If you go to the ER expecting to see a specialist, go during the day. Your odds are a little better than at night. Very rarely do specialists come to the ER in the middle of the night. The rest of Big Medicine—besides the ER—does not really operate 24/7. Yes, at large hospitals, there are always many specialists on call. But it takes a real emergency for them to actually come to the ER.

These are not the same thing, although they are often confused. Generally speaking, surgery involves cutting into the body to repair, remove, or readjust tissue or organs. A procedure, on the other hand, can involve looking into the body but usually does not involve making a new incision. Any intervention is most often carried out through a naturally occurring orifice.

Appendectomy, cholecystectomy, craniotomy, and total hip/knee arthroplasty are all examples of surgeries. Surgeries are performed under sterile conditions in the operating room. They usually involve general anesthesia, which includes placing a breathing tube in the trachea.

Even if you don’t have high medical literacy, at least have some situational awareness. When I ask you about a recent admission, at least be able to tell me the highlights. When I ask about past medical history (PMH), please don’t start with… “In 1999 I had…” The farther away the thing was, the less important the details are. Of course it’s important to know you had a heart attack and had stents placed 20 years ago. What I DON’T need to know is who did it, the exact date, all the details of your ER visit and hospitalization, or what meds you were started on at that time.

Hypertension (HTN) in the ER is one of the least interesting things we deal with. Through many discussions with colleagues, this is a fairly universal sentiment among ER doctors. There are very few conditions in which we need to immediately lower a patient’s blood pressure. Aortic dissections, hypertensive emergencies, acute strokes, acute coronary syndrome, and preeclampsia are about the only ones that come to mind. These are referred to as “end-organ damage,” i.e., the HTN is actually causing an acute issue damaging the brain, heart, or kidneys, and it needs correcting.

Very frequently, when asking patients about their medical problems, they will tell me the name of their specific provider. Sometimes this is a primary care provider; sometimes it’s a specialist. Their tone suggests that they assume I know who they’re talking about.

Me: What other medical problems do you have?

Patient: I see Dr. Johnson—you know, across the street—for my heart stuff. He did my angiogram last year.

Me outloud: OK.

I believe that chiropractors bring something to the table that Big Medicine doesn’t. In my ER, when a patient is diagnosed with back pain, the medical record prompts me at discharge to order consults to physical therapy (PT) and chiropractic. Both are valid options.

I’ve had episodes of severe torso pain—sometimes in my ribs after a collision during ultimate frisbee, sometimes a tightness between my shoulder blades or in my lower back. Sometimes this happens with no apparent injury or trauma. I distinctly remember some severe episodes of low back pain during medical school that would happen when bending over a drinking fountain. My back would become very tense with severe pain for no apparent reason. It was very painful, but these episodes never lasted for more than a few days.

My only incentive to do less for a patient is because it’s the right thing to do.

A common example is upper abdominal pain most likely from severe gastritis or acid reflux. Patients just can’t believe that their stomach hurts that badly from something like that. They often have a history of acid reflux, but this episode feels different to them. It is lasting longer than usual or is more severe.

I think that’s one of the hardest things for patients to understand. Kids in particular have a hard time with this. I had to relocate a dislocated shoulder for a 15-year-old girl who was in a lot of pain. She had dislocated her shoulder during swimming practice. She was very anxious, but she was also very anxious about us placing an IV or giving her pain medicine before we pulled on her shoulder. Her shoulder was clearly hurting. The sooner we can get it back in place, the better.

The purists would argue about these two terms and get wrapped around the axle. TRF is technically a version of IF. There are no definitive long-term studies that prove which IF or TRF protocol is the “best.” Being a purist is not necessary, although calorie restriction and IF are not the same.

We evolved in a world of feast and famine. (Famine is fasting, but not by choice—i.e., starving.) We now live in a world of only feasting, with groceries within blocks, a fridge/freezer in your kitchen, another freezer in the basement, and a beer fridge in the garage. There is no shortage of food in our modern environment, but that does not mean feasting without fasting is normal.

Do you have any medical problems?

I ask patients this question frequently. Some immediately get irritated with me and tell me to “just look in the computer.” And as with every patient, I do look in the medical record regarding their prior medical problems, recent clinic/ER visits/hospital admissions, and medications. However, asking the question tells me a lot about how tuned in they are to their medical problems, and it gives me some idea of their medical literacy. Their involvement and degree of concern about their medical problems often figure into whatever is going on.