Just finished ALS course and have an urging question / scenario. Say you get a patient with hypothermia eg 26 degrees Celsius they look dead ( pale and not shivering) has faint pulse and severe bradypnoea that might be mistaken for not breathing. Do you start CPR? Is it wrong if you started CPR on that particular patient that may be breathing spontaneously but it's too weak and slow you didn't notice? And if you started CPR when do you stop? Walk me through your management here +/- hypothermia situations that may or may not be similar

Case review of fentanyl at 5 mcg/kg as induction agent for RSI (followed by roc, usual dose). This was a neuro case, but the fentanyl was not pre-treatment followed by induction, rather it was the induction agent. Thoughts?

Hypothetically speaking, what are the drugs, either used clinically or recreationally, that you would want to try at some point in your life. For the hypothetical’s sake, you face no consequences for trying them (legal, professional, or personal repercussions) but you still experience the drugs effects and/or adverse effects.

And then why would you choose said drug(s)?

- if this isn't allowed by sub rules please let me know -

I'm writing a story to be published online. I want the characters to practice some basic first aid so that people reading might remember how to do it in case there's an emergency. (this sounds super cheesy when I write it) basic things like stopping bleeding, the ABC's of first aid, EpiPens, things like that. What are some other things I could include?

Preference of meds and dosing

Have had a few patients who still have RAS +2 despite being on 3 sedative max drips.

Mostly looking for safe bolus doses options that you give to get the patient up to the ICU instead of mucking around with drips for a long time.

Question for the ED residents and attendings on this sub. I’m a lowly 4th year med student, but I was wondering what percentages of your learning in residency comes from on-shift teaching points, didactics and personal time spent using resources like uptodate, wikiem, etc. 50% self-taught, 40% on shift, 10% didactics? What’s the breakdown look like for you. I’m talking about learning points that you’ve actually retained. Mostly curious if what you’ve learned and retained is info that you’ve sought out on your own, because at least right now that’s been my personal experience. As a side question, what percentage of information you now have memorized would you estimate that you had to sit down and force yourself to memorize (as opposed to getting drilled into your head through repetitions from seeing patients)?

Hi all, my husband is an ER doc and I've been closely following what his director and team have been doing to handle the NES situation so I am curious to know what others are doing. My husband's director was able to get the hospital to take on the team of docs and PAs on as full-time, but for a much lower salary, and they can have benefits now (though my husband is hoping he can opt out since he has health insurance through me). I'm also thinking that he can now get PSLF in 10 years since the hospital is a 501c3, as is the umbrella company that it's a part of, but I'm unsure since he's always been 1099 and we haven't looked too deeply into how this works. I'm hoping this is true, and it can somewhat make up for the lower annual pay.

As for NES, they are looking to file individual lawsuits for the last two months of no pay, but I don't think much is going to come of it since the company doesn't have any money. Is there a anything else they can do to obtain their hard-earned money?

What is the direction that your teams are taking? Are you being folded into the hospital you work at as W-2s? Are you just forgetting about the lost salary? Are you lawyering up? Would love to get some ideas to see if I can pass it onto my husband's team and maybe help them.

https://preview.redd.it/qq8bsu24wwzd1.png?width=2490&format=png&auto=webp&s=bbfedd1521264fffcd515365188dc2fb3fdb8fb6

What do you guys do with legitimate (ie, not just TP) traumatic fractures of the T and L spine in a community setting with no neurosurgery/spine coverage?

I trained and mostly work at an academic site with trauma and spine coverage. In general, grandma’s mechanical fall leading to an isolated spinal fracture gets appropriate CT imaging, a spine consult, and winds up discharged in a TLSO brace. Obviously these are patients who have no neuro deficit, no significant retropulsion or cord involvement, etc.

I’m now working at a community site without such coverage and struggling what to do with such cases. My partners do a bunch of plain films instead of CT and are clearly just missing these cases, so they insist it’s a rare event. When I call the nearest trauma center with spine coverage, they bemoan me for transferring simple T/L spine fractures that are nonoperative and just tell me to “prescribe a brace and discharge them.” Being the receiving doc at my academic job, I don’t fundamentally disagree. I don’t think these patients need anything more than a brace, ideally a surgeon reviewing the imaging/agreeing with the plan, and outpatient follow-up. For C-spine anything beyond TP, I frankly will insist on transfer until someone smart convinces me otherwise. But what am I supposed to do in the community? I can’t give the patient a TLSO (if that’s even the right brace for their fracture pattern), I don’t have a spine surgeon to review imaging/discuss with, and outpatient follow-up for this patient population is often iffy at best unless I move heaven and earth to make it happen. Any thoughts?

Seems like this practice would use useful for improving service integration and a good refresher on some of the more niche areas of practice, but I don't think I've ever observed this in the wild.

Are there good reasons for that other than, "my hospital won't pay me to do it," or the logistical challenges? If you got paid the same for the occasional week in L&D, hospital medicine, surgery, etc. would you do this?

Do you think, as a standard practice, this would improve care?

George had some pain in his neck, thought he had slept on it wrong. Then massaging the side of his neck, he felt it; a large irregular lump. So he came to the ED, "my wife is worried, she thinks its cancer and she just wants to make sure its nothing bad".

George was a nice guy, so we all know where this was going to end up. A few hours and a CT later confirmed it. I am a midlevel, and part of my job is to train the new hires, and run education for the group. One of the things I stress is to never leave the bad news to the consultant. You ordered it, you own it. So George and I had a talk while we waited on the ENT resident. My mentor attending taught me to give it to them plain and straight, and don't try to soften the blow. Nothing you can say on the front end will soften the shock of the news.

George was of course far more concerned about his family and wife and how they would take the news than his own mortality. And after an exam and a long talk with a wonderful and compassionate ENT resident, George had a game plan for the next steps, and was waiting for his wife to come pick him up. He asked me if he needed to stop smoking now (30 year PPD history). He said all he wanted right now was to have a smoke and clear his head.

I pointed him in the direction of the smoking area outside of the waiting room. The irony of the likely cause of his cancer currently serving double duty as his only source of momentary peace was not lost on me, and I wondered if he was thinking the same thing.

What gets me the most was when I was leaving shift he was still waiting on his wife. She did not know the news yet, and I cannot imagine the weight on his shoulders of having to tell her. But he smiled and waved me over to tell me how thankful he was for us, and how kind we were to him. It felt like he was trying to console me in some way, to offer his gratitude for the very little that we actually were able to do for him tonight.

It was such a kindness that I absolutely don't deserve from him in the face of his terrible new diagnosis, and all I can do is send up a prayer that his road leads to a good outcome and a long life. And life goes on, another shift is over. And I won't ever look him up to follow his progress, because for me I would rather live with blissful ignorance and delusional assumptions that his biopsy was favorable, and his procedures had clean margins.

Thank you all for what you do, and what you endure. And I am fine, I just from time to time reflect on a patient and journal my thoughts into a public post. Just need to get the thoughts out, and arrogantly think that maybe someone else can relate and maybe feel at least a kinship that others are going through a similar struggle.

Be well, be kind, and be grateful.

Happened during a procedure; it's a known risk and she was properly consented. Thankfully it was minor and only required a bit of observation. The patient was soooo nice even after I told her what happened. When she was discharged she asked the nurse to reiterate how grateful she was for her care and how wonderful a doctor she thought I was. I know if she had been less kind and forgiving she might be threatening lawsuit but damn if I don't somehow feel more guilty that it happened to such a wonderful human being.

Edit: thank you everyone for your supportive comments and stories! I know these things happen and will happen. I've talked to a few colleagues about their technique and how I might do better. I appreciate that I can come here to share with people who've been in my shoes

I am about to sign a contract for an attending position as a new grad.

I have read that it is not really worthwhile to get a contract lawyer to try to negotiate anything (and I don't really have anything specific to negotiate at this point). I have read through the documents sent to me, and to be honest, a little bit of it goes over my head. In terms of contract review, what are the specific big things that I could potentially be burned on that I should be looking out for? Any examples of things you wish you would have reviewed more closely when you were in my position?

Honest answers ONLY

I'm a international medical student about to do an EM elective at an academic centre in the US. I was wondering if it's possible to request an eSLOE if I won't be using it this year? I plan to use it next year in the 2026 cycle as I want to complete my internship back home after I graduate. Do I need to create a MyERAS account and purchase a token now? Is it even possible to save an eSLOE to be used in later cycles? Will be very grateful for any guidance, thank you!

We can finally put orders on epic Haiku on Android!! Finally I can justify buying a foldable phone lol. You can also write notes, and assign yourself to patients from the app.

Has anyone taken the "Difficult Airway Course"? If so, was it worth it? What is the structure like? I am a senior EM resident and feel decently confident in my airway skills but I would still like to improve and learn as much as possible before I graduate and am considering using my CME funds for it

Hello! Nurse here studying for the CEN. I understand both mag and calcium can cause neuromuscular depression. Knowing this, I’m confused why we give calcium gluconate in cases of mag toxicity. That seems counterintuitive. Anyone care to explain?

I had a really bad angioedema airway my last shift. Pt stopped breathing and turned grey while we were preparing to intubate. It was one of the two or three worst airways I have ever seen, but I got them intubated quickly and the pt will be fine. I was thinking afterwards about why these bad airway situations terrify me so much. I realized that it is the only situation I can think of where a pt will either live or die in the next couple minutes based on how well I, and I alone, can do a really hard procedure.

Resuscitating a sick patient is a team effort, and the other emergent procedures are really not technically difficult. The difference is that bad airways are emergent, difficult, and entirely on me. I can't really think of another situation that has all three of those qualities.

Every RSI drug has a weight-based dosage range. But every code I’ve been in, the doc just seems to throw out a number for the doses very easily, without obvious calculation. How do you do this? Do you have go-to dosages for typical patients?

Which RSI drugs do you prefer? Why? How do you decide which one to use?

What are your go-to ETT sizes?

The reason I ask is to help myself and my team get better at anticipating what the doctors are likely to order so they can be prepared.

Well I'm happy to post an update about the case. And that the patient is doing fine. We have a confirmed diagnosis and outcome.

Pt is a 73 male, with diabetes, high blood pressure, parkinson, hipotiroidism, miositis, smoker, COPD, 6 previous stents due to previous infarction.

Started a 5 weeks ago with can be described as unstable angina. Typical chest pain (oppressive, blunt, mid esternal) associated with dyspnea and sudoration. Those episodes were mostly random, appeared even in rest. But in general short mins and generally mild. He didn't want to call in fear of a new catheterization.

Sunday at night a new episode started wile was at rest, with a more severe pain, and persistent. Lasting more than 20 mins with notable shortness of breath. Most interesting finding was silent or at least inaudible lung sounds in both pulmonary bases. No oedema was found. An 12 lead EKG showed and old RBBB with 1st degree AV block, noticed ST depression in V3 to V6, not justifiable by the RBBB.

Was transported to an hospital with capable cath lab, but protocol no activated. Interpreted ACS (possible N-STEMI). An CHF.

Based on a increasing troponins curve and poor response to nitrites he went to cath lab a few hours later. During catheterization, the found that an old stent located in LAD was obstructed by a clot in a 99%. Also Cx had a restenosis of 95% proximal to another old stent. 2 new stents were placed. Final diagnosis was N-STEMI plus CHF with acute pulmonary edema.

Today pt was discharged from hospital (a bit too fast if you ask me). Ecocardiography before discharge found 60% eyection fraction with basal akinesia. Also EKG before discharge found a persistent V3 to V6 st depresión.

He called again to our emergency service due to headache with bright spots in vision. He was fearing a stroke. I was dispatched to check the patient. Truly a great luck and coincidence. He was happy that I was attending him again.Tonight complain was interpreted as migraine. Patient was worried about and stroke. When I left he was already feeling better (before calling he took tynelol). I hope he keeps going well.

I may or may not be from a certain country that the future looks bleak. I won’t disclose what country.