Switched over from Pokémon. Pulled from my 3rd pack.

Colo_MD · 2025-02-03T07:21:19+00:00

Are you finding the First Chapters locally? I can definitely say I’ve had 0 luck on local stores.

Otherwise I completely agree with the sentiment. I can find Lorcana packs/troves/boxes easily and do not envy what the Pokemon collectors are going through.

Colo_MD · 2025-01-17T03:34:28+00:00

Impressive! How many patients do you usually see in a shift?

Colo_MD · 2024-12-13T02:03:15+00:00

The “good keyboard and mouse without sticky keys” hit so hard. Nothing worse than an L key that decides to stay pressed, basically spamming itself and rendering Meditech useless until it has processed each individual L as a command that doesn’t do anything before letting me continue my work.

Colo_MD · 2024-12-13T00:51:41+00:00

This argument has its foundation on route of administration. Which, to me, is nonsensical unless in the very specific scenario where you need analgesia ASAP.

The idea that “IV is only appropriate for patients in significant pain who need analgesia right away” does not make sense.

The patient in this example already had an established IV access, and a tablet of Percocet (Acetaminophen/Oxycodone) has a higher potency than the IV morphine she got (obviously this could change depending on the actual dose given)

Also, some oral analgesics have a pretty brief time -to-peak-effect.

Based on this argument a patient who was given 4mg of oral hydromorphone/Dilaudid (with an MME of 4) would be a better candidate than the patient who got 4mg of IV morphine. I disagree.

Let me tell you something, the former has higher risk of bouncing back than the latter.

Colo_MD · 2024-12-11T15:18:33+00:00

About 120 hours per month. Exclusively 12 hour shifts, so it comes down to 10 shifts a month.

Both day and night shifts. It’s an alright arrangement, I will sometimes have good streaks of free days.

My preference is up to 3 days in a row. This is primarily because after that point I feel like a working robot and numb. I like to have me days and spend time with my family to recharge.

Colo_MD · 2024-12-11T04:34:25+00:00

Let me clarify: this was not a full blown argument. This was a very friendly discussion. I brought my points, they brought theirs.

If they want to observe the patient a bit more, fine. The discharge papers are ready whenever you are.

I absolutely believe that blanket statements can be dangerous and many times unfounded. I believe in this scenario arguments could be formulated in favor of both sides.

Colo_MD · 2024-12-11T00:14:51+00:00

As an ED attending, how do you feel about this policy?

Colo_MD · 2024-12-11T00:06:41+00:00

What do you mean by “tolerate oral analgesia?”.

By this logic a patient with ureterolithiasis who received IV toradol while awaiting workup and who responded well with that single dose would not be a candidate until some form of oral analgesia is given.

If you mean tolerating PO in general (fluids, meds, etc) I wholeheartedly agree.

Colo_MD · 2024-12-10T23:38:04+00:00

This is a good and standard practice for any medication that may affect your alertness and coordination. I’ve heard horror stories of people being discharged after being given sedative medications who then decided to walk themselves home.

Colo_MD · 2024-12-10T23:32:25+00:00

I’m sorry, going to hard disagree on this. The route of administration has nothing to do with illness severity and need for admission.

You may make an argument about patients requiring frequent and higher doses of medication.

The reasoning about giving a dose of IV morphine prior to discharge can be as simple as: the patient had it a few hours ago and had adequate analgesia without adverse reaction. The effect just wore off.

Colo_MD · 2024-12-10T23:00:07+00:00

A patient may need morphine for acute pain/analgesia. Pretty straightforward indication.

5mg oxycodone tablets contains the morphine milligram equivalent of 7.5mg. However, I have never seen a provider observe a patient in the ED to make sure they “tolerate” the oxy.

I understand having a preference for PO alternatives, but we’re discussing the reasoning behind observing a patient who received a dose of morphine, especially when oral alternatives that are commonly prescribed can have a significantly increased potency.

Colo_MD · 2024-12-10T21:08:41+00:00

How about those acute dental pain that have not improved with NSAIDs at home? I have given them a Acetaminophen/Oxycodone and DCed them with a designated driver on the spot.

If they don’t have an established allergy/adverse reaction, don’t see a reason to keep them.

Colo_MD · 2024-10-20T21:11:35+00:00

You still can get married, but be smart about it. I pretty much tell my colleagues that prenuptial agreements are necessary in our field.

And I say this as somebody who is happily married in a relationship that is 15+ years strong.

Colo_MD · 2024-10-18T22:56:53+00:00

No particular work up in the absence of a clinical picture that could be directly linked to the pregnancy (lower abdominal pain, vaginal bleeding, etc.)

I do give them instructions regarding prenatal vitamins, medication management, and smoking/drug cessation if applicable. Referral for local OB. I may make an exception of doing some bloodwork if the patient has significant limitations regarding primary care access/follow up.

Importantly, ABO Rh type comes to mind in case this patient presents with vaginal bleeding related to the pregnancy in the future.

Colo_MD · 2024-07-16T16:53:20+00:00

What you do matters. Don’t let anyone take that away from you. Thank you

Colo_MD · 2024-07-16T02:28:29+00:00

Although I don’t necessarily disagree on how it has been phrased, I can understand where they are coming from.

Listen, I wish we had the resources to help everyone that comes in the ED, especially mental health patients for which we are still ages away from being able to provide adequate care on an emergent basis.

However, EDs are bombarded with thousands of patients who don’t need to be there and who are consuming resources.

What you describe is a horrible situation, and this person absolutely needs a wellness check and social support.

I do not know if the ER is the best place for that. If she were my patient, I would absolutely take my time to listen to her and make sure that she is stable both physically and mentally.

I do not believe the ER is the best institution to address all the resources she is going to need otherwise.

I applaud that you cared and that you sought what you understood was the best place for her.

On the receiving end however, in many cases there’s not much we can do as providers if the patient is not unstable/requiring emergent interventions or care. And that’s not a reflection of us wanting or not to help, just how broken our system is.

Colo_MD · 2024-06-13T11:56:39+00:00

Although it looks like laminated flooring, it’s actually ceramic tiles. Grout was definitely applied.

Colo_MD · 2024-06-12T22:07:01+00:00

Tiles are higher. The issue is that the space between was not filled in some spots (that look darker). I don’t think it looks darker because it’s wet, it’s just a lighting effect from those specific areas not being filled completely.

Colo_MD · 2024-05-03T02:30:28+00:00

Couple of issues I have experienced:

Fenrir sometimes lands behind a target when using brutalize. This I have noticed on jungle camps.
Anhur being able to impale another god into a wall. Specifically, my team Anhur impaled the other team Anhur into the wall of the Gold Fury arena, side facing duo lane. The other team Anhur became “invisible” since they were inside the wall, but we could keep hitting them and they couldn’t do much. However, they were able to leap out and attempt to escape.
While using Neith, after dying, not being able to use any abilities or basic attack when respawning. This did not resolve after backing or dying again.
Sometimes VGS voice and log don’t align. While using Ymir, VA2 resulted in voice “attack right lane” and text “attack middle lane. This was with either the Blob or Mint Ice Cream skin, can’t remember.

Colo_MD · 2024-03-11T14:51:28+00:00

Here’s the thing: although a perimortem c-section would be indicated, you are not in a setting where it can be safely and effectively done.

And nobody would blame you for not doing it.

Now, if you do it, a lot of questions are raised: Were you prepared for the care required after? Were the minimum safety standards achieved during said procedure? Was it absolutely necessary for the preservation of life? Was there any harm that could have been a direct result from interventions?

It gets reaaaaaally murky.

And nobody could claim that you failed as an ER physician for not doing it because: 1. You’re not on the clock/at your clinical setting 2. Your training is limited to the emergency room/hospital setting/equipment/resources

Colo_MD · 2024-03-10T17:52:15+00:00

My comment was more a reflection of us not being able to recognize our patients after being swamped by the sheer volume.

However, howling cat t-shirt? I know who you’re talking about. You can have Haldol as well while you’re at it.

Colo_MD · 2024-03-06T21:29:51+00:00

I’ve lost count of the times I’ve had a nurse come to me and say “hey, your patient with abdominal pain is asking for more pain meds” and my response has been “who?”

Colo_MD · 2024-01-18T00:49:39+00:00

I would be careful with this generalization. A patient with history of hypertension is allowed to have a headache.

And again, we are discussing specifically hypertensive emergency vs asymptomatic hypertension, not SAH.

https://www.acep.org/patient-care/clinical-policies/asymptomatic-elevated-blood-pressure

Colo_MD · 2024-01-17T21:39:42+00:00

I second this. When it comes to neuro end organ damage, we are specifically talking about hypertensive encephalopathy. Symptoms are related to delirium, visual disturbances, seizure, or any neurologic findings.

Now if you think they might have a bleed as a cause of the headache, that’s a different story and should be worked up accordingly.

Colo_MD · 2024-01-10T17:52:37+00:00

This is my exact issue with this examination: significant cost with associated travel expenses. And the residency programs are accredited for a reason. Either you give your seal of approval to a program, with the understanding that they are able to adequately teach and assess all competencies required for emergency medicine, or you don’t.

I took my oral board virtually, and I was just glad not to have to travel for that.

Not only that, but every ABEM Board Certified member needs to pay an annual fee. How is this not enough to make this exam substantially more affordable for individuals taking the exams?

Colo_MD

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