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The Knife & Gun Club said:
Academically more interesting…

60yo M presents to ED as pedestrian hit by car. AO3/GCS15 on arrival but w/ BP 85/50, palpably widened pubic symphesis on survey. No other injuries. 2 units blood in the bay. BP doesn’t budge but he’s mentating fine and fast is negative. Place pelvic binder. Trauma scan with an open book pelvis and hematoma but nothing crazy.

Booked for the OR with ortho, ED/Trauma teams call me down to admit the guy to the unit post-op. He says he has a “problem with his heart and high pressure.”

Anesthesia goes to intubate the dude and he drops like a f*ing stone. Pressures in the 60/20 range. Ortho aborts the case and throws on an ex fix, he comes up to the unit with a BP of 50/— in RVR and having runs of pulseless vtach. ABG with a pH of 7.1, K 6.9, lactic 7. POCUS with RV completely blown out, LVEF looks fine. Bolus amio, then start epi—>norepi—>vaso and max then all. Push 3 amps of bicarb, calcium, mag and BP creeps up to 70/40. Dude starts hemorrhaging from his ex-fix site so call for blood, took quick clot and shoved in down holes for the ex-fix rods and pack it tight against the bone. Repeat fast negative. Optimize the vent with low tidal volumes and peep to try to unload the strain off the right heart. Maybe a PE?

Every time the vent delivers a breath his a-line flatlines.

Probably time to stop screwing around and call the adults, so call in my attending from home, and he suggests calling the CVICU in too. Luckily today the Trauma ICU attending is EM+surgical critical care and the CVICU attending is EM+medicine critical care. The cavalry arrives.

CV guy drops a TEE probe in while I float a swan with the trauma attending. PA pressures are 70/40. On TEE we can see he’s got a flail mitral valve. Hook up nitric to the vent to drop the PA pressure. Add on milrinone, dig load, 8 of bumex + 120 of lasix + drip, start to peel back the NE and the dude starts to turn pink again (from a robust shade of purple).

Lactic starts to come down and urine starts to flow in the foley. By morning the labs normalized and he’s being prepped for OR for a new mitral valve.

Personally convinced if it wasn’t for it being all EM people doing the resus the dude would have been dead as a rock.
Click to expand...

So this guy was hit by a car. He also randomly blew his mitral valve? You trauma scanned him and he had no thoracic injury.

Such a weird story. Well done though. haven't seen an acute flail leaflet in some time (years).
 
The Knife & Gun Club said:
Academically more interesting…

60yo M presents to ED as pedestrian hit by car. AO3/GCS15 on arrival but w/ BP 85/50, palpably widened pubic symphesis on survey. No other injuries. 2 units blood in the bay. BP doesn’t budge but he’s mentating fine and fast is negative. Place pelvic binder. Trauma scan with an open book pelvis and hematoma but nothing crazy.

Booked for the OR with ortho, ED/Trauma teams call me down to admit the guy to the unit post-op. He says he has a “problem with his heart and high pressure.”

Anesthesia goes to intubate the dude and he drops like a f*ing stone. Pressures in the 60/20 range. Ortho aborts the case and throws on an ex fix, he comes up to the unit with a BP of 50/— in RVR and having runs of pulseless vtach. ABG with a pH of 7.1, K 6.9, lactic 7. POCUS with RV completely blown out, LVEF looks fine. Bolus amio, then start epi—>norepi—>vaso and max then all. Push 3 amps of bicarb, calcium, mag and BP creeps up to 70/40. Dude starts hemorrhaging from his ex-fix site so call for blood, took quick clot and shoved in down holes for the ex-fix rods and pack it tight against the bone. Repeat fast negative. Optimize the vent with low tidal volumes and peep to try to unload the strain off the right heart. Maybe a PE?

Every time the vent delivers a breath his a-line flatlines.

Probably time to stop screwing around and call the adults, so call in my attending from home, and he suggests calling the CVICU in too. Luckily today the Trauma ICU attending is EM+surgical critical care and the CVICU attending is EM+medicine critical care. The cavalry arrives.

CV guy drops a TEE probe in while I float a swan with the trauma attending. PA pressures are 70/40. On TEE we can see he’s got a flail mitral valve. Hook up nitric to the vent to drop the PA pressure. Add on milrinone, dig load, 8 of bumex + 120 of lasix + drip, start to peel back the NE and the dude starts to turn pink again (from a robust shade of purple).

Lactic starts to come down and urine starts to flow in the foley. By morning the labs normalized and he’s being prepped for OR for a new mitral valve.

Personally convinced if it wasn’t for it being all EM people doing the resus the dude would have been dead as a rock.
Click to expand...

What's frustrating about this case is that ultimately the patient will believe the CT Surgeon saved his life. Years later he will tell the story like "A car hit me and I had a broken pelvis, but they discovered I also had a ruptured heart valve. I was near death and the CT Surgeon saved my life!" And there won't be a single mention of the CCU doc.

I remember I had a 50s F w/ STEMI who coded, and I shocked her THIRTY TWO TIMES. The only thing that got her out of VT was actually pushing etomidate/roc. After the 15-20th time, the interventional cards was in the room too and suggesting stuff...but what stopped the incessant VT was sedation, much to my surprise. She got her LAD stent and resumed zumba classes a month later.

I, along with a few other docs and nurses, were honored at some yearly EMS Survivors event put on by the county EMS system. It's a cool event and we all get distingushed letters of commendation from the US State Representative from the district. Anyway....the pt said basically what I wrote above. On the microphone to the entire room she thanked the cardiologist who put in her stent and said he saved her life. I went up to her later that evening and said "do you remember me? I'm Dr. ER doc". She said no! I said I'm not surprised...because you were unconscious for most of those 32 shocks. I'm the one that pushed the button so many times, and you finally got out of it when I sedated you and intubated you. She was thankful for what I did, but didn't remember me at all.

:shrug:
 
thegenius said:
So this guy was hit by a car. He also randomly blew his mitral valve? You trauma scanned him and he had no thoracic injury.

Such a weird story. Well done though. haven't seen an acute flail leaflet in some time (years).
Click to expand...
more likely to be a chronic flail that decompensated in the setting of trauma from the sounds of it
 
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Apollyon said:
When pts would say, "what are they going to do?", I would say, "I am 'they'."
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Radetzky said:
more likely to be a chronic flail that decompensated in the setting of trauma from the sounds of it
Click to expand...
Yeah, our best guess is that he had some pre-existing structural problem with his mitral, and when he got hit by a car it just broke.

Weird mechanism, weird Pathology, but a good case
 
Not nearly as cool as some of the other posts here but finally found a patient with too much adipose tissue for a standard central line kit needle to actually hit the femoral vein.

61 year old morbidly obese ESRD vasculopath with bilateral AKAs who decided he didn't want to go to HD anymore arrives peri-arrest after family calls 911 since he looked like death (literally)

Somehow despite not having legs dude still weighs over 400 lbs and the humeral IOs dislodge. EKG brady in 40s with a QRS >160 msecs

Try to go for a femoral CVL and the standard finder needle can't reach the femoral vein despite two nurses holding the pannus and a med student pushing down on the skin

Finally a grizzly older attending procures a not-so-sterile 18G spinal needle and by the grace of God it gets into the vein and I can thread a wire through it.

3g of CaCl, 3 amps of bicarb and RSI meds later nephrology actually agrees to dialyse this hot mess and I avoid running a ****show of a code.
 
Lexdiamondz said:
Not nearly as cool as some of the other posts here but finally found a patient with too much adipose tissue for a standard central line kit needle to actually hit the femoral vein.

61 year old morbidly obese ESRD vasculopath with bilateral AKAs who decided he didn't want to go to HD anymore arrives peri-arrest after family calls 911 since he looked like death (literally)
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had the family only waited another 6 hours or so.
 
thegenius said:
What's frustrating about this case is that ultimately the patient will believe the CT Surgeon saved his life. Years later he will tell the story like "A car hit me and I had a broken pelvis, but they discovered I also had a ruptured heart valve. I was near death and the CT Surgeon saved my life!" And there won't be a single mention of the CCU doc.

I remember I had a 50s F w/ STEMI who coded, and I shocked her THIRTY TWO TIMES. The only thing that got her out of VT was actually pushing etomidate/roc. After the 15-20th time, the interventional cards was in the room too and suggesting stuff...but what stopped the incessant VT was sedation, much to my surprise. She got her LAD stent and resumed zumba classes a month later.

I, along with a few other docs and nurses, were honored at some yearly EMS Survivors event put on by the county EMS system. It's a cool event and we all get distingushed letters of commendation from the US State Representative from the district. Anyway....the pt said basically what I wrote above. On the microphone to the entire room she thanked the cardiologist who put in her stent and said he saved her life. I went up to her later that evening and said "do you remember me? I'm Dr. ER doc". She said no! I said I'm not surprised...because you were unconscious for most of those 32 shocks. I'm the one that pushed the button so many times, and you finally got out of it when I sedated you and intubated you. She was thankful for what I did, but didn't remember me at all.

:shrug:
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If they don't remember you, they can't put on a complaint. Insert standard "thinking" gif.
 
CajunMedic said:
Here's another one of CajunMedic's spinchter-clenching patients,

29 Female, seizure history, comes in by EMS in status epilepticus. Had seized 7 times prior to EMS' arrival, twice with EMS, receiving a total of 10 mg Versed PTA. Normal person, takes their meds, follows with neuro at Big University system across the state line. Promptly seizes again as soon at EMS crosses into the room. Give 4 of Ativan as that's the quickest thing we can get our hands on, then the 1 gram of Keppra we have in the Pyxis. Still seizing and now Hypoxic. Pull the trigger and RSI. Have the PA call the pharmacy for the phenobarbital dosing. Call the nursing supervisor for the EEG machine, because it's going to be a while for transfer and transport, figure we'd need it. Can't get it, only 1 in hospital and no tech on call to set it up. Gets the Phenobarb, still seizing once the roc wears off. Lactic of 11. WBC 33K, labs otherwise OK. Give the remainder of the weight-based Keppra dose. Still seizing, but not as often. Transfer center finally calls back and puts me through to the ICU doc, recommends cranking the Propofol up, giving Valproic Acid, and starting Levophed if needed for the pressure after maxing out the Propofol. Finally stops seizing, core temp 102.9. Now cooling and giving IV tylenol. Central Line, Art line, and Levo on standby. Can't get a bird due to weather and no critical care ground assets for transport. At shift change, she's stable as I can get her and I sign her out to the day doc pending transport.

I came back on that night to find out, she stayed stable, but could never get a helicopter. At 10 AM, They wound up sending a local ALS truck with a new medic, an ER nurse, and a hospital RT to manage the vent and went an hour by ground.

Wishing I got an RVU Bonus! Level 5 patient, with 360 mins of CC time and procedures...
Click to expand...

EPILOGUE: Working a night shift last week when a guy comes in with an infected chin lac. I walk in and introduce myself "Hey, I'm Dr. Cajun, what's going on tonight? The patient looks at me and says "You're Dr. Cajun? We'd never thought we'd see you again! You saved my wife's life!! and he points to her. She says "You probably don't recognize me, I'm not seizing!" She spent a month in the Neuro ICU, multiple specialists, EEG's, etc. wound up getting a whole new med regimen and hasn't had a breakthrough seizure since!


Here's one from the rural EMS medical director files.
I'm pretty active with my agencies and have scheduled work days where I'm running calls in my chase truck and doing "Hip-pocket" training with the on-duty crews, QA/QI, just being available to the crews and administration. I was sitting in an advisory council meeting for our in-house training center when a call comes in for the local clinic: 4 month old, distended abdomen. Don't think twice and go back to what I'm dealing with. I hear the crew go on-scene and a few minutes later ask for the status of our local helicopter. I figure it's bad, jump in my truck and get enroute. I pull up as they're bringing them outside. I introduce myself to mom and the clinic nurse and jump in the truck. Kid looks sick. Born at 26 weeks with a long NICU course. Abdomen so distended the veins are engorged, lethargic. Belly is hard as a rock with no bowel sounds. I pop my head out and ask if they did an x-ray. They did, but it isn't read yet. They brought me inside and let me look at it on the PACS. Massively distended bowel with what looks like a volvulus. About that time dispatch says that first flight service declined due to the mother's weight, and they're calling the next one. I key up and tell them that this is a surgical emergency and let HEMS know that. Next crew accepts with a 15 minute ETA to our helipad. Head that way and meet the crew there. Bird lands and I give report to the crew. I had looked for an IV, but mom said all the patient had ever gotten were central lines and umbilical lines. Flight nurse tried for an ankle, but couldn't get anything. They load up and head out.

A couple of weeks later, I'm working my regular job and get a phone call from the Pediatrician thanking us for our care, the clinic was impressed with the quality of the crew, and the fact that I showed up on scene. The patient did have a volvulus, went straight to the OR and was still in the PICU with an open abdomen, but minimal vent settings with plans to re-anastomose that week.
 
CajunMedic said:
About that time dispatch says that first flight service declined due to the mother's weight, and they're calling the next one.
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If being so fat that your weight is directly delaying transportation for your critically ill child to go to the OR isn't a reason to lose weight, I don't know what is.

That said, I'm also so utterly jaded from this job that I would bet money that it had no effect whatsoever.
 
BoardingDoc said:
If being so fat that your weight is directly delaying transportation for your critically ill child to go to the OR isn't a reason to lose weight, I don't know what is.

That said, I'm also so utterly jaded from this job that I would bet money that it had no effect whatsoever.
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Well, Stat MedEvac in Western PA puts their flight crews on the scale periodically (I forget if it's quarter, half, or yearly), and, if even one pound over, you're off the flight line.
 
BoardingDoc said:
If being so fat that your weight is directly delaying transportation for your critically ill child to go to the OR isn't a reason to lose weight, I don't know what is.

That said, I'm also so utterly jaded from this job that I would bet money that it had no effect whatsoever.
Click to expand...

The problem was, she wasn't. she actually was a little person and was maybe 60kg.
 
CajunMedic said:
The problem was, she wasn't. she actually was a little person and was maybe 60kg.
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Whaaaat? I clearly don't understand critical care helicopter rules. How could that possibly have been a contraindication to flying? Mom plus baby must be what, 62kg then? I've definitely helicoptered out patients who weigh well over 100kg before.
 
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And now one from the "you learn about it in medical school, but will never see it in real life" file.

39F comes in with what looks like a migraine headache. Started out sharp, left-sided, radiated to right side behind eyes and then all over. accompanied by photophobia, nausea, vomiting, etc. I'd seen this patient a couple of weeks prior and admitted her for rhabdo with 0 apparent cause. Something about the presentation today set off my "Not Quite Right" light. Did my usual migraine cocktail: Liter of NS, 25 of Benadryl, 10 of Reglan, and 30 of Toradol. Decided do to labs, CT, CTA. Labs and CT are OK, Head CT is negative.

But then I get an Epic message from the radiologist: "patient surprisingly has occluded proximal L MCA with reconstitution by tangle of collaterals consistent with moyamoya disease..."

wait, what? yup. It was visible, even to me on CTA. Called big hospital system across the state line (closer than our new in-state mothership), spoke with the neurovascular specialist who wanted to fly her, but couldn't due to weather, and got her transferred. I hope to find out what happened.

The residents at my new job next week are going to get some interesting case presentations from me!
 
CajunMedic said:
And now one from the "you learn about it in medical school, but will never see it in real life" file.

39F comes in with what looks like a migraine headache. Started out sharp, left-sided, radiated to right side behind eyes and then all over. accompanied by photophobia, nausea, vomiting, etc. I'd seen this patient a couple of weeks prior and admitted her for rhabdo with 0 apparent cause. Something about the presentation today set off my "Not Quite Right" light. Did my usual migraine cocktail: Liter of NS, 25 of Benadryl, 10 of Reglan, and 30 of Toradol. Decided do to labs, CT, CTA. Labs and CT are OK, Head CT is negative.

But then I get an Epic message from the radiologist: "patient surprisingly has occluded proximal L MCA with reconstitution by tangle of collaterals consistent with moyamoya disease..."

wait, what? yup. It was visible, even to me on CTA. Called big hospital system across the state line (closer than our new in-state mothership), spoke with the neurovascular specialist who wanted to fly her, but couldn't due to weather, and got her transferred. I hope to find out what happened.

The residents at my new job next week are going to get some interesting case presentations from me!
Click to expand...
Maybe a month ago I had a woman roll in at like 3am or something on a night where I had previously cleared the whole ED out. Complaint? Tinnitus. I was bragging to my scribe about how fast I intended to discharge this old abuela. I wasn't even trying to get a 'quality' history. I was just trying to hear enough to punt her, except she literally dropped pathology bomb after pathology bomb in a row.

To get to the point. It was less tinnitus and more "a woosh woosh woosh" in her ears.
little spooky
"Oh also. I never have high blood pressure. So you have to repeat that. There is no way I'm 220/110"
very spooky
"weirdest thing of all doc, if i press on my neck I can make the wooshing noise go away in one ear"
CTA time baaaaaaby

The radiologist called me to say that there was no way the findings were real 'but i had to report it for CYA purposes' and he basically fought me that this woman had some novel and complex sclerotic/calcific pathology of her carotids and that the visibly obvious bilateral dissections just cant be because 'whats the odds of that'.
 
I'd like to take this opportunity to announce my first day owning a pair of reading glasses. I have officially graduated into old man status. I can't believe how much better I can see up close. I won't have to punt all the lac repairs to my APC anymore since I can actually see sutures again. Up until now I was having to have a nurse hold my iPhone over the lac to use the zoom feature so I could see what I was doing. These things are like voodoo magic!
 
Groove said:
I'd like to take this opportunity to announce my first day owning a pair of reading glasses. I have officially graduated into old man status. I can't believe how much better I can see up close. I won't have to punt all the lac repairs to my APC anymore since I can actually see sutures again. Up until now I was having to have a nurse hold my iPhone over the lac to use the zoom feature so I could see what I was doing. These things are like voodoo magic!
Click to expand...

Okay I have to ask, did any patients ever raise an eyebrow at that, like "can this guy see well enough to fix me up?" It's hilarious to picture.
 
gruemd said:
Okay I have to ask, did any patients ever raise an eyebrow at that, like "can this guy see well enough to fix me up?" It's hilarious to picture.
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You know, I've been doing it so long that it just seemed natural to me. Like....I forgot that it's normal to be able to see up close. Now that you mention it, they were probably making faces at the nurse but I just never noticed. It came to a breaking point other day when some old guy came in for suture removal and I didn't have a nurse to hold the iPhone so I was squinting and holding my phone up and having to snip them with one hand. He actually said something. "Your eyes ok doc?" I thought he was being a smart ass.
 
Groove said:
You know, I've been doing it so long that it just seemed natural to me. Like....I forgot that it's normal to be able to see up close. Now that you mention it, they were probably making faces at the nurse but I just never noticed. It came to a breaking point other day when some old guy came in for suture removal and I didn't have a nurse to hold the iPhone so I was squinting and holding my phone up and having to snip them with one hand. He actually said something. "Your eyes ok doc?" I thought he was being a smart ass.
Click to expand...
You'll love bifocal reader safety glasses then. Don't ask me how I know...
 
Groove said:
I'd like to take this opportunity to announce my first day owning a pair of reading glasses. I have officially graduated into old man status. I can't believe how much better I can see up close. I won't have to punt all the lac repairs to my APC anymore since I can actually see sutures again. Up until now I was having to have a nurse hold my iPhone over the lac to use the zoom feature so I could see what I was doing. These things are like voodoo magic!
Click to expand...

It was amazing when I started wearing them when I sutured. Trying to hold the driver an arms length away became very tiring!!
 
Groove said:
I'd like to take this opportunity to announce my first day owning a pair of reading glasses. I have officially graduated into old man status. I can't believe how much better I can see up close. I won't have to punt all the lac repairs to my APC anymore since I can actually see sutures again. Up until now I was having to have a nurse hold my iPhone over the lac to use the zoom feature so I could see what I was doing. These things are like voodoo magic!
Click to expand...

Man my friend reached her mid 40s and had to put something at arms length to read it and I was like uh oh...
 
Groove said:
I'd like to take this opportunity to announce my first day owning a pair of reading glasses. I have officially graduated into old man status. I can't believe how much better I can see up close. I won't have to punt all the lac repairs to my APC anymore since I can actually see sutures again. Up until now I was having to have a nurse hold my iPhone over the lac to use the zoom feature so I could see what I was doing. These things are like voodoo magic!
Click to expand...
You're not old until you start looking at the fiber content of your cereal.
 
Groove said:
I'd like to take this opportunity to announce my first day owning a pair of reading glasses. I have officially graduated into old man status. I can't believe how much better I can see up close. I won't have to punt all the lac repairs to my APC anymore since I can actually see sutures again. Up until now I was having to have a nurse hold my iPhone over the lac to use the zoom feature so I could see what I was doing. These things are like voodoo magic!
Click to expand...
I read this yesterday, and I'm still in shock that someone works at a place that has a nurse available to hold a phone during a lac repair. Hold onto that job!
 
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Groove said:
You know, I've been doing it so long that it just seemed natural to me. Like....I forgot that it's normal to be able to see up close. Now that you mention it, they were probably making faces at the nurse but I just never noticed. It came to a breaking point other day when some old guy came in for suture removal and I didn't have a nurse to hold the iPhone so I was squinting and holding my phone up and having to snip them with one hand. He actually said something. "Your eyes ok doc?" I thought he was being a smart ass.
Click to expand...
Got bifocal contacts several years ago, it really is crazy when you realize "oh yeah, the world is supposed to be clear".
 
VA Hopeful Dr said:
Got bifocal contacts several years ago, it really is crazy when you realize "oh yeah, the world is supposed to be clear".
Click to expand...

I totally get it now! I've got an appt to get set up with bifocal lenses. I kept getting annoyed that I was having to lower the reading glasses to look away from my computer screen and back to the patient. I totally can see how bifocal lenses are the answer.
 
gutonc said:
Wait a minute...bifocal contacts are a thing? My world is about to get turned upside down.
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I had a friend who used to ski with one near contact and one far contact before the bifocal contacts were a thing. She was still one of the best skiers I've had the privilege learning from. It was wild.
 
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VA Hopeful Dr said:
Got bifocal contacts several years ago, it really is crazy when you realize "oh yeah, the world is supposed to be clear".
Click to expand...

Are there progressive contacts? I just started wearing progressive glasses. No bifocals. They give not two focal lengths for far and near, but a range of them.

They took some time for me to get used to, but they are pretty good.
 
As my favorite marching cadence from my Army days goes: "Heeere we go again....same old stuff again..."

Sitting in my office this morning, in my PJ's, on Teams for the monthly ED staff meeting. Start time: 0730
0735: Director of EM Services "We've got an MCI at the main campus from a house fire, mulitple peds patients, need everyone available to go in"
0745: rolling out the door
0805: Roll in to main campus to utter chaos, and try to ascertain who's in charge and what's going on. Only ED staff is an attending and a kick-ass senior resident. Immediately get pulled into trauma bay with intubated 5 y/o with visible airway swelling, covered in soot. Tachycardic, hypertensive, but satting well and synchronous with vent. Do quick ABC's and call for x-ray. ETT right mainstem. Pull back a couple of cm's, and breath sounds get better. Random admin, anesthesia, surgeons, and pediatrics popping in and out to check on us. Call pharmacy to get Cyanokit dosing for peds. Hand calculate the drip rate because it's not in the pumps.

While I've got this going on, I'm hearing the rest of the story: Mom woke up to smoke in the house, she was on the 3rd floor and pushed a window A/C out to get out onto the roof. Lost airway shortly after arrival and got intubated. My patient was with her, rescued by FD, who slapped on an NRB and jumped in the back of a cop car to transport the 5 mins to our facility. Firefighter fell 15 feet from ladder going up to rescue her and one of the other siblings who coded and the other doc got ROSC. The youngest one was at the seat of the fire, came in in arrest, and got called. There were worked by surgery and anesthesia with peds input. The FF is next door, banged up with some fractures, but overall OK.

My kid arrived unresponsive with a GCS of 3, but before transport was waking up and showing purposeful movement, to the point we had to swap up sedation and flight crew wound up giving them Roc.

Original destination plan was to go to the closest hyperbaric center, but that changed after the repeat ABG's. Looks like CO/Cyanide poisoning with a primarily airway involvement. No real burns other than superficial, mine had some superficial corneal involvement (did an eye exam while waiting on the bird)

All 3 helicopters arrived within minutes of each other. One on the roof helipad and the other 2 at the county fairgrounds.

First patient arrived at approximately 0725, last one left for the tertiary center at approximately 1045. All of them intubated, sedated, stabilized and showing some positive signs. The 2 kids got Cyanokits. All while dealing with a pedi code and and injured firefighter. Off-duty PA came in in civvies and was seeing the exisiting roomed patients and yeeting what he could from the waiting room. Admin stayed out of the way, took notes and made phone calls for us. The unit secretary needs an award and a raise for the job she did coordinating things. The non EM docs stayed in their lanes and offered assistance where needed. I volunteered to hang around and help decompress the department, but me and the off-duty PA were told to GTFO by the 10am doc and resident

This was the second MCI we've had in less than 6 months. The first one had 5 patients, all with >50% TBSA burns from an oil-well explosion, tubed, IO'd, and flown out.
 
Here's another one from Uncle Cajun's "This job is aging me in dog years" file

Working the Freestanding ED with another doc, 2 PA's and a medical student. EMS brings us one from across the frozen river/state line, bypassing the closest facility. No NTG, patient declined IV. 75ish woman with chest pain: crushing, substernal, radiated to neck/jaw, etc. EKG is only LBBB w/o Sgarbossa. Vitals are better than mine. Only history is a aorto bi-fem graft, done in 2009 at a hospital that's now been closed to 10 years. Being evaluated for EVAR of an AAA around the graft. Negative chemical stress test 2 weeks ago. No belly pain, nausea, etc. Give her ASA, but something tells me to hold the nitro, Dilaudid for pain. Standard chest pain stuff, but throw in a CTA of the abdomen/pelvis given the history.

Hemoglobin comes back first: 5.9. "Ma'am, has there been any blood in your stool?", "Now that I think about it, I figured i had food poisoning on Monday and Tuesday. I was vomiting black stuff and my diarrhea was black and smelled really bad." Type and cross for 2 units. and bump her to the head of the CT line

Rest of the labs start coming back: Trop's 280, BNP 5000, Coags up a little. I went to CT with her.

I'm watching the CT as its being done: AAA is definitely there and looks awful close to the bowel.

Radiology calls me: aorto-enteric fistula, with likely infection of the graft, free air in retroperitoneal space.

Now it's official: likely sentinel bleed from aorta-enteric fistula with a significant blood loss caused an NSTEMI.

Call in-house vascular surgery PA at main campus: Surgeon is on vacation, needs to ship to tertiary care center.

1st call: Big state university in patient's home state: Accepted to the ED, with immediate plans to go to OR. They want Vanc/Zosyn, 3rd unit of blood, and Esmolol drip, with permissive hypotension at SBP 85-90. Call for helicopter: Private one we have a contract with declines due to weather. Destination says they'll send theirs with a 76 min ETA. Nope, problems on the pad, can't lift off, next one is an hour and a half out. Will launch as soon as the pilots shift change.

CT surgeon calls back in the interim: "Sorry, we've got to decline this patient after all. we don't have enough platelets to perform the surgery. This came from the department chair. Call us back if you can't find anyplace else"

Call other tertiary referral in their home state: No capacity. 2 other hospitals with CT surgery: nope, we won't touch that

Big state university 2 hours up the road: We'll take her when she has a bed, other state universities excuse is BS, and try a bigger center just in case we can't get a bed.

Now we call gigantic, world-renowned tertiary care center. Accepted to CVICU, bed available, will go to cath as soon as stable, then they'll discuss aorta repair. They auto-launch their helicopter: and no-go due to weather. Now, there's a question of ground asset being able to go that far. In-state university calls with a bed at the same time. Patient wants to go to the state university, she's been there before and her husband really isn't able to make it to the gigantic care center.

So, patient ultimately goes to in-state hospital by ground unit with a nurse on-board to titrate Esmolol. This takes up the last 7 hours of an 11 hour shift, I bill 450 minutes of critical care time. Thank God for my colleagues that helped me out while I was tied up with that freaking disaster.
 
Janders said:
Well if that doesn’t summarize the issue with modern EM, no post will
Click to expand...
@CajunMedic has the most fuxxored time all of the time.

I couldn't agree more that the worst cases I've had involve PITA transfers / consultants not behaving / patients not accepting transfer to the place that has a bed and is ready for them.
 
thegenius said:
Yea there needs to be a revision of EMTALA that in real medical or surgical emergencies, like REAL ones like the one above, they get auto launched to the closest center and they deal with it.
Click to expand...
And what is this BS that people trained in the problem at hand refuse to treat the patient saying it's too complicated?

More BS

I had a Urologist once try to not come in for penis trauma. "I don't do penis trauma" he quips. I mean WHAT THE FUUUKKK who is supposed to fix a penis then?
 
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thegenius said:
And what is this BS that people trained in the problem at hand refuse to treat the patient saying it's too complicated?

More BS

I had a Urologist once try to not come in for penis trauma. "I don't do penis trauma" he quips. I mean WHAT THE FUUUKKK who is supposed to fix a penis then?
Click to expand...
The system I worked for just got hit with an EMTALA fine for a vascular surgeon who refused to fix a carotid hematoma from a recent endarterectomy because the surgeon who did the procedure originally was at another hospital.

Didn't help that he refused to even come into the hospital and examine the patient, this was all over the phone between him and the ED doctor.
 
RustedFox said:
You heard me.
Click to expand...
Started on the "hybrid" ATLS renewal course.

The videos are worse than the early 1990s Red Cross CPR videos.

$1K to watch videos and learn about how important trauma prevention is, how there are new acronyms (XABCDE, MIST, RICE, etc), and how important communication is.

Have surgeons gone soft? Is the world upside down??
 
Boatswain2PA said:
Started on the "hybrid" ATLS renewal course.

The videos are worse than the early 1990s Red Cross CPR videos.

$1K to watch videos and learn about how important trauma prevention is, how there are new acronyms (XABCDE, MIST, RICE, etc), and how important communication is.

Have surgeons gone soft? Is the world upside down??
Click to expand...

Haven't renewed my ATLS since residency.

Only reason I renew ACLS is because the brass tell us: "we get a big insurance discount if you're all certified".

I don't really believe them.

Follow the money. Squeeze the juice.
 
Continuing the trend of "you'll hear about this in medical school or residency, but its rare in real life"

78 M checks in for "swelling to eye." Figure it's the usual Chalazion/Stye/cellulitis, etc. Walk in the room and the patient has a HUGE angry, red, indurated area to the medial side of the right eyebrow that extends up the forehead and down the side of the nose. Developed over 24 hours. Has a history of of endoscopic sinus surgery, chronic sinusitis, and is seen at state university medical center 3 hrs up the road by ENT. Little tachycardic, temp 99.7. Order basic labs, CT head, and CT facial bones. CT's come back with what I suspected: Pott's Puffy Tumor. His right frontal sinusitis and eroded through to the subcutaneous tissue and formed an abscess. Start the transfer process to go up the road. "We'll accept him ED to ED, but we're on diversion. We evaluate diversion every 3 hours and we'll call when we get a bed." I go off-duty at 0100, and sign out to the overnight doc. I came back on the next day at 1500 and he's still there. Got a bed about 10AM, but no transport. Finally, a BLS crew from middle of nowhere picks him up.

Followed up today. They confirmed the diagnosis and took him to the OR a couple of hours ago for endoscopic I&D. Gonna grab an intern or a PGY-2 and see if we can get it published.
 
Not specifically emergency medicine related, but I think you guys would appreciate this more than most other sections of this website would

Down here in Miami there is a hospital system called Larkin. I hesitate to refer to it as a hospital system, but I don't know what else to call it. It's three very small hospitals that all seem to be built extremely close to pockets of nursing homes. I don't know where exactly the name Larkin came from, but they are privately owned hospitals that are owned and ran by the doctor who provides all the medical care at the nursing home. Obviously the structure was set up prior to the ACA, as this would be illegal after the ACA. You can immediately see what the game is here. What's a little terrifying is that Larkin has some residencies at their hospitals, which absolutely should never be having residents.

Somehow, despite living down here for close to a decade, I missed the fact that there is also a Larkin University. It basically pumps out bad nurses and medical techs.

Well, they just announced that they intend to open a medical school at the same campus that they teach the nurses and the techs at. And I'm certain this is going to be a big hit in the larger medical student community when they roll in for an interview and see that the medical school is located in a strip mall between pawn shop and car parts Warehouse it faces directly towards the number one strip club in America.

For those strip club aficionados reading, it's directly in front of tootsies, which used to be a BJ's wholesale club, but is now the first or second biggest strip club in America and is consistently rated the number one strip club in America. Personally, I think this would be the only compelling argument for this medical school. Quick access to after school entertainment
 
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