GetMeOuttaThisMess Posted January 12, 2014 Share Posted January 12, 2014 Interesting follow ups. BTW, I heard that the "Texas Strong" phrase that UT/others has been pushing actually has a negative connotation about it but I don't remember what exactly. Ah, I miss the aroma.....(I actually do). Quote Link to comment Share on other sites More sharing options...
skyblu Posted January 14, 2014 Share Posted January 14, 2014 It was piña colada, but hey, same difference! I don't get echos in my community hospital unless it's business hours. Even then, they take 5-6 hours to get back. And MRI is limited, too. So I'm going to admit the guy and let neuro sort it out from there. The 23 patients in my waiting room will thank me. Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 15, 2014 Share Posted January 15, 2014 ^^^ Amen to that. BTW, you haven't had a true Mai-tai unless it was made locally ;-). Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 21, 2014 Author Moderator Share Posted June 21, 2014 finally made the decision to buy a (very) small place in the rural community I have been doing per diem shifts in for the last 7 years. the mortgage expense/mo will work out to almost exactly what I have been paying for hotels and restaurants every month. the place is also walking distance to the hospital and a short walk to many local restaurants and places of interest. this will allow me to build some equity and make picking up shifts on short notice easier. also not having to check in/out on someone else's schedule will be nice. I also expect that having my own kitchen will encourage me to eat better when away from my primary home. 6 Quote Link to comment Share on other sites More sharing options...
delco714 Posted June 22, 2014 Share Posted June 22, 2014 Ya sure you don't want to move to Maine still? We could use you, ya know! :-P Steve PA-C, Maine, urologic surgery Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 22, 2014 Author Moderator Share Posted June 22, 2014 Ya sure you don't want to move to Maine still? We could use you, ya know! :-P Steve PA-C, Maine, urologic surgery I tried for maine and VT but the wife really wants to stay on the west coast... Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 19, 2014 Share Posted July 19, 2014 Steve - are the blackflies gone for the year yet? We're heading up your way in about 4 days for 2 weeks of vacation. I did two tours in Maine while active duty and still own a house just beyond Ellsworth, so we will be driving right through Bangor.E - Maine is beautiful, and it's especially nice end of July-August. But it gets a LOT colder there in the winter than coastal Oregon. Best description of how cold it gets comes courtesy of a former shipmate of mine. We were coming back from a mission and, despite layers and layers and layers of PPE, we were all mildly hypothermic. As we were walking up to the locker room he described it as it is "OH MY GAWD EVACUATE THE f^#k!@g STATE COLD". But back to the "Why I love rural EM". Last few days in a very rural ED (4 hours from tertiary care). Peritonsillar abscess, A-flutter, classic clinical picture of SAH (but CT, LP, and CTA negative), MC fx in a 6 yo, precipitous home delivery of a 38 weeker in the shower, bunch of chest pains (none ruled in for MI), three ESRD trainwrecks (one 33 yo who coded and we got back), and a whole bunch of lesser sick people. In the local tertiary center I would only have seen the abscess and MC fx (and the non-sick folks) The A-flutter, possible SAH, chest pains, and ESRDs would have been handled by the EPs. 1 Quote Link to comment Share on other sites More sharing options...
delco714 Posted July 21, 2014 Share Posted July 21, 2014 Hey Boat, hmm.. depends. Near water like lakes and ponds, the mosquitoes are vicious. Up north in the county the flies I'm sure are still pestering, but down here not as much. I'd bring some bug spray,esp ,for dusk. I was at a lake side campsite this weekend on the west side of the state,, whewwwww I got eaten up by flies, mosquitoes and whatever else Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 21, 2014 Share Posted July 21, 2014 Yeah, but mosquitoes respect deet...whereas blackflies will swim through the bug spray just to bite your eyeballs! Leaving in the morning. Drive 2 days to Boston to see friends, be at Georges Pond on Saturday!! Quote Link to comment Share on other sites More sharing options...
delco714 Posted July 22, 2014 Share Posted July 22, 2014 That's true,, those bastards loooove to bombard my conjunctivae.. so, realistically, no issue with blackflies this away. I'd imagine down near the coast more, I'd be even better Quote Link to comment Share on other sites More sharing options...
jen0508 Posted July 25, 2014 Share Posted July 25, 2014 so what is considered rural? I love my job but I'm not sure if what i love is rural EM or just country EM ??? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 1, 2014 Author Moderator Share Posted August 1, 2014 so what is considered rural? I love my job but I'm not sure if what i love is rural EM or just country EM ??? a rural dept likely sees fewer than 75 pts/day and does not have immediate access to multiple specialists. the e.d. is likely also 10 beds or less and may be the only hospital covering a large geographic area. this is why it is more challenging for clinicians. I work at a place that frequently does not have local ortho on call for example, so the option is do the reduction myself or have the pt drive 3 hours to the nearest orthopedist. for easy to moderate reductions I will do them myself. for tougher ones likely requiring surgery, the pt may still need to take that 3 hour drive. at my urban job, ortho does almost all reductions just because that is the standard and they are immediately available. we also don't have cardiology in house so we need to decide TPA vs no TPA, transfer for cath vs medically manage in our ICU, etc. We don't have urology around either so I have had to deal with pts with priapism in the E.D. and do the phenylephrine injections myself whereas these are always done by urology in a community or academic e.d. In rural EM you will be more challenged and stretched as a clinician than in the community or academic centers because YOU are the resource, not a specialist or team. you can certainly get phone consults but if they are hours away you are the one doing the procedure and making the decisions. 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 2, 2014 Author Moderator Share Posted August 2, 2014 working a rural shift today. arrived to find a 60 yr old female pt with new onset afib/flutter 3 hrs ago after drinking an energy drink. feels a little dizzy. no chest pain or sob. VS other than pulse of 150 nl. no chest pain. labs including cardiac enzymes, metabolic profile, tsh, uds, cbc nl. ED course quick consult to cards by phone after no conversion with diltiazem 20 mg and amiodarone 150 mg. cards requested trial of adenosine( uh, ok...no response with 6 mg, 12 mg) then cardioversion. procedural sedation done with propofol 120 mg, synchronized cardioversion at 100J effective for 1-2 min with return to nsr then return to afib with rvr. cardioversion with 200J with same result. admitted on diltiazem drip(hospitalist preference) with plan to transfer for ablation if no rate control within 6 hrs on dilt drip. fun stuff. I love this job. 2 hrs later pt rate controlled on dilt drip in the 70s. new pt 60 yr old male with 2 weeks of neck pain. looks like crap. afib 170/min. labs essentially nl. cxr with very large heart. BNP 3300. rate to 130 after dilt 20 mg iv, now on drip at 10 mg/hr. CT chest with IV contrast in progress to eval aortic dissection at request of hospitalist(doubt but gotta check). did I mention I love this job....:) hospitalist preference to continue single agent for now. not clinically chf (no edema, clear lungs, no jvd) despite cxr and bnp findings. CT chest neg PE or Dissection. per rads multiple coronary calcifications makes pt a "ticking time bomb". rate on dilt increased to 15/hr by me prior to admit. after several hours on tele still not rate controlled. given PO metoprolol by hospitalist, dilt continued. lovenox given. this guy may just need ablation... same shift- 65 yr old african american male smoker with hx of pvd and prior fem-pop bypass with cold, pulseless(by dopler) foot x 3 hrs. heparinized and transferred to closest vascular surgeon. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 6, 2014 Author Moderator Share Posted August 6, 2014 finally made the decision to buy a (very) small place in the rural community I have been doing per diem shifts in for the last 7 years. the mortgage expense/mo will work out to almost exactly what I have been paying for hotels and restaurants every month. the place is also walking distance to the hospital and a short walk to many local restaurants and places of interest. this will allow me to build some equity and make picking up shifts on short notice easier. also not having to check in/out on someone else's schedule will be nice. I also expect that having my own kitchen will encourage me to eat better when away from my primary home. It's amazing how much extra stuff folks have lying around. I just outfitted an entire condo with extra towels, plates, flatware, etc lying around the house and 200 bucks worth of furniture from Ikea. It will be really nice to not throw away money every month on hotels and restaurants and have a place to leave things for work. p.s. just got the electric bill for the first month, granted I only stayed there one day to set the place up. 11 cents. based on my regular shifts there every month I am looking at a bill of less than 1 dollar/mo. 1 Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 7, 2014 Share Posted August 7, 2014 so what is considered rural? I love my job but I'm not sure if what i love is rural EM or just country EM ??? I work in several different places, but sounds like none of them are as busy as EMED's. #1 place: 5 bed ED + 2 Trauma rooms. 36 room hospital with 5 bed ICU. Almost 9000 ED visits per year. Single coverage, mostly PAs but also filled in with some FP docs. One general surgeon in town who isn't always on call. We have occasional (ie: traveling) ortho, onc, and podiatry. One hour transit to tertiary hospital. No responsibility for anything but the ED and code situations on the floor. Mostly 12 hour shifts, although occasionally I pull 24 or 36 hour shifts. Reallllllllly hate the 36 hour ones, I keep telling scheduler not to give me those. I can stay up 24 hours and be functional. 36 hours = I'm not safe. #2 place: 2 bed ED. 10 room hospital. 48-60 hour shifts. 2000 ED visits per year. The hospital owns a nice house in town for their locum providers to stay at. This town is about 1.5 hours from tertiary center. #3 place: 3 bed ED + 2 Trauma. 28 room hospital with 2 bed ICU. About 5000 ED visits per year. Single coverage. One gen surgeon who IS always on call, with no specialty. FOUR hour ground transit to tertiary hospital. 24-72 hour shifts with responsibility for clinic during work days and some hospital rounding. #4 place - first shift there next week. Low volume, high acuity, very rural. Been told 5-6 patients per day, 48 hour shifts, ED only. It's amazing how much extra stuff folks have lying around. I just outfitted an entire condo with extra towels, plates, flatware, etc lying around the house and 200 bucks worth of furniture from Ikea. It will be really nice to not throw away money every month on hotels and restaurants and have a place to leave things for work. In one town I worked at we bought a house with an apartment over the garage out back. Plan was to rent out the house and I stay in the apartment when I'm in town. Spent a year fixing up the house and then someone gave me a GREAT offer to buy the house.....so I'm back to driving back and forth! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 7, 2014 Author Moderator Share Posted August 7, 2014 In one town I worked at we bought a house with an apartment over the garage out back. Plan was to rent out the house and I stay in the apartment when I'm in town. Spent a year fixing up the house and then someone gave me a GREAT offer to buy the house.....so I'm back to driving back and forth! maybe they will give you a deal to rent the apt(?) Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 8, 2014 Share Posted August 8, 2014 maybe they will give you a deal to rent the apt(?) Naaa. This worked out real well. I'm no longer working much at that shop anyway. Virtually all nights, and busy. I still work there 3-4 nights a month, but I would rather have 24-72 hour shifts in slower places so I can have better quality time off. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 24, 2014 Author Moderator Share Posted August 24, 2014 so some days aren't as good as others in the rural environment..... today we have no beds in the hospital, no surgeon or ortho, and the CT scanner is down for 48 hrs for servcing. EMS knows all this but we are the only show in town so of course my patients today(in addition to a host of minor stuff): Non-stemi: stabilized and transfered new cva: transfered trauma auto/ped: multiple extermity fxs, FAST neg, agitated, unable to clear head or c-spine, resuscitated, blood hung, Flown CHF/renal failure/poorly controlled dm (begged for and got 1 bed here) very frustrating... same shift. have a pt with renal colic and hematuria(still no ct). I said to one of the (younger) docs" well, I guess we canstill get an IVP if we really have to". Doc : "A what?". apparently I've been doing this for a long time... 1 Quote Link to comment Share on other sites More sharing options...
medic25 Posted August 24, 2014 Share Posted August 24, 2014 have a pt with renal colic and hematuria(still no ct). I said to one of the (younger) docs" well, I guess we canstill get an IVP if we really have to". Doc : "A what?". apparently I've been doing this for a long time... Are you guys doing many ultrasounds in place of CT? A lot of the stones we used to CT (especially with a known history) we are looking at the urine and an ultrasound to eval for hydronephrosis and stopping there. Quote Link to comment Share on other sites More sharing options...
Guest Paula Posted August 24, 2014 Share Posted August 24, 2014 This is such an interesting thread and half of us Forum members live vicariously through you all! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 24, 2014 Author Moderator Share Posted August 24, 2014 Are you guys doing many ultrasounds in place of CT? A lot of the stones we used to CT (especially with a known history) we are looking at the urine and an ultrasound to eval for hydronephrosis and stopping there. nope, although it's a good idea. we have to call U/S in from home and we generally have CT 24/7. Quote Link to comment Share on other sites More sharing options...
primadonna22274 Posted August 24, 2014 Share Posted August 24, 2014 You should do an US course E. One of the reasons I chose my residency is the high quality US curriculum we get. Very, very useful! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 24, 2014 Author Moderator Share Posted August 24, 2014 You should do an US course E. One of the reasons I chose my residency is the high quality US curriculum we get. Very, very useful! I've done the FAST course for trauma, but none of the others. 1 Quote Link to comment Share on other sites More sharing options...
gbrothers98 Posted August 24, 2014 Share Posted August 24, 2014 Are you guys doing many ultrasounds in place of CT? A lot of the stones we used to CT (especially with a known history) we are looking at the urine and an ultrasound to eval for hydronephrosis and stopping there. Problem with only US flank pain is that dont know where stone is in its course, cant give pt idea of it will pass, dont know size. Could do KUB but stone usually only apparent on KUB after seen on CT unless big. I like to tell pt how big a stone, where it is and likelihood of passage. Helps with follow up also. G Brothers PA-C Quote Link to comment Share on other sites More sharing options...
medic25 Posted August 25, 2014 Share Posted August 25, 2014 Problem with only US flank pain is that dont know where stone is in its course, cant give pt idea of it will pass, dont know size. Could do KUB but stone usually only apparent on KUB after seen on CT unless big. I like to tell pt how big a stone, where it is and likelihood of passage. Helps with follow up also. G Brothers PA-C I'll still do a CT in some patients (e.g. first presentation, bounce backs, etc), but in a lot of these patients with recurrent stones, the size/location of the stone doesn't seem to make a big difference in the ED setting. If the pain is controlled and there's no sign of infection, they'll be discharged on pain meds and referred to a urologist regardless if it's a 2mm or a 9mm stone. If the stone passes in a couple of days (like many do), you've spared them the radiation; if it's a week or two later and they still have pain, the urologist can get the CT as an outpatient. We wrapped up a lengthy study in our shop looking at making a clinical decision rule for renal colic patients, so we got very used to doing bedside ultrasound for this population. Even if you're not comfortable doing the US yourself, it's an option worth thinking about to have radiology perform. When you get that 30 year old with 4 visits in the past year for kidney stones, it's nice to sometimes spare them the CT scan. P.S.- if interested, here's a link to the study we published. If you listen to EM:RAP they had a nice review of it this past month. http://www.bmj.com/content/348/bmj.g2191.long Quote Link to comment Share on other sites More sharing options...
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