The ED Hat Trick

[dchristismi]

So, we all have those things we love. Tonight I had a near hat-trick... or at least, MY hat trick:

A STEMI, an Appy and TPA.

The STEMI turned out to not be a *rush to the cath lab now*, but a "we'll go to the cath lab tomorrow" ACS. But still - close enough. The CVA actually was able to give me a high-five after her TPA. And no, this is not the place to debate the literature. I work in a very pro-TPA shop, and she was a good candidate. Besides, if it was me in her place, I'd have wanted it.

So what are yours? I mean, your big 3 favorites?

FWIW, I nearly ran the table today as well - with 6 critical care cases + the usual, I consulted (some multiple times) Medicine (duh), Pulm, Critical care, Cards, Ortho, Gen Surg, Peds, Neuro, Onc, Nephro, Uro, Psych, and, um, probably someone else. My poor secretaries couldn't keep up.

And I saw a textbook anticholinergic syndrome that I then had to explain to the admitting NP. Sigh.
Yep, it was a good shift.

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[RustedFox]

Wow.

I miss you AND your shop.

No joke.

Hat trick in these parts is [ANY PATIENT under 20 years old] + STEMI + [ANY PATIENT above 100 years old]

Its actually not all that hard of a hat trick. The STEMI is the rate-limiting factor. Also, the "under 20" is more rate-limiting than you'd think. 100+? Please, I work between eleventeen nursing homes.

Florida, man.

*** For the uninitiated ***

A "hat trick" is a phenomenon that occurs during ice hockey games in which one player scores three goals in one game. In response to the stellar performance, the crowd is *obligated* to throw their hats onto the ice to celebrate that player's achievement. A variation is the "Gordie Howe" hat trick, in which a player records a goal, an assist, and a fight in one game. Gordie Howe was well-known for his skill both with the stick, and with his fists.


If I had to vote for "faves"...

STEMI. US-guided-IJ. Sweet shoulder reduction (I am short. I am bulit 'low to the ground'. I can reduce, smartly.)

 

[WildcatS11]

Wow.

I miss you AND your shop.

No joke.

Hat trick in these parts is [ANY PATIENT under 20 years old] + STEMI + [ANY PATIENT above 100 years old]

Its actually not all that hard of a hat trick. The STEMI is the rate-limiting factor. Also, the "under 20" is more rate-limiting than you'd think. 100+? Please, I work between eleventeen nursing homes.

Florida, man.

*** For the uninitiated ***

A "hat trick" is a phenomenon that occurs during ice hockey games in which one player scores three goals in one game. In response to the stellar performance, the crowd is *obligated* to throw their hats onto the ice to celebrate that player's achievement. A variation is the "Gordie Howe" hat trick, in which a player records a goal, an assist, and a fight in one game. Gordie Howe was well-known for his skill both with the stick, and with his fists.


If I had to vote for "faves"...

STEMI. US-guided-IJ. Sweet shoulder reduction (I am short. I am bulit 'low to the ground'. I can reduce, smartly.)

Did you really just explain what a hat trick was.

 

[WildcatS11]

Wow.

I miss you AND your shop.

No joke.

Hat trick in these parts is [ANY PATIENT under 20 years old] + STEMI + [ANY PATIENT above 100 years old]

Its actually not all that hard of a hat trick. The STEMI is the rate-limiting factor. Also, the "under 20" is more rate-limiting than you'd think. 100+? Please, I work between eleventeen nursing homes.

Florida, man.

*** For the uninitiated ***

A "hat trick" is a phenomenon that occurs during ice hockey games in which one player scores three goals in one game. In response to the stellar performance, the crowd is *obligated* to throw their hats onto the ice to celebrate that player's achievement. A variation is the "Gordie Howe" hat trick, in which a player records a goal, an assist, and a fight in one game. Gordie Howe was well-known for his skill both with the stick, and with his fists.


If I had to vote for "faves"...

STEMI. US-guided-IJ. Sweet shoulder reduction (I am short. I am bulit 'low to the ground'. I can reduce, smartly.)

More seriously... I'm not entirely sure why people like taking care of stemis. Unless it's a particularly ambiguous EKG, the ED management and cognitive load is virtually nil. I mean sure, every once in a while you get a v-tach or something else exciting out of it, but most go to cath lab land within whatever metric your hospital has deemed.

 

[Boatswain2PA]

1. CVA, pushed TPA (hate that stuff). Rapid improvement before shipping out.

2. STEMI, pushed TNKase, watched the conversion & ST elevation improve before shipping out.

3. Big saddle PE, stable but sucking wind. I wanted to push TPA on her as well but receiving intensivist didn't want me to, so Heparin bolus/drip and shipped out.

The clotting hat trick, all in one day in a little 6000 annual visit ED.

 

[Arcan57]

Hypertensive basal ganglia ICH
Traumatic SAH w/ B SDH s/p MVC
Epidural hematoma s/p orthostatic syncope s/p vodka, hot tub, Viagra

 

[BoardingDoc]

I consulted (some multiple times) Medicine (duh)

What kind of things do you get a medicine / critical care consult for? I've worked in shops where you have to get an ICU "consult" in order to admit the patient, but in those cases I'm not asking management questions, I'm asking "do you want this patient?"

 

[WilcoWorld]

Procedural hat trick:
1) Intubation
2) Chest tube
3) Hip reduction
Double points if you do all three on the same patient.

 

[dchristismi]

What kind of things do you get a medicine / critical care consult for? I've worked in shops where you have to get an ICU "consult" in order to admit the patient, but in those cases I'm not asking management questions, I'm asking "do you want this patient?"

I suppose "consult" for IM was meant more as "admission" because it's still a phone call, and IM admits pretty much everything at my shop. So I called 3 different hospitalist groups a dozen times. And they want me to call the CC guys to let them know that they'll be on the hook for vent management. Which again, is just how my shop does it. (Few of these calls were actually management questions - but "consult physician" is the order I have to put in the computer to make sure the consultants have their precious list.) And they're still phone calls I had to make. (As in "hi, Dr Oncology, I just wanted to let you know that your patient Mrs X crashed in the infusion center and I intubated her, got a pulse back, and Dr Y is admitting, Dr Z is managing the vent, and I've also talked to her nephro because she's a dialysis patient." Cumbersome? Absolutely. The best thing for patient care in my particular shop? Yeah, that's why I do it. YMMV)

Oh, and I just adore STEMIs.
A) with my luck and patient population, they very well may crash, and B) I still get an adrenaline rush out of it. So yeah, there's that. And on a more personal note, my husband is a cath lab nurse, and the night of our first date we talked for hours, then I went and worked an overnight shift, and at 6:50 am, he came in to take my STEMI to the cath lab. So it's a little nostalgic as well. (We managed to keep *us* a secret, even in our little hospital - and you all KNOW how the gossip is - for nearly 3 months.)

 

[Psai]

I suppose "consult" for IM was meant more as "admission" because it's still a phone call, and IM admits pretty much everything at my shop. So I called 3 different hospitalist groups a dozen times. And they want me to call the CC guys to let them know that they'll be on the hook for vent management. Which again, is just how my shop does it. (Few of these calls were actually management questions - but "consult physician" is the order I have to put in the computer to make sure the consultants have their precious list.) And they're still phone calls I had to make. (As in "hi, Dr Oncology, I just wanted to let you know that your patient Mrs X crashed in the infusion center and I intubated her, got a pulse back, and Dr Y is admitting, Dr Z is managing the vent, and I've also talked to her nephro because she's a dialysis patient." Cumbersome? Absolutely. The best thing for patient care in my particular shop? Yeah, that's why I do it. YMMV)

Oh, and I just adore STEMIs.
A) with my luck and patient population, they very well may crash, and B) I still get an adrenaline rush out of it. So yeah, there's that. And on a more personal note, my husband is a cath lab nurse, and the night of our first date we talked for hours, then I went and worked an overnight shift, and at 6:50 am, he came in to take my STEMI to the cath lab. So it's a little nostalgic as well. (We managed to keep *us* a secret, even in our little hospital - and you all KNOW how the gossip is - for nearly 3 months.)

That is very impressive, on all fronts.

 

[alpinism]

Procedural Grand Slam

1) Intubate
2) Chest tube
3) Central line
4) Burr hole

Seen it done twice.
Including once when they made a full recovery.

 

[Boatswain2PA]

...Including once when they made a full recovery.

And THAT is what makes it all worth it.

 

[deleted245139]

Few weeks ago...
1. Lateral canthotomy
2. Thoracotomy
3. Half a dozen tubes and lines, but really after the first two, was just gravy lol

 

[USCDiver]

From today
1) Low volumes
2) Unambiguous dispos
3) Left on time

 

[WilcoWorld]

From today
1) Low volumes
2) Unambiguous dispos
3) Left on time

The best hat trick in the game.

 

[deleted109597]

$2000 shift bonus
Broke ground on my own freestanding
Bought TGIFridays for all the staff at midnight

 

[Psai]

$2000 shift bonus
Broke ground on my own freestanding
Bought TGIFridays for all the staff at midnight

Nice bro

 

[engineeredout]

My procedural hat trick would be:

1) Chest Tube
2) Intubation
3) TV Pacer

 

[gman33]

I love stemis too, but because they are usually the easiest patient I see all day.

 

[deleted547339]

So, we all have those things we love. Tonight I had a near hat-trick... or at least, MY hat trick:

A STEMI, an Appy and TPA.

The STEMI turned out to not be a *rush to the cath lab now*, but a "we'll go to the cath lab tomorrow" ACS. But still - close enough. The CVA actually was able to give me a high-five after her TPA. And no, this is not the place to debate the literature. I work in a very pro-TPA shop, and she was a good candidate. Besides, if it was me in her place, I'd have wanted it.

So what are yours? I mean, your big 3 favorites?

FWIW, I nearly ran the table today as well - with 6 critical care cases + the usual, I consulted (some multiple times) Medicine (duh), Pulm, Critical care, Cards, Ortho, Gen Surg, Peds, Neuro, Onc, Nephro, Uro, Psych, and, um, probably someone else. My poor secretaries couldn't keep up.

And I saw a textbook anticholinergic syndrome that I then had to explain to the admitting NP. Sigh.
Yep, it was a good shift.

You are aware that there is no debate regarding early improvements in post-tpa patients? Regardless of your overall feeling on the drug, even the most pro-tpa MDs don't argue that it helps acutely.

 

[RustedFox]

You are aware that there is no debate regarding early improvements in post-tpa patients? Regardless of your overall feeling on the drug, even the most pro-tpa MDs don't argue that it helps acutely.

To be clear; you're stating that it DOESN'T help acutely - correct?

 

[Mighty Mouse]

More seriously... I'm not entirely sure why people like taking care of stemis. Unless it's a particularly ambiguous EKG, the ED management and cognitive load is virtually nil. I mean sure, every once in a while you get a v-tach or something else exciting out of it, but most go to cath lab land within whatever metric your hospital has deemed.

Only reason I like a STEMI is the immediate dispo I get out of it.

 

[deleted547339]

To be clear; you're stating that it DOESN'T help acutely - correct?

Yes. All those that beleive in it's efficacy only argue for its utility on scale of weeks to months, not hours to days. That's up for debate (on a different thread, per dchristismi's request), but whether or not it works in hours to days is not up for debate - it doesn't.

 

[DoctorMedic]

I always thought a hat trick was intubation, central line, and chest tube on the same patient. Had a few of those.

 

[deleted547339]

I always thought a hat trick was intubation, central line, and chest tube on the same patient. Had a few of those.

Only if you didn't cause the ptx by the cvl.

 

[da8s0859q]

Only if you didn't cause the ptx by the cvl.

Which is sort of like a penalty kick you score which you got from a bull**** faked injury in the first place.

 

[Dred Pirate]

1. CVA, pushed TPA (hate that stuff). Rapid improvement before shipping out.

2. STEMI, pushed TNKase, watched the conversion & ST elevation improve before shipping out.

3. Big saddle PE, stable but sucking wind. I wanted to push TPA on her as well but receiving intensivist didn't want me to, so Heparin bolus/drip and shipped out.

The clotting hat trick, all in one day in a little 6000 annual visit ED.

gotta ask- when you "push TPA" do you really push it - or do you mean the standard 1 hour infusion (nerd rph here)

From the RPh perspective - the hat trick would be
-pushing narcan in the unresponsive OD and watching them wake up before my eyes
-mag for torsades and resolving
-adenosine

I enjoy the meds that actual work as you use them and see a noticeable change

 

[dchristismi]

Uh, I tell the nurse to give it. As I understand, there is a bolus and a drip, but I physically push neither.

Hell, the only drug I ever actually physically administer is diprivan.

 

[Tenk]

1) work note

2) workers comp form

3) AMA form

If you score all three in one patient you will instantly win medicine and can retire.

 

[Boatswain2PA]

gotta ask- when you "push TPA" do you really push it - or do you mean the standard 1 hour infusion (nerd rph here)

Bolus & drip, then the looooooong wait for transport.

 

[e30ftw]

Residency hat trick:

1. Intubation
2. CVL
3. Chest tube

Attending hat trick:

1. Pick up last minute shift for double pay.
2. Dispo all your patients without ordering a single test.
3. Sleep > half the shift.

 

[Dred Pirate]

Bolus & drip, then the looooooong wait for transport.

thankfully we don't get stuck with the ICU patients for long - I work in both ICU and ED - our RN's just don't have much experience titrating drips in the ED