Ominous signs

[Arcan57]

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During training, everyone develops a sense of when things are about to turn bad. Signs that we don't initially recognize and then never forget. I thought it might be useful (or at least entertaining) to come up with a list of signs that portend badness. I'll start with two.

1. Polytrauma patients that have absolutely no reaction to the foley being placed.

2. Patients with sore throats who have put themselves into the sniffing position.

 

[docB]

Patients who say they're going to die.

Breathers with real cyanosis.

(Great idea for a thread BTW 👍)

 

[WilcoWorld]

Kids that don't fight IV placement.

 

[FiremedicMike]

Patients who say they're going to die.

Definitely!

1. Gray matter mushrooming out of a GSW to the head
2. COPDer's who, when asked, state they are tired of breathing and ready to be intubated

 

[SoCuteMD]

Kids that don't fight IV placement.

This one scares the CRAP out of me.

 

[The right Path]

Patients with copious secretions and a weak cough.

 

[jbar]

Kids that don't fight IV placement.

Along with that, kids who should have stranger anxiety but don't. When I was on the ambulance it stuck with me seeing that four year old who should have been terrified by some strange, giant EMT picking him up but was too focused on trying to breath.

 

[WerdSalid]

pulling back the sheets of a nursing home patient and finding mottled skin

 

[docB]

Bad: Ambulance tele with sirens and screaming in the background

Worse: Ambulance screeches up to door with lights and sirens and no one had time to call

 

[Daiphon]

salicylate-poisoned patients with a high level but a normal respiratory rate

corollary = any ASA poisoned patient I have to intubate. pucker factor = 11

 

[medic25]

1) A trauma patient with completely white soles and palms.

2) A chest pain patient drenched in sweat, despite the 30 degree temperature outside.

 

[Arcan57]

Keep them coming!

I thought of a few more:

1. young women with hypotension whose periods are late

2. diabetics with Kussmaul respirations

3. Doing a femoral line on a GI bleeder (or trauma patient) and having the vein collapse when you draw back on the syringe

4. pts with SAH being transferred from OSH who have "no focal neuro deficits" but are described as "drowsy"

 

[deleted109597]

pCO2s greater than pO2s by a significant margin.
Today saw one that was 7 times higher (6.8/106/16!)

 

[beanbean]

Patients with platelets, WBC, and HCT approximately the same number.

Copious amounts of blood coming out of the nose, mouth, rectum, or vagina. Actively exsanguinating patients are somehow even more frightening when the bleeding is all over the stretcher, the floor and you rather than those who bleed cleanly and internally.

 

[Stitch]

The Stitch Index: Mom's age in years + gestational age in weeks

If the sum is less than 40, the outcome doesn't look good.

 

[Mighty Mouse]

a real deal chest pain patient who says they need to poop = they are going to code

a bradycardic ill kid = they are going to code

a nice older person who has never been to your ED before = they will have real bad pathology

 

[GeneralVeers]

A patient who is nice and pleasant to be around = they will have horrible metastatic cancer.

 

[Rendar5]

actually, had a 40year old nicest guy ever come in with painless hematuria x2 days. had a mild rhabdo from walking around the last couple days, and also recent pharyngitis. Gave him a uro follow-up anyway cause my attending swore that he's gonna have bladder cancer since he was so pleasant.

 

[doctorFred]

A patient who is nice and pleasant to be around = they will have horrible metastatic cancer.

55 year old retired comedian/comedy writer. would have spent all day with him if i could. shortness of breath x few weeks = bilateral dvts + massive fungating colonic mass

 

[Universe_Explorer]

lactate level greater than or equal to hemoglobin level

 

[Arcan57]

When all the labs are back but the CBC. Also lipases that take more than an hour after the CMP results to come back.

 

[po' boy]

a real deal chest pain patient who says they need to poop = they are going to code

a bradycardic ill kid = they are going to code

a nice older person who has never been to your ED before = they will have real bad pathology

agree with all of these.

DIAPHORESIS of any kind scares me. Always associated with badness, whether shock, MI, or a blood sugar of 20.

 

[docB]

Drooling. Not like when they're asleep, I mean they're sitting there leaning forward not able to tolerate their own secretions.

 

[name?]

When they're getting combative and asking for water... usually the young guy with multiple bullet holes in him

 

[Rendar5]

d/c'd a 72yo with vague abdominal pain a few days ago with normal labs, normal vitals appropriate for pt (COPD), CT showing some biliary dilatation, had a lap chole long time ago in the past. Came back with sudden death 3 days later. I just reviewed my note on the patient. For some damn reason, I wrote "very pleasant" on the note, not something I usually do. I think that was probably a warning sign...

 

[GeneralVeers]

d/c'd a 72yo with vague abdominal pain a few days ago with normal labs, normal vitals appropriate for pt (COPD), CT showing some biliary dilatation, had a lap chole long time ago in the past. Came back with sudden death 3 days later. I just reviewed my note on the patient. For some damn reason, I wrote "very pleasant" on the note, not something I usually do. I think that was probably a warning sign...

Some of my partners dictate "very pleasant" on all their patients charts. Their patients should be very, very worried!

 

[docB]

Some people use code words in their charts to give them extra, unspoken info down the road. One guy I knew who did a lot of peds never used the adolescent unless he suspected drug abuse or some other psych issue.

 

[Apollyon]

Some of my partners dictate "very pleasant" on all their patients charts. Their patients should be very, very worried!

I asked a hospitalist about this: he said "pleasant" was for nice/not troublesome patients. If a patient was demanding, abusive, disruptive, or a just plain difficult case, the wording was "unfortunate".

 

[FoughtFyr]

The young person with the headache, never been to your ED before, fever noted in triage, sitting in a dark room who doesn't turn their head to look at you when you come in...

Any college kid coming off the weekend bender with pulse north of 140. I've had 3 necrotizing pancreatitis cases in 6 months. Truly sucky to tell the patient about the hell they are about to face - especially when they look relatively "o.k." in the department. Had one who literally had time to file a complaint because I "un-necessarily" flew him to the tertiary care center. By the time admin addressed the complaint, he was intubated, had gone through his third washout, 6 abd drains in place, ARDS on a roto-bed (it was a short meeting with the QI/QA folks...).

- H

 

[Arcan57]

Anaphylactic patients whose stridor only transiently responds to epi.

 

[docB]

EMS rolling in with an ultra morbidly obese patient with obvious angioedema (big tongue popping out).

 

[dchristismi]

Mottling.

Have seen it a couple of times. Never, ever bodes well.
Had a lady several months back in Status Hispanicus (yes, yelling and screaming) who presented with CC: "not feeling well" - frankly mottling, floridly septic, crashed and burned. Died within a couple of hours despite everything.

 

[FoughtFyr]

Mottling.

Have seen it a couple of times. Never, ever bodes well.
Had a lady several months back in Status Hispanicus (yes, yelling and screaming) who presented with CC: "not feeling well" - frankly mottling, floridly septic, crashed and burned. Died within a couple of hours despite everything.

Ditto. Worse in infants (6d old sepsis and 3m old poly trauma come to mind)

 

[Arcan57]

Diff breathers who keep tearing the 100% NRB off. These also seem to be the population that you can't get a pulse-ox to pick up on. Bonus points if they are stalking around the room, refusing to lie on the bed.

 

[WilcoWorld]

Last night I had a patient in her 70's whose previous MI presented with waaaaay atypical symptoms (privacy precludes specifics) and who last night was having even more atypical symptoms. ECG normal. Trop negative. Symptoms reproducible with exam maneuvers. Was considering discharge until it struck me, "This woman and her son are really nice." So I promptly put her in the Obs unit.

 

[dchristismi]

Diff breathers who keep tearing the 100% NRB off. These also seem to be the population that you can't get a pulse-ox to pick up on. Bonus points if they are stalking around the room, refusing to lie on the bed.

+2 if they are cursing the nurse
+3 for marked cyanosis

-5 if they're homeless +/- vet
-5 if last time you saw him, you had to send a nurse in to push the etomidate...and ninja intubate him.

those guys never die.

 

[Dwindlin]

...and ninja intubate him.

Best quote ever.

 

[Hawkeye Kid]

Last night I had a patient in her 70's whose previous MI presented with waaaaay atypical symptoms (privacy precludes specifics) and who last night was having even more atypical symptoms. ECG normal. Trop negative. Symptoms reproducible with exam maneuvers. Was considering discharge until it struck me, "This woman and her son are really nice." So I promptly put her in the Obs unit.

EVERY time I've had a patient with ridiculously atypical symptoms followed by "last time I felt this way I had a heart attack," they ruled in. EVERY TIME.

I don't know why EMR programs have "atypical chest pain" as a diagnosis choice...

 

[corpsmanUP]

-The young muscular psych patient who isn't taking his Risperdal/Depakote who is posturing in a way that you know you are about to fight. Of course the 67 year old rental cop is on duty and you have only female RN's.

- The super septic patient with no blood pressure and all the RN's in the department have failed to get access, you can't hit the femoral, you can't hit the subclavian, and the IJ is like one fifth the diameter of the carotid on US.

- The young MI patient who goes into v-fib while you are talking to them

- EMS toned out for a major MVC and it's raining so you know they won't be able to fly, and you are about to get stuck doing rural multi-traumas alone

 

[WilcoWorld]

- The super septic patient with no blood pressure and all the RN's in the department have failed to get access, you can't hit the femoral, you can't hit the subclavian, and the IJ is like one fifth the diameter of the carotid on US.

Ms. Tibia, I'd like to introduce you to Mr. IO...

 

[corpsmanUP]

Ms. Tibia, I'd like to introduce you to Mr. IO...

Oh that's already in! Now we are actually trying to get meaningful access to push high volumes of fluid, blood, and to RSI. Oh my God, I never want to try and RSI someone again with an IO. It never works.

 

[deleted6669]

, I never want to try and RSI someone again with an IO. It never works.

We actaully did this last weekend at my rural gig and it worked.
morbidly obese polypharmacy o.d.

 

[medic25]

Oh that's already in! Now we are actually trying to get meaningful access to push high volumes of fluid, blood, and to RSI. Oh my God, I never want to try and RSI someone again with an IO. It never works.

If you aren't already, try using the proximal humerus. Much better flow rates than the tibia.

 

[ispic]

For the 4th of july...

Commercial fireworks display gets tipped over and fires into crowd...EMS calls to give a "heads up" on the three ALS ambulances with 2 patients per truck, unknown amount/quantity of burns/abrasions, half are peds...2 - 3 BLS with one each, 4 - 5 walk ins and x2 unknown coming in...vitals unknown but "stable"...all will be in within 5 - 10 minutes.

I have enough time to ask...anyone dying yet? "Nope". Vital signs? "Don't have any yet, but they look stable" 🙂

Best part: One attending, me (3rd year) and a PA, with 20 deep in the waiting room...worked out pretty good, cleared most out of the ED in 1.5 hours, with one being sent to the burn center with phosphorus burns/lacerations to LLE that Peds Trauma thought that they could go "home" after the lac repair. Gotta love the consultants 👍

As for the waiting room...