Two nurses, one of them still in training, were responsible for 16 emergency room patients, including a baby with RSV who needed to be transferred. Molly Murray, a physician assistant in emergency medicine, says that was her last shift. She says the baby, in all likelihood, should have been one-to-one, and that administration said, “Well, technically there are two of you, so this seems like a fair staffing ratio.” She says it wasn’t, because one of the two was still in training. What else she says the nurses were juggling on the same shift: Patients asking for medications, water, and discharge paperwork, some of them yelling at the nurses. Two ICU holds, one of them a GI bleed. Consultants to talk to, orders to carry out, and blood products to pick up. Hours of documentation after the shift was over. What does your unit get when the nurses call administration for help? Listen to the full conversation on The Podcast by KevinMD. Link in the replies. Search "The Podcast by KevinMD" wherever you listen to podcasts. #EmergencyMedicine #ThePodcastbyKevinMD

Her descending aorta, normally about 2 centimeters, was down to 4 millimeters. The first physician to listen to her abdomen in four years of symptoms was in an ER. Victoria Rundus, MD, a board-certified pediatrician in middle Tennessee, tells it from the patient side. Her symptoms started in late 2021 with back pain, neck pain, and stiffness. Then came malaise, tachycardia, dizziness, a burning sensation in her back when she stood up, and colicky abdominal pain. An orthopedist and later a rheumatologist saw her. She was diagnosed with fibromyalgia, which she did not accept. Fibromyalgia is a real condition, she says, and those patients deserve good medical care. But she feels that diagnosis sometimes closes the door to everything else. Then an ER physician listened to her abdomen and discovered a bruit, and sent her on. She was later diagnosed with Takayasu’s arteritis, an autoimmune inflammatory condition of the large vessels. On the diagnosis itself, Rundus says labs are not typically helpful, and her CRP and sed rate were normal. It is usually found by CT scan, PET scan, or CT angiogram. She learned in medical school that it mostly affects Asian women in their 20s and 30s, and she fit neither demographic. She also had claudication and did not recognize it, because ankylosing spondylitis already limited how far she could walk. "I wonder how long I had the bruit and no one had listened." She is careful about where she puts the blame: "It’s not that there are bad physicians out there. We are all victims of this diagnostic bias." Her take-home for clinicians: "Although we usually do see horses, we have to always keep an open mind to those zebras." Of the ER physician who finally listened, she says she appreciates the time she took "to not only listen to what I was saying, but also literally listen to me." What is one symptom a patient mentioned in passing that changed your next question? Listen to the full conversation on The Podcast by KevinMD. Link in the replies. Search "The Podcast by KevinMD" wherever you listen to podcasts. #DiagnosticBias #ThePodcastbyKevinMD

A flight’s medical kit held epinephrine only at the strength used for cardiac arrest, in a device the doctor who answered the call had never used. Samara Friedman, MD, a pediatric orthopedic surgeon in private practice, was on a long flight when the call came: is there a doctor on board? A 20-year-old college student had eaten the meal, found nuts in it, and could not find her auto-injectors. A nurse had already given her an allergy pill. When that did not help, the nurse said, "Maybe it’s a panic attack. Why don’t you sit down, relax, and see how things go?" Dr. Friedman took a history. The student’s throat was itchy, her nose was running, her pulse was fast. No hives and no wheezing, and nobody could say yet whether it was anaphylaxis. Her reasoning is worth saving. If it was anaphylaxis and went untreated, the ramifications could be disastrous. If it was a panic attack, the cost was a painful shot with minor side effects. With limited resources on an airplane, she says the right call was unquestionably to give the epinephrine. The flight kit did have epinephrine, but not in an auto-injector and not at a concentration meant for anaphylaxis. It was the cardiac arrest kind, in a device she was completely unfamiliar with. "I had to MacGyver this epinephrine." She got it into a needle and syringe and converted the dose herself. The injection came out to about 10 times the volume of an auto-injector, because the concentration was 10 times more dilute. Within minutes the itchy throat and runny nose resolved and her pulse returned to normal. Her point is the system, not the rescue. In a flight of 300 or 400 people, she says, there are at least three or four who cannot eat the food. She says an airline could afford auto-injectors: "They probably prefer not to, and they just push that off to you, the doctors that have to deal with it when the issue arises." As an orthopedic surgeon she uses maybe three or four medications in her practice, and she says she would not have known the proper anaphylaxis dose offhand without a personal reason to know it. An auto-injector, she says, could be used by a flight attendant, a paramedic, or a nurse. What should an airline medical kit hold so that anyone on board can use it? Listen to the full conversation on The Podcast by KevinMD. Link in the replies. Search "The Podcast by KevinMD" wherever you listen to podcasts. #FoodAllergy #ThePodcastbyKevinMD