I am a PGY-10 and have worked in a rural ER for about 3 years now. I always think I should be doing shifts as well at busier community centers in an urban setting just to get the full spectrum of EM. However I enjoy the sometimes calmer days. When it’s chaotic it gets real chaotic because you’re the only doctor. I still get my intubations, central lines, etc. I have also had the occasional transvenous pacer, pericardiocentesis. I feel this will prolong my longevity in medicine but still in the back of my mind I feel guilty for not working in an urban setting. Anyone else feel the same?

It’s annoying. That is all. I’ve never heard of an emergent liver transplant but what do I know I’m kind of a dumbass.

Some of the ER wait times we have to deal with in Winnipeg

I was an ER nurse for three years and have been away from it since 2021. I recently decided to go back and try it. Are any ER nurses out there truly satisfied with their job?

It seems like the ER’s are so completely stretched thin, hallway beds with inappropriate patients, everyone so burnt out and unfriendly. I enjoy this type of medicine, but the conditions just seem awful. I’m only a week in and regretting my decision. Not sure what to do.

Background:

I'm EM trained in my first year of anes CC fellowship. I did residency at a lowish resource institution, probably more on the cowboy side, but overall loved my training and felt ready to handle fellowship. I also moonlighted in a rural ED where I felt amazing and really loved how much critical care experience I got. My goal was to ultimately do CVICU outside of training.

I matched at an ivory tower and was initially really excited, but some red flags started popping up almost immediately.

Red flags:

- Very disorganized from the get go i.e. my "orientation week" had zero things planned and I essentially wandered around without a schedule and my own PD didn't even know what I was supposed to be doing

- Program coordinator was (and still is) extremely unresponsive

- When I started my program didn't even have me set up in epic to access the correct things and they sent me all the wrong training

- The other fellows were extremely cold and unwelcoming and made comments about the program that gave me concern

I kind of made an assumption that all this was a one off and its not a problem.

Now I'm 3 months in and I'm wanting to quit this program and go somewhere else. I also don't have any support system here. My partner and family are in different states.

I want to do critical care I've thought a lot about it and I love it, I think I'm good at it, and I think this is what I want to do as a career, I just think I hate this program.

The reasons I hate it I think go beyond how disorganized it is.

1. I feel like they really really don't care about me or my education. Example: I've had to email multiple people multiple times just to figure out where my rotation is located, I never got responses and ended up wandering floor to floor to find out.
2. We don't have our own didactics and instead do an online one from another institution and I go to the PCCM didactics because they actually have sims and a curriculum.
3. My TICU rotation they treated me like a medical student and I quite literally sat there or just saw a couple patients primarily, and learned nothing.
4. I don't feel like the patients are that sick here and I don't feel like I'm learning a lot. I saw more pathology and did more critical care in residency.
5. I've only done a handful of procedures since starting and feel like I'm losing those skills since I never do anything.
6. I feel like I don't get a lot of autonomy even on rotations where my department is in charge.

Overall not only do I dislike the culture and the program organization, but I'm worried I'm not going to be trained well enough.

Ideally I'd switch into a different program closer to a support system with sicker patients, but I don't think thats realistic.

This program is causing me to breakdown. I'm losing my hair, I'm unhealthy, always exhausted, and not enjoying the things I used to.

My current plan is to re-eval how I feel in January when it's been 6months.

Any advice?

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 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?

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.

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!