sound-90A 54-year-old male is in the ED for a paracentesis because he states he is uninsured and has nowhere else to go. He states his last “tap” was about 4 weeks ago and he is starting to feel short of breath even at rest because of all the fluid. He states these are the same symptoms he always gets and denies any issues that are atypical for him. Just to be sure, you run down a list of pertinent negatives and he politely denies fever, pain, melena, confusion, vomiting, and chest pain.

sound-90An 84-year-old woman is brought to the emergency department by ambulance for evaluation of altered mental status and syncope. Per family, the patient had complaints of abdominal pain for two days, tactile fevers, decreased PO intake and one episode of non-bloody, non-bilious vomiting. The patient also fell from her bed to the carpet with loss of consciousness for 10 seconds.

incidental-gallstone-90A 22-year-old G4P2 female is brought to the emergency department by her boyfriend for pleuritic right sided lower chest pain that she has had for approximately 18 hours. The pain is in the low anterior right side of the chest and radiates to the scapula and upper abdomen. It has been constant, but is not associated with nausea, vomiting, fever, chills, diarrhea or shortness of breath.

“If you are given a second chance in life, don’t blow it,” you advise your eager resident. It has been an overwhelmingly busy day in the department. Interspersed between the motor vehicle collisions, hypoxic and hypotensive CHF exacerbations, and patients with florid sepsis, your team is trying to see and help all of the ankle pains, throat pains, and dysuria that have also walked through the waiting room doors.

Your next patient is a young African-American female with no history of sickle cell disease, ocular conditions, or any other medical problems. She was triaged with a chief complaint of “floaters” in her right eye.

“Let’s move it, guys, the bus is unloading!” You cringe as you hear the jaded tone in your nurse’s voice. Your department has been especially busy this past month with high-acuity patients, and your hospital is slowly and surely running out of space and resources.

altParamedics bring in a 60-year-old male who collapsed at work and remained unresponsive. They state that there was bystander CPR and a lot of freaking out by coworkers. The only past history they have was from a coworker who thought he had high blood pressure. There was also a witness who told them he was just walking, then doubled over and collapsed without saying a thing.

alt“I have to do a cost-benefit analysis of the situation,” your eager intern replies. It’s the end of the academic year and you are forcing your soon-to-be R2s to become more autonomous and confident in their management plans. You are amazed at the various answers you now get when you ask the simple question, “What do you want to do?”

altIt’s busy. There are twenty-eight patients in the waiting room with the longest waiting 4 hours. The queue for CT scans is over 2 hours and the one for ultrasounds is even longer; a staggering 4 hours, plus another hour to get results. Lots of people are frustrated. Your next two patients are both pregnant females in their first trimester with vaginal bleeding.

alt“I need a breath of fresh air,” your senior resident states. He has had a pretty rough night. He missed an LP on a rather robust woman with “the worst headache of her life” and then the trauma team swooped in and “stole” his thoracotomy on a GSW that was dropped off at the ambulance door. You tell him to take all the time he needs as you turn your attention to the intern that has been patiently awaiting your emergence from the critical care bay.

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