Imposter Syndrome, ED Crowding, Unequal Pupil

In Episode 3 of APP EM Ready, we tackle three challenges every emergency medicine clinician faces — imposter syndrome, emergency department crowding, and a high-stakes case of an unequal pupil.

We start by addressing imposter syndrome in emergency medicine — that feeling of self-doubt that can creep in during difficult shifts, high-acuity cases, or early in your career. We discuss why it happens, how common it is, and practical strategies to build confidence and clinical resilience.

Next, we dive into emergency department crowding — a daily reality that impacts patient care, decision-making, and provider well-being. We explore actionable approaches to maintain efficiency, prioritize safely, and stay calm when the department feels overwhelming.

Finally, we walk through a real-world case of an unequal pupil — a potentially life-threatening presentation. We break down the differential diagnosis, key exam findings, and how to approach this situation with clarity and confidence.

Whether you're a new clinician or a seasoned provider, this episode will sharpen your thinking and strengthen your confidence in the emergency department.

Transcript

SPEAKER_00 0:14

Have you ever had a patient who looked completely stable, and then hours later you realized something important was evolving, or walked out of a ship thinking about the one case you might have approached differently? Emergency medicine is full of moments where we are forced to make decisions with limited information, constant interruptions, and real consequences. This podcast is about those moments.

SPEAKER_01 0:35

Welcome back to APPEM Ready, where we help advanced practice providers build confidence, think critically, and thrive in emergency medicine. Today we're talking about something that almost every APP experiences at some point. Imposture syndrome in the emergency department. You walk into your shift, you look at the board, high acuity patients, complex complaints, and a packed waiting room. And then that thought creeps in. Am I really ready for this? If you've ever had that thought, you're not alone. Imposture syndrome is incredibly common in emergency medicine. Whether you're a new graduate, transitioning specialties, or even years into practice, it happens because emergency medicine is different. You're making rapid decisions, you're balancing risk, you're often working with limited information, and sometimes making high-stakes decisions in minutes. Even experienced providers still second guess themselves. They ask colleagues for input. They replay questions after their shift. And here's the important part. That's not weakness, that's good medicine. Imposter syndrome often looks like second guessing your decisions, feeling like you don't know enough, comparing yourself to more experienced colleagues, worrying about missing something serious. Sound familiar? Here's the truth. Confidence in the ED doesn't come from knowing everything. It comes from knowing how to think, how to recognize risk, and when to ask for help. Here are three quick strategies to manage impostor syndrome. First, normalize it. Almost every APP has experienced imposture syndrome. Even experienced physicians still consult colleagues. Emergency medicine is a team sport. Second, focus on safe decision making, not perfection. You don't need to know everything. You need to recognize sick versus not sick, identify red flags, and escalate care when needed. Third, build confidence through repetition. Every shift, every patient, every case builds experience. Confidence grows quietly over time. And remember, if you care enough to worry about doing a good job, you're already on the right path, because the most dangerous provider isn't the one who questions himself, it's the one who never does. So if you've ever walked into the ED feeling unsure, if you've ever replayed a case after your shift, if you've ever wondered whether you belong, you do. Imposter syndrome doesn't mean you're not capable, it usually means you're growing, and growth is exactly what makes great emergency providers. Now let's continue with discussing systems in the ED. Why is the emergency department always full? Have you ever walked into the emergency department and wondered why is it always full? It doesn't matter if it's Monday morning, Friday night, or even a holiday. The waiting room's packed, ambulances are lining up, patients are boarding in the hallways. So what's really going on? Today let's break down this into three key reasonings boarding throughput and hospital bottlenecks. First, boarding. This happens when a patient is admitted to the hospital but there's no inpatient bed available. So what happens? They stay in the emergency department, sometimes hours, sometimes for an entire shift, sometimes even longer. Now imagine this. If twenty patients are admitted and they're stuck in the ED waiting for beds, that's twenty rooms that can't be used for new patients. And then suddenly the waiting room grows, ambulances hold patients, care slows down. Boarding is one of the biggest reasons that the emergency department stays full, even when patient volume isn't high. Next is throughput. Throughput is how efficiently a patient moves through the emergency department from door to triage, triage to room, room to provider, provider to disposition. Every step matters. If labs take longer, if imaging is delayed, if consultants take time, everything backs up. Think of it like traffic. If one lane slows down, it causes miles of traffic jam. And in emergency medicine, small delays quickly turn into big ones. Improving throughput means faster triage, efficient evaluations, clear decision making, early dispositioning planning. Even small improvements can make a big difference. Finally, hospital bottlenecks. The emergency department does not operate in isolation. It is connected to the entire hospital. If the inpatient units are full, if discharges are delayed, if staffing is limited, patients can't move upstairs. And when patients can't move upstairs, they stay in the ED, which brings us right back to boarding. This is why emergency medicine is dealt with crowding and rarely is just an ED problem. It's a hospital wide issue. The bottom line is the emergency department is always full. It's because of boarding, throughput delays, hospital bottlenecks. Until we address all three, crowding will continue. Understanding this helps us do two things. First, reduces frustration, and second, focus on solutions because improving patient flow improves patient care, and at the end of the day, that's what emergency medicine is all about. Now let's talk about a case discussion. This is a case that it's a reminder that sometimes the most dangerous patients do not look sick at all. A middle-aged man presents to the emergency department after noticing that one of his pupils looks slightly different than the other. He feels completely fine, no headache, no neck pain, no trauma, no visual changes, no weakness, no numbness, no dizziness. He only notices that his right pupil looks different in the mirror. His past medical history none. Medications none. Nonsmoker, no alcohol, exercises regularly. On arrival, vital signs are completely normal. He is normal tensive, apebrile, and not tachycardic. You perform a neurological exam. Everything is normal. Strength is normal. Sensation is intact. No facial droop. Speech is normal, no ataxia. But you do notice something subtle. Right sided anisocoria. His right pupil is smaller than the left. You check extraocular movements. They're normal. No diplopia. No tosis. No cranial nerve three palsy. Pupils both react equally to light. The patient looks well, really well. This kind of patient can easily be dismissed. But subtle findings matter. You obtain a CT of his head. It is negative. At this point, some clinicians may feel reassured, but something doesn't feel right. Isolated anasecoria in a middle-aged man with no prior history deserves further evaluation. So you order a CT angio of the head and neck. And this is where the case takes a turn. CT angiography reveals a right internal carotid artery dissection. There is high grade narrowing in the distal cervical portion along with focal medial outpatient pouching consistent with a dissecting aneurysm. More concerning, there is near complete occlusion distally involving the proximal portion. This patient looks completely fine, is at high risk for a stroke. What this patient is demonstration is partial horner syndrome caused by internal carotid dissection. Carotid dissection may disrupt sympathetic nerves running along the internal carotid artery. This results in anasochoria, mildosis, and sometimes facial anaurosis. Here's the key teaching point. Pain is not often required. We associate carotid dissections with severe headache or neck pain, but 10 to 20% of patients may present painless, and sometimes the only clue is slight anisocoria. This is why isolated anasochoria should never be dismissed, because carotid dissection is one of the leading causes of strokes in young middle-aged adults. This patient is omitted, neurology consulted, and anathrombialic therapy was initiated to reduce stroke risk. Fortunately, in this case, the diagnosis was made before neurological deficits developed. But without imaging, this patient could have been easily discharged and hours later returned with a devastating stroke. Here's the takeaway from today's case. Not all dangerous neurological presentations look dramatic. Sometimes the only sign of an impending stroke is a slightly unequal pupil. Always reassess, always trust subtle findings, because compensated patients look fine until they don't. Thanks for listening. Check out my website at ap emready dot com. Stay confident, stay prepared, stay APP EM ready.