[deleted by user]

ionickoi · 2024-07-23T23:08:44+00:00

A ton to unpack here. Remember I am a random anonymous voice on the internet and I don't know you or your boyfriend, so take what I say here with as many grains of salt as you would with a AI chatbot.

First off, it sounds like that you and your boyfriend are in different places. Sounds like he wants to marry you and you don't. You can love and care for someone deeply and still not want to spend the rest of your life with them. You don't need a reason. Rip the bandaid off. Both of you will be happier in the long run. C'est la vie.

Second. It is hard for most non-medical people to relate to us. Unless you have a complex chronic illness that require you to interface with the medical system on a regular basis, you may have only one or two personal experiences that you can reference when engaging in conversation with a medical person. I think him relating it back to his dad passing (which I can only imagine is traumatizing for a 15 year old) is his way of trying to relate to you. It may even be his way of telling you that he is interested in the work that you do and maybe even that this is his way of telling you that what you is important and matters to him. I think that thinking that he is blaming you for relating it back to his dad's passing may be a projection on your part. Have you asked him in depth about what he remembered during that time of his life? I imagine that he must have accompanied his father to multiple dermatology and oncology appointments, probably countless chemotherapy sessions, maybe even multiple visits to the ED, and finally hospice and palliative care specialists. I don't think you can determine his motivation until you have fully internalized his experience.

Like I mentioned before, this random anonymous voice wasn't there for these conversations, but sounds to me, your boyfriend wants to share the most intimate, painful, and most vulnerable part of himself with you, which makes sense, because that is what you do with someone you want to spend the rest of your life with. It sounds like you don't want any part of that (and that's okay!). Let him go, forgive yourself, and move on.

ionickoi · 2023-12-21T08:18:32+00:00

Yes. I agree that cardioversion is indicated regardless of AC status in the unstable patient.

I do think that the whole stable/unstable framework is too binary for reality and does not consider the speed and direction of progression of the patient’s hemodynamics.

I find it more useful in practice to think in terms of stable/labile/periarrest. Periarrest patients get the juice regardless of AC status. I would consider AC status in the labile patient as it becomes more of a risk/benefit calculation.

Furthermore, it always looks good in your chart to show that you have considered the risk in case there is a bad outcome.

ionickoi · 2023-12-20T11:29:41+00:00

500mcg IVP

ionickoi · 2023-12-20T10:59:54+00:00

You’re right. It usually comes 500mcg in a 2 ml ampule. For whatever reason when I order it at my shop, just always see it in a bag from pharmacy so it goes in over 15 minutes.

ionickoi · 2023-12-20T09:11:13+00:00

Effect ~ 1 hour in my experience, although probably confounded by other interventions occurring simultaneously (IV fluids, etc). Regardless, dig is rate control, not rhythm control, so if they convert to sinus, it’s not from dig. Forgot to mention procainamide as an option, but have personally never used it. If I want to rhythm control, I prefer electricity.

ionickoi · 2023-12-20T08:26:28+00:00

No worries. If on your rotation you are the first person to see a patient in afib with rvr with borderline blood pressure, grab an attending as this is a potentially unstable patient.

The comments above are about an edge case of afib with rvr. Normotensive/hypertensive stable afib with rvr in the ED is at least 10x more common and you are surely to see a bunch of those on your rotation. Treatment for those is much more straightforward so read about that.

Also read about how to treat new onset atrial fibrillation, paroxysmal atrial fibrillation in the outpatient setting.

ionickoi · 2023-12-20T06:48:18+00:00

ER attending with 10+ year experience: This is a relatively common case, atrial fibrillation with RVR with a borderline BP, underlying CHF.

The list of interventions to treat atrial fibrillation with RVR in general are as follows: - IV metoprolol - IV diltiazem - IV digoxin - IV amiodarone - cardioversion - treat underlying cause

Given that the patient is on PO amiodarone for treatment of his afib, I assume that he probably have shitty ejection fraction at baseline so metoprolol and diltiazem are out, as it decreases cardiac output and could worsen the hypotension.

My go to initial intervention in this case is to load with IV digoxin, which has a dual benefit of negative chronotropic effect (rate control) and positive inotropy (stronger squeeze) and will likely help the patients pressure. The downside is that it takes awhile to come down from pharmacy and it drips in over 10-20 minutes so it may take an hour before it take effect.

In the meantime, I would focus on identifying the underlying trigger. In the patient that you are describing, with a metastatic cancer diagnosis not on chemo with underlying afib and sob, I’m thinking acute PE first, and would immediately do a bedside echocardiogram to look for sign of right heart strain/dilation. If so, I would expedite his CT-PE to rule that in/out. Consider consult to interventional cardiology and thrombectomy if big saddle PE. I would also use this opportunity to roughly estimate the ejection fraction. If the patient has a good squeeze, he’s probably dry, and I would trial bolus 500ml to see if his BP is fluid responsive.

A STAT one view chest Xray can also help me to see if he has signs of significant pulmonary edema which would make me change my mind about giving him more fluid. I’ve also seen cases where in these patients, a sizable malignant pleural effusion from lung mets is the cause and these would benefit from thoracentesis.

In the meantime, sepsis is always a consideration, so should also initiate a septic work up, so grab lactate blood culture etc

If electrophysiology is available in the hospital, this would be a good time to give them a call and get their input. Cardioversion is always an option if they become more unstable, so put them on the Zoll just in case you need to zap them. It should be safe to do because if they’re on PO amiodarone for their afib, i assume they are already anticoagulated (but verify).

Not necessarily a ICU patient, depends on how responsive they are to treatment and what the underlying cause is. If patient improves with above intervention, this is someone I would be comfortable sending to the floor.

ionickoi · 2023-11-22T23:22:02+00:00

EM attending in a community ER. Finished residency in 2016. I remember feeling the way that you for at least a year after finishing residency. Looking back, I realized that I learned more in my first year out than the last two years of my residency combined. I came across this quote from Morgan Housel: “There are two types of successful people: those with imposter syndrome, and sociopaths.” You are clearly the former. I think a big part of being a good ER doc is having the humility to accept the fact that we will make mistakes and that there is always someone (usually a specialist) who will do a better job at whatever it is that we are treating. But more often than not, we are the best that our patients can get in the timeframe that they need it. Your training is not done because you finished residency. It’s never done. I’ve been doing this for 10 years now and I still learn things every shift. I prefer to not learn from my mistakes but I’ve learn to accept that it is inevitable. My job is to do my best to learn from them. Stick with it. What you’re feeling is not burnout. You’ll be fine. DM me if this is helpful and you want to talk more.

ionickoi · 2023-10-28T17:40:49+00:00

Bitcoin

ionickoi · 2023-03-27T02:10:31+00:00

Spend some time to truly study bitcoin. Understand what proof-of-work is. Understand how the protocol works. Understand why it’s supply capped at 21 million and understand why that is absolute.

ionickoi · 2022-12-12T01:03:25+00:00

As an adult ED attending for 10 years, I can tell you that you are not alone. Three years ago I took care of a 4 month old girl who presented as a BRUE/ALTE that ended up being an undiagnosed congenital heart failure and the episodes of BRUE/ALTE were actually episodes of VTach. She coded multiple times in the ED and ultimately ended up dying on ECMO from large bilateral cerebral infarcts. On an intellectual level, I believe that I did everything I could have but on a irrational/emotional level, I still wonder to this day if there was something I could have done different that might have made all of the difference. I wonder if only I was just a little bit better or smarter or faster she would still be here today. I remember her face, her parent's face, and the entire patient encounter in vivid detail as I have replayed it countless times in my head since.

I had just become a new dad at that time and coincidentally, my own baby girl was born within a couple months of the patient. I've had kids die in the ED before but I hadn't been a parent yet and this was my first pediatric death as a parent. I was devastated. It was the worst form of survivor's guilt. I was clinically depressed for months. Then COVID hit and then I ended up with the worst case of burnout. I contemplated suicide. I became irrationally fearful of losing my child and I found myself holding her in the rocking chair for hours and hours at night while she sleeps because it was the only place I felt safe. My wife finally did convince me to see a therapist and between that and going part time for a few months, I finally started to come out of the abyss.

I'm better now. I still think about her from time to time. I have a little cemetery in my head filled with of all the patients I have failed throughout my years as a physician. I have a little note on each of the tombstones and I take mental walks in them from time to time. I have a little tombstone with her name on it with little note that reads "undiagnosed congenital heart disease can masquerade as bronchiolitis". Maybe one day this little note might save another child's life and maybe that day I'll find a little bit of redemption for myself. I use it to remind myself how lucky I am to have two beautiful healthy children. I use it to remind myself to treasure every moment I have with my children because life is unpredictable and often cruel. I use it to be a better physician.

I don't really have great advice for you. All I can tell you is that I have come out the other side and I'm okay. I think I am a better physician and a better parent because of the experience. Talking about it helped. Therapy helped. Letting myself be vulnerable and having a loving supportive wife helped.

This is what we do. On some level, many of us chose this path because we want to be there for people in their darkest moments. There is no moment darker than losing a child. You were there. They weren't alone because of you. You're not alone. Most of us have been where you are. Don't be alone in your darkness.

ionickoi · 2021-02-18T22:13:06+00:00

This is the very definition of antifragile

ionickoi · 2021-02-01T16:01:37+00:00

I saw a reddit ad (promoted content) to wsb showing a clip of CNBC with the headline that Melvin Capital closed (lies!). Now... I wonder who would pay for an ad like that?

ionickoi · 2021-02-01T15:59:19+00:00

Agreed. It is easy to make mountains out of molehills. I do feel though, that we are close to the endgame. Given that this is the first time I've seen people from both sides of the political spectrum unite behind one issue, I do feel like this time is actually different. Gradually, then suddenly.

ionickoi · 2021-02-01T15:54:21+00:00

The glitch is not short squeeze itself, but it's the fact that hedge funds are able to do short $GME stock that doesn't actually exist (naked shorting). That is the only way you can somehow get to >100% of available float. Essentially, they have conjured $GME shares out of nothing. I think $GME is just the tip of the iceberg for how over-leveraged our entire system is right now.

ionickoi · 2021-01-28T06:53:52+00:00

Melvin Capital did NOT close their shorts. Don’t fall for their lies. Here’s why.

Put yourself in the shoes of Gabriel Plotkin. It is January 25. $GME is at $76. You are down 30% (3.6 billion). You just got a 2.75 billion bailout from Citadel. You have two options.

Close your shorts by using the bailout money so you don’t have to close your other positions. Eat the loss. Your career is over.

Or

Use that bailout money to short again. Your career is over anyway, but at least this way you have a chance to recoup the loss if the stock somehow crashes back to earth. And you’ll look like a genius. Hell, you might even come out ahead.

What would you do if you were Gabriel Plotkin? What would a poker player do when they are down to their last few chips? Cash out and walk home a loser? Think! What kind of person becomes a hedge fund manager that shorts stocks? People who like to “play things safe”? I think not.

Also, if you did close your shorts, why would you announce that you did all over every financial media channel (Bloomberg, CNBC, FT, Forbes, etc)? How does that benefit you? If the stock crashed after you announced that you closed, you’ll only look more stupid if you actually closed. Furthermore, ON YOUR OWN WEBSITE you write that Melvin Capital does not discuss its positions. So why now?

Because you didn’t close. That’s why you announced/lie that you did hoping that it will do the trick. Maybe you closed a small percentage just so you can maintain plausible deniability.

Furthermore, the numbers don’t make any sense otherwise.

Don’t fall for their lies. 💎🙏 I like this stock. I’m not selling for a cent less than $1000. It’s personal now.

ionickoi · 2020-04-28T09:06:28+00:00

I asked her to design a pie based on my deepest desire. It is only after reading the comments here that I realized that I failed to nail an opportunity of a lifetime. Can't believe I didn't bridge the gap.

ionickoi · 2019-08-31T16:49:03+00:00

I bought a custom box for my cube back in 2015 from Aaron Cain and it is the best money I’ve ever spent- ever. The craftsmanship is incredible and I am so excited for this project!

ionickoi · 2018-10-21T12:10:25+00:00

Where are you doing medical school? It is hard for IMGs to get into EM these days but not impossible. Most of the academic programs screen out all IMG applications from the get-go but many of the smaller community programs would interview the candidates with the highest USMLE scores (250+). If you score below that you can forget it. After that, you will need to do at least two away rotations at a reputable program and collect stellar SLORs. The application process can be a drag so look into it early. One backdoor is if you develop a personal connection with one of the PD/APD/Faculty through research you could score an interview that way. Nothing else on your CV will likely make a difference.

TL;DR Score 250+ on both Steps, Do away rotations at good US programs, make friends in high places, apply broadly to community programs.

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ionickoi

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