What are your most frustrating patient encounters? Challenging/stressful EM situations...

[SERENITY NOW]

Hey gang,

I'm working with some new grad trainees on some education topics and I like to keep it practical.  I'd like to review with them situations that would leave most providers, especially new grads, feeling stressed and uncomfortable.  And then we will dive in and dissect how "experienced providers" have learned to deal with these.  

It could be basic stuff like roadblocks we encounter, "I want CT with contrast for RLQ pain but found out they have an AKI, what do I do now?" to "I've been trying to manage this cyclic vomiter's symptoms for 5 hours and I'm getting nowhere, how could I do this better next time?"  

So please share away!  What are your most frustrating patient encounters?

 

I'll share one of mine from recent shifts...

-arguing with consultants to do what the patient needs.  Ie, Unstable upper GIB needing endoscopy for source control, but they say "too sick for us now", and if you do manage to stabilize them then they say "great job now they're stable enough for me to see tomorrow".  No dude, come in and do your job!  What do I need to say to make it happen from the beginning?!

 

[EMEDPA]

2 hours ago, SERENITY NOW said:

"I've been trying to manage this cyclic vomiter's symptoms for 5 hours and I'm getting nowhere, how could I do this better next time?" 

 

great topic. 

The cyclic vomiter scenario: 

Start with haldol/droperidol. Accept no zofran/compazine/phenergan/reglan suggestions, they won't work. . "Drug em until you like them...and I don't like them yet..."

[ohiovolffemtp]

Typical transfer scenario:

Need to transfer patient to higher level of care (I work at a rural critical access hospital and a small community hospital).  Most recent example: 44 y/o/m firefighter/paramedic (former co-worker from my fire/EMS days) with chest pain, persistent wide complex tachycardia and frequent bi/tri gemini which he says is his baseline (and he's right).  Cardiologist who's on call for his cardiology practice says, yes, we should see him at the tertiary facility which is their practices primary location.   Cardiologist fine with lidocaine drip, has us add metoprolol.  Patient's rhythm improves.   Hospitalist says, "he's too sick for med/surg, can't take anyone on a lidocaine drip, but don't turn it off, talk to the intensivist".  Intensivist says "he's not sick enough to need the ICU, maybe not even step down".  Arghh!!!  

My response, "how about we send him to you, you see how he does if you turn off the drip and/or change meds, and then you pick the appropriate bed".

Had similar situation many times in the COVID era, usually over what unit would take high flow O2 like Vapotherm/Airvo or Bipap, especially if needing any kind of anxiolytic, whether PRN benzo or ketamine (many hospitals very fearful of ketamine).

It seems like hospitalists and intensivists in the same receiving hospital don't talk and don't agree on who gets what.