Just 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.
You got stuck with another holiday shift. As usual it starts off slow,
but eventually a bolus of patients arrives, to make up for lost time and
then some. Fortunately most of your patients aren’t that sick.
“There is no such thing as a ‘black cloud’,” your colleague jokingly
retorts. “We all get the same chances to make the diagnosis and to do
what’s right.” You give him your best pseudo-evil-eye as you continue to
recount the number of unfortunate cases you’ve seen with the residents
this evening already.
It’s one of those average days in the ED where you work. It’s not too
busy, but it’s not exactly what you would call slow either. Your shift
has been a little bit on the boring side: lots of URIs, non-specific
abdominal pain, low-risk chest pain, ankle sprains, and the occasional
mild CHF or COPD flare. Also, too many people with the dreaded “multiple
A 34 y/o male presents to your emergency department with an obvious
shoulder deformity after trying to wash his hair and hearing his
shoulder “pop.” The patient has a past medical history of three shoulder
dislocations in the last month. He was drinking alcohol last night and
took off his arm sling to shower when the incident occurred. Exam
reveals a shoulder deformity consistent with a left anterior shoulder
“Get them out of here,” you hear your colleague next to you exclaim.
“Treat ‘em and street ‘em. We need to open up some more beds.” You
wrinkle your nose and wonder quietly if we’ve all become so focused on
throughput that we’ve somehow lost sight of why we all signed up for
this job in the first place.
A 20-year-old male presents to your ED complaining of five days of
throat pain and tactile fevers. He reports that the pain is worse on the
left, and is associated with oropharyngeal swelling and odynophagia.
“Are you sure I don’t need that magic stroke medication that I saw on
TV?” you hear a patient ask through the curtains in your acute care
area. “I am within the 3-hour window.” You pause to listen to your
senior resident reassure the patient that she is not having a stroke and
explain to her the risks and benefits of that “magic stroke
“You need to have a rectal exam” you explain to one of your patients.
He’s a 47-year-old with chronic back pain who is in the ED for an
exacerbation of his pain accompanied by many of the associated
accoutrements, such as sciatica, numbness and trouble urinating.
“Do you know the four A’s of being a great emergency physician?” a
colleague asks. He just overheard you giving your “It’s a virus” lecture
to a twenty-something with a bad URI and no PMD to call her in a
useless prescription for Fogmentin or Maxiﬂoxicin.