Post a good case, dammit.

[Birdstrike]

aren't the [old] glory days of EM littered with trauma/penis stories?

There is no better penis/trauma story than current EM

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[RustedFox]

There is no better penis/trauma story than current EM

/endthread.

 

[The Knife & Gun Club]

There is no better penis/trauma story than current EM

Man, that’s deep.

 

[RustedFox]

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.

Great case.
What steroid and dose did you give? - and tell us more; do we know her long-term outcome?

 

[RustedFox]

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.

Wow.
Great, great case.
This sounds like something I'm destined to encounter (in terms of tragedy/severity) at my current shop.
I work in a level-1 noncompliance center.

 

[lymphocyte]

Great case.
What steroid and dose did you give? - and tell us more; do we know her long-term outcome?

100mg IV hydrocortisone, which is my standard dose in refractory (non-septic) shock. She did well with conservative management. No surgery. Just medications for panhypopituitarism.

 

[Dred Pirate]

Kounis syndrome

we had this a couple of months ago - pt receiving vancomycin - all of a sudden chest pain, ST elevation. STEMI activated, cardiology told us to just stop vanc and see what happens - EKG normalized. I had never seen it before, then 2 months later - different pt, same thing.

 

[southerndoc]

we had this a couple of months ago - pt receiving vancomycin - all of a sudden chest pain, ST elevation. STEMI activated, cardiology told us to just stop vanc and see what happens - EKG normalized. I had never seen it before, then 2 months later - different pt, same thing.

What is the mechanism behind this? I have to say that if cardiology told me that, I would look at them with a glazed-eye "WTH?!?" look. Did it normalize because of the vancomycin stopping, or did it normalize because they stopped their ischemic event? Tight lesion can give ST changes, get a little blood flow (from just an aspirin), and they resolve.

 

[maxxor]

What is the mechanism behind this? I have to say that if cardiology told me that, I would look at them with a glazed-eye "WTH?!?" look. Did it normalize because of the vancomycin stopping, or did it normalize because they stopped their ischemic event? Tight lesion can give ST changes, get a little blood flow (from just an aspirin), and they resolve.

The article on Wikipedia is detailed but can be summed as:

Allergic ige mediated coronary vasospasm , possibly from mast cell overactivation.

Vancomycin red man syndrome is purportedly from mast cell activation also.

 

[Dred Pirate]

What is the mechanism behind this? I have to say that if cardiology told me that, I would look at them with a glazed-eye "WTH?!?" look. Did it normalize because of the vancomycin stopping, or did it normalize because they stopped their ischemic event? Tight lesion can give ST changes, get a little blood flow (from just an aspirin), and they resolve.

I think it is due to coronary vasospasm, why vanco can cause that, I don’t specifically know.

Edit. I see someone beat me to it.

 

[southerndoc]

That's interesting. Thanks @maxxor and @Dred Pirate. Learn something new everyday!

 

[gutonc]

What is the mechanism behind this? I have to say that if cardiology told me that, I would look at them with a glazed-eye "WTH?!?" look. Did it normalize because of the vancomycin stopping, or did it normalize because they stopped their ischemic event? Tight lesion can give ST changes, get a little blood flow (from just an aspirin), and they resolve.

Only semi-related, but I've had 2 cases (in 10 years) of 5-fluorouracil induced coronary artery vasospasm resulting in STEMI looking EKG changes and troponin elevation that cards didn't believe me about. Both were sent to the ED after hours (you call me or my group at 3am with chest pain, you're getting send to the ED no matter what) and both had 5-FU CADD pumps on.

The first was taken to the cath lab with the pump still running and documented vasospasm on cath. The 2nd actually called me first and i suggested stopping the chemo and repeating an EKG, trop and maybe an exam. All normalized within 20 minutes and the cath team went home.

 

[thegenius]

Only semi-related, but I've had 2 cases (in 10 years) of 5-fluorouracil induced coronary artery vasospasm resulting in STEMI looking EKG changes and troponin elevation that cards didn't believe me about. Both were sent to the ED after hours (you call me or my group at 3am with chest pain, you're getting send to the ED no matter what) and both had 5-FU CADD pumps on.

The first was taken to the cath lab with the pump still running and documented vasospasm on cath. The 2nd actually called me first and i suggested stopping the chemo and repeating an EKG, trop and maybe an exam. All normalized within 20 minutes and the cath team went home.

does benadryl help in these allergic reaction type STEMIs?

 

[gutonc]

does benadryl help in these allergic reaction type STEMIs?

No. Stopping the drug will resolve the issue in minutes though.

ETA: I don't know about the vanco issue. in the case of 5FU related coronary vasospasm, it's a direct drug effect. And since the t1/2 is ~10 minutes, just stopping the infusion fixes it quickly. Usually fast enough that you guys will call me before you activate the cath lab.

 

[Dred Pirate]

No. Stopping the drug will resolve the issue in minutes though.

ETA: I don't know about the vanco issue. in the case of 5FU related coronary vasospasm, it's a direct drug effect. And since the t1/2 is ~10 minutes, just stopping the infusion fixes it quickly. Usually fast enough that you guys will call me before you activate the cath lab.

Agreed. Technically antihistamines could provide some help with the vanco, but mainly for some of the other symptoms that can go along with (if or has other signs of anaphylaxis). There is more than just histamine causing the vasospasm, and like mentioned if you stop the drug, it tends to resolve pretty quickly, at least from I found out after digging into the literature after our cases. But like others said, I think most people are going to error on the side of caution and activate the cath team (or at least call cards to start the process), and I wouldn’t blame them one bit.

 

[thegenius]

Agreed. Technically antihistamines could provide some help with the vanco, but mainly for some of the other symptoms that can go along with (if or has other signs of anaphylaxis). There is more than just histamine causing the vasospasm, and like mentioned if you stop the drug, it tends to resolve pretty quickly, at least from I found out after digging into the literature after our cases. But like others said, I think most people are going to error on the side of caution and activate the cath team (or at least call cards to start the process), and I wouldn’t blame them one bit.

in fact histamine release usually causes the opposite, vasodilation

 

[The Knife & Gun Club]

Had another good one last night. Guy with IVDU (not immunocompromised), hx septic arthritis a few years back, comes in with knee pain and restricted ROM. Normal WBC, CRP 1.2, normal lactic. Gets tapped in the ED, WBCs around 5k, gram stain negative, ortho consulted anyway who says “meh, not my problem.” ED doc at the time actually was gonna discharge but admitted the guy to obs for pain control because he’s howling in the hallway. Of course he signs out AMA about 4 hours later to go score some fentanyl.

Comes back on my shift now 12 hours later with “numb foot.” Says everything below his knee is numb. DP pulse is weirdly diminished. Anterior thigh is tense but looks otherwise pretty normal, not discolored or huge. New labs show a CRP of 18.3, whites now 12. CTA leg shows presumed infectious myositis of the vastus intermedius muscle. Emergent surgical Eval, book him for the OR for fasciotomy. Spontaneous compartment syndrome due to deep space infection.

Cherry on top the guy left AMA from PACU while they’re prepping the OR to go get more fentanyl.

 

[Dr Mantis Toboggan]

Had another good one last night. Guy with IVDU (not immunocompromised), hx septic arthritis a few years back, comes in with knee pain and restricted ROM. Normal WBC, CRP 1.2, normal lactic. Gets tapped in the ED, WBCs around 5k, gram stain negative, ortho consulted anyway who says “meh, not my problem.” ED doc at the time actually was gonna discharge but admitted the guy to obs for pain control because he’s howling in the hallway. Of course he signs out AMA about 4 hours later to go score some fentanyl.

Comes back on my shift now 12 hours later with “numb foot.” Says everything below his knee is numb. DP pulse is weirdly diminished. Anterior thigh is tense but looks otherwise pretty normal, not discolored or huge. New labs show a CRP of 18.3, whites now 12. CTA leg shows presumed infectious myositis of the vastus intermedius muscle. Emergent surgical Eval, book him for the OR for fasciotomy. Spontaneous compartment syndrome due to deep space infection.

Cherry on top the guy left AMA from PACU while they’re prepping the OR to go get more fentanyl.

Was he shooting into his thigh?

 

[RustedFox]

Just posting to reiterate that this is the type of good discussion/thread that we need more of.

 

[BoardingDoc]

Floated a wire last night in a guy who came in afib brady to 25 with a pressure in the toilet. Was on Dig and Dilt. Normal dig lvl. Normal renal function. Hadn't been taking extra meds as far as anyone knew. Assuming AV conduction issue given that he temporarily got better with the atropine that I gave him when he rolled in. As he's rolling out to go to our lady of tertiary care, he comes back covid positive and his temp is now 93. Not sure that Covid directly caused his conduction problem, but it certainly didn't help.

Last night I also had a lady with HHS screaming that she was blind (she wasn't) who required a precidex gtt in the ED (ask and ye shall receive), as well as an 18F whose entire right side of her face was blown up like a balloon over 24 hrs who had a rapidly progressing fungal (per radiology. Not sure how you tell that on a CT scan) dental infection invading her max sinus. OMFS is doing something with her in the OR now. I'll post again if they find anything cool.

 

[RustedFox]

Forgive me; what's HHS again?
I should know.

Edit: hyperosmolar hyperglycemic state.

I see "HHS" and my brain always goes to HUS or Hereditary Hemowhatever Syndrome.

 

[Apollyon]

Forgive me; what's HHS again?
I should know.

Edit: hyperosmolar hyperglycemic state.

I see "HHS" and my brain always goes to HUS or Hereditary Hemowhatever Syndrome.

Health and Human Services.

 

[The Knife & Gun Club]

Was he shooting into his thigh?

Yea he had a nice vein below the knee. Denied it up and down but track marks don’t lie.

Nurses tried to have me do the first IV cuz he’s “gonna be a hard stick.” Nope I was born in the night but it wasn’t last night. You’ve gotta try and fail first for me to break out my ultrasound.

 

[Zebra Hunter]

Yea he had a nice vein below the knee. Denied it up and down but track marks don’t lie.

Nurses tried to have me so the first IV cuz he’s “gonna be a hard stick.” Nope I was born in the night but it wasn’t last night. You’ve gotta try and fail first for me to break out my ultrasound.

Unless they are dying (in which case I grab an IO) I usually just tell them they are on their own with IV access, or tell them I don’t know how to do US guided IVs. I worked at one location where several of the docs were pushovers about placing US guided lines when the nurses asked and the nurses at this location became so damn lazy. Every single shift I was asked 3-4 times to place an US guided line, and many of them had already been taught how to perform US guided IVs. I eventually started lying that I didn’t know how to get them to stop asking.

Amazingly they were eventually always able to get a line when they realized that they had to figure it out themselves.

 

[Apollyon]

That reminds me of a story. A little over 25 years ago, we had a visitor to lecture, and he was a Maryland State Police fight medic (who happened to live in Erie, PA). He told of a junkie on Death Row in Maryland who had to be stuck 19 times to get the line in, because his vessels were so sclerosed.

 

[DocEspana]

Literally JUST had a trauma that EMS was too lazy to bring to the trauma center, so my DISTINCTLY non-trauma center (literally a few miles between two huge ones) brings me a ped struck who was reported to be ambulatory and without complaints. They dropped him off saying that they only brought him into a hospital at all because of protocol and *not* because they suspected any injuries, and then booked it FAST. So fast I knew there was **** up. But the '****' that 'was up' wasn't his injuries. and there were plenty. Splenic lac. Two broken vertebrae. Open book pelvic fracture. Left femoral fracture. So obviously this guy was not ambulatory. I knew that as soon as I identified that his knees were looking at each other.

no. the part that was up, and why I am here telling this story, was that they left out that he was high as a kite on heroin. They snuck it into their EMS printed report but said nothing to me or the nurse or on their call-ahead. But they knew. And i found out when I found this guy, legs dangling in weird angles behind him, on the ground next to his stretcher going through his post-trauma-shears pants on the ground and pulling a needle pre-loaded with heroin out of his pocket and then undoing his pelvic binder so he could try to use it as a tourniquet for vein injection. I literally had to steal the needle out of his hand right now and watch this crumpled mess of a man suddenly bark and yell like he was not significantly deformed that I need to give him his **** back because he paid for it. And as I threw it out he tried to reach for a second one, but was too slow and I had to chuck that needle too.

 

[The Knife & Gun Club]

Literally JUST had a trauma that EMS was too lazy to bring to the trauma center, so my DISTINCTLY non-trauma center (literally a few miles between two huge ones) brings me a ped struck who was reported to be ambulatory and without complaints. They dropped him off saying that they only brought him into a hospital at all because of protocol and *not* because they suspected any injuries, and then booked it FAST. So fast I knew there was **** up. But the '****' that 'was up' wasn't his injuries. and there were plenty. Splenic lac. Two broken vertebrae. Open book pelvic fracture. Left femoral fracture. So obviously this guy was not ambulatory. I knew that as soon as I identified that his knees were looking at each other.

no. the part that was up, and why I am here telling this story, was that they left out that he was high as a kite on heroin. They snuck it into their EMS printed report but said nothing to me or the nurse or on their call-ahead. But they knew. And i found out when I found this guy, legs dangling in weird angles behind him, on the ground next to his stretcher going through his post-trauma-shears pants on the ground and pulling a needle pre-loaded with heroin out of his pocket and then undoing his pelvic binder so he could try to use it as a tourniquet for vein injection. I literally had to steal the needle out of his hand right now and watch this crumpled mess of a man suddenly bark and yell like he was not significantly deformed that I need to give him his **** back because he paid for it. And as I threw it out he tried to reach for a second one, but was too slow and I had to chuck that needle too.

How the hell does EMS not bring that to a trauma center? How far are you from Ryder? We literally have a trauma surgeon, an ortho, and a neurosurgeon in the ED 24/7 for this exact purpose.

On a more serious note we all like to laugh a bit at the absurd situations some of these addicts find themselves in (I’m a chronic offender), but this story does highlight that the psychiatric and behavioral changes we see in the patients are all part of the disease process. Their neuroanatomy has been completely re-arranged to prioritize that drug over everything else, even grievous bodily injury and crippling pain. I try to remember that when they’re “misbehaving”.

 

[southerndoc]

Literally JUST had a trauma that EMS was too lazy to bring to the trauma center, so my DISTINCTLY non-trauma center (literally a few miles between two huge ones) brings me a ped struck who was reported to be ambulatory and without complaints. They dropped him off saying that they only brought him into a hospital at all because of protocol and *not* because they suspected any injuries, and then booked it FAST. So fast I knew there was **** up. But the '****' that 'was up' wasn't his injuries. and there were plenty. Splenic lac. Two broken vertebrae. Open book pelvic fracture. Left femoral fracture. So obviously this guy was not ambulatory. I knew that as soon as I identified that his knees were looking at each other.

no. the part that was up, and why I am here telling this story, was that they left out that he was high as a kite on heroin. They snuck it into their EMS printed report but said nothing to me or the nurse or on their call-ahead. But they knew. And i found out when I found this guy, legs dangling in weird angles behind him, on the ground next to his stretcher going through his post-trauma-shears pants on the ground and pulling a needle pre-loaded with heroin out of his pocket and then undoing his pelvic binder so he could try to use it as a tourniquet for vein injection. I literally had to steal the needle out of his hand right now and watch this crumpled mess of a man suddenly bark and yell like he was not significantly deformed that I need to give him his **** back because he paid for it. And as I threw it out he tried to reach for a second one, but was too slow and I had to chuck that needle too.

I would report this to the your state office of EMS.

 

[DocEspana]

How the hell does EMS not bring that to a trauma center? How far are you from Ryder? We literally have a trauma surgeon, an ortho, and a neurosurgeon in the ED 24/7 for this exact purpose.

On a more serious note we all like to laugh a bit at the absurd situations some of these addicts find themselves in (I’m a chronic offender), but this story does highlight that the psychiatric and behavioral changes we see in the patients are all part of the disease process. Their neuroanatomy has been completely re-arranged to prioritize that drug over everything else, even grievous bodily injury and crippling pain. I try to remember that when they’re “misbehaving”.

10 miles from Ryder 5 miles from Aventura.

The EMS in this area is notoriously lazy and they know damn well when they're being lazy because it's always associated with a quick exit from the premises instead of a prolonged stop and chat with all the nurses. More on that in one post

 

[DocEspana]

I would report this to the your state office of EMS.

It would be the fourth or fifth case I personally have brought to them. Probably the fortieth or fiftieth my group would have brought (since there are 10 of us). After filing so many, and the state saying that the local leadership just deflects left right front and center saying every horrendous transport was a "limited information decision" that the local leadership supports, the state told us to appoint a physician from our group to meet with local EMS leadership each month. All just to stop it going up the chain and then just getting rebuffed immediately by local EMS who has ZERO fear of the state.

So of course what happens? They have zero fear of some random physician either. Every case is 100% defensible to them. Every situation is explained by EMS having limited info. Even blatant stuff like the (two!) motorcycle accident case(s) dropped off casually after the helmet was removed on scene "to check for injuries" and "to allow the Miami J to fit better".... Were deemed reasonable mistakes and the conversation about how you both transport that to a non trauma center and run the risk of internally decapitating a guy on the road are both squashed.

"Trauma with no complaints being brought in due to protocol" is the Miami fire rescue equivalent of "I was walking back from church on a weekday minding my own business." Complete nonsense and translates directly to "some **** went down."

Maimi Dade fire rescue does. Not. Care. (About trauma designations of hospitals).

 

[WilcoWorld]

Floated a wire last night in a guy who came in afib brady to 25 with a pressure in the toilet. Was on Dig and Dilt. Normal dig lvl. Normal renal function. Hadn't been taking extra meds as far as anyone knew. Assuming AV conduction issue given that he temporarily got better with the atropine that I gave him when he rolled in. As he's rolling out to go to our lady of tertiary care, he comes back covid positive and his temp is now 93. Not sure that Covid directly caused his conduction problem, but it certainly didn't help.

Last night I also had a lady with HHS screaming that she was blind (she wasn't) who required a precidex gtt in the ED (ask and ye shall receive), as well as an 18F whose entire right side of her face was blown up like a balloon over 24 hrs who had a rapidly progressing fungal (per radiology. Not sure how you tell that on a CT scan) dental infection invading her max sinus. OMFS is doing something with her in the OR now. I'll post again if they find anything cool.

Mucormycosis?

 

[maxxor]

Mucormycosis?

Hyperdense invasive stuff in the sinuses (and hopefully a prior to compare) is basically a board exam question for can’t miss diagnosis of invasive fungal infection.

 

[BoardingDoc]

Mucormycosis?

OR apparently got pushed to today. Shes added on for later today for EUA and biopsy.

 

[southerndoc]

It would be the fourth or fifth case I personally have brought to them. Probably the fortieth or fiftieth my group would have brought (since there are 10 of us). After filing so many, and the state saying that the local leadership just deflects left right front and center saying every horrendous transport was a "limited information decision" that the local leadership supports, the state told us to appoint a physician from our group to meet with local EMS leadership each month. All just to stop it going up the chain and then just getting rebuffed immediately by local EMS who has ZERO fear of the state.

So of course what happens? They have zero fear of some random physician either. Every case is 100% defensible to them. Every situation is explained by EMS having limited info. Even blatant stuff like the (two!) motorcycle accident case(s) dropped off casually after the helmet was removed on scene "to check for injuries" and "to allow the Miami J to fit better".... Were deemed reasonable mistakes and the conversation about how you both transport that to a non trauma center and run the risk of internally decapitating a guy on the road are both squashed.

"Trauma with no complaints being brought in due to protocol" is the Miami fire rescue equivalent of "I was walking back from church on a weekday minding my own business." Complete nonsense and translates directly to "some **** went down."

Maimi Dade fire rescue does. Not. Care. (About trauma designations of hospitals).

That's sad. Their medical director (Marc Grossman) was at Jackson Memorial, but I've heard rumors he's at an HCA shop now. One would think he would understand the need for trauma patients to be sent to a trauma center. Donald Rosenberg (a cardiologist) is also something to do with their medical direction there. I would reach out to them directly.

 

[Dr Mantis Toboggan]

It would be the fourth or fifth case I personally have brought to them. Probably the fortieth or fiftieth my group would have brought (since there are 10 of us). After filing so many, and the state saying that the local leadership just deflects left right front and center saying every horrendous transport was a "limited information decision" that the local leadership supports, the state told us to appoint a physician from our group to meet with local EMS leadership each month. All just to stop it going up the chain and then just getting rebuffed immediately by local EMS who has ZERO fear of the state.

So of course what happens? They have zero fear of some random physician either. Every case is 100% defensible to them. Every situation is explained by EMS having limited info. Even blatant stuff like the (two!) motorcycle accident case(s) dropped off casually after the helmet was removed on scene "to check for injuries" and "to allow the Miami J to fit better".... Were deemed reasonable mistakes and the conversation about how you both transport that to a non trauma center and run the risk of internally decapitating a guy on the road are both squashed.

"Trauma with no complaints being brought in due to protocol" is the Miami fire rescue equivalent of "I was walking back from church on a weekday minding my own business." Complete nonsense and translates directly to "some **** went down."

Maimi Dade fire rescue does. Not. Care. (About trauma designations of hospitals).

Who does the transporting when these folks are transferred? Sad that they care so little.

 

[Dr Mantis Toboggan]

That's sad. Their medical director (Marc Grossman) was at Jackson Memorial, but I've heard rumors he's at an HCA shop now. One would think he would understand the need for trauma patients to be sent to a trauma center. Donald Rosenberg (a cardiologist) is also something to do with their medical direction there. I would reach out to them directly.

Do these docs have much power with the union etc?

 

[bravotwozero]

Who does the transporting when these folks are transferred? Sad that they care so little.

I can guarantee you it’s not going to be Miami dade EMS. That’s why they don’t care.

 

[DocEspana]

That's sad. Their medical director (Marc Grossman) was at Jackson Memorial, but I've heard rumors he's at an HCA shop now. One would think he would understand the need for trauma patients to be sent to a trauma center. Donald Rosenberg (a cardiologist) is also something to do with their medical direction there. I would reach out to them directly.

One of our guys is the formal go to man to bring all our complaints to (I believe) Grossman. Says he gets rebuffed every time he tries to bring stuff up. What I hear is that it's not because Grossman isn't sympathetic, but because MD fire rescue is completely in lockstep to excuse and deny fault in any mistake no matter how grievous.

 

[aafisahar]

Floated a wire last night in a guy who came in afib brady to 25 with a pressure in the toilet. Was on Dig and Dilt. Normal dig lvl. Normal renal function. Hadn't been taking extra meds as far as anyone knew. Assuming AV conduction issue given that he temporarily got better with the atropine that I gave him when he rolled in. As he's rolling out to go to our lady of tertiary care, he comes back covid positive and his temp is now 93. Not sure that Covid directly caused his conduction problem, but it certainly didn't help.

i'm a cards fellow and we actually see a fair amount of conduction delays with covid. none of them do well.

 

[maxxor]

i'm a cards fellow and we actually see a fair amount of conduction delays with covid. none of them do well.

Have any of the patients been well enough to get some imaging to see if it’s myocarditis?

 

[southerndoc]

Do these docs have much power with the union etc?

If they don't, then they need to walk. I'm glad I'm medical director where I have teeth. If this issue happened where I'm medical director, there would be a meeting with me, the EMS division chief, and the EMS captain along with their battalion chief and possibly their lieutenant. Some screwups in the past have led to performance improvement plans, time off, demotion, and one was subsequently terminated due to unsafe patient care. If my system didn't give me that authority (considering the paramedics are operating under my protocols and I'm liable for their care), then I would say peace out and move on to an agency that did give me that authority.

I do not know their medical directors at all (just know of them). MFDR's medical directors aren't even members of NAEMSP according to the directory, and I never see them in any NAEMSP committees, Gathering of the Eagles, etc. Paul Adams is an Eagle, but he's with City of Miami and not Miami-Dade (if I'm not mistaken they're two different entities).

 

[DocEspana]

question: does it count as cannibalism if youre eating the ashes of a human?

I diagnosed it as, and this is not a joke, ingestion of a foreign body.

(this was obviously a psych patient. I really dont think the rest of the story is needed. The actually-happened punchline is the entire story)

 

[DocEspana]

If they don't, then they need to walk. I'm glad I'm medical director where I have teeth. If this issue happened where I'm medical director, there would be a meeting with me, the EMS division chief, and the EMS captain along with their battalion chief and possibly their lieutenant. Some screwups in the past have led to performance improvement plans, time off, demotion, and one was subsequently terminated due to unsafe patient care. If my system didn't give me that authority (considering the paramedics are operating under my protocols and I'm liable for their care), then I would say peace out and move on to an agency that did give me that authority.

I do not know their medical directors at all (just know of them). MFDR's medical directors aren't even members of NAEMSP according to the directory, and I never see them in any NAEMSP committees, Gathering of the Eagles, etc. Paul Adams is an Eagle, but he's with City of Miami and not Miami-Dade (if I'm not mistaken they're two different entities).

This is correct for everything else, so I assume would be for EMS/fire rescue as well. The city has its own stuff (fire, police, etc) with the county being both in and outside of the city and somehow not stepping on the city-specific toes.

 

[BoardingDoc]

Updates:
Dental girl they now think it's just run of the mill, nasty bacterial infection in the setting of having piss poor dental hygiene. They did an I+D and she's getting better.

The COVID+ guy I floated the wire in is doing better. Hasn't needed pacing in almost 24 hrs now, so they're going to pull the wire today. Looks like he's going to live.

The HHS lady is awake, alert, and off the precidex gtt. They're trying to calmly explain that she should, you know, take her insulin so she stops almost dying.

 

[deleted836128]

I had a 28 year old dude come in saying “I think I am having a heart attack.” He had been working in 105F heat on a pool when he started feeling lightheaded and near-syncopal. When he came into the ER he said he thought he was having a heart attack but denied chest pain, shortness of breath, nausea, dizziness. No pain anywhere. I remember being very perplexed because he said NO to every point on the ROS but insisted he was having a heart attack. Labs were normal except trop a little elevated. EKG stone cold normal. Chest x-ray normal. I give the guy some fluids and check back in and he’s holding his head and talking to me. I ask him why he’s holding his head; “do you have a headache?” He looks at me kinda annoyed and says “NOW I do.” So I scanned his head. Massive subarachnoid hemorrhage. He didn’t make it. But it was a weird presentation for sure.

 

[southerndoc]

I had a 28 year old dude come in saying “I think I am having a heart attack.” He had been working in 105F heat on a pool when he started feeling lightheaded and near-syncopal. When he came into the ER he said he thought he was having a heart attack but denied chest pain, shortness of breath, nausea, dizziness. No pain anywhere. I remember being very perplexed because he said NO to every point on the ROS but insisted he was having a heart attack. Labs were normal except trop a little elevated. EKG stone cold normal. Chest x-ray normal. I give the guy some fluids and check back in and he’s holding his head and talking to me. I ask him why he’s holding his head; “do you have a headache?” He looks at me kinda annoyed and says “NOW I do.” So I scanned his head. Massive subarachnoid hemorrhage. He didn’t make it. But it was a weird presentation for sure.

I'm sure the aspirin given for this "heart attack" didn't help the subarachnoid hemorrhage.

 

[Phantom Spike]

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.

Was there no discernible finding on the MRI either?

 

[Jabbed]

Had a "better to be lucky than good" case. 33 F presenting with post-op pain from major abdominal surgery. No other medical problems. She has wound site tenderness and minimal serous drainage. HR 72 BP 118/72. CT A/P with venous contrast was apparently sub-optimally timed and is in the arterial phase and shows an aortic dissection flap!! I add a dedicated angio and she's torn from the subclavian to the iliacs. SBP in both arms is <120, intestines are perfused, pulses are symmetric. I never in a million years would've ordered an angio.

 

[thegenius]

Had a "better to be lucky than good" case. 33 F presenting with post-op pain from major abdominal surgery. No other medical problems. She has wound site tenderness and minimal serous drainage. HR 72 BP 118/72. CT A/P with venous contrast was apparently sub-optimally timed and is in the arterial phase and shows an aortic dissection flap!! I add a dedicated angio and she's torn from the subclavian to the iliacs. SBP in both arms is <120, intestines are perfused, pulses are symmetric. I never in a million years would've ordered an angio.

I actually think a standard CT A/P would have picked up on this. But nevertheless great catch and case

 

[Zebra Hunter]

Had a "better to be lucky than good" case. 33 F presenting with post-op pain from major abdominal surgery. No other medical problems. She has wound site tenderness and minimal serous drainage. HR 72 BP 118/72. CT A/P with venous contrast was apparently sub-optimally timed and is in the arterial phase and shows an aortic dissection flap!! I add a dedicated angio and she's torn from the subclavian to the iliacs. SBP in both arms is <120, intestines are perfused, pulses are symmetric. I never in a million years would've ordered an angio.

Has to be a chronic dissection...right? For my own sanity.