During my time at NYPQ I got to see how patients are brought into the emergency room either from the waiting room or ambulance and then triaged and placed in various areas of the hospital. I saw how a chief compliant and vitals are a starting point but cannot always be trusted and you need to start from scratch yourself and re-verify the story several times to make sure you are not missing any red flags. A lot of the emergency room is trying to decipher if there is an emergent diagnosis that requires immediate action or if this is something that should be followed up outpatient for a formal diagnosis and treatment. There is a lot of Zofran, fluids, Maalox, morphine, and Pepcid given. Most people who are placed into the main hospital will get a CBC, CMP, EKG and depending on their age and complaint troponins, lipase, lactate, and coags. It can be exhausting hearing the same story by different people, and you have to be trained to decipher between malingering and true symptoms. I was once fooled by a malingering patient who was a frequent flyer who gave a very convincing story of having a ETOH withdrawal seizure and even faked auditory/visual hallucinations, tremors (even with his tongue), and formication. I calculated his CIWA score to be 23 when it was actually a 3. Most people with a chest/abdominal complaint will get a chest x-ray and possibly a CT scan of the abdomen. Point of care ultrasound is used but is not relied heavily on due to the ultrasound service being a learning experience for residents rather than a formal report. However when they are formally ordered and completed by ultrasound technicians they are used reliably. There is a lot of hard and soft skills to be learned in the ED and I can see how a new physician assistant would need to be in a teaching hospital with a warm, accepting environment for them to have a good learning curve.
H&P_ hypoxia_hyperkalemia. pdf
