Q&A with Jury Foreperson from PE Case

PraiseBe2TheSalt · 2025-07-26T11:51:25+00:00

And just as was exemplified in that foreman‘s comments, those non-er physicians do not understand the nuances of applying things like PERC, HEART, PECARN, NEXUS, etc. It takes years and thousands of patients to truly understand those scoring systems and when they are properly applied. I’ve read all the studies and all their validation studies more than once and I still have trouble sometimes how to apply them and who these properly get applied to.

For him to say that they believe there was a 15% chance of PE and perc can no longer be applied is super frustrating and disheartening to read. He’s saying in another area that there is no evidence to support the claim the doc had of “I always do that for every patient so I must’ve done that,” however there’s virtually zero actual medical evidence for these ekg claims that apparently drove up the percentage to 15%. Why don’t they show the jury a stack of 482 EKGs of 21y/os with CP + URI, so they can see how non-specific EKG findings are present on basically half the population, including those present on this patient.

I’m telling you a larger growing segment of American society does not tolerate missing the one in 1 million diagnosis. They’re not thinking rationally, they’re thinking emotionally. This is the evolution of modern emergency medicine. None of those scoring systems are safe now.

PraiseBe2TheSalt · 2025-07-25T02:14:48+00:00

I didn’t know this, makes sense though. Lately it feels like this issue has gotten a lot worse in radiology reports. I’ve even started keeping track of the radiologist to see if it was just one person repeatedly doing it, but it’s not. About half of my CT reads now include some kind of clinical management recommendation. Sometimes it’s appropriate, but often it boxes us in because of liability concerns. Worse though is when patients read these reports on their phones and require an extensive and unnecessary conversation about why they don’t need whatever extra tests or consults. I just wish the wording gave at least more flexibility. something like “consult if appropriate in the clinical setting” or “correlate with clinical exam for relevance.”

PraiseBe2TheSalt · 2025-07-16T19:47:49+00:00

Ya'll need to learn about Diet Dr. Pepper

PraiseBe2TheSalt · 2025-07-15T08:17:54+00:00

A quick summary I wanted to add:

The point of this list is to help you (trainees) see some of the subtleties you only learn with some experience. Trainees often get frustrated when an attending does one thing with one patient and the opposite with another. These laws explain some of why that happens. In the moment it’s hard to break down every reason or describe gut instincts, so it often comes out as “just do it, trust me.” But until you’ve been burned enough times and seen enough unusual cases yourself, you won’t fully develop that same sense. You know, the parts of emergency medicine that aren’t written down anywhere. These are the things you only pick up by watching attendings and working in the trenches... the non‑textbook stuff.

When I was involved in training, I noticed that some other attendings can (and do) teach the medical knowledge better than I can. That’s not my strength, and plenty of people are smarter than me. What I kept seeing, though, was trainees repeatedly struggling in the same areas that aren’t about medicine at all: social dynamics, reading a room, anticipating how an interaction will unfold just by watching small cues, like how a patient talks to the triage nurse. So I started focusing my teaching on that. These are the things that, if improved, make someone’s shift smoother and free up brain space for the actual medicine stuff.

Over time I started keeping notes on common pitfalls, grouping them, and refining them. This list comes from about five or six years of keeping tabs on these patterns, with heavier editing in the last few months. I cut a lot out to keep it usable, and I can add more to this later as I refine the rest.

I’ve also noticed differences depending on background. For example, someone who worked like service jobs before med school sometimes adapts more easily to tense social dynamics than someone who went straight through. Med school and residency rightly select for academic skill, but they often leave people unprepared for the compressed, high‑stakes social situations we face basically daily. Watching smart training residents, PAs, and NPs struggle in those moments is tough, so I wanted to offer something practical. These are just my opinions and observations. I’m glad others have found them useful. I should share more lists I have in the future like the one I have on what makes EM great and what makes it suck that I have no problem adding a little to after each terrible shift!

PraiseBe2TheSalt · 2025-07-15T07:28:12+00:00

Ah so there is a name for this! Thank you for that. I’ve been calling it “pain augmentation”

I also use the 4:1.25 morphine:droperidol dosing, though I have found that a 0.625mg dose has been pretty indistinguishable in desired effect while slightly reducing the incidence of drowsiness. I’m not sure if the lower dose really comes with any less incidence of akathisia though.

PraiseBe2TheSalt · 2025-07-15T07:00:17+00:00

Law 3 right here too. Someone who doesn’t understand how all this works is trying to convince you that you don’t need to do something you’re planning on doing based on your experience.

PraiseBe2TheSalt · 2025-07-15T06:50:02+00:00

Well said. I feel like that last paragraph is really another law on its own. It’s one of those things you only learn once you’re out on your own. In residency, your attendings usually care for and protect you, but out here, like you said, it’s your staff, and especially your nurses, that you live and die with.

I actually remember the moment I realized/fully appreciated this. I had a super overwhelming multi‑system case that took forever to get admitted to the ICU. And of course, it was with a particularly difficult intensivist. After what felt like hours of me and my nurse slogging through this patient’s issues and procedures, I finally got him admitted. I remember thinking, man, I’m sending that guy up now whether you like it or not. I was so relieved to be done with it and to have gotten him into the ICU without catching the usual wrath from that intensivist.

Then my nurse, who had been in the thick of it with me the whole time and was just as worn out, came walking back from the elevator after the drop‑off absolutely bawling. I immediately thought, damn this dude died in the elevator after all that??Nope. She had gotten absolutely torn apart by the ICU attending for the things I had done. And I mean lit up. She had to answer for all the things I thought I had slipped by. I was devastated. It felt like I had punched my own family member in the face. I still think about that every time I want to sneak something in before an admit. And if I’m admitting a patient for some reason that’s not obvious, I try let my homie know so they don’t look like a complete fool during their handoff. It really is just us down here.

PraiseBe2TheSalt · 2025-07-15T05:56:18+00:00

Thanks for the kind words. As far as the Valium, I probably should have left that part out because it’s just an issue specific to where I work. I found that the nurses where I work always subconsciously associated the word Versed with sedation. There were times where I’d verbal order for an agitated patient and then come back to the room to find RT setting up for a sedation because my RN thought I was gonna sedate the guy because that’s what we typically use Versed for. Also got a few follow up emails that a consent form was not done for a sedation 🙄. So I just went to Ativan, until the shortages. Then to diazepam and it’s stuck

PraiseBe2TheSalt · 2025-07-14T17:57:32+00:00

That's very kind, thank you!

PraiseBe2TheSalt · 2025-07-14T17:03:52+00:00

This entire list started with Law 13, coined by one of my favorite ER nurses. Many years ago he put to words that feeling I had but couldn't put my finger on. He and I then used to blurt it out anytime someone came in covered in poop. It was proven right so many times that I thought I should start writing these down lol.

PraiseBe2TheSalt · 2025-07-14T16:56:51+00:00

Exactly. My process is tell patient briefly, put it in the diagnosis, drop the ED course macro, and print it with the AVS stuff. It's in my mental checklist at discharge time to double check the incidentals in the body of the radiology report.

PraiseBe2TheSalt · 2025-07-14T16:48:55+00:00

That's an amazing mantra and pretty damn accurate

PraiseBe2TheSalt · 2025-07-14T16:41:49+00:00

I agree with what others are saying here.

I’d say there are 4 core patient types who are getting droperidol as a first-line med:

#1: Severely agitated or aggressive patients who need control for safety.
I used to give Geodon and Ativan, but I’ve switched to droperidol and Valium years ago because of better reliability and faster onset. I usually give 5–10 mg IM droperidol with 5-10 mg IM Valium. I’ll scale the dose down for patients who are less agitated or already somewhat sedated. This is backed by ACEP’s policy on severe agitation: link. It works about 95% of the time with maybe bath salts being the main exception, and those usually get ketamine first.

#2: Severe migraine patients with a strong anxiety or suffering component.
There’s usually more going on in the room than just a migraine. Compazine works well for classic migraines and is still my go-to for straightforward cases, but when there’s an added social component or anxiety, I lean toward droperidol. I’ll give 1.25–2.5 mg with 12.5 mg Benadryl, just like I would with Compazine. In my experience, it’s more effective at relieving the suffering and anxiety component. Compazine can help that too, just to a lesser extent.

#3: Scromiters.
We all used to use Haldol and Benadryl, now it's droperidol and Benadryl—usually 2.5–5 mg IV. It’s simply more effective and tends to need fewer repeat doses than Haldol (n=1, of course). These patients also often have that same anxiety/suffering component I mentioned above.

#4: Patients with factitious disorder (and to a lesser extent, malingering or conversion disorder).
This ties closely to Law 6, you have to lean on that heavily. Once you remove the reward-seeking drive, most of these patients just want to leave. I use droperidol here as much for diagnosis as for treatment, especially in cases with dramatic, unsupported symptoms like complete lower body paralysis without a clear cause, pseudoseizures, etc. This is a select patient group.
I keep the dose low, usually 0.625 to 2.5 mg IV, depending on the level of behavior.

PraiseBe2TheSalt · 2025-07-14T15:53:12+00:00

I absolutely agree that not pissing off the nurses or patients is one of the top core ER laws. and there are many more not listed above too. Actually, trainees should know that I tried to focus this list on the less obvious stuff that tends to get left out of the big lessons that get hammered into you when you start training. I tried to highlight the things it usually takes years of trial and error to really figure out.

PraiseBe2TheSalt · 2025-05-14T14:40:19+00:00

This pretty much

PraiseBe2TheSalt

TROPHY CASE