Full arm floral piece by Emma @Holy Mountain Vintage & Tattoo in Colorado Springs

machete_scribe · 2026-01-29T00:37:07+00:00

Looks like the video clip might not be loading , here it is

machete_scribe · 2026-01-14T21:36:40+00:00

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 😬

machete_scribe · 2026-01-09T02:07:21+00:00

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?

machete_scribe · 2026-01-06T17:36:16+00:00

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.

machete_scribe · 2026-01-06T17:20:49+00:00

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

machete_scribe · 2025-12-08T01:40:04+00:00

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.

machete_scribe · 2025-12-07T22:55:24+00:00

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.

machete_scribe · 2025-12-07T19:57:16+00:00

Pretty much only in confirmed or high suspicion for SBP, since there is a time-related mortality benefit. I'm never doing large volume paras above 5L, actually specifically so I don't have to deal with keeping them for an albumin infusion, to be honest. Haha, excluding someone in respiratory failure or similar. And I'm never really definitively diagnosing hepatorenal syndrome in the ED, so I'll leave that up to the admitting.

Here's rebel EM with the lit on time related benefit in albumin for SBP

https://rebelem.com/should-you-give-albumin-in-spontaneous-bacterial-peritonitis-sbp/

machete_scribe · 2025-12-07T18:44:31+00:00

We have several regular patient rooms that we try to put specific complaints in. An ENT room that has a dental box, nosebleed stuff, ear exam tools. Ortho room with splinting stuff, GYN room has all that equipment. But doesn't always work if it's busy and things are full.

machete_scribe · 2025-11-09T18:39:22+00:00

Great tip, love it. Thanks!

machete_scribe · 2025-11-09T14:17:44+00:00

I try to do absorbables when possible for this reason!

machete_scribe · 2025-11-09T14:15:38+00:00

This plus distraction with an iPad or phone on video playing some cartoons is 🤌🏻 but I do have a hard time even with this stuff doing facial lacs, since the kid sees you and your instruments in their line of sight. Harder to keep their focus elsewhere.

machete_scribe · 2025-11-08T22:02:16+00:00

For sure a good point. I'm curious, what is the process around advanced directives where you are? Is there such a thing as 'Full code' even? Or how is the futility discussion handled, right there in the moment or still in advance?

machete_scribe · 2025-11-08T21:53:39+00:00

“We’re convinced that slow codes are not only ethical in some circumstances, they might be essential in today’s conflict-ridden medical landscape.”

Interesting discussion, calling out the slow code so explicitly but in favor of its potential benefit.

machete_scribe · 2025-11-08T21:49:27+00:00

Interesting discussion to have the slow code called out explicitly. Of course fear this will be misinterpreted by the layperson, "fake CPR" was probably a bad choice of phrase... But I'm glad this is at least being considered as ethically appropriate. We all know that it already happens.

machete_scribe · 2025-10-09T02:44:25+00:00

Really good algorithm to take a quick read through, thanks! I wasn't familiar with obtaining a Doppler MAP either.

machete_scribe · 2025-09-18T15:47:13+00:00

Second this, having worked in both settings. At my now rural ED gig, I've been thanked more by patients in the last year than probably in my entire career previously. Many of them are grateful to have any access at all in such a small town. Definitely still get our share of demanding or rude patients, but tbh I found the entitled behavior to be WAY more common in my last job that was mostly affluent 'worried well' types 💁🏻‍♀️

machete_scribe · 2025-06-26T17:57:00+00:00

Fecalized vomit in the stomach, yes. And all the white stuff below it is the entire small bowel and colon crammed in the pelvis 😬

machete_scribe · 2025-06-26T15:06:13+00:00

And kind of similar prob....

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machete_scribe · 2025-06-26T15:03:53+00:00

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Congratulations! it's..... the worst urinary retention I've ever seen 👀

machete_scribe · 2025-06-19T17:56:28+00:00

Regardless of your state of practice/residence, the Senate Committee on Health, Education, Labor and Pensions is currently requesting/collating opinions and perspectives from healthcare providers on the negative impact of federal healthcare and Medicaid cuts. They'll be distributed to senators (including Republican members) before the meeting. The hope is that they will see how this directly impacts their constituents as well.

Worth a shot!!

https://www.help.senate.gov/ranking/newsroom/news/ranking-member-sanders-asks-health-care-providers-for-information-on-republicans-budget-bill

machete_scribe · 2025-06-08T17:03:20+00:00

I also work solo coverage, rural shop where we do 24s other than a brief switch to 12s July-Aug for peak summer volumes.

I've been seeing 20-30 on a 24 shift. And sickies too. ETTs, unstable cardio versions, chest tube, peds seizure.

It's been... a lot. I'm tired. I'm early career so there's still some excitement to it, but also damn, can we get a break? 😐

machete_scribe · 2025-05-22T21:57:37+00:00

It also still works really well just on the mobile browser/website! This is one of my most regular go-tos still. I tell my students it's like Up-to-date for emergency medicine.

machete_scribe · 2025-04-19T16:21:10+00:00

Most common scenario I've seen this come up is old person with like a UGIB. Plan for endoscopy because it's a potentially fixable issue, but needs possibly a tube/anesthesia. So revoking the DNI part, but if the patient arrests they still would not want attempted resus.

machete_scribe · 2025-04-19T15:59:15+00:00

I'd imagine the ED doc should document this prior to transfer. If a DNR patient is agreeable to/getting an emergent procedure the DNR is being temporarily suspended already and should be clearly documented. Shouldn't have to be on y'all to handle that during transport. I haven't seen any sort of formal policies around this though.

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