As a new Emergency Medicine attending 10 years ago I was asked to write about my insights into what it's like to be an ER Doctor. After all these years I'm amazed by how much this all still rings true in my heart today.

Here’s what I wrote: 🧵 MAKE THINGS HAPPEN, SAVE LIVES, ALLEVIATE SUFFERING

My Emergency Department is a battlefield. Volumes are high and the pace is fast. To succeed as an Emergency Physician I must be an expert of efficiency. I also must be an expert of triage. I am constantly triaging and re-triaging as things evolve. The ED is highly unpredictable. My entire shift I am on guard and ready for any emergency to come flying through the doors at any moment. In the meantime I am either taking care of or seeking out other emergencies. My job is not to be expert in all of medicine. My job is to be jack of all trades and master of diagnosing and treating what can and will kill you. If I cannot provide the definitive care you need, my job does not end until I have gotten you there.

Just to be crystal clear, “I feel fine but my wife made me come in” has a positive predictive value for something being *really* fucking wrong that approaches 100% Unless the patient is a farmer, in which case the positive predictive value approaches 1,000%

Here’s a very important #ECG of a 60-year-old lady who presented with chest pain and shortness of breath that began while walking her dog. She was also COVID+

What’s the diagnosis? If you’re a new follower I always post the answer with explanation the next day. If you’re new to my account—follow me if you want to learn about medical emergencies

Here’s the #ECG of a 68 year old man who was rushed to the ER by paramedics

BP: 80/40
HR: 150
RR: 35
SPO2: 95%

What’s the diagnosis? Answer: HYPERKALEMIA

There’s a wide complex tachycardia with RBBB morphology. There are features here concerning for several life-threatening diagnoses including: V-Tach, Pulmonary Embolism, Acute Coronary Occlusion. But ALL these changes resolved with empiric ↑K+ treatment…

Here’s an important ECG of a 30 year old man who presented to the ER with chest pain. This tracing was recorded just minutes before he collapsed into cardiac arrest.

What’s the diagnosis? If you’re a new follower I always post the answer with explanation the next day. If you’re new to my account, follow me if you want to learn about Emergency ECGs

Here’s a great #ECG of a man who presented to the ER with crushing chest pain.

[thread] Here’s the ECG Computer Read:

"Non-specific ST abnormality, consider anterior subendocardial ischemia."

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Here’s a great #Echo of a young lady who suddenly collapsed to the ground in Cardiac Arrest. Bystander CPR was performed and 911 was called. Paramedics shock her once for pulseless VT and get ROSC on the scene. She’s intubated, in shock, on an Epi drip.

What’s the diagnosis? The RV is very dilated with poor systolic function. The RA is also very big. The LV is Hyperdynamic with no obvious wall motion abnormality. This appearance of Severe Right Heart Strain is common during arrest, but when it persists AFTER ROSC, you must think Massive PE!

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A 17-year-old boy was rushed to the ER by his brothers struggling to breathe...

[thread] He was in profound respiratory distress with deep retractions breathing 40 times per minute. It turns out he was a severe asthmatic in the midst of the worst asthma attack of his young life.

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Watch this great video showing the Modified Valsalva Maneuver converting a patient in SVT to Normal Sinus Rhythm

If you’re not doing this, you’re not doing SVT right!

Video courtesy: @julesantosER
#FOAMed

In the REVERT Randomized Controlled Trial the success rate was 43% vs. 17% for the standard Valsalva Maneuver!

Read about it here: ncbi.nlm.nih.gov/m/pubmed/26314…

Hi, ER Doc here.

Opioids like Heroin and Fentanyl kill because they stop people from breathing.

[thread]

https://twitter.com/lynnelyman/status/1150262201749426176

Narcan is the opioid antidote. It works by blocking the effects of these drugs at the receptors. So when you give it to people who have overdosed, they will typically wake up and resume breathing...

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I recently had a patient who presented in profound acute renal failure with a BUN of >200, creatinine of 13.5, and critical pH of 6.7, on the brink of death...

[thread] The only reason he was still alive is because he still had a strong enough respiratory drive to blow his CO2 down to almost nothing!

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This is the bedside Echo of a critically ill young lady who presented to the ER in shock

[thread] Those bright, whip-like structures emanating off the tricuspid valve are infective vegetations. They look similar to blood clots-in-transit except that instead of free floating you can see that they are tethered down.

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Here’s an Echo of a man who was in persistent PEA after multiple rounds of CPR per ACLS

You can see his heart collapsing and struggling to beat as it is being smothered by surrounding fluid.

This is Pericardial Tamponade!

<thread> Once you have diagnosed a coding patient with Pericardial Tamponade you have 2 options:

A) You can keep doing ACLS for a while and then call the code

B) You can remove pericardial fluid and save your patient’s life

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External Laryngeal Manipulation

1. Move the Laryngeal Prominence (Adam's Apple) around with your free hand until your view is optimized

2. Have an assistant hold it there while you pass the tube

It’s amazing how much this can improve your view!

<Thread> The reason External Laryngeal Manipulation (ELM) is so effective is that it allows real-time visual feedback to the intubator who finds the precise direction and force required on the thyroid cartilage to optimize their laryngeal view!

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Check out this amazing pictorial showing the relative flow rates of various intravenous catheters. The numbers represent how long in minutes it takes for each catheter to deliver one liter of saline under 300 mmHg of pressure!

<thread> So the catheters are positioned above in order from fastest to slowest going left to right.

Here is a chart listing the catheters from fastest to slowest going top to bottom with their respective infusion times to the second.

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