Some fun cases.

[The Knife & Gun Club]

---

Members don't see this ad.

First shift back in our high acuity county ER resus area, with a full complement of residents after being away doing fellowship stuff with for the last 14 months with just a couple mid acuity ER shifts sprinkled in. Cuz bonkers to be back and felt like sharing.

Cases:
1) cyanide exposure after inhaling smoke from burning upholstery. Neon pink skin, lactic 17, pH < 6.8, hypotensive and peri arrest, intubated, cyanokit, admitted to ICU

2) acute aortic dissection with RVR to 140s and SMA occlusion, Esmolol drip and OR with vascular

3) 8 cm AAA with contained rupture, transfusion, OR with vascular.

4) acute renal failure with a Cr of 23 and K of 7 in a 38 year old with no PMH

5) septic neutropenia fever

6) seizing depressed skull fracture

7) afib RVR with EF of 10%, fever, life vest fired

9) liver transplant with K of 7 For no reason explicable reason.

10) septic nursing home dump on pressors and all that jazz

The cyanide one was particularly interesting, never even saw a real cyanide in residency for fellowship at a level 1 trauma center covering the burn ICU.

What neat stuff have you all seen recently?

 

[HemorrhagicShock]

That all seems extremely exhausting for ONE shift.

Imagine all the consultants screaming at you while you try to get them to help out your patient. Or even better yet, scream at you for idiosyncratic reasons related to how your resident or midlevel presented the patient to them, immediately backpedaling because "the resident didn't tell me that, are they even staffing this with their attending?!?!?"

Imagine getting the RNs to do even 1/10th of the critical orders on all of those patients in anything considered to be a timely manner.

Imagine all the documentation pitfalls in that list. Imagine all the metrics you missed and will hear about after the fact.

Imagine the BS you'll have to deal with when the resident dissects the ICA when putting in the dialysis catheter because nobody else is willing to help you (IR says they're too sick for an IR line, Crit care is too busy, Surgery is too busy)

And then you get to leave, only to repeat it the next day for a run of 4 shifts.

You then catch up with your friend that weekend. He's an anesthesiologist. He complains about how bored he was grinding out ASA 2 cases for a call shift he picked up for $10k. He tells you about how he caught up with another friend from medical school who is a radiologist. You hear how much he's making with zero exposure to COVID patients, or ANY patients. The radiologist's wife, a radiation oncologist, is considering cutting back to 3 days a week only in her private practice with banker's hours.

You come back home from that night out with your gas friend, and you wonder what the hell happened and how you ended up in such a terrible specialty despite being on equal footing as the plastics and derm people back in medical school.

This is EM in 2024.

 

[BigRhinoGuy]

We need a pinned thread for complaints/grievances. It took exactly one post for this to turn into yet another “EM sucks” thread.

The handful of vocal malcontents have ruined this forum. Yes there are legitimate problems facing EM but most docs I know don’t hate their lives.

 

[The Knife & Gun Club]

That all seems extremely exhausting for ONE shift.

Imagine all the consultants screaming at you while you try to get them to help out your patient. Or even better yet, scream at you for idiosyncratic reasons related to how your resident or midlevel presented the patient to them, immediately backpedaling because "the resident didn't tell me that, are they even staffing this with their attending?!?!?"

Imagine getting the RNs to do even 1/10th of the critical orders on all of those patients in anything considered to be a timely manner.

Imagine all the documentation pitfalls in that list. Imagine all the metrics you missed and will hear about after the fact.

Imagine the BS you'll have to deal with when the resident dissects the ICA when putting in the dialysis catheter because nobody else is willing to help you (IR says they're too sick for an IR line, Crit care is too busy, Surgery is too busy)

And then you get to leave, only to repeat it the next day for a run of 4 shifts.

You then catch up with your friend that weekend. He's an anesthesiologist. He complains about how bored he was grinding out ASA 2 cases for a call shift he picked up for $10k. He tells you about how he caught up with another friend from medical school who is a radiologist. You hear how much he's making with zero exposure to COVID patients, or ANY patients. The radiologist's wife, a radiation oncologist, is considering cutting back to 3 days a week only in her private practice with banker's hours.

You come back home from that night out with your gas friend, and you wonder what the hell happened and how you ended up in such a terrible specialty despite being on equal footing as the plastics and derm people back in medical school.

This is EM in 2024.

Yea it was super exhausting and I’m pretty sure I fell out of every conceivable metric in the hospital. Luckily it’s a county hospital with reasonable admin and there’s sovereign immunity or else I’d be pretty darn concerned.

And that’s not even including the other 25 or so normal sick people I had in the shift.

I’m just going to quietly check my email every five minutes for the next week waiting to hear about the stemi that Im sure I missed somewhere in there

 

[southerndoc]

Cases:
1) cyanide exposure after inhaling smoke from burning upholstery. Neon pink skin, lactic 17, pH < 6.8, hypotensive and peri arrest, intubated, cyanokit, admitted to ICU

Sounds like a fun time!

My fire department started carrying CyanoKits about 10 years ago when I took over as medical director. They're expensive and we had to justify it. We've had numerous use cases. The most impressive were not the people in respiratory distress or altered mental status, but the 14 patients we've had over the years who were pulled out in asystole and survived to walk out of the hospital. Another 3 got ROSC but unfortunately became organ donors.

 

[Apollyon]

My fire department started carrying CyanoKits about 10 years ago when I took over as medical director.

Amyl nitrite, sodium nitrate, and sodium thiosulfate was the traditional setup. Were your guys carrying those before the hydroxycobolamin?

 

[southerndoc]

Amyl nitrite, sodium nitrate, and sodium thiosulfate was the traditional setup. Were your guys carrying those before the hydroxycobolamin?

Yes, but it was never used.

 

[Apollyon]

Yes, but it was never used.

But, now, they have used the Cyanokit 17 times? That sounds like a mighty big coincidence!

 

[southerndoc]

But, now, they have used the Cyanokit 17 times? That sounds like a mighty big coincidence!

Where did you get they've used it 17 times? They've probably used it 50+ times.

Not all units carried the older kits. It was on a specialty ops truck and wasn't readily available.

EDIT: Never mind. You added up all the asystolic patients. We've had a ton more with favorable outcomes who had AMS, respiratory distress, etc. We were one of the first in the nation to standardize its use and to deploy on all apparatus.

 

[Apollyon]

Where did you get they've used it 17 times? They've probably used it 50+ times.

Not all units carried the older kits. It was on a specialty ops truck and wasn't readily available.

EDIT: Never mind. You added up all the asystolic patients. We've had a ton more with favorable outcomes who had AMS, respiratory distress, etc. We were one of the first in the nation to standardize its use and to deploy on all apparatus.

I mean, I was just thinking, in Buffalo, every paramedic bus (15 or 20) had the basic cyanide kit.

 

[FirstNobleTruth]

Sounds like a fun time!

My fire department started carrying CyanoKits about 10 years ago when I took over as medical director. They're expensive and we had to justify it. We've had numerous use cases. The most impressive were not the people in respiratory distress or altered mental status, but the 14 patients we've had over the years who were pulled out in asystole and survived to walk out of the hospital. Another 3 got ROSC but unfortunately became organ donors.

This is amazing data! Have you looked at publishing this? As an EM/EMS doc in a big academic system, we have some "non-believers" about CyanoKits and I'm not sure if data this robust has been published (or at least I couldn't find it the last time I looked.). Thank you!

 

[southerndoc]

This is amazing data! Have you looked at publishing this? As an EM/EMS doc in a big academic system, we have some "non-believers" about CyanoKits and I'm not sure if data this robust has been published (or at least I couldn't find it the last time I looked.). Thank you!

Yes, but haven't had the time to do so. Maybe I'll do it in the next few months. 🙂

 

[CajunMedic]

Not sure if i'd call it neat, but I've become the necrotizing fasciitis whisperer lately. In the last 3 months, between 2 community hospitals, I've had 3 cases.

20 M, 48 hrs prior shot himself in the Right groin, with the bullet in the popliteal fossa. Originally flown to trauma center and bullet removed. Comes to me with an open wound between the entrance and exit wounds. Dishwater grey discharge, dead muscle visible, gas along the fascia, the whole thing. ABX and helicopter back to trauma center.

32F, Triaged as "bump below breast." I go stomping and grumbling down the hall and then the smell hits me. Large necrotic area below right breast, developed over 24 hours. normal person, otherwise healthy. Crepitus noted to the area, CRP off the charts, LRINEC score high. I spun around through the curtain and went to our unit clerk: "Umm, could you call CT and have them clear the table, have LifeFlight check weather and could I get the Transfer center...K Thanks..."

50's M. PA picks them up, "Wound on foot." I can see the necrosis and wound on the security cameras, its that bad. Purulent drainage. CT crashes before he can go over. Gas on plain x-ray, ABX and shipped to tertiary care center