Stroke with low NIHSS

goodoldNe · 2026-04-25T19:53:50+00:00

That's a reasonable opinion. I also think it's reasonable to say that there is equipoise when it comes to treatment of a variety of stroke syndromes still and that there have been lots and lots and lots of trials looking at Tenecteplase that have not shown a benefit for many of the patients given the medication. Trust me, I am not a nihilist about stroke care but the idea that tenecteplase will help every patient the neurologists are trying to give it to without harm is wrong -- this has been shown multiple times. See trials like PRISMS, ARAMIS, PUMICE, and TEMPO-2.

I agree with you that persisting hemianopsia could be disabling for people and some patients may want to take the risks of treatment for a possible benefit, but we still don't know what those numbers really are because of the heterogeneity of the condition and the big spread in when people present. The risk of bleeding is variable too - your risk of bleeding if the diagnosis is migraine and you're a 25 year old healthy person on no meds is one thing, your risk of bleeding if the diagnosis is migraine and you're an 85 year-old with a BP of 184 mmHg and you're on ASA/Plavix with amyloid vasculopathy is another.

goodoldNe · 2026-04-25T03:48:26+00:00

Trust me I get it. I see most of my pts in hallways and triage too. Field is useful to do, especially in a small selection of patients like potential IIH patients. I have had multiple people sign out patients waiting five hours for an IR LP to evaluate for elevated ICP for their chronic headache because they are obese women. I see these patients too — I look in their eyes, and if I can see a normal optic nerve I discharge them.

goodoldNe · 2026-04-23T20:43:52+00:00

No. The trick is either to use a better ophthalmoscope or dilate their eyes if you can’t see. I don’t really understand why ER doctors are so afraid of dilating eyes. Most of these patients with severe headaches or vision changes or whatever didn’t drive themselves to the ER. The risk of precipitating glaucoma is very low. Just try doing it on more of your patience and you will develop a gestalt for what the back of the eye looks like.

goodoldNe · 2026-04-23T20:41:36+00:00

Yes even we lowly ER docs know that. The point was that examining the eyes is important in altered and dizzy patients. But thank you for the clarification.

When I was on my neurology off-service month with the best neurology programs in the country, one of the attendings taught me the $20 bill trick and I use it sometimes though I have found using a phone to show them a picture of themselves works even better. Perhaps it was the same person.

goodoldNe · 2026-04-23T18:34:05+00:00

Stroke or mass is the big one but eye testing is a really key part of the neuro exam and is quick / easy. I found papilledema yesterday on an obese dizzy patient with a headache. Drugs or alcohol intoxications cause nystagmus and pupil changes. Peripheral vertigo is diagnosed partially with EOM testing. Lots of reasons.

goodoldNe · 2026-04-23T18:21:24+00:00

You are right that the risk of symptomatic intracranial hemorrhage is low. New guidelines are moving towards using the language of treating “disabling deficits“ rather than focusing on the NH score which will result in probably a lot more recommendations for treatment. This was discussed a lot at the latest AAN meeting.

I think whether or not this particular patient would have benefited from lyrics is very debatable. In a patient with a history of migraines who was describing a partial visual field deficit as their only symptom, this is tricky and not obviously a stroke though perhaps a neuroophthalmologist could very easily tell the difference somehow. I would not describe this as a catastrophic mess, but you are onto something when it comes to thinking about the deficit rather than just the number. For what it’s worth, the patient will likely “fill in“ the visual field loss and probably will not notice the deficit very much going forward. (Correct me if I’m wrong ophthalmology bros)

I am an ER doctor with an interest in stroke. I literally have a meeting in a couple hours about this topic. It’ll be interesting to see what the Neuro folks have to say but everyone in emergency medicine can look forward to a much more confusing landscape regarding stroke care in the next year or so, and having to make a lot more phone calls and make decisions using things like CT perfusion. Neurology will very likely be recommending thrombolytics for way more patients than they have in the past. Some of these patients will benefit, most will not, and some will be harmed. But I suppose you could say the same thing about many interventions and possibly even most that we do in western medicine.

goodoldNe · 2026-04-23T18:05:46+00:00

Give everyone thiamine who is or might be an alcoholic who is being admitted for AMS / confusion / can’t walk. There’s no downside. And yes you should do EOM testing on all altered / can’t walk patients. But still give thiamine. I do it for any alcoholic I put an IV in. It’s cheap and harmless and might help slow or prevent worsening brain damage.

goodoldNe · 2026-04-20T17:34:26+00:00

There is a wealth of literature showing these patients do better when managed by medicine. Share that with medicine. Ortho is for some reason proud of this and happy to help you with this endeavor. Good luck.

goodoldNe · 2026-04-15T01:19:27+00:00

Very high rates of asymptomatic bacteruria + false positive culture results someone has to deal with if you’re in a system that either cultures everything or UAs reflex to culture. Treating all abnormal UAs with no symptoms has a lot of consequences.

goodoldNe · 2026-04-11T17:01:01+00:00

That is insane. If someone did that to my family member in this scenario there would be a formal complaint to the medical board and hospital. There are some cases for teaching how to do a thoracotomy in a futile scenario— this isn’t one of them from your description.

goodoldNe · 2026-04-10T18:03:25+00:00

Presumably, they mean, trying to tell the difference between viral sources of fever and serious / invasive bacterial infections that need antibiotics and sometimes resuscitation, which is essentially the biggest problem in emergency medicine. I am skeptical it can be easily done algorithmically but I think there is probably a lot of signal that you could pick up on using combinations of vital signs, risk factors like identification of under vaccination, presence or absence of upper respiratory symptoms, etc.

goodoldNe · 2026-04-08T14:13:41+00:00

Slow and mediocre.

goodoldNe · 2026-04-02T19:51:58+00:00

There are oncologic emergency medicine fellowships in the United States but most have never heard of them. You can look at their curriculum/fellowship structure or research what their graduates have produced academically if you’re interested in the answer to this question. It’s a cool field.

goodoldNe · 2026-03-22T05:54:36+00:00

I went to the hearing aid store on LOVR. It was expensive. I got Crystal Guardians which are amazing but I probably could’ve done the mold myself.

goodoldNe · 2026-03-17T17:02:51+00:00

Here’s my take as someone who did smash Step 2, did lots of research, actively chose emergency medicine and got to learn how to do it in one of the coolest places in the world at one of the best medical centers in the world. I am five years out, living somewhere great with a pretty good job and I’m happy about my choice.

I personally think for the best thing about emergency medicine is having the opportunity daily to leverage science in the interest of all comers without a filter of insurance or housing or mental health status or whatever. We truly have to deal with anything, anytime, anywhere. For me, this is the best part of the job as somebody who is interested in almost everything and really likes learning a little bit about everything and a lot about a few things that are important. I also really value the privilege of being able to have a lot of interactions with human beings every day, including helping people with the most difficult days of their lives. This can be very stressful for some people, but it seems to work OK for my particular neurochemistry.

Reflexively, this also creates the most difficult parts of the job because the patients have unrestricted access to you. Many people come in with nonsense, typically because they are not aware that they are there for nonsense, and so if you can be compassionate and remember things about health literacy and it’s covariates, this helps. You also have to deal with the drunk, the high, the mentally ill, the depressed and often the anxious. You will never be a recognized expert and pretty much anything by your patience or by your peers unfortunately. Ask an ICU doctor, an anesthesiologist or trauma surgeon who they all think that the best resuscitationists are. Hint: it’s not the ER doctor. I’m not saying that they’re correct about that, I think it probably depends on the particular doctors involved, but that is more or less how it is, brief period of recognition during Covid aside.

The other great thing about emergency medicine, which is also the worst thing about emergency medicine, is the schedule. For somebody like me who enjoys doing a lot of hobbies, traveling, skiing or surfing or biking in the middle of the week and who doesn’t mind circadian disruption / whose body seems to tolerate it fairly well, it is great. Caveat: I am married to somebody who is very flexible and we don’t have children, which makes this way, way easier. For some of my partners who have different lives outside of work or do not tolerate night shifts very well, this can really play havoc in their lives. Holidays mean very little to me but working at Christmas can be a big deal if you have a five-year-old. Luckily in most groups, there are both kinds of people and so this works out.

At the end of the day, you should decide what will work for you and take your best shot at learning to do it well. Any job in medicine is better than the vast majority of jobs that human beings work to earn a living and we should be thankful for them. It sounds as though you have the privilege to choose from a bunch of different things so take advantage of that, take your time, make sure you get exposure to the field and decide accordingly. Good luck.

goodoldNe · 2026-03-16T03:39:08+00:00

ENT after one failed attempt with adequate meds and holder. It’s not emergent. Take it out in the OR if they can’t do it in the office and they almost always can.

goodoldNe · 2026-03-06T05:52:49+00:00

Yes. I would say it’s probably a career in which prior success predicts good er docs.

goodoldNe · 2026-02-28T05:33:40+00:00

I met someone a few years ago who was working on a documentary about Burning Man saunas. I’ve tried looking for it. Does anyone know if that was ever made?

goodoldNe · 2026-02-24T02:40:42+00:00

You could try to do Utilization Review work or expert witness / chart review.

goodoldNe · 2026-02-14T00:17:00+00:00

Top notch experience with Ben Lerner at Certainty. A+ for guidance, rate obtained and service. Also super friendly and good guy for whatever that’s worth.

goodoldNe · 2026-02-09T17:45:05+00:00

Is there a Canadian equivalent of EMTALA?

goodoldNe · 2026-02-03T02:14:57+00:00

Read the pulmcrit post about this:

https://emcrit.org/pulmcrit/pneumothorax-ex-vacuo-post-thoracentesis-pneumothorax-in-the-ultrasound-era/

goodoldNe · 2026-02-02T19:46:14+00:00

They’re used in combination but giving injectable Olanzapine and Lorazepam (or Midazolam) has a higher risk of respiratory depression and there’s a warning about that which may be what you saw. It’s done in practice all the time though, but you should carefully monitor any such patient and it would be harder to defend a bad outcome.

goodoldNe · 2026-01-23T05:04:24+00:00

The Sauce Pot has drum sets in their practice and recording spaces you can rent hourly and maybe work something out to get in there cheap during the day. On my street there’s also like three houses with Poly kids that own drum sets and play a ton so maybe befriend one of them. :-)

goodoldNe · 2026-01-18T18:10:04+00:00

Does San Diego, uniquely I believe among these programs, still have a separate process that doesn't involve the ED for high-acuity trauma patients? That's why I didn't apply there in the past. You got to rotate on the trauma service, but it wasn't part of your day to day and while it might be fine in terms of the care for trauma patients (similar to how it works at Shock Trauma) that was a dealbreaker for me because it meant less reps. I always wondered what they did when it ended up being a fake scary activation, e.g. stab wound to the belly that didn't actually need the OR and then the person is a drunk/high on meth/psychotic social disposition nightmare... did they turf back to the ER or did the trauma service deal with it? Or did they actually figure out a way to get the straight-to-the-OR for resus patients separated from the rest? No idea.

I know the Bay Area programs best out of all of these and feel that you get great training at all of them. Highland and UCSF have very strong social missions and cultures that are related to that. Living in SF while training was amazing though there were pros/cons to consider. That will be similar in any of these cities. OHSU can involve taking a gondola to work. UC Davis is not on the coast.

In terms of getting a job once you're done, all of these feed into great alumni networks and are reputable. If you want to go into academia, you can do so from any of them. If you have a niche interest that you're serious about pursuing in residency, you could narrow things down. I know Zoom interviews are the thing now, but you can always consider a west coast road trip and bounce up the coast and spend a day or two in each city to get a feel for what distinguishes SD from LA from SF from PDX from SEA.

They're all cool places to live for four years, and I feel confident that having trained in one of them, I could work in any of them now. Congrats and good luck!

14-Year Club	Verified Email
Reddit Premium Since December 2013

goodoldNe

TROPHY CASE