ER Hall of Fame

[docB]

I had a guy last night that should get an honorable mention for a bounceback. Long haul trucker presents with ETOH of 515, GCS 3, almost got intubated (it was they guy before me that didn't tube him). Walks out of ER 12 hours later with an ETOH of 140. Bounces back to the ER 4 hours later with ETOH of 440. What a champion.

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[iliacus]

I had a guy last night that should get an honorable mention for a bounceback. Long haul trucker presents with ETOH of 515, GCS 3, almost got intubated (it was they guy before me that didn't tube him). Walks out of ER 12 hours later with an ETOH of 140. Bounces back to the ER 4 hours later with ETOH of 440. What a champion.

300 ETOH increase in 4 hours. I don't think an entire frat house could get their cummulative BA that high so quick? He had a long way to go and a short time to get there.

 

[Apollyon]

I had a guy last night that should get an honorable mention for a bounceback. Long haul trucker presents with ETOH of 515, GCS 3, almost got intubated (it was they guy before me that didn't tube him). Walks out of ER 12 hours later with an ETOH of 140. Bounces back to the ER 4 hours later with ETOH of 440. What a champion.

That's clearing at 31mg/dL/hour. I KNEW it! The alcohol dehydrogenase ramps up in people who chronically use alcohol - people use 20-30/hr, but I always go on the high side, because I know (just as I know Elvis and Jim Morrison are still alive, working with Bruce Lee and Jimmy Hoffa) that the ETOH'ers move it out faster. Hell, he was >500 and not dead! And you titrated him to walking straight and his hands not shaking, right?

 

[Sessamoid]

That's clearing at 31mg/dL/hour. I KNEW it! The alcohol dehydrogenase ramps up in people who chronically use alcohol - people use 20-30/hr, but I always go on the high side, because I know (just as I know Elvis and Jim Morrison are still alive, working with Bruce Lee and Jimmy Hoffa) that the ETOH'ers move it out faster. Hell, he was >500 and not dead! And you titrated him to walking straight and his hands not shaking, right?

I'd wager that a fair amount of that 31 mg/dL/hour is not just hepatic clearance, but dilution. In that time he must have received at least 2 liters of NS, right?

 

[leviathan]

As a Tech (i.e., minion), one of my duties is to get EtOH readings via breathalyzer. I've seen >250 enough now that it's no longer shocking.

I don't think >250 is very shocking. The only time I used a breathalyzer (a coin-op one at a bar) it read 270, and I was not all that drunk. I was still completely coherent and responsive. But I can easily understand anyone in the 500s is gonna be gone.

 

[docB]

I'd wager that a fair amount of that 31 mg/dL/hour is not just hepatic clearance, but dilution. In that time he must have received at least 2 liters of NS, right?

Yeah, he soaked up a 'nanna bag & a but load of IVF. As for Jim Morrison, I think that by the time he died (in 1971 BTW apollyon ) his liver could actually metabolize alcohol that was just in the same room with him, he did'nt even have to drink it.

 

[iliacus]

As for Jim Morrison, I think that by the time he died (in 1971 BTW apollyon ) his liver could actually metabolize alcohol that was just in the same room with him, he did'nt even have to drink it.

 

[EctopicFetus]

RBC 0.4.... the labs you guys are saying are completely insane.. and these people lived???? GOOD LORD!!!

 

[tupac_don]

WBC 0.1 (4.0-10.0).... is currently septic

That's not impressive, many BMT patients have such counts, even 0.0 WBC is not rare.

What is impressive I saw was bilirubin (T/D: 35/30) Pt was in very bad shape however.

 

[EctopicFetus]

WBC count 393,000

New onset ALL.

WBC 395.5 (had to be diluted) the folks in the ED said they have never seen one so high. Still no definitive diagnosis. Waiting for the labs to do their things. Pt is getting a bone marrow done today. They are also doing leukophoresis to decrease the WBC. 25 y/o male is in no pain his spleen crosses the midline and drops almost to his iliac crest.

 

[Scrubbs]

Probably not impressive to you WBC = 0.0, but I had a guy the other day with an ANC of 40... if you included his 7% bands that is

 

[jlw2004]

Probably not impressive to you WBC = 0.0, but I had a guy the other day with an ANC of 40... if you included his 7% bands that is

Here's one along the same lines. Guy sent in by his oncologist for presumed neutropenic fever. WBC 2 days ago 0.6 WBC today -- 33.9. Guess he's not neutropenic anymore, just septic!

 

[jashanley]

Here's one along the same lines. Guy sent in by his oncologist for presumed neutropenic fever. WBC 2 days ago 0.6 WBC today -- 33.9. Guess he's not neutropenic anymore, just septic!

He probably received filgrastim (neupogen). The Heme-onc guys use it for lymphoid malignancies to help avoid prolonged neutropenia and aid the maturation of cells. Works real well as you can see. Doubt that sepsis would cause that in a neutropenic fever. I just finished a month of hematology wards. I saw my fair share of neutropenic fever and none developed a high ANC while they had a neutropenic fever. They all stayed neutropenic. They develop a fever while neutropenic and it resolves once the neutropenia resolves. (the fever is presumed to be due to extravasation of organisms across the gut wall and into the blood stream.)

 

[Apollyon]

He probably received filgrastim (neupogen). The Heme-onc guys use it for lymphoid malignancies to help avoid prolonged neutropenia and aid the maturation of cells. Works real well as you can see. Doubt that sepsis would cause that in a neutropenic fever. I just finished a month of hematology wards. I saw my fair share of neutropenic fever and none developed a high ANC while they had a neutropenic fever. They all stayed neutropenic. They develop a fever while neutropenic and it resolves once the neutropenia resolves. (the fever is presumed to be due to extravasation of organisms across the gut wall and into the blood stream.)

Hey, who let this guy in?

 

[Midwest Medic]

Had a 24 y/o come in with his mom with a BAC of 520. This guy could still walk and talk...although not straight and not coherent. The funny thing his mom didn't even know he drank! Hard slap of reality considering he had to have worked long and hard to get that kind of tolerance!

 

[jashanley]

Hey, who let this guy in?

Sorry, as EM/IM; I sometimes cross the fence. I'm on medicine now.....and I'm dreaming of getting back in the ED.

 

[Apollyon]

Sorry, as EM/IM; I sometimes cross the fence. I'm on medicine now.....and I'm dreaming of getting back in the ED.

Oh, I know you're in a dual program - just bustin' chops. You'se gettin' too technical there...although we did discuss the theory of the protective nature of cystic fibrosis in the Peds ED this evening (decreased GI motility is protective vs. cholera - 50K years ago, it may have had legs).

 

[Hotsauce21]

you should send that one in. that might be a record

ETOH of 830.

No one in our ED had ever seen anything quite like it. We're not sure it wasn't a lab error to this day.

Guy wasn't walking, nor really what I would call "talking", but more mumbling and taking weak swings at people who came near his stretcher. He also looked a little like Santa Claus, only Santa doesn't have things growing in his beard like this human liver machine did.

He was, however, breathing quite well on his own.

 

[beyond all hope]

WBC count 393,000

New onset ALL.

WBC of 430000 and a spleen the size of texas...CML me thinks.

 

[EctopicFetus]

The same patient I had with 393K had a repeat shortly thereafter which was 411K, after Hydrea he was D/ced with a WBC of 115K. Confirmed CML with Philadelphia positive. It is a shame.. nice young guy.

 

[W222]

It is a shame that he was diagnosed with CML but the fact that he was Philadelphia postive is a good thing. He atleast has Gleevic to buy him some time and possibly provide a longterm treatment. I know recurrance rates for Gleevic are high after several years but its an option.

 

[beyond all hope]

Patient was mostly assymptomatic. Had a sore throat with exuduate DD: Diptheria vs thrush. I thought that level of glucose would make you at least obtunded if not comatose. Learn something new every day.

 

[docB]

I just had a guy who maxed his drug screen. At my house that's PCP, MJ, coke, amphetamines, benzos and opiates. That's not too uncommon but I bet someone's house out there has a more extensive drug panel and some champions who have met the challenge.

 

[Apollyon]

Longest duration of problem without ever having it evaluated - 39 years. 51 y/o male, who, since age 12, has had episodes (approx 1/month or more frequent) of palpitations and heart racing, with a sensation of near syncope ("Like I"m gonna fall out"), fatigue, with cramping in hands, with a touch of chest pain, and, as a younger man, would actually black out, with these s/s resolving with pt lying down and resting.

 

[anonymousEM]

Appolyon, what'd the guy say to your "so what was different today that made you decide to come in after 39 YEARS?!?"

 

[APRN-BC]

Just had a pre-employment DS screen out for 21,000 ng/ml of Methadone and she still swears she doesn't even know what Methadone is. Swears all she took was a big white Tylenol.

 

[Docxter]

Patient was mostly assymptomatic. Had a sore throat with exuduate DD: Diptheria vs thrush. I thought that level of glucose would make you at least obtunded if not comatose. Learn something new every day.

I once saw a glucose of in the couple of thousands and the patient, but asymptomatic in that regards. Turned out the nurse had got the sample immediately after stopping the D10W that was going through the same IV line.

 

[emt30119]

I think i have the highest K so far
K 13.7
Patient currently in OR. 13 y/o ruptured aorta from a fall 15ft into water at swmming pool

 

[Seaglass]

must be hemolyzed unless they are letting their congenital Polycystic kidney disease kid have a dip.

 

[notstudying]

Hb <1, HCT 7. Symptomatic, but not dead, and the most pale person I have ever seen, after several months of dysfunctional uterine bleeding. Transfused, and shipped off really fast to a place with IR to do an embolization!

 

[Tas]

I'm not a doctor, i work for ems - but I wondered if anyone has had a blood glucose under 7 (he lived)?

 

[12R34Y]

I've had plenty of 10's and 12's for blood sugars. i had a 15 talking once (finger stick checked twice) He needed 2 amps of D50 plus some coke.

later

 

[docB]

I've had plenty of 10's and 12's for blood sugars. i had a 15 talking once (finger stick checked twice) He needed 2 amps of D50 plus some coke.

later

Coca-cola or cocaine? I've had pts that self treat their diabetic problems with either with varying degrees of success.

 

[spyderdoc]

I don't think >250 is very shocking. The only time I used a breathalyzer (a coin-op one at a bar) it read 270, and I was not all that drunk. I was still completely coherent and responsive. But I can easily understand anyone in the 500s is gonna be gone.

I'd be concerned if I were you. Your "tolerance" must have come from somewhere... Any person who is not a regular drinker would be in a coma at that level. My buddies and I got "drunk" one night and thought we would top out the breathalyzer, right? Well, mine read 30. I felt there was no way I would be driving....My buddies were all at the same level. All 50mg/dL UNDER the legal limit, yet feeling pretty out there....
For you to be at 270 and feel sober, wake up my friend, me thinks YOU have a problem.
Mark

 

[Freeeedom!]

OK yeah...I just had a patient with a Sodium of 95.

 

[undecided05]

Patient with HIT last year... Plt=4. I think we placed him on bed precautions till the platelets started to rise on their own. It was amazed how excited we were when checking his labs his platelet count rose to 11.

Also had a guy that died of prostate cancer.. presented with PSA=1437. Mets to every bone in his body.

 

[NateatUC]

A couple patients:

I know this one's already been beaten, but good anyway. When I was an EMT / ER Tech, we had a guy with an H&H of 2.5 and 8.1. Pt. walked into triage on his own with a chief complaint of "fatigue". He was (probably still is) one of those mobile wedding DJ's, and was finding it harder and harder to move all of his equipment around.

And a little more recently: 6.5 month old presented to PMD last week having gained NO weight since his last visit 4.5 months ago. Immediately admitted to our service, weighing 4.95 kg. Has since gained >600g in about 5 days in the hospital.

 

[Seaglass]

Plt of 3 is nothing. Had plt of 0 in a leukemia pt I had in the MICU as a student.

 

[erbound]

ER hypokalemic patient.

K= 1.7

Patient walked in and stated to the triage nurse,"I don't feel good." Quite the understatement. Given oral and IV K push. Recovered and released the next day.


erbound

 

[Amik25]

IV K push?? I doubt they recovered and went home...lol!

 

[Midwest Medic]

Had a 22 y/o come in last night for feeling tired after "walking to my car".....had a hgb of 3.5!

 

[debvz]

62 WM transferred from outside hosp for "possible diverticulitis," stat CBC with 22,000 WBC, with 15,000 bands, for total of 68% bands .... immediately took him back to the OR and discovered a perfed left colon, which has since been removed, and he's now relatively stable in the ICU....

 

[Sessamoid]

IV K push?? I doubt they recovered and went home...lol!

Unless he lives in a "funeral home".

 

[jlw2004]

I had one sick old lady in DKA and ARF yesterday. You could smell the ketones from down the hall. Not a record on here, but impressed me.

pH 6.82
BS 1478 -- after 8L NS and ~30 u insulin came down to 1047
K+ 10.7 repeat after NS/ insulin was 9.8
Gap 48

To get her results, I had to call the lab because it had been taking so long. The first time I had the tech tell me that she wouldn't tell me the number because they were "too high to be real". She even hung up on me. I called back and asked her supervisor to get me the numbers. When they reprted it in the comuputer, it was listed as "10.7 Hemolysis not visible but assumed". Why won't the techs call outlandish values? Just call it what you see. Even if they might be in error, they might not be and we need to know them!

 

[Arcan57]

Schizophrenic belly pain, non-specific exam. Went back in forth with the R4 about scanning him. While waiting for the results, labs come back. Lipase = 62,500. CT showed hemorrhage were his pancreas used to be.

 

[Hotsauce21]

a friend's patient had k of 0.8

 

[supercut]

Trauma pt: Hct 19, Na 145, Cl 135, K 2.9 . All values miraculously normalized when drawn away from the IV site.

As a med student: HIV pt with 1 lonely CD 4 cell.

And called by the ED for surgery consult (r/o chole becuase of RUQ pain): Tbili 2.9, AST 2985, ALT 7839, ALK 85. ED here typically calls before any workup is done (barely after labs are drawn). Hopefully I don't have to say that the pt did NOT have cholecystitis.

 

[Sessamoid]

Trauma pt: Hct 19, Na 145, Cl 135, K 2.9 . All values miraculously normalized when drawn away from the IV site.

As a med student: HIV pt with 1 lonely CD 4 cell.

And called by the ED for surgery consult (r/o chole becuase of RUQ pain): Tbili 2.9, AST 2985, ALT 7839, ALK 85. ED here typically calls before any workup is done (barely after labs are drawn). Hopefully I don't have to say that the pt did NOT have cholecystitis.

What kind of fool called a surgery consult for that?

 

[leviathan]

I'd be concerned if I were you. Your "tolerance" must have come from somewhere... Any person who is not a regular drinker would be in a coma at that level. My buddies and I got "drunk" one night and thought we would top out the breathalyzer, right? Well, mine read 30. I felt there was no way I would be driving....My buddies were all at the same level. All 50mg/dL UNDER the legal limit, yet feeling pretty out there....
For you to be at 270 and feel sober, wake up my friend, me thinks YOU have a problem.
Mark

Hmm..possibly the machine was not working properly, or is just highly inaccurate, because I don't think I have a high tolerance. I drink maybe once or twice at the most per month. That night I had 3 shots of hard liquor, 2 pints of beer, and 2 triple long-island iced teas. That's 11 drinks in total. I'm a 155 pound male, and using a BAC calculator it just said over the 3 hours I had them I would be at about 209. And I definitely was very drunk, but I was still able to walk and talk straight.

 

[leviathan]

Also, I don't believe tolerance means increased tolerance to a specific alcohol level. It just means that you are metabolizing the alcohol quicker so that 11 beers for a tolerant person = a lower EtOH than someone who does not drink often.