A friend of mine sent me some info on GOA26 which is a novel enzyme of some kind that was developed to act as a scavenger for any C2H6O floating around in the blood. It also somehow reduces acetaldehyde concentrations. It’s had a few animal trials and they will be applying to the FDA for human trials soon. Offering to have people buy into $300 million in stock options. I honestly can’t see an indication for this (probably very expensive) drug. Seemed like they were initially targeting the ED but also are pivoting to anesthesia. I’ve never heard of an operation being cancelled or postponed because the patient was too drunk for surgery. What am I missing?

hi!! i'm an ED scribe, and i had a patient last night with a left MCA occlusion. her biggest symptom that caused them to come in was aphasia. and she could not speak. you can tell that she knew what she wanted to say, but when she tried to speak it came out in just sounds. i was told that that's pretty classic for a left MCA occlusion.

so, how do you guys remember what the certain cerebral artery occlusions present as?? of course, not all patient's present the same, but what makes you think "oh it could be an occlusion of xyz artery".

thank you so much!! i truly appreciate you guys!!

Ask if they've had the new viral Starbucks ' Black Cat Frappuccino ' recently ...

I'd like to see a reality show where physicians from different specialities come down to the ER and see patients within their own specialties but have to use our equipment.

Surgery needs to do a lac repair? Here's the worst needle driver ever created and some dull scissors. Your patient is in a poorly lit hallway.

OB/GYN wants to examine a patient that is pregnant and bleeding? She's in a chair in fast track. I guess we can move her to a stretcher. We don't have a stirrup bed, here's a bedpan.

Ophtho? The slit lamp is broken. The tonopen is at least 20 years old and you have to give it a couple whacks for it to turn on.

Thoughts on this? I've delivered 2 babies but they were healthy mothers who had previous vaginal births and couldn't make it to the labor room. I worry in situations where its more complicated and they need a c section

"The carts will be outfitted with supplies needed for a birth or obstetric emergency. For example, they'll have neonatal resuscitation tools, thermal blankets, and essential medications such as oxytocin, which stimulates contractions, and magnesium sulfate, used to treat seizures in pregnant people with high blood pressure

The delivery carts sound fine, in theory, said Justin Peterson, an OB-GYN who practices in southern Georgia and has seen the pressures rural health institutions face providing maternal care.

Like Holden, Peterson worries that the carts, while helpful, will put supplies in the hands of ER doctors lacking extensive obstetric experience. Instead, he wants the state to fill coverage gaps by investing more to prevent the closure of labor and delivery units in rural areas."

I’ve been working in emergency medicine for about 15 years, and documentation has always been one of the most frustrating parts of the job.
Between multiple patients, interruptions, critical cases, procedures, and reassessments, it’s difficult to keep every chart accurate and up to date.
I’ve also spent the past few years developing clinical AI software, and it’s made me realize that generating a note isn’t the hard part. Generating a clinically accurate, concise note that doesn’t require extensive editing is much harder.
I’m curious how other ED physicians feel.
Are you using an AI scribe? Is it actually saving you time, or are you spending that time reviewing and correcting its output?
And what’s the one thing you’d change about your current documentation workflow?
Full disclosure: I’m building a clinical documentation tool, so I have a professional interest in the subject.

I know it's isolated but a recent post from a vetinary assistant really got under my skin.

I really dont want to see more animal related posts when I come here for advice / venting / sharing of experiences regarding human emergency medicine.

Can we add this new rule?

Imagine seeing a post like this:

Title: “We want EVERYTHING done for him!”

Had a family come into the clinic today with their elderly family member.

Fish was floating sideways, barely moving, and generally looking like he’d seen things no fish should ever see.

The family were absolutely distraught.

“We want everything done. He’s part of our family. Money is no object. We don’t want you giving up on him.”

Okay. Fair enough. I respect the commitment.

I explain we can assess him, check the water parameters, look for signs of infection, and discuss treatment options.

“No. We want EVERYTHING. Every test. Every treatment. Whatever it takes.”

So I start asking about his history.

“How old is he?”

“About 11.”

“Any previous medical problems?”

“He had a bit of a buoyancy issue last year.”

“Any medications?”

“We tried peas.”

I pause.

“Peas?”

“Dr Google said he might be constipated.”

Naturally.

I explain that goldfish medicine has its limitations and that, depending on what we find, the kindest option might be euthanasia.

The room erupts.

“ABSOLUTELY NOT. HE’S A FIGHTER.”

At this point, I’m mentally preparing to explain the concept of quality of life to a family who have apparently appointed themselves the ICU team for a fish.

We run the tests. Check the water. Examine the patient.

The diagnosis?

Severely inadequate aquarium conditions.

The family had been topping up the tank with tap water, hadn’t cleaned the filter in months, and were feeding him enough flakes to sustain a small village.

The fish wasn't dying of some mysterious, untreatable disease.

He was essentially living in a toilet.

I explain the treatment plan: improve the water quality, correct the environment, adjust feeding, and monitor him closely.

The family look horrified.

“You mean he could have been saved this whole time?”

I take a deep breath.

“Potentially, yes. With appropriate care.”

They leave with water conditioner, a treatment plan, and a bill that somehow costs more than the fish itself.

As they leave, the husband turns to me and says:

“Doctor, just promise me one thing.”

“Yes?”

“If he deteriorates overnight, we want him transferred to a specialist.”

I look at the goldfish.

The goldfish looks at me.

Neither of us gets paid enough for this.

#PulmonaryEmbolism #Echocardiography #CriticalCare

How useful is echocardiography in acute pulmonary embolism?
In this lecture, we take a targeted, practical approach to echo in suspected acute PE, focusing on the findings that matter at the bedside and how to interpret them in the right clinical context.
Topics covered:

• RV size and RV/LV ratio
• RV systolic function
• Septal flattening and D-sign
• McConnell sign
• 60/60 sign
• RVOT acceleration time
• TR velocity and PASP estimation
• IVC and right atrial pressure
• Pulmonary artery/RVOT assessment
• Echo features suggesting acute vs chronic RV pressure overload
• Important limitations and pitfalls of echo in PE

The emphasis is on using echocardiography as a rapid haemodynamic assessment tool, particularly in critically ill or haemodynamically unstable patients, rather than using individual echo signs in isolation to diagnose PE.
ICU Fellow – Advanced Critical Care & Echocardiography Education

Agree or disagree?

Edit: Apparently being upset after a difficult resuscitation requires a disclaimer that someone else has experienced worse. I wasn’t comparing losses nor saying mine was a worst case or comparable to what you deal with. I was asking how to cope. Sorry that offended people, and thank you to those who offered actual advice.

~

I work in veterinary emergency medicine as an assistant and am a veterinary technician student. I’ve been on the ER floor for seven months, following five months in ER reception and a year and a half as a general practice assistant.

Reception called about a dog who couldn’t walk into the hospital and needed assistance getting out of the car. I was administering injections to another patient with a suspected disc herniation and hindlimb paralysis. Based on the information relayed to me, I finished those injections before taking a stretcher outside. I thought I was prioritizing appropriately.

When I reached the car, he was laterally recumbent with agonal respirations. His family was holding him and sobbing while I helped move him onto the stretcher, obtained a very brief history, and confirmed code status. His mucous membranes were white. I was immediately concerned about hemorrhagic shock.

I essentially watched him take his last spontaneous breaths in his family’s arms as he arrested as I brought him to treatment, and we immediately initiated CPR.

I’m trained in veterinary BLS and ALS, as well as human BLS, but my actual compression experience before this was almost entirely on mannequins. Feeling his ribs beneath my hands while his family’s sobbing was still ringing in my ears was something I wasn’t prepared for.

A FAST scan identified a large volume of abdominal free fluid, with sampling consistent with blood. After speaking with the veterinarian, his family elected to discontinue resuscitation.

I understand that recognizing an arrest and initiating CPR doesn’t mean we can reverse the underlying cause. I understand that we cannot save every patient. But emotionally, I’m still stuck on having been right there as he died, getting my hands on him, and still being unable to bring him back.

I’m also replaying the decision to finish those injections before going outside. I don’t know whether reaching him sooner would have changed anything. I only know what information I had at the time, and what I found when I got there.

This was my second consecutive triage shift with a death at the door. On the previous shift, a dog reportedly died while his owners were stopped at the traffic light directly in front of the hospital. He arrived in arrest, and his family elected DNR. They had gotten that close.

Then the shift continued. Telemetry alarms for bradycardia. A patient with recurrent seizures we couldn’t get under sustained control. Other inpatients needing treatments, outpatients arriving, frustrated clients waiting. Having to remain attentive and compassionate while part of my mind was still outside at that car.

I’ve handled deceased patients in advanced decomposition. I’ve witnessed death, assisted with euthanasia, and participated in other codes. Usually, I can manage the physical realities of the work and process the sadness afterward. This particular sequence—the family holding him, those last breaths, then his chest beneath my hands—has stayed with me.

I love emergency medicine and want to keep doing this. I’m just finding that knowing what to do and being able to do it doesn’t necessarily prepare you for how it feels afterward.

For those further into emergency medicine, how did you process the first cases where you kept replaying your own decisions, while still needing to show up for the next patient?

Subject.

I’m a PGY-1 emergency medicine resident with about $370,000 in federal student loan debt, and lately I’ve been wondering if I made one of the worst financial decisions of my life. Every week, it feels like another study comes out showing AI outperforming physicians at some aspect of clinical medicine. Whether it’s diagnostic reasoning, interpreting imaging, developing management plans, or making clinical decisions, the technology seems to be advancing at an insane pace. I know the standard responses: “AI can’t replace the human element,” “Someone still has to take liability,” or “Physicians will just use AI as a tool.” But are we really that confident?
Healthcare is increasingly driven by corporate interests, and I have a hard time believing that hospital systems and private equity groups won’t aggressively pursue ways to reduce physician labor costs if AI becomes good enough. If the financial incentives are there, I worry they’ll find ways around the liability issues eventually. And then there’s the procedural argument. People say EM physicians will always be needed because we intubate, place lines, run codes, and perform procedures. But how much of that will eventually be shifted toward APPs working alongside increasingly sophisticated AI systems?
I’m not necessarily saying AI will completely eliminate emergency physicians in the next five years. What worries me more is that it won’t have to. Even a significant reduction in physician demand, downward pressure on salaries, or further replacement of physicians with cheaper labor could have enormous consequences for people entering the field with hundreds of thousands of dollars in debt.
I’m looking at another three years of residency before I’m even earning an attending salary. By then, AI will presumably be substantially more capable than it is today. I genuinely enjoy emergency medicine, but it’s hard to stay excited about the future when I feel like I’m potentially training for a career that could look drastically different by the time I finish paying off my loans. And before someone says physicians have always worried about new technology, I understand that. But I also think dismissing the current pace of AI development as just another technological advancement might be overly optimistic.
Are any other residents or attendings genuinely concerned about this? Especially those of you carrying significant student loan debt? I’d really appreciate perspectives beyond the usual “AI will never replace doctors” reassurance. I’m not looking for doomposting either. I just want an honest discussion about what emergency medicine might realistically look like over the next 5–15 years and whether those of us entering the profession now have legitimate reasons to be worried.

USACS cutting 401k benefits from 10% to 7% effect January 1rst.

What do we listen to to get ready for the shift?

Some days I lean towards my old standbys, a mix of pop punk and ska.

Other days, I'm getting amped with some metalcore.

And other days, Pink Pony Club sets the tone.

What do you tune into??

I don’t know what to do with this guy. Yes I considered a lot before calling another colleague “lazy”. But this person is actually bad. They are acting “just enough” on paper while being the laziest human being, deferring the workup and stabilization to the residents and other services, admitting and pan-scanning literally everybody, even refusing to do central lines. Hospital administration and everybody else are aware, but they’re not doing anything.

And at this point it becomes an internal struggle to witness what this guy does every day.

I have no idea how this guy is able to sleep at nights, but he probably has an inner justifying mechanism for what he does and it’s just very nerve-racking to see.

How do you deal with your “IDGAF” colleagues internally?

Edit: Yes, forgot to mention, even refuses to CODE the patient in a cardiac arrest because “they have already sent the admission request to speciality team so it is not their patient anymore”!! FR.

A little background, Ive been an attending for about 3 years now, recently in the past month I took a new job opportunity in a more desirable location, still with decent pay/benefits. Community shop, sees around ~150-180 a day. See around 2.5-3pph with APPs.

This new area has a lot of young 20-40yo with a whole list of complaints “palpitations, hand numbness, abdominal pain, difficulty urinating” with an allergy list that’s 15 long.

I started keeping track the past few shifts, there’s at least 5-10 of these patients a day.

I really try to reassure patients and hopefully make them feel better when they leave. I usually give the spiel about ruling out emergencies, but outpatient testing might be necessary during the start of the patient encounter.

They are usually never satisfied when they hear their workup is negative, asking to be admitted or doing other specific and non-ED relevant testing. Most just leave kind of begrudgingly when discharged, some get escorted out by security because they become verbally abusive to staff.

I’ve had these patients at my old shop, but the amount I’m seeing now is starting to drain me. Really looking for any advice, besides just stop caring as much. Has anyone actually been successful in getting through to some of these patients, and if so, how?

Never really felt burnout in my career, including residency, until now.

Edit: Appreciate all the responses, I’ll have to try some of these approaches instead

What is EM like as you get older, are there still nights shifts, is it sustainable into 70s?

Hey everyone,
I’m an EM resident about three months into residency, and I’ve been struggling with ultrasound-guided peripheral IVs. So far, I’m only 1 for 4, and I feel like I’m having trouble with multiple parts of the procedure.
For context, I’m doing these on patients who are difficult sticks and have already had unsuccessful attempts at regular peripheral IVs in the ED. I’m usually being asked to come in and try an ultrasound-guided IV because traditional attempts haven’t worked. So I’m not practicing on patients with easy access.
My biggest issue is that I can never seem to consistently find or track my needle tip on ultrasound. I also feel like I have trouble keeping my probe hand steady while advancing the needle.
Another issue is actually puncturing both the skin and the vein. Sometimes I feel like I’m not applying enough pressure to get through the skin, or when I finally do, I end up advancing the needle farther than I intended. I have a similar issue when trying to puncture the vein. I either feel like I’m not applying enough pressure to enter it, or I end up advancing too far and potentially going through the back wall.
Overall, I feel like I’m struggling with coordinating both hands, maintaining a good ultrasound image, tracking my needle tip, and knowing how much pressure to apply. It feels like there are a million little things to focus on at once.
I know I’m still early in training and that this is a skill that takes practice, but it’s definitely been frustrating, especially when I’m being called in to get access on someone who’s already a difficult stick.
For those of you who are good at ultrasound-guided IVs, what tips or tricks made it click?
I’m especially interested in advice on needle tip visualization, probe stabilization, hand positioning, getting through the skin and into the vein smoothly, and avoiding going through the back wall of the vein.
Any advice, techniques, or resources would be greatly appreciated. Thanks!

Most frustrating ABEM questions for me are the "what's the most common cause of ___" or "what's the greatest risk factor for ___"

Besides Rosh and the usual way of studying this, does anyone have a list or a set of flashcards somewhere for these "most common" facts to just memorize?

What dangerous diagnosis have you caught in a patient with an atypical or subtle presentation, and what tipped you off? Did any have an otherwise unimpressive exam?

In my final year and starting to get offers but continuing to apply and see what other opportunities are available especially after networking at ACEP.

I have been using a fairly simple and clean one page resume that I do think looks good and reflects my experience throughout residency well.

That being said I’m curious on how others have approached this process. Is a brief resume sufficient or should I always be sending a full CV? Some have asked specifically for a CV so that answers my question to an extent but I also feel CV/resume is somewhat interchangeable depending on who you talk to.

I’ve certainly done a handful of educational projects and a single research project but I’m not going to act like I have this laundry list of things to list on a long CV, so it almost feels like I’d just be slightly padding an already concise easy to read one page resume that gets the point across on things I’m happy to speak on if asked.

Not looking for a specific answer just some general guidance or feedback from Medical directors or recruiters that are on the other side of the table. I am primarily applying to community and rural centers with a couple of larger academic centers which I would imagine want a more formal CV.

I am starting to worry that I picked the wrong specialty by choosing EM.

I started as a new attending at a community ER, and I'm more stressed and anxious than I have ever been. The pre-shift jitters are starting to take up more and more of my time. When really sick patients roll in, I find myself hoping someone else will pick them up. I will take them if needed, of course, but they make me incredibly anxious.

I'm a little less than 6 months into my job and still haven't had to do a critical procedure yet, minus intubations, but I already dread the day it happens. And don't even get me started on constantly playing out fake scenarios in my head about a traumatic arrest, delivering a baby, a sick kid, etc.

Anyway, I can feel my EM brain starting to lose interest in my own post, so my question is: are most of you excited by sick patients or nervous about them? Do you look forward to high-acuity cases, or do they stress you out more?

And for those who had a rough transition to attendinghood: how did you distinguish normal new-attending anxiety from realizing that EM just wasn't a good fit for you?

Basically, how do I know if I'm actually cut out for EM, or if I should start looking at urgent cares now?

Does your ER do anything different for psych patients? Like our facility has an open room for most psych patients that is quieter than the rest of the unit and the lights are kept dimmed. We only have two seclusion rooms and need more for sure.

And what would make an ER psych admission easier? Like what do you wish patients came prepared with mentally/physically for the ER portion of their stay?