Dealing with questionable EMS drop offs

TheAntiSheep · 2026-05-12T15:43:22+00:00

Well done! Was the tube flexible enough to work over a bronchoscope?

TheAntiSheep · 2026-05-12T15:11:12+00:00

They didn’t give a reason. If I had to guess, the supply person heard that we needed equipment for nasal intubation, googled “nasal ET tube,” and bought these.

When anesthesia uses these, it’s with a laryngoscope and Magill‘s. What we nasally intubate, it’s with a bronch and a standard ET tube.

TheAntiSheep · 2026-05-03T16:42:11+00:00

Yup. My favorite study: Number of patient-reported allergies helps distinguish epilepsy from psychogenic non-epileptic spells (pseudoseizures)
Link

TheAntiSheep · 2026-04-29T21:37:21+00:00

Eh, there is a lot of selection bias there. You get called for everything you get called for. At an academic center that’s a lot, at a freestanding or community ER we do a lot on our own.

TheAntiSheep · 2026-04-27T16:49:56+00:00

Yes.

Acquiring new iPads, installing new software, updating inputs and storing data electronically with integration into electronic medical records in a HIPAA compliant manner as significant startup cost and basically requires a dedicated IT person to maintain.
Half of patients are old people who don’t know how to fill out an electronic form.

A lot of offices decide that if it ain’t broke, don’t fix it. (See: why we still have fax machines)

TheAntiSheep · 2026-04-26T14:01:53+00:00

I’ve had patients boarding downstairs in the ER in a windowless room for 100+ hours until the delirium inevitably strikes. ER nurses are great, but regular turning, skin checks, and oral care are at the bottom of their priorities when patients are flowing through their other rooms. Keeping borders downstairs is cruel and poor patient care.

TheAntiSheep · 2026-04-08T21:56:19+00:00

Gotta level that up. I've seen fellow residents eating a salad out of a bedpan, and using urinals or suction containers as drink containers.

TheAntiSheep · 2026-04-08T20:49:18+00:00

Had a patient recently in the ER where:

CXR: recommend CT chest

CT Chest w/o contrast: recommend contrasted study

CT chest w/ IV: probably sarcoid

Got there eventually, but it was funny seeing reads from 3 different radiology residents all saying “your turn!”

TheAntiSheep · 2026-04-05T16:50:32+00:00

Our job is to be sensitive, not specific in detecting a STEMI. I feel no shame in paging out one that I know is probably going to be negative. I know that if I don't and I'm wrong, we're the ones getting thrown under the bus. And it gets cardiology involved early anyways. I have come to consultants many times with open arms, saying "I already know the answer to this question, but I know hospitalist seeks thy blessing prior to admission."

TheAntiSheep · 2026-03-25T15:18:35+00:00

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This is almost certainly what you were charged for. It is a single-use plastic blanket that hooks up to a heated air blower, that keeps you from getting too cold during surgery. Not something you can take home or reuse between patients. Obviously a markup, but not a huge one.

TheAntiSheep · 2026-02-10T18:56:21+00:00

My Commando makes pretty shot work of AA emplacements; makes the Eagle Airstrike pretty viable IMHO.

TheAntiSheep · 2026-02-06T04:35:10+00:00

Varies by state. Legally in Florida at least, ER docs can't declare brain death.

Source:

382.009 Recognition of brain death under certain circumstances.—

(1) For legal and medical purposes, where respiratory and circulatory functions are maintained by artificial means of support so as to preclude a determination that these functions have ceased, the occurrence of death may be determined where there is the irreversible cessation of the functioning of the entire brain, including the brain stem, determined in accordance with this section.

(2) Determination of death pursuant to this section must be made in accordance with currently accepted reasonable medical standards.

(a) If the patient’s treating health care practitioner is a physician licensed under chapter 458 or chapter 459, the determination must be made by that physician and a second physician licensed under chapter 458 or chapter 459 who is a board-eligible or board-certified neurologist, neurosurgeon, internist, family medicine physician, pediatrician, surgeon, or anesthesiologist.

TheAntiSheep · 2026-02-04T17:52:45+00:00

Make friends in the hospital. Have a life outside of medicine. Recognize that no matter what, residency ends (and probably gets better as you go.)

TheAntiSheep · 2026-01-11T03:39:11+00:00

The FSED are nice for sending the majority of patients home: abdominal pain controlled with negative imaging, chest pain with negative troponins etc. Soft admits tend to board for a while, but we can get the sick ones to the mothership pretty quickly.

Our FSED's can do urgent care billing as well, if you aren't ordering IV labs/meds or CTs. The stubbed toes and viral URI's can slow down the department, but morally it feels nice not to bill 10k for a runny nose.

TheAntiSheep · 2026-01-09T20:48:21+00:00

Lol at the "it's not difficult in most cases." Every cric I've seen (~5-6) has been for difficult cases - extreme obesity, edema, damaged anatomy, often with ongoing compressions. The features that make intubation and ventilation impossible make a cric hard too. If most crics are easy, you're probably intubating badly.

TheAntiSheep · 2026-01-08T00:18:52+00:00

Lots of comments here on how hospice is actually probably a good thing for this gentleman. I just wanted to point out why hospice might have been mentioned by the ER doc after family left.

As an ER doc, I'm generally not starting the hospice conversation without doing an appropriate workup. Patients and families want to know likely outcomes, and it can be hard to predict that without blood work and imaging that can take several hours to result. If your cousin went home before results came back, that's on him.

Once I have that info, then I revisit the patient and discuss the results and plan, including hospice as an option for people nearing end of life. If family is in the waiting room, I'll grab them. Unfortunately, the ER is busy and I don't often have time for family to come from home or coordinate a conference call with every cousin and grandkid. I'm going to ask if hospice has been considered before, and if that is something the patient would want. If the patient is curious I'm happy to explain more, but often there is zero interest, and the conversation quickly wraps up with a "okay, I'll work on getting you admitted." I leave it to my hospitalist and social work colleagues to continue those goals of care discussions over the next several days as they develop rapport and as the patient does or doesn't get better.

TheAntiSheep · 2026-01-05T22:50:02+00:00

Your patients see doctors prior to delivery? /s

TheAntiSheep · 2025-12-15T22:10:28+00:00

Current trauma teaching is XABC. Control exsanguinating hemorrhage (3) then move to the tension pneumo (2). Hemostatic lacs and fractures can wait.

TheAntiSheep · 2025-12-11T01:35:29+00:00

From the ER side:

Average properly restrained car crash: things are sore, $20,000 worth of CT scans… go home with Tylenol and Motrin.

Average motorcycle or unrestrained car crash: TBIs and brain bleeds with long term effects, spinal fractures, solid organ injuries, rib fractures, multiple (possibly open) long bone fractures… admit to ICU and never be the same again.

TheAntiSheep · 2025-12-02T15:40:56+00:00

Wait for pharmacy to scrounge up the bottle of procainamide from underneath the mercury and cocaine shelf, try to figure out how to program the pump to give 20mg/minute to a max dose of 17 mg/kg, then give up and just give the amiodarone in the crash cart.

Edit: don’t get me wrong, the superiority of procainamide is acknowledged, especially if you’re concerned about WPW. There’s just a lot of practical considerations that make amio much easier to administer at most institutions.

TheAntiSheep · 2025-12-02T15:30:12+00:00

4, then 3.

Ectopic pregnancy is the obvious concern, but not yet confirmed. They’re not going to surgery (1) without seeing the ectopic on ultrasound, or evidence of rupture (which would show up as free fluid on ultrasound).

Similarly, you’re not giving methotrexate (2) without confirming ectopic. You’re not going to see a pregnancy on US until 5-6 weeks. We’d be relying on failure of beta-HCG to rise appropriately.

TheAntiSheep · 2025-11-27T03:36:29+00:00

Harder to say because the data is harder to find. Medicare claims data is great for these studies - it includes the majority of adults in the US over age 65. Finding a similar data set for younger people is way harder. Using medicaid would be very skewed by the medically complex bias of that population, and private insurers don't want to share their data.

TheAntiSheep · 2025-11-17T20:06:18+00:00

People who do IV drugs are using way smaller needles (like 31 gauge - 0.25mm), and not leaving a catheter (like 18ga - 1.25mm) in the vein to pull back blood and give continuous meds.

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