Emergency physicians have the lowest rate of practice ownership among specialties, per the American Medical Association 2020 Physician Practice Benchmark Survey. Only 27.9 percent of emergency physicians reported having an ownership stake in their clinical practice.   For nearly three-fourths of U.S. emergency physicians who are non-practice-owners, working conditions are determined through negotiations between employees and employers. Evidence is accumulating that those negotiations are going poorly.  The Medscape Physician Burnout & Depression Report 2024 showed that emergency ..read more

A 68-year-old man presents to the emergency department (ED) with altered mental status and fever. Vital signs on arrival are: Temperature: 38.8 degrees Celsius Heart rate:128 Blood pressure: 74 over 48 Respiratory rate: 10 Oxygen saturation: 77 percent Physical examination was notable for lethargy and confusion. He has an absent gag reflex. He has a Class I Mallampati view and lung sounds were diminished in all fields. How Should His Airway Be Managed? A study in the February issue of Annals conducted a meta-analysis of 18 studies and concluded that bougie use was associated with increased f ..read more

By late 1988, 11 Black women had been found dead in the same area of Miami with low levels of cocaine in their blood. Forensic pathologist Dr. Charles Wetli of the University of Miami had conducted autopsies that he said, “conclusively showed that they have not been murdered.”1,2 He attributed their deaths to a female-specific manifestation of the mysterious phenomenon he had identified in men who had also died after consuming less-than-lethal amounts of cocaine. Antoinette Burns was the twelfth victim, a 14-year-old girl without any evidence of cocaine consumption at all. At the urging of her ..read more

A 33-year-old woman presents with confusion, abdominal pain, and fever. Her vital signs are: Blood pressure of 118 over 93 Heart rate of 120 Respiratory rate of 18 She has a history of lupus. CBC shows a thrombocytopenia of 27 x 109/L platelets. What is the best management of this condition? For six decades, the pentad of fever, thrombocytopenia, hemolytic anemia, renal injury, and neurological manifestations has remained the classic clinical diagnostic criteria for Thrombotic Thrombocytopenic Purpura (TTP).1 Unfortunately, fewer than 10 percent of patients present with this constellation of ..read more

An abdominal aortic aneurysm (AAA) develops with age, occurring primarily in those older than 55 years. Risk factors include smoking, hypertension, male sex, atherosclerotic disease, and family history of AAA. Although AAA is less common in women, rupture is more common.1 Most aneurysms are less than 4 cm, with the normal diameter of the aorta less than 3 cm. When the aneurysm is greater than 5 cm, there is a risk of a rupture, which increases with increased aortic diameter. The classic triad of abdominal pain, hypotension and pulsatile abdominal mass is present in less than 25 percent of pati ..read more

Post-arrest patients with more significant reperfusion injury (for example, Pittsburgh Cardiac Arrest Category (PCAC) greater than or equal to 3, revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia score (rCAST) greater than 6, evidence of shock, and/or longer arrest times) may benefit from mild hypothermia to 33 degrees Celsius, while less severe post-arrest patients may benefit from fever prevention at less than 37.5 degrees Celsius. How Did We Get Here? Targeted temperature management (TTM) for patients following cardiac arrest resuscitation has gone through several dosing iter ..read more

“How bad could it be?” was the last thought before I took a small bite of the Carolina Reaper pepper I had grown in my (toxicology-required) garden. “Am I going to die?” was the next thought as I swigged milk to extinguish the blowtorch in my mouth, mopped sweat off my forehead, tried not to retch, and rethought recent life-choices. The Carolina Reaper pepper. The Chili Pepper Chili peppers (Capsicum species; Greek Kapto, “to bite”) are thought to have been domesticated in central and south America in about 10,000 BCE. There are five primary species used commercially and are upright annual s ..read more

An 18-year-old woman presented to the emergency department (ED) with symptoms of nausea, vomiting, diarrhea, and abdominal pain. She reported that these symptoms started two days prior, shortly after consuming a fruit known as ackee. Since the onset of illness, she had been unable to tolerate any oral intake. Before arriving at our ED, the patient sought care at an urgent care clinic, where she was prescribed ondansetron without improvement. Upon physical examination, the patient was noted to have dry mucous membranes. Abdominal exam was benign. Most pertinently, her point of care glucose was ..read more

Posterior circulation strokes make up 20 percent of all strokes but account for 40 percent of stroke misdiagnoses.1 Vertigo and dizziness are often the hallmarks, but distinguishing a central (brain) from a peripheral (vestibular) etiology is difficult. Dizziness is especially tricky, with up to 40 percent of strokes presenting with dizziness being missed.2 Vertebral artery dissection (VAD) is notoriously elusive, producing anatomically scattered symptoms that may stutter for days.3 Case 1: Posterior Stroke Presenting as Food Poisoning A 42-year-old man presents to the emergency department (ED ..read more

Every year, the volume of published research continues to outpace capacity to consume. “Gotta catch ‘em all!” may be an appealing mantra, however it is impracticable to achieve with the medical literature. The Sisyphean task remains to try to keep up—and, in that vein—here is a light round of the emergency medicine literature from 2023. How Best to Stop the Bleeding in Trauma? All bleeding stops. The delicate trick is to stop the bleeding before the patient dies, while also simultaneously not tilting the coagulation cascade too far in the direction of excessive clotting. The past decade has se ..read more