Case

[glorfindel]

---

Members do not see this ad.

The anesthesiology thread is filling up with great clinical cases. These cases would make me want to be an anesthesiologist if I were a medical student -- but I wonder how typical they are of the day-to-day work of the specialty?

Here on the EM forum we value verisimilitude above all else. Here is a case that is guaranteed to be typical of real emergency medicine practice in the community. It's directed at students thinking about specializing in EM, but anyone is welcome to jump in. 🙂

CASE:

56-yo male comes to the ED with his wife at 11 pm on a Saturday complaining of left lower leg pain x 3 days. Asked about leg swelling, the patient reports "maybe." Asked about fever, he reports that "I've felt hot." He reports that he's had cp and sob "for a while, on and off." He denies trauma, numbness, weakness. His wife helpfully interrupts to remind him that he did get pretty drunk a few days ago and fell in the living room when he tripped over the family dog, but that the dog is OK. He is pleasantly requesting Rx for Vicodin, because his doctor is "on vacation."

Pmhx niddm, htn, obesity, back pain. SocHx smoker, social etoh, works as long-haul truck-driver. "I used to be on meds but I ran out." His wife interrupts to note helpfully that he snores loudly at night.

Exam: Obese alert well-appearing male, strong odor of tobacco, insouciant historian. 160/90, 90, 14, 37, 98% ra sat. Bruise to L lateral mid-calf. Left calf diffusely tender. Bilateral symmetric venous-stasis pigmentation changes of LE. Normal distal pulses. Otherwise unremarkable.

The state prescription-monitoring program website reveals that he has filled > 10 RX for opiates in the past two weeks, all from different providers in different cities.

Context: All your ER beds are full and there are multiple elderly abdominal pain patients in the waiting room.

There is a post-cocaine thunderclap HA lady with a negative head CT in Room 11 awaiting disposition. You had planned to do pelvic exams on two first-trimester vaginal bleeders in Rooms 7 and 8, one of whom has a boyfriend who is standing in the door stating "Hey, she's really in pain and you guys haven't done anything for her."

Thirty minutes ago the US tech went home for the night.

Last month your Press-Ganey scores were the lowest in the department, and your CMG medical director has asked you to "kick it up a notch." You're not sure if he was referring to your PG scores or to your ED length-of-stay, which is in the last quartile of your group, but which you are sure is because of your night-shift heavy schedule when you tend to get a lot of intoxicated patients who require multiple hours of observation, or if that doesn't work then it's because the hospital's ancillary services are least available at night. You disagree that it is because you like to tweet sarcastic comments about your clinical interactions under a pseudonym during your shifts.

Your friend at the academic center in town called you yesterday to tell you that they are looking to hire, and you have always thought academics would be fun. You think the EM:RAP guys seem cool and wouldn't mind working alongside Stuart Swadron, but you're ambivalent about research and only enjoy teaching "smart" residents.

---

Ok, folks; try not to go all dry in the mouth with case-anxiety right away. Remember: airway, breathing, circulation, disposition.

 

[beakerdan]

As an EM interested student, I love cases like this, and I'll start out here.

Airway - he's talking to us, no mental status change, no reason I would think that he can't protect his airway.

Breathing - RR 14, 98%, I expect that he has crappy lung sounds from smoking, but he seems to be oxygenating well on RA.

Circulation - BP 160/90, normal distal pulses, so far so good.

Plan - he's got risk factors for DVT/PE coming out of his ears, love that we don't have overnight US here at House of God. If there's any way to get a LE Doppler for him, definitely want it. I'm also ordering CXR, tib-fib XR. I'm also thinking about PE, but right now, his Wells score is 0, so I don't know if I want to jump to CT.
He also gets 30mg of toradol for pain, no narcotics. EDIT: assuming lytes show he hasn't killed his kidneys yet... 🙂

 

[jdh71]

toradol for a patient with hypertension, diabetes, all apparently rather untreated without an evaluation of renal function? 🙂

 

[Arcan57]

I've got it! He's got a sub-acute compartment syndrome that has lead to him trying to self medicate the pain away. Remember everybody that pulse loss is the last sign of a compartment syndrome and if you wait too long he could lose his leg. I'd pull out the Stryker to check compartment pressures and if elevated then STAT page vascular. If they were negative, I'd be concerned that there may have been a deep compartment I missed or that the Stryker wasn't calibrated correctly so I'd still STAT page vascular. While waiting for them to come in, I'd be concerned that he was was developing a tolerance to narcotics so I'd go ahead and give him dilaudid 2mg IV q20min prn pain>4 to try and overcome that resistance and I'd throw an U/S probe on and inject 20ml of bupivicaine around the femoral nerve as an adjunct. Sure it's going to make vascular's exam harder and I haven't done a sensory exam yet but everyone knows this guy needs to be in the OR for fasciotomy and it's our job to keep him comfortable until that happens. Since you've stabilized him and have a consultant coming in, you go ahead and right holding orders to get the pt upstairs so he's not tying up a bed.

BTW Beaker, I'm going to guess he's allergic to toradol.

 

[FirefighterDoc]

I've got it! He's got a sub-acute compartment syndrome that has lead to him trying to self medicate the pain away. Remember everybody that pulse loss is the last sign of a compartment syndrome and if you wait too long he could lose his leg. I'd pull out the Stryker to check compartment pressures and if elevated then STAT page vascular. If they were negative, I'd be concerned that there may have been a deep compartment I missed or that the Stryker wasn't calibrated correctly so I'd still STAT page vascular. While waiting for them to come in, I'd be concerned that he was was developing a tolerance to narcotics so I'd go ahead and give him dilaudid 2mg IV q20min prn pain>4 to try and overcome that resistance and I'd throw an U/S probe on and inject 20ml of bupivicaine around the femoral nerve as an adjunct. Sure it's going to make vascular's exam harder and I haven't done a sensory exam yet but everyone knows this guy needs to be in the OR for fasciotomy and it's our job to keep him comfortable until that happens. Since you've stabilized him and have a consultant coming in, you go ahead and right holding orders to get the pt upstairs so he's not tying up a bed.

BTW Beaker, I'm going to guess he's allergic to toradol.

Oh he is. He likes " The stuff that starts with a D" because that's the only thing that works for him. It makes him itchy though, so he needs Benadryl with it too.

 

[beakerdan]

BTW Beaker, I'm going to guess he's allergic to toradol.

And Acetaminophen and ibuprofen and that stuff that killed Michael Jackson....

FYI: His allergic reaction to ibuprofen? Abdominal pain.

 

[Arcan57]

And Acetaminophen and ibuprofen and that stuff that killed Michael Jackson....

FYI: His allergic reaction to ibuprofen? Abdominal pain.

Nah, that's bush-league. Everybody knows that the only true way to respond to "what happens when you take x" is: it made me swell up and I couldn't breathe.

 

[dotcb]

I've got it! He's got a sub-acute compartment syndrome that has lead to him trying to self medicate the pain away. Remember everybody that pulse loss is the last sign of a compartment syndrome and if you wait too long he could lose his leg. I'd pull out the Stryker to check compartment pressures and if elevated then STAT page vascular. If they were negative, I'd be concerned that there may have been a deep compartment I missed or that the Stryker wasn't calibrated correctly so I'd still STAT page vascular. While waiting for them to come in, I'd be concerned that he was was developing a tolerance to narcotics so I'd go ahead and give him dilaudid 2mg IV q20min prn pain>4 to try and overcome that resistance and I'd throw an U/S probe on and inject 20ml of bupivicaine around the femoral nerve as an adjunct. Sure it's going to make vascular's exam harder and I haven't done a sensory exam yet but everyone knows this guy needs to be in the OR for fasciotomy and it's our job to keep him comfortable until that happens. Since you've stabilized him and have a consultant coming in, you go ahead and right holding orders to get the pt upstairs so he's not tying up a bed.

BTW Beaker, I'm going to guess he's allergic to toradol.

You're joking, right? Do a femoral nerve block on a guy without a surgery consult, whose compartment checks you don't trust, who you've decided needs to go to the OR?

 

[dchristismi]

Of course he's joking.

But he can't for long, because the radio just crackled that medic 52 is enroute with a 23 yo F, actively seizing, appears to be about 8 months pregnant without any prenatal care, found down in a known crackhouse, no response to ativan, requesting medical control, combitube in place, ETA 3 minutes.

 

[Rendar5]

well, sir I kindly cannot give you or prescribe you narcotics under any circumstances whatsoever because you've had >10 different Rx's in 2 weeks. Unfortunatley, the pharmacist will automatically trigger a call the cops to have us both arrested and I can't do anything about that. But I can examine your leg and do some tests to see if your chest pain and trouble breathing is anything that is life threatening or that can leave you permanently disabled. Let the ****er AMA. And if he doesn't want to AMA, I can then do a workup. I'm feeling lazy and stupid so CTA Chest with venous run-off of the legs if his d-dimer is negative.

I'm more curious why his doctor shopping behavior's been going on for 2 weeks, but his injury is only 3 days old.

 

[Greenbbs]

Of course he's joking.

But he can't for long, because the radio just crackled that medic 52 is enroute with a 23 yo F, actively seizing, appears to be about 8 months pregnant without any prenatal care, found down in a known crackhouse, no response to ativan, requesting medical control, combitube in place, ETA 3 minutes.

Followed in by the ever popular "104 year old NH resident who was found by the tech 8 hours ago- 'he just don't look right to us'" who has a BP in the 50's (or at least he did 8 hours ago when last checked)

 

[la gringa]

next up: 55 y/o h/o "unknown" from a NH, for "AMS", per medics none of the nurses know anything about him b/c he just got there 3 days ago.

(fortunately he was dc'ed from your hospital and you have an EMR so you can find out his dc baseline and know he's newly gorked out and full code... but ya'll know this one too well)

 

[Arcan57]

Unfortunately just as you're dispo'ing the gorked 55yo, he's replaced by a 34 yo with HTN, DM, and ESRD who due for dialysis today but came in because on the way to dialysis (via ambulance, because of course) he was complaining of feeling short of breath. His BP is 210/113, RR 14, satting 98% on RA. EKG shows LVH and he'll complain of chest pain if it seems like he's not being seen fast enough.

Your move.

 

[Greenbbs]

Unfortunately just as you're dispo'ing the gorked 55yo, he's replaced by a 34 yo with HTN, DM, and ESRD who due for dialysis today but came in because on the way to dialysis (via ambulance, because of course) he was complaining of feeling short of breath. His BP is 210/113, RR 14, satting 98% on RA. EKG shows LVH and he'll complain of chest pain if it seems like he's not being seen fast enough.

Your move.

Rumor is the person next to them is a 42 yo male sent in by EMS from the PCP's office because of an asymptomatic BP of 162/88. Checkmate.

 

[EM2BE]

Rumor is the person next to them is a 42 yo male sent in by EMS from the PCP's office because of an asymptomatic BP of 162/88. Checkmate.

Until a "friend" drops off a 30-something yo who is unresponsive. Has been for a few hours. They get that way sometimes. Not breathing.

 

[loveoforganic2]

Not particularly interested in EM, but always enjoy cases. Just toward the end of my second year, so be kind (or not)

Seems like a DVT is fairly likely, whether he's malingering or not. Before addressing the impossibility of the Rx, explain that you're worried about a DVT and the possible implications of that if it is the case (hopefully keep him from signing out AMA when you get to discussing the pain Rx). I'd want to check pitting edema bilaterally and order a ddimer, then explain why the Rx he wants is outside the realm of possibility and offer an alternative to him while you wait for labs to come back.

 

[VentdependenT]

admit to medicine...... 😉

 

[Arcan57]

admit to medicine...... 😉

But you're working at a for-profit hospital and the c-suite requires that all unresourced patient admits be reviewed by the CEO.

Do you:
1) Send the patient home, hoping nothing bad happens.
2) Call the CEO and document they're refusual to allow the admit, which causes you to be terminated during your next semi-annual review when they audit your charts.
3) Jiggle his electrodes and capture an episode of "v-tach" thus strengthening your case for admission.

P.S. I wish that I was making up the start of this scenario, but there's a shop where this happens in my city.

 

[goodoldalky]

But just before it calms down, you are sent a 97 year old female who is referred from her PCP with chief complaint of "I haven't pooped in two weeks, can you get it out?"

 

[TooMuchResearch]

But you're working at a for-profit hospital and the c-suite requires that all unresourced patient admits be reviewed by the CEO.

Do you:
1) Send the patient home, hoping nothing bad happens.
2) Call the CEO and document they're refusual to allow the admit, which causes you to be terminated during your next semi-annual review when they audit your charts.
3) Jiggle his electrodes and capture an episode of "v-tach" thus strengthening your case for admission.

P.S. I wish that I was making up the start of this scenario, but there's a shop where this happens in my city.

If you think he needs the admission, do #3. And personally draw a BMP from the line as fast as possible.

 

[jdh71]

admit to medicine...... 😉

I think you mean admit to the MICU . . . to die

heh

 

[jdh71]

But you're working at a for-profit hospital and the c-suite requires that all unresourced patient admits be reviewed by the CEO.

Do you:
1) Send the patient home, hoping nothing bad happens.
2) Call the CEO and document they're refusual to allow the admit, which causes you to be terminated during your next semi-annual review when they audit your charts.
3) Jiggle his electrodes and capture an episode of "v-tach" thus strengthening your case for admission.
P.S. I wish that I was making up the start of this scenario, but there's a shop where this happens in my city.

awesome

can't stop giggling

 

[glorfindel]

Clearly there is a wide range of appropriate workups for this guy, ranging from

a) (most conservative) CT eval for thromboembolism, admit to micu

to

b) (least conservative) GTFO.

I personally would do ambulatory HR and o2 sat, d-dimer then gtfo, if + dimer then LE doppler and gtfo.

But that's just because I have low suspicion for fx and no suspicion for PE. But I'd probably be screwed because his ambulatory sat will turn out to be 87% and his HR 110.

I'm more curious why his doctor shopping behavior's been going on for 2 weeks, but his injury is only 3 days old.

Even doctor-shoppers and narcotic-seekers get drunk and trip over their dogs.

admit to medicine...... 😉

I think you mean admit to the MICU . . . to die

heh

I defer to the hospitalist/intensivist about which inpatient bed he should be in. 🙂

PS: all these other patients coming in are the meat and potatoes of EM practice. Pay attention, medical students! It's not all about saving lives!

 

[jdh71]

I defer to the hospitalist/intensivist about which inpatient bed he should be in. 🙂

Clearly needs the hospitalist admit. They can consult us if need be 😉

 

[glorfindel]

Clearly needs the hospitalist admit. They can consult us if need be 😉

Your point is well-taken. In my practice I consult with and admit to hospitalists all the time. I never actually talk to intensivists.

I'm aware that they exist and that hospitalists can consult them, but at my hospital the closest I've come to actually interacting with an intensivist is looking at their pictures on the website. They've saved many of my admitted patients, though -- glad they exist.

 

[Bostonredsox]

Clearly needs the hospitalist admit. They can consult us if need be 😉

Well at my shop I get to be both at night so I guess Im Fu&*ed either way.