Post a good case, dammit.

[RustedFox]

Here's mine.

54 year old female. No meds. Near syncope while at work (here at the hospital).

Says she felt this "incredible pressure and coldlike sensation" in her head just prior to almost going down.

Workup negative.

She had that look, like: "turn off the damn lights" in a room that is not abundantly lit.

CT brain = small subarachnoid bleed in the circle. Subsequent CTA = no aneurysm, AVM, or other anatomic abnormalities.

She just "looked that way".

Your turn.

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[bravotwozero]

Twenty something year old male, presents to the ED with left periorbital/forehead swelling.

Says it's been going on for a month, with no improvement.

Was seen at this ED a month ago, diagnosed with preseptal cellulitis, sent home on po and topical antibiotics.

The lack of improvement with antibiotics, and particularly the unilateral forehead swelling made me worried, so I got a CT max/face with contrast.

Get a call back from the radiologist asking what's going on with the patient, says he hasn't seen this in years.

Guy has a left orbital abscess, with intracranial extension. My first and only case I have ever seen so far.

What really surprised me was how otherwise completely unimpressive his exam was. Sure, lots of peri orbital swelling, but no photophobia, direct or reactive, no proptosis, intact EOM.

Called on call ophtho at our hospital's mothership, says he needs to be transferred to a place that has 'oculo-plastics'. Didn't even know that was a specialty. Gave zosyn and shipped out promptly.

 

[Mr. Vandemar]

Younger guy without any known history comes in with anaphylaxis after eating a new food. Rash, angioedema, hypotension the whole deal which mostly responds to epi aside from he continues to look like ****. Get an EKG and he’s having a STEMI. I guess he failed his stress test?

 

[RustedFox]

Younger guy without any known history comes in with anaphylaxis after eating a new food. Rash, angioedema, hypotension the whole deal which mostly responds to epi aside from he continues to look like ****. Get an EKG and he’s having a STEMI. I guess he failed his stress test?

Younger; but buttery?

What was his (estimated) BMI?

 

[turkeyjerky]

Younger guy without any known history comes in with anaphylaxis after eating a new food. Rash, angioedema, hypotension the whole deal which mostly responds to epi aside from he continues to look like ****. Get an EKG and he’s having a STEMI. I guess he failed his stress test?

Kounis syndrome

 

[Mr. Vandemar]

Younger; but buttery?

What was his (estimated) BMI?

He was...not small.

Kounis syndrome

Wow! TIL.

 

[Jabbed]

Here's mine.

54 year old female. No meds. Near syncope while at work (here at the hospital).

Says she felt this "incredible pressure and coldlike sensation" in her head just prior to almost going down.

Workup negative.

She had that look, like: "turn off the damn lights" in a room that is not abundantly lit.

CT brain = small subarachnoid bleed in the circle. Subsequent CTA = no aneurysm, AVM, or other anatomic abnormalities.

She just "looked that way".

Your turn.

Perimesencephalic hemorrhage. Excellent prognosis.

 

[Apollyon]

Wow! TIL.

Me too!!

 

[RustedFox]

He was...not small.


Wow! TIL.

So.... "pizza rolls are a staple of my diet"-style pudgy, or "drinks melted butter thru a straw" lard@ss?

 

[Tenk]

I had a meth head who started freestyle rapping in the hallway and me and 3 other nurses just stood there listening for like 5 minutes.

 

[RustedFox]

I had a meth head who started freestyle rapping in the hallway and me and 3 other nurses just stood there listening for like 5 minutes.

Great case. Much academic.

 

[CajunMedic]

I had a meth head who started freestyle rapping in the hallway and me and 3 other nurses just stood there listening for like 5 minutes.

Ours have a nasty habit of getting tubed because they look like a head bleed, going to the ICU, self-extubating and leaving AMA the next day. Or, repeatedly punching themselves in the face and chest a la Jim Carrey in "Liar, Liar"

College cheerleader comes in after falling during a pyramid attempt. Describes the fall as "getting folded in half backwards". RLE weakness and numbness. Our newest neurologist (who hangs out sometimes in the ED when she's on stroke call) sees the patient with me and pushes them to the front of the MRI line. Ultimately diagnosed with SCIWORA, and a lumbar plexopathy. Won't cheer for at least a year, but is getting rehab and walks with a walker for now with no bowel/bladder issues.

 

[Apollyon]

Ours have a nasty habit of getting tubed because they look like a head bleed, going to the ICU, self-extubating and leaving AMA the next day. Or, repeatedly punching themselves in the face and chest a la Jim Carrey in "Liar, Liar"

College cheerleader comes in after falling during a pyramid attempt. Describes the fall as "getting folded in half backwards". RLE weakness and numbness. Our newest neurologist (who hangs out sometimes in the ED when she's on stroke call) sees the patient with me and pushes them to the front of the MRI line. Ultimately diagnosed with SCIWORA, and a lumbar plexopathy. Won't cheer for at least a year, but is getting rehab and walks with a walker for now with no bowel/bladder issues.

When I was a student, I was taught that this is a purely pediatric thing (and, I remember specifically, because the guy teaching, my friend had the hots for). Like, college cheerleader is too old for that.

 

[lymphocyte]

Lady with a new diagnosis of "migraine" at the age of 68 two days prior. No imaging. Rolled into ED Fast Track on a wheelchair wearing sunglasses because she was so photophobic. Intern thankfully gets a CT before starting her on a chloropromazine infusion because "that's what you give migraines." She becomes profoundly hypotensive.

I empty a whole stick of metaraminol (which is like phenylephrine) into her. Blood pressure doesn't budge much. No fevers to suggest sepsis. Nornal ECG. Normal TTE. Not hemorrhaging. I can't figure out why she's shocked. I said, "**** it, let's try some steroids." It works like magic. Meanwhile the CT comes back (almost at the same time). Pituitary apoplexy. It explained everything! Turns out she had a pituitary macroadenoma lost up follow-up. She became Addisonian when the thing popped two days ago.

 

[PianoMedic]

Had a mid-50s male come in as a pre hospital stroke alert. Classic hemiparesis, facial droop, aphasia so I’m thinking large vessel MCA. Head CT shows a ton of blood, most in the parenchyma with some ventricular extension. Platelets come back at 14k, order those. Patient then proceeds to teach me my first learning point: don’t let headbleeds puke. He started retching then become more somnolent but pupils the same still. Intubated him. Less than five minutes later I get a call from the heme tech: “can I get a path consult on this patient’s slide? I think I see promyelocytes”. “Uh sure?” I knew that was something I’d heard in med school but couldn’t remember anything about it. I got called back into the room and had other patients to take care of (he started herniating so I updated nsgy resident and gave hypertonic). I got a call from the pathologist personally about a half hour later (he was somehow reading from home) who tells me “this patient’s slide looks like promyelocytic leukemia, we need a stat onc consult” “ok, will do after I stop him from herniating…”

Learning point 2: if people seem to care intensely about something and you have no freaking clue why, ask them! I did get the onc consult, leading to Learning point 3, which is this guys disease: acute promyelocytic leukemia, APML.

Treatment is all trans retinoic acid, aka ATRA. It converts all of those cells to neutrophils. But this causes a massive sirs response and these ppl can go into pulmonary edema, pericardial effusions, cerebral edema, etc. Basically fluid everywhere. They have to go to the ICU after you give it usually. My patient was too far gone at that point. Josh Farkas’ site has some really good info on this disease if you want more. One of the people I discussed APML with described it as “like DIC, but instead of the pt being clotty-bleedy, these ppl are just bleedy-bleedy”. They usually are found when they have a major hemorrhage. If they survive their presenting complaint and get ATRA, they do pretty well. But they often present in extremis and on death’s door. I’ll wait and post other cases later but I have quite a few if I can just remember them all.

 

[Apollyon]

Had a mid-50s male come in as a pre hospital stroke alert

Was this from where you were a resident? (I live there)

 

[RustedFox]

Had a mid-50s male come in as a pre hospital stroke alert. Classic hemiparesis, facial droop, aphasia so I’m thinking large vessel MCA. Head CT shows a ton of blood, most in the parenchyma with some ventricular extension. Platelets come back at 14k, order those. Patient then proceeds to teach me my first learning point: don’t let headbleeds puke. He started retching then become more somnolent but pupils the same still. Intubated him. Less than five minutes later I get a call from the heme tech: “can I get a path consult on this patient’s slide? I think I see promyelocytes”. “Uh sure?” I knew that was something I’d heard in med school but couldn’t remember anything about it. I got called back into the room and had other patients to take care of (he started herniating so I updated nsgy resident and gave hypertonic). I got a call from the pathologist personally about a half hour later (he was somehow reading from home) who tells me “this patient’s slide looks like promyelocytic leukemia, we need a stat onc consult” “ok, will do after I stop him from herniating…”

Learning point 2: if people seem to care intensely about something and you have no freaking clue why, ask them! I did get the onc consult, leading to Learning point 3, which is this guys disease: acute promyelocytic leukemia, APML.

Treatment is all trans retinoic acid, aka ATRA. It converts all of those cells to neutrophils. But this causes a massive sirs response and these ppl can go into pulmonary edema, pericardial effusions, cerebral edema, etc. Basically fluid everywhere. They have to go to the ICU after you give it usually. My patient was too far gone at that point. Josh Farkas’ site has some really good info on this disease if you want more. One of the people I discussed APML with described it as “like DIC, but instead of the pt being clotty-bleedy, these ppl are just bleedy-bleedy”. They usually are found when they have a major hemorrhage. If they survive their presenting complaint and get ATRA, they do pretty well. But they often present in extremis and on death’s door. I’ll wait and post other cases later but I have quite a few if I can just remember them all.

Great case.
This is the stuff that we should be discussing with regularity on here.

 

[RustedFox]

“like DIC, but instead of the pt being clotty-bleedy, these ppl are just bleedy-bleedy”

I can hear this being said in @dchristismi 's voice. (For the others on here that know him/her in real life).

 

[Jabbed]

36 year old is seen at a workman's comp clinic for a neck injury. They call EMS to send him to the ED for MRI (ya, okay..). En route with EMS he gets reflux that develops into real chest pain. EMS records six EKGs, the fourth of which shows an inferior STEMI. On arrival to the ED he still looks like ****, waxy and diaphoretic. EKG is normal though. I activate cath lab based on the fourth EMS EKG. 100% RCA.

 

[southerndoc]

36 year old is seen at a workman's comp clinic for a neck injury. They call EMS to send him to the ED for MRI (ya, okay..). En route with EMS he gets reflux that develops into real chest pain. EMS records six EKGs, the fourth of which shows an inferior STEMI. On arrival to the ED he still looks like ****, waxy and diaphoretic. EKG is normal though. I activate cath lab based on the fourth EMS EKG. 100% RCA.

What did his C-spine MRI show?

 

[The Knife & Gun Club]

Tox. 28 year old software engineer eats a ‘shrooms candy bar he bought off the internet. Hallucinating for 6h, then acute GI Upset, dehydration, seen in ED, fluids, ct scan, discharge.

Comes back 4 days later, acute renal failure with cr of 12, pulmonary edema, tubed, lined, to ICU. Call Tox, our badass Tox attending says they’ll “review the literature.”

Next day, he has an answer: Amanita Smithiana toxicity. Less than 10 cases reported in the US, ever. Causes GI upset with delayed acute renal failure. Treatment is dialysis and steroids. 1 week in and hes extubated, off dialysis, making urine again, and coding on his laptop from them floor. Currently pending mass spec for confirmation for the Amanita Smithiana toxin, which is so rare it literally doesn’t even have a name.

 

[Mr. Vandemar]

36 year old is seen at a workman's comp clinic for a neck injury. They call EMS to send him to the ED for MRI (ya, okay..). En route with EMS he gets reflux that develops into real chest pain. EMS records six EKGs, the fourth of which shows an inferior STEMI. On arrival to the ED he still looks like ****, waxy and diaphoretic. EKG is normal though. I activate cath lab based on the fourth EMS EKG. 100% RCA.

@turkeyjerky is there a syndrome for this one?

 

[Apollyon]

Tox. 28 year old software engineer eats a ‘shrooms candy bar he bought off the internet. Hallucinating for 6h, then acute GI Upset, dehydration, seen in ED, fluids, ct scan, discharge.

Comes back 4 days later, acute renal failure with cr of 12, pulmonary edema, tubed, lined, to ICU. Call Tox, our badass Tox attending says they’ll “review the literature.”

Next day, he has an answer: Amanita Smithiana toxicity. Less than 10 cases reported in the US, ever. Causes GI upset with delayed acute renal failure. Treatment is dialysis and steroids. 1 week in and hes extubated, off dialysis, making urine again, and coding on his laptop from them floor. Currently pending mass spec for confirmation for the Amanita Smithiana toxin, which is so rare it literally doesn’t even have a name.

Reminds me of a case from when I worked in SC. Dude's girlfriend picked a mushroom in the front yard, and cooked it, and, knowingly, he ate it. When he comes in, you know the way people say, "I can't stop puking", but, they have clean teeth, no puke breath, and look fine? This brother was not that. It was a bit to get him into a bed. But, the GFs father was with him, and brought one of the 'shrooms with him. I recall consulting one of the myriad books that are there, bit no one ever needs to open; maybe it was Goldfrank's. I found the image, but, also, I found out, on a Sunday evening, that South Carolina has a "state mycologist"! Guy's Cr comes back at 3.4, and I got a concise tidbit from the Tox guy on the phone, which I didn't learn in med school or residency: if you throw up in an hour, you're gonna die. If you throw up in 4-6 hours, you're not going to die, but, you're going to feel like you're dead alive. The first is the A. phylloides, and the second A. muscaria. This dude lived.

But, A. smithiana? What the actual F? People be cray, end of story.

 

[turkeyjerky]

@turkeyjerky is there a syndrome for this one?

Lol. There's gotta be some eponym out there for a pithy maxim about the misblaming of symptoms on an incidental trivial injury.

 

[The Knife & Gun Club]

Reminds me of a case from when I worked in SC. Dude's girlfriend picked a mushroom in the front yard, and cooked it, and, knowingly, he ate it. When he comes in, you know the way people say, "I can't stop puking", but, they have clean teeth, no puke breath, and look fine? This brother was not that. It was a bit to get him into a bed. But, the GFs father was with him, and brought one of the 'shrooms with him. I recall consulting one of the myriad books that are there, bit no one ever needs to open; maybe it was Goldfrank's. I found the image, but, also, I found out, on a Sunday evening, that South Carolina has a "state mycologist"! Guy's Cr comes back at 3.4, and I got a concise tidbit from the Tox guy on the phone, which I didn't learn in med school or residency: if you throw up in an hour, you're gonna die. If you throw up in 4-6 hours, you're not going to die, but, you're going to feel like you're dead alive. The first is the A. phylloides, and the second A. muscaria. This dude lived.

But, A. smithiana? What the actual F? People be cray, end of story.

That’s a great quote. I’m gonna steal that for my library.

Apparently there’s a whole variety of lesser known Amanita mushrooms besides phylloides and muscarina which cause all sorts of weird exotic toxidromes. But they’re so rare they’re no one teachers about them.

 

[WilcoWorld]

Tox. 28 year old software engineer eats a ‘shrooms candy bar he bought off the internet. Hallucinating for 6h, then acute GI Upset, dehydration, seen in ED, fluids, ct scan, discharge.

Comes back 4 days later, acute renal failure with cr of 12, pulmonary edema, tubed, lined, to ICU. Call Tox, our badass Tox attending says they’ll “review the literature.”

Next day, he has an answer: Amanita Smithiana toxicity. Less than 10 cases reported in the US, ever. Causes GI upset with delayed acute renal failure. Treatment is dialysis and steroids. 1 week in and hes extubated, off dialysis, making urine again, and coding on his laptop from them floor. Currently pending mass spec for confirmation for the Amanita Smithiana toxin, which is so rare it literally doesn’t even have a name.

Seems odd that he hallucinated from A. smithiana, no?

 

[Apollyon]

Seems odd that he hallucinated from A. smithiana, no?

With less than 10 reported cases, I don't know how much you can really extrapolate!

 

[Birdstrike]

I had a meth head who started freestyle rapping in the hallway and me and 3 other nurses just stood there listening for like 5 minutes.

How was his flow? Smooth?

 

[WilcoWorld]

With less than 10 reported cases, I don't know how much you can really extrapolate!

I was inferring from the fact that they're not just a different species, but an entirely different genus from the psilocybin containing mushrooms.

 

[Tenk]

How was his flow? Smooth?

Far better than you’d think.

 

[The Knife & Gun Club]

Seems odd that he hallucinated from A. smithiana, no?

I was inferring from the fact that they're not just a different species, but an entirely different genus from the psilocybin containing mushrooms.

It was a “shrooms candy bar” aka they pick a bunch of mushrooms, do some sort of extraction and blending process, then use that base to make the bar.

So likely it had both psilocybin and Amanita toxins in the mushroom.

From what we could read on the process it doesn’t involve heating or cooking, just a bunch of squishing of the mushroom and different solvents. These things are semi legal in the PNW and they’re popping up at Tox centers across the country now.

 

[Fox800]

Elderly female comes in by EMS for sudden-onset dyspnea. History of COPD. Took her SPO2 reading at home at it was in the high 60s. Used albuterol x1. When EMS arrived, it was 74%. Improved to 95% with 4LPM nasal cannula. She is on 2LPM all the time.

On arrival to the ED, totally asymptomatic. No complaints. Never had chest pain. Stoic old lady. Mild wheezing but adamantly denying any complaints. No longer short of breath. SPO2 readings are 86-89% on her usual 2 LPM (she has COPD and is on 2LPM all the time). HR solidly in the 80s the whole time. No pleuritic CP, no historical risk factors for PE. Wheezing every time I listen to her.

Wanted to leave, but agreed to stay for a work up. About 3 hours in, now admits she is feeling slightly dyspneic. CXR clear, ECG nonischemic, no RV strain, HR in the 80s. Trop is barely elevated above the cutoff. Still wheezing. Gets nebulizers and steroids.






Bilateral PEs.

 

[BoardingDoc]

50ish year old lady comes in with a chief complaint of "my sinuses hurt, I think I'm having a heart attack."

BL Max sinus tenderness w/ percussion. Otherwise well appearing. VSS. Pt says that she had these sx before and her doctor told her it was because she was having a heart attack. I explain that this sounds insane. She says she was having the sinus pressure and they ran a whole bunch of tests and they finally found out that it was her heart. Out of "why the F not" I decide to order a trop and EKG.
EKG is fine.
Trop is >1. Normal baseline trop and renal function. WTF. Her anginal equivalent is sinusitis.

 

[Jabbed]

40-something male MCC polytrauma. He's intubated, transfused, etc. Cut off his clothes and find a male chastity cage with a lock! We can't clip it-- it's apparently made of titanium. We talk to his wife and she says that she doesn't have the key, but she knows who does. We call the number that she provides and this person is on the other side of the country! But they promise to Fedex overnight the key.

We ended up calling a locksmith.

 

[Dr Mantis Toboggan]

Perfect illustration of how this can be the best and worst job in the world. Often on the same shift.

 

[Birdstrike]

Cut off his clothes and find a male chastity cage with a lock!

You're joking, right?

 

[WilcoWorld]

40-something male MCC polytrauma. He's intubated, transfused, etc. Cut off his clothes and find a male chastity cage with a lock! We can't clip it-- it's apparently made of titanium. We talk to his wife and she says that she doesn't have the key, but she knows who does. We call the number that she provides and this person is on the other side of the country! But they promise to Fedex overnight the key.

We ended up calling a locksmith.

There are MANY unanswered questions here...

 

[RustedFox]

There are MANY unanswered questions here...

... that need, NEED to remain unanswered.

 

[The Knife & Gun Club]

40-something male MCC polytrauma. He's intubated, transfused, etc. Cut off his clothes and find a male chastity cage with a lock! We can't clip it-- it's apparently made of titanium. We talk to his wife and she says that she doesn't have the key, but she knows who does. We call the number that she provides and this person is on the other side of the country! But they promise to Fedex overnight the key.

We ended up calling a locksmith.

I had a similar one with a guy found passed out at the wheel in middle of the highway at a dead stop. Tubed by EMS.

Nurse is cutting off his clothes and find a huge steel hex nut at the base of penis with rock hard priapism with signs of ischemia. Called Fire rescue for boot cutters as we proceed with resus. They couldn’t get it off. Ended up sticking a needle in it, draining the priapism, and then get the bolt off that way.

End of the story he was at a marathon sex party, did meth and injected alprostadil into Penis, and had a brain bleed found on CT.

 

[thegenius]

I had a similar one with a guy found passed out at the wheel in middle of the highway at a dead stop. Tubed by EMS.

Nurse is cutting off his clothes and find a huge steel hex nut at the base of penis with rock hard priapism with signs of ischemia. Called Fire rescue for boot cutters as we proceed with resus. They couldn’t get it off. Ended up sticking a needle in it, draining the priapism, and then get the bolt off that way.

End of the story he was at a marathon sex party, did meth and injected alprostadil into Penis, and had a brain bleed found on CT.

LMAO

 

[Zebra Hunter]

Had a very unfortunate case of a 50 yo M brought in by EMS for bilateral leg pain and is hypotensive and tachycardic. Tachy to 140s, BP 100/60 (after EMS gave 1L). Apparently was seen at another ER 4 hours prior for bilateral leg pain and was discharged after DVT study and CT were negative for acute abnormalities.

I removed the patients pants and find that both legs are swollen AF and purple, very taut diffusely. He is clearly in severe pain, as well. Intact, but faint, b/l DP pulses.

"Sir, you have a hx of DVTs?"

"Yeah"

"Are you supposed to be on blood thinners?"

"Yeah, but I haven't taken my coumadin in a month because I didn't think I needed to."

Perform a quick bedside US of bilateral femoral veins, and he has occlusive clots throughout. Start him on heparin and fluids immediately, asked CT to take him for a CTPA and CT abd/pelvis w/ contrast immediately. Told our US tech to come do a formal DVT scan. Then I asked our clerk to call vascular surgery STAT for bilateral phlegmasia cerulea dolens.

Chart review while he is in CT and see that he was seen at our sister hospital 4 hrs prior. B/L DVT studies are negative (I confirmed by looking at them myself), but they performed a CT abd/pelvis non con (no contrast because he had a mild AKI) but somehow were able to note he had extensive IVC clot w/ a IVC filter in place, but they read it as "stable compared to previous exam" from 1 yr prior. I reviewed his chart from 1 yr ago, luckily he was seen at our hospital, and it appears he had a near identical presentation 1 yr prior requiring thrombectomy of b/l femoral/iliac veins and an extensive ICU stay. The CT the radiologist was comparing was an exam performed prior to thrombectomy being performed. He had a heme consult then, but they could not figure out why he had such a terrible clotting disorder.

I get a call from the same radiologist who read the imaging 4 hrs prior who states "I've never seen anything like this, are you sure this is the same patient? Because now he has clot that has basically extended completely from IVC down to b/l popliteals based on the CT abd/pelvis and US of LEs."

Vascular asks that I call IR first to attempt catheter directed thrombolysis first. He also states that this guy is likely not long for this world based on the extent of clot. IR guy says "this guy clearly needs mechanical thrombectomy, as the tPA isn't going to work quick enough for this guy." But says he'll call vascular surgeon personally and they'll hash it out.

IR ends up taking him for thrombolysis, but on the table, right before administering tPA, the patient starts vomiting copious amounts of blood, so they decide against tPA and call vascular. Vascular then comes in immediately and performs an extensive thrombectomy and bilateral 4 compartment fasciotomy.

The patient then ends up re-clotting the next day and gets taken back for another thrombectomy procedure.

He ended up requiring CRRT, developed fulminant hepatitis, went into respiratory failure and unfortunately passed a few days later. Makes me sad because he was a very nice guy who just made a very poor decision for himself.

I, also, had never seen Phlegmasia Cerulea Dolens prior to this patient, let alone bilateral.

 

[WilcoWorld]

I had a similar one with a guy found passed out at the wheel in middle of the highway at a dead stop. Tubed by EMS.

Nurse is cutting off his clothes and find a huge steel hex nut at the base of penis with rock hard priapism with signs of ischemia. Called Fire rescue for boot cutters as we proceed with resus. They couldn’t get it off. Ended up sticking a needle in it, draining the priapism, and then get the bolt off that way.

End of the story he was at a marathon sex party, did meth and injected alprostadil into Penis, and had a brain bleed found on CT.

I'm no prude, but this just doesn't sound fun - even without the brain bleed.

 

[WilcoWorld]

they read it as "stable compared to previous exam" from 1 yr prior...The CT the radiologist was comparing was an exam performed prior to thrombectomy being performed

 

[thegenius]

I had a similar one with a guy found passed out at the wheel in middle of the highway at a dead stop. Tubed by EMS.

Nurse is cutting off his clothes and find a huge steel hex nut at the base of penis with rock hard priapism with signs of ischemia. Called Fire rescue for boot cutters as we proceed with resus. They couldn’t get it off. Ended up sticking a needle in it, draining the priapism, and then get the bolt off that way.

End of the story he was at a marathon sex party, did meth and injected alprostadil into Penis, and had a brain bleed found on CT.

Did they save his penis?

 

[Birdstrike]

I had a similar one with a guy found passed out at the wheel in middle of the highway at a dead stop. Tubed by EMS.

Nurse is cutting off his clothes and find a huge steel hex nut at the base of penis with rock hard priapism with signs of ischemia. Called Fire rescue for boot cutters as we proceed with resus. They couldn’t get it off. Ended up sticking a needle in it, draining the priapism, and then get the bolt off that way.

End of the story he was at a marathon sex party, did meth and injected alprostadil into Penis, and had a brain bleed found on CT.

Civilization had a good run.

 

[WilcoWorld]

Did they save his penis?

You're going to have to be more specific

 

[dchristismi]

“like DIC, but instead of the pt being clotty-bleedy, these ppl are just bleedy-bleedy”

I can hear this being said in @dchristismi 's voice. (For the others on here that know him/her in real life).

Yeah actually, I can also hear myself saying this...

FWIW, this thread is the reminiscent of the glory days of this forum.
It has made me smile. Granted, there were some gratuitous trauma/penis stories, but aren't the glory days of EM littered with trauma/penis stories? (With some meth and actual mushrooms sprinkled in for good measure)

 

[The Knife & Gun Club]

Did they save his penis?

Well it was still attached to his body when he went to ICU. Beyond that your guess is as good as mine.

Our community hospital is a priapism center of excellence. We have the prefilled phenylephrine syringes in the ED pyxis and do a few every month due to an…adventurous…patient population.

 

[The Knife & Gun Club]

Had a very unfortunate case of a 50 yo M brought in by EMS for bilateral leg pain and is hypotensive and tachycardic. Tachy to 140s, BP 100/60 (after EMS gave 1L). Apparently was seen at another ER 4 hours prior for bilateral leg pain and was discharged after DVT study and CT were negative for acute abnormalities.

I removed the patients pants and find that both legs are swollen AF and purple, very taut diffusely. He is clearly in severe pain, as well. Intact, but faint, b/l DP pulses.

"Sir, you have a hx of DVTs?"

"Yeah"

"Are you supposed to be on blood thinners?"

"Yeah, but I haven't taken my coumadin in a month because I didn't think I needed to."

Perform a quick bedside US of bilateral femoral veins, and he has occlusive clots throughout. Start him on heparin and fluids immediately, asked CT to take him for a CTPA and CT abd/pelvis w/ contrast immediately. Told our US tech to come do a formal DVT scan. Then I asked our clerk to call vascular surgery STAT for bilateral phlegmasia cerulea dolens.

Chart review while he is in CT and see that he was seen at our sister hospital 4 hrs prior. B/L DVT studies are negative (I confirmed by looking at them myself), but they performed a CT abd/pelvis non con (no contrast because he had a mild AKI) but somehow were able to note he had extensive IVC clot w/ a IVC filter in place, but they read it as "stable compared to previous exam" from 1 yr prior. I reviewed his chart from 1 yr ago, luckily he was seen at our hospital, and it appears he had a near identical presentation 1 yr prior requiring thrombectomy of b/l femoral/iliac veins and an extensive ICU stay. The CT the radiologist was comparing was an exam performed prior to thrombectomy being performed. He had a heme consult then, but they could not figure out why he had such a terrible clotting disorder.

I get a call from the same radiologist who read the imaging 4 hrs prior who states "I've never seen anything like this, are you sure this is the same patient? Because now he has clot that has basically extended completely from IVC down to b/l popliteals based on the CT abd/pelvis and US of LEs."

Vascular asks that I call IR first to attempt catheter directed thrombolysis first. He also states that this guy is likely not long for this world based on the extent of clot. IR guy says "this guy clearly needs mechanical thrombectomy, as the tPA isn't going to work quick enough for this guy." But says he'll call vascular surgeon personally and they'll hash it out.

IR ends up taking him for thrombolysis, but on the table, right before administering tPA, the patient starts vomiting copious amounts of blood, so they decide against tPA and call vascular. Vascular then comes in immediately and performs an extensive thrombectomy and bilateral 4 compartment fasciotomy.

The patient then ends up re-clotting the next day and gets taken back for another thrombectomy procedure.

He ended up requiring CRRT, developed fulminant hepatitis, went into respiratory failure and unfortunately passed a few days later. Makes me sad because he was a very nice guy who just made a very poor decision for himself.

I, also, had never seen Phlegmasia Cerulea Dolens prior to this patient, let alone bilateral.

I’ve always wanted to say “phlemasia Cerulean Dolens” in a real clinical context. It’s got to be one of the most exotic sounding terms in medicine.

Did you shout it with a sense of urgency for dramatic effect?

 

[VA Hopeful Dr]

Well it was still attached to his body when he went to ICU. Beyond that your guess is as good as mine.

Our community hospital is a priapism center of excellence. We have the prefilled phenylephrine syringes in the ED pyxis and do a few every month due to an…adventurous…patient population.

That's not actually a thing, is it?