Last nights case

[Noyac]

So I'm Sitting in the airport with a layover after a horrendous call last night. I'm thinking about the antics that went on last night and just glad to get out of there unscathed.

First case after working 12 hrs straight was a G7P0 27 wk steroid dep severe asthmatics with multiple intubations in the past for status asthmaticus on meth with a breast abscess that looks like it could be advancing to necrotizing fasciitis. Glucose is 47. Eyes are swelling shut from the rash which appears to be traveling up the chest and face from the breast abscess. Poor IV access as you could imagine and ate a f'in burrito 2 hrs ago.

Following case was 72yo morbidly obese guy s/p posterior cervical fusion 1week ago with new onset left sided weakness and a presumed epidural hematoma. He has been off Coumadin and all anticoagulants for 2weeks for which has was taking for anAVR 4yrs ago. CVA from carotid disease and severe PVD, PHTN, OSA, MP4 with unstable neck potential. Surgeon wants to evacuate a cervical epidural hematoma prone with neuromonitoring. 20g in AC from our friends in the ER.

Damn I love this job. Seriously.

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[deleted162650]

So I'm Sitting in the airport with a layover after a horrendous call last night. I'm thinking about the antics that went on last night and just glad to get out of there unscathed.

First case after working 12 hrs straight was a G7P0 27 wk steroid dep severe asthmatics with multiple intubations in the past for status asthmaticus on meth with a breast abscess that looks like it could be advancing to necrotizing fasciitis. Glucose is 47. Eyes are swelling shut from the rash which appears to be traveling up the chest and face from the breast abscess. Poor IV access as you could imagine and ate a f'in burrito 2 hrs ago.

Following case was 72yo morbidly obese guy s/p posterior cervical fusion 1week ago with new onset left sided weakness and a presumed epidural hematoma. He has been off Coumadin and all anticoagulants for 2weeks for which has was taking for anAVR 4yrs ago. CVA from carotid disease and severe PVD, PHTN, OSA, MP4 with unstable neck potential. Surgeon wants to evacuate a cervical epidural hematoma prone with neuromonitoring. 20g in AC from our friends in the ER.

Damn I love this job. Seriously.

G7P0 meth head now at 27wks. What happened, coat hangers only came in a 6-pack??

 

[Noyac]

G7P0 meth head now at 27wks. What happened, coat hangers only came in a 6-pack??

You sick bastard!!!
You know the kind well apparently. Yes she had many late term abortions.
Sad. But she said this one was different. She wanted this baby. So now if something goes south its even worse since she isn't looking to terminate this one.

 

[confusingleaf]

holy **** to both. just......holy ****. one is a bad call. two is.....are you the blackest black cloud there ever was?

 

[Noyac]

holy **** to both. just......holy ****. one is a bad call. two is.....are you the blackest black cloud there ever was?

The funny thing is that I didn't really think much of it all when it was all going on. I just considered it another call night I kept trudging along. It wasn't until I got delayed in my flight and was sitting here alone in the airport and started to think about the night. I've seen a lot of **** in my 15 yrs since residency now. It's funny but these cases are actually routine these days. So I don't look at it as a bad call until after the fact I guess. Some things might make me pucker but these two cases didn't. One surgeon actually stated, as the sats in the asthmatic came back, "I've still never seen you stressed." I take that as an ultimate compliment. The spine surgeon even had nicer things to say about me to the pt.
So I'm not trying to toot my own horn here as much as it sounds but instead I'm getting drunk at the airport bar mostly because this cute bartender keeps pouring me gin and tonics while I wait for my plane to board. She says she wants me to enjoy my time with her. At this pace I won't remember my time with her.
It's really a good place to be in when cases like this come your way and you just roll with it stress free. But I didn't start this thread to talk about me. Or did I?

 

[pgg]

Nice.

 

[Planktonmd]

The funny thing is that I didn't really think much of it all when it was all going on. I just considered it another call night I kept trudging along. It wasn't until I got delayed in my flight and was sitting here alone in the airport and started to think about the night. I've seen a lot of **** in my 15 yrs since residency now. It's funny but these cases are actually routine these days. So I don't look at it as a bad call until after the fact I guess. Some things might make me pucker but these two cases didn't. One surgeon actually stated, as the sats in the asthmatic came back, "I've still never seen you stressed." I take that as an ultimate compliment. The spine surgeon even had nicer things to say about me to the pt.
So I'm not trying to toot my own horn here as much as it sounds but instead I'm getting drunk at the airport bar mostly because this cute bartender keeps pouring me gin and tonics while I wait for my plane to board. She says she wants me to enjoy my time with her. At this pace I won't remember my time with her.
It's really a good place to be in when cases like this come your way and you just roll with it stress free. But I didn't start this thread to talk about me. Or did I?

Enjoy your airport bartender and the cocktails my friend... because when you come back more crap will be waiting!

 

[Noyac]

Nice.

Don't patronize me. I'm drunk.

 

[Planktonmd]

Don't patronize me. I'm drunk.

 

[Noyac]

Enjoy your airport bartender and the cocktails my friend... because when you come back more crap will be waiting!

Sweet. I'll be cleavage.

Wait, sorry the bartender just bent over in front of me and I lost my train of thought.

Where were we?

 

[Planktonmd]

Sweet. I'll be cleavage.

Wait, sorry the bartender just bent over in front of me and I lost my train of thought.

Where were we?

Oh,... the glory of a well formed behind... isn't that the ultimate glorious representation of God's gift to us mortals???

 

[Psai]

Sweet. I'll be cleavage.

Wait, sorry the bartender just bent over in front of me and I lost my train of thought.

Where were we?

thread is useless without pics

 

[deleted162650]

are you the blackest black cloud there ever was?

His friends call him Katrina.

I'm getting drunk at the airport bar mostly because this cute bartender keeps pouring me gin and tonics while I wait for my plane to board. She says she wants me to enjoy my time with her.

I bet you think strippers like you too



First case doesn't bother me too much. RSI 'cuz nothing will make those bronchioles spasm like some carne asada in the airway. Once tube is in, Sevo to 8 and have a little 10mcg epi available . . . ketamine and Mg if you wanna get real cute. Fetal monitors on the (exceedingly unlucky) little bugger before induction. Central line once she's asleep due to her crappy veins, and the ICU will thank you later. 99% chance she goes to unit with a tube.

Next.

This one is more PITA than anything else. AFOI given the airway, and the fact that you will be thankful you had the post-intubation neuro exam documented when the abogados come knocking (sorry still have carne asada on the brain) since you know this guy is waking up with some lasting deficits. Oh, and make sure the surgeon is holding the head during the flip . Art line and some more IV access and your neuromonitoring anesthetic of choice.


Seriously though Noy, I'm not buyin' it. You either:

a) Really are the blackest Cat 5 cloud out there
b) Your little corner of the Rockies has the highest per capita rate of oddball trainwrecks in the US
or
c) You lay awake at night thinking of the next weird-ass scenario you can post to SDN and then count how many posts it takes someone to say "retrograde wire."

I'm thinking C

The more you post this crap the happier I get you weren't hiring when I came outta residency.

You sick bastard!!!

And here's a sick bastard joke for ya:

A priest is on vacation and checking into his hotel. He's finished the paperwork, and the clerk is about to hand him his room keys

Clerk: It's so nice to have you staying with us Father. Before you head up to your room is there anything else I can do for you?
Priest: Ah, yes. (talking quietly) Can the porn channel in my room be disabled?
Clerk: NO, you sick bastard!!! We just have regular porn!

 

[pgg]

Don't patronize me. I'm drunk.

I do wish those patients would have the decency to come in during daylight hours though. Still, I wouldn't trade a night like that for a whole 9-4 week of being a dermatologist!

 

[Planktonmd]

I do wish those patients would have the decency to come in during daylight hours though. Still, I wouldn't trade a night like that for a whole 9-4 week of being a dermatologist!

Nothing compares to spending your life popping pimples...

 

[Noyac]

SaltyDog, you are starting to give me a complex.

A,B orC pick one, they all fit.

Did I ever post my epiglottis case here. I can't remember since I get so many good cases. It was about 3-4 weeks ago. It was a doozie!

That priest is a sick MOFO!

 

[Noyac]

thread is useless without pics

Your avatar is close.

 

[deleted162650]

SaltyDog, you are starting to give me a complex.

A,B orC pick one, they all fit.

Did I ever post my epiglottis case here. I can't remember since I get so many good cases. It was about 3-4 weeks ago. It was a doozie!

That priest is a sick MOFO!

Ha. I think your the one that gives many of us complexes from time to time. I don't remember the epiglottis. Let's hear it.

I'll post the next interesting case I get, but I think you get more in 2 weeks than I've had in the last 3 years.

 

[sevoflurane]

Sweet. I'll be cleavage.

Wait, sorry the bartender just bent over in front of me and I lost my train of thought.

Where were we?

...!

Thank you for this and this alone.

Nice cases bro... Those martinis always feel good after a long night of crazy... I hope you taught her how to make them correctly.

 

[sevoflurane]

1st case: Eyes swelling shut from a BREAST abscess...? Hmmmm. I did see your AW from a couple weeks ago... Hope this one wasn't THAT bad.

2nd case: When was the cervical fusion scheduled and when did the new onset weakness start? What kind of valve? 2 weeks of no anticoagulation...?
Cards check an echo after the new onset weakness? In other words... are we sure that the CVA is from carotid disease or is this just pmhx?

All that being negative, why is her cervical spine unstable after a fusion?
"Presumed epidural hematoma" d0es not fly for me unless I see an MRI with some evidence. Unless... it's an exclusion diagnosis and you have to go look.

Take that 20g, put a wire through it and bust out a RIC.

 

[Robotic Wis-Hipple]

They're really going after a "presumed epidural hematoma" in a guy with a mechanical valve that's been off anticoagulation?

 

[confusingleaf]

so after you sober up, Noyac, are you going to tell us what you did?

 

[Noyac]

so after you sober up, Noyac, are you going to tell us what you did?

I'm on vacation so that might be a while.

 

[IlDestriero]

Enjoy your airport bartender and the cocktails my friend... because when you come back more crap will be waiting!

Yes enjoy! And don't forget that many airports now have small private "meeting" rooms you can rent by the hour to use for brief encounters.


--
Il Destriero

 

[Psai]

Yes enjoy! And don't forget that many airports now have small private "meeting" rooms you can rent by the hour to use for brief encounters.


--
Il Destriero

How did you come to find out about these meeting rooms

 

[Noyac]

Yes enjoy! And don't forget that many airports now have small private "meeting" rooms you can rent by the hour to use for brief encounters.


--
Il Destriero

Thanks but I'm deathly afraid of my wife so I would never.
Plus, she is hot as **** so I have no reason to.
But I can look still.

 

[Noyac]

so after you sober up, Noyac, are you going to tell us what you did?

Ok not sober but here goes with case number 1
This wigged out pregnant lady was actually pretty nice. She knew she was in trouble and that we were her only chance of getting out of it. I was pretty damn sure I could intubated her and that here airway was not compromised but I didn't know how her asthma was going to react. Her asthma was actually bad enough that she was on theophylline. I haven't seen that in a long long time.
So I induced her RSI had a great grade one view and placed the tube after thoroughly spraying here trachea with Lidocaince. Once the tube was in I got zero CO2 return. I knew I was in the trachea but the sats now started to drop. They got as low as 49 but returned rapidly. Entire time below 90 was maybe 20 seconds. Possibly 30. Felt like 5 min.
The hardest part was convincing everyone in the room that it was going to return. Talk about looking like a rockstar when you calmly tell everyone in the room that the sats are going to continue to drop but they will return and just trust me. I'll admit that at a sat of 50 I was starting to second guess myself just a bit. But I had cranked the Sevo and I finally won the battle. The upslope was pretty impressive on the expiratory tracing the entire case but I extubated her and she did pretty well. The rash was pretty much gone the next day. The babies heart tones never changed.

 

[deleted162650]

It's been my experience that hypoxia breaks brochospasm pretty effectively (just like laryngospasm).

 

[Noyac]

2nd case: When was the cervical fusion scheduled and when did the new onset weakness start? What kind of valve? 2 weeks of no anticoagulation...?
Cards check an echo after the new onset weakness? In other words... are we sure that the CVA is from carotid disease or is this just pmhx?

All that being negative, why is her cervical spine unstable after a fusion?
"Presumed epidural hematoma" d0es not fly for me unless I see an MRI with some evidence.

All your comments a well warranted.
I got called at midnight after working 17 hours and was told we had an epidural hematoma by the surgeon. I just came in. When I got there this is the case I found. The preceding surgery was one week earlier. This guy was at an extended care facility and started having ongoing left sided weakness during the day. It took that long to get to the hospital and to get an MRI. The MRI showed hematoma with significant spinal cord compression from C5-7. I didn't argue. There wasn't time to get an echo. I listened to his heart and I could hear the click of his St Jude Valve. So I assumed it was not from the valve. Mental status was unchanged.
Unstable may not have been the correct description of her C spine. I considered it because of the compression of the cord and therefore was not interested in extending it.

My approach was to take off the front of his collar and intubate him with the glidescope asleep. He was already wired for monitoring some I would know if something went wrong albeit too late. But something was alway wrong so, oh well. Plus I had the record from the previous cervical fusion case which reported an easy intubations vein though his MP score was poor. During the previous case the BP was low with TIVA so I told the surgeon and neuromonitoring guy, no TIVA therefore just SSEP's. They were fine with it. His left sided motor function was **** anyway.

When I woke him up his left arm was improved but his left leg was not.