coal mine. We see some of this indirectly in Rads and what some people are willing to come in for at 3am is ridiculous. These same people wouldn’t call a plumber for a long-standing issue in the middle of the night because it would actually cost them money. But come on in to the ED for an on-demand medical team and CT scan for your troubles for some minor issue that’s been there for months. Medicaid and others who essentially don’t pay can treat it like a McDonald’s drive thru and EM docs are the fast food workers. Always available and at your service. Would you like fries with your runny nose? It’s so ridiculous. I’m all for helping the needy but there needs to be more skin in the game for these people to act as some sort of deterrent and incentive for outpatient visits. I had Medicaid as a med student briefly and it cost me $0 for an ER visit (including an ambulance) and $3 for the prescription medication. Gee I wonder why people abuse this service?

While other fields like tech and business have made huge strides in compensation and perks for their workers (work from home, half day Fridays, big stock bonuses), healthcare workers across the board are working harder and harder for less and less. Talented people including damn good EM docs are looking to exit ASAP. We are going to have a massive issue with piss-poor medical care and it makes me worried for my own healthcare when I get older. What talented college kid looks at the trajectory of tech/finance and then at medicine and says “yeah I’ll put myself through 10 years of hell and hundreds of thousands of debt for that moral-injury laden sweatshop”.

Had to get it off my chest. Rads is great for now but what I see from other clinicians pisses me off and makes me depressed. Im sorry for y’all.
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Not sure that I have much of a right to be posting in this section because I’m not a doctor (yet) but just wanted to say that I am one of those kids making the grind rather than the initial dream of programming because I want to do humanitarian work with Doctors Without Borders after residency in EM. Currently work on an ambulance. I want to do something meaningful, giving to others. But posts like these do worry me because I hope there will be doctors like you and the good people who frequent this subforum when it’s time for residency. If I have to be mentored by soulless MD’s who only care about their career thus put up with these conditions IDK if I’d make it 😬 majorly conflicting interests.
 
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FairlyOrganic said:
Not sure that I have much of a right to be posting in this section because I’m not a doctor (yet) but just wanted to say that I am one of those kids making the grind rather than the initial dream of programming because I want to do humanitarian work with Doctors Without Borders after residency in EM. Currently work on an ambulance. I want to do something meaningful, giving to others. But posts like these do worry me because I hope there will be doctors like you and the good people who frequent this subforum when it’s time for residency. If I have to be mentored by soulless MD’s who only care about their career thus put up with these conditions IDK if I’d make it 😬 majorly conflicting interests.
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Everyone is very idealistic when they’re a premed. I’m still very idealistic now. I love doing good by my patients, going the extra mile to get them the care they need, being respectful that they come from a different walk of life from me.

But until you’ve spent some time in the ED as a doc it’s tough to explain how this sentiment will, to some degree, will be impressed upon everyone. Your empathy and desire to help people will be tested when someone who came in at 3am for a STI test and then calls the cops to the ER to claim you sexually assaulted them (always have a chaperone!).

How about the IV drug user guy with HIV/HepC who spits blood in your eye because you won’t give him IV opiates. I have an entire philanthropic organization that provides care for IV drug users. But stuff like that breeds burnout and changes the way you approach patient care.

It’s a job. And many times, your customers are pieces of crap.
 
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FairlyOrganic said:
Not sure that I have much of a right to be posting in this section because I’m not a doctor (yet) but just wanted to say that I am one of those kids making the grind rather than the initial dream of programming because I want to do humanitarian work with Doctors Without Borders after residency in EM. Currently work on an ambulance. I want to do something meaningful, giving to others. But posts like these do worry me because I hope there will be doctors like you and the good people who frequent this subforum when it’s time for residency. If I have to be mentored by soulless MD’s who only care about their career thus put up with these conditions IDK if I’d make it 😬 majorly conflicting interests.
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It's challenging in any walk of life to remain compassionate in the face of reality. Emergency Medicine presents more challenges than most. So it's quite understandable that many docs end up seeming like "soulless MD's". Burnout is real. But some of us still actually still enjoy practicing medicine and feel as if we're doing good for the world. Here are a couple things to be aware of:

-Internet forums like this attract the unhappy because we can freely gripe in them, so we might have a skewed sample here.
-The attitude of the attendings will come through in your interviews if you pay attention. So consider focusing on that (rather than their sim lab/meal plan/brand name) when evaluating residency programs.
 
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FairlyOrganic said:
Not sure that I have much of a right to be posting in this section because I’m not a doctor (yet) but just wanted to say that I am one of those kids making the grind rather than the initial dream of programming because I want to do humanitarian work with Doctors Without Borders after residency in EM. Currently work on an ambulance. I want to do something meaningful, giving to others. But posts like these do worry me because I hope there will be doctors like you and the good people who frequent this subforum when it’s time for residency. If I have to be mentored by soulless MD’s who only care about their career thus put up with these conditions IDK if I’d make it 😬 majorly conflicting interests.
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And if you make it through all of your above plan, you will (I’d imagine- have not worked with MSF) realize that 95% of your patients in 3rd world countries living on $2 a day are MUCH MORE grateful than 95% of our patients here (who can pick up the phone at any hour and have a trained dispatcher send trained paramedics to their home to bring them for evaluation by a board certified emergency physician for whatever they feel like, of any chronicity, at no cost to them) -
I would have never believed how crappy people treat us, before I was doing it.
I’ve worked fast food, waiting tables etc - at least then they are worried you’ll spit in their food if they are really egregious - at least then they have to pony up out of their own pocket - at least then they can’t sue you.
Seriously. I’m not saying it’s not great to be idealistic and it’d be concerning if you were jaded at this point in your journey, but .. we’re not bad people, promise. 😉
 
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