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This place is getting boring, post something good.
Started by RustedFox
Life is short
Life can also be long
Life can also be long
Anyone read the brothers karamazov, by Dostoevsky? I'm in a book club, and that's what's up next...
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Does it really make sense to travel outside the US with how terrible medical care is in the rest of the world?
Air embolism? Pneumo? Underwater seizure?
Dive/undersea medicine is probably one of the coolest niches of EM
I'm going to go with good ol' ACS, especially in an open water dive class.
Sorry, acute coronary syndrome.
I wish it was something as sexy.
So this is a general dive boat that the open water class was on. It’s day 2, so open dive number 3 and 4. The boat has other groups besides the class.
There’s a fairly decent current, but that’s not abnormal and normally there’s no or minimal current on the sea floor. The class was on the lag line finishing our skills (surface marker buoy, clearing goggles, duffing/donning the BCD in the water) and about to go for the dive when I see a life ring float past. “Uhh, instructor, I don’t think that’s supposed to be out here…”
We get told to get back on board. As we get back towards the back of the boat they’re trying to recover a diver that’s unresponsive. 18 year old, certified (not what level, but at least open water). Apparently he never ended up diving to depth (so lung reexpansion injury shouldn’t be possible) and the depth (50 feet) and time would be a non-decompression dive anyways.
I realize what’s happening. Scramble on board, grab their o2 setup. Patient gets pulled out in arrest and it’s almost impossible to ventilate due to size (obesity, round face) and atelectasis from loss of surfactant. Coast guard was there in what felt like 10 minutes (nothing to add but manpower unfortunately). Fire rescue in 15. Got him on the LUCAS. Life pack showed asystole. Fire rescue then transported while the boat waited for 3 hours for the state law enforcement to come out and take pictures of the boat.
In the future I’m going to ask if I can ride with fire rescue and “help” if for no other reason than not be stuck on the boat for hours doing nothing.
An OPA would have been nice to have. I’m also sure that I have a deposition in my future (should have federal and state good Sam protection, so I shouldn’t be a named party).
It’s never the cool sexy pathology. It’s always ACS.
I love scuba -and have seen the cpr on a dive boat - not fun - if you want ideas of places to go - shoot me a message - heading to Bonaire for the 8th time in a month or so
are you sure the lung injury/emoblism isn't a possiblity? I mean from 33 feet to the surface is one atm = doubling of the air size. if you hold your breath without doing a CESA from that depth you can definitely get a fatal injury - The greatest percentage increase is in that last atmosphere -
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My understanding is he didn’t actually start the dive and the entire event was at the surface.
Sure. You can get expansion injury from a relative short uncontrolled ascent.
ahhh - gotcha - that makes more sense,
I figured to have an event at the surface for an 18 year old would be pretty rare,
So here’s a case I would love some thoughts on:
35 year old female, previously healthy-ish but IVDU, came in as a cardiac arrest. Per EMS her jaw had “locked up.” Down time unknown and asystole on the monitor. No drug paraphernalia on the immediate scene.
Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.
We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.
We were trying to decide if it’s worth it to cric and establish a definitive airway. Likelihood of success is obviously exceedingly low but she’s a previously healthy-ish, and in a can’t intubate can’t ventilate situation with a presumed hypoxic arrest.
I decided to cric - got the airway, got ETCO2 and O2 sat went from undetectable to 95%. Ran CPR a few more rounds. Ultimately called it.
In the end I felt better talking to the family (her mom, husband, little kid at home) and being able to tell them we really did try absolutely everything to give her any shot and they were grateful. I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)
35 year old female, previously healthy-ish but IVDU, came in as a cardiac arrest. Per EMS her jaw had “locked up.” Down time unknown and asystole on the monitor. No drug paraphernalia on the immediate scene.
Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.
We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.
We were trying to decide if it’s worth it to cric and establish a definitive airway. Likelihood of success is obviously exceedingly low but she’s a previously healthy-ish, and in a can’t intubate can’t ventilate situation with a presumed hypoxic arrest.
I decided to cric - got the airway, got ETCO2 and O2 sat went from undetectable to 95%. Ran CPR a few more rounds. Ultimately called it.
In the end I felt better talking to the family (her mom, husband, little kid at home) and being able to tell them we really did try absolutely everything to give her any shot and they were grateful. I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)
everything prior to when he was pulled back on the boat is second hand. There was some comment that his regulator got entangled. However that’s what the octo is for.
I was looking online to see if dive boats carried any airway gear. It was a little surprising to see no suction or OPAs on board as those would be low skill, high dividend tools. I subsequently came across this blog post relating what seemed to be a similar story of a young diver drowning on the surface. Essentially if you don’t have your reg in and grab onto a line in a current, you will be inhaling water.
011 Airway Control: What's All The Fuss? - ScubaGuru
In this episode of The Dive Locker podcast you’ll learn why airway control is such an important life saving skill for scuba divers.
scubaguru.com
ya- I live in NC - so we have some good off shore diving, but also can get into some sketchy situations pretty quick with heavy currents, and 8 foot seas coming out of nowhere.everything prior to when he was pulled back on the boat is second hand. There was some comment that his regulator got entangled. However that’s what the octo is for.
I was looking online to see if dive boats carried any airway gear. It was a little surprising to see no suction or OPAs on board as those would be low skill, high dividend tools. I subsequently came across this blog post relating what seemed to be a similar story of a young diver drowning on the surface. Essentially if you don’t have your reg in and grab onto a line in a current, you will be inhaling water.
011 Airway Control: What's All The Fuss? - ScubaGuru
In this episode of The Dive Locker podcast you’ll learn why airway control is such an important life saving skill for scuba divers.
always have the reg in your mouth before leaving the boat, seen people jump in over weighted with their snorkle in their mouth, and then a frantic few moments while they struggle to not die. We are all just a bad decision or two from getting ourselves in a world of ****. And every new diver is over weighted.
Oh man, you've gotta try the hail marry on that one. Can't let a 35 yo die an airway death without using all your tools. Good job.
A woman goes to five different doctors with a complaint of palpitations. No one orders any labs on her. She was given mainly reassurances and discharged. One of the doctors even did a heart cath on her.
Woman still having symptoms, finally goes to the Cleveland Clinic, where she had lab tests done that showed hyperthyroidism. She was started on appropriate treatments and symptoms finally abated.
Woman's name: Oprah Winfrey.
Moral of the story: Outpatient medicine is dead?
www.latimes.com
Woman still having symptoms, finally goes to the Cleveland Clinic, where she had lab tests done that showed hyperthyroidism. She was started on appropriate treatments and symptoms finally abated.
Woman's name: Oprah Winfrey.
Moral of the story: Outpatient medicine is dead?
A doctor told Oprah to 'embrace hunger.' How it changed her view of medicine forever
Ahead of a new documentary about racial inequities in healthcare, the TV host opens up to The Times about her own experiences.
www.latimes.com
That's a tough one. My first thought is deep space infection, followed by tetanus. I've seen some weird infections in my IVDU population. Unable to ventilate, even with an NPA sounds like maybe a retro-pharyngeal abcess? But the bilateral mandible swelling is odd as well.
Yep. As said above, that's one you've got to use whatever you've got in the toolbox for the patient. Strong Work!
Yea that’s the tough thing about IVDU, they really do manifest just the most bizarre infections even in healthy people.
I’m sure where you’re located in the northeast/Appalachia you probably see more of it than I do. Even at our large tertiary center in Miami we don’t see all that much. People here tend to prefer drugs they can snort.
If I had to guess I’d put my money on something along the RPA/Ludwig’s/PTA spectrum.
Maybe with a sprinkle of danger space infection.
I didn't get eased into attendinghood. 3 of my first 4 night shifts I had major traumas that my community hospital is not used to, nor has much capability to care for.
#1- Teen gets thrown from ATV that subsequently lands on their unhelmeted head, gash from nasolabial fold, to corner of mouth, to angle of mandible. Almost completely through to buccal mucosa. Full trauma workup and helicopter ride to peds trauma center with OMFS standing by.
#2- Old enough to know better, intoxicated on Fireball, jumps from ATV, with the ATV running their foot over. Open bi-mal fracture/dislocation. conscious sedation, reduction, and our ortho won't touch it. Ground to trauma center for ortho
#3- Trauma code with ROSC and intubation in the field. This was the impressive one. EMS decided to come to us because the bird was going to take a while. I had a solid PGY-3, 2 PGY-2's, and 1 intern who hadn't taken ATLS yet. Plus, we actually had enough nurses who were experienced. Elderly patient on NOAC, found at bottom of stairs in pool of blood, actively exsanguinating from where the stairs effectively scalped them. Got blood, TXA, Keppra loading, Trauma scans, KCentra (despite the pharmacist telling me on the phone "umm, I can't order this under my name, it's kinda expensive.", "Well, put it under mine then"). Wound up on Levophed. I did a subclavian with a PGY-2 at my side, walking them through it (they don't do many of them). Had the goals of care conversation with the family multiple times, they wanted the transfer despite knowing the likely outcome. At least they agreed to DNR. They had a a skull fx, multiple spinal fx, broken ribs, SAH, SDH, you name it. Got a lucky break in the weather to get the helicopter to pick up the patient. Despite not having a true trauma team or trauma bay, it was one of the smoothest running traumas I have participated in. Everyone performed exceptionally well. Unfortunately, even with everything we did, they died the next day.
#1- Teen gets thrown from ATV that subsequently lands on their unhelmeted head, gash from nasolabial fold, to corner of mouth, to angle of mandible. Almost completely through to buccal mucosa. Full trauma workup and helicopter ride to peds trauma center with OMFS standing by.
#2- Old enough to know better, intoxicated on Fireball, jumps from ATV, with the ATV running their foot over. Open bi-mal fracture/dislocation. conscious sedation, reduction, and our ortho won't touch it. Ground to trauma center for ortho
#3- Trauma code with ROSC and intubation in the field. This was the impressive one. EMS decided to come to us because the bird was going to take a while. I had a solid PGY-3, 2 PGY-2's, and 1 intern who hadn't taken ATLS yet. Plus, we actually had enough nurses who were experienced. Elderly patient on NOAC, found at bottom of stairs in pool of blood, actively exsanguinating from where the stairs effectively scalped them. Got blood, TXA, Keppra loading, Trauma scans, KCentra (despite the pharmacist telling me on the phone "umm, I can't order this under my name, it's kinda expensive.", "Well, put it under mine then"). Wound up on Levophed. I did a subclavian with a PGY-2 at my side, walking them through it (they don't do many of them). Had the goals of care conversation with the family multiple times, they wanted the transfer despite knowing the likely outcome. At least they agreed to DNR. They had a a skull fx, multiple spinal fx, broken ribs, SAH, SDH, you name it. Got a lucky break in the weather to get the helicopter to pick up the patient. Despite not having a true trauma team or trauma bay, it was one of the smoothest running traumas I have participated in. Everyone performed exceptionally well. Unfortunately, even with everything we did, they died the next day.
Septic arthritis of TMJ maybe? Personally, I wouldn't put too much stock into jaw swelling-some people just look like chipmunks. I think you did the right thing cric'ing the patient, sounds like a resp arrest in a young patient--I never call codes w/o establishing an airway. (although I wouldn't criticize someone for just calling one in an unwitnessed asystolic arrest).
Ballsy move w/ a doac on board, good on you.
I had a very similar case in a young guy a while ago, presumed to also be an IVDU. I gave benzos and even paralytics for fun just to see if it will relax his jaw with no success. So also ended up cric'ing him just to say I got an airway before calling it. Found some case reports afterwards that describe similar patients: Emergency cricothyrotomy for trismus caused by instantaneous rigor in cardiac arrest patients - PubMed
Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidism 😉A woman goes to five different doctors with a complaint of palpitations. No one orders any labs on her. She was given mainly reassurances and discharged. One of the doctors even did a heart cath on her.
Woman still having symptoms, finally goes to the Cleveland Clinic, where she had lab tests done that showed hyperthyroidism. She was started on appropriate treatments and symptoms finally abated.
Woman's name: Oprah Winfrey.
Moral of the story: Outpatient medicine is dead?
A doctor told Oprah to 'embrace hunger.' How it changed her view of medicine forever
Ahead of a new documentary about racial inequities in healthcare, the TV host opens up to The Times about her own experiences.
A surprising amount of scuba drownings occur at the surface. Strong current/waves, seawater in the face/mouth, panic sets in, irrational behaviors, more seawater aspiration, death spiral. That’s why they encourage regulator in your mouth at all times until back on the boat and establishing full buoyancy once at the surface.
That being said, I have no idea what happened, could have been an unrelated rare medical event in a young thought to be healthy person (massive PE from unknown clotting d/o, STEMI from ALCAPA, VF from underlying sodium channel-opathy, etc.)
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You did the right thing. Low likelihood of success but I think 35 yo relatively healthy you gotta pull out all the stops.
That reminds me of a sucidal ideation that was triaged to our fast track once. Pleasant middle aged woman, no obvious red flags. "So ma'am, the nurses tell me you want to kill yourself. Can you tell me what's going on?" "Well, I have these horrible headaches that started a couple if years ago and nobody can help me." "So tell me about your headaches.". She goes on to describe a classic space occupying lesion headache...which the CT scan confirmed.
For a minute I thought, how does an alpaca cause a STEMI, and what's one doing out on the water?!?
But that is the whole thing. Most people with palpitations go to the ER or the PCP, not to the chair of cardiology at Mayo or whatever .. the chair of cardiology assumes the labs were already normal before the patient got to them…
During residency a patient signed in for SI and was triaged to our locked psych area. When I went to see him no one had gotten him undressed yet … he had a self inflicted GSW to the abdomen .. “I told them I was going to kill myself!” 🤦🏻♀️
and threads like these are why i love this forum…
Like for real. No one has heard of TSH?
What I want to know is what was the CTA finding that led to the CT Abd/Pelvis.
And will of course lead to countless future visits and scans b/c of "i have a clotting disorder".
What was the issue?
This was probably the second-most spinchter-clenching case of my entire medical career.
EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital
EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital
Damn.
You're getting trial by fire early in your young attendinghood.
I don't think there's anything you're gonna do there beyond what you did.
Perimortem c-section?
No thanks! I could be perfectly happy never performing that procedure. If mommy lives and that baby dies, regardless of care, just get ready for a monster lawsuit that will 100% settle because the optics of these of cases are always terrible and no jury is going to be able to think straight. They'll get focused on the 30-90 seconds worth of nursing note timestamps that make it seem like you delayed the procedure.
That's probably the worst part of OB/peds...the almost guaranteed threat of suit if you screw it up. I don't envy OB at all with their monstrous malpractice premiums. I probably spend more time on defensive documentation in OB/peds cases than I do during anything else.
Yes, in kids with unrepaired Tet squat/knee to chest will help. But it is also kids with Tet -a subset of them, at least- that will turn blue with crying/agitation, not transposition.
But, yeah, DORV with TGA who has had 5 surgeries is likely single ventricle physiology and something hasn't gone well to get to 5 surgeries...
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Medicine or Edison? Looks like you went for medicine, but why not cardiovert?
Cool case to share from the other day:
ED Case:
28yo F presents to the ED for 2 weeks of malaise, subjective fevers at home, chills, scant vaginal bleeding, chest pain, RUQ & RLQ abd pain, and palpitations. Arrived here from Guatemala 2 weeks ago, denies PMH/PSH/meds/allergies.
Triage vitals HR130, BP 91/45, O2 100, Temp 37.1, RR 16.
Got fentanyl and IVF 1L.
POC preg faintly positive.
US - no baby, ball looking thing in uterine wall, not sure what it is, FAST negative, IVC plethoric, RV strain with bowing of the cardiac septum.
Send labs, Trop in 0.2 (normal 0.034), BNP 2000, HCG 150 (so barely positive by our assay), WBC 13, AST/ALT 500s, elevated alk phos, normal Tbili. Hb 13. Urine is bloody, not infected. Lactic 1.3.
EKG is just sinus tachycardia wo RV strain pattern or stemi.
No idea wtf is going on - so decide risks outweigh benefits, CTA for PE and CT Abd with IV contrast - all completely negative. Again they see this ball thing in the uterus - they call it as likely a fibroid. So we get a transvaginal US, which is read as normal, but again they note an “intraluminal uterine fibroid, attention on followup”.
She responds well to IVF, gets a 2nd L and BP increases to 110/55.
Pelvic exam shows scant blood without discharge, fetal parts/tissue, or hemorrhage. Normal cervix.
We call OBGYN - not sure what’s going on but maybe it’s an ectopic somewhere? Is the ball really a fibroid? OBGYN resident signs off, says repeat bHCG in 48 hours, the ball is probably a fibroid, and the beta is likely from a completed spontaneous AB - possibly due to structural issues from fibroid.
Pt spikes fever to 38.5. At this point we surrender, cover with vanc and Cefepime, admit to medicine for septic workup without a source.
Inpatient course:
Blood cultures come back 2/2 positive for EColi. Super weird.
Formal echo shows mild RV strain, trended trops remain stable and modestly elevated at 0.2. Cards says likely a stress cardiomyopathy from sepsis, maybe with so pre-existing pulmonary HTN. No evidence of endocarditis or valve pathology. Nothing to do on their end.
Given the elevated transaminases surgery is consulted, they get a Hida scan, and it’s negative for biliary pathology. They sign off.
HCG at 48 hours is unchanged, still low 100s.
Repeat echo at 48 hours shows worsening global myocardial dysfunction. She’s still spiking fevers.
I’m curious and still following along, so at this point I decided to ask my wife - who’s the senior resident covering nights on GYN to look over her chart and see if there’s anything the other Day gyn resident missed.
Wife reads the TVUS and says that’s not a fibroid, that looks like retained products of conception. She goes at 3am to talk to the patient when her family is not there. The patient confesses to her that she actually had a surgical termination of pregnancy done in Guatemala 2 weeks ago immediately before coming to the US, but didn’t want her family to know so she didn’t tell anyone.
Wife gets a stat pelvis MRI at 3am (fancy toys at the womens hospital), they confirm a “loculated retained POC w/ signs of infection - most consistent with a septic abortion”. GYN team is with her in the OR now doing a formal dilation and evacuation.
So moral of the story, septic AB with stress cardiomyopathy from sepsis in a 28 year old.
ED Case:
28yo F presents to the ED for 2 weeks of malaise, subjective fevers at home, chills, scant vaginal bleeding, chest pain, RUQ & RLQ abd pain, and palpitations. Arrived here from Guatemala 2 weeks ago, denies PMH/PSH/meds/allergies.
Triage vitals HR130, BP 91/45, O2 100, Temp 37.1, RR 16.
Got fentanyl and IVF 1L.
POC preg faintly positive.
US - no baby, ball looking thing in uterine wall, not sure what it is, FAST negative, IVC plethoric, RV strain with bowing of the cardiac septum.
Send labs, Trop in 0.2 (normal 0.034), BNP 2000, HCG 150 (so barely positive by our assay), WBC 13, AST/ALT 500s, elevated alk phos, normal Tbili. Hb 13. Urine is bloody, not infected. Lactic 1.3.
EKG is just sinus tachycardia wo RV strain pattern or stemi.
No idea wtf is going on - so decide risks outweigh benefits, CTA for PE and CT Abd with IV contrast - all completely negative. Again they see this ball thing in the uterus - they call it as likely a fibroid. So we get a transvaginal US, which is read as normal, but again they note an “intraluminal uterine fibroid, attention on followup”.
She responds well to IVF, gets a 2nd L and BP increases to 110/55.
Pelvic exam shows scant blood without discharge, fetal parts/tissue, or hemorrhage. Normal cervix.
We call OBGYN - not sure what’s going on but maybe it’s an ectopic somewhere? Is the ball really a fibroid? OBGYN resident signs off, says repeat bHCG in 48 hours, the ball is probably a fibroid, and the beta is likely from a completed spontaneous AB - possibly due to structural issues from fibroid.
Pt spikes fever to 38.5. At this point we surrender, cover with vanc and Cefepime, admit to medicine for septic workup without a source.
Inpatient course:
Blood cultures come back 2/2 positive for EColi. Super weird.
Formal echo shows mild RV strain, trended trops remain stable and modestly elevated at 0.2. Cards says likely a stress cardiomyopathy from sepsis, maybe with so pre-existing pulmonary HTN. No evidence of endocarditis or valve pathology. Nothing to do on their end.
Given the elevated transaminases surgery is consulted, they get a Hida scan, and it’s negative for biliary pathology. They sign off.
HCG at 48 hours is unchanged, still low 100s.
Repeat echo at 48 hours shows worsening global myocardial dysfunction. She’s still spiking fevers.
I’m curious and still following along, so at this point I decided to ask my wife - who’s the senior resident covering nights on GYN to look over her chart and see if there’s anything the other Day gyn resident missed.
Wife reads the TVUS and says that’s not a fibroid, that looks like retained products of conception. She goes at 3am to talk to the patient when her family is not there. The patient confesses to her that she actually had a surgical termination of pregnancy done in Guatemala 2 weeks ago immediately before coming to the US, but didn’t want her family to know so she didn’t tell anyone.
Wife gets a stat pelvis MRI at 3am (fancy toys at the womens hospital), they confirm a “loculated retained POC w/ signs of infection - most consistent with a septic abortion”. GYN team is with her in the OR now doing a formal dilation and evacuation.
So moral of the story, septic AB with stress cardiomyopathy from sepsis in a 28 year old.
I know I was really hoping for some neat tropical medicine stuff.
We actually sent Chagas. Our hospital has an in house Chagas immunoassay because we do see it here occasionally, but it was negative...good for the patient I guess but would’ve been cool. Also tested her for like dengue, chickengunya, malaria, and a host of other tropical crap that was all negative.
Carlos Chagas, of the massive ego: "Everyone looked, but I was the only one that saw."
Yup. Young people get extraordinary measures. I don’t care if it’s a cric/thoracotomy/prolonged CPR I’m going to do whatever I have to do to sleep at night.
