Recent college grad here who is seriously considering medical school (lengthier post coming soon) with a strong interest in emergency medicine. I’ve always gravitated towards it, but the more I read about it the more it seems like a good fit for me. However I’m wondering what it is you guys (and girls) do during real emergencies? I know you deal with a lot of bs patients (heartburn from Indian buffet, thinks it’s the big one, stubbed toe, needs dilaudid etc.) but when someone comes in who should have been in the er hours ago and they’re sick as f**k what do you guys do? How much saving of their lives do you do before they go to some other specialist?
If you guys could briefly run through some ways people’s bodies try to kill themselves and what you do in that situation (before they go to someone else) that would be awesome. Also simplified medical language is a plus. I’m just a lowly college grad.
Thnx
Patient comes in sick as snot and is unable to provide a history because he is delirious and can't breathe. Only history EMS can tell you is "he fell".
No specialist will touch the patient in this state, but the Emergency Physician calmly yet deliberately walks to the bedside. As she does she instructs the nurse to get the patient on the monitors and to place an IV, the medic to run an ECG, a second nurse to get a blood glucose - all the while the physician is setting up airway equipment.
The patient rips off the leads, then the O2 mask and tries to get up from bed gasping "I ...can't ...breathe. I've [gasp] got to get [gasp] out of here."
The pulse ox is intermittent picking up & reading 82%. It's the only vital sign you've seen yet, then you hear the glucose - it's 42.
Recognizing that the patient needs to chill in order to get his life saved, the EP orders a whopping dose of ketamine, to be given intramuscularly (the patient still doesn't have an IV).
As the ketamine's being drawn up the EP calls to the clerk "page RT and have them bring BiPap".
While the patient is tranquilized, the EP orchestrates getting IV access, a set of vitals, and an ECG...all while the patient is being placed on BiPap and the O2 sats start coming up to the mid 90's.
The EP orders an ampule of dextrose to treat the hypoglycemia, and also asks for some rocuronium to facilitate intubation now that the patient can tolerate a few moments of apnea. She passes the endotracheal tube with ease. When she looks up from the vocal cords she can see that the ECG shows a STEMI, but the patient's not ready for the cardiologist yet. He's got this big hematoma on his head - he could have a head bleed from the fall. Knowing that time is of the essence, the EP activates the Cath lab as she calls radiology to tell them that this STAT head CT is actually
STAT. Before heading to CT the EP has defibrillator pads placed, just in case.
She reviews the images in real time and sees that there is no major intracranial bleeding - just a big ol scalp hematoma. So she orders aspirin to be crushed and given down the orogastric tube that she dropped before the post-intubation chest X-ray was shot. She starts a nitroglycerine drip at 100mcg/min (because the BP = 220/120 and the EP interpreted thenCXR as showing pulmonary edema before the Rads tech even left the room) - she asks the nurse to use the 2nd IV to start a heparin bolus.
A minute later the patient goes into pulseless v tach, fortunately he's got pads on, because the EP knew that this could/would happen. As the medic starts CPR the EP charges the defibrillator, she & the medic nod at each other and the EP delivers the shock...the heart returns to a sinus rhythm... one that still has ugly ST elevations evident on the monitor.
The repeat glucose is 140, and the patient is taken up to the cardiac catheterization lab. After thanking the team for doing such a great job and telling the patient's family that things are very serious, but that he's doing much better now, the EP sees that there's someone with 3 months of abdominal pain waiting to be seen. The EP takes a deep breath as she walks into the room, then sits down and says to the patient "So I understand that you're pretty worried about this pain that just won't seem to go away..."
