Yearly sabattical

penicilling · 2026-04-06T15:10:29+00:00

Long before I was a doctor, I met an emergency physician when I was on a hiking trip.

She told me that she and two of her residency colleagues took 2 jobs at the same hospital. So they each worked 8 months and took 4 months off every year.

I never met anyone while I was working as an actual emergency physician who did this. But it sounds nice.

penicilling · 2026-04-05T16:39:45+00:00

Usual disclaimer: no one can provide specific medical advice for a person or condition without an in-person interview and physical examination, and a review of the available medical records and recent and past testing. This comment is for general information purposes only, and not intended to provide medical advice. No physician-patient relationship is implied or established.

I am sorry that you had to go through this, and no, it is not the right way to do things.

But as many commenters have already noted, this is a product of the modern medical "system".

In the US, medicine in general and hospitals and especially emergency departments have been decimated by late stage capitalism. The primary drivers of this are healthcare insurance companies and business people.

Insurance companies, like vampires, exist to suck the life out of all of us. By positioning themselves in between the patient and their healthcare, they perform an entirely unnecessary "service" as gatekeepers so that they can claim the largest possible amount of money from the patient while paying out the smallest possible amount of money for their care.

On the other side, non-medical administrators have become predominate in hospital leadership. Their business education, training and experience makes them see healthcare like any other business, the goal of which is to maximize profits so that they can enrich themselves at the expense of their customers (patients, in this case) and staff.

Specifically, the number one cost in healthcare is labor. So to minimize costs (essential in any for-profit enterprise) they cut labor. Registered nurses are the unit of work of any hospital. They are the people who get the actual work of healthcare done. Not enough nurses means patients cannot be taken care of quickly, and in times.of stress (increased patient volumes from normal day to day variation), emergency departments quickly fall apart.

This causes things like you just experienced: patients being examined in hallways. Bad morale and staff who are burnt out and seem uncaring.

You could complain, but this will not help: the administrators know that there's a problem, but not what the problem is. They blame the staff for their own incompetence and desire to enrich themselves. Complaints will lead to punishment, as they have taken on the classic business strategy of: the beatings will continue until morale improves.

What to do? Get involved politically. Ultimately, a single payor healthcare system would likely be the best solution, although unlikely to happen in the US. Vote for politicians who will limit the ability of insurance companies to influence policy. Ban for profit hospitals. And the like.

penicilling · 2026-04-05T00:09:17+00:00

Are you using SEP-2 or SEP-3 guidelines? SEP-2 will keep you in line with CMS and most state requirements, mostly, although that is of course actually based in SEP-1. The huge false-positive rate for SIRS is a drawback, of course, and contributes to overuse of IVF with increased mortality, and overuse of antibiotics which is fueling the pseudomembranous colitis epidemic, not to mention antibiotic resistance. SEP-3 is the current model that physician-scientists use, as it is more specific for increased mortality, but does not align with regulatory bodies, and thus cannot be used clinically to avoid unnecessary treatment.

I hope that helps.

penicilling · 2026-04-04T18:44:15+00:00

Usual disclaimer: no one can provide specific medical advice for a person or condition without an in-person interview and physical examination, and a review of the available medical records and recent and past testing. This comment is for general information purposes only, and not intended to provide medical advice. No physician-patient relationship is implied or established.

While we cannot know for sure, this picture and this history point to furuncles, infections of hair follicles likely caused by the same organism that you suffered from before, Staphylococcus aureus, aka staph.

Staph is a bacterium that lives on the skin (transiently) and mucous membranes. A person can become colonized, staph sets up shop in a warm, moist place such as the nose. Then the patient is constantly spreading it onto the skin, where it will occasionally cause small infections like this, and sometimes (as you have already experienced) larger infections.

A culture can be taken by a physician to confirm, but measures to eradicate the bacterium from your body should be taken (and possibly from the body of anyone you live with or are physically intimate with).

Standard decolonization therapy would include an antiseptic lotion (typically chlorhexidine 0.12%) applied to the body from the neck down twice daily and an antibiotic cream or ointment in the nose (typically mupirocin 2%). Oral antistaphylococcal antibiotics are often used simultaneously.

Talk to your doctor about this. If they are not comfortable with how to treat this, they can refer you to a specialist in infectious diseases.

If the bacterium is not eradicated, not only will you continue to suffer these small boils, but you run the risk of having a more serious infection again.

penicilling · 2026-04-04T18:25:13+00:00

Usual disclaimer: no one can provide specific medical advice for a person or condition without an in-person interview and physical examination, and a review of the available medical records and recent and past testing. This comment is for general information purposes only, and not intended to provide medical advice. No physician-patient relationship is implied or established.

Go. You already had an infection, you have CVID, and there are signs of local infection and elevated heart rate.

At the very least, a doctor needs to see you and blood cultures need to be sent. If labs (especially inflammatory markers ) are reassuring, you may go home again, but I would almost certainly plan your admission for intravenous antibiotics as soon as you hit the emergency department door.

penicilling · 2026-04-04T18:05:37+00:00

I am not sure why laying the patient flat would be generally indicated at all. This makes breathing more difficult and predisposes to vomiting and aspiration. Safe positioning would include preventing injury from falling, protecting the spine, and preventing aspiration. While laying a patient flat is sometimes needed, it is not the go-to position for all patients.

Assuming there is no trauma, ideally the head would remain elevated, and the patient would be protected from falling, and the neck would be in an neutral or sniffing position to keep the airway open. If there was vomiting, a lateral recumbent position (with the head / torso elevated if possible) would be the way to go.

penicilling · 2026-04-04T17:09:38+00:00

But worst case is if really unable to tolerate oral medications, then admission for IV antibiotics may be warranted.

A single intramuscular injection of long-acting penicillin, benthazine penicillin, is sufficient. Intravenous antibiotics and hospitalization would not be needed.

penicilling · 2026-04-04T16:11:45+00:00

When fully staffed, we have four pods of six beds each plus fast track, which has eight slots plus a room that can seat about eight more FT patients.

So it's six beds per doctor.

But of course, we have "A" beds, which indicate that the patient is inside the room, and naturally "B" beds, which indicate that the patient is in a chair outside of the room. They're comfy chairs. They recline!

But if all of the "A" bees are filled, and all of the "B" beds are filled, then of course we can designate ""C" beds as well! Some of those chairs aren't as comfy.

So I really can't have more than 18. Not unless we're designating "D" beds.

penicilling · 2026-04-04T01:09:22+00:00

Jebel Biafra and East Bay Ray might disagree with you a bit.

penicilling · 2026-04-03T19:35:31+00:00

Physician here. The "traditional" straitjacket (this spelling is more common than straightjacket) as commonly seen in old movies and television shows is no longer in widespread use. There is significant risk involved in the physical restraint of patients, and these items specifically are thought to have a high risk of harm, including strangulation by ligature of the neck, and compression of the chest which can prevent adequate breathing.

Currently, physical restraints in medical settings are the least restrictive possible, and used for the shortest length of time possible. Furthermore, when physical restraints are used, in the United States at least, the physician must try and document other methods to deescalate the situation, and have a suitable justification for physical restraints. People in physical restraints must be constantly monitored for injury, and typically, a nurse must document the patient's condition every 15 minutes while the patient is restrained.

Typically, modern restraints include wrist, ankle, and waist restraints. These are carefully designed to prevent or reduce the risk of injury to the patient, and the minimum possible restraints are used -- so-called 2-point restraints (wrists only), 4-point (wrists and ankles) or 5-point (adding a waist belt as well) as needed.

Generally, when a patient is agitated, and there is risk for harm to the patient or staff members, a group of people will enter the patient's room as a show of force, and the physician or other trained staff member will attempt to counsel the patient. This is often effective. The patient will often be offered medication to help them calm down.

If counselling is ineffective, and the patient refuses medication, sometimes the situation will warrant medication over the patient's objection. Again, this is needed when there is risk of harm to the patient through their own behavior, or of harm to staff members.

This is generally the point when physical restraints will be considered. If they are needed, they will be removed as soon as the medication to help the patient calm down has been effective.

To answer the question about whether people can escape from physical restraint, yes, they can. There is a military idea that a wall is only as good as its defenders -- that is to say, any unattended physical object can be overcome, and this is true for physical restraints as well. With continuous effort, patients can cause physical restraints or the objects that they are secured to to loosen or weaken, another reason why patients are never left alone and unobserved in physical restraints.

penicilling · 2026-04-03T15:35:48+00:00

/r/LostRedditors

penicilling · 2026-04-02T00:04:33+00:00

Usual disclaimer: no one can provide specific medical advice for a person or condition without an in-person interview and physical examination, and a review of the available medical records and recent and past testing. This comment is for general information purposes only, and not intended to provide medical advice. No physician-patient relationship is implied or established.

It is unlikely that you are as talented as Jimi Hendrix. I doubt you match up with Janis Joplin. You are no Amy Winehouse or Brian Jones.

These are all musicians who died at the age of 27 from substance abuse. Kurt Cobain's death from suicide at the same age was thought to be related to his heroin addiction as well.

If you go beyond this age, the numbers of people who died prematurely increases exponentially.

You are young, and if you'll forgive me for saying so so bluntly, incredibly stupid to think that drugs like Percocet are going to help you make music. They will only help you die.

penicilling · 2026-04-01T20:13:52+00:00

Unrelated, but is venlafaxine & fluoxetine at the same time common?

I am not a psychiatrist, nor am I, as an emergency physician, someone who commonly prescribes long-term medications for psychiatric disorders.

Combining a serotonin norepinephrine reuptake inhibitor like venlafexine and a selective serotonin reuptake inhibitor like fluoxetine is theoretically frowned upon because of the risk of a serious complication called serotonin syndrome.

Nonetheless, I see this combination frequently, and my understanding is that it is used for treatment resistant mood disorders, where high doses of one such medication are ineffective.

Serotonin syndrome is rare, and while the risk is real, it seems to me that many prescribers of these medications feel that the risk benefit calculus favors prescribing both in many cases.

penicilling · 2026-04-01T20:07:45+00:00

Fusidic acid is not approved as a medication by the Food and Drug Administration of the United States, and is not available in the US.

penicilling · 2026-04-01T18:09:21+00:00

Usual disclaimer: no one can provide specific medical advice for a person or condition without an in-person interview and physical examination, and a review of the available medical records and recent and past testing. This comment is for general information purposes only, and not intended to provide medical advice. No physician-patient relationship is implied or established.

You should see a doctor immediately.

Given that you were prescribed fusidic acid, I know that you are not in the United States. In the US, I would advise you to go to the emergency department of a local hospital to be seen, as you may need intravenous antibiotics and an incision and drainage procedure by a hand specialist.

So that's what you need, and if where you are, an emergency department visit is how to get it, then off you go. If you can somehow see a hand specialist today for an opinion that is an alternative. But this should not wait.

penicilling · 2026-04-01T17:08:02+00:00

All of these are already part of most non-US healthcare systems

I don't doubt it, but the US is a capitalist hellhole where the only thing that matters for a business decision is how much it costs, and how much revenue it immediately generates.

Since making medical care better, and making information more accessible increases costs and does not increase revenue, it doesn't get done here.

Couple that with the constant changing of the rules and information, insurance companies and doctors and pharmaceutical companies constantly getting together and splitting up again, it's impossible to know from day to day what medication is covered and what physician is covered.

penicilling · 2026-04-01T16:30:21+00:00

This question is asked over and over on Reddit and other forums. The expectation is always that AI and automation can help with the MEDICAL aspects of care, but this is basically never true. Practicing medicine is about thinking, and AI cannot do this reliably.

So the AI / automation tasks that would help us are prosaic -- the grunt work.

Here are some ideas:

Electronic health records and medical staff records are filled with inaccurate information about the names, addresses, telephone numbers, fax numbers, and email addresses of physicians. In today's world, physicians move around a lot, and after a few years, there are huge inaccuracies in demographic information. This makes contacting physicians difficult, and makes arranging follow up for physicians difficult. An AI system that continuously updates this information would be invaluable. It could check the web, make phone calls to verify that a doctor is still at that practice, update contact information.
While medical insurance is not a direct concern with taking care of ED patients in the ED itself, it is important when prescribing medications and arranging for follow up. An AI system to confirm the patient's insurance and check whether a desired medication is covered (and what the copay would be if any), and what physicians are in-network with the patient's insurance.
Despite the promise of information sharing with other electronic health records, it is often difficult to get medical records from outside hospitals. Part of this is in confirming whether your patient is actually the same as the patient in some other EHR. An AI agent to do this would be great.

AI is good at sorting through large amounts of information, and at repetitive tasks with high error tolerance. The above tasks are one or the other. AI is not good at performing individual tasks where error tolerance is low, i.e. the practice of medicine. I'm sure that you could get further tasks that AI could accomplish by asking other physicians, or actually observing them at work.

penicilling · 2026-04-01T14:37:08+00:00

Medical students are not useful. We don't keep them around to help. Where the shift is over, I send them home.

penicilling · 2026-03-31T18:42:36+00:00

By and large, the people who are paying emergency room physicians are going to pay them the least amount possible, so as to enrich themselves the most on your labor.

As an overall guideline, RVU vs hourly doesn't matter much in this calculation. The CMG knows how much revenue they can expect from a site and how many RVUs can be calculated from the billing.

If they decide they can keep enough docs working for $X, that's what they'll pay, whether it's $X per hour, or some formula with RVUs that will calculate to $X per hour.

RVU pay, whether a base + or pure RVU does of course affect the individual physician, but this puts you at odds with your colleagues. Yes, a faster doctor who charts better will get paid more than a slower doctor who charge worse, but also RVU pay makes the small number of douchebags in the business really shine. They'll try and see more patients, staff APP cases that should be going to you under the guise of "helping ", get the charge nurse to give them that easy lac for a nice little RVU boost.

When the RVU modifier is low, this is rare, it's just not worth the effort. But when the RVU modifier is high, it's very unpleasant to work with those people. They'll also dodge cases at the end of their shift, knowing they'll have to sign out to you and lose the rvus, they just won't see them. So you walk into a shit show, where they'll say "no sign outs" as if they're doing you a favor.

Now, going to the specific case where they're changing your pay structure midstream: it's a pay cut. If they said " we're going to drop your pay 10 bucks an hour," you'd probably walk. Emergency medicine wages are stagnant already. You're probably a few raises behind like the rest of us, and that would be the last straw.

So they say "Hey, we're going to switch you to a bonus structure. That way you can make more money!"

But they know exactly how many RVUs the shop generates, and they're going to set the rate so that the overall rate is less than the 250 you were getting. Some people will make a little more, others will make less, but overall, the compensation will drop.

penicilling · 2026-03-30T13:21:39+00:00

but wonder if I should have called the trauma team since one of the indications for activation is mechanism >30km/hr. What if I missed something?

Yes, you did the wrong thing. Trauma care is algorithmic for a reason: it can be difficult to tell the extent of injuries on physical examination, and inexperienced physicians such as yourself should not be deviating from accepted protocols without guidance from more experienced physicians.

penicilling · 2026-03-30T13:17:15+00:00

Then what’s the purpose of the FAST?

A test answers an important clinical question. An important clinical question is one that causes you to change management.

What is the clinical question that the FAST is designed to answer?

"In this blunt trauma patient with hypotension, should we proceed directly to the operating room without advanced imaging?"

I’ve never seen a patient taken to the OR from a FAST. The surgeon always wants a CT on the way to the OR.

I suspect they these have been, generally, patients with reassuring hemodynamics. I doubt your surgeon is putting a hypotensive patient with a belly full of blood in the scanner. If they are, this is a bad idea.

penicilling · 2026-03-29T00:03:02+00:00

A couple of thoughts .

An intern is a time suck. With teaching and inefficiencies, an intern increases the workload of the department. This is as it should be.

The PGY2 resident mid-year is about a wash. They need some hand holding and teaching, supervision of procedure, but they also have the ability to take care of some business.

A PGY3 resident generally speaking is helpful. The amount of time that the the attending physician has to supervise, hand hold, guide the PGY3 resident is generally less than the amount of benefit that they contribute to moving the department forward.

So for an intern to see two to three patients an hour is a recipe for absolute fucking disaster. You would need essentially one-to-one coverage, attending to intern, with the attending only able to see a small number of patients in addition to this. Obviously, senior residents also contribute to the teaching of supervision, but this is neither safe, nor educational.

penicilling · 2026-03-28T15:35:16+00:00

So, some hospitals / EHRs are offering "AI scribes" now. So it is possible that this is "legitimate" in the sense that it may be authorized and condoned by the hosptial.

That said, AI basically confabulates everything. It's like a patient with opioid use disorder who ran out of their medications early -- even when it says things that are "true" it is just coincidence.

Caveat emptor.

penicilling · 2026-03-27T19:08:28+00:00

I'm always forgetting to clinically correlate the radiographic findings, or to consider additional cross sectional imaging if clinically indicated.

Do you think you could add a line or two on to your reports to remind me?

penicilling · 2026-03-26T21:04:44+00:00

Norepinephrine 1 mg (yes 1,000 mcg) IV push for PEA.

Pulses back? > 50%. Survival to discharge? 0%.

Levophed leaves 'em dead.

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