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Discussion in 'Emergency Medicine' started by docB, 04.12.04.

  1. emtp2pac

    emtp2pac Member

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    SDN Members don't see this ad. (About Ads)
    1.5 pks cigarettes/day starting at age 5

    next pt: ivda since age 11....( where does a 5th grader score heroin?)
  2. Smoke This

    Smoke This Sweet cuppin' cakes!

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    Cr 21.9, BUN I can't remember exactly but it was well over 120. For her that's a calculated GFR of about 1.

    This person is an uncontrolled hypertensive who came in c/o nausea and vomiting, had recently started going to nephrology clinic after about a 4 year hiatus precipitated by them telling her she needed dialysis (Cr was "only" 6 back then) and she was frightened by the thought of dialysis access. I actually posted this before reading the whole thread and saw that someone had me beat, but we all thought it was impressive that she was still walking around alive!

    I do have another lab value that would be hard to beat--BNP of 5311. CHF pt who went on a drug, alcohol, and food binge and came in dyspneic despite feeling a CHF exacerbation "coming on" and taking three 80mg tabs of lasix all at once in an attempt to head it off.
  3. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    The highest BNP I ever saw was ~14,000 (14612, I believe). This was a year ago, when I didn't know a damn thing about it - the patient just looked like a bad (but not critical) CHF'er. I remember vaguely the time period, so I will hit the computer tomorrow and post it (or if I have a faulty memory, and am FOS).
  4. ERMudPhud

    ERMudPhud Back for a visit

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    I'm just curious what people think the utillity of BNP is in cases where the physical exam, history, and CXR pretty clearly show CHF. Is this just a case of if you invent a test it will get used more than you ever thought or does it add something in a patient with a known history of CHF who presents now with a clear cut CHF exacerbation? Is IM getting them on every CHF'er you admit? I've only order it twice so far and both were on patients in whom the etiology of their SOB was quite unclear. One turned out to be negative and the other was quite elevated in a patient who was subsequently found to have a severely reduced EF secondary to diffuse CAD but who still had a remarkably normal CXR. In that case it turned out to be quite useful.
  5. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    We talked about that at length in journal club, and we still evaluate it. One thing we stated was we need multiple BNP levels in patients, to see where their baselines are. What is the utility? It is still unclear. However, as we get more experience, we can hone our use of it (and figure out where it lies on the meter).
  6. Jeff698

    Jeff698 Chief Resident

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    There was just an interesting discussion on this on EMED-L. Here's a post from someone really into all things EBM:

    ****
    From: Jeffrey Mann
    Date: Fri Sep 03 2004 - 08:40:25 PDT

    Dave suggests that the diagnostic properties of the BNP are similar to
    that of a pregnancy test - with respect to FP/FN problems. Surely not!

    A urine/serum HCG test has a very high sensitivity and specificity,
    which makes it a very reliable test to diagnose pregancy. However,
    consider the senstivity/specificity properties of a BNP test.

    The best article that I have read on BNP testing in an ED setting is
    Schwam's from the June 2004 issue of the Academic Emergency Medicine
    journal.

    Schwam reviewed the BNP literature (55 articles) and chose 6 articles
    for a detailed analysis. Schwam does a good job of showing the
    weaknesses/biases of those studies. He demontrates that clinicians are
    good at accurately diagnosing CHF clinically only if they estimate the
    probability of CHF as being <5% or >95%. He states that clinicians are
    less accurate if they estimate that the patient has an intermediate
    probability of CHF (5-95% probability). He states that the LR of a BNP
    test is 3.5 overall, but the LR is only 2.0 for intermediate probability
    CHF patients with a predicted probability of CHF of 20-80%. A LR of 2.0
    (sensitivity 88% specificity 55%) is so low as to not significantly
    change the pretest probability of CHF. Consider the following practical
    demonstration of that fact.

    Presume that a patient with a known history of COPD presents to the ED
    with acute dyspnea. Does a BNP help diagnose CHF? Presume that the EP
    thinks that the patient is unlikely to have CHF but orders a BNP in case
    his low clinical prediction of the pretest probability of CHF of 30% is
    wrong. Does a positive BNP test (>100 pg/ml) prove that CHF is present?
    Using this online Bayesian calculator
    (http://www.intmed.mcw.edu/clincalc/bayes.html) and inputting the
    following facts -- prevalence 0.3, sensitivity 0.88, specificity 0.55 --
    the positive predictive value of a positive BNP test is 45.6%. In other
    words, there is no significant change in the probability of CHF (which
    went from 30% to 46%) and the results are no better than tossing a coin
    (~50%). The LR+ of the test is 1.95 and the test has no useful positive
    predictive power.

    Let's instead presume that the EP strongly suspected that the COPD
    patient had CHF and that his pretest probability estimation is 80%. Can
    a negative BNP test rule-out CHF? According to the online Bayesian
    calculator, if the prevalence is 0.8, sensitivity 88%, specificity 55%,
    then the negative predictive value is 53.4% . In other words, a negative
    BNP has no ability to exclude CHF and the results are no better than
    tossing a coin (~50%). The LR- of the test is 0.21 and therefore the
    test has no useful negative predictive power.

    Schwam does something interesting and useful by introducing the idea of
    interval LRs. He divides the BNP test results into subcategories and
    calculates the LR for each subcategory.

    The following list from three studies summarises his results.

    BNP level pg/ml) ----- LR (95% confidence intervals)

    Multinational Study

    <50 ---- 0.048 (0.03?0.07)*
    50?79 ----- 0.33 (0.23?0.50)
    80?99 ---- 1.5 (0.78?2.74)
    100?124 ---- 1.0 (0.60?1.82)
    125?150 ---- 0.50 (0.27?0.91)
    150?400 ---- 3.1 (2.5?3.8)
    400?1,000 ----19 5.0 (3.3?7.9)
    >1,00018 --- 16 (10?26)*

    Lainchbury et al.

    <69 ---- 0.068 (0.02?0.26)*
    69?105 --- Indeterminant
    106?208 ---0.14 (0.04?0.56)
    209?277 --- 1.4 (0.57?3.3)
    278?346 --- 1.0 (0.32?3.1)
    >346 ---- 4.8 (3.2?7.2)

    Logeart et al.

    <80 ---- 0.11 (0.04?0.35)
    80?100 ---- 0.25 (0.03?2.5)
    101?150 ---- 0.21 (0.06?0.75)
    151?200 ----Indeterminant
    201?250 ---- 0.17 (0.04?0.74)
    251?300 ---- 0.16 (0.05?0.52)
    301?400 ---- 1.5 (0.43?5.3)
    >400 ---- 11 (4?33)*

    *LR >5 or <0.2 (test result produces moderate shifts in disease
    probability). *LR >10 or <0.1 (test result produces large shifts in
    disease probability).

    Schwam then makes the following statement "BNP levels less than 50?80
    pg/mL effectively rule out the diagnosis of HF. Levels between 400 and
    1,000 pg/mL have moderate ability to diagnose HF, and with levels more
    than 1,000 pg/mL, there is a large likelihood of HF. The BNP levels
    between 80 and 400 pg/mL have little utility for the diagnosis of HF.
    Overall, these results are consistent with those generated by
    application of the HF and Fagan nomograms and with the
    pathophysiological data showing that many diseases cause BNP levels in
    this range."

    In his discussion, Schwam states "To rule out HF, a lower cutoff of
    50?80 pg/mL has excellent diagnostic value with a negative LR of 0.05.
    This finding virtually rules out HF in all patients with low or
    intermediate pretest probabilities. Selection of the upper cutoff is
    more problematic. The lowest acceptable limit would be 400 pg/mL, with
    an associated positive LR of about 5. Recently, several Multinational
    Study investigators have also suggested 40019 or 500 pg/mL20 as the
    upper limit. The 1,000 pg/mL cutoff has a positive LR of 16.5, which is
    excellent. Although data for intermediate levels are not available, the
    linearity of the ROC curve between 400 and 1,000 pg/mL suggests that the
    interval LR remains about 5 between these two values. Thus, there is no
    diagnostic advantage to using a value between 400 and 1,000 pg/mL, suggesting that 400 pg/mL is the preferred cutoff. In deciding on the optimal cutoff, it is helpful to consider the consequences of a false-positive diagnosis of HF. Both pulmonary embolism and sepsis can produce BNP concentrations well above 1,000 pg/mL. If the pretest probability of either disease is intermediate to high, then even an extremely elevated BNP cannot discriminate these from HF, and no cutoff is adequate. Failure to treat either sepsis or pulmonary embolism would have substantial adverse effects. ------

    It is instructive to consider the diagnostic contents of the ??gray zone?? between 50 and 400 pg/mL: HF, asymptomatic left ventricular dysfunction, chronic pulmonary hypertension, myocardial ischemia, atrial fibrillation, pulmonary embolism, left ventricular hypertrophy, lung cancer, renal failure,
    sepsis, and a small percentage of healthy elders. The next step in this
    analysis is to tabulate the percentage of BNP values that fall above and
    below the cutoffs and within the 50?400 pg/mL nondiagnostic gray zone.
    In the Multinational Study, 40% of all BNP values fell within the
    nondiagnostic range, and roughly 50% of patients with HF were also in
    this zone. As a diagnostic test, BNP may be analogous to the ventilation
    perfusion scan, in which normal and high-probability scans are very
    useful, but most scans are indeterminate. Sometimes, the physician will
    find the BNP assay to be very helpful, but at least 40% of the time, it
    will be inconclusive."

    He then concludes his article by saying "B-type natriuretic peptide is a
    useful test for the clinical diagnosis of HF, but its limitations must
    be understood to apply it properly. Using the history, physical
    examination, electrocardiography, and chest radiography, physicians in
    the ED setting can accurately categorize many patients with very low
    (0?4%) or very high (95?100%) pretest probability of HF, where no
    further testing can be justified. For patients with intermediate
    probability estimates (5?94%), BNP levels under 50?80 pg/mL have good
    ability to rule out HF. A BNP level above 400 pg/mL has moderate
    ability, and a BNP of more than 1,000 pg/mL has substantial ability to
    rule in the diagnosis of HF. However, sepsis and pulmonary embolism can
    also cause levels above 1,000 pg/mL. For these reasons, at least 40% of
    the time, BNP testing will be nondiagnostic."

    If Schwam is correct that nearly 50% of suspected CHF patients have
    intermediate BNP results (50-400 pg/ml), which implies a low
    positive/negative predictive power, then it would seem that the BNP test
    has a very limited diagnostic value for many suspected CHF patients in
    an ED setting. What do you think?

    Jeff.
    ***

    Please note I'm not the same Jeff. EBM makes my head hurt, I just found his message helpful. Here's the URL for that message in the EMED-L archives. You can follow the discussion there if you're interested.

    Take care,
    Other Jeff
  7. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Here's how BNP works at my house:
    Me: CHFer. Gotta come in.
    Consult: What's the BNP?
    Me: Dunno.
    Consult: Whay didn't you get a BNP?
    Me: 'cause it's a 48 hour send out. Come on down!
  8. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    We did BNP in a journal club (in a club room at the baseball stadium!), and came up with the same results. (edit: I see that I said that once already...)

    Regardless, when I researched today, the first one I came up with on a pt. I saw in the ED last fall was 6941.

    The second, and the one I was looking for, was (and I **** you not): 168951. I remember it being high, but convinced myself (until I found it again) that it was 5 digits. And that is with >255 being high at our hospital. This patient was a pretty bad CHF'er, but did not get tubed, did not have an MI, and did not have a PE. The cards fellow on echo came in, and found normal wall motion.
  9. anonymousEM

    anonymousEM Senior Member

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    ETOH 225...in a 2 year old. Daddy shouldn't have left his gin 'n juice on the portch in a bottle!
  10. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    That kid's a lush.
  11. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    Honorable mention from the SICU (at the VA, of course):

    420 pack/year smoking history - a carton of butts a day, for 42+ years.
  12. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    That would be like doing a bronch on a coal mine.
  13. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Trop 600 and 4 mm of ST elevation in a totally silent MI. Pt had absolutely no CP or SOB. Her CC was trouble speaking. She looked great when I admitted her yesterday but then went into pulm edema in the ICU and I just got back from tubing her.
  14. mikecwru

    mikecwru M.D. = Massive Debt

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    Glucose of 1410 the other day.

    mike
  15. supercut

    supercut Senior Member

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    From the OR

    SaO2 down to 18.

    A thoracic case, requring single lung ventilation and therefore a double lumen ETT. Anesthesia attending I've never seen before. Difficult intubation. Resident intubates, doesn't get end tidal CO2, pt seems to ventilate OK. But SaO2 heads south. I was expecting the EET to be removed, pt bagged and another attempt. But the attending won't let the resident do that, just tells him to keep bagging. Meanwhile the tone on the montitor gets lower, and lower, and lower...and I'm starting to get nervous and pushing for another attempt. Finally the poor anesthesia resident is allowed to get the tube out. Pt bagged back up OK, took a few minutes. The resident attempted a couple more times, never got it. Anesthesia attending never helped him. My attending finally came in, said, "Let me try" and got it. This is also the most useless anesthesia attending I have ever seen.
  16. DrQuinn

    DrQuinn My name is Neo Moderator Emeritus

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    Bizump.

    Had a CPK of 80,000 two nights ago. Guy came in with a complaint of left foot pain and left hip pain. Couldnt' remember the past two days. EMS said when they dropped him off "oh he's fine." I walk in, the guy has a pee bottle around his junks and said "Man, I can't pee." Looks like he's peeing kidney tissue when he does get something out! CPK took FIVE hours to get back for whatever reason, but started him on therapy anyways. MICU residents say he still doesn't know what the hell happened to him.

    Q
  17. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    We had stuff like this happening to us to. We'd be waiting for a trop or an ETOH and they would take forever, especially when we were suspicious. It turned out that the lab was doing serial dilutions to get the number. We had to really argue to convince them that if they were doing dilutions they needed to tell us IMMEDIATELY that the value is HIGH. We also found out that the old policy (old because we got it changed) was for the lab tech to order a repeat draw and not to release the abnormal value until it was confirmed. They were doing this with stuff like high potassiums! Now they release the abnormal and let us clinically corelate and get a repeat if we want.
  18. jdpharmd?

    jdpharmd? Turning lead into gold

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    Weight: 362 (Kilograms)
    CC: SOB :rolleyes:
  19. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    ~800 lbs. Woo hoo! I've noticed that people like that never understand how their weight makes it almost impossible to care for them. I had a guy like this who was yelling because I told him that he was too big for the CT table, the angio table and that the xrays were suboptimal and a VQ would be as well. His attitude was "Well what are YOU going to do about it?" So I said that I was going to admit him and put him on lasix and lovenox and hope for the best.
  20. Dr.Evil1

    Dr.Evil1 Senior Member

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    Saw this guy during neuro at the VA, my attending showed me a graph of his Na which started out at 102 then QUICKLY went up to 140 (presumably after hypertonic saline). The more impressive thing was the MRI report which read "large hypodense lesion in the mid pons possible infarction, please correlate clinically"
  21. ekydrd

    ekydrd Senior Member

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    You sure this was an accidental ingestion? Several years ago, when I was still a security officer at my hospital, we had a 2yo with an EtOH well over 200. Seems the babydaddy couldn't handle the crying so thought a little "juice" might make her sleep a while. Oh, and did I mention the baby's diaper was so full and wet that it must have weighed 10 lbs, and that she had one of the worst cases of diaper rash I've ever seen? I wonder why she was crying!?! :mad:
  22. USCDiver

    USCDiver Percocet-R-US

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    Meant to post this one last month when I was on Neuro consult service. Called by nephrology to see ESRD on dialysis with other problems who was "unresponsive". Had been walking and talking on admission a week ago. I go in to evaluate, she's staring into space, coarse breath sounds, heart beating, but that's about it. I go to look at her labs... FSBS 53 and 51 the last two mornings respectively. I ask the nurse "Did she get a finger stick this morning?" Her reply, with a dirty look, "No, she's not diabetic."

    So I says to her, I says "Why don't you get a finger stick and page me with the results"

    20 minutes later, I'm seeing another patient, the pager goes off, it's the nurse, "Blood sugar is.... 5"

    "Why don't you give her an amp of D50 and set up a drip and recheck in an hour."
    She didn't wake up at all.... FSBS now 73. I think to myself, "hmm, that ain't good, but that ain't it"

    Kicker is, I go back to round on the patient with the attending in the afternoon. Walk in the room, she's staring off into space as before, but there's no more coarse breath sounds. And no heart sounds. Son is in the room and says "She kind of stiffened up about 5 minutes ago"
  23. fuegorama

    fuegorama Senior Member

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    :eek: :eek:
    :eek: :eek: :eek:
    God that's awful. I hope there's one less chair full at that nursing station.
  24. USCDiver

    USCDiver Percocet-R-US

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    The other funny thing is that the nephrologist called about half an hour after I initially saw the patient and told the nurse to get a finger stick because "it'd be embarrassing to call the neurologist if it was just hypoglycemia"
  25. rdennisjr

    rdennisjr SDN Super Moderator Moderator Emeritus

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    New personal record I saw last night - new onset DKA in a youngish guy - probably a simmering type 2 that got pushed over the edge. BS initially of 1965. :love: Prime effort there! While you knew he was going to be high just by looking at him, he was carrying on a (generally) coherent conversation at presentation. Ph was only 7.01

    Dennis
  26. MechE

    MechE Med School's Slave

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    Holy Crap! :wow:
  27. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    Lipase 35137 - history of HCTZ-induced pancreatitis, pancreas divisum, stenting. I know it's not the highest, but this lady perked right up after 2 of morphine, and didn't look too bad to start. 2/5 Ranson's criteria on admission (age - 67, LDH - 418). Amylase 1192.
  28. HamSandwich

    HamSandwich Member

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    "doc, I have some bumps on my knees and elbows that hurt"

    TC 1,200
    TG 12,000
  29. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Did the blood have that milky layer that rises to the top in the tubes? That always freaks me out.
  30. ERMudPhud

    ERMudPhud Back for a visit

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    Never had time to post at work before but just had HCT of 72. Go to love smokers who live at 12,000 feet
  31. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Wow! Was the blood actually liquid or some kind of gel? Isn't the Hct of a bag of PRBCs about that?
  32. cdr50

    cdr50 Junior Member

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    ok. i haven't read all the posts in this thread... but i am confident that i've seen the world's record for corneal foreign bodies!!!

    dude presents with a chief complaint of "something in my eyes." seems he was workin' under his car "about a week ago" and while he was "lookin' up" at his work, "somethin' fell into" his eyes. now, after seven days, his eyes are hurtin' and he can't sleep! he said he'd "like to have 'em checked out."

    initial ophthalmoscopic exam was... unbelievable... and the slit lamp exam revealed 50+ imbedded metallic foreign bodies... IN BOTH EYES!!!

    "why have you waited so long?" i inquired.
    " i had to get my car runnin' 'efore i could drive into town." was the response... and his brother would not return tools that were needed to complete the repair!!!
  33. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    Our ABG machines don't register a number under 6.80, or a lactate greater than 15. After 8 amps of bicarb, a pH of....6.81, and a lactate of 15.0.

    Suicide attempt, complicated by 2L of upper GI bleeding (I actually tried to put an S-B tube in). Ended up pulling the plug after 3+ hours of work.
  34. SBL

    SBL Junior Member

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    On my IM rotation we had a patient with Hep C cirrhosis AND CHF who went into septic shock, most likely from SBP.... and had a glucose of 3!

    He was a little drowsy but was able to talk during this experience.

    And he survived that episode.
  35. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    New highest proBNP: 331042. This was historic from 1 week ago - she was 128000 when she was brought in yesterday with flash pulmonary edema, but bounced back immediately after Lasix from EMS.

    Interestingly, she is on dialysis, but still makes a reasonable amount of urine. Her troponin was 0.12, after being 0.16 in January, and 0.45 last week when she had a silent MI. (For those wondering what the hell I'm saying, renal players keep their troponin T up, 'cause they're not clearing it; over 0.10 is chemical evidence of MI in the non-renal player.)
  36. bcsmith

    bcsmith Member

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    42 y/o with acute RF, BUN/Cr = 212/47.4, K=9.7

    Interestingly, her Calcuim is 12 or so... probably stabilized her myocardium enough to survive a K of 9.7. Of course EKG was wide complex, T waves out the roof.

    I have her right now, we're still trying to sort out why her beans aren't working...

    B
  37. AJM

    AJM SDN Moderator Moderator Emeritus

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    I just saw a new Troponin I record: 1,100!

    The patient is still alive after cath and multiple stents, although does now have an EF of 20%.
  38. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I'll phrase this like a TILFMP post because there is a moral here. If your stomach hurts and you're puking blood don't treat it with ever increasing doses of aspirin and xanax. You'll wind up with a bicarb of 6 and an anion gap of 37.
  39. ERMudPhud

    ERMudPhud Back for a visit

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    You could treat it instead like one of my patients with ever increasing doses of ibuprofen and baking soda. Eventually giving yourself a bicarb of 44 and a venous ph >7.7 with tetany from hypocalcemia and all sorts of other electrolyte problems. We actually joked that aspirin might have been a better choice than ibuprofen since the metabolic acidosis of aspirin and metabolic alkalosis from the massive bicarb overdose might have cancelled each other out.
  40. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    These folks just don't think ahead.
  41. Jambi

    Jambi Caldari

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    67 y/o male Pt found pulseless and apneic and a board and care facilty. He was in V-Tach, defibed once with an AED. Regained pulses, ventilated for ~2 minutes, started breathing in his own. He regained consciousness, sat up, and said, "thanks guys." He then wanted to sign AMA. He couldn't understand why we were to insistent on taking him the hospital when he was "obviously" okay.
  42. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I had a patient today with pain that was a 10. Wow! The worst pain a person could ever have! This guy had injured his ankle somehow. He wasn't sure how because he was pretty drunk. In fact he was asleep. Every time I'd wake him up he'd sort of half open his eyes and slur that he needed narcotics. His pain? Always a 10/10. Amazing.
  43. Sessamoid

    Sessamoid 1K Member

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    I've pretty much given up asking about that useless 1 to 10 pain scale. There are only two intensities of pain in the ER: 10/10 or none.

    Or if the patient is Spanish speaking, there is only "too much" pain or none.
  44. AJM

    AJM SDN Moderator Moderator Emeritus

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    What about 15/10 pain? I love hearing that. :)
  45. KevJones

    KevJones Junior Member

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    How about a tooth to tattoo ratio of 6:23? Some of the artwork blended together, but he was certain that he had 23 separate pieces of work. Only two of the teeth were actually ajacent to each other.
  46. ERMudPhud

    ERMudPhud Back for a visit

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    Give me a month and I'm pretty sure I can find someone with no teeth left and at least one tattoo, thus setting an unbeatable ratio. :D
  47. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization

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    Isn't there some kind of a rule that they have to have at least a fraction of a tooth left?
  48. mikecwru

    mikecwru M.D. = Massive Debt

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    The person has to be completely edentulous and not with those little brown nubbles of teeth.

    mike
  49. rdennisjr

    rdennisjr SDN Super Moderator Moderator Emeritus

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    Not to break into the tooth:tattoo ratio discussion, but I was very excited last night to see a young man with an ETOH of 625. He really did breath much better after being snorkled.....that's the high mark any of us had seen for ETOH.


    Dennis
  50. Sessamoid

    Sessamoid 1K Member

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    At some point it must be easier to forego the blood alcohol level and just do a blood blood level and assume the rest is etOH.

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