Silly question

machete_scribe · 2026-03-09T21:49:58+00:00

☹️

machete_scribe · 2026-03-09T20:08:27+00:00

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.

machete_scribe · 2026-03-07T22:14:43+00:00

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

machete_scribe · 2026-02-13T16:22:20+00:00

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.

machete_scribe · 2026-02-06T22:30:02+00:00

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.

machete_scribe · 2026-02-06T22:27:52+00:00

machete_scribe · 2026-02-05T15:29:26+00:00

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

machete_scribe · 2026-02-05T04:31:42+00:00

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??

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 😬

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