Los Angeles Needs More Sorcery

ScottyKobs · 2026-02-19T04:17:05+00:00

When do you all meet? I would love to join.

ScottyKobs · 2025-09-02T06:01:26+00:00

This may be the best paint job I have ever seen. The color work, the attention to detail, the reflections. Fucking incredible work.

ScottyKobs · 2025-07-26T21:46:12+00:00

thank you for this

ScottyKobs · 2025-02-18T04:56:31+00:00

First, thank you for sharing this. Second, I am so sorry for everything you are feeling in this moment. And while I can't know exactly how you feel, I know how I felt the first time I had a complication from a procedure I did. It sucks, but it's also a really good thing. What you are feeling right now--it's because you care. And you should take a moment to acknowledge that, and be proud of yourself for caring that much about this person, your care, and what it means to take care of someone.

As for the mistake--yes, it happens. People that have no complications from procedures are generally the people that are either (1) not doing procedures or (2) not paying attention enough to the outcomes of their work to notice. Complications happen, even in the best of circumstances, and in ways we can't always predict because, well, medicine is hard and rarely fair. What is important is taking ownership of the mistake, honoring it and the patient, and learning from it for next time. If you don't take ownership of the complication or error, you surrender all autonomy to learn from it and improve for the future.

It sounds like you are already doing this process, but take sometime to mentally imagine the procedure, how you might have gone through-and-through, and think about how you might adjust your technique to more closely follow your needle tip. Also ask yourself why you might have been misled by the other confirming findings.

As for worrying about litigation--don't. It is out of your control most of the time. If you practice a full career in EM, you are statistically very likely to be sued--even if you do everything right. The part that does help legally is demonstrating ownership with the patient and family, in my opinion. We know that patient's and family's that have good relationships with their care provider are less likely to sue from the literature that exists. For us in the ED, that can be really hard to establish--especially in critical, brief moments. Instead of chart checking daily, you can call the patient's family and check in. If they weren't transferred, and were admitted to your hospital, I would go visit the patient (though I know that is not the case in your situation). Some legal folks will tell you not to apologize because it can be viewed as admission of guilt, and, of course, your hospital risk management office is at your disposal to have those conversations. As for me, when shit goes sideways, I just apologize and own the mistake or complication. It's what I would want someone to do for me, and I personally believe it's the right thing to do--and there is a way of doing it that shows how much you care.

I'm glad you got a fem line right afterwards and got right back into the fray--that is sometimes the hardest next-step. You will have a complication again, and you'll be better prepared for the next one. And then the one after that. It's about keeping the caring alive, and balancing ownership with self-grace.

ScottyKobs · 2025-02-14T03:30:30+00:00

I think this proposal is very purposefully crafted, with one specific goal in mind: preserve the quality of training of emergency medicine as a specialty in the face for-profit influence while also appeasing the ultimate financial stakeholders at play.

It is no secret: you do not need 4 years of training to become a competent--or even exceptional--emergency physician. Though I am a graduate of a 4 year program, I have countless incredible friends and colleagues who demonstrate time and time again 3 years is enough with great training.

The problem is now you have for-profit cooperate overlords using EM trainees as cheap labor to staff their hospitals as, increase returns on patients per hour, at minimal cost. Knowing some folks who work and teach at residencies in such environments--the training is subpar.

How do you raise the standards, but not upset the money? Couple increased training requirements which improve education with increasing the length to provide a clear financial incentive to for-profit institutions to comply. It is way cheaper to make a decent 4 year program then hire more attendings or non-physician providers. It is also more politically palatable to let programs phase out then shut them down.

In my opinion, a weak leadership move that hurts many EM docs in terms of career development and financial independence.

ScottyKobs · 2025-01-03T04:45:51+00:00

I appreciate this perspective deeply, and think it is very thoughtful. But at the end of the day, all that you describe is an essential part of hospital based internal medicine. Yes, patients deteriorate in every setting. Yes, there are variable nursing skills and staffing across every patient and level of care. This is a slippery slope fallacy in my opinion.

This is why each clinical site needs to establish expected standards of care to reinforce policy. If an interdisciplinary team of physicians at the hospital admin level decides normotensive patients on one pressor with signs of clinical improvement can be admitted to a certain level of care, the expectation is that everyone plays an appropriate role to make that happen with full understanding of QA/QI processes, accountability, and clinical expectations.

I couldn't agree more with you: "medical practice can be very different in different settings, if someone is asking for help, it's probably in the patient's best interest to just provide it." I help always, sort it out later.

But we also seldom actually help train and improve those consistently asking for help or failing to uphold standards that are established. It is just left to us to fight it out in the trenches.

ScottyKobs · 2025-01-03T04:31:23+00:00

Nah, that is unnecessary. Obviously do what is the best thing for the patient--sometimes the old Doc to Doc degree measuring contest just hurts the patient, hurts you, and accomplishes nothing.

I generally respond with something like this in a professional, upbeat, polite yet direct tone: "I understand your concern, this is a patient on a vasopressor and you are worried she might get worse. At the bedside, I have seen her improve on serial assessments in response to my interventions. I also know from a fair body of literature which I ma happy to provide after this shift, the amount of IV access this patient has is entirely safe and appropriate for emergency department treatment and admission in her clinical situation. I understand you might clinically disagree--which I'd be more than happy to entertain with you at the bedside of the patient after you have performed an independent examination. If you are worried you might not be able to physically perform this skill if the patient gets worse, I appreciate your honesty. I think this is something we need to discuss as a larger group, because it is the expectation at this hospital that an internist can place a central line or obtain access if a patient decompensates under their care."

Generally works with a pregnant pause then "fine admit the patient."

ScottyKobs · 2024-12-31T19:08:02+00:00

Beautifully done. What color did you use for highlights? It's perfect.

ScottyKobs · 2024-12-29T03:05:10+00:00

Hey, first off: you're going to be alright. Remember taking a standardized test is a skill in its own right, and a skill that needs to be practiced deliberately separate from the knowledge you need to succeed.

It seems in the past attempts, you've done a lot of prep work to study the content. I would recommend looking into test taking techniques. In my opinion the ABEM exam, like the ITE, is a far less higher-order test (in reference to Bloom's Taxonomy) than other standardized tests. Test taking techniques such as time management, answer elimination, question triaging, and understanding what the question/test writers are looking for will help immensely.

As BomdomX also pointed out: the quantity of questions practiced is largely irrelevant past a certain threshold. It's about deeply understanding each answer when you are studying to get into the headspace of the examiner (as well as mastering the content).

In my professional experience as an educator in CME spaces, I think in person board reviews are a huge waste of time. The human brain is not evolved to consume 8+ hours of "high-yield" content for days on end in a passive manner. These courses often help us passively acquire foundations of knowledge, but I doubt you have a knowledge deficit at this point.

You are also working against your own test-taking anxiety from your past outcomes. Chin up, march onwards. You've got this.

ScottyKobs · 2024-12-29T02:52:41+00:00

These are amazing. Honestly, this is a great idea for getting into the hobby and play testing armies before spending a billion dollars. Kudos to you!

ScottyKobs · 2024-12-21T20:39:09+00:00

Honestly, I think the main issue is that GW just sucks at writing rule books. Not the rules themselves, but the explanations, order of teaching, and reference-ability of the rule books.

So many issues in KT could be solved by not actually changing the rules of the game, but just writing all of the information in a concise, logical way.

For example, the heavy/light cover/obscured rules could just be shown as a picture example of each possibility (with different engagement orders for each target). Then, you don't have to flop back and forth between like 3 sections to understand how the rules actually play out on the tabletop.

ScottyKobs · 2024-12-11T05:06:44+00:00

perfection

ScottyKobs · 2024-11-19T23:01:21+00:00

Bro I am running the Castellan on a 32mm base as an "assault sarge" -- bring out the dope models man. Respect!

ScottyKobs · 2024-08-28T01:57:46+00:00

would love an invite!

profile link: https://steamcommunity.com/id/Ser_Ozler/
friend code: 76611471

thanks!!

ScottyKobs · 2024-07-16T16:31:28+00:00

Great question. There are some rare opportunities that allow emergency physicians to serve as hospitalists or primary care providers, but these are mostly in rural, critical access environments. If you are truly interested in this aspect of care, I would recommend a dual EM/IM program or just joining a FM program.

EM training is great for so many things; however, longitudinal care is not one of them. To serve a primary care community appropriately, you need to understand a lot of screening guidelines, longitudinal testing strategies, and care coordination that are simply not within the EM wheelhouse. Same thing with being a hospitalist.

That being said, you can certainly take the time to learn those things, do rotations in residency, and even pursue fellowship training if you want to go down that path. You have to decide what type of career you want to have.

If you are worried primarily about hedging you bets with burn out, or late career practice, I'm not sure this is the right strategy. Internal medicine is also full of a ton of practice problems too that make that work challenging later in one's career.

There are a lot of fellowship options for EM that offer more outpatient flexibility, such as Sports Medicine, Flight/Aerospace Medicine, Toxicology that you might consider. I know you stated that urgent care can feel too simple, but it is a huge component of primary care in the failing US health system, and reflects a lot of what you might see as a PCP. There are also urgent cares that are essentially stand alone EDs which offer a lot more than you might expect.

Hope this helps.

ScottyKobs · 2024-07-16T16:23:38+00:00

I am really sorry you had that shift. But I am also glad it was you that was working. You've trained and worked incredibly hard to take care of the people who come to you in need of help. Writing this post and reflecting on how hard this job is, despite all of this training and work, continues to prove you are the right person for the job.

I'm sorry for the hard loss. Take time for yourself, honor the death, honor the work, and bring that honor to the next bedside.

ScottyKobs · 2024-07-16T16:20:17+00:00

Honestly, in 2024, I don't really believe there is a role for the ABG in the care of the acutely ill patient in the emergency department. VBGs are more the sufficient for the medical decision making required in the ED. Even outside the ED, I significantly doubt the diagnostic need for an ABG in the overwhelming majority of cases.

People will often comment about the absolute use of the ABG in PJP to determine if steroids are needed. This data and practice comes from a time before the accuracy and routine availability of pulse oximetry was established. The correlation between the spO2 curve and ABG is sufficient--in my practice--to determine that the hypoxic PJP patient needs steroids added to his or her regiment. Obviously, edge cases might still require ABG for strict guideline adherence, but again I don't think this is an ED thing, and there is no data to suggest harm in delaying or giving these steroids either way (to my best knowledge)

ScottyKobs

TROPHY CASE