altYou just heard a great lecture on minimizing radiation exposure from diagnostic testing and your next patient may give you the opportunity to put the lecturer’s plan into practice. The patient is a 19-year-old male who thinks he may have food poisoning due to the fact that he developed abdominal pain last night after eating a burrito at a local “Roach Coach”.

alt“Nothing in medicine is black and white,” you hear your colleague explain to one of the rotating medical students. She looks perplexed as he goes on to explain that there is an “art” to medicine and just because she learned how to evaluate and manage a certain type of patient presentation one way, doesn’t mean there aren’t other “right” ways to do it.

altDuring a busy swing shift, a 45-year-old male presents to the emergency department with two days of worsening right knee pain. He denies any injury, but states that the knee feels warm and swollen and now he can barely walk on it. He had a meniscal injury to the same knee about 8 years prior, and is now using crutches that he has left over from that time.

altYou really hope today’s shift is better than yesterday’s. You had to tell a really nice homeless man that internal medicine refused to admit him for his femoral DVT because he doesn’t meet “admission criteria” and that he would have to find the means to pay for his outpatient Lovenox on his own. Then a patient came into the ED with chronic pack pain, and you ended up diagnosing him with metastatic prostate cancer with spinal metastases.

altYour next patient is a 28 year old female who has been triaged by one of the new nurses as” right lower quadrant pain for about nine hours”. Knowing that clothes generally stay on in the triage area, and the belly button usually remains unseen, the first thing you do after you close the curtain and introduce yourself is to have the patient pull up her blouse and point to where she feels the pain.

altWhy does it always feel like a battle between good and evil? You want to admit the 78-year-old male who had a syncopal event, but the internal medicine service feels that he can be worked up as an outpatient.

altWhat an interesting week it’s been. You witnessed the untimely death of a young mother and an ED delivery of a newborn in the same shift. You took care of an elderly man with hypermagnesemia and then a  young, otherwise healthy man with vomiting and hand cramps that made all his fingers look like they had swan-neck deformities. You just tapped an ankle and diagnosed new onset gout. Now you are about to tap a wrist, and, given how your week has been going, you figure it will probably be pseudogout.

altIt’s going to be one of those shifts. You just sent a 29- year-old male to the cardiac cath lab for a bona-fide ST elevation MI. Your patient with a chief complaint of “eye pain” ended up having metastatic cancer within his right orbit, and your seemingly straight-forward post-partum woman with a headache had an MR venogram showing a dural vein thrombosis.

altIt seems like your entire shift has been non-specific abdominal pain, peppered with a few non-cardiac chest pains and some non-organic headaches that are only relieved by Dilaudid. No one feels your pain from taking care of patients that don’t really need to be in the ED in the first place, but hey, it’s job security, right? So you suck it up and grab the next chart in the to-be-seen box. The chief complaint reads “gas pains.”

altJust when your evening can’t get any worse, two of your stellar EM residents come up to you and inform you that the internal medicine team is trying to “block” yet another admission. This is the 5th attempt at refusal today. The patient in question is acidotic, thrombocytopenic, altered, and bleeding from around the PICC line that was placed while he was in the hospital last week.

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