1. As far as I know, there are 3 paths to critical care fellowship - EM, surgical, pulmonary. I believe anesthesia also has a path. As an EM resident, you can apply to all 3.

  2. Also neuro critical care, EM can apply to that as well.

  3. Y’all posting NY Times like paywall isn’t a thing. Any way to read this for free?

  4. https://archive.ph/VUqvO

  5. The question isn’t repeat head CT or OR. The question is bedside burr hole or OR. Residency trained ER attendings should know how to do them and I’ve been trained on them at least with cadavers and sim lab. While very rare, I’ve had ER colleagues do burr holes when neurosurgery is a long transfer ride away.

  6. Unfortunately this isn't true for a lot of residency programs. We were never taught how to do it, not even in a simulation. It's not a required procedure to do to graduate, we're not even required to sim the procedure to graduate (there are some we can do as sim and it counts per ACGME like crics). I've looked up videos on how to do it but luckily I've never needed to. Also if you have any good video suggestions I'll take those as well!

  7. Yeah I've seen their videos, decent. Wasn't sure if there was anything else better out there but it'll do, ty.

  8. Haha yeah I'm aware of its challenges but I'll be much happier.

  9. Did he also throw a scalpel at a student?

  10. Lmao I know exactly who you're talking about.

  11. Be me, Super Brand new Three-Weeks of Clerkship deep M3, retracting some dude's L2 spinal muscles during Surgery rotation:

  12. Ortho knew what the circle of willis was?

  13. Eh I stand by my joke, but that does clarify things lol.

  14. I’ve listened to years of people trying to sell me snake oil to work up vertigo without an mri. There is no reliable test that can be routinely performed by non hyper specialized physicians.

  15. I'll also agree because with an MRI I have a paper trail. Can't duplicate my neuro exam in court, and 5 different people will get 5 different neuro exams. I can just point to the MRI and say no stroke... kinda.

  16. The kinda part will get you screwed. Don't get the MRIs in the ED. I've had DWI negative MRI at 8hrs with diplopia and facial droop. A third of the pons infarcted at 48hrs, no change in clinical exam at any point. Try to get coronal DWI of the brainstem if radiology is smart enough to offer it. Don't discharge patients with obvious posterior circulation symptoms (eg diplopia, unilateral hearing loss, direction changing nystagmus, ptosis) from the ED based on MRI. This sounds crazy but I have seen it, particularly hospitalists aren't aware of the limitations of MRI.

  17. I agree that's why I said kinda, if they still have concerning symptoms I'll admit. It does help me dc the ones I was on the fence about. Interesting point about the brainstem MRI though I'll look into that.

  18. Agree, they warned us day 1 that that would lead to expulsion.

  19. A federal judge in Texas made the opposite ruling which means it's going to SCOTUS and now my previous (somewhat joking) comment about how they will find EMTALA unconstitutional hits a little too close to home.

  20. That's still criminally low, if I worked 28 days straight I'd make close to $80,000 for that month alone.

  21. I have no experience with this so tell me, how much blood do those patients usually get?

  22. Occasionally it’s a beautiful case and only like 10 units. Other times it’s a shit show, and it’s replacing their entire blood volume every few min for hours. Highest I heard was over 300 total blood products (miraculously they lived) but it’s not terribly uncommon to routinely give in the 75-125 range

  23. Jfc where is it all going? You guys spraying it on each other like that Zoolander scene? Amazing what we'll give one person to save them.

  24. “I think I’m about to be sick. I was exposed to (insert diagnosis du jour). Can you give me some antibiotics just in case?”

  25. Bruh we literally have those all the time. "Exposee to COVID, asymptomatic." We also had someone check in because they thought maybe a spider bit their ears, they weren't sure, had no pain, no rash, no symptoms at all and just wanted us to look at his ears.

  26. Okay I actually thought this was real for a second

  27. I wish it was. We've definitely let some frequent flyers sit out there a little longer until they got bored and left.

  28. Next up: SCOTUS rules 6-3 that EMTALA isn't constitutional and that the founding fathers would have wanted you to die.

  29. As long as they are P > 1. Ain’t nobody in the ER who wants to deliver a para 1 😬

  30. Ain't nobody in the ER wanna deliver para anything.

  31. i get erect when deleting "allergies" out of the EMR.

  32. Same. Contrast allergies? No sir you had a CTA chest abdomen pelvis yesterday. Antibiotic allergies? Nope. You're allergic to NSAIDs? The 800 ibuprofen you've been popping for your back pain would like a word with you.

  33. No, not what I envisioned it to be or what it's being sold as.

  34. Exactly. I already do this. And why I’m not ordering it. If their doctor sends them in for a nonemergent test (like a knee MRI for possible ACL tear) I will also send the doctor a message letting them know why the test wasn’t done.

  35. I'll usually just send the patient back to them pissed off, that way no one is happy and we all lose. This is the way.

  36. "What did you react to? Have you ever had a reaction to contrast? Good news!!!! The agent we are using today doesn't have any interactions and we can proceed!"

  37. I'll try that next time instead of sighing for a very long time lol

  38. Best wishes - you are the authority! And if they react anyway, you always have epinephrine 0.5mg IM in the thigh at your disposal hahaha

  39. I have definitely told CT before that if they react I'll do just that. They weren't happy haha, and guess what? No reaction!

  40. yea, no way our hospitalists would admit, OP didnt mention heart scores on these people (he admitting a 20 yo CP?). There would have to be extraneous circumstances, and likely cardiology on board already for medicine to OK negative trop normal EKG CP needing further cardiac work up

  41. I imagine it’s a 50+yo with multiple risk and a bread and butter story. Has to be lol. I’ve done that before and occasionally they end up in the cath lab the next day

  42. Correct, I'm definitely not admitting 30yr olds with CP unless their dad died at 30 from an MI or something.

  43. No not 20yr olds, they got 1 trop and go home unless something is extremely off. They're usually 40ish + year olds with medium to high risk.

  44. What examples do you have of meds the nurses weren’t “comfortable” with? Genuinely curious

  45. Morphine, Ativan, D50 were the ones I remember.

  46. In most places they do, but NYC is a different beast. I remember moving to the west coast for residency and was amazed that nurses did all this stuff.

  47. ED solo coverage. Terrifying. You will second guess every decision you make and quadruple check things. Makes you appreciate when you had someone to fall back on in residency or bounce ideas off.

  48. Be able to recognize when your patient is sick, getting sicker/decompensating. It's something you'll learn in time so don't be afraid to come get me if you're worried. Shit hits the fan and we get quite busy so sometimes I don't get a chance to see patients for a few hours until I'm about to dispo them, so I rely on you.

  49. I'm totally using that next time.

  50. Did they actually tell you that was the reason? Because it's very strange for an employer to specifically say that. They usually just say something generic.

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