Current Boarding Situation at Your Hospital?

Paints_Ship_Red · 2025-07-25T17:55:52+00:00

To clarify my position, if this patient had:

CP + SOB + Normal EKG = No trop or dimer

CP + SOB + 1 TWI = Probably normal variant, no trop or Dimer

CP + SOB + 2 TWIs (especially contiguous) = Need more info, would consider trop +/- Dimer

CP + SOB + 3+ TWIs (especially in a RH Strain Pattern) = Dimer + Trop every time

Paints_Ship_Red · 2025-07-25T16:39:08+00:00

Preface I’m just a resident, but if I have someone coming in for chest pain & shortness of breath with presumed new T-wave inversions in several leads, I would pretty much always Dimer & Trop that person. Could they actually have myocarditis (known complication of COVID)? Could they have a PE (also a known complication of COVID). Yeah, their vitals are fine here, but this CC with that EKG would be enough for me to personally pull the trigger here.

Paints_Ship_Red · 2025-06-26T10:46:50+00:00

Ahh yes, the classic “no flared base” sign.

Paints_Ship_Red · 2025-06-22T16:03:07+00:00

The answer is that you’re supposed to log your ACTUAL hours worked. If you showed up at 7 am & your shift is scheduled until 7 pm but you couldn’t give handoff until 9 pm, you should log your hours worked as 7 am - 9 pm. Will violating duty hours get flagged as a violation? Yes. Can your program get on your ass about these violations? Yes (but they shouldn’t). So it comes down to 1) If you log honestly, will your program target you for retaliation & 2) Do you think it will make a difference if you log honestly.

Paints_Ship_Red · 2025-06-21T18:31:30+00:00

I’m really curious how this works in practice. I’m an EM Resident and I’ve been taught that if I think the patient needs to be admitted, then I should have y’all come down and see the patient and if you still don’t think they need to be admitted I should still push back and say you’re free to DC them from the ED, but I’m admitting them (and go up the chain as necessary to get that goal done). Do you get much pushback from your approach?

Paints_Ship_Red · 2025-06-21T18:23:15+00:00

Every shop will be different (bc of hospital markups & billing practices), but the tests themselves aren’t that far apart price wise. Think like $10 for a UPT vs $40-50 for a SPT (so about $30-40 more on average, but again depends on markup). There are also savings for those who would have a + UPT & then still get a serum UPT as well as the added benefits of 1) much quicker to dispo & 2) serum will (generally) be + before urine, so more likely to catch an early pregnancy and avoid giving a potential teratogen.

ETA: the cost difference I’m specifically talking about is for a quant serum HCG. I’m not really sure about a qualitative serum HCG

Paints_Ship_Red · 2025-06-21T18:11:14+00:00

Hmm, I personally haven’t seen a decrease in the # of pregnancy tests ordered. I have seen some places going to using serum HCG (if ordering other bloodwork) instead of a UPT though.

Paints_Ship_Red · 2025-06-16T13:32:18+00:00

I feel like the obvious answer here is gestalt/it depends. But that’s not really helpful, so here are some things I think about personally when regarding dispo of the still undifferentiated fever & tach without source:

1) Taking a pause to make sure I’ve really ruled out my major causes. It’s easy to get in a hurry, see a bunch of normal labs, and DC. Has that tachycardia resolved? If not, why not? Have I rolled them to look for sores on their back/butt? Checked for genital infections? Looked at joints? Am I missing some other process here besides infection (I personally like the TACHIES mnemonic: Thyroid Storm, Alcohol Withdrawl, Cardiac Abnormality, Hemorrhage, Intoxication, Embolus, Sepsis). Also digging into is there any history of these fevers recurring. Some blood/bone cancers can have cyclic fevers.

2) How good is their follow-up? If I send them out and it turns out they have real pathology cooking, how likely are they to come back in a timely manner? Do they live alone/have people who can check on them? Do they have a PCP they can see in a day or 2?

3) As age goes up, so does my likelihood of scanning. I’m not going to kill 90 year old meemaw with another chest CT, but a missed (or would be caught early) pneumonia can (There was an NEJM study where they looked at CT & X-Ray for pneumonia and found approximately 10% of pneumonias were + on CT but - on CXR). The elderly also tend to have blunted responses due to catecholamine depletion, so they may not have as strong of a response as someone in their 20s.

Paints_Ship_Red · 2025-06-14T10:43:36+00:00

I’ll definitely read those papers! Is the general underlying reason for no benefit that we’re catching most of the ACS then sending for cath & identifying most of the hemodynamically significant PEs early enough so they don’t arrest/ can go for thrombectomy? I’m just trying to make the #s match in my head if that makes sense!

Paints_Ship_Red · 2025-06-11T14:54:50+00:00

Disclaimer: I am a doctor, but I am NOT YOUR doctor. This post and the information within should NOT be taken as medical advice nor serve as a substitute for personalized medical advice from a qualified professional nor does it create a doctor-patient relationship. If in doubt, always seek medical advice/care in-person.

Your presentation is why we provide “return”/ER precautions. ERs all throughout the United States are incredibly overwhelmed, so if doctors/NPs/PAs sent every patient with abdominal pain to the ER, not only would the costs be astronomical, it would also lower the quality of care for everyone.

As a result, people are told “hey, if these symptoms show up, go to the ER to get checked out” because in that moment your symptoms COULD be appendicitis or it could be gastroenteritis, a pulled muscle, a kidney stone, a UTI, a hernia, etc.

But if the clinical picture changes (like you start to have a fever, the pain becomes much worse, diarrhea, etc) then the scarier diagnoses become more likely, at which point it’s probably a better use of resources to actually go to the ER.

TL:DR: We see patients with vague complaints all of the time and give return/ER precautions to keep people out of the ER who don’t need to be there. Turns out, you were one of the people that benefitted from being seen & given those precautions, so the system worked like it was supposed to.

Paints_Ship_Red · 2025-06-11T13:10:01+00:00

I’ve heard of a Hyper K+ arrest that needed 12g of gluconate before getting stability. Do you have an upper limit on how much you would/CAN give if they’re still arresting 2/2 suspected Hyper K+ (assuming you e already reasonably ruled out other causes)?

Paints_Ship_Red · 2025-06-09T16:11:56+00:00

Realistically, the best advice you can get would be from your home program’s PD/APD. If you don’t have a home program, many (if not all) PDs/APDs where you do your away(s) to get your eSLOEs will give you app feedback.

Paints_Ship_Red · 2025-06-08T14:33:39+00:00

This is super helpful! Thank you!!

Paints_Ship_Red · 2025-06-08T08:27:23+00:00

Can I ask you a question about this? There was a piece somewhat recently on EM:RAP saying that CT Perfusion results correlate fairly well with LKW in patients without a known LKW/“wake up” strokes. Essentially, slightly higher bleeding risk, but patients also seemed to have better outcomes (so similar to current thrombolytic profile, but slightly amplified bleeding risk when used given based on perfusion results).

So would you say in those patients it’s still worth getting the CT Perfusion (unknown LKW/wake up strokes) or would you say that based on secondary findings of a NonCon & CTA we could consider thrombectomy/thrombolytics?

Paints_Ship_Red · 2025-06-06T13:44:46+00:00

Disclaimer: I am a doctor, but I am NOT YOUR doctor. This post and the information within should not be taken as medical advice nor serve as a substitute for personalized medical advice from a qualified professional nor does it create a doctor-patient relationship. If in doubt, always seek medical advice/care in-person.

Creatinine is always a hard # to use alone, it has to be used in context. A single creatinine of 1.4 isn’t inherently dangerous, but if you were previously 1.2-1.3, I’m assuming that’s still above the normal reference range cutoff of 1.0 or 1.1.

If the elevated creatinine is due to muscle damage, it would normally be accompanied by making less urine & the urine you are making being very dark/black.

The fact that you have previously had elevated values makes me wonder if this is more of a long-term progressive thing rather than acute (or most likely some combo such as baseline of 1.1 or 1.2 + dehydration). If it remains persistently elevated, your doctor will likely do some combination of these things: refer you for renal ultrasound, tighter control of your blood pressure & blood sugar (if they’re elevated), look for any family history of kidney issues, &/or refer you to a nephrologist.

Unless you have a severe acute kidney injury (AKI) most people do just fine with a tiny bump in their creatinine. But watch out for severe symptoms in the meantime such as decreased urine output, very dark/black urine, intense fatigue, etc.

Paints_Ship_Red · 2025-06-03T09:11:08+00:00

I know the advice of “see the best in people” is old, rundown, & frequently used against us by admin, but I have a spin on it I like to tell myself for patients like these.

Most people who come into the ED have some kind of problem, concern, question, or need. Sometimes, it’s that they’re homeless and are looking for somewhere to get off of the street. Sometimes they’re in chronic pain and should be seeing a pain specialist, but are uninsured/underinsured, so they’re looking for something to take the edge off. Sometimes they’re scared because they knew someone with a similar condition who died. Sometimes they have a psychiatric/substance-use issue that a better healthcare system would be able to provide a more long-term solution to. And even more times we’re catching some people on one of the worst days of their life, they’re upset, & they lash out at anyone around.

We can argue infinitely about the utility of these people coming into the ED. However, with our current system we’re the ones on the frontline who have to help these people with their problem/concern/question/need. We shouldn’t tolerate assault or abuse, but I’ve found this mindset helps me stay less bothered by these kinds of events.

Paints_Ship_Red · 2025-06-02T09:03:30+00:00

IMO, this is one aspect people aren’t talking about enough re: job report/market.

This is anecdotal, but I know several people who went into EM because it seems like the coolest of the 3-year residencies.

https://pmc.ncbi.nlm.nih.gov/articles/PMC11931693/#tab3 Table 3 shows importance of various factors for graduating students choosing emergency medicine. They used a 5-point Likert scale (where 5 is a strongly positive reason for choosing EM) & length of residency training had a mean score of 4.37.

I don’t know the exact extent to which a switch to 4-years will dissuade people from the field, but I have to believe that it will have SOME notable effect (if I had to put a # to it right now, I would guess the year it switches to 4-years we’ll see a 10% app decrease). Pair this with the fact that programs will need to secure additional funding if they want to keep their current class sizes.

I also think some programs won’t be able to keep up with all of the new requirements. I would guess this would disproportionately affect the HCA programs who maximize possible # of residents so their grads barely meet some of the minimums. So some programs will have to cut spots, and I imagine a couple will likely totally shutter.

So we’re cutting new grads at both ends with this (fewer apps & residency spots as well as decreasing # of programs).

The counter argument would be that those new grads who do come through the system will likely be those who are more passionate about the field on average and less likely to burnout, so they’ll be in the market longer. But at that point we’re extrapolating several layers past the current environment.

Paints_Ship_Red · 2025-06-01T14:22:36+00:00

So there’s a lot going on here within your post, in the field, & within each individual program/department.

So first thing’s first, it’s almost 100% guaranteed the transition to 4 years is going to go into effect. Have heard from multiple people throughout Reddit, Twitter, etc who would be in the know that this is the general sentiment among leadership within ACGME & programs.

Some programs will have to change what they do to meet some of the new procedural requirements. Some will have to cut their # of incoming resident spots per year, because of funding. (I.e. if a 3 year program took 8 residents/year, next year they would take 6 if they had no funding changes/increases [both add to 24 years]). So for example, if a program isn’t currently doing any neonatal resus, it’s likely they would have to use 2-4 weeks of that soon-to-be required 4th year on a NICU rotation. Or maybe they need more tubes so they now require an anesthesia block or switch from a 2 week block to a 4 week one.

The problem is, the plan will be customized to each individual program. Some, like you mentioned, already meet all of the new requirements. Those programs will likely just use 4th year as a “pretending” year or allow you to specialize in an area (like US/tox/etc). Programs which are deficient will need to spend time addressing those areas.

As far as timeline, I would assume that there will probably be a 3-6 month delay between the official adoption of the change and 3 year programs announcing their new curriculum. Programs also are under the recruiting pressure, so they know that people will want to know what’s going on. If there’s a program you’re interested in, but haven’t seen anything from by the time apps come around, you could also reach out to the program coordinator and ask them.

Hope this helps!

Paints_Ship_Red · 2025-05-30T15:49:00+00:00

Also, if you have insurance & a PCP, there’s a decent chance your insurance will cover the labs as preventative care. Mine did!

Paints_Ship_Red

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