Things I Learn From My Patients

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Originally Posted by link2swim06

Not always, alot of hospitals have a stroke or brain attack team setup. At the hospital I work at it is common to be able to give tPA within 20-40 minutes of neurology being paged.

And what do you figure is the median time from symptom onset to presentation in the ED?
There's a reason why the best set-up stroke centers in the country are giving fewer than 5% of their acute CVA patients tPA.

Originally Posted by DrSnips

1 hour? You'd have to be an inpatient already with a very attentive doctor/nurse. Or have your stroke in the lobby.

Maybe. My point was that neuro always talks about tPA as though it was a wonder drug at 1 hour or less, that got less and less effective as you approach the 3 hour mark. As in:

Stroke in the lobby --> 1 hour --> tPA --> full recovery
Call EMT at symptom onset --> 2 hours --> tPA --> dramatic improvement in function
"We'll go after Judge Joe Brown!" ---> 3 hours --> tPA --> barely statistically significant

I was wondering if anyone here had seen/done truely fast tPA administration, and if it was really as dramatic an improvement as the Neuro people say it is.

Originally Posted by Perrotfish

Maybe. My point was that neuro always talks about tPA as though it was a wonder drug at 1 hour or less, that got less and less effective as you approach the 3 hour mark. As in:

Stroke in the lobby --> 1 hour --> tPA --> full recovery
Call EMT at symptom onset --> 2 hours --> tPA --> dramatic improvement in function
"We'll go after Judge Joe Brown!" ---> 3 hours --> tPA --> barely statistically significant

I was wondering if anyone here had seen/done truely fast tPA administration, and if it was really as dramatic an improvement as the Neuro people say it is.

In SC, had a guy came in right away with R sided dense hemiplegia. Stat CT shows a textbook L MCA infarct. The neuro on-call was a complete ***hole usually. This was a Sunday evening, around 9pm. However, neuro came in, and gave this pt the t-PA. It was truly incredible. The guy came to life right in front of my eyes.

There are the total scoffers here on SDN that say, bar none, when someone gets better after t-PA, it is because they were having a TIA. For this one anecdotal case, with a positive (not equivocal or negative) CT, it worked. That's enough to convince me that it isn't worthless, as some here might make you think. I mean, if it truly was, considering the risk of bleeding, then why do P&T committees nationwide still have it on formulary, while pulling droperidol? It is NOT all bad and no good, as some people here might make you think.

Originally Posted by Apollyon

In SC, had a guy came in right away with R sided dense hemiplegia. Stat CT shows a textbook L MCA infarct. The neuro on-call was a complete ***hole usually. This was a Sunday evening, around 9pm. However, neuro came in, and gave this pt the t-PA. It was truly incredible. The guy came to life right in front of my eyes.

There are the total scoffers here on SDN that say, bar none, when someone gets better after t-PA, it is because they were having a TIA. For this one anecdotal case, with a positive (not equivocal or negative) CT, it worked. That's enough to convince me that it isn't worthless, as some here might make you think. I mean, if it truly was, considering the risk of bleeding, then why do P&T committees nationwide still have it on formulary, while pulling droperidol? It is NOT all bad and no good, as some people here might make you think.

Okay, so bottom, bottom line: get through rotations and EM residency, gain a bunch of experience, see first hand what tPA does in different scenarios, and develop your own opinion of it.

Originally Posted by Perrotfish

I was wondering if anyone here had seen/done truely fast tPA administration, and if it was really as dramatic an improvement as the Neuro people say it is.

In medical school, I was on inpatient neuro and we were consulted for a stroke in an elderly patient who was admitted for something completely non-related. He had complete L-sided paralysis (and a previous right AKA). tPA was given within an hour of onset of symptoms. The patient then had an ICH and died.

Originally Posted by Perrotfish

I was wondering if anyone here had seen/done truely fast tPA administration, and if it was really as dramatic an improvement as the Neuro people say it is.

Sure. The problem is, we don't know which population it will help, and which it hurts. Remember, the whole reason the 4.5 hour window exists is because so many people kept violating the 3 hour window. I fully believe that there are people out there who would benefit from the drug. I just don't know who they are yet.

Originally Posted by Unzbuzzled

Okay, so bottom, bottom line: get through rotations and EM residency, gain a bunch of experience, see first hand what tPA does in different scenarios, and develop your own opinion of it.

Except that most people don't give it often enough to reach validity, so they are stuck with a plurality of anecdotes.

Originally Posted by Apollyon

I mean, if it truly was, considering the risk of bleeding, then why do P&T committees nationwide still have it on formulary, while pulling droperidol? It is NOT all bad and no good, as some people here might make you think.

Since there aren't any good studies showing droperidol is bad, but the government under duress from big pharma put the warning on it, the formularies are trying to protect their hides. The logic is that a doctor could claim the hospital as co-defendant because "if the drug wasn't safe, why could I give it?"
Also, more people are sued for not giving tPA than for giving tPA (as of now). Give it time, and I'm sure you'll start getting 1-800 BAD DRUG ads for tPA as well.

Originally Posted by Hypomanics

In medical school, I was on inpatient neuro and we were consulted for a stroke in an elderly patient who was admitted for something completely non-related. He had complete L-sided paralysis (and a previous right AKA). tPA was given within an hour of onset of symptoms. The patient then had an ICH and died.

Again, anecdote. The stat that gets said up front is that "7% of people that get this drug will have bleeding into their brain, and most of those people will die". As a neurologist said to a patient, "What that means is that, if I gave this drug every day for 2 weeks, statistically, one person would die from it".

When I was attending on a Sunday afternoon in South Carolina, a mountain man came in complaining of severe pain in his back, and in his left leg, superior and anterior. This was about 1:20pm Right in front of me, I watched his 3-lead EKG infarct - right in front of me. It was remarkable, in that, in 30 seconds, his ST segment rose like a wave on the beach. This was about 1:40pm.

I called the acute MI team at the main hospital. I told the cardiologist that he infarcted right in front of me, but he had only been there about 20 minutes, and I had a strong suspicion that he also had an AAA. Guy was flown out (was a lovely day - possibly the best utilization I'd seen for the helicopter in 10 years), and directly to the cath lab. They went in through the R groin. They revascularized him. They also shot the aorta, and saw a big, leaking AAA. He went from the cath lab to the OR, where vascular repaired his aorta with a Dacron graft. Then he arrested and died.



That was around 5pm. On autopsy, they found another aneurysm in the Right CFA - just distal to the puncture for the cath. Recall he had pain in the Left leg, and that one was intact. Fortunately, cards didn't put a hole in that one in the leg.

Originally Posted by Apollyon

Again, anecdote. The stat that gets said up front is that "7% of people that get this drug will have bleeding into their brain, and most of those people will die". As a neurologist said to a patient, "What that means is that, if I gave this drug every day for 2 weeks, statistically, one person would die from it".

When I was attending on a Sunday afternoon in South Carolina, a mountain man came in complaining of severe pain in his back, and in his left leg, superior and anterior. This was about 1:20pm Right in front of me, I watched his 3-lead EKG infarct - right in front of me. It was remarkable, in that, in 30 seconds, his ST segment rose like a wave on the beach. This was about 1:40pm.

I called the acute MI team at the main hospital. I told the cardiologist that he infarcted right in front of me, but he had only been there about 20 minutes, and I had a strong suspicion that he also had an AAA. Guy was flown out (was a lovely day - possibly the best utilization I'd seen for the helicopter in 10 years), and directly to the cath lab. They went in through the R groin. They revascularized him. They also shot the aorta, and saw a big, leaking AAA. He went from the cath lab to the OR, where vascular repaired his aorta with a Dacron graft. Then he arrested and died.



That was around 5pm. On autopsy, they found another aneurysm in the Right CFA - just distal to the puncture for the cath. Recall he had pain in the Left leg, and that one was intact. Fortunately, cards didn't put a hole in that one in the leg.

In other words, have reasonable expectations.

Older guy came into the ED with two broken digits and ended up getting diagnosed with early colon cancer. Lesson: sometimes it pays to ask lots of questions. This guy will probably be fine because of it.

Originally Posted by Unzbuzzled

Older guy came into the ED with two broken digits and ended up getting diagnosed with early colon cancer. Lesson: sometimes it pays to ask lots of questions. This guy will probably be fine because of it.

makes one wonder how he broke his fingers? d;-)

nice catch!
-d

Originally Posted by Perrotfish

Maybe. My point was that neuro always talks about tPA as though it was a wonder drug at 1 hour or less, that got less and less effective as you approach the 3 hour mark. As in:

Stroke in the lobby --> 1 hour --> tPA --> full recovery
Call EMT at symptom onset --> 2 hours --> tPA --> dramatic improvement in function
"We'll go after Judge Joe Brown!" ---> 3 hours --> tPA --> barely statistically significant

I was wondering if anyone here had seen/done truely fast tPA administration, and if it was really as dramatic an improvement as the Neuro people say it is.

I'm a medical student but was working up a lady who fell on her face at the flea market infront of an EMS vehicle. Came in with left mca signs. Got a scan and neuro was called all in 50 minutes. I watched the improvements right infront of me. I did exams q 5 minutes and she was improving by the exam. I visited her the next day and she had made a 95% full recovery . Just some minor facial droop.

Saw a guy a few days ago in the ED who got into a slow speed MVC and was brought in to the ED. It was then notice that he had complete left sided hemiparesis, so stroke likely caused is MVC. Pt was alert, head scanned and negative, tPA was given under 60 min from his MVC, 4 hours later pt went completely apneic and comatose. Repeat head CT with hemorrhagic conversion of his ischemic stroke, midline shift, blown pupil, neurosurg said no intervention and that he was going to be brain dead. tPA can be a life saver or a killer...

Originally Posted by RafaTech

Saw a guy a few days ago in the ED who got into a slow speed MVC and was brought in to the ED. It was then notice that he had complete left sided hemiparesis, so stroke likely caused is MVC. Pt was alert originally, head scanned and negative, tPA was given under 60 min from his MVC, 4 hours later pt went completely apneic and comatose. Repeat head CT with hemorrhagic conversion of his ischemic stroke, midline shift, neurosurg said no intervention and he was going to be brain dead. tPA can be a life saver or a killer...

If he was able to become a donor I would still consider it a life saver.

Originally Posted by dpmd

If he was able to become a donor I would still consider it a life saver.

True, last I heard about the case the organ donation line was calling the family. Never found out what happened on that end.

Originally Posted by RafaTech

True, last I heard about the case the organ donation line was calling the family. Never found out what happened on that end.

Imagine being the guy that makes that phone call. Real hero's . I would have such a difficult time being able to have such a conversation with a mother or daughter etc....

Originally Posted by Apollyon

Again, anecdote.

Of course - I was just answering that specific question. I have had a patient receive tPA 2 other times. Another time while on the same neuro rotation and once this year as an intern. Both of those lived and had complete reversal of symptoms, but neither were given in under 1 hr from onset. I'm definitely not against using tPA.

Am I the only one that would be skiddish to order TPA in a trauma patient? The above examples of falling face first, MVC, etc. would make me unlikely to order TPA.

Still on tPA? What have I done?

Always bear in mind who your patient is. A mom and her 12-year old son got into a car accident, and the kid complained of some minor wrist pain. Rad resident took a wrist x-ray and diagnosed him with a severe Colles fracture with a similar fracture along the distal ulna. Luckily before telling the kid's mother, the attending took a look and nearly slapped the resident upside the head. Turns out, normal epiphyseal growth plates might to the untrained eye look suspiciously similar to a really clean Colles fracture.

Originally Posted by southerndoc

Am I the only one that would be skiddish to order TPA in a trauma patient? The above examples of falling face first, MVC, etc. would make me unlikely to order TPA.

Nearly 20 years ago - guy in a low speed MVC, having an MI. In the ED, he gets the streptokinase (I'm tellin' ya - long time ago). Bleeds out internally, dead. Who knew? I just keep that one in the back of my mind.

Wasn't my call; it was a fellow paramedic (well, I was just EMT at the time I heard the story).

Today, in rural Indiana, I learned that you can be on plavix and aspirin, fall "At least 60 feet, hitting 5 trees", after having some beers and trying to shoot some coyotes with a shotgun and live to tell about it with only some mild contusions.

Oh, and the longer he was in the ED, the farther he fell.

Miracles

If you and your brother are hemophiliacs. Please do not get into a fistfight.

Originally Posted by Rendar5

If you and your brother are hemophiliacs. Please do not get into a fistfight.

Or take the woodcarving merit badge at Boy Scout camp.

Originally Posted by K31

Or take the woodcarving merit badge at Boy Scout camp.

When I was on staff at a Boy Scout summer camp, we called the class "fingercarving" and basketry was "basketcases." Of course this was only between staff members, not to the campers or the other leaders.

dsoz

Originally Posted by Drawing Dead

Today, in rural Indiana, I learned that you can be on plavix and aspirin, fall "At least 60 feet, hitting 5 trees", after having some beers and trying to shoot some coyotes with a shotgun and live to tell about it with only some mild contusions.

Oh, and the longer he was in the ED, the farther he fell.

Miracles

If he fell 60 feet in Indiana, it was off a building.

Originally Posted by Dr.McNinja

If he fell 60 feet in Indiana, it was off a building.

Maybe he fell down a hill?

When making a rolling right turn at a busy crosswalk, try not to hit the elderly woman on the electric scooter. Nuff said.

I found out that in 1995 the Ig Noble price for Literiture went to two people for their work on a report titled. "Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World's Literature." Figure it's relevant to this thread and that the ER and Proctology Docs here should look it up.

Originally Posted by Aoirann

I found out that in 1995 the Ig Noble price for Literiture went to two people for their work on a report titled. "Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World's Literature." Figure it's relevant to this thread and that the ER and Proctology Docs here should look it up.

Against my better judgement, I logged onto my school's electronic database (for the first time ever, mind you) and typed in "Rectal Foreign Bodies: Case Reports" to see if there was anything of note in there. Didn't find your article, but I did find a couple of goodies, like "Rectal bleeding due to a leech bite: a case report," and "Rectal obstruction by a giant pharmacobezoar composed of magnesium oxide: report of a case."

I wonder if my school keeps tabs on student search queries. If so, they may wonder why, after never using the e-database, I suddenly decided to research rectal foreign bodies...

Originally Posted by Unzbuzzled

Against my better judgement, I logged onto my school's electronic database (for the first time ever, mind you) and typed in "Rectal Foreign Bodies: Case Reports" to see if there was anything of note in there. Didn't find your article, but I did find a couple of goodies, like "Rectal bleeding due to a leech bite: a case report," and "Rectal obstruction by a giant pharmacobezoar composed of magnesium oxide: report of a case."

I wonder if my school keeps tabs on student search queries. If so, they may wonder why, after never using the e-database, I suddenly decided to research rectal foreign bodies...

Here is the Ig Nobel link: http://www.improbable.com/ig/winners/#ig1995


Here is the article abstract link: http://www.ncbi.nlm.nih.gov/pubmed/3738771

"The citations include reports of, among other items: seven light bulbs; a knife sharpener; two flashlights; a wire spring; a snuff box; an oil can with potato stopper; eleven different forms of fruits, vegetables and other foodstuffs; a jeweler's saw; a frozen pig's tail; a tin cup; a beer glass; and one patient's remarkable ensemble collection consisting of spectacles, a suitcase key, a tobacco pouch and a magazine."

This particular patient must have really made a go of it. I applaud the enthusiasm.

I don't even know where to begin with the frozen pig's tail.

Originally Posted by Unzbuzzled

I don't even know where to begin with the frozen pig's tail.

I see your frozen pig's tail and raise with a live eel -

http://drmarkgriffiths.wordpress.com...oreign-bodies/

Originally Posted by shopsteward

I see your frozen pig's tail and raise with a live eel -

http://drmarkgriffiths.wordpress.com...oreign-bodies/

Fold.

Now let's see if anyone can one-up a live eel placed rectally.

I don't think it beats a live eel, but got this out of a guy this weekend



The best part-it kept spraying as we tried to get it out so things smelled great. It was bigger than my fist and I can't imagine how it even fit up there. Maybe now he can pleasure himself through the ostomy we had to give him.

Originally Posted by dpmd

I don't think it beats a live eel, but got this out of a guy this weekend



The best part-it kept spraying as we tried to get it out so things smelled great. It was bigger than my fist and I can't imagine how it even fit up there. Maybe now he can pleasure himself through the ostomy we had to give him.

Wow that's pretty impressive.

So random, I was listening to one of Sam Tripoli's podcasts today (recorded yesterday) and he brought up a story where a man had to be hospitalized for an eel in his rectum (http://www.dailymotion.com/video/xtv...-rectum_travel). That story is dated only four days ago. After googling it, it turns out that placing eels rectally isn't all that unheard of. I guess you learn something every day.

Originally Posted by shopsteward

I see your frozen pig's tail and raise with a live eel -

http://drmarkgriffiths.wordpress.com...oreign-bodies/

I fold. The best I've got was a salsa jar, and I don't even know if it was regular or extra spicy.

Originally Posted by dpmd

I don't think it beats a live eel, but got this out of a guy this weekend



The best part-it kept spraying as we tried to get it out so things smelled great. It was bigger than my fist and I can't imagine how it even fit up there. Maybe now he can pleasure himself through the ostomy we had to give him.

Reminds me of my guy who put a Mango Yankee Candle (still in the glass jar) up there. I could smell it before I could see it! Those things sure are fragrant.

And yes, he also bought himself a bag.

I would think an eel would be tickly. Then again, perhaps that's what they're going for.

Originally Posted by Winged Scapula

Reminds me of my guy who put a Mango Yankee Candle (still in the glass jar) up there. I could smell it before I could see it! Those things sure are fragrant.

And yes, he also bought himself a bag.

I would think an eel would be tickly. Then again, perhaps that's what they're going for.

Unless of course it eats your bowels, like it apparently did to a guy in China (http://www.geekologie.com/2010/05/ma...p-eel-eats.php). By the way, even though this has been reported all over the web, I have yet to find a reputable source, so it all might be hogwash.

Originally Posted by Unzbuzzled

"The citations include reports of, among other items: seven light bulbs; a knife sharpener; two flashlights; a wire spring; a snuff box; an oil can with potato stopper; eleven different forms of fruits, vegetables and other foodstuffs; a jeweler's saw; a frozen pig's tail; a tin cup; a beer glass; and one patient's remarkable ensemble collection consisting of spectacles, a suitcase key, a tobacco pouch and a magazine."

Is that a rolled up news magazine, or a firearm magazine?

Not sure I want to know.

On a recent ER visit....

Psych patient (admitted on a section, under guard) yelling loud enough for the entire department to hear -

"I'm not psychotic, just because I want to kill myself and kill other people, why do you keep telling me I'm being held as a danger to myself and others?"

Ahh, gee, I don't know...let me think

Originally Posted by Ceke2002

On a recent ER visit....

Psych patient (admitted on a section, under guard) yelling loud enough for the entire department to hear -

"I'm not psychotic, just because I want to kill myself and kill other people, why do you keep telling me I'm being held as a danger to myself and others?"

Ahh, gee, I don't know...let me think

Perhaps he's a believer of ethical subjectivism, in which case his sense of morality is equavilent to your own and thus it is morally permissable for him to take the lives of others and himself.

Indeed, this implies you are also morally free (perhaps even obligated) to restrain him from doing so if it is what your own set of ethics permits you to do.

Of course, if you subscribe to the objectivist line of thought, well, that's a whole other can of philosophical worms.

Originally Posted by Ceke2002

On a recent ER visit....

Psych patient (admitted on a section, under guard) yelling loud enough for the entire department to hear -

"I'm not psychotic, just because I want to kill myself and kill other people, why do you keep telling me I'm being held as a danger to myself and others?"

Ahh, gee, I don't know...let me think

Sounds like it's time for a visit from every EM doc's best friend, good Mr. Haldol.

If you are a diabetic, don't try to cut a callus off your toe with a Swiss Army knife. Not only will you get a non-healing ulcer on the toe, but you will also develop heavy MSSA bacteremia and an epidural abscess at C4.

If you have been treated successfully for throat cancer, it is not advisable to continue to smoke a pack a day so that your cancer has a higher chance of recurring, thereby ensuring you can stay on disability. There are plenty of perfectly enjoyable jobs out there that are preferable to chemotherapy and the possibility of death.

While you may have dressed as Mary Poppins for a heavily alcoholic Halloween party, that does not necessarily mean your umbrella will save you from injury when you jump off a roof...

Cutting yourself severely on the back of your neck will get you a trip from lock up to the ER. Pissing off the doc who is trying to stitch you up will only get you an enraged doctor who will offer you lessons on how to correctly kill yourself. The doc in question went from speaking slightly accented English to speaking a heavily accented, very broken form of English with what the officer swears was Manadarin curse words thrown in.

This is a GREAT forum. Believe it or not, found the forum through a link on FaceBook. I am no longer in the health care industry (used to be) but still retain an interest in the medical profession.

Have a funny one for you. I was in a treatment room at our local hospital with a screaming migraine (the PLEASE just shoot me kind) and they put a patient in the next bed. Here is what I overheard:

Nurse: "Hey sweetie, what happened to you?"
Man: "I was on patrol, minding my own business, when a deer jumped into my patrol car and proceeded to kick my *ss!"

I tried SO hard not to laugh. For 2 reasons - the first and foremost was that my head would explode if I did, and the second was that I didn't want the poor cop to know I overheard. I STILL laugh at that memory. I imagine he does too, by now. I'm sure none of his co-workers ever let him live it down.

If you're a social worker at the VA, and one of your patients arrives for his appointment in a wheelchair, pushed by a friend, before rolling eyes and making an accusation of "malingering," you should probably double check with the ER that patient didn't actually arrive convulsing with cluster headaches, incoherent, pulse 190, BP 180/130, with an injured knee from a fall. Especially when that is exactly what happened to your patient, and his friend pushing the chair is the one who drove him to the ER that morning.

Originally Posted by Design Lady

This is a GREAT forum. Believe it or not, found the forum through a link on FaceBook. I am no longer in the health care industry (used to be) but still retain an interest in the medical profession.

Have a funny one for you. I was in a treatment room at our local hospital with a screaming migraine (the PLEASE just shoot me kind) and they put a patient in the next bed. Here is what I overheard:

Nurse: "Hey sweetie, what happened to you?"
Man: "I was on patrol, minding my own business, when a deer jumped into my patrol car and proceeded to kick my *ss!"

I tried SO hard not to laugh. For 2 reasons - the first and foremost was that my head would explode if I did, and the second was that I didn't want the poor cop to know I overheard. I STILL laugh at that memory. I imagine he does too, by now. I'm sure none of his co-workers ever let him live it down.

So now we have COPMOB (cop on patrol, minding own business) as a supplement to the standard SOCMOB?

Sure. Why not? [grin]

Have another one for you: If you are the ER/Urgent Care MD, and you are preparing to cut into a toe, make SURE you hit the nerve cluster with the local, and the toe really IS numb. Saw a doc (on the little wheelie stool) bounce off of a wall when the patient he cut on FELT it and kicked. Poor doc!

I recently learned that opthalmology can have fatalities. A flourescein angiographer had a guy go into anaphylaxis after an injection and the guy went down right in front of him. So, even though you're a retina specialist, you might want to have a solid emergency plan in place, especially when your practice sees a high amount of traffic.

Originally Posted by Unzbuzzled

I recently learned that opthalmology can have fatalities. A flourescein angiographer had a guy go into anaphylaxis after an injection and the guy went down right in front of him. So, even though you're a retina specialist, you might want to have a solid emergency plan in place, especially when your practice sees a high amount of traffic.

That's awful. Yikes...ACLS anyone? Epi? Eek!