Expectations on Paul Nystrom

False Expectations

Wed, 25 Mar 2026 00:00:00 +0000

“Life is pain, Highness.” — Dread Pirate Roberts, The Princess Bride

“Suffering is a precondition for existence.” — Jordan Peterson

It’s not realistic to believe you will go through life without any pain, hurt, illness, or discomfort. It’s also not realistic to expect that the ER can immediately eliminate those symptoms whenever you decide it’s time. The body simply doesn’t work that way. Healing takes time.

I frequently see patients who have broken a bone and explain that bones generally take about six weeks to heal. That’s a general rule, of course, and it varies somewhat depending on the patient and the injury. My youngest daughter broke her collarbone when she was a toddler. I have a video of her doing the “wheelbarrow” just two weeks later with no apparent discomfort. If you’re older or in poor health, however, six weeks may not be enough. There is very little that Big Medicine can do to meaningfully speed up that natural process.

The ER and Porn

Tue, 07 Oct 2025 00:00:00 +0000

Lately, I think the ER is, in many ways, the same as porn. Porn overpromises and underdelivers. In a twisted sort of way, the ER does the same thing. That’s not because I think we do bad work in the ER—in fact, I think we do amazing work as we try to solve all the ills of society and all the problems in the medical system that arise when clinics are closed (the vast majority of the time—e.g., evenings, nights, weekends, and holidays). Do the math: If most clinics are open from 8:00 a.m. to 5:00 p.m., Monday through Friday, how many total hours per week are they open compared to how many hours per week they are closed? The majority of the time, we are the only game in town.

Bell Curve

Sat, 06 Sep 2025 00:00:00 +0000

My job is to reassure people that their symptoms are not too far outside the norm, or the “bell curve.” Most patients don’t understand what the bell curve means, but when their illness or injury doesn’t progress as expected, I reassure them that their condition is within one to two standard deviations from the mean.

For example, an 80-year-old woman had been dealing with upper respiratory infection (URI) symptoms for over ten days. She visited the clinic and was started on antibiotics for a possible sinus infection and prednisone for wheezing (i.e., reactive airway disease). The prednisone improved her symptoms, but she reported that her previously prescribed albuterol didn’t seem to help. This piece of history is sometimes revealing because, although the patient may not always remember, someone prescribed that medication in the past, suggesting she likely had similar symptoms before. As a provider, it’s reassuring to know the patient has experienced this condition previously.

MRIs in the ER

Sat, 06 Sep 2025 00:00:00 +0000

There are only 2 MRIs that typically need to happen in the ER. Brains and spinal cords. There are virtually no extremity MRIs that have to happen emergently. I see patients regularly that have things that could be diagnosed on an MRI… rotator cuff tears, meniscus injuries, torn ACLs. But none of those things need emergency surgeries so they don’t need emergent MRIs. Patients often come to the ER within minutes of a knee injury and they may very well have a torn ACL. But I don’t have to find it immediately. No Ortho surgeon is rushing to the ER to fix it. You would not want them to in most cases. For things like rotator cuff tears and minor tendon or ligament tears, the first line of treatment is physical therapy and pain medicine. This is referred to as “conservative therapy”. Most of the time, this resolves the problem. Surgery is something to consider when conservative therapy fails. It is not the thing that has to happen immediately upon finding an injury.

Expectations

Sat, 23 Aug 2025 00:00:00 +0000

I often reach the end of an ER visit without a definitive diagnosis, which is not uncommon for complaints like dizziness, chest pain, or abdominal pain. I explain to the patient all the emergency and serious conditions we’ve ruled out and clarify that I don’t have an exact answer. Patients are often incredulous that I don’t have all the answers.

On one hand, I could feel proud that they think I know so much. They are extremely confident in my abilities and assume I represent the best of medicine. While this seems like a compliment, it doesn’t make me feel better because I know it’s not true. If the ER had definitive answers for every condition patients present with, there would be no need for other specialties. No one would ever need to see a specialist in a clinic if the ER had all the answers.