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.
“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
“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…
The 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.
“Seeing is believing” you mutter as you shake your head in amazement.
You can’t believe your good luck tonight. You ordered a CT scan on a
patient with pleuritic right-sided chest pain looking for a pulmonary
embolism, and instead you found her leaking thoracic aortic aneurysm.
And then, your senior resident performed a bedside abdominal ultrasound
on a 40-year-old male with chronic back pain and discovered a 5 cm
abdominal aortic aneurysm.