Post your boring, nonsense shifts!

[thegenius]

Let's play the fun game of illustrating all the nonsense that comes into the ER! Write a numbered list with a one-liner of all the patients you saw on a particular shift. I'll start:

8 hr shift

1. 23 yo man with CP and SOB after J&J COVID shot, vitals and EKG OK. discharged.
2. 71 yo woman with FTT. Labs and vitals OK (BP was 210/110). standard workup neg. discharged.
3. 19 yo woman with uncomplicated urticaria for 4 days. No anaphylaxis. discharged.
4. 40 yo woman with CP, sounds like GERD. Workup and two trops neg. Low risk. discharged.
5. 101 yo woman with GLF, hurt L shoulder and knee. Imaging neg. She could walk. discharged.
6. 31 yo woman with traumatic (and dramatic) knee pain. XR neg. I'm not even convinced she actually has internal knee damage. discharged.
7. 51 yo man post op urethral reconstruction with a mouth buccal graft has AUR with UTI. Not septic but close. Abx given. discharged.
8. 36 yo man with hyperemesis cannabinoid syndrome. Gave supportive care. discharged.
9. 52 yo woman with dentalgia and minor face swelling. No I&D needed. discharged.
10. 28 yo man with nonsense abd pain and scant hematochezia. Vitals, exam, and labs normal. discharged.
11. 22 yo man with epilepsy, med noncompliance with seizure. Back to normal. discharged.
12. 59 yo man with COPD p/w dyspnea. Actually here because just wants housing. Kept for SS in AM.
13. 17 yo woman was pre-syncopal while cooking. Back to normal. EKG and labs OK. discharged.
14. 29 yo man with intermittent abd cramping and hematochezia for months. Missed apt for upper and lower scope as outpatient. Vitals and labs OK. discharged.
15. 68 yo woman with transient palpitations near her right axilla. Resolved in ED. Everything neg (no ddimer sent thank goodness.) discharged.
16. 50 yo woman with R Flank pain. Surprisingly, labs, UA, US Renal and CT are all neg. Everything is neg. Not sure what was going on. discharged.
17. 40 yo woman with respiratory infectious symptoms and WBC 17. XR, UA, and CT C/A/P all neg. COVID neg. I signed her out and next doc admitted her for obs.
18. 70 yo woman with confusion and weakness - and had a legit exam to boot. Every single thing was negative. Literally. After about 6 hours she got better...and I saw her walk around. discharged.
19. 47 yo woman with Hg 4.4. Has known uterine fibroids. Was signed out to me after prior doc ordered 4U pRBC! Repeat crit was 8.6. discharged.
20. 34 yo woman with miscarriage 6 wks ago with HA and dizziness. BP normal. HCG was still going over past few weeks and is now 100. Nonvascular products in the uterus. Kind of a weird case. discharged.
21. 20 yo woman with left foot pain due to a congenital AVM overlying the 1st-3rd metatarsal bones. Interesting exam and history. I spoke to her for about 20 minutes about stuff. Might be infected and gave Abx. discharged.
22. 64 yo man with LBP with no concerning features. Labs 3 days ago normal. Toradol IM. discharged.
23. 25 yo woman with superficial dog bite to finger. Only needed wound care. discharged.

The only interesting ones were #7, 16, 17, 18, and maybe 21. I felt bad for 21.

Lots of young people on this particular shift.

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[RustedFox]

Eff you.

Come work at my shop.

 

[thegenius]

Eff you.

Come work at my shop.

It's simple. Take all my ages...and add 62. That's your shop.

Even your 163 yo woman

e.g.

1. 23+62 = 85 yo man
2. 71+62 = 133 yo woman
3. 19+62 = 81 yo woman
4. 40+62 = 102 yo woman
5. 101+62 = 163 yo woman
6. 31+62 = 93 yo woman

et cetera

 

[RustedFox]

It's simple. Take all my ages...and add 62. That's your shop.

Even your 163 yo woman

e.g.

1. 23+62 = 85 yo man
2. 71+62 = 133 yo woman
3. 19+62 = 81 yo woman
4. 40+62 = 102 yo woman
5. 101+62 = 163 yo woman
6. 31+62 = 93 yo woman

et cetera

Surprisingly accurate.

 

[GassYous]

101 gilf? pics?

 

[turkeyjerky]

No offense but your partners sound kinda nutty

 

[Zebra Hunter]

No offense but your partners sound kinda nutty

You mean you don't hand off pts with a hgb of 4.4 to get transfused in the ER so they can be discharged afterward?

Honestly, unless she was almost done with her final unit, I would've told him to admit that s**t and refused handoff, or taken it and immediately admitted them. Especially given you are seeing 3 pts/hr, although sounds like mostly BS.

 

[bravotwozero]

I would have obs admitted #17 for a TIA workup, and the vag bleeder, but that's me...

 

[Dr Mantis Toboggan]

Let's play the fun game of illustrating all the nonsense that comes into the ER! Write a numbered list with a one-liner of all the patients you saw on a particular shift. I'll start:

8 hr shift

1. 23 yo man with CP and SOB after J&J COVID shot, vitals and EKG OK. discharged.
2. 71 yo woman with FTT. Labs and vitals OK (BP was 210/110). standard workup neg. discharged.
3. 19 yo woman with uncomplicated urticaria for 4 days. No anaphylaxis. discharged.
4. 40 yo woman with CP, sounds like GERD. Workup and two trops neg. Low risk. discharged.
5. 101 yo woman with GLF, hurt L shoulder and knee. Imaging neg. She could walk. discharged.
6. 31 yo woman with traumatic (and dramatic) knee pain. XR neg. I'm not even convinced she actually has internal knee damage. discharged.
7. 51 yo man post op urethral reconstruction with a mouth buccal graft has AUR with UTI. Not septic but close. Abx given. discharged.
8. 36 yo man with hyperemesis cannabinoid syndrome. Gave supportive care. discharged.
9. 52 yo woman with dentalgia and minor face swelling. No I&D needed. discharged.
10. 28 yo man with nonsense abd pain and scant hematochezia. Vitals, exam, and labs normal. discharged.
11. 22 yo man with epilepsy, med noncompliance with seizure. Back to normal. discharged.
12. 59 yo man with COPD p/w dyspnea. Actually here because just wants housing. Kept for SS in AM.
13. 17 yo woman was pre-syncopal while cooking. Back to normal. EKG and labs OK. discharged.
14. 29 yo man with intermittent abd cramping and hematochezia for months. Missed apt for upper and lower scope as outpatient. Vitals and labs OK. discharged.
15. 68 yo woman with transient palpitations near her right axilla. Resolved in ED. Everything neg (no ddimer sent thank goodness.) discharged.
16. 50 yo woman with R Flank pain. Surprisingly, labs, UA, US Renal and CT are all neg. Everything is neg. Not sure what was going on. discharged.
17. 40 yo woman with respiratory infectious symptoms and WBC 17. XR, UA, and CT C/A/P all neg. COVID neg. I signed her out and next doc admitted her for obs.
18. 70 yo woman with confusion and weakness - and had a legit exam to boot. Every single thing was negative. Literally. After about 6 hours she got better...and I saw her walk around. discharged.
19. 47 yo woman with Hg 4.4. Has known uterine fibroids. Was signed out to me after prior doc ordered 4U pRBC! Repeat crit was 8.6. discharged.
20. 34 yo woman with miscarriage 6 wks ago with HA and dizziness. BP normal. HCG was still going over past few weeks and is now 100. Nonvascular products in the uterus. Kind of a weird case. discharged.
21. 20 yo woman with left foot pain due to a congenital AVM overlying the 1st-3rd metatarsal bones. Interesting exam and history. I spoke to her for about 20 minutes about stuff. Might be infected and gave Abx. discharged.
22. 64 yo man with LBP with no concerning features. Labs 3 days ago normal. Toradol IM. discharged.
23. 25 yo woman with superficial dog bite to finger. Only needed wound care. discharged.

The only interesting ones were #7, 16, 17, 18, and maybe 21. I felt bad for 21.

Lots of young people on this particular shift.

What am I missing on 17? Why did that need to be admitted or worked up that extensively…

 

[thegenius]

Re: vag bleeder, by the time I got sign out she was finishing unit 3 of 4. It would have been hard to admit her at that point, and I was going on vacation the next day, so I didn’t want to ruffle anyone’s feathers and get all worked up in a tizzy. I did make sure to ask the prior doc that she had follow up, and he unconvincingly said yes. 👀. She was otherwise young and healthy and could handle the 4U over 8-10 hrs total.

Re: #17…she looked bad. At time of me signing out she had WBC 17K and neg CXR and other labs. I suggested that if she was + COVID, that’s probably good enough to stop workup and dispo (although COVID pts tend to have normal or slightly low WBC). But if COVID neg to scan C/A/P. She was one of those pts who was all bundled up in 4 layers of clothes and thus hard to get a good exam on unless and it would just be easier to have radiology do the PE. But I would have not admitted her with neg scans.

And yes…and bunch of nonsense that day. The only thing really interesting was that foot (mostly for the conversation) and the guy who had a buccal implant in his urethra. Which made me think that he now has to live with the thought that he is blowing himself 24/7

 

[thegenius]

I would have obs admitted #17 for a TIA workup, and the vag bleeder, but that's me...

A TIA workup for #17?

 

[Fox800]

If I'm giving more than like 1 units of PRBCs I'm admitting someone, either to ED OBS or inpatient. Move on with your life.

Even 2 units of PRBCs is like a minimum of 4-5 hours right there by the time they type and cross, send it over, the nurse has to hang it...it takes like 2 hours for each unit to go in on the pump. Most of the order sets want stupid stuff like post-transfusion hemoglobin checks, etc. Admit and move on. Our ED OBS team eats this stuff up.

Same thing with intractable pain, admitting some elderly obese grandma for PT/OT because meemaw can't (read: won't attempt to) walk after a fall with negative imaging, etc.

"Looks bad" septic workup without a source is a reasonable ED OBS as well if they are older, esp if persistently tachycardic. Follow cultures, give additional fluids and fever meds, control symptoms, consider additional imaging, likely DC in the morning.

I don't DC home older people or people with significant comorbidities (transplants, immunosuppressed) if they come in with any variation of fever + tachycardia, elevated lactate, leukocytosis (not trivial like 12.2), etc and I don't have an obvious explanation like a URI (assuming their vitals get fixed easily with APAP and some fluids). I like to OBS those people. I have seen more than a few have bacteremia, or end up getting a CT abdomen that shows some wonky thing with NO abdominal/GI symptoms, also had a septic hip caught on CT with no hip pain or swelling or external signs......just weird stuff.

 

[Fox800]

A TIA workup for #17?

I think they meant to say #18 would get a TIA work-up. I also have a super low threshold to admit old people for this, and our neurology service agrees. They pretty much all get imaging (MRI/MRAs or CT/CTAs) and get admitted to tele overnight on observation.

 

[bravotwozero]

I think they meant to say #18 would get a TIA work-up. I also have a super low threshold to admit old people for this, and our neurology service agrees. They pretty much all get imaging (MRI/MRAs or CT/CTAs) and get admitted to tele overnight on observation.

Yes meant #18 sorry

 

[BoardingDoc]

Yeah, 100% would have admitted the VB patient unless she had a well documented history of coming in for this, getting transfused and being discharged with close outpatient follow-up (e.g like with some rare patients with MDS who get transfused once every month or so). Even in the case of the mds patient, I'd probably blink at an initial hb of 4.

 

[thegenius]

Yea #18 was weird. She was globally weak, kind of. Had history of chronic SIADH and hyponatremia and takes salt tabs. Last Na was 113 and was admitted 3 months ago for the same thing. She had no focal neuro deficits and if anything was mildly encephalopathic. But it wasn’t really an encephalopathy either. Anyway this kind of presentation is extremely rarely a stroke. Much more likely metabolic. I was going to admit her if she stayed weak, but she was walking around looking better. Na 132, k+ 2.9. Gave her a bunch of K and discharged her. I felt ok about it.

 

[thegenius]

No offense but your partners sound kinda nutty

Hah yea kind of I agree.

We have problems admitting people with low hemoglobins without active bleeding for transfusions. There shouldn’t be a problem admitting someone who is 4.4, ever. But I know that sometimes it’s such a fight it’s terrible.

 

[panscan]

1. Unvaxxed covid, 42% RA, improved with HFNC, no PE, admitted.
2. Diverticulitis with possible abscess, admitted.
3. Weakness, missed HD. K 8.6 with significant ekg changes (nearly sine wave, intermittent VT). Difficult IV access, IO placed standard treatment given. Central line. Emergent HD. Admitted to ICU
4. Old, can’t walk, admitted for rehab placement.
5. 2 week old dog bite, CT showed no drainable fluid collection, dc.
6. Scrotal abscess, I&D, dc.
7. Weird vague symptoms with neg workup and normal VS x 10+, dc.
8. can’t afford xarelto, case management, dc.
9. Well appearing infant with GI sx, dc.
10. Post op bile leak, admitted
11. Vomiting and lactic acidosis that somehow got worse with fluids, admitted.
12. Fall, normal imaging, wants dilaudid, nope

 

[thegenius]

1. Unvaxxed covid, 42% RA, improved with HFNC, no PE, admitted.
2. Diverticulitis with possible abscess, admitted.
3. Weakness, missed HD. K 8.6 with significant ekg changes (nearly sine wave, intermittent VT). Difficult IV access, IO placed standard treatment given. Central line. Emergent HD. Admitted to ICU
4. Old, can’t walk, admitted for rehab placement.
5. 2 week old dog bite, CT showed no drainable fluid collection, dc.
6. Scrotal abscess, I&D, dc.
7. Weird vague symptoms with neg workup and normal VS x 10+, dc.
8. can’t afford xarelto, case management, dc.
9. Well appearing infant with GI sx, dc.
10. Post op bile leak, admitted
11. Vomiting and lactic acidosis that somehow got worse with fluids, admitted.
12. Fall, normal imaging, wants dilaudid, nope

There’s some good stuff there.

I laughed out loud to #11. How old was he/she?

 

[panscan]

There’s some good stuff there.

I laughed out loud to #11. How old was he/she?

Assuming you meant #12 but they were upper 30s if I recall correctly.

#11 looked awful and I expanded workup bc of multiple comorbidities. Didn’t see obvious source except vomiting…maybe opioid withdrawal playing a role too

This is cool, I enjoy reading what seemingly mundane cases others have and how they manage them.

 

[thegenius]

Assuming you meant #12 but they were upper 30s if I recall correctly.

#11 looked awful and I expanded workup bc of multiple comorbidities. Didn’t see obvious source except vomiting…maybe opioid withdrawal playing a role too

This is cool, I enjoy reading what seemingly mundane cases others have and how they manage them.

Actually I meant 11….was thinking it was some bs 30 yo guy or gal with vomiting like we see 50 times / month. I can imagine the initial lactate of 2.7…you give 2L and the repeat is now 4.6!!! And thinking to yourself “whoa!!! Well you are getting admitted” even though your 6th sense is that they are actually not sick. But now have to get the obligatory CT and admit

12 I get so often and reminds me over and over about the millions of forlorned in our society. Why can’t they just disappear

 

[panscan]

Actually I meant 11….was thinking it was some bs 30 yo guy or gal with vomiting like we see 50 times / month. I can imagine the initial lactate of 2.7…you give 2L and the repeat is now 4.6!!! And thinking to yourself “whoa!!! Well you are getting admitted” even though your 6th sense is that they are actually not sick. But now have to get the obligatory CT and admit

12 I get so often and reminds me over and over about the millions of forlorned in our society. Why can’t they just disappear

Oh gotcha. So sad and true haha. Yeah that was exactly it. Nice that it wasn’t cannabinols hyperemesis for a change…

 

[HemorrhagicShock]

I've caught some weird intracranial stuff on these "chronic" vomiters - masses etc. When I get to the point where I'm consider the CT A/P, I usually take a few seconds to cognitively consider whether I need to scan the head as well (especially if they're already taking a trip to the donut of truth)

 

[panscan]

I've caught some weird intracranial stuff on these "chronic" vomiters - masses etc. When I get to the point where I'm consider the CT A/P, I usually take a few seconds to cognitively consider whether I need to scan the head as well (especially if they're already taking a trip to the donut of truth)

Yep, same. Recently had a young guy in 20s come in looking terrible, vomiting, just had that look you’re going to find something bad. Benign belly. Had a large AVM/ICH. Did well fortunately

 

[thegenius]

Yea I usually don’t go the CT Head route once they have hit their 10th visit of the year by the first week of March.

I caught a pineal gland tumor causing hydrocephalus in a 17 yo with headache and vomiting. I’m happy to say I scanned his head because he had abnormal ocular movements - had parinauds syndrome.

 

[emergentmd]

1. Unvaxxed covid, 42% RA, improved with HFNC, no PE, admitted.
2. Diverticulitis with possible abscess, admitted.
3. Weakness, missed HD. K 8.6 with significant ekg changes (nearly sine wave, intermittent VT). Difficult IV access, IO placed standard treatment given. Central line. Emergent HD. Admitted to ICU
4. Old, can’t walk, admitted for rehab placement.
5. 2 week old dog bite, CT showed no drainable fluid collection, dc.
6. Scrotal abscess, I&D, dc.
7. Weird vague symptoms with neg workup and normal VS x 10+, dc.
8. can’t afford xarelto, case management, dc.
9. Well appearing infant with GI sx, dc.
10. Post op bile leak, admitted
11. Vomiting and lactic acidosis that somehow got worse with fluids, admitted.
12. Fall, normal imaging, wants dilaudid, nope

This brings back bad memories where half my shifts were clearly worse and hald better. I would call this an average hospital shift but 2x the pts in a 8 hr shift.

Now my shift typically is
#1-4 URI, Covid test DC
#5 Young sports injury, DC
#6-8 URI DC
#9 Young Abd pain, workup, CT, DC in 120 min
#10-16 URI DC
#17-19 sports injury DC
#20 UTI DC
#21-25 URI DC
#26-27 sports injury DC
#28-33 URI DC
#34 lac DC
#35-38 URI DC
#39 Anxiety
#40 sports injury DC

Midlevel sees 15 of those, I see 25 so about 1pph, all typically little comorbidites straight forward.

 

[Apollyon]

@emergentmd what's up with #39, anxiety? Should I wonder about a different discharge?

 

[emergentmd]

@emergentmd what's up with #39, anxiety? Should I wonder about a different discharge?

missed the DC. Typically someone comes in complaining of vague stuff all put under the anxiety umbrella.

 

[The Knife & Gun Club]

@emergentmd what's up with #39, anxiety? Should I wonder about a different discharge?

Anxiety in the triage note always worries me. Like 75% actually anxiety, 25% some secret real medical problem that I’ll have to tease out of a grown adult who doesn’t have the cognitive/emotional capacity to localize their symptoms. So basically big people peds.

 

[The Knife & Gun Club]

Here’s mine. Bonus points cuz I got pulled to cover this dumpster fire shift.

1) Kidney stone stuck at tip of penis. Could grab it with forceps but it won’t come out. Called uro who pushed it back into the bladder with a foley. DC w/clinic FU.

2) “this time I’m really suicidal”, clearance labs and ship to psych hospital

3) 50 yo Vomiting bounce back w/ clean CTAP 2 days ago. BPPV, dc with Eply video and meclizine

4) Ehlers Danlos with a wrist dislocation while getting cuffed by police. She put it back in herself, NVI, short arm splint, ortho hand follow up, DC to cops.

5) 29M “naturopathic physician” on anabolic steroids, testosterone, and daily ketamine use with 7 legit separate CCs. Work up Neg. Demanding to read his own CTPE. Asked to speak to my supervisor and told my attending I was autistic. Escorted out by security.

6) 52M drunk, metabolize to freedom, halfway through shift chugged a bottle of cooking wine he had in his backpack. DCd eventually.

7) 52M Malaise, +COVID. Bought Russian Sputnik vaccine on the black market, upset it didn’t work. DC

8) OR nurse in fentanyl withdrawal, wearing scrubs. Dose of Bup, given list of rehabs, reported.

9) 25 M w/ epigastric pain, GI cocktail, DC

10) 59F syncope after Brazilian Butt Lift. Hb 6.6. Scan, no active bleed, Transfused —> DC

11) 63M + COVID, not hypoxic, DC

12) 67M drunk fall from standing, CTB neg, DC

13) 39F employee felt dizzy at work, IVF + zofran, DC

14) 32M from jail with face lac after razor blade fight. Repaired and DC.

15) 82M syncope, neg work up, admitted Obs

16) 29F motor cycle crash, traumatic arthrotomy, ortho took to OR for washout.

17) 69F w/ massive stroke. ICA occlusion, NIH 20 previously with no deficit, went for thrombectomy

18) 57M cardiac arrest w/ BGL 20, got D50 + epi, ROSC, admitted to ICU

 

[Fox800]

Here’s mine. Bonus points cuz I got pulled to cover this dumpster fire shift.

1) Kidney stone stuck at tip of penis. Could grab it with forceps but it won’t come out. Called uro who pushed it back into the bladder with a foley. DC w/clinic FU.

2) “this time I’m really suicidal”, clearance labs and ship to psych hospital

3) 50 yo Vomiting bounce back w/ clean CTAP 2 days ago. BPPV, dc with Eply video and meclizine

4) Ehlers Danlos with a wrist dislocation while getting cuffed by police. She put it back in herself, NVI, short arm splint, ortho hand follow up, DC to cops.

5) 29M “naturopathic physician” on anabolic steroids, testosterone, and daily ketamine use with 7 legit separate CCs. Work up Neg. Demanding to read his own CTPE. Asked to speak to my supervisor and told my attending I was autistic. Escorted out by security.

6) 52M drunk, metabolize to freedom, halfway through shift chugged a bottle of cooking wine he had in his backpack. DCd eventually.

7) 52M Malaise, +COVID. Bought Russian Sputnik vaccine on the black market, upset it didn’t work. DC

8) OR nurse in fentanyl withdrawal, wearing scrubs. Dose of Bup, given list of rehabs, reported.

9) 25 M w/ epigastric pain, GI cocktail, DC

10) 59F syncope after Brazilian Butt Lift. Hb 6.6. Scan, no active bleed, Transfused —> DC

11) 63M + COVID, not hypoxic, DC

12) 67M drunk fall from standing, CTB neg, DC

13) 39F employee felt dizzy at work, IVF + zofran, DC

14) 32M from jail with face lac after razor blade fight. Repaired and DC.

15) 82M syncope, neg work up, admitted Obs

16) 29F motor cycle crash, traumatic arthrotomy, ortho took to OR for washout.

17) 69F w/ massive stroke. ICA occlusion, NIH 20 previously with no deficit, went for thrombectomy

18) 57M cardiac arrest w/ BGL 20, got D50 + epi, ROSC, admitted to ICU

#5 is everything that's wrong with America. I would love to have watched as they got booted by security.

 

[CajunMedic]

Here's my last 10HR shift

1) 92F, Tooth pain. Neg work up and DC from WR after Tylenol.

2) 55M, Hepatic Encephalopathy and HAP. on EMS cot for 6+hrs. Admit tele when finally roomed and boarded in ED

3) 61F, Sent from PCP for urosepsis. Immunocompromised from CA. 12+ hours in WR with Fluids and ABX

4) 88M, AECHF, Hx of 7cm AAA. Admit to only private admitting doc we have left

5) 75M, Syncope/ Bradycardia. Sent by his cardiologist for admission to obs unit for likely pacer placement

6) 70M, Sent by PCP for hyperglycemia. Fluids, SQ insulin in WR and D/C with PCP follow-up

7) 89F, Symptomatic Bradycardia. N/V for 2 days, complete heart block at a rate of 28, but conscious and alert. Goes straight to cath lab and TV pacer placed

8) 57F, symptomatic anemia. Sent from Cancer Center for transfusion. DC

9) 77M, hypotension. UGIB, Hemglobin of 4, INR >9.5, AECHF. Transfuion, KCentra, pressors, CVL and admit ICU. Now has pleural effusions and got a chest tube yesterday

10) 96F, hypoxia and bradycardia. HR of 39, but with a systolic in the 190's. Questionable PNA on CXR. Admit stepdown

11) 61M, seen and DC by day crew for post-op knee pain 2/2 TKR. Passed out when they stood up after signing DC papers. Workup negative and DC

12) 60F, prosthetic hip dislocation. Sedation, reduction, and DC

 

[emergentmd]

Here's my last 10HR shift

1) 92F, Tooth pain. Neg work up and DC from WR after Tylenol.

2) 55M, Hepatic Encephalopathy and HAP. on EMS cot for 6+hrs. Admit tele when finally roomed and boarded in ED

3) 61F, Sent from PCP for urosepsis. Immunocompromised from CA. 12+ hours in WR with Fluids and ABX

4) 88M, AECHF, Hx of 7cm AAA. Admit to only private admitting doc we have left

5) 75M, Syncope/ Bradycardia. Sent by his cardiologist for admission to obs unit for likely pacer placement

6) 70M, Sent by PCP for hyperglycemia. Fluids, SQ insulin in WR and D/C with PCP follow-up

7) 89F, Symptomatic Bradycardia. N/V for 2 days, complete heart block at a rate of 28, but conscious and alert. Goes straight to cath lab and TV pacer placed

8) 57F, symptomatic anemia. Sent from Cancer Center for transfusion. DC

9) 77M, hypotension. UGIB, Hemglobin of 4, INR >9.5, AECHF. Transfuion, KCentra, pressors, CVL and admit ICU. Now has pleural effusions and got a chest tube yesterday

10) 96F, hypoxia and bradycardia. HR of 39, but with a systolic in the 190's. Questionable PNA on CXR. Admit stepdown

11) 61M, seen and DC by day crew for post-op knee pain 2/2 TKR. Passed out when they stood up after signing DC papers. Workup negative and DC

12) 60F, prosthetic hip dislocation. Sedation, reduction, and DC

Is your ER attached to a nursing home? Avg age looks about 70.

 

[The Knife & Gun Club]

Here's my last 10HR shift

1) 92F, Tooth pain. Neg work up and DC from WR after Tylenol.

2) 55M, Hepatic Encephalopathy and HAP. on EMS cot for 6+hrs. Admit tele when finally roomed and boarded in ED

3) 61F, Sent from PCP for urosepsis. Immunocompromised from CA. 12+ hours in WR with Fluids and ABX

4) 88M, AECHF, Hx of 7cm AAA. Admit to only private admitting doc we have left

5) 75M, Syncope/ Bradycardia. Sent by his cardiologist for admission to obs unit for likely pacer placement

6) 70M, Sent by PCP for hyperglycemia. Fluids, SQ insulin in WR and D/C with PCP follow-up

7) 89F, Symptomatic Bradycardia. N/V for 2 days, complete heart block at a rate of 28, but conscious and alert. Goes straight to cath lab and TV pacer placed

8) 57F, symptomatic anemia. Sent from Cancer Center for transfusion. DC

9) 77M, hypotension. UGIB, Hemglobin of 4, INR >9.5, AECHF. Transfuion, KCentra, pressors, CVL and admit ICU. Now has pleural effusions and got a chest tube yesterday

10) 96F, hypoxia and bradycardia. HR of 39, but with a systolic in the 190's. Questionable PNA on CXR. Admit stepdown

11) 61M, seen and DC by day crew for post-op knee pain 2/2 TKR. Passed out when they stood up after signing DC papers. Workup negative and DC

12) 60F, prosthetic hip dislocation. Sedation, reduction, and DC

Any idea what was wrong with #10? I assume you scanned their head? Both because Cushings but also because it feels like I end up CTB scanning every 96yo I admit for anything these days.

 

[The Knife & Gun Club]

#5 is everything that's wrong with America. I would love to have watched as they got booted by security.

Yea it was really a spectacle.

Truly bizarre. He kept calling me by my first name because he “is a doctor too.” Even as he was getting lead out by the guards.

Attending that day was one of the original LAC grads, nearly 70, astronomically wealthy from work outside of medicine, who works a few shifts a month purely for the fun of it. “you’ve made your dispo, let security enforce it.”

 

[CajunMedic]

Is your ER attached to a nursing home? Avg age looks about 70.

No. Tertiary referral center, plus our older population is ridiculously unhealthy and pretty much only comes to the ED when they are mostly dead

Any idea what was wrong with #10? I assume you scanned their head? Both because Cushings but also because it feels like I end up CTB scanning every 96yo I admit for anything these days.

Thinking sick sinus syndrome. Records show she had been evaluated for it in the past, but all EP did was stop their beta-blocker. CT was negative.

 

[BoardingDoc]

Here's my last 10HR shift

1) 92F, Tooth pain. Neg work up and DC from WR after Tylenol.

2) 55M, Hepatic Encephalopathy and HAP. on EMS cot for 6+hrs. Admit tele when finally roomed and boarded in ED

3) 61F, Sent from PCP for urosepsis. Immunocompromised from CA. 12+ hours in WR with Fluids and ABX

4) 88M, AECHF, Hx of 7cm AAA. Admit to only private admitting doc we have left

5) 75M, Syncope/ Bradycardia. Sent by his cardiologist for admission to obs unit for likely pacer placement

6) 70M, Sent by PCP for hyperglycemia. Fluids, SQ insulin in WR and D/C with PCP follow-up

7) 89F, Symptomatic Bradycardia. N/V for 2 days, complete heart block at a rate of 28, but conscious and alert. Goes straight to cath lab and TV pacer placed

8) 57F, symptomatic anemia. Sent from Cancer Center for transfusion. DC

9) 77M, hypotension. UGIB, Hemglobin of 4, INR >9.5, AECHF. Transfuion, KCentra, pressors, CVL and admit ICU. Now has pleural effusions and got a chest tube yesterday

10) 96F, hypoxia and bradycardia. HR of 39, but with a systolic in the 190's. Questionable PNA on CXR. Admit stepdown

11) 61M, seen and DC by day crew for post-op knee pain 2/2 TKR. Passed out when they stood up after signing DC papers. Workup negative and DC

12) 60F, prosthetic hip dislocation. Sedation, reduction, and DC

You worked a 10 hr shift, had patients with 6 hr waits and only saw 12 people? Your ED is either crazy overstaffed or has a severe throughput problem.

 

[skougess]

You worked a 10 hr shift, had patients with 6 hr waits and only saw 12 people? Your ED is either crazy overstaffed or has a severe throughput problem.

I’m doing about the same these days. Academic tertiary medical center also. I can assure you it’s a throughput problem. I spend probably half my shift arguing with people trying to get my patients placed.

 

[Fox800]

We are chronically full but have a midlevel out in triage. I've considered seeing folks out in triage but have basically been told "don't bother" by my physician colleagues. We have enough patients in the back to hit 2 PPH. I'm exhausted from that and staying busy. I don't know how you folks are hitting 3PPH without scribes and a good EMR (we have no scribes and Cerner).

 

[RustedFox]

"Cerner is a good EMR" he said, as he banged the F9 key in futility in the Meditech window, which cannot even be resized and is impossible to read.

 

[southerndoc]

We've had major throughput problems from decreased staffing in the inpatient side. Severe nursing shortage (like everywhere else). I went from seeing 20-25 per 10 hour shift down to 12-16 usually. One shift last week I only saw 8 patients in 9 hours.

When you look at our waiting room, we're usually +/- the number of admission holds we have. In other words, most of the time the waiting room would be empty if there were no patients holding. We have a 36-bed transition unit upstairs but no nurses to staff it.

I saw 18 today and was thrilled.

 

[thegenius]

We are chronically full but have a midlevel out in triage. I've considered seeing folks out in triage but have basically been told "don't bother" by my physician colleagues. We have enough patients in the back to hit 2 PPH. I'm exhausted from that and staying busy. I don't know how you folks are hitting 3PPH without scribes and a good EMR (we have no scribes and Cerner).

I have scribes. Our EMR is Cerner.

 

[The Knife & Gun Club]

You worked a 10 hr shift, had patients with 6 hr waits and only saw 12 people? Your ED is either crazy overstaffed or has a severe throughput problem.

We've had major throughput problems from decreased staffing in the inpatient side. Severe nursing shortage (like everywhere else). I went from seeing 20-25 per 10 hour shift down to 12-16 usually. One shift last week I only saw 8 patients in 9 hours.

When you look at our waiting room, we're usually +/- the number of admission holds we have. In other words, most of the time the waiting room would be empty if there were no patients holding. We have a 36-bed transition unit upstairs but no nurses to staff it.

I saw 18 today and was thrilled.

Yea we’re doing about the same at our academic/county site. 50 in the waiting room but it doesn’t matter cuz half our beds are boarded, the ICU and IMCU are full. The waiting list for our IMCU is around 36 hours, because despite there being entire floors of the hospital open they can’t seem to find nurses. They’re offering $150/hour mercenary nursing rates (higher than the Hospitalist running the IMCU!) yet still can’t find nurses.

 

[CajunMedic]

You worked a 10 hr shift, had patients with 6 hr waits and only saw 12 people? Your ED is either crazy overstaffed or has a severe throughput problem.

Severe throughput problem. That particular site has 60-80 closed beds due to nursing shortage on any given day. 60+ hour boarding times in the ED are almost the norm. I can see patients in the waiting room all shift, have their workups complete, but can't get them admitted until they are physically in an ED bed. Not enough staff to keep all the ED beds open. On a good day, I have maybe 3 to work out of, of a total of 34. We are the main referral center for the southern half of the state, and everyone else is in the same shape we are

 

[allantois]

I remember there were docs on SDN saying they could function perfectly without nurses LOL

 

[thegenius]

Severe throughput problem. That particular site has 60-80 closed beds due to nursing shortage on any given day. 60+ hour boarding times in the ED are almost the norm. I can see patients in the waiting room all shift, have their workups complete, but can't get them admitted until they are physically in an ED bed. Not enough staff to keep all the ED beds open. On a good day, I have maybe 3 to work out of, of a total of 34. We are the main referral center for the southern half of the state, and everyone else is in the same shape we are

That is just terrible. So it’s not COVID but a nursing shortage?

It’s like all the nurses colluded together to stop working and charge more money or else they won’t work.

 

[Kryptocoin]

It’s like all the nurses colluded together to stop working and charge more money or else they won’t work.

Not a bad strategy. The rates are starting to creep up a bit in my area as older docs are finally retiring or moving back to clinic lifestyle (FM docs). The COVID pandemic and overall toxic ER work culture have finally pushed some docs on the fence to hang up the shingles.

 

[bravotwozero]

I have scribes. Our EMR is Cerner.

My new shop used to have Cerner, and switched to Meditech.

It's the p doc version, but still.

FFS man.

 

[RustedFox]

My new shop used to have Cerner, and switched to Meditech.

It's the p doc version, but still.

FFS man.

Why on God's green Earth would any hospital switch from Cerner to Meditech?!

That's like going from email to parchment and quill.

 

[southerndoc]

I think over the next two years we're going to see a lot of docs on the fence about retirement, career change, etc. exit the field.

Nurses have definitely banded together throughout history, and the pandemic is no exception. Between tons of nurses leaving jobs to be travel nurses, going to NP school online, quitting, etc., there is a nationwide severe nursing shortage. We are paying $10,000/week for nurses to travel across the city to work at our hospital, and nurses have left our hospital to work across the city doing travel assignments. It's robbing Peter to pay Paul, and the only ones winning are the nurses and the travel agents brokering them. They are earning a killing right now.

Texas introduced (and I think passed) legislation forbidding nurses from working travel assignments within the state if they live in the state. Not sure if it's legal/constitutional, but it's going to be enforced until challenged. Several other states are also looking at similar legislation.