What the hell does this even mean?!?
Like seriously if your paediatrician is ok with it then they are a shitty paediatrician!
I obviously give the usual little spiel about why it matters but there is no point pushing these patients too hard because then they out the child at risk by taking them home too early or not re-attending!
I am 40, 6ft4, 95kg and I've been gyming now for 1 year.
I aim to go to the gym every other day for at least 1 hour and I have seen benefits in regards to my weight lifting for example going from 20kg dumbell presses 3 x 12 to 36kg and likewise with other exercises.
I started doing boxing HIIT for 30 mins on my off days as I want to cut and get rid of my dad belly.
The issue is finding the time and the energy.
I am an ER consultant/attending and I work 50hrs / week either 8-6 or 2-00 which means my sleep schedule is all over the place.
Couple this with having a 4yr old son and the need for family time means I often don't get anytime to exercise on some weeks.
On my best weeks I can find the time to follow my routine, on my worst weeks (like the one just gone) i barely find the time or energy to do one workout due to being too tired from the late nights/early starts/child care/family activities etc.
Anyone else with similar work hours / family dynamics have any advice.
Hey guys I hope this is the right sub for this question.
I've been doing a bunch of weight exercise but wanted to get into boxing for my cardio.
I thought my gym had access to heavy bags out of hours but it doesn't seem to be the case.
I've been given permission by wife to get a heavy bag for the garage.
How best to mount the bag?
I've seen wall mounts and I've seen stands, my preference for ease would be a stand but I'm concerned it may not be sturdy enough.
Has anyone got any advice about the best way to mount a heavy 4-5ft bag?
Young patient with: gastroparesis / pots / hEDd / MCAS / ?munchaussens / SVT (although thought to be self induced with ventolin) and a whole bunch of other comorbidities.
Presented with hypoglycaemia.
Finger prick 2.1 but VBG showed 3.3. Her finger prick ketone showed 4.6 but ours showed 2.4.
Seen by endo 5 days before who are suspicious of rhe cause an ordered insulin levels, sulphonylurea levels and some others and a documented plan of only treat if BSL < 3.
I followed that plan.
We observed and BSL stayed 3.3, 3.2, 3.3.
Ketone stayed 2.4, 2.5, 2.3.
No acidosis.
Patient PEJ unable to be flushed (some concern she may be tampering with it previously).
Admitted for redo PEJ.
I offered oral glucose.
Patient refused due to nausea.
Never once vomited.
Looooong discussion was provided which was very heated and eventually patient took the oral glucose to good effect.
No vomiting.
Then refused any tests / refused port access / refused further glucose.
Essentially letting herself become more hypoglycaemic until BSL hit the magic <3 and then when they got what they wanted magically we are now allowed to use the port and commence iV glucose.
Such a frustrating case.
They present every few days and then DAMA prior to any actual workup and yet state all Doctors are Gaslighting them because theu understand medicine better.
I wanted to tear my hair out and it felt as if the only way you would ever "win" them over is to throw the whole medical textbook out of the window to appease them.
Me again, the ED doc attempting to learn more regarding FND.
Where do you all stand / think regarding the ED need for objective testing in the ED.
What I mean by this is objectively testing and proving patient symptoms, examples:
- patient states unable to swallow food so we give a trial of food to watch for obvious swallowing issues/gagging etc.
- patient states cannot walk so we get them to stand and mobilise.
- patient states pain so we trial analgesia and monitor response.
The reason I ask is I've had a patient recently complain of nausea and vomiting but no vomiting seen in the ED and refusing to try eating / oral fluids entirely to the point of mild hypoglycaemia. When I have had a strong / difficult discussion we finally came to agreement to try oral glucose which they tolerated well and sugars stabilised but then refused any thing further and even refused IV hydration / port access unless we gave them what they wanted.
There was no objective / clinical need to provide said treatment as objectively we had proven the alternative therapy worked but patient subjectively was stating extreme nausea.
I am well aware a patient has a right to decline treatment and respect it and would monitor until a deterioration prompted a need to intervene.
But as a clinician I cannot justify providing or escalating treatment based off subjective complaints.
Hey guys
I'm always looking for ways to share knowledge and improve my own and others education and I have hopefully come up with an idea that will help us all.
It's called The ED Casebook and it's a small free webapp which I hope will be used to capture interesting cases from all your great ED clinicians.
It should all be de-identified and Free to access for all!
It has a newsletter feature which will allow you to download the monthly cases as a PDF for distribution locally if you see fit.
Mods - I am not making any profit from this and I am offering it up for everyone to use and contribute to so please don't take this down.
To access it:
Hope everyone finds it useful.
Anyone had any interactions with this team?
We have a property being managed by them in Brisbane.
We were notified there was a toilet leak and they sought our approval for repair.
We decided to obtain quotes for repair vs replacement of the toilet as we wished to ensure no further issues in the future.
We decided to go forward with a replacement.
The team at Ray White had already gone ahead with the repair (despite us not approving it whilst waiting on quotes).
When we found this out we communicated with them and informed them of this and told them we wished the toilet to be replaced.
At the time they apologised and organised for the toilet to be replaced.
They also stated we would not be charged for the repair invoice as we had not agreed to it.
This was back in May.
We have just had our July finances sent through and they have now charged us for this invoice.
We have escalated and shown proof of emails etc but they are adamant we approved the repair on 5th May despite the first correspondence with us being on 11th May.
They are not answering their phone when we attempt to call them and are showing us a file that they have which states we approved the invoice on 5th may without proof it was us who approved it.
I feel like some shady stuff is happening and ultimately our next steps are:
- speak to them directly including going to the head huncho.
- leaving their service as we cannot trust them anymore.
- potentially escalating to legal services such as QCAT or other however the sum of money is only ~$400 so whether or not it's worth it??
Has anyone else had any bad experiences with them?
Can anyone else give more advice about what you would do?
We have a property being managed by a team in Brisbane.
We were notified there was a toilet leak and they sought our approval for repair.
We decided to obtain quotes for repair vs replacement of the toilet as we wished to ensure no further issues in the future.
We decided to go forward with a replacement.
The team had already gone ahead with the repair (despite us not approving it whilst waiting on quotes).
When we found this out we communicated with them and informed them of this and told them we wished the toilet to be replaced.
At the time they apologised and organised for the toilet to be replaced.
They also stated we would not be charged for the repair invoice as we had not agreed to it.
This was back in May.
We have just had our July finances sent through and they have now charged us for this invoice.
We have escalated and shown proof of emails etc but they are adamant we approved the repair on 5th May despite the first correspondence with us being on 11th May.
They are not answering their phone when we attempt to call them and are showing us a file that they have which states we approved the invoice on 5th may without proof it was us who approved it.
I feel like some shady shit is happening and ultimately our next steps are:
- speak to them directly including going to the head huncho.
- leaving their service as we cannot trust them anymore.
- potentially escalating to legal services such as QCAT or other however the sum of money is only ~$400 so whether or not it's worth it??
Has anyone else had any bad experiences like this?
Can anyone else give more advice about what you would do?
Anyone had any interactions with this team?
We have a property being managed by them in Brisbane.
We were notified there was a toilet leak and they sought our approval for repair.
We decided to obtain quotes for repair vs replacement of the toilet as we wished to ensure no further issues in the future.
We decided to go forward with a replacement.
The team at Ray White had already gone ahead with the repair (despite us not approving it whilst waiting on quotes).
When we found this out we communicated with them and informed them of this and told them we wished the toilet to be replaced.
At the time they apologised and organised for the toilet to be replaced.
They also stated we would not be charged for the repair invoice as we had not agreed to it.
This was back in May.
We have just had our July finances sent through and they have now charged us for this invoice.
We have escalated and shown proof of emails etc but they are adamant we approved the repair on 5th May despite the first correspondence with us being on 11th May.
They are not answering their phone when we attempt to call them and are showing us a file that they have which states we approved the invoice on 5th may without proof it was us who approved it.
I feel like some shady shit is happening and ultimately our next steps are:
- speak to them directly including going to the head huncho.
- leaving their service as we cannot trust them anymore.
- potentially escalating to legal services such as QCAT or other however the sum of money is only ~$400 so whether or not it's worth it??
Has anyone else had any bad experiences with them?
Can anyone else give more advice about what you would do?
Have you ever done this? It's what I say when I see a patient languishing in bed, feeling sorry for themselves and often I've had a persistent semi-low BP around 90's systolic or ongoing nausea but without any objective cause that I can find.
I get the patient to sit up / walk around / have something to eat and General return them back to "normal".
Magically the low BP returns to normal, the nausea improves, the pain improves and the complaints lessen.
There is definitely an element of "acting sick will make me sick" so acting normal helps to return them to normal.
These tend to be the young patients I do this for and not the geriatric ones, classically it's the 20's male or female who has mummy or daddy hovering over them and speaking for them with normal bloods and investigations.
As some of you might know I am a Dr with a specialist interest in FND.
I work in an emergency department in Aus and we see a high number of FND patients, at least 1 a shift, and I recognise it is a difficult thing to manage acutely.
I am due to give a lecture to Junior doctors in ED about FND.
I already have the bulk of it planned out but I wanted to know if there is anything the community think is a good idea to include.
For those who didn't see the last post I made it was basically how do you go about it when 2 consultants have different management styles for the same patient when the diagnosis is potentially different and it was between anaphylaxis Vs paroxysmal vocal cord dysfunction.
Long story short - she represented whilst I was on shift today.
No trigger again, maybe having some reflex recently, hoarse voice and difficulty breathing.
No other signs of anaphylaxis and all obs stable with sats 100%.
This time I decided to withhold any treatment.
I explained my rational and I've kept her in Resus on full monitoring with adrenaline already drawn up and patient happy with this.
We will do a nasoscope to view vocal cords for oedema vs dysfunction and base our diagnosis on this.
I'll let you know the outcome.
Edit / update:
Patient remained well.
Nasoscope = nil oedema or anatomical issue noted, some mild paradoxical movement seen again.
Patient diagnosed as paroxysmal vocal cord dysfunction.
Provided a small valium and voice returned to normal.
Discharged home with breathing techniques, PPI and gaviscon for reflux and to obtain formal diagnosis eith ENT / Immunology.
I am so glad she came back when I was on shift.
Facem here, just wondering if anyone can give me insight into becoming a HOD for ED.
It's crossed my mind a few times and then a NUM recommended I would be good at the job.
I'm only EDSS level 4 at the moment so keen to look into snd potentially pursue this.
Had a very frustrating conversation today in ED.
Now I work in Australia.
I saw a patient with acute on chronic RUQ pain who had been seen in my department 3 times in the last 1 month and had CT scans which showed no cholecsytitis / gallstones etc. Each time reviewed by Gen Surg who were happy no emergency issues.
Each time bloods normal.
Had an outpatient HIDA scan which showed evidence of biliary dyskinesia and then came back to the ED.
Pain settled with buscopan but patient refusing to take anything stronger than paracetamol unless it was morphine.
Examination showed soft abdomen, Murphy -ve with normal ultrasound.
I reviewed scans and also not significant faecal loading on the right side.
My plan was to provide analgesia whilst also providing some laxatives and suggest the patient follow up as an outpatient with Gen surgery.
Then her son called....
He is an Internal medicine doctor in America.
He was rude and abrasive on the phone.
He demanded she be admitted for a cholecystectomy. He refused any and all explanations I provided for what was happening. He stated she NEEDED it NOW and stated she was taking 4g paracetamol a day so she was in severe pain.
He would not let me explain how it wasn't an emergency, he would not let me explain how I planned on providing analgesia and also manage the faecal loading.
He accused me of not doing my job.
He has never actually examined his family member.
I get there is concern for a loved one but come on this is an entirely different medical system and he should know this is not a medical emergency!
In the end I agreed to get a surgical review and reminded him that it was THEIR decision and NOT his regarding surgery - the chat was going no where.
Patient reviewed by surgery and her pain settled.
Patient was discharged home to see outpatient Gen surgery.
It's a bit of a rant I know but seriously if your ever in a similar situation please be respectful of different countries and their medical systems!
Example case: mid 30s female presented as anaphylaxis.
States acute onset of throat tightening without known precipitant - maybe some itching to chin but no rash and no angiooedema.
Took own epi but called ambos who gave another and came to ED.
Similar hx few weeks before.
Apparently under immunologist for years but no cause found.
BG of depression, acute on chronic headaches and presented once with multiple syncope but normal ED investigations and discharged against medical advice.
Important to note - never any obvious objective findings apart from a hoarse voice in last 2 admissions.
I (as a consultant doing what we call VMO work I.e locum work) assessed and something didn't add up to me and my treatment plan was to hold any further treatment I.e. no steroids or further antihistamine or adrenaline as the patient was well without any stridor/swelling/rash and normal obs.
I wanted to do a nasoscope to investigate paroxysmal vocal cord pathology.
Another consultant (who works in the place full time) also reviewed and instead decided on IV hydrocort + further antihistamine.
I then decided to do a nasoendoscopy anyway, due to ongoing hoarse voice, and found no oedema or anatomical abnormality at the cord level but did find paradoxical movements which was confirmed by ENT review of the video.
I personally think this lady is suffering from PVCD and not anaphylaxis but the other consultant has written notes basically just stating it was another anaphylaxis again.
The reason I am a tad annoyed is the failure to consider other pathologies which unfortunately will continue the mismanagement of the patient.
Granted I am aware it is often safer to treat for anaphylaxis than not but in this situation I felt we could have observed and not rushed to enforce a potential misdiagnosis.
I am tempted to call the patient tomorrow and explain my thoughts to guide her to see an appropriate speech/ENT specialist.
In the future if this similar interaction occurs how would you handle it - as 2 senior doctors.
I have had similar interactions with this consultant who has failed to act quickly enough (in my opinion) resulting in poor outcomes.
Elbow dislocation techniques
How do you relocate your elbows?
For some reason I keep coming across other Docs who find it difficult using rhe traction / counter traction technique and often I come in an use my own technique which has worked 100% of the time and is easy peasy.
I've looked up different techniques and the one I use hasn't been described - I would love to have a technique with my name on it! But before I try and do that I wanted to see if anyone else does it.
Without giving the game away, how do you guys relocate the elbow?
Edit: people getting snarky in the comments - thid is supposed to be a bit of a light hearted discussion so keep the negativity away, I am just asking how others do it.
Also apparently me not knowing the formal pathway to get a technique described means I can't be a consultant ?!? I'm sorry but I'm not a researcher/academic - I work hard on the shop floor and I'm not interested in these things.
Edit: OK so I'll just describe my technique as I still haven't seen anyone describe theirs and even with a post detailing 7 different techniques it's not written.
It's a single operator, double handed technique similar to the double thumbs.
Have the patient sat down and you are facing them.
The arm is held in a position of comfort- likely partially extended with palm upwards.
You use your hands to "grip" the elbow.
Your 2 middle fingers "hook" the olecranon posteriorly and your 2 thumbs are positioned on the anterior distal humerus.
Then you push with your thumbs and pull with your fingers in a rotating fashion to pull the olecranon down and your thumbs push the distal humerus backwards.
As you do this you will notice the elbow tends to flex abd then "clunk" it's back in place.
I've done it with sedated and non sedated patients and, for me anyway, it's as easy as putting a patellar back into place.
Mid 50s female batcall sepsis, obese, no neck.
DC recently with large purulunt ascites and new Malignancy.
Re attended 2 days post DC SoB and agitated.
- BP 80
- Tachycardia 130
- Sats 100% on 15LNRB
- Pale clammy
- Periarrest
- No IV access.
- non compliant with positioning / monitoring
- Able to get some poor IV access
- Fluid resus and BP >100
- A line inserted
- Abx given
- Pocus = reaccumulation ascites (?loculated) and bilateral large pleural effusions, heart hyperdynamic nil effusion.
- hyperglycaemia but ketone 1.5
Taken for CT but IVC lost enroute so noncon CT completed = large pleural effusions, ascites, nil obstruction or perf.
Back to resus.
Attempted NGT for large stomach and further IVC.
Managed IVC but pt non compliant for NGT.
Attempted CVC but pt non compliant agitated needing more sedation with ketamine / midaz.
Looking worse.
Unable to get non-invasive BP due to Agitation.
A line poor trace but sometimes reading 100 systolic.
Blood gas at this time = 7.295, lactate ~ 4, K5.6 rest unremarkable, ongoing IVF.
Decision for tube to facilitate management/transfer/likely IR drainage of ascites/effusions.
- RSI ramped with Roc and Ketamin (reduced dose)
- Gentle bagging.
- rescue drugs ready and Cric kit on hand.
- Sats 100% BVM prior and last reading a Line 100 systolic
- Grade 1 CMAC.
- large vomit during ett and aspiration but tube secured.
- sats dropped to 69% but bagged back to 78% post some inline suction.
- became Brady and arrested.
CPR commenced.
-repeat Gas showed K6 and hypercapnia.
- multiple coached rounds and at 24 mins brief rosc
- adrenaline infusion and boluses commenced plus calcium chloride provided and insulin.
- cpr ongoing for 45 mins and all rhythms non shockable.
- repeat gas worsening acidosis, K7 and lactate 8.
- decision to stop at 45mins.
Just thinking if anything else could have been done.
Could we have pressed on for NGT? She was agitated and non-compliant so would need more sedation and risk of losing airway with this hence decided not to press it.
It was overall a pretty shitty case and from the start she was cold as ice/clammy/agitated/delirious etc
I am trying ti find an alternative route to what we did but I am struggling to justify any other management at this time.
Any suggestions for future learning?
Hot debrief at the time- no other suggestions
What are your techniques for removing difficult FB from ear canal.
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Generally I use analgesia + alligator forceps or flushes depending on the FB.
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However there is always that one case where pain becomes too much of an issue and it's difficult to get to so I send to ENT.
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My question is what analgesic methods are you using to help with ear canal pain and what do the ENT guys do differently apart from deeper sedation as needed?
We are having more and more patients arrive with this combo and my God are they a difficult bunch.
I know the standard at the moment is symptomatic management - maybe some IVF, laxatives, analgesia and then back to community followup.
I have been doing a deep dive into these conditions and one paper hints that MCAS may provide a unifying diagnosis. It can cause multiple physical and neuropsychiatric issues which are common in this population with some evidence of resolution of symptoms after managing the MCAS with histamine blockers / mast cell stabilisers etc.
Does anyone have any evidence / anecdotal reports on whether or not providing these patients with H1 / H2 receptor meds or steroids may reduce their symptoms burden and hopefully reduce their ED presentations in the acute setting?
The more common this becomes the more issues in regards to ED workflow develop and I am trying to find some sort of quick fix that actually works as I'm getting tired of the arguments / the lack of trust / the difficult conversations.