What did you see on your last shift?

[DrQuinn]

So its been like five months since I've been back in the ED, but my first three patients today were like this:

46 year old female with bladder cancer on chemo presents with weakness and palpitations. She had gone to three EDs in the past week, D/Cd home all three times. Allergic to Iodine... but V/Q scan was high probability PE.

32 year old female unrestrained driver in low speed MVA, hit head with windshield, spiderwebbed, tiny lacs on face/scalp, possible LOC, ambulatory at scene, no neck pain, no paresthesias. Head CT negative but she had a C6/C7 facet fx.

57 year old diabetic male, hypertensive, presents with sudden onset abdominal pain, diaphoresis, nausea. No hx of GERD, constipation, tics. AAS shows free air. Whisked up to surgery, he had a perfed ulcer.

I am SO glad my first three patients had real diseases, as it was back to the "crap" that we're used to for the next 20 patients. But it was sure nice having patients who had true emergencies!

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[Annette]

Sounds like you had a nice career affirming day. Unfortunately, they are too rare. While I seriously doubt that I'll go into primary care (thinking crit care), I really enjoyed my last clinic day- two young healthy compliant patients and one non-compliant diabetic patient I think I actually got through to! I wish you many more good days!

 

[mikecwru]

So its been like five months since I've been back in the ED, but my first three patients today were like this:

46 year old female with bladder cancer on chemo presents with weakness and palpitations. She had gone to three EDs in the past week, D/Cd home all three times. Allergic to Iodine... but V/Q scan was high probability PE.

32 year old female unrestrained driver in low speed MVA, hit head with windshield, spiderwebbed, tiny lacs on face/scalp, possible LOC, ambulatory at scene, no neck pain, no paresthesias. Head CT negative but she had a C6/C7 facet fx.

What led you to film her neck? Just mechanism?

mike

 

[southerndoc]

I violated 8 patients during my overnight 12 hour shift. 5 rectals and 3 pelvics.

I did have a good case though... patient with endometritis s/p "self D&C." White count of 22, febrile at 102.

Other than that, an SBO that went to the OR, a drug seeker, a guy trying to bail out of jail by claiming back pain, a good asthmatic, two drunks, and a partridge in a pear tree.

(off to bed I go!)

 

[DrQuinn]

What led you to film her neck? Just mechanism?

mike

WHen I first walked in the room, I didn't think I was going to do much. She was standing talking on her call phone and craning her neck to watch CNN on the TV. She had just a few scratches on her face and R arm. Talking to her, though, she was unrestrained, hit the windshield, and couldn't remember certain details of the accident. I put her in a c-collar then scanned her bean and neck. BOOM!

Atleast now I have a story to tell all the radiology residents who whine about us doing too many CTs of the neck (basically at our institution if you are scanning a head/chest/abd/pelvis in a trauma patient, you go ahead and scan the neck). Granted, it was a nondisplaced VERY stable fracture, but still.

Got a shift in 3 hours. Wholly not expecting to find what I saw yesterday.

 

[DrQuinn]

I violated 8 patients during my overnight 12 hour shift. 5 rectals and 3 pelvics.

I did have a good case though... patient with endometritis s/p "self D&C." White count of 22, febrile at 102.

Other than that, an SBO that went to the OR, a drug seeker, a guy trying to bail out of jail by claiming back pain, a good asthmatic, two drunks, and a partridge in a pear tree.

(off to bed I go!)

Self D&C? Wow. Was she "with it" or a bit psychotic?

 

[Sessamoid]

Self D&C? Wow. Was she "with it" or a bit psychotic?

Not to turn this into a political thread, but before the advent of generally available medical abortions, this was pretty common. Resulted in a lot of dead women of child-bearing age.

 

[DrQuinn]

Not to turn this into a political thread, but before the advent of generally available medical abortions, this was pretty common. Resulted in a lot of dead women of child-bearing age.

Yeah I know, but I haven't seen one or heard of one in a while. I get the "my soon-to-be-baby-daddy" punched me in the stomach. No coathangers.

 

[dchristismi]

I had an interesting one today...
Pleasant 63 y.o. FW with "confusion." Children were a little worried as she couldn't figure out how to use the phone, and was having trouble reading the caller ID. She also felt "a little funny," and might have had some balance problems. Seemed a little loopy to us, but not so far out that we'd call psyc. H/o optic migraines, and "TIA," and she's on lithium for bipolar.

Scheduled for MRI later this week, but the kids were really worried so they brought her in anyway.

Scan of her head showed a large sellar mass extending superiorly.

Not exactly an emergency, but real pathology. (Meaning pathology that doesn't involve trichomonas!)

 

[southerndoc]

It was an ortho shift for me yesterday... one distal fingertip avulsion, one thumb amputation, one hemarthrosis (on Coumadin) of the elbow, one effusion of the knee.

Other than that, a trigeminal neuralgia, pericarditis, and a bunch of other things that weren't really eye catching.

 

[lawmd]

Busted my first drug seeker. Story didnt add up, MVCyesterday, said his wife was a nurse at a local hospital who just dropped him off. I called the hospital, gave me her number. She has been at the beach for two days, told me explicity not to give him narcotics and he didnt have a wreck. Did a FAST exam (negative) came back in the room and he was gone. Screw you!!!!!

Another guy was shot in the leg, came in with pain 3 days s/p GSW. the screw came out of his crutch, so he wanted a new set of crutches. "it's OK, I got Medicaid, give me a new set" "No", I said, "buy a screw for 15 cents." he got pissed off when I told him that is why our taxes are so high. I found a screw, saved the taxpayers of North Carolina 4o bucks. Great day.

 

[southerndoc]

Speaking of screwing the taxpayers, I hate the people who want you to call an ambulance or wheelchair car because "they don't want to pay for a taxi." Well guess what? We call them a taxi.

 

[margaritaboy]

Had a 16 yr old kid with enterovirus meningitis, as demonstrated a couple of days later with PCR.

Came in with fever, vague migratory HA and lower back pain with chin-to-chest manuver. Didn't look bad at all.
LP: 34 WBC with occational monocytes on gram stain, cell count showed elevated neutrophills, normal glucose, and elevated protein.

Kinda werid.

My buddy had an adult patient with acute epiglotitis. Thumb print positive lateral neck XR and hot potato voice.

 

[deleted6669]

Motorcycle(without Helmet) + 6 Pack Beer Vs Tree= Open Zygomatic Fx
(rest Of Workup Including Ct Neck/chest/head/ Abd And Multiple Plain Films Neg)

New Onset L Arm/leg Weakness In Twenty Year Old With Significant Cerebral Palsy= Multiple Sclerosis By Stat Mri Brain

2 Appys, 1 Pyelo, Several Chronic Pelvic Pain/headaches/back Pain/dental Pain

1 Neg Cardiac Workup In Demented 75 Year Old Diabetic With Chest Pain

Large (> 20 Cm) Full Thickness Leg Lac( 3 Layer Closure)

 

[anonymousEM]

the pediatrician offered to see the 57 yo female who was "emotional" after a 10 day "get in touch with your emotions" conference if I'd go to his continuity clinic for 4 hours after the overnight shift.

Let the guy sleep through the 6am teen preg vag bleeder and got the pleasure of delivering the 18wk fetus.

 

[spyderdoc]

19 yo healthy male with a few weeks of non-specific chest pain, malaise and poor appetite shows up at 3AM during a busy night. Pretty normal exam except for some mild LUQ tend to deep palpation...I did a cxr and basic labs and the poor kid had a huge mediastinum chock full of lymphadenopathy. WBC 31k with lymphocytic predominance and 50 platelets...He was admitted for the lymphoma workup...Luckily, he doesn't have any of the "B" symptoms so hopefully we caught it early enough for treatment...
All I have to say is that I am glad that I wasn't too grumpy that night and bitch slap his ass out of the ED for coming in with 3 weeks of non-specific symptoms......

 

[mikecwru]

19 yo healthy male with a few weeks of non-specific chest pain, malaise and poor appetite shows up at 3AM during a busy night. Pretty normal exam except for some mild LUQ tend to deep palpation...I did a cxr and basic labs and the poor kid had a huge mediastinum chock full of lymphadenopathy. WBC 31k with lymphocytic predominance and 50 platelets...He was admitted for the lymphoma workup...Luckily, he doesn't have any of the "B" symptoms so hopefully we caught it early enough for treatment...
All I have to say is that I am glad that I wasn't too grumpy that night and bitch slap his ass out of the ED for coming in with 3 weeks of non-specific symptoms......

I had a very similar story several months ago: 19 y/o kid tall nad lanky c sudden onset R sided pleuritic CP. Decreased BS. Thought it was going to be a spontaneous PTX. CXR c r sided effusion and large ball mass in upper lobe. Turned out to have a very rare, very bad extraskeletal sarcoma.

mike

 

[Chris_Topher]

Had my first patient with a rectal foreign body - bottle of Old Spice. Best smelling farts around.

 

[Chris_Topher]

(turns out the bottle was full)

 

[Sessamoid]

"What did you see on your last shift?"

A bunch of non-urgent crap. Most boring shift of my life, except for one potential child abuse case. Those always ruin my day.

 

[lawmd]

two days in a row I got a 60yo male with dyspnea, decreased breath sounds, dullness to percussion-both had totally whited out lungs, got to do a thoracentesis on both.

had a 20yo girl with vaginal bleeding for a few months and complained of a big lump in her vagina. Pelvic exam had some old blood with a paper like consistency. While checking for CMT, she said "yeah thats it, thats that lump I have been trying to pull out." I calmly said, "Ma'am, that is your cervix, please don't pull that out." She then explained that she had been sticking her whole hand into her vagina to try and pull out her cervix, then commenced to stuff toilet paper inside to stop the bleeding, thus explaining the paper consistency. Ahhhhhhhh-job security...

 

[cardiotonic]

I was volunteering today and experienced death for the first time . A 56F came in under cardiac arrest, two weeks after she had a pacemaker put in. I was suprised, a nurse that has worked in the ED for a while couldn't even come in the room, while I was in there taking it relatively well. I also helped put the woman in a body bag (also a first).

 

[Daedalus]

had a 20yo girl with vaginal bleeding for a few months and complained of a big lump in her vagina. Pelvic exam had some old blood with a paper like consistency. While checking for CMT, she said "yeah thats it, thats that lump I have been trying to pull out." I calmly said, "Ma'am, that is your cervix, please don't pull that out." She then explained that she had been sticking her whole hand into her vagina to try and pull out her cervix, then commenced to stuff toilet paper inside to stop the bleeding, thus explaining the paper consistency. Ahhhhhhhh-job security...

damn

 

[IdiotBoxen]

Followed up on previous case (16 year old female, she couldn't get the tampon out, so she put 2 more in subsequent to that). Patient is doing ok on the wards, has recieved additional information on the correct usage of tampons. Microbiology was ok, was scared because she was febrile, but that went away.

Delivered a baby, 23 year old mother got a 6lb 9oz female. Pure magic. Baby is doing well.

Reviewed case with a private doc at hospice. Patient with cervical cancer is being transfered to hospice care. The patient has declined further treatment and the private wanted me to arrange the transfer and work with the pain management service.

Had an awesome lunch at Quizno's.

Horrible afternoon followed though...

Had a 13 year old sent up by radiology after she wasn't sure if she was pregnant or not. Turns out she wasn't pregnant and had the CT later.

Unfortunately, it got worse with delivery of a very early premie. The neonatology fellow just looked at me with the saddest eyes i've ever seen. We spoke to the parents, and they agreed that it was best not to try heroics. So we wrapped the boy up in the blue blanket and gave him to his mother and father. There was just no way he was going to survive. He died 30 minutes later in their arms.

(Something odd, I edited that last paragraph after I realised I use the term 'it' instead of 'him'. I feel very bad when I do that.)

Went home. Cried. Feel much better now.

 

[ERMudPhud]

Pediatric cardiac arrest from an intentional overdose and a whole lot of stuff that seemed pretty pointless in comparison

 

[roja]

23 yo female sitting at her desk in a car dealership. somebody test driving a suv, accidently hit reverse and rammed into the dealership. She was pinned between her desk and wall...

t10 spinous process fracture, splenic injury, fractured kidney, contused pancreas.

Hopefully she will do well.

 

[margaritaboy]

8 yr old male with 20 day hx of unsteady gait, 7 day hx of right ptosis. Previously healthy.

Exam: unsteady posture while sitting, moderatly ataxic gait, rhomberg neg. No cerebellar drift. Restricted EOM in R eye, + light perception, pupil reactive, but Marcus Gunn +.

Labs: CT -, MRI possible pontine infarct.

Prelim dx: Brainstem Astrocytoma with focal necrosis.

 

[margaritaboy]

Quintuple trauma. MVA vs Tree.

Unrestrained, nonejected passengers 11, 8, and 5 yrs old. 11 and 5 yr olds lucky, with both having left radial buckle ftxs.

8 yr old less lucky: Apparently tried to grab the steering wheel as intoxicated driver passed out while driving. Broken R proximal femur, humerous, and radius. Against all odds: no TBI

 

[DrQuinn]

Two days ago, multiple trauma alerts, I ran all of them, declared one dead, others had minimal injuries (mostly soft tissue). Its here in the news!
Click here suckers!

30 year old had massive facial trauma, intubated on scene with a combitube. No pulse on scene. No motion on bedside ultrasound, code called shortly after arriving in ED.

2 1/2 year old with open skull fracture, though.
Q

 

[IdiotBoxen]

More fun to report!

There is a special word we use to describe people who rely on the man pulling out before ejaculating : parents.

It's better to mention to me your previous pregnancy loss early on, not as you are leaving the office. This makes me unhappy, why couldn't you have said this when I asked you at the start of the history?!

Had fun in the ER dealing with ectopic pregnancy. Man that's fun, especially when the resident yells at us for not coming down before he rang for us to come down. I guess we missed those psychic courses they run...

Usual well women things... pelvics, breast exams, etc...

However, we have SOLVED our mystery case. Patient has been unwell for quite some time with very odd symptoms. Diagnosis : Malaria. It was such an odd presentation (mostly gyne symptoms, so she came to us) we never considered it, along with a -ve travel history. Lab missed it first time But not the second time! Now tagged to our friends at infectious diseases. Enjoy, suckers.

Delivered the first twins in my time today. Freaking awesomeness goodness. I so love deliverying babies...

 

[ERMudPhud]

However, we have SOLVED our mystery case. Patient has been unwell for quite some time with very odd symptoms. Diagnosis : Malaria. It was such an odd presentation (mostly gyne symptoms, so she came to us) we never considered it, along with a -ve travel history. Lab missed it first time But not the second time!.

You can't just throw that out without a little more explanation. What symptoms did she have and how the heck did she get malaria without traveling?

 

[Apollyon]

More fun to report!

There is a special word we use to describe people who rely on the man pulling out before ejaculating : parents.

It's better to mention to me your previous pregnancy loss early on, not as you are leaving the office. This makes me unhappy, why couldn't you have said this when I asked you at the start of the history?!

Had fun in the ER dealing with ectopic pregnancy. Man that's fun, especially when the resident yells at us for not coming down before he rang for us to come down. I guess we missed those psychic courses they run...

Usual well women things... pelvics, breast exams, etc...

However, we have SOLVED our mystery case. Patient has been unwell for quite some time with very odd symptoms. Diagnosis : Malaria. It was such an odd presentation (mostly gyne symptoms, so she came to us) we never considered it, along with a -ve travel history. Lab missed it first time But not the second time! Now tagged to our friends at infectious diseases. Enjoy, suckers.

Delivered the first twins in my time today. Freaking awesomeness goodness. I so love deliverying babies...

I'm guessing you are in or from the UK. I think this because 1. "...he rang for us...", 2. "gyne", 3. "-ve", and, finally, 4. delivering twins. When I did my ob block a few months back, two attendings said that functionally, all twins are delivered by C-section today. One said she had never naturally delivered twins.

Good to hear your reports, though. In the VA SICU, it is certainly not so exciting.

 

[ERMudPhud]

4. delivering twins. When I did my ob block a few months back, two attendings said that functionally, all twins are delivered by C-section today. One said she had never naturally delivered twins.

Thats kind of scary and probably indicative of the overall wide regional variation in frequency of c-sections in this country. A friend of mine, here in Colorado, just delivered twins the old fashion way.

 

[Sessamoid]

Thats kind of scary and probably indicative of the overall wide regional variation in frequency of c-sections in this country. A friend of mine, here in Colorado, just delivered twins the old fashion way.

I think it's more a sign of the fear that obstetricians have regarding potential malpractice suits. Twins are already higher risk pregnancies, and delivering vaginally leaves too much to chance for many obstetricians in the US.

 

[IdiotBoxen]

You can't just throw that out without a little more explanation. What symptoms did she have and how the heck did she get malaria without traveling?

I wrote that before I went to bed. I was tired. Gimme a break

She began having very odd menses. Going from exactly 29 days, to bleeding every 3-5 days. This then stopped for 3 months and she went back to the normal cycle. Then started again, this time with a low fever just at nighttime. We though nothing of this as it's winter here, and it must be just the heating or something. Pt then began to get pain on intercourse. We did all the tests then, as we were really worried by the symptoms. There was nothing wrong we could find, but we had no reason to doubt her.

Saw pt again recently this time she said she was feeling very cold and was experiencing moderate clitoral pain, we did the lab tests again, and, sure enough, they got malaria on the slide. My resident asked path to go back and look at the slide from last time, they did, and there was no malaria there then.

The only place the pt has been is a year ago to Japan, and as far as we know, there is no malaria there. So, we have no idea whatsoever....

UPDATE : +ve Plasmodium vivax.

 

[roja]

60 something year old intox, presumed assault:

subdural
SAH
Post orbital fracture
Humeral head fracture with about 1 liter of blood in the shoulder.

....

Malaria

.....

Mandibular fracture (drunk)
....

Traumatic SAH (another drunk)

.....
3 drunk columbia students

.....

ruptured appy

......

phimosis

 

[mikecwru]

yesterday...

skull fracture in a 4 m/o

butt abscess

multiple traumas, two with a GCS of 8; one's sugar was just low, the other choked on some of my plastic

we had one trauma crich, but i didnt do it

knee avulsions b/l and open calcaneus fx

partial finger amputation

fever w/u in a gome, LP

acute anterior MI c ST elev on pre-hospital EKG, door to cath time, 20 minutes

little gomelin (neurologically devastated) 5 y/o c stridor


I also have a ? for you guys. How many of you let the trauma team do a rectal exam when the pt is logrolled? I've heard some people think this ok, but I think if you've got someone in "TLS precautions" then doing a rectal when they're probably going to severely arch their back is not the best idea in the world.

mike

 

[ERMudPhud]

I also have a ? for you guys. How many of you let the trauma team do a rectal exam when the pt is logrolled? I've heard some people think this ok, but I think if you've got someone in "TLS precautions" then doing a rectal when they're probably going to severely arch their back is not the best idea in the world.

We always did the rectal with them still flat on their backs. As a side note we never log rolled blunt trauma patient until after the C-spine was radiographyically clear. The feeling was that in blunt trauma you werent going to find much that would matter in the next 30 minutes or so.

 

[ERMudPhud]

The only place the pt has been is a year ago to Japan, and as far as we know, there is no malaria there. So, we have no idea whatsoever....

UPDATE : +ve Plasmodium vivax.

Cool case. The only two things I might add is that vivax can hide in your liver for a long period of time so a travel history >1year might matter. At least here in the USA we have case reports of people who live or work near international airports being infected by mosquitos arriving on the planes. I suppose the same could apply in your case. By the way where are you at? Australia, New Zealand, other?

The initial miss on the blood smear points out the importance of asking the lab to do a thick rather than thin smear and telling them you are specifically concerned with malaria, although in your case I could see why that would not have been on your list.

 

[peksi]

Ok here is the count from the past 2 days...mostly highlights.

1. Began the shift with a 90 yo ruptureed AAA, 6.5-7.2 on ED US and left Retro Peritoneal collection. prohospital BP 52 palp with syncope x 2
2. Then a 50 yo male 1 week s/p AAA repair with graft with severe abdminal pain. Sent in by vascular surg for "kideny stone"...now don't they get it. We identified a 3 cm perigraft hematoma with active color jet and spectral broadening on ED US . No free fluid...stat call to vascular and to the OR for graft leak.
3. 23 trauma patient who had an industrial auger fall on him, EMR intubated, patient. the patient had a "free floating spine" ( a new one for me) at the level of L1-L4. Patient was forcibly hyperflexed (folded in 2 by several hundred pounds)
4. Heart Alert/Code, IW/ MI - to cath lab immediately
5. Prosthetic Posterior hip dislocation with EM resident Proc sedation and reducaiton
6. Urospetic patient...central line...sepsis protocol..early intubation etc
7. A narc seeker who threatened my staff...who was then evidently threatended by THOR...one of our 150lb German Sheperds at the Hospital
8. A few suicidal ideations
9. 2 first trimester vag bleeders, one with twins with twin B as a fetal demise on our US
10. A 10 yo with a classis abdominal handle bar injury with FF on FAST and evidence of bowl hematoma on CT (this is WILL be a board question for all of you)! Sent to our low acuity side where I worked 9/3
11. A SAH on a very nice 43 you gal Hunt and Hess 1
12. multiple lacs
13 About 5 renal colic players
14 About 8 chest pain workups
15. An 8 month old with orbital cellulitis
16. A few bogus belly pains
17. 2 hip and one acetabular fracture
19. A supperatuve adenitis in a 38 you lady
20. DKA and MI in a 60 yo diabetic
21. A classic line sepsis.
22. A 19 you female appy

These are the ones that stick out.

 

[Jeff698]

Even though I've never been close to Newark, I'm thinking that any place with a 150lb Shepard named THOR has got to be OK.

Take care,
Jeff

 

[Scrubbs]

Happened a few weeks ago, but I had a pretty interesting neuro case...

Early 50's male vasculopath comes in with acute onset blurry vision and dizziness... upon further questioning the blurry vision is actually double vision when both eyes are open. On exam, he can't cross midline with either eye (bilateral CN III)... sort of bizarre.

CT neg, MRI neg... since he's still in the ED, we decided to try a Tensilon... which was also negative (though very cool as I hadn't done one before). Anticholinesterase Ab subsequently neg also... Neuro is calling it intranuclear opthalmoplegia from microvascular infarct. Of course, they also say its really rare to catch both CN III without any other involvement. Pretty cool - though not for the pt of course...