Case - mouth bleeder

SDN Members don't see this ad. (About Ads)

Saturday, 5am, ENT team pages for an urgent case.

The patient is 54, long history of smoking, CAD with drug-eluting stents 4 and 15 months prior, bleeding from his tongue x 2 hours at home. He has known squamous cell carcinoma, left tongue base, had a radical neck dissection 4 months before, follow-up biopsied 6 days ago. Since then, some off-and-on oozing but this is pretty steady and ENT wants to do microDL and cauterize the source, which they think is arterial. Guy takes aspirin, plavix, ACE inhibitor, and took all of these yesterday AM.

When he got to the ED 2 hours ago, HR was in 100's and BP normal. They trickled in a liter or two of NS through a 18 gauge PIV, sent some basic labs.

He comes to the OR, sitting up, spitting clots into a kidney basin. He had a Yankauer and suction down in the ED, but not during transport to the OR, and now is asking "can I have the sucker back?" Won't lay supine, "I feel like I'm choking if I lay flat." Vomits up about 50ml fresh blood. Looks pretty pale. First vitals HR 152, BP 56/33 sat 99%. He's a MP1, oral cavity fairly blood stained but nothing pumping/oozing in there that you can see with the naked eye, normal teeth, jaw protrudes normally, but head extension stinks, "this neck scar is so tight I can't tilt my head back."

Your plan, doctor? Anything else you'd like to know or do before your anesthetic?

Keep him breathing until ENT gets there. Get a 16g that flows like Niagra Falls. Hang some blood. Look at the old anesthesia record and see if he's an easy DL before the radical neck. DID HE GET RADIATION TO THE NECK?

2 options: Pent, sux, tube or awake intubation (fiberoptic or glidescope). ENT at bedside if you get into trouble.

good airway exam, keep him sitting up, induce and lay flat, first look is the best look, followed by ENT look and/or retrograde wire. i wouldnt mess with awake FOI in the hemorrhagic airway

Originally Posted by Idiopathic

good airway exam, keep him sitting up, induce and lay flat, first look is the best look, followed by ENT look and/or retrograde wire. i wouldnt mess with awake FOI in the hemorrhagic airway

Idio, I agree with what you are saying but I've been told retrograde takes a while to do in real life (I've only done it on a mannequin). Can you comment on that?

My approach would be similar to yours except I would want to have the neck prepped and ENT ready to do a quck trach if needed. I realize he's had a neck dissection before, but hopefully his mid-line anatomy hasn't been disturbed.

Obviously as others have said, also get blood and better access first (if possible). Inducing a 54 year old guy with a BP in the 50s and heart rate in the 150s and history of CAD seems like a setup for a post-induction arrest no matter what agent you use. For now he seems to be maintaining his sats, so it buys a little bit of time to give blood, even if it is only through the existing 18 ga. and under a pressure bag.

Definitely an interesting case. I can only comment based on the information I have. I would love to hear what was actually done and the outcome.

agreed. FOI with all that blood? Not likely. You could awake retrograde too...

Order blood, pre-oxygenate, hang fluid, add access (you're going to say he's a former IV drug abuser, right?).

ENT in room for induction. I generally favor the awake FOBI in the seated patient (have done a couple seated, anterior-approach Glide intubations), but agree that the hemorrhage this can be a time-waster. That said, we've all been fooled by MP1 exams in patients with previous XRT to the neck. Assuming he's thin and assuming the ENT is there with knife in hand, I'd induce upright (midaz, succ, norepi).

The decision trees here, though, are going to be:

1) how long you'll struggle with difficult additional access (not long if your 18 is servicable),
2) how long you'll wait for RBCs to arrive prior to going to OR (this is tougher; he's already in profound shock but I'd be tempted to resuscitate before induction. You'll inevitably run into the whole chicken/egg thing with the surgeons: He's in shock because he's bleeding, so it's stupid to wait if we can STOP the bleeding in the OR vs the high mortality of inducing a shocky, bleeding patient prior to adequate resuscitation. If he's really 150s and 56/33, he gets a couple litres and, I hope, some RBCs beforehand.
3) the aformentioned airway issues.

How'd it go?

Agree. Start blood, suction, RSI with ENT at bedside ready to trach. You wouldn't see past the tongue using a FO with all that blood.

Just curious, would anyone consider an awake look with DL after suctioning? And if it didn't look like pt was easy to intubate, ask ENT to do an awake trach?

Originally Posted by Metalblade

Agree. Start blood, suction, RSI with ENT at bedside ready to trach. You wouldn't see past the tongue using a FO with all that blood.

Just curious, would anyone consider an awake look with DL after suctioning?

I've done this on more than one occasion. Particularly with a glidescope. Tremendous amount of information can be had with this approach.... You see cords... you can push the sux with full force and confidence. If you don't see much... prep the neck and consider prophylactic trach (although that would be kinda crazy for a toungue lac).

If you do see the goal within punting range with an awake look... might as well place some PVC while you're there.

I wouldn't assume that he's intubatable based on an airway exam, after a radical neck, and with the limited ROM seen on exam, XRT or no.

With a tongue base lesion, any instrumentation of this airway, gentle or not, is surely going to make the bleeding worse. Induction --> DL would not be my plan A. I'd consider a gentle awake look with a Glidescope, or possibly a nasal FOI look, recognizing that the FOI is probably doomed by a bloody oro- and hypopharnyx. But these are things that can be done quickly while IV access is improved and blood is obtained.

From the story (2 hours of goofing off in the ED) and vitals he's surely lost a lot of blood, but it doesn't sound like he's bleeding FAST, so you may have time to resuscitate him and get blood going. I might try a couple hits of phenylephrine as the fluids are getting ready; although he's mentating OK that heart can't be liking his HR and BP.


I'm not convinced there's a time-critical airway-securing emergency here.

I think he can sit there with the Yankauer until he's had some blood and his HR is below 100 and his SBP is above 100. Getting freaked out and rushing into an ill-advised stat intubation attempt is what other specialties do.

Are you using Cetacaine spray to topicalize prior to awake look with the Glidescope? If not, how do you like to do it?

Also, this guy may be really tough to get additional access given his degree of hypovolemia from the hemorrhage. He's got an 18g in place, why not put a wire in it and upgrade to a RIC?

I guess the risk would be losing his one IV but you could have the ability to dump volume in in a matter of minutes. Never done it but have often thought about it.

Originally Posted by SexPanther

Are you using Cetacaine spray to topicalize prior to awake look with the Glidescope? If not, how do you like to do it?

Also, this guy may be really tough to get additional access given his degree of hypovolemia from the hemorrhage. He's got an 18g in place, why not put a wire in it and upgrade to a RIC?

I guess the risk would be losing his one IV but you could have the ability to dump volume in in a matter of minutes. Never done it but have often thought about it.

If someone else got an 18 in him, I'm confident I can at least get another 18 if not a 16. I definitely wouldn't attempt to lose my only IV access by messing around with trying to wire a RIC in through it.

Originally Posted by pgg

I wouldn't assume that he's intubatable based on an airway exam, after a radical neck, and with the limited ROM seen on exam, XRT or no.

With a tongue base lesion, any instrumentation of this airway, gentle or not, is surely going to make the bleeding worse. Induction --> DL would not be my plan A. I'd consider a gentle awake look with a Glidescope, or possibly a nasal FOI look, recognizing that the FOI is probably doomed by a bloody oro- and hypopharnyx. But these are things that can be done quickly while IV access is improved and blood is obtained.

From the story (2 hours of goofing off in the ED) and vitals he's surely lost a lot of blood, but it doesn't sound like he's bleeding FAST, so you may have time to resuscitate him and get blood going. I might try a couple hits of phenylephrine as the fluids are getting ready; although he's mentating OK that heart can't be liking his HR and BP.


I'm not convinced there's a time-critical airway-securing emergency here.

I think he can sit there with the Yankauer until he's had some blood and his HR is below 100 and his SBP is above 100. Getting freaked out and rushing into an ill-advised stat intubation attempt is what other specialties do.

Just be careful topicalizing his airway with the lidocaine as it is very vascular and you can run into an issue of absorption and seizures. This happened to me once after an ER attending tried many brutal attempts at an intubation in a known difficult airway that was discovered when I looked at a band on the patient.

First resuscitate the patient properly, replace volume and fix the BP.
Then ask yourself the following 2 questions:
1- Can I ventilate this guy?
2- Can I intubate this airway?
Actualy the answer to question 2 is irrelevant!
If the answer to 1 is yes, which appears to be the case here, then do not waste time, just induce GA and do DL or use your favorite video laryngoscopy device, if you can't intubate just place an LMA and ask them to do a tracheostomy.
If the answer to question 1 is no because of some anatomical challenge then an awake tracheostomy is your best approach.
But remember your priorities are to first resuscitate the patient and correct the hypotension and second to try have an intelligent plan to secure the airway without killing the patient.

Originally Posted by sevoflurane

I've done this on more than one occasion. Particularly with a glidescope. Tremendous amount of information can be had with this approach.... You see cords... you can push the sux with full force and confidence. If you don't see much... prep the neck and consider prophylactic trach (although that would be kinda crazy for a toungue lac).

If you do see the goal within punting range with an awake look... might as well place some PVC while you're there.

So this guy wouldn't lie flat based on the prior post...do you do an awake DL with glidescope while he is sitting up??

Yep. That's an easy problem to get around if you are not a tall dude. Get some step ups or lower the bed.

Anyone thought that maybe this guy isn't simply bleeding from the biopsy site? Anyone think that possibly he has a vascular lesion secondary to his neck dissection or perhaps eroded tumor that is bleeding? Just a thought when I read the story combined with the vitals.

Originally Posted by fakin' the funk

Your plan, doctor?

Propofol, Fentanyl, Pancuronium.. bag with iso until the pan kicks in.. blind nasal intubation. If it doesnt go in first try, keep fiddling around its sure to go in.

Also consider giving dec early so dont have to worry about airway edema when you pull that tube deep.

Originally Posted by RxBoy

Propofol, Fentanyl, Pancuronium.. bag with iso until the pan kicks in.. blind nasal intubation. If it doesnt go in first try, keep fiddling around its sure to go in.

Zippy?

Originally Posted by RxBoy

Propofol, Fentanyl, Pancuronium.. bag with iso until the pan kicks in.. blind nasal intubation. If it doesnt go in first try, keep fiddling around its sure to go in.

Also consider giving dec early so dont have to worry about airway edema when you pull that tube deep.

Are you serious?

Originally Posted by cchoukal

Zippy?

pent/sux/tube? Where's urge?

Originally Posted by fakin' the funk

Saturday, 5am, ENT team pages for an urgent case.

The patient is 54, long history of smoking, CAD with drug-eluting stents 4 and 15 months prior, bleeding from his tongue x 2 hours at home. He has known squamous cell carcinoma, left tongue base, had a radical neck dissection 4 months before, follow-up biopsied 6 days ago. Since then, some off-and-on oozing but this is pretty steady and ENT wants to do microDL and cauterize the source, which they think is arterial. Guy takes aspirin, plavix, ACE inhibitor, and took all of these yesterday AM.

When he got to the ED 2 hours ago, HR was in 100's and BP normal. They trickled in a liter or two of NS through a 18 gauge PIV, sent some basic labs.

He comes to the OR, sitting up, spitting clots into a kidney basin. He had a Yankauer and suction down in the ED, but not during transport to the OR, and now is asking "can I have the sucker back?" Won't lay supine, "I feel like I'm choking if I lay flat." Vomits up about 50ml fresh blood. Looks pretty pale. First vitals HR 152, BP 56/33 sat 99%. He's a MP1, oral cavity fairly blood stained but nothing pumping/oozing in there that you can see with the naked eye, normal teeth, jaw protrudes normally, but head extension stinks, "this neck scar is so tight I can't tilt my head back."

Your plan, doctor? Anything else you'd like to know or do before your anesthetic?

This is the classic presentation of a "sentinel" bleed that happens before a carotid blowout. This patient is not going to do well.

Originally Posted by Fah-Q

This is the classic presentation of a "sentinel" bleed that happens before a carotid blowout. This patient is not going to do well.

My thoughts exactly.

Originally Posted by Fah-Q

This is the classic presentation of a "sentinel" bleed that happens before a carotid blowout. This patient is not going to do well.

How are you differentiating this from a bleeder at the biopsy site?

Whatever it is anybody inducing this guy with those vitals is a strait up murderer.

SAT99% I'm not touching him before he gets at least 5 PRBC 5 FFP and possibly a bag of platelets.

Originally Posted by dhb

Whatever it is anybody inducing this guy with those vitals is a strait up murderer.

SAT99% I'm not touching him before he gets at least 5 PRBC 5 FFP and possibly a bag of platelets.

Exactly!

Originally Posted by Bertelman

How are you differentiating this from a bleeder at the biopsy site?

I don't know for sure but this is what you have to assume with the given history. A tongue biopsy site that is bleeding should not produce this clinical picture.

Massive pharyngeal bleeding in a patient previously treated for head and neck cancer = carotid blowout until proven otherwise.

Originally Posted by Fah-Q

Massive pharyngeal bleeding in a patient previously treated for head and neck cancer = carotid blowout until proven otherwise.

Never heard of it. After googling it seems like the correct diagnosis.

Now I'm confused whether I should pent sux tube him or send him to neuro IR.

Actually my original plan was to have ENT do an awake trach, but the pent sux tube in me is strong.

So this pt had both a radical neck and a drug eluding stent 4 months ago?? Someone please shoot the cardiologist who didnt place a bare metal stent on a pt who just either had or was about to have a radical neck.

Originally Posted by RxBoy

Propofol, Fentanyl, Pancuronium.. bag with iso until the pan kicks in.. blind nasal intubation. If it doesnt go in first try, keep fiddling around its sure to go in.

Also consider giving dec early so dont have to worry about airway edema when you pull that tube deep.

Ha.

Originally Posted by Fah-Q

I don't know for sure but this is what you have to assume with the given history. A tongue biopsy site that is bleeding should not produce this clinical picture.

Massive pharyngeal bleeding in a patient previously treated for head and neck cancer = carotid blowout until proven otherwise.

The scenario doesn't make me think massive bleed and carotid blowout - he sat in the ED for two hours and is Yankauering himself.

Regardless - it doesn't change our management now.

The airway does not appear to be an emergency. I think it's worth mentioning that a HR of 152 and BP 56/33 doesn't HAVE to be hypovolemic shock in this patient, though probably is 90% of it. Myocardial ischemia has to be part of the differential; inducing him now is probably going to result in chest compressions on an empty, ischemic heart.

The patient needs volume resuscitation and blood, rate control once adequately resuscitated, followed by a more deliberate approach to the airway, induction, and exploration by ENT.



OK fakin' you've teased us long enough, tell us what happened.

Originally Posted by urge

Never heard of it. After googling it seems like the correct diagnosis.

Really? I have seen 3 of them during residency. Two of them were very similar to the case above. The other was following a carotid endart so that doesn't really count.

Originally Posted by Fah-Q

I don't know for sure but this is what you have to assume with the given history. A tongue biopsy site that is bleeding should not produce this clinical picture.

Massive pharyngeal bleeding in a patient previously treated for head and neck cancer = carotid blowout until proven otherwise.

My favorite circulator RN lost her 17 year old son to carotid blowout. Previously dx'd at age 15 with oral rhabdomyosarcoma, aggressively treated at St. Jude's with surgery etc etc. Was one week away from scheduled mandibular reconstruction and neck free flap when he quickly bled to death orally from carotid blowout. JPP you might have been on duty when EMS rolled into Cabrini's ER with him.

Originally Posted by sevoflurane

Keep him breathing until ENT gets there. Get a 16g that flows like Niagra Falls. Hang some blood. Look at the old anesthesia record and see if he's an easy DL before the radical neck. DID HE GET RADIATION TO THE NECK?

2 options: Pent, sux, tube or awake intubation (fiberoptic or glidescope). ENT at bedside if you get into trouble.

This is pretty much what we were thinking and our approach. Even with a MAP in the 40s this guy was kind of mentating (he was a little agitated/noncooperative), not having angina, and maintaining a sat, so we didn't feel in any hurry.

So we got a 2nd PIV and an A-line, poured in 1-2L of NS, some albumin, and 2 units pRBCs. Based on how much he's suctioning in that time we think his blood loss in the last 3-4 hours has been 1-2L. Within 30 minutes of arrival he's HR low 100's MAP 80s. ENT folks have been in the room the whole time, now getting a little antsy, but understanding that we received a horribly, horribly underresuscitated guy from the ED. The chicken/egg discussion does happen and in retrospect we could've and should've kept going with the resuscitation before inducing.

The airway exam is a little more reassuring than I seem to have implied, i.e. hyoid, thyroid, cricoid, trachea all midline.

Awake FOI is discussed but not chosen due to the patient-cooperation, airway-topicalization (i.e. it's covered in blood), and FOB-visualization issues mentioned above. But I do believe this is the "board answer." Neither of us have done or seen retrograde wire.

So, etomidate sux MAC3 we get a Grade 4, those submandibular tissues were tight (as the patient had told us!) and the oropharyngeal anatomy all distorted by his left tongue mass. Glidescope just barely gets a Grade 2ish view, the lens gets a little gooped up with all the blood in so we actually have to take the whole blade out and wipe the lens down a couple times. Next view manage to goose the tube, blood outta the ETT like crazy, suction applied to ETT, then ETT out. Next view with more anterior Brutane applied, in the airway with CO2 and chestrise and all that good stuff.

A couple of mask breaths were given between all those MAC/GS views, which led to the NEXT problem...that a fair amount of blood got sent down the trachea, which we become aware of AFTER the tube's in he becomes hypoxemic. So we do bronch and clear out frank clots in the R main and all the segmental bronchi in the RML and RLL.

Case proceeds and it actually takes 2+ hours for the ENTs to find the source, a tiny little piddly arterial pumper somewhere in the far, far lateral reaches of his tongue/jaw area. Sorry, carotid-blowout fans.

Ends up needing 8 units of product total, to ICU intubated but stable, with ENT dreaming of how neuro IR is going to fix this guy if/when he bleeds again.

I'm wondering: Would anyone give platelets in this situation? (i.e. bleeding on plavix, last dose >24 hours ago?) How would you all like to keep his stents open post-op?

As a 4th year student, I just want to say that these kinds of discussions are awesome and something I look forward to reading on this forum. I encourage you and other attendings/residents to keep bringing them up.

What did ENT think about awake trach? That would have been my first choice

Originally Posted by fakin' the funk

When he got to the ED 2 hours ago, HR was in 100's and BP normal. They trickled in a liter or two of NS through a 18 gauge PIV, sent some basic labs.

Originally Posted by fakin' the funk

So we got a 2nd PIV and an A-line, poured in 1-2L of NS, some albumin, and 2 units pRBCs. Based on how much he's suctioning in that time we think his blood loss in the last 3-4 hours has been 1-2L. Within 30 minutes of arrival he's HR low 100's MAP 80s. ENT folks have been in the room the whole time, now getting a little antsy, but understanding that we received a horribly, horribly underresuscitated guy from the ED.

So, let's step back from the "ED suxx suxx suxx" which is omnipresent in this thread; you're a resident, ENT is residents (at 5am on Saturday) and I'm guessing there is also an EM residency. A normotensive patient with HR in the 100s (by your wording, I am thinking like 100-110 - not 150), with a reason for tachy (like fear, which hemoptysis and equivalents can do, along with physio factors). "Some basic labs" - like a CBC? 20 minutes. You don't state what the H&H was. I'm guessing it wasn't bottomed. Or maybe it was equivocal.

Call to ENT, with the discussion being "this guy had a procedure by you guys; he's suctioning blood from the airway, but is normotensive and well-appearing. It might be nothing, or a breath away from catastrophe, but he's good right now." "OK, we'll be in, and we'll take him to the OR and take a look". Then, anesthesiology gets the call.

But when does he go from 120/80/HR 100 to 56/33/HR 150? And, for the forceful management dictated after, it is illogical that whomever pre-oped this guy (presumably in the ED) didn't dictate putting more fluid into him - unless the anesthesiologist agreed that the pt looked good. And, prospectively, I believe we all have to consider whether putting 4 liters into a pt with CAD is not going to make things worse.

But the animus towards the ED is clear. Were they aware of such disdain, or were you collegial and smiling? I know that there has to be a villain, but, to a certain subset on SDN, it's always the ED, with the black hat and Snidely Whiplash mustache, who are actively trying to kill the patients, until <fill in specialist> swoops in on a white horse and saves the day.

My point is, taken from a more objective perspective, as I can see this guy in my mind's eye, I wonder if he appeared to be such a bomb waiting to blow up, from the way the story was laid out.

Originally Posted by fakin' the funk

The chicken/egg discussion does happen and in retrospect we could've and should've kept going with the resuscitation before inducing.

Why do you say that? How did his hemodynamics react to induction/ventilation?
Like i said i would have given more blood products to this guy: from the values you gave he probably has lost 40% of blood mass so probably a solid 2L.
If he's been oozing/bleeding for a long time so he's been consuming coagulation factors hence the FFP. I would add platelets too.

My buddy in residency was a magnet for carotid or lingual blowouts. He had his hand on about a half dozen of them, more than many of the ENT residents at our place. One of them was on the floor - difficult airway with <1cm oral opening (2/2 XRT). He did an awake blind nasal - kept the guy breathing spontaneously and had him pant to aid placement.

Originally Posted by Apollyon

So, let's step back from the "ED suxx suxx suxx" which is omnipresent in this thread; you're a resident, ENT is residents (at 5am on Saturday) and I'm guessing there is also an EM residency. A normotensive patient with HR in the 100s (by your wording, I am thinking like 100-110 - not 150), with a reason for tachy (like fear, which hemoptysis and equivalents can do, along with physio factors). "Some basic labs" - like a CBC? 20 minutes. You don't state what the H&H was. I'm guessing it wasn't bottomed. Or maybe it was equivocal.

Call to ENT, with the discussion being "this guy had a procedure by you guys; he's suctioning blood from the airway, but is normotensive and well-appearing. It might be nothing, or a breath away from catastrophe, but he's good right now." "OK, we'll be in, and we'll take him to the OR and take a look". Then, anesthesiology gets the call.

But when does he go from 120/80/HR 100 to 56/33/HR 150? And, for the forceful management dictated after, it is illogical that whomever pre-oped this guy (presumably in the ED) didn't dictate putting more fluid into him - unless the anesthesiologist agreed that the pt looked good. And, prospectively, I believe we all have to consider whether putting 4 liters into a pt with CAD is not going to make things worse.

But the animus towards the ED is clear. Were they aware of such disdain, or were you collegial and smiling? I know that there has to be a villain, but, to a certain subset on SDN, it's always the ED, with the black hat and Snidely Whiplash mustache, who are actively trying to kill the patients, until <fill in specialist> swoops in on a white horse and saves the day.

My point is, taken from a more objective perspective, as I can see this guy in my mind's eye, I wonder if he appeared to be such a bomb waiting to blow up, from the way the story was laid out.

Do you really have to turn this into Anesthesia versus ER pissing match?

Originally Posted by Planktonmd

Do you really have to turn this into Anesthesia versus ER pissing match?

Exactly. Who cares what happened in the ED.
The case was presented to discuss the prep, induction and intubation, and management strategy.
Good case.

Originally Posted by Apollyon

So, let's step back from the "ED suxx suxx suxx"

I thought it was "ED 20-40-mg-etomidate suxx page-anesthesia-stat" ...



Lighten up, Francis.

Originally Posted by fakin' the funk

oropharyngeal anatomy all distorted by his left tongue mass

Sounds like recurrent/persistent cancer after surgery and radiation. Very very poor prognosis.

Originally Posted by fakin' the funk

Case proceeds and it actually takes 2+ hours for the ENTs to find the source, a tiny little piddly arterial pumper somewhere in the far, far lateral reaches of his tongue/jaw area. Sorry, carotid-blowout fans.

He'll be back and probably not as lucky next time.

Very nice save though. He'll at least have some more time with his family and be able to get his affairs in order, etc.

Originally Posted by Planktonmd

Do you really have to turn this into Anesthesia versus ER pissing match?

Originally Posted by IlDestriero

Exactly. Who cares what happened in the ED.
The case was presented to discuss the prep, induction and intubation, and management strategy.
Good case.

Originally Posted by pgg

Lighten up, Francis.

That's all you guys got? First, what I said was look at it objectively. I didn't say that it was unfairly dumping on the ED. There's no pissing match - it's anesthesiology pissing on EM only. As for "who cares what happened in the ED", multiple posts are making it sound like somebody in the ED was making an arteriotomy on this guy to make things worse. It was clearly stated by the OP in subsequent posts that he thought that whatever care this pt got in the ED was inadequate (his writing makes it sound like a guy came in spitting blood, and no one did anything except call ENT and let the guy sit there and bleed to death).

As for your oft-reused line from "Stripes", I think you're missing the point a bit. I wasn't there; I can't say if the ED just plainly dropped the ball (as was clearly stated), or whether it's a perspective issue. Remember propaganda? "Soviet Union finishes second. USA finishes second last!!!!" (When there are only 2 competitors.) In the polarized capitalist/communist perspective, the anesthesiologists are the capitalists. I am just taking the measured, European perspective - stepping back from the rah-rah. That's all.

The winners write the history books. This case reaffirms that. I am NOT saying that you guys are unfairly dumping on the ED - I am saying that you are dumping on the ED. If I wanted pissing matches, I could roil you guys into a lather on a regular basis, and some people would jump at every challenge. But, as my history shows, I like you guys, even if you don't like me.

Originally Posted by Apollyon

That's all you guys got?

The point is that none of us are taking this seriously. It was a good case to discuss from an anesthesia management perspective. My reference to the ED was more that it provided reassuring context - ie he was there for two hours and isn't dead so this is likely a slow bleed not a carotid blowout; we have time and can PROBABLY catch up on resuscitation before doing anything else.

Originally Posted by Apollyon

But, as my history shows, I like you guys, even if you don't like me.

Speaking just for me, I like having you EM guys visit us from time to time, even if you mock us for being NPO-pansies and trying to take propofol away from you. We mock you for being etomidate-lovin' cowboys and consult parrots. There's mutual respect even if we trade barbs.

Settle down.

Originally Posted by pgg

Settle down.

"Lighten up Francis". "Settle down." Who's riled? It's not me. I'm flying over to Maui in an hour.

Emergency medicine is really hard. I have a lot of respect for EM docs. The breadth and depth of knowledge required is incredible. I could never do what EM docs do.

That being said, every time I get a call from the ER for an epidural blood patch consult (because they did an LP with a huge cutting needle on someone who almost certainly didn't have meningitis by history but certainly do have a post-dural puncture headache now) on a 20 year old Medicaid patient at 3 am, I say the same thing: "F$$king stupid ER!"

But we here in this forum are extremely tame and polite. You should hear what the surgeons say about you after _they_ get a consult from the ER.

Originally Posted by Apollyon

"Lighten up Francis". "Settle down." Who's riled? It's not me. I'm flying over to Maui in an hour.

Wow, you can afford Maui with your EM salary?

Originally Posted by bullard

That being said, every time I get a call from the ER for an epidural blood patch consult (because they did an LP with a huge cutting needle on someone who almost certainly didn't have meningitis by history but certainly do have a post-dural puncture headache now) on a 20 year old Medicaid patient at 3 am, I say the same thing: "F$$king stupid ER!"

Never forget the time I got a call in the ED for an EBP for PDPH in a post-partum. My jaw dropped to the floor when she told me it was a natural birth, that she didn't even have an epidural.

Granted, it was likely a resident, and an off-service one at that. Either way.

Originally Posted by Planktonmd

Wow, you can afford Maui with your EM salary?

I live on O'ahu. Just a visit to Maui. Friends (neurorads and her husband - Microsoft exec) are staying on Maui. The brought the nanny with them!