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One of the problems we have had here is that getting a Dr's app. Honestly you could wait for months (I have). Comming through emergency was a way to by pass that so we would get called. What our hospital did to help correct this was, in the morning (you have to call around 8 am) you call and ask to see the Dr. on call. The days that the on-call doc is on the appointments are kept open so you can get in that day, and if not you call the next day. As for the frequent flyiers, I know we get tired of them but there is going to be one day that they really do have an emergency and you will be caught of guard. I have a flyer and one day he was unresponsive and drunk. I did notice this time he was a bit more out of it than normal. I didnt really think he was more than drunk as all vitals were good. They did a 12 lead on him and he has a left sided bundle with bunny ears (which really dosnt mean alot as I dont read the strips) but now I will look at him alittle different. Also with the ones that just call use them as practice. Give them a good look over pretend your back in school doing your final test and after think about what you missed. I do

That's a very nice hotel with lots of food options very close and a short ride to DC on the red line... just know, North Bethesda is just the fancy name for Rockville... It's still a good bit away from downtown but not a bad METRO ride at all, and like I said close to some really good food and shopping.

It's really not (or shouldn't) be a matter of reversal agents being available for particular drugs. RSI is something you are doing because you have determined a clear need. If you are dicking around half-way through thinking about "revesing" it, then I suggest that the need wasn't there in the first place. It's no excuse for medical directors to implement half-baked protocols that are likely to cause more harm than good. Educate your medics, trust your medics or don't: there's no half way.

How do you do this? How many TAAs have you seen? In what percentage of the times that you thought you saw a TAA were you right? In what percentage were you wrong? How many patients have you evaluated who you didn't think had a TAA? How often were you right? How often were you wrong? How do you feel this compares to assessment by a ER fellow? IM / Cardiology? Can you beat U/S or mediastinial changes on CXR? How do you compare to thoracic CT? What makes you think that you can do this better than everyone else? With less education, and less technology? Physicians in the ED with a million times more experience, education and training time, and better technology miss these on a regular basis. Has it? Perhaps it has, I don't know. Or has an increase in education made us more aware of diagnostic uncertainty? Are we better able to understand the limitations and benefits of the technology available to us? I can't. I can identify clear presentations of any of these conditions, but I can't always differentiate them in a complex setting. And perhaps it's because I'm too reliant on technology, and that my physical examination and history taking skills are inferior to yours. Or possibly it's because I know that each of these diseases can occur in the presence of the other. Perhaps I also know that physical exam has limited diagnostic utility for either condition. Perhaps it's because I know that they can look almost identical in early presentations. Or perhaps it's because I know that even far better trained and educated ER physicians routinely misdiagnose CHF and pneumonia patients because even with better technology, e.g. labs, U/S, CXR, cultures, there remains a lot of diagnostic uncertainty. So, just so I understand your position -- you're a paramedic (like me). You've had (maybe) 3 years of education specific to "medicine". You've worked in an ambulance, or perhaps a fixed wing or helicopter for a number of years. And now you feel that you can better diagnose disease states than a physician with a 4-year BSc, 4-year MD, 5 year ER residency, and years of clinical practice. A physician who probably sees more patients in a shift than a medic sees in a tour, who's had extensive rotations through every medical specialty (not just 2 weeks in the OR, 2 weeks in case room, a couple of weeks in CCU, and a couple of days in NICU), and has imaging technology and the ability to get chemistry / microbiology. And you think that you're better than that? Because if you are, we should start collecting money. All of us. And we should send you to Harvard or Yale, or Columbia. you can go talk to the Dean of Medicine there, and show them what they're doing wrong. We can shorten physician training down to 3 years, sell of all the CT machines, get rid of the U/S, put all the RTs on welfare (sorry guys!), close all the medical schools, and you can show them how it's done better. I'm not going to get into the quagmire that is beta-agonists in CHF. Don't have the energy. Am J Emerg Med. 2010 Oct;28(8):862-5. Epub 2010 Mar 25. A multicenter analysis of the ED diagnosis of pneumonia. Chandra A, Nicks B, Maniago E, Nouh A, Limkakeng A. Source Department of Emergency Medicine - Duke University Medical Center Durham, NC 27710, USA. abhinav.chandra@duke.edu Abstract OBJECTIVES: The objective of this study was to describe the prevalence of pneumonia-like signs and symptoms in patients admitted from the emergency department (ED) with a diagnosis of community acquired pneumonia (CAP) but subsequently discharged from the hospital with a nonpneumonia diagnosis. METHODS: A retrospective, structured, chart review of ED patients with CAP at 3 academic hospitals was performed by trained extractors on all adult patients admitted for CAP. Demographic data, Pneumonia Patient Outcomes Research Team scores, and discharge diagnosis data (International Classification of Diseases, Ninth Revision [iCD-9] codes) were extracted using a predetermined case report form. RESULTS: A total of 800 patients were admitted from the ED with a diagnosis of CAP from the 3 hospitals, and 219 (27.3%; 95% confidence interval [CI], 24-31) ultimately had a nonpneumonia diagnosis upon discharge. Characteristics of this group included a mean age of 62.6 years, 50% female, and a history of congestive heart failure (CHF) (14%) or cancer (12%). After excluding patients with missing data, 123 patients (65%) had an abnormal chest x-ray, and 13% had abnormal oxygen saturation. Cough, sputum production, fever, tachypnea, or leukocytosis were present in 91.5% of this cohort, and 63.8% had at least 2 of these findings. Twenty alternate ICD-9s were identified, including non-CAP pulmonary disease (18%; 95% CI, 13-24), renal disease (16%; 95% CI, 13-19), other infections (9%; 95% CI, 7-11), cardiovascular diseases (3%; 95% CI, 2-4), and other miscellaneous diagnosis (28%; 95% CI, 25-31). CONCLUSIONS: Our data suggest that the ED diagnosis of CAP frequently differs from the discharge diagnosis. This may be due to the fact that a diagnosis of CAP relies on a combination of potentially nonspecific clinical and radiographic features. New diagnostic approaches and tools with better specificity are needed to improve ED diagnosis of CAP. Copyright © 2010 Elsevier Inc. All rights reserved. PMID: 20887906 [PubMed - indexed for MEDLINE]

Ah, here is the problem. You don't think you are an awesome medic nor hear the voice of god. You truly think you are god. Explains alot. Thanks for playing, your tin foil hat is waiting.