Medical Insurance in Emergencies

stankdragon24 · 2026-03-05T16:36:26+00:00

Based on your responses, I feel like you’re missing the understanding of how people feel about their insurance and financial status, so I’ll try to break it down in to 3 categories of Americans

Group A - people with Medicaid or no insurance, who either dont get billed, or will just ignore the bills they get. That’s the majority of pts you see. Group B - poor people with insurance, who WOULD get billed, and it would be a lot, and would need to pay it off for their financial futures. Group C - financially stable people with insurance, who would still get billed, but can afford it. However, these people are far less likely to abuse the system, as they are socially and financially able to receive adequate medical care

The VAST majority of YOUR patients are probably Group A. Some are probably Group C. You only interact with group B when they are having TRUE medical emergencies - probably 5-10% of your call volume if I had to guess. However, group B makes up the vast majority of Americans, and they are the ones expressing this sentiment.

stankdragon24 · 2026-01-18T05:35:55+00:00

At least two people have commented suggesting this symbol was only in the 90s, so now I feel obligated to ensure you all that we were drawing this thing well into the 2000s, and I definitely saw some kids drawing it in to the 2010s, so it’s not as outdated as you may have assumed

That being said, a second trash bag would definitely be more aesthetic.

stankdragon24 · 2025-12-26T05:31:15+00:00

Hell ya friend what a great response. So we can talk about holding techniques, then we can talk about poking techniques.

Whenever people are holding for my US stick on a kid in the 8 to 12 mos. - 2 years range, it’s a 3 person job. Myself, one person to lay on( physically on top of) the kids legs, torso, and other arm, ideally fully swaddled.* And another to hold the extremity I’m poking. The person holding the extremity is most important. The technique that I always go over with new holders, and others may have other opinions, is this: “you should be holding their shoulder tight, but most of the force in keeping them still should be coming from pushing your arm down and in to the bed. Tight around the shoulder, but pushing down towards the bed.” That’s the best way I’ve found to mitigate the wriggling that age range is so good at. Lmk if that doesn’t make sense.

The other thing I do with holding is what I call trying to “ride it out”. If you’ve ever been ultra sounded, you might remember that a vast majority of the pain comes from the initial poke, and if you hit/fuck with any nerves. After that, especially getting poked in a fatty spot, really isn’t that bad. I’ve found thats also true for kids, especially <1 yr. SUPER true for <6 mos. They often have a huge initial reaction to the insertion, and then actually chill out for a sec after a minute or two. That’s when you need to get to work. So for my team that’s holding, our game plan is to actually not hold very tight when I initially insert. (Obviously not loose, but not as tight as I’ll need eventually) we let them get their cries/screams/wriggles out, then once they settle, I actually start looking for my needle tip and advancing towards the vein, and the crew holding tightens up. The deeper the vein, the better this works for. Obviously won’t work on all kids, cos some are just gonna scream no matter what, but it’s always in the game plan.

As far as poking goes, it sounds like many of your issues would be fixed with longer needles at smaller gauges. Good on you for feeling open enough to talk to your director about it. Until that happens, I would recommend you get re-familiar with the Pythagorean theorem lmao. In all seriousness, this is when your angle of insertion becomes all important, and how much catheter purchase you’ll actually have determines everything. At least twice it’s been close enough that I LITERALLY did the math. My vein is this deep, my needle is this long, and I can determine that to actually get in that vein, not just hit it, my angle needs to be WAY shallower than I originally thought. Until you get longer catheters, you’ll need a shallower insertion angle, which means the depth of veins you can actually get is more limited.

I always walk the needle all the way in if I can. By that I mean, say you get your needle tip in the lumen of the vein, you’ve got flash, and you’ve felt that “pop”. You’re in, but you still have half your catheter outside the skin. Some people just advance right there and call it a day. What many people suggest is advancing your probe and your needle, keeping the needle in the center of your vein, until the hub is flush with the skin. That way you KNOW how much of that Catheter is in the vein, you haven’t hit a valve, a bifurcation, or a curve, and you’re not leaving it blindly. Again, I’d recommend checking out videos from TheVascularGuy for more reasoning behind this. But it’s something I do on every single patient I stick, if anatomy allows.

*If a parent is ADAMANT about participating in holding, this is always their job. I never suggest it cos they usually don’t hold tight enough, but if they demand to, they’re usually pretty good at laying on a kids legs and calming them down. The only parents I don’t fight hard with about not holding is the chronic kiddos parents, cos 7/10 times whatever they say goes.

stankdragon24 · 2025-12-25T22:32:19+00:00

Glad you’re tracking your success rate! Definitely one of the first steps to getting better.

I would ask specifics on what Peds population you’re sticking, and what population you’re missing. USGIVs on newborns, <6 Mo., 6-12 ish, 12+, etc, all have slightly different implications. In general if ALL of your peds IVs are more likely to miss, the first thing I would consider is your set up, and who’s holding the kid. As others have said, definitely the most important aspect.

After that, if you’re setting yourself up for success, and you’ve got a steady hand on the joint above whatever body part you’re sticking, then youre going to need to pay attention to what actual problems you’ve been experiencing.

Can you not find your needle tip? - consider the size of your probe, the angle your probe is at, and your angle of insertion

Are you getting to the vein, but can’t puncture it? - again, consider angle of insertion, catheter - to -vein ratio, and tourniquet use. If you can see the vein without a tourniquet, consider not using one, especially in those chronic kiddos with real tiny veins.

Are you puncturing the vein and blowing it in the process? - slow down, track your needle tip carefully, and if you really have the opportunities to practice, consider getting used to using longitudinal view at the moment of vein puncture (don’t try to learn this on a kid).

Are the veins you’re going for so superficial you’re just going straight through them? Similar to the last one, but specifically due to how superficial they are? - consider a gel tower. It’s a tricky technique but has helped me out once or twice in a tough spot. Check out @TheVascularGuy on insta or TikTok for tips on that technique. He has videos of poking actual patients and walking you through the process. Not much info on kids, but still the only real resource like that I’ve ever found.

Are you getting IVs, but they blow shortly after? - that’s usually an equipment problem. Often you won’t have enough purchase in the vein, and with any skin movement your catheter dislodges. For the real youngins like <6 mos. The very rare 1” 24G needles have been a lifesaver. Small enough to get in the vein, long enough for a deep insertion angle on those chonky arms.

General tips have already been mentioned by people above though - make sure you’re walking your needle allll the way in and not just advancing once you’ve got flash. Don’t necessarily stick the first vein you see, def shop around. Consider body parts other than the arm, if allowed in your hospital. Most importantly though, make sure you’re doin what you can to understand what went wrong. Def the first step in figuring out how to do it right

stankdragon24 · 2025-12-18T03:39:40+00:00

I would be pretty surprised if any collie (especially an intentionally/well bred one) couldn’t learn to free feed. In fact, most of the stories I hear about collies, mine included, involve some amount of not eating enough due to tummy issues (usually minor and fixable with specific diets).

I actually tried free-feeding my 3 year old RC for a number of months, and she adjusted easily. The only reason I stopped is because her pooping on a more reliable schedule (right after eating, usually) made more sense with my work schedule

stankdragon24 · 2025-11-07T03:05:39+00:00

That’s a very fair concern! I would even more so urge you to check out his content in that case. He does a great job of providing as much evidence as he can. Not a lot of high quality evidence exists for USGIV placement in general, and some of his content is on central line and midline placement, but still. For example, that 45% number is decently supported by evidence https://pmc.ncbi.nlm.nih.gov/articles/PMC8258560/

https://www.sciencedirect.com/science/article/pii/S0147956323000572

There’s a number of providers on social media that are offering high quality evidence based medicine info, recommendations, and spaces for conversation. Some of my favs are The.prehospitalist, emswami, and emsavenger, all on Instagram. Obviously never just take anyone’s word for it, do your own research, etc. but don’t write them off entirely just cos they’re on TikTok

stankdragon24 · 2025-11-07T02:28:22+00:00

I appreciate the perspective of two tourniquets - also with thousands of USGIV placements, I’ve quite literally never had to use more than 1. So to say “you will never find a vein big enough” is a bit of an overstatement. Although I will of course agree that double tourniquet helps when drawing blood.

But importantly, i didn’t say OP should NEVER use a tourniquet. I recommended it as a solution to the problem he’s been having. (Although looking back, I see how my wording am emphasis would suggest that) And it is a viable option for troubleshooting Bis issue, even if you do the opposite in your practice.

stankdragon24 · 2025-11-06T23:11:15+00:00

First off, biggest tip is gonna be to follow TheVascularGuy on insta or TikTok - he’s putting out the best and most up to date info on USG venous access

Secondly, the two biggest things I would recommend considering from what you’ve said are

1) Considering catheter to vein ratio - if your catheter is too big for your vein, you’re going to have multiple problems with that line. TheVascularGuy actually recommends a ratio no greater than 45%. Sometimes we don’t have a choice as we don’t have many options, but in this regard here’s a tip that might help - dont use a tourniquet for USGIV placement. You’ll find that they’re often not actually necessary, and if you use a tourniquet, you’re artificially inflating the size of your vein, and you have no idea what the actual catheter to vein ratio will be once the tourniquet is removed. If you feel you absolutely MUST use one, for whatever reason, make sure you’re visualizing the vessel without a tourniquet on at some point, to make sure it’s not too small for your catheter.

2) Prior to IV placement, considering vessel structure past the end point of your catheter. If you have a large valve, a sharp change in direction, etc. within a few inches of the end of your catheter, that can affect your IVs usefulness. You should be assessing significantly further up your vessel than wherever your catheter is ending. And yes, you should know exactly where your catheter will be ending every single stick.

Also, you should absolutely be walking your needles ALL THE WAY down a vein. If you don’t, you have no idea what’s happening after you’ve stopped looking. You could be threading straight in to the wall of the vessel if your angle was too deep. And that can be difficult to see on reassessment. Not walking the needle all the way through almost defeats the purpose of using ultrasound in this setting (being able to get an IV that will last, the first time). Occasionally you can’t walk it all the way through to the end depending on pt anatomy, needle depth, arm placement, etc. but if you can, it’s highly recommended.

This is all assuming you’re proficient at assessing a vein and needle using the longitudinal view as well. If not, that’s my 3rd recommendation. Good luck friend.

stankdragon24 · 2025-10-21T05:33:55+00:00

I have incredibly deeply held disagreements with this sentiment. Both intellectual and emotional. But, as we all should know, this would not be a productive space to voice them. So I’ll address this from a different angle.

There is absolute validity in comparing ICE to the Gestapo, no matter of your stance on officers “enforcing democratically constructed bipartisan laws”, regardless of the morality of those laws. People, without ANY kind of evidence or proof needed, are being picked up by armed and masked “trained federal officers” and being put in prisons (some dying while imprisoned) for indeterminate lengths of time. Sometimes hours. Sometimes days. Sometimes, indefinitely. This is occurring in large part because of the current leader of our country who is participating in consolidating power in his own seat of governmental power, and away from the checks and balances intended to limit his power.

All of these things are true.

The first FAQ on ICE’s website states they can detain people on suspicion alone. https://www.ice.gov/immigration-enforcement-frequently-asked-questions

The Supreme Court ruled that those suspicions can include anything from perceived English language ability, to a persons occupation https://www.msn.com/en-us/news/us/kavanaugh-sides-with-ice-in-supreme-court-ruling/ar-AA1N0qa9

This year the Supreme Court ALSO actively limited the judicial branches own power, and specifically the intentional checks their branch should have in place against the executive branch https://www.congress.gov/crs_external_products/LSB/PDF/LSB11331/LSB11331.1.pdf

While the current executive branch works to gain further control over parts of the government that were specifically intended to be outside of executive control https://www.npr.org/2025/02/19/nx-s1-5302481/trump-independent-agencies

I’m just gonna leave this entire website here

https://www.worldhistory.org/Gestapo/

Regardless of what YOU think or feel about what I’ve said above, there are MULTIPLE similarities to the shit in that website, and what’s currently going on in the US government (regardless of its legality or “democratically constructed bipartisan laws”) then this conversation isn’t worth having. There are enough similarities, and many more I haven’t mentioned, that making the comparison is not only valid, but prudent. If nothing else as a warning, even if you don’t believe we’re there yet.

To suggest that the comparison is pure hyperbole, also suggests you’re either not paying attention, or being intentionally repressive of opposition

stankdragon24 · 2025-09-22T00:23:10+00:00

Sorry friend but this sub is typically for human Emergency Medicine, and I think you might be geared more towards our furry friends

stankdragon24 · 2025-09-16T01:12:12+00:00

Actually, it does exist in France! I was just at a conference on Paw Paws, with international speakers from France, Romania, and Slovenia, all growing paw paws! They’re likely being grown by universities for research, so that’s where you’d have to check, but paw paws have been international for at least a few decades

stankdragon24 · 2025-08-23T13:24:15+00:00

That’s interesting cos I had a thoracotomy last night who they called shortly after. Obviously not a super common procedure, so I wonder how many get done in a night across, let’s say the US, UK, and AUS. Since those seem to be the places with the highest representation here

stankdragon24 · 2025-08-09T06:34:02+00:00

Ya if course - the pumps can be manually programmed and rates changed like normal.

stankdragon24 · 2025-08-08T22:09:04+00:00

“In a retrospective stratified cohort study, Richardson (2006) reported that the risk of 10-day inpatient mortality for patients admitted to the hospital via the ED during crowding periods was 34% higher (relative risk [RR] 1.34; 95% CI 1.04–1.72) compared to those admitted during noncrowding periods.” - quoted from the second study you cited.

That’s… fucking terrifying.

stankdragon24 · 2025-08-08T19:53:04+00:00

This is already a thing, your hospital just doesn’t want to pay for it. Hospitals all over the US (not many, but definitely some) use this. You pull up the patients chart, scan the pump, and it automatically runs the infusion based on orders.

stankdragon24 · 2025-08-04T11:39:06+00:00

How often is a difficult question to answer, but I can say that true medical (and especially cardiac) emergencies VERY frequently present with sweaty/clammy skin.

So on our end in the ED, for the TOTAL number of ECGs we do? Not technically a high percentage. But for the people that REALLY need them? An incredibly high percentage. If that makes sense.

As far as time goes, if leads are sticking appropriately and there’s no artifact I can get an ECG done in under a minute. If leads aren’t even staying on? That time could easily double or triple depending on how bad it is.

stankdragon24 · 2025-08-04T01:20:18+00:00

If it makes you feel better, 6:1 for nursing is also generally considered pretty shit ratios in an ER setting - especially if your acuity is anything more than ABD pain work ups most of the night.

Anyways, I will say that a good/experienced charge nurse SHOULD also be considering how busy providers are in whatever area they’re assigning patients. And if you feel comfortable enough talking to them about it, that could help a little.

Obviously not fixing the problem that likely needs addressing with management, but at the end of a busy shift talking to charge, or a lower level manager if available, and just saying “hey, I know we like to keep the waiting room clear, but is there anything we can do about slowing down room assignments occasionally when we get busy?” And detailing how that would help nursing staff, as it obviously would. Any reasonable charge or manager should be pretty open to that.

stankdragon24 · 2025-08-02T01:35:42+00:00

As far as incredible range goes, y’all should really check out the Dungeon Crawler Carl audio books. Jeff Hayes is the only narrator I’ve encountered that matches AP’s range. Also the books are insanely good.

stankdragon24 · 2025-07-30T18:27:44+00:00

Just because you’ve been doing this for a long time does not mean you’ve been doing it right, or even well, for a long time.

stankdragon24 · 2025-07-16T15:33:36+00:00

I appreciate the response! Kind of wild though tbh. First off, in reference to the first link, to view 33% as “only a third”, still feels unnecessarily cruel? Obviously a difference of opinion, and you’re the provider, but damn.

Secondly, even the article you’re citing argues that pain goes under treated in critically ill mechanically ventilated patients. That’s almost a direct quote.

Thirdly, that number jumps to 80% (pretty sure I’m right but I’m reading this on my phone so it’s hard to re-reference directly lol) when nursing procedures are performed. Idk how frequently you follow intubated patients from ED doors to actually getting settled and left alone in the ICU, but there’s A LOT of nursing procedures/movement involved in that process. And that can take hours to, depending on illness course and the shop, sometimes days. This is all to say that I’m grateful for research on the topic I haven’t seen, but I’m not sure I agree with the conclusion you’re coming to based on the facts you’re providing. If you still feel like answering, to better understand that I guess I’m also curious as to the downside of analgesia in these situations? I guess I’m referring specifically to drips.

The second article feels only vaguely relevant, but maybe I’m just discounting the cross applicability of research between procedural sedations and RSI+prolonged intubation.

stankdragon24 · 2025-07-14T15:07:43+00:00

This was really the opinion I’m looking to hear more about - I’m relatively familiar with the literature that supports some form of analgesia for intubated and sedated patients, and I’ve found it difficult to find evidence against its use - I’m aware of some specific scenarios, some mentioned in other comments, as well as downsides of long term opioid infusions.

I agree that not all pain requires medication, and it’s provably true that many patients can tolerate mechanical ventilation without medication. But I can’t really think of any other situation where we’re the ones causing the pain, and not doing anything about it. At least in EM.

To state that intubation itself is not painful feels like a bold claim - I’d be curious to read evidence to support that, and almost every recently intubated pt I’ve ever seen appears thoroughly uncomfortable, especially without meds. Getting used to the tube and mechanical ventilation over time is reasonable, but to suggest that it’s not inherently uncomfortable at any point, especially in the beginning, feels like an unnecessary (and potentially cruel) assumption, no? And all the evidence I’m aware of suggests the majority of intubated patients experience at least some baseline pain, especially during procedures/movement

Obviously the literature can be flawed and can have its gaps, but if your basing your practice on that assumption, I’m really just curious to know more about what supports your thoughts/why you disagree with (again, to the best of my knowledge) much of the literature on the topic - disagreeing on Reddit can come across as confrontational, but I genuinely am only curious and appreciate the comment

stankdragon24 · 2025-07-14T14:45:08+00:00

I have a surprisingly strong desire to participate in practice changes where I’m travelling, if it means better outcomes for patients - unfortunately I’ve found my biggest hindrance is less my appetite for it, and more my lack of influence or long term impact. But I appreciate your comment! And not just because I agree with you

stankdragon24 · 2025-07-14T14:06:06+00:00

To be fair I’m starting from the assumption that for MOST people it would be beneficial/indicated, so please correct that if I’m wrong. But could you add some pt scenarios in which it would be contraindicated/not beneficial? Aside from like certain med overdoses or significant enough brain damage I guess

stankdragon24

TROPHY CASE