altIt’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 complaints” presentation.

altA 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 dislocation

alt“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.

altA 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. 

alt“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 medication”.

alt“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.

 alt“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.

alt“Hey, save some pizza for me!” your resident exclaims as he joins the masses indulging in a late night treat from the ED administration. Over the past few months, the department’s “door-to-doc” times and “length-of-stay” times have improved enough to warrant a pizza party for the staff.

alt“I’m 0 for 2 tonight” your resident says after yet another exasperating interaction with one of your institution’s feisty surgery residents. “The first consult was called too early. The last one was called too late!” Overhearing your conversation, the charge nurse walks over and says, “Well Goldilocks, maybe this next consult with be just right…

altThe labs have all come back on a 38-year-old female who you suspected had pyelonephritis. She had presented with 24 hours of flank pain and fever but no vomiting, abdominal pain or dysuria. Her last menstrual period was 2 weeks ago and she denies any possibility of pregnancy.

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