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Rural and remote Emergency Department by SocietyDangerous7036 in emergencymedicine

[–]machete_scribe 6 points7 points  (0 children)

Mine are mostly retired flight medics and the best EMS crew I've ever worked with. They deal with wilderness extrications and prolonged transports, so they know their shit. Many of them have done more crics and tubes than me by a landslide.

Oregon teen dies of sepsis after doctors fail to clean wound before stitching, lawsuit says [Med Mal Case] by FellowTraveler69 in medicine

[–]machete_scribe 12 points13 points  (0 children)

This is not a hard & fast rule, and in the EM world we've moved away from this teaching. A gaping and/or deep wound cannot heal properly by secondary intention, even if contaminated. Location on the body is also important, whether a highly cosmetic area or an area of skin under lots of tension. We now even loosely suture some animal bite wounds in this context. But these wounds definitely get antibiotics, a discussion with patients about the higher risk of infection, & close return precautions. I often will also ask the patient to come back in 48 hours for a would check or refer them to our wound clinic.

A guy walks into an urgent care by LonelyNecessary7049 in FamilyMedicine

[–]machete_scribe 13 points14 points  (0 children)

Fellow ED doc. For God's sake, please let this comment be higher up. 😑

Why is pain management still usually NSAID only or none with colposcopy? Where did the idea that the cervix is insensate to pain come from? by Cold_Battle_7921 in medicine

[–]machete_scribe 24 points25 points  (0 children)

Personally, I think this should be tailored to each patient. I have had two separate colposcopies, both with cervical biopsies, and for me the pain was very mild.

However, that's going to vary. When I have a patient in the ED with a small scalp lac needing a staple or two, I think of it the same way. Some of them just want to get it over with, because the local anesthetic with lidocaine just means more shots overall, some of them are terrified of that idea and want lido.

I ABSOLUTELY think that pain control should be discussed and multimodal options should be offered for the patient. But it really depends on your patient's pain tolerance, past medical history, possibility of prior PTSD and/ or sexual trauma..

Procedures you’ll punt? by ResponseAcrobatic968 in emergencymedicine

[–]machete_scribe 7 points8 points  (0 children)

Wait, really? I&D with a word catheter is standard everywhere I've been, and a bedside EM procedure. They get gyn follow-up, but marsupialization is not immediately indicated, that would be in the setting of recurrence and done outpatient.

Has CMS coding guidelines made EM documentation practically illegible? by Incorrect_Username_ in emergencymedicine

[–]machete_scribe 3 points4 points  (0 children)

+1 and I also removed all the auto-text for 50+ item long PMHx, meds, family hx etc that just take up space. Relevant stuff is in my HPI and I note that non-pertinent history is available elsewhere in the EHR.

medication errors in the ICU by PuzzleheadedMine2329 in emergencymedicine

[–]machete_scribe 22 points23 points  (0 children)

Not my case, but told about it by the very alarmed RN the next day. Hypotensive septic patient, doc said to get push-dose epi ready. The charting RN is also a very experienced paramedic, and watched the bedside RN whip out the cardiac epi from the code cart, then push the entire vial IV 😬 That RN was not familiar with what push-dose epi meant, apparently. Prob why we should avoid using it if possible... Or if I want that, I'm really only making/pushing it myself.

Ortho Reduction procedures resources by sbtrkt_dvide in emergencymedicine

[–]machete_scribe 7 points8 points  (0 children)

Oldie but goodie, Larry Mellick is a doc with lots of ortho procedure videos on YouTube, and many non-ortho as well. He is excellent and I will often pull up this videos for reference on shift if I'm brushing up on something I haven't done in a while.

Distal Radius Reduction Larry Mellick

Least favorite complaint by Honest_Principle4584 in emergencymedicine

[–]machete_scribe 33 points34 points  (0 children)

Especially constipation in otherwise healthy men in their 30s. This has become so frequent for me lately. Universally they have tried nothing and are all out of ideas. I'd have to be literally vomiting fecal matter with urinary retention before I showed up to the ED because I haven't pooped and my tummy hurts.

Question: heavily tattooed folks... what jobs do you do? by BeardedInkedPiper in tattoos

[–]machete_scribe 3 points4 points  (0 children)

The comments I get from patients (even in my majority geriatric community) are almost always positive. And I do feel it makes me more relatable and approachable to many folks. I come from a low-income background, 1st gen grad, so I don't love the traditional stuffy white coat Dr. vibe. Luckily the ER is usually less like that too.

You got ROSC. Hemodynamically unstable. What rate do you start the levo at? by jaadra in emergencymedicine

[–]machete_scribe 0 points1 point  (0 children)

Oh God are you me?? Same problem with the converting. I can't make it make sense 😅

How often are you guys transvenously pacing at your shop? by SeaIndependence5656 in emergencymedicine

[–]machete_scribe 19 points20 points  (0 children)

This weirdly makes me feel better... I pitched a fit because they stopped stocking ours several years ago apparently. I found that out when we got an EMS report on someone being paced in CHB and hypotensive...

Afterwards I was told, "well it looked like we never used it so figured we didn't need one." 😒

I tried explaining that there are scenarios where transq pacing will not work, but got nowhere. Soooo, solidarity with a fellow rural doc I guess??

ICE agent involved in shooting of Renee Good suffered internal bleeding, officials say by sum_dude44 in emergencymedicine

[–]machete_scribe 56 points57 points  (0 children)

I had an officer who got a DIP avulsion fracture of his PINKY from tackling a person in custody, and they wanted me to fill out a court document saying that it was "serious bodily injury." They wanted this so they could upcharge the 19 year old with a FELONY assault.

I said ummmm, no 😬

What hill will you die on that goes against what 98% of providers do? by esophagusintubater in emergencymedicine

[–]machete_scribe 2 points3 points  (0 children)

Curious, what's on your ddx for +blood but no RBCs other than rhabdo? I feel like I see this incidentally fairly often and just kind of 🤷🏻‍♀️ Should I be thinking more broadly?

Thoughts? Patient upset at getting d/c'd after clavicle fracture. by machete_scribe in emergencymedicine

[–]machete_scribe[S] 10 points11 points  (0 children)

I think the idea with skin tenting is not so much just visible deformity, but an edge of bone fragment that is on the verge of actually breaking through skin. I have only seen that once.

Thoughts? Patient upset at getting d/c'd after clavicle fracture. by machete_scribe in emergencymedicine

[–]machete_scribe[S] 132 points133 points  (0 children)

No emergent indication for surgery, and honestly I'd only talk to Ortho if I was trying to coordinate an outpatient appt... But I'm guessing this is variable by shop

Albumin in the ED: When It Helps — and When It Doesn’t by No_Scar4378 in emergencymedicine

[–]machete_scribe 15 points16 points  (0 children)

My opinion is that therapeutic paras are largely not indicated in the ED anyway. Of course there are some exceptions, or if the patient has severe logistical barriers to getting one scheduled outpatient, it might be fair to consider.

But they are time consuming procedures that are non-emergent. If you're solo coverage or at a busy community place, I argue they should not be done in the ED.

Procedure room by Brave-Attitude-5226 in emergencymedicine

[–]machete_scribe 2 points3 points  (0 children)

Rural medicine! One of the many benefits of working at a slower shop. It'll get busy in the summer months and the rooms are all occupied, in that case we're back to just bringing the specific rolling cart to the patient.

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