GoodOldNe

I feel for the people that get called to deal with these people. In the ED I have access to drugs that can bring people down fairly quickly if necessary, and teams of people who are used to physically restraining people without hurting them. It doesn't always work the way we want it to, but we can generally get people safe without hurting them. Cops don't have that training or context, and I have a lot of admiration for the ones that can (and many do) deal with stuff like this without hurting people on a daily basis.

Someday we'll just have ketamine blow darts. (Seriously. Maybe.)

More people should know this. There is a great piece in the Washington Post today about how a false positive result from tea bags left in the trash (which was being sifted through by Sheriff's Deputies after they saw a homeowner shopping at a gardening store, giving them what apparently passes for PC these days) led to a no-knock raid with a SWAT team holding a middle-aged couple that doesn't use drugs at gunpoint for an afternoon.

No. There are plenty of other options for treating their pain without using opioids -- first I would educate them about the relative risks and benefits of, say, acetaminophen/APAP. I could use something like intravenous lidocaine or low-dose ketamine, or if it's a traumatic type of pain some kind of regional anesthesia. If it's more neuropathic, you can use tricyclics or drugs that work on GABA pathways. Beyond all that, I try to talk to people about the harms associated with opiates/oids such as hyperalgesia that develops in many long-term users, which is a really significant and underappreciated harm alongside things like addiction and potential respiratory depression.

I have seen people in the ED with marijuana-related complaints. I can count the total number on my hands. Every single one of those patients has been absolutely fine. Am I aware of patients with marijuana-related complaints who weren't fine? Sure, a few case reports. But overall, the "dangers" of marijuana do not exist in a real sense, compared to the dangers of every other recreationally-used/abused substance out there, or compared to prescription medications, both psychotropic and not. Not even close.

According to one higher-up in the SFFD EMS, this has to do with the software used to dispatch apparatus to calls. It was designed for a two-tier response (ALS v. BLS, as is used in many other cities) but since we don't do that sort of bifurcation of dispatch, it just sends the closest rig which is often fire. Beyond being noisy, can you imagine the damage done to the SF streets by having pumpers filled with water driving on them every day, and the damage done to the apparatus which are by no means cheap?

One thing I wish this article would have touched on is what's featured in the caption to the photograph-- the ability for FD/PD to transport low-risk patients who are just drunk or high to sobering centers rather than to EDs. It's a fairly novel approach, and has made the quality of care provided to these people (and those others in the ED who actually need to be there) way better.

This sounds like a setup for badness the first time someone has bronchospasm or goes apneic when they push the full dose or aspirates their vomit. Probably not a good idea to go to your local FP or internist-- or anyone else not prepared to take over your airway for you-- for a ketamine treatment.

That said, in third year when I did my clinical rotations, I went into every rotation thinking honestly that I could see myself doing it. I am and was interested in pretty much every field (which helps in EM). If you can force yourself to step back and realize how cool much of what we do in medicine is, from a scientific or technologic perspective, and how great the trust that others place in the field and its practitioners is, I think it makes it easier to learn and succeed as a student.

Living out here in SF it's interesting to compare my past and current life to the friends I have who are involved in tech. I think similarities are the often-seen lack of work/life balance (something I think I developed over three years of working before entering medical school and I would encourage any new MS1 to prioritize thinking about), and the sometimes-overwhelming feelings of "imposter syndrome" or constantly feeling like you somehow fooled people into getting where you are, or that you don't know the things other people think you know. There's also a lot of love for the latest and greatest in technology or theoretical frameworks for understanding disease, sometimes at the expense of things that have been used for ages and that work quite effectively (tincture of time and observation for almost anything, ice for pain, physical exam for evaluation of hemodynamic status).

Tips for incoming first year -- if you're tech-savvy, or at least can touch-type, consider checking out Anki, and reading others' tips for utilizing spaced repetition in your studying. Focus on backwards planning your own curricula, using released tests or your professors' advice to get an idea of what will be tested material. Get, and do, as many questions as possible -- BRS, UWorld, NBMEs, etc. Make flashcards from the questions you get wrong. Repeat and repeat.

Feel free to ask any other specific questions, I'm a bit fried from a long shift. :-)

You get that "neurotoxicity" in this case is almost exclusively referring to deleterious effects that local anesthetics can have on nerves at the site of injection, right? Subcutaneous injection of local anesthetics will have very little, if any, involvement with your brain.

You did the right thing finding a surgeon that would work with a block instead of GA if you were concerned about the (potentially real, if not that bad, effects of GA) but I think your fears of local anesthetics causing CNS damage are overblown and I wouldn't want others to refuse the use of them in themselves or their children based on your post.

There are several companies (including a couple YC alums like Aptible) working in the helping-developers-deal-with-HIPPA space already. Creating a compliant application for transmitting ECGs wouldn't really be a new thing-- when attending an emergency medicine conference two years ago I met a physician/programmer who had done just this for both stroke and heart attack, designed and marketed as a wraparound subscription-based solution. The trick is doing it well, and if you could integrate the information with the receiving hospital's workflows (e.g. EPIC integration or something) you could sell it easier. Pictures of ECGs are also a fairly inelegant solution compared to sending it to the ECG printers that a receiving hospital has, or sending the actual waveform data, but for rural/underfunded EMS agencies it would be nice.

(FWIW, I work in a Bay Area emergency department that is a STEMI receiving center but does not receive field-transmitted ECGs prior to arrival. There's room to work on this stuff. If anyone wants to do research relating to it or build a system and then let me do research with it, get in touch.)