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Please tell me you nonchalantly replied "I am the airway team..." or "your secret airway team" or something like that...
Please tell me you nonchalantly replied "I am the airway team..." or "your secret airway team" or something like that...
Jeezus. I thought I had put in some complex work. Holy hell, you rocked that one!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.
Very few things infuriate me more than a non-physician trying to dictate what is within a physician's scope of practice.Anesthesia nowhere to be found, just walked to the head of bed and popped a “difficult anatomy” ETT in the seconds. Nurse screaming “YOU CANT INTUBATE WITHOUT THE AIRWAY TEAM.”
When pts would say, "what are they going to do?", I would say, "I am 'they'."Very few things infuriate me more than a non-physician trying to dictate what is within a physician's scope of practice.
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.
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.
more likely to be a chronic flail that decompensated in the setting of trauma from the sounds of itSo 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).
When pts would say, "what are they going to do?", I would say, "I am 'they'."
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.more likely to be a chronic flail that decompensated in the setting of trauma from the sounds of it
18g spinal needle will get you almost anywhere.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.
ALMOST.18g spinal needle will get you almost anywhere.
had the family only waited another 6 hours or so.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)
If they don't remember you, they can't put on a complaint. Insert standard "thinking" gif.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.
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...
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.About that time dispatch says that first flight service declined due to the mother's weight, and they're calling the next one.
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.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.
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.
Ooof 😞The problem was, she wasn't. she actually was a little person and was maybe 60kg.
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.The problem was, she wasn't. she actually was a little person and was maybe 60kg.
Plot twist: the helicopter crew was superfatWhaaaat? 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.
Said no one in an ED ever…Like for real. No one has heard of TSH?