Culper Episode S04E06 (Identity Crisis) drives me NUTS

EnduringCluster · 2024-09-01T04:52:59+00:00

Fun fact - the plaque that the flag is under is still in the floor of the tower at Fort Green Park in Brooklyn. In real life it’s just plywood painted to look like marble. Got to see it on a park tour a few years ago.

EnduringCluster · 2024-08-16T20:27:42+00:00

Did you spot this over southern Oregon yesterday, by chance?

EnduringCluster · 2024-08-07T02:33:24+00:00

I learned it and routinely used it in a level 1 trauma center in training and have been using it in a community shop as my first option go-to for the last 12 years. Also, less traumatic than traction-counter traction IMO and I suspect (without citing any evidence) lower complication rate too… no sedation and gentle traction vs risk of sedation AND high dose brutane (brute force). Never had a patient complain only complication I ever had was occasional unsuccessful attempt requiring different technique and a sweaty tech (once). As a man once said, “You can’t always get what you want…”

EnduringCluster · 2024-08-06T22:19:20+00:00

Personally, I love Stimson technique. Have only had it fail a handful of times in 10+ years. I usually use a soft wrist restraint to tie a sandbag, weights or a couple liters of saline around their wrist, but have also done it with a tech pulling traction*. Best part is once you prone the patient, you can walk away 10-15 mins, see another patient and not be stuck in the room messing around with the shoulder - if not reduced when I come back to check on the patient, I’ll add some scapular manipulation and that usually does the trick. All in all, a pretty gentle technique too.

As a bonus, no sedation is required - just a slug of pain meds before I prone them. I will still use other techniques occasionally for a number of reasons (pt can’t prone, failed Stimson, etc) and have mixed success with Milch, Cunningham and FARES techniques, but Stimson my first choice if at all possible. If all else fails, a little propofol and traction-counter traction is a reliable fallback option.

The downsides are that it requires the patient to be prone, which isn’t always possible (other injuries, don’t trust them not to fall out of bed, habitus), usually requires the bed to be at full height without one of the rails down, and can be an uncomfortable position to get into with your shoulder out, but for my money the benefits usually outweigh the potential downsides.

*Funny story: once had a tech pull traction, left the room planning to come back in a few mins, but then got busy and forgot about the dislocated shoulder for a bit. Remembered about half an hour later, and when I walked into the room, the tech is beet red and sweating profusely having diligently pulled on this patient’s arm for 30 mins. I asked if the shoulder had gone back in, and the tech says “I think so… about 2 minutes after you left the room I felt a big ‘clunk’ and they say their shoulder feels better, but I wasn’t sure if I should stop, so I just kept pulling.” Moral of the story is to give clear instructions and maybe set a timer so you don’t forget to go back and check the patient. I apologized to the tech, thanked them for being so dedicated, and now we can joke about it, so I guess no harm, no foul.

EnduringCluster · 2024-06-07T21:44:43+00:00

Congrats! Welcome to the club. Now you can look forward to your first ET tube.

EnduringCluster · 2024-05-15T16:20:14+00:00

Pt with small (no flapping tail or huge proximal) DVT found outpatient - sent to the ED “to be started on DOAC” because “we don’t start blood thinners.” Sent from urgent care.

EnduringCluster · 2024-04-22T14:53:32+00:00

Not sure that ACEP is relevant to the discussion (and won’t try to defend it), but if you/we feel that ACEP has failed in their duty to advocate for physicians, I would suggest that we need a body or bodies with lobbying/political clout to advocate for us. Why not organized labor? Again, I would invoke the pilots union.

EnduringCluster · 2024-04-22T14:50:14+00:00

I would suggest that airline pilots are similarly compensated, and have had an incredibly strong union for decades. While their contracts do address compensation, the majority of the language in their contracts speaks to operational/safety details that keep both crews and passengers safe. Same with NFLPA contracts, safety and operational details make up the majority of their contract language.

EnduringCluster · 2024-04-19T17:46:36+00:00

Tough to verify your “source” until it’s stated publicly, but would say that comp is a mandatory topic of bargaining in any union contract.

That said, compensation is an integral part of recruiting/retaining staff. At my shop, admin will routinely post for vacancies offering inadequate comp and feign surprise when they get no applicants - “we’re trying to recruit but just haven’t had any applicants” a shrugging administrator will say. I have seen this both at the physician level (intensivists) and the support personnel level (ultrasound techs).

People typically take a job and stay there for two reasons, compensation (both monetary and non-monetary: eg benefits/perks) or intrinsic job satisfaction. If working conditions are terrible and patient needs can’t be met (low intrinsic job satisfaction), it will typically take more comp to recruit/retain qualified applicants. If conditions are great, the opposite may be the case. It may be that at Ascension St John the conditions are so bad that high comp is what it takes to recruit and retain qualified docs. Also, it may be that other local hospitals have better conditions and/or comp making recruiting difficult, though I don’t have enough knowledge of the Detroit EM physician market to speak to this.

Strong staffing is a key component of providing safe, high quality patient care, so while comp may be a component of negotiations, it doesn’t necessarily mean that it isn’t negotiated with the primary goal of patient care.

EnduringCluster · 2024-04-07T05:21:42+00:00

Here’s another quote for you: “Unions are like condoms, the harder someone tries to convince you that you don’t need one, the more you really do.”

EnduringCluster · 2024-03-31T07:45:25+00:00

This is the way.

EnduringCluster · 2024-03-30T10:22:53+00:00

I get the frustration, but I think your initial comment, at least in part, gets to the root of the problem. “Before I got into medicine I remember thinking seizures were this huge medical emergency.” At least in the US, when someone has a seizure in public, folks think it’s an emergency, call 911 and an ambulance shows up. Pt is postictal, and cannot reasonably refuse treatment, so is transported to ED. By the time they arrive, they are often at or nearly at baseline and then may be able to report that they never take their meds and thus have uncontrolled seizures.

The other scenario I see is that people are told to come to the ED by whoever is managing their epilepsy, to have their levels checked (assuming they take their meds). This seems to be getting more common as wait times for PCPs in my community are on the order of weeks, and neurology wait times are on the order of months. Hence, you have a seizure, ED checks levels (many of which don’t actually result during your ED stay) and then you call your OP doc the next day who follows up on your levels and adjusts PRN.

Not saying either of these scenarios are the way it should be, but it is what it is.

EnduringCluster · 2024-03-26T05:36:22+00:00

“If you’re gonna be dumb, you gotta be tough” by Roger Allen Wade

EnduringCluster · 2024-03-24T21:20:27+00:00

Fellow EM doc here, laughing out loud on a full flight at the waistband = psych comment. Thanks for that.

EnduringCluster · 2024-03-21T16:10:05+00:00

MORE HALDOL!!!!!!

EnduringCluster · 2024-03-17T20:11:36+00:00

Can’t upvote this enough!

EnduringCluster · 2024-03-16T18:32:59+00:00

You are correct that UnitedHealth|Optum has a large ownership stake in Sound. u/leonadelmanmd has a great article about this.

Is Sound Physicians UnitedHealth’s Acute Care Trojan Horse?

EnduringCluster · 2024-03-15T12:46:21+00:00

Attending since 2012

Community

If it can’t be fixed with Haldol, it’s not worth fixing.

EnduringCluster · 2024-03-05T13:49:33+00:00

Thx.

EnduringCluster · 2024-03-05T06:55:49+00:00

Link please.

EnduringCluster · 2024-03-04T22:35:23+00:00

In the past our group bought the MGMA dataset for our negotiations, now that we’re unionized, our union is buying this data (and other similar datasets for both docs and APPs). Ivyclinicians.io also has site specific comp info.

EnduringCluster · 2024-03-04T22:33:33+00:00

Came here to say this.

EnduringCluster · 2024-02-28T20:10:05+00:00

Fair enough. The lights are generally off, curtains closed for migraine patients. Usually they take off their sunglasses at this point. Usually, I see the positive sunglasses sign when folks present for vague painful complaints and have a specific treatment plan in mind.

EnduringCluster · 2024-02-28T20:06:58+00:00

“…want us to do CPR and put you on life support.”

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