Why you shouldn't do EM

[deleted1027621]

I am 5.5 years out of EM residency. I went to residency at a well regarded academic center. There were 3 attendings over the age of 50 at that time.

1. A gentleman who was in his 70s, did 4-5 weekday 0700-1500 shifts a month to teach because he liked teaching. He was a highly successful businessman. He built a SDG and multiple side businesses before coming to academics. And he loved working with us residents. He was kind, compassionate and.... incredibly up to date on the latest and greatest in EM. He was what I wanted to be.
2. A lady in her 50s, bitter, mean, and always looking to crush the souls of subordinates. Of course she was in a leadership position.
3. A gentleman in his early 60s, weaning off leadership roles and drifting towards retirement. A legend. Great guy. Exuberant and frankly seemed to take joy from everything in life. Likely diagnosis of hyperthymia.

Everyone else working clinically was early 40s or younger. Yeah, I thought that was weird. But in my sweet naive mind, I thought everyone "retired" to an "easier" community job. Such a sweet summer child. Sure there are outliers. I have seen them in some of my community jobs. But the number of practicing EM physicians plummets at 50.

It is hard out there and getting harder. We are squeezed by all sides. IM, FP or even general surgery trained? Sure, take ACLS, ATLS and PALS and go work in the ER! No problem! NP, PA? Sure! Go work in the ER! EM trained? Well, there are a bunch of threads regarding what else you can do. It is really hard to see your colleagues that are not EM trained work in the dept with equal pay while you have no option to do IM clinic or do an IM fellowship. EM one year fellowships are available for FP to do EM, but no similar programs for EM to do FP or IM. It is disheartening. We are not valued. We are not only interchangeable with other EM board certified docs, but also with FP and IM and even Gen Surg Docs in the eyes of administrators and insurance companies. I didn't think this would bother me as I was told as a resident that it was only a matter of time when EM boarded docs would "push out" docs trained in other specialties. I have not seen this happen. Actually, I have seen shops that had been previously all been EM boarded open up to non-EM boarded docs. The mid-level crisis is a dead horse I won't go into in this post.

And I am a good doc. I was just given the "doctor of the month" award in our two hospital system. I have worked there 4 months. I have worked hard to try and save as much as I could so I would have a parachute for when either conditions deteriorate so much that I can't do this anymore or pay crashes so much that it isn't worth the stress and heartache. But I am scared. I hate that I am scared. I worked so hard to be an expert and to see the writing on the wall fills with me dread. I hate that I don't have faith that I can keep the current pay that I have now to be fully FI in 5 years. It breaks my heart.

I wish I could talk to med student me. I wish I could tell the younger version of myself that I wasn't special and I should pick something else if longevity was important to me.

Our leadership also needs to look into helping EM docs change pathways to helps us continue to practice medicine. Whether that be integrated pathways to shorten a new residency to change specialities or something I don't have the wisdom to imagine, but we need something.

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[GatorCHOMPions]

It is hard out there and getting harder. We are squeezed by all sides. IM, FP or even general surgery trained? Sure, take ACLS, ATLS and PALS and go work in the ER! No problem! NP, PA? Sure! Go work in the ER! EM trained? Well, there are a bunch of threads regarding what else you can do. It is really hard to see your colleagues that are not EM trained work in the dept with equal pay while you have no option to do IM clinic or do an IM fellowship. EM one year fellowships are available for FP to do EM, but no similar programs for EM to do FP or IM. It is disheartening. We are not valued. We are not only interchangeable with other EM board certified docs, but also with FP and IM and even Gen Surg Docs in the eyes of administrators and insurance companies. I didn't think this would bother me as I was told as a resident that it was only a matter of time when EM boarded docs would "push out" docs trained in other specialties. I have not seen this happen. Actually, I have seen shops that had been previously all been EM boarded open up to non-EM boarded docs. The mid-level crisis is a dead horse I won't go into in this post.

I wish I could talk to med student me. I wish I could tell the younger version of myself that I wasn't special and I should pick something else if longevity was important to me.

Our leadership also needs to look into helping EM docs change pathways to helps us continue to practice medicine. Whether that be integrated pathways to shorten a new residency to change specialities or something I don't have the wisdom to imagine, but we need something.

Quoted and bolded for emphasis. I also took the “only a matter of time before ABEM is required in all ED’s and our skill set is only going to get more in demand” bait.

 

[deleted1027621]

Furthermore, I want to be comforted. I want to feel like I didn't waste my 20s to be replaced by and told I am equivalent to a NP with an online degree and 600 hours of "patient contact."

I want to be told that my financial future is not screwed. I don't want to be anxious that I will soon be forced to work more for less pay and more liability. I want to feel that the $225,000 in debt I hustled to pay off was worth it. I want to be comforted that I am not going to get the doom and gloom 90 day notice that either my job is cut completely or that my pay is to be slashed by 25%, 30% or more.

But the public is against us. How can't they be with these private equity backed groups are charging astronomically for our services and then suing patients (recent NPR story. TeamHealth has since stopped this practice as it was reported, but the public rage and damage to doctors' image remain). The political will to take a swipe at EM billing is there. It is pretty much the only thing both parties agree with and that is terrifying. Billing is so opaque. Of course the public thinks we are getting paid the $5000+ from the billing of a single ED visit. I feel the public wouldn't feel so hostile towards us EM docs if they knew the doctor will actually pocket about $100 per pt. Now where the rest is going....

I read these forums and others hoping to get a glimmer of light. Hoping to be comforted. Humph.

 

[Cath Up]

At my interviews, there was everything from graduating EM PGY-3's, to EM PGY4 chiefs, to EM attendings that graduated >10 years ago.

The door is always open.

More competitive? Yes, with the appreciation that it is currently not competitive to match somewhere (of course, as with all specialties, the big names are going to be competitive). But, if the goal is simply to match and be a happy pallimed doc -- any accredited program will work out great. If we are talking more of the community-based programs in states which might not have a lot of people going out of there way to call home, then it is understandably easier. Given the nature of the work, it will never be one of the MOST competitive fellowships in medicine. But for the right person, it is certainly the most desirable.

Thank you!! Very helpful.

 

[AlmostAnMD]

I get some of those points.

While not for everyone, the option to pursue a medicine-based fellowship would be practice changing. All the ED fellowships really don't change that much for day to day practice.

ABEM's website says only 10 ED docs are boarded in pain, seems like half of them are on this website. That's probably the only practice-changing fellowship we have and options are limited.

Even if the specialty as a whole rallied behind going into other specialties via fellowship (including general medicine), I would imagine the others would be so protective of their turf we'd never be let in though.

 

[Birdstrike]

Does Your Earning Potential Drop To Zero Once You Step Outside The Circadian-Scrambling Pressure Cooker?

It's gut-wrenching reading some of these posts, because I've lived it. Make yourself less financially dependent on earning your living in one specific setting, that is only emergency departments. That doesn't mean you have to quit EM, or can't go into EM (although both fix the problem) it just means you're best advised to not be 100% pigeon-holed with your skills so that the emergency department is the only place you can go with them to earn your entire living.

That could be doing a fellowship, like I did (Interventional Pain) or any of the other EM fellowships. That's the path of least resistance and allows you to earn your EM-physician wage doing things other than ED shifts like administration, teaching, research, directing a fellowship, pain procedures, sports medicine work, critical care shifts, hyperbarics or toxicology consult service. Or it could be outside revenue streams unrelated to Medicine as such as real estate, investing, medical-legal consulting, insurance work or others. Either way, the Emergency Physician, in my opinion is best served by modifying your skill set such that your money making skills aren't worthless outside of an emergency department.

I can't tell you how liberating it was to step out of fellowship being able to think to myself, "I can either work 100%, 50%, 1% or 0% in the ED and not lose a penny." I went from 100% dependent on being battered, physically, spiritually and emotionally, to having no dependency at all. I imagine people with outside revenues streams or the ability to earn a substantial portion of their income as physicians outside of the ED setting, feel much the same way. Perhaps the less dependent we become on the ED, the more of us can stay doing the work the patients so desperately need.

 

[deleted497653]

Furthermore, I want to be comforted. I want to feel like I didn't waste my 20s to be replaced by and told I am equivalent to a NP with an online degree and 600 hours of "patient contact."

I want to be told that my financial future is not screwed. I don't want to be anxious that I will soon be forced to work more for less pay and more liability. I want to feel that the $225,000 in debt I hustled to pay off was worth it. I want to be comforted that I am not going to get the doom and gloom 90 day notice that either my job is cut completely or that my pay is to be slashed by 25%, 30% or more.

But the public is against us. How can't they be with these private equity backed groups are charging astronomically for our services and then suing patients (recent NPR story. TeamHealth has since stopped this practice as it was reported, but the public rage and damage to doctors' image remain). The political will to take a swipe at EM billing is there. It is pretty much the only thing both parties agree with and that is terrifying. Billing is so opaque. Of course the public thinks we are getting paid the $5000+ from the billing of a single ED visit. I feel the public wouldn't feel so hostile towards us EM docs if they knew the doctor will actually pocket about $100 per pt. Now where the rest is going....

I read these forums and others hoping to get a glimmer of light. Hoping to be comforted. Humph.

Hugs*

I.e side hug ....

 

[miacomet]

Furthermore, I want to be comforted. I want to feel like I didn't waste my 20s to be replaced by and told I am equivalent to a NP with an online degree and 600 hours of "patient contact."

I want to be told that my financial future is not screwed. I don't want to be anxious that I will soon be forced to work more for less pay and more liability. I want to feel that the $225,000 in debt I hustled to pay off was worth it. I want to be comforted that I am not going to get the doom and gloom 90 day notice that either my job is cut completely or that my pay is to be slashed by 25%, 30% or more.

But the public is against us. How can't they be with these private equity backed groups are charging astronomically for our services and then suing patients (recent NPR story. TeamHealth has since stopped this practice as it was reported, but the public rage and damage to doctors' image remain). The political will to take a swipe at EM billing is there. It is pretty much the only thing both parties agree with and that is terrifying. Billing is so opaque. Of course the public thinks we are getting paid the $5000+ from the billing of a single ED visit. I feel the public wouldn't feel so hostile towards us EM docs if they knew the doctor will actually pocket about $100 per pt. Now where the rest is going....

I read these forums and others hoping to get a glimmer of light. Hoping to be comforted. Humph.

Truth. I'm glad @gamerEMdoc and @ShockIndex are happy and that the latter is happy with EM exit strategies, but you speak the truth. I don't know what to tell you because, well, we are replaceable and are being replaced. We are just like autoworkers or travel agents- everyone is replaceable. Education is rarely worth it. EM is a particularly limiting field. I can't tell you that you didn't waste your twenties; you probably did.

Like all other workers replaced by automation and deskilling, we have to move forward. Just remember we have more in common with all the other W2 workers and their fragile jobs than with the truly wealthy.

And be glad you aren't a pharmacist!!

 

[Sushirolls]

I am 5.5 years out of EM residency. I went to residency at a well regarded academic center. There were 3 attendings over the age of 50 at that time.

1. A gentleman who was in his 70s, did 4-5 weekday 0700-1500 shifts a month to teach because he liked teaching. He was a highly successful businessman. He built a SDG and multiple side businesses before coming to academics. And he loved working with us residents. He was kind, compassionate and.... incredibly up to date on the latest and greatest in EM. He was what I wanted to be.
2. A lady in her 50s, bitter, mean, and always looking to crush the souls of subordinates. Of course she was in a leadership position.
3. A gentleman in his early 60s, weaning off leadership roles and drifting towards retirement. A legend. Great guy. Exuberant and frankly seemed to take joy from everything in life. Likely diagnosis of hyperthymia.

Everyone else working clinically was early 40s or younger. Yeah, I thought that was weird. But in my sweet naive mind, I thought everyone "retired" to an "easier" community job. Such a sweet summer child. Sure there are outliers. I have seen them in some of my community jobs. But the number of practicing EM physicians plummets at 50.

It is hard out there and getting harder. We are squeezed by all sides. IM, FP or even general surgery trained? Sure, take ACLS, ATLS and PALS and go work in the ER! No problem! NP, PA? Sure! Go work in the ER! EM trained? Well, there are a bunch of threads regarding what else you can do. It is really hard to see your colleagues that are not EM trained work in the dept with equal pay while you have no option to do IM clinic or do an IM fellowship. EM one year fellowships are available for FP to do EM, but no similar programs for EM to do FP or IM. It is disheartening. We are not valued. We are not only interchangeable with other EM board certified docs, but also with FP and IM and even Gen Surg Docs in the eyes of administrators and insurance companies. I didn't think this would bother me as I was told as a resident that it was only a matter of time when EM boarded docs would "push out" docs trained in other specialties. I have not seen this happen. Actually, I have seen shops that had been previously all been EM boarded open up to non-EM boarded docs. The mid-level crisis is a dead horse I won't go into in this post.

And I am a good doc. I was just given the "doctor of the month" award in our two hospital system. I have worked there 4 months. I have worked hard to try and save as much as I could so I would have a parachute for when either conditions deteriorate so much that I can't do this anymore or pay crashes so much that it isn't worth the stress and heartache. But I am scared. I hate that I am scared. I worked so hard to be an expert and to see the writing on the wall fills with me dread. I hate that I don't have faith that I can keep the current pay that I have now to be fully FI in 5 years. It breaks my heart.

I wish I could talk to med student me. I wish I could tell the younger version of myself that I wasn't special and I should pick something else if longevity was important to me.

Our leadership also needs to look into helping EM docs change pathways to helps us continue to practice medicine. Whether that be integrated pathways to shorten a new residency to change specialities or something I don't have the wisdom to imagine, but we need something.

You do have an out. It's your medical license. If ND and Chiro are making living with cash pay patients, you too can quit EM, open your own private cash practice and make it what you want. No guarantees you'll hit current EM pay, but you can make your practice what you want. Freedom is priceless.

 

[namethatsmell]

It is really hard to see your colleagues that are not EM trained work in the dept with equal pay while you have no option to do IM clinic or do an IM fellowship. EM one year fellowships are available for FP to do EM, but no similar programs for EM to do FP or IM. It is disheartening.

There is a training program for non-primary care docs to transition to adult outpatient IM/FP -- Physician Retraining and Reentry | Joint Sponsorship and Accredited by UCSD PRRPROGRAM

While I have no first hand knowledge of the program, it's as official as the EM fellowships you mention (that is, neither lead to board certification). The demand for pcp's is massive and as a board-certified EM physician with additional training and experience, I imagine many patients will glady chose you over an NP/PA. You could probably do this program and, if you moved to a bigger metro, open up your own direct-pay primary care practice and be your own boss.

To clarify, I'm not saying you should do this (though props if you decide to)...what I am saying is that we as EM docs DO have options. So many options. The beauty of EM training is that you develop both hard and soft skills that are highly useful and applicable to many endeavours aside from working shifts. A curse of EM training is that the powers that be want you to think you can only work inside the box. Well, turns out they don't know shi*t. The most relevant force keeping your options limited is you. Go break out of the box.

 

[TooMuchResearch]

You'd think if the public knew what we actually get is less than we pay our plumber, we'd get a little sympathy. Nope.

Furthermore, I want to be comforted. I want to feel like I didn't waste my 20s to be replaced by and told I am equivalent to a NP with an online degree and 600 hours of "patient contact."

I want to be told that my financial future is not screwed. I don't want to be anxious that I will soon be forced to work more for less pay and more liability. I want to feel that the $225,000 in debt I hustled to pay off was worth it. I want to be comforted that I am not going to get the doom and gloom 90 day notice that either my job is cut completely or that my pay is to be slashed by 25%, 30% or more.

But the public is against us. How can't they be with these private equity backed groups are charging astronomically for our services and then suing patients (recent NPR story. TeamHealth has since stopped this practice as it was reported, but the public rage and damage to doctors' image remain). The political will to take a swipe at EM billing is there. It is pretty much the only thing both parties agree with and that is terrifying. Billing is so opaque. Of course the public thinks we are getting paid the $5000+ from the billing of a single ED visit. I feel the public wouldn't feel so hostile towards us EM docs if they knew the doctor will actually pocket about $100 per pt. Now where the rest is going....

I read these forums and others hoping to get a glimmer of light. Hoping to be comforted. Humph.

 

[deleted836128]

Sad post but you make a lot of good points.

What’s wearing on me the most this week is nursing attitude when I order work ups the triage nurse in her thirty second assessment thought was a “quick in and out” patient. “Why are you ordering a work up on this patient with restless legs?” “She mentioned restless legs in triage but this 80 year old woman’s real concern is new onset thoracic back pain, so she needs a work up.” (Then I watch the nurse roll her eyes and go talk **** about me to the ER nursing director scowling over her computer) My favorite line this week was a nurse who said to me (about my 90 year old patient who came in for leg pain and also mentioned he had chest pain) in the most accusatory way, “Ugh, he only has chest pain because YOU asked about it.” You gotta love it.

 

[cyanide12345678]

Sad post but you make a lot of good points.

What’s wearing on me the most this week is nursing attitude when I order work ups the triage nurse in her thirty second assessment thought was a “quick in and out” patient. “Why are you ordering a work up on this patient with restless legs?” “She mentioned restless legs in triage but this 80 year old woman’s real concern is new onset thoracic back pain, so she needs a work up.” (Then I watch the nurse roll her eyes and go talk **** about me to the ER nursing director scowling over her computer) My favorite line this week was a nurse who said to me (about my 90 year old patient who came in for leg pain and also mentioned he had chest pain) in the most accusatory way, “Ugh, he only has chest pain because YOU asked about it.” You gotta love it.

YES!!!!!! One of my nurses in particular who just hates to work, anytime i order something, she just rolls her eyes at me and gives me sarcastic crap. She's a very experienced nurse, but if it was up to her, everything would be a quick I'm and out.

If i refer order a septic work up with blood cultures, then there is so much passive aggressiveness. I just explain why something is medically necessary and move on.

 

[cyanide12345678]

You'd think if the public knew what we actually get is less than we pay our plumber, we'd get a little sympathy. Nope.

Plus 50-70 percent of our patients probably don't even pay. I mean....a plumber wouldn't be providing any services without compensation for their time.

I sometimes wonder if medicare for all will increase reimbursement by increasing the percentage of people that pay, while decreasing payment per patient seen. Maybe in some of the poor run down inner city areas of the country?

 

[Birdstrike]

Plus 50-70 percent of our patients probably don't even pay. I mean....a plumber wouldn't be providing any services without compensation for their time.

I sometimes wonder if medicare for all will increase reimbursement by increasing the percentage of people that pay, while decreasing payment per patient seen. Maybe in some of the poor run down inner city areas of the country?

Yep, "Medicare for All" will be wonderful, especially when they start asking the achievers (yes, that includes you and I) to pay the $30 trillion tab every April 15th. You all are worried about your incomes dropping and you don't even think about the fact that we as physician high-earners are always the sacrificial lambs offered used to fund vote-buying schemes. Medicare for All would such devastate the tax base we'd be lucky to be paid $7.25 per hour after the tax rates get rearranged to the desires of the achievement-punishers. You all don't realize the left simply uses top 49% of achievers to buy the votes of the bottom 51%, to achieve power and enrich themselves?

 

[deleted836128]

YES!!!!!! One of my nurses in particular who just hates to work, anytime i order something, she just rolls her eyes at me and gives me sarcastic crap. She's a very experienced nurse, but if it was up to her, everything would be a quick I'm and out.

If i refer order a septic work up with blood cultures, then there is so much passive aggressiveness. I just explain why something is medically necessary and move on.

Ugh, it’s disheartening, isn’t it? I know life isn’t about being liked, but it sucks to be at odds with the nurses for stupid things like work ups or holding a patient in the ER while you try to get in touch with their PCP for follow up. Ironic because if it was their family member they would expect that kind of care, but they want you to turn and burn everyone else. No one gets rewarded for being thorough and catching an important diagnosis, but we get spit on for doing “too much” instead of “treating them and streeting them.”

 

[Arcan57]

Ugh, it’s disheartening, isn’t it? I know life isn’t about being liked, but it sucks to be at odds with the nurses for stupid things like work ups or holding a patient in the ER while you try to get in touch with their PCP for follow up. Ironic because if it was their family member they would expect that kind of care, but they want you to turn and burn everyone else. No one gets rewarded for being thorough and catching an important diagnosis, but we get spit on for doing “too much” instead of “treating them and streeting them.”

Everyone thinks everyone else sucks. We're trained to find the faults (in our patient's health, in ourselves, in our coworkers) and gratitude is often the first emotion to vanish from our repertoire when we become emotionally exhausted. Also, you probably are over working up people. Most of us do, for a variety of reasons ranging from the crass to the noble. Have an honest assessment of whether what you're doing actually has a benefit for the patient or it's just to make you feel better. Giving someone a follow up appointment /= them going to the follow up appointment and if that little extra comfort measure is causing an occupied bed for 2-3 hrs, is it worth it? FWIW, what's your plan if PCP doesn't call back?

There are a lot of ways to handle passive aggressive comments, some adaptive, some not. Some say let them bounce off you, I prefer to let them slide off. Your affect doesn't matter a lick to me as long as you do what I need you to do. A smooth, blank wall gives them nothing to find purchase on. "[He/she] makes me take care of patients" is a hard complaint for an RN to sell to their nursing leadership.

 

[emergentmd]

EM Medicine is one of the best fields to get a feel of other specialists and I would never do anything else hospital based. NONE, ZERO, Can't think of any other hospital based field.

Radiology, No thanks. 20 yrs ago, you could not find anyone going into it. They have their headwinds too that have to work in a dark room 24 hrs a day

Anesth - Ughhhh.. Probably the most unsocial/depressed looking of the bunch. Every specialty that comes to the ER I know well and have good convo except our gas buddies. Maybe just me, but I can't name you one by name. Any consult is met with an unhappy voice who leaves the ER without even saying a word. Maybe they are too busy but an unhappy looking bunch with a bunch of headwinds too.

Path - Ughhhh, no need to say more

Hospitalist - about a 25% happy group. Rest are grumpy, stressed out all the time, always complaining about a consult/hospital/pay/social issues/schedule.

Surgeons - Overworked. Clinic all day with surgeries, right into call. Never happy when they have to come in and will push everything on the hospitalist who gets abused by everyone. When they have to come in, boy are they sleepy/unhappy. I would be too if I did a full clinic and then have to come in for a 1am bowel ischemia and then facing a full clinic schedule the next day.

OB/GYN - See Surgeons x 10. Pre residency, I thought OB/GYN would be one of the happiest groups. Healthy babies, unicorns, happy familes. Yikes. Probably the worst of all hospital based fields. Imagine Surgeons+Anesthesia wrapped into one.

Surgical specialist - seems like the happiest of all. Why wouldn't they be? They almost never come in and always punt it to the hospitalist. Can't remember an ortho coming in for almost anything middle of the night. Open fracture.... IV abx and will wash out in AM. Reduction - I do them all and can't remember the last time they came in for anything.

TLDR - We have issues, but Lord, they all have issues x 10.

 

[EvoDevo]

In general these people don't have a medical emergency and are there for secondary gain. If I believe that, I chart as such using words like "belligerence, shouting, insulting" directly on the chart. I won't officially discharge them until any pending labs are back, but I certainly won't talk to them again.

The worst one I had was in South Texas. An entitled older white guy came in, with A-fib RVR (in the 130's) and chest pain. Right from the start he began name-dropping his cardiologist in Houston, and demanding that I talk to him before ordering any meds or tests. When I told him I wasn't going to do that, he began berating me, and stating that I "knew nothing", and that he wanted to see someone else. I told him I was going to admit him to the hospital and walked out of the room. I ordered all the meds, labs, etc and didn't go back in the room once. I called the hospitalist to admit him. The idiot patient ended up signing out AMA after the hospitalist talked to him and left.

If I truly think they might have a medical emergency, I let them AMA or elope rather than have a confrontation with them.

I just look at patients like this with a smirk. I let them rant. Then long awkward silence. Then after that, the "Are you finished now?" in an exaggerated Texas drawl.

Gets them abashed and listening instead of yelling/demanding.

No complaints yet.

YMMV

 

[SamtheWise]

Sad post but you make a lot of good points.

What’s wearing on me the most this week is nursing attitude when I order work ups the triage nurse in her thirty second assessment thought was a “quick in and out” patient. “Why are you ordering a work up on this patient with restless legs?” “She mentioned restless legs in triage but this 80 year old woman’s real concern is new onset thoracic back pain, so she needs a work up.” (Then I watch the nurse roll her eyes and go talk **** about me to the ER nursing director scowling over her computer) My favorite line this week was a nurse who said to me (about my 90 year old patient who came in for leg pain and also mentioned he had chest pain) in the most accusatory way, “Ugh, he only has chest pain because YOU asked about it.” You gotta love it.

It is very easy to disagree with a workup on a patient when your medical license and livelihood aren't on the line. Yeah the charge nurse is right, there's probably a 90-95% chance the old lady with restless legs probably just has restless legs and an acute deficiency of coping skills, but there's also a maybe a 5-10% chance it's something more sinister, and those aren't odds you should bet your career on just to satisfy a charge nurse. Also I feel like a 90 year old who isn't seeking comfort focused care and comes in with chest pain plus any other symptom needs a CTA of their entire great vessel system.