ER Hall of Fame

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Wow. Slow day today?

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Had a patient I was transporting home for hospice care- Lung CA. SpO2 32% on BiPAP. RN staff said that had been normal for him for three days now. He was lucid and talking to me, but definitely as white as a sheet and could not sit up.

The only time I had ever seen a SpO2 that low before was in codes, so my pucker factor was definitely high. It's fine by me if this guy wants to go home to die, but don't do it in my ambulance!!!
 
I lead in something! My CSF count rocks... 'specially 'cause that kid did well, got antibiotics (after much yelling at pharmacy), went home and is meeting developmental milestones.

How cool is that?
 
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Keep in mind that most pulse oximeters aren't calibrated to measure below 60-70% even under optimal flow conditions. Although I would like to see someone with a 50% sat with "optimal" peripheral blood flow.
 
I guess it's not a record, but at least an honorable mention. ESRD pt (not diabetic) with what was probably sepsis/Addisons, c/o 4 months of "overall weakness." Lab calls to tell us Glucose is 15. Pt is A&OX3. Must be lab error, so we check finger stick. It's 7. After D50, pt says he feels better (go figure). Also had a lactate of 12.9.
 
Nice. Sodium of 104. Patient altered but can respond to simple commands. After labs came back, including Osm's and Urine sodium, etc., Patient had SIADH. Admitted to MICU and downgraded to Floors in about 3-days. Returned to baseline and walked with family.
 
TSH of 188. I think we found the source of the "feeling tired". Not a critical value, but damn impressive level of abnormality.

- H
In my hospital the whole "critical value" thing is just wacky. That CK of >80k was reported as routine but every stinking K of <3.2 gets called like a code blue. Whatever.
 
Abdominal mass -- 30 X 30 X 15 cm (final path report -- ovarian serous cystadenoma)

honarable mention, ovarian serous cystadenoma weighing in at 71lbs (I think thats about 30L of fluid given 2.24lbs per Kg and 1Kg per Liter), it popped in the OR.
 
male, 48
Troponin of 200
wants to leave AMA :laugh:
 
Not all of these are records, but some of them are interesting...

Glucose:

Highest: 2190. New onset DKA, pH of 6.7. Symptomatic but not comatose!
Lowest: 3. 1-month old with MCAD deficiency.

A1C: 17.9. Not as high as the other one posted, but still damned impressive! And of course this kids *always* takes his insulin. Uh huh.

TSH: Highest was 2010. Yes, two *thousand* ten. This kid was 13 years old and still had baby teeth. When we checked him in the office, I honestly thought I had the birthdate wrong. He looked like he was about 6.
 
guy in Phoenix in July, doing meth early in the evening, fell asleep in his car, found next day at 3 pm (118 outside), pulled out of car by "passers by" - core temp of 116, walked out of the hospital, no brain damage 5 days later...
 
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Worth an honorable mention, as there were so many "personal records" in one patient...

29 yo previously healthy male, c/o SOB and CP. Buys a tube immediately, with bloody frothy sputum. The lab finally calls with BUN >250, Cr 28. ABG shows pH 6.56.

Sucked to be him - his family let him die rather than stay a vegetable when he didn't wake up a couple weeks later. Never figured out what the hell happened... Pulmonary-renal syndrome of some sort as best we guessed. The thing is, he presented to a different ED 3 days prior and was Dx with URI. No labs at that time.

Lets just say it put the fear in me... I check a lot of basic chemistries these days...
 
Abdominal mass -- 30 X 30 X 15 cm (final path report -- ovarian serous cystadenoma)

Saw a teenage girl with a very similar size ovarian mass to this on my FP rotation. Came in with mom. Looked like she was in her third trimester. C/O discomfort under her inferior ribs (ya think?!?). Still can't imagine how she waited that long since she knew she wasn't pregnant (teenage girls being prone to worrying about their appearance and all). I remember 32x13, but I can't remember the third dimension.
 
I saw a patient who had an eosinophil of 58% and diarrhea for 2 months.
 
Maybe not a record but...

55 yo F comes in with back and chest pain. Hx of Hep C and alcoholism. Fell 2 weeks ago and complains of tendersness to the upper back. Her chest xray suggests a T4 compression fx. She is AOx3 with some mild ataxia and asterixis. She has a history of hepatic encephalopathy so that seems to fit the picture and her ammonia is 70.

Lab calls and says their Lytes machine is down, it will be an hour and a half until they can get us results. I start getting this patient admitted for hepatic encephalopathy, since she lives alone and her gait is a little unsteady.

Lab calls...BUN 234 and Cr 24.5. Since she is AOx3 and the lab is having issues, we figure this is wrong. I draw an ABG and get lytes off it, which confirms. Next call Nephro followed by ICU and off to dialysis.

I figure a BUN of 234 with normal mentation has to be some kind of record.
 
This is my personal record for the least helpful lab interaction of all time.

Lab: 'critical lab values': glucose of 25, pH 6.8, K of 7.5.

Me: uh, yeah, thanks for that prompt feedback. We'll be happy to forward that information to the team now caring for him. He's been in the morgue for about two hours now.

Me: BTW, I don't suppose you have the urine I sent off about three hours ago on another patient, do you?

Lab: Let me look. Oh what do you know, it's on the machine right now.


Take care,
Jeff
 
This happened a couple of weeks ago. I am currently doing my general surgery rotation and we were called down to the ER because there was an 18 year old with abdominal pain, they wanted to rule out appendicitis. Well it turns out she didn't have appendicitis, she was pregnant and what she had was round ligament pain, nothing special right...

she was G5P4!!
 
ESRD pt w sob x 1 wk p/w hh 2.3/8.1. living a month later, w cdiff of course...
 
oh and t max 108 in a trached pt w large ex vacuo encephalomalacia and asp pna.
 
Ok, can we have mandatory tubal ligations for some folks?

Supreme Court says "No" but maybe if they overturn Roe v. Wade and there's a sudden influx of children dependent upon the public's tax dollars they could be convinced to revisit the issue.

But I really don't like that idea.
 
I didn't see any records for ammonia so I nominate my patient tonight with a stellar... DA DA DADA 302 ! Yes she's altered. Yes she's ESLD. Let me call the internist. I know he'll be proud.

Don't know quite why I measured it but I had a 450 yesterday. The more interesting record on this guy from my point of view was the record for fewest number of normal labs. Endstage hepatorenal with massive GIB and who knows what else. Initial labs included CBC, 7, LFT's, PT/PTT, ABG, ammonia, lactate and only his Na and Cl where normal. Everything, and I mean everything else was abnormal.
 
Ok, can we have mandatory tubal ligations for some folks?



I think she's cool. The G12P12 women are the ones that terrorize the grocery stores.
 
An older gentleman crash landed his cessna 152 on a local road during a cross country flight. He had bumps and bruises and an etoh of .26
 
Don't know quite why I measured it but I had a 450 yesterday.

481 on a guy I consulted on for the GI service the other day. Found down by his mom, drinks "a crapload" according to her and she hadn't seen him in a couple of days even though he lives in her house. I heart the vets.
 
K of 0.9....

Oh and i dont know if it matter but our lab doesnt give us pHs below 6.8 or lactates above 15..

We did have a Bhcg of 2,500,000... turns out it was a lab error..
 
We did have a Bhcg of 2,500,000... turns out it was a lab error..

My father (who is a medical technologist) had one that they had to serially dilute I think he said five or six times to get it down to a level where they could get a quantitative reading on the analyzer. I don't recall the exact figure but it was freakishly high and the result of some form of cancer that I don't recall.
 
Let's try this again.

490735453_c03fd6e324.jpg
Wow......Aub, you really need to stop going out drinking with the surgeons..... :laugh:
 
That's like, what, antifreeze?

Nope......antifreeze, in its most common formulation is ethylene glycol. :p
 
Thought this was the highest lactate I had ever seen: 19.0

Then one week later, I had another patient with a lactate of 19.7
 
Thought this was the highest lactate I had ever seen: 19.0

Then one week later, I had another patient with a lactate of 19.7
Did they live?
 
Na: 96 Cl: 59 K: 1.7

Lung cancer --> SIADH + Lasix

GOt that beat. K=1.2. Lots of ectopy on EKG. She came back a few weeks later with K=1.5. No diuretics or findable malignancy.
 
GOt that beat. K=1.2. Lots of ectopy on EKG. She came back a few weeks later with K=1.5. No diuretics or findable malignancy.

we have a pt like that who ends up in our obs unit every few months. loosing k from somewhere/something resistant to workup/IM flogging. when her k gets below 1.5 she presents with flacid paralysis effecting all her voluntary muscular action. when it gets over 2 she is fine.....weird.......
 
we have a pt like that who ends up in our obs unit every few months. loosing k from somewhere/something resistant to workup/IM flogging. when her k gets below 1.5 she presents with flacid paralysis effecting all her voluntary muscular action. when it gets over 2 she is fine.....weird.......

We had a lady like this that used to huff toluene.

mike
 
Record for number of home medications taken by a patient with "no medical problems" on history.

15

ASA
NTG PRN
Lortab PRN
Ambien
Atenolol
Xanax
Norvasc
Lisinopril
Glucophage
Lasix
K-Dur
Glipizide
Nexium
Paxil
Neurontin
 
I had a kid last night s/p chemo who came in febrile and every number on his differential was 0.
 
Bicarb of 2. DKAer. Actually did pretty well. pH was 6.90 and she was awake and talking.
the one time i'll ever be able to beat docB--and not by much: pH 6.9 with bicarb of 1.5. also DKA, also doing well.
 
my record in the Gravid dept was a 23 year old G17P1 with 16 miscarriages. When I saw her she had a fully formed 2 inch fetus between her legs. actually make that G18P1.
 
I got one that no ONE else in the hospital could touch..
 
Except for maybe the NICU/Peds..

68 y/o guy.. yellow like my urine.. Total Bili 25.9... YEP TWENTY FIVE POINT NINE...

Most people I spoke to guessed something like 12.. YOWZA!
 
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