Why I love rural EM

[EMEDPA]

strong work...I think a lot of folks would not have even checked labs, so good pick up!

[sk732]

Truth be told, I was going to call it "acute wussyitis", but I saw a number of cases like this when I was in the Army unfortunately - older person or more sedentary one trying to do a Battle Fitness Test cold without work up, or just trying too hard and then end up totally messed up...usually with a pre and or post dose of too much ibuprofen and not enough water, just to speed up the AKI.  At least she was smart enough to not take any...she had visited Dr Google and found out about rhabdo before visiting and was scared $hitless before I even set foot in the room

 

SK

[EMEDPA]

at my solo double coverage gig this weekend. rock and roll time.

my partner cardioverted a 1 month old with wpw

I had a 90 yr old trauma with a hemopneumothorax after a fall: chest tube, intubation, blood, transfer

one of our frequent flyers coded and was worked for over an hr.

[sk732]

Last week had a case brought in from another facility that choked on something - NO BYSTANDER BLS - paramedics did 4 rounds of CPR and got ROSC.  They were still obtunded so I went to intubate - had to McGill out a couple ounces of sticky roll before tubing.  Also had a patient the other day come in with a colovesicular fistula peeing poop. 

 

I still can't even think of cinnamon buns...

 

SK

[ventana]

nice experience at the rural job yesterday. was pretty busy at the beginning of the shift with 3 sick pts at once so I missed lunch in the hospital cafeteria. lady who runs the cafeteria comes over right after they close, hands me a plate of lasagna, and says" I didn't see you over there so thought you might be busy and need this".

bless you.

this is just reason #10 of 5 million that I no longer work at a busy inner city trauma ctr where no one knew my name after 15 years there or would notice if I missed a meal or worked sick as a dog as long as I showed up.

 

 

 

This is probably the best "practicing medicine" feel good story I have seen.  

 

That lunch lady did more for her community then most!  She recognized a need and filled it *your stomach!"  Wish there was more people like that.....

[ventana]

   Also had a patient the other day come in with a colovesicular fistula peeing poop. 

 

 

 

SK

 

 

Whats wrong with that???

[sk732]

Whats wrong with that???

 

It apparently feels like "pissing razor blades"...nothing wrong for me, it's an LCF (Look Cool Factor) case.  The triage nurse had a "I just saw a 4 headed alien" look on his face when the patient explained what was going on - he thought he was exaggerating or something.

 

SK

[EMEDPA]

walked into 9 pts at the solo rural job today including 2 abd pain, 2 chest pain, and a sob with sao2 78%.... and they kept checking in....urosepsis, chronic pain pts x 2, etc....just getting caught up now...

[sk732]

They knew you were coming :-D.

 

SK

[sk732]

Nasty fracture weather this weekend - past week has been freeze/thaw repeat hourly/daily, so lots of ankles hips, backs and a couple femurs...not to mention lots of head CT's on old folks going down on their noggins.  Adding insult to injury, our ortho centre in the city was overwhelmed as one of the rural ortho referral centres in the west of the province had to close down from power failures, so we couldn't move our patients requiring ORIF's until last night.

 

SK

[sk732]

Old dude comes in with blood gusing out of somewhere in his mouth - sneezed and the lower denture bridge came out and cut somewhere.  I found the lac on the ® sublingual vein...took 2 whip stiches to make it stop for good.  That was exciting, trying to keep the field clean, clear and the tongue from moving around...messy too.

 

SK

[sk732]

Weird weekend here - my atending got a hinky feeling about a dude she had with tingly extremites and frank leg weakness and pain...sent him to neuro at our urban referral centre and he was admitted with GBS.  No apparent precipitant, unless ice fishing can be considered one.  I had an old dude that might have been a stroke...or could have a radial nerve palsy...or could have some sort of embolic event in his brachiocephalic plexus...he's seeing neuro today.  The cool stuff we see here is what has kept me from quitting so many times, since our region couldn't manage itself out of a wet paper bag with a map and direct supervision.

 

SK

[EMEDPA]

Had an interesting pt at shift change(20 min before end of my shift) on the floor. older lady with multiple issues admitted for psych stuff. should have been DNR, but wasn't. nurses call me for SOB x 3 hrs. find her hunched over in bed looking like death with sao2 74% on simple mask at 5L(WTF). other VS : R40, P 120, bp 170/95, T 97.4 Temporal, monitor ST without ectopy.

a little positioning, removing pillow that was flexing neck, insert nasal airway, switch to nrb mask at 15L, ok 90%. gcs in the toilet. responds to pain by moaning only. intubated. chart review shows chf hx. has rales b/l,  nl temp, +JVD, no edema, and bedside lactate of 0.5. PCxr big heart, but nothing different than prior studies so ddx chf vs basilar pneumonia vs flash pulmonary edema, etc. stated abx and Lasix and KVO fluids and placed ntg paste on chest, which tanked bp. initial procalcitonin and BNP nl but next several procalcitonin trend upwards. intensivist opted to tx as likely aspiration pneumonia. 6 hrs later required more fluids and pressors. I'm thinking this lady was sick for more than 3 hrs at the point they called me.

(side note: this is a new solo rural job . this was the first PA-performed intubation without a physician present in this ED as far as I can tell).

CHF vs pneumonia can be harder than you might think if the pt is afebrile and can't give an adequate hx.

[sk732]

30yom, abrupt CP, tachycardia and "numb" left side.  Pretty boring history...when asked about street drugs, adamantly "NO"...I always follow up with "Weed's a sreet drug right?" (though not for much longer here it would seem)..."NO, I DON"T DO DRUGS".  OK then - HR is between 130 and 150, ordering labs, then he looks at me funny and says "My friend gave me somw odd cookies an hour or two ago...How odd?...Brown off green...earhy taste?...Yeah"  Eyes are glazing over at this point...then he starts panicking again. 

 

UDS (+) for cannabinoids.  A bit of lorazepam, fluids and a rest and he was much better a few hours later...I'm pretty sure his "buddy" is black and blue today though (or here's hoping - if it had been a friend of mine who did that, they'd be).

 

SK

[Guest JMPA]

Had an interesting pt at shift change(20 min before end of my shift) on the floor. older lady with multiple issues admitted for psych stuff. should have been DNR, but wasn't. nurses call me for SOB x 3 hrs. find her hunched over in bed looking like death with sao2 74% on simple mask at 5L(WTF). other VS : R40, P 120, bp 170/95, T 97.4 Temporal, monitor ST without ectopy.

a little positioning, removing pillow that was flexing neck, insert nasal airway, switch to nrb mask at 15L, ok 90%. gcs in the toilet. responds to pain by moaning only. intubated. chart review shows chf hx. has rales b/l,  nl temp, +JVD, no edema, and bedside lactate of 0.5. PCxr big heart, but nothing different than prior studies so ddx chf vs basilar pneumonia vs flash pulmonary edema, etc. stated abx and Lasix and KVO fluids and placed ntg paste on chest, which tanked bp. initial procalcitonin and BNP nl but next several procalcitonin trend upwards. intensivist opted to tx as likely aspiration pneumonia. 6 hrs later required more fluids and pressors. I'm thinking this lady was sick for more than 3 hrs at the point they called me.

(side note: this is a new solo rural job . this was the first PA-performed intubation without a physician present in this ED as far as I can tell).

CHF vs pneumonia can be harder than you might think if the pt is afebrile and can't give an adequate hx.

right sided heart failure with ams, r/o PE

tanking on ntg think right hf/pulmonary embolism

[south]

r/o PE but right heart / pulm side will fail first in a slow failure - since it's structurally weaker - gives all the respiratory sx

 

thinking any combo of your ddx is quite possible given JVD

 

i love these cases

[sk732]

Afternoon from Mars yesterday...was on with a dude I have very bad call kharma with.  Elderly couple come in by EMS post MVC...both restrained...A/B deployed. after clipping someone turning left in front of them at about 80km/h (~50mph).  I get the lady, who's got sternal/retrosternal pain.  Hx is lupus, "lung infection", HTN, hypothyroid and cognitive decline/outright dementia.  Here are the problems - no CT tech after 1600, CXR is equivocal, CP not improving with small aliquots of hydromorphone.  Chemistry analyzer is down...CBC shows WBC of 29.1 /c <shift, Pl 650, Hb 126 (something normal).  EKG has decreased voltages, sinus arrhythmia and she has wandering O2 sats (even before 0.5mg of HM).  U/S was US (unserviceable).   Had to send for trauma team assessment at the trauma centre...still waiting back (on a day off and don't want to go in to find out).

 

Had another on Saturday that came in with a brutal radial styloid fracture - hardest part was calming them down enough that they'd stop clamping down so we could get an IV in to sedate and reduce...2 hours of skilled nurses trying and I managed to float a 24g in a tiny wrist vein (go Army training!!).  I was a hair's width from just giving a buttload of ketamine and midazolam IM when I got it...problem of course is the SP I was with is scared of ketamine for some off reason (and their own shadow and of being wrong and of screwing up and you can see where I'm going), so that might not have flown...also, some of the RN's had that same odd ketamine phobia.  I'm seriously considering an Ortho job that's opening up in the city south of here...despite the ortho program likely getting shunted elsewhere due to the mentally challenged restructuring going on there, I actually wanted to do ortho when I got out of the Regular Army, but no jobs available at the time, so had to settle for FM and EM.

 

Watch and shoot.

 

SK

[GetMeOuttaThisMess]

Afternoon from Mars yesterday...was on with a dude I have very bad call kharma with. Elderly couple come in by EMS post MVC...both restrained...A/B deployed. after clipping someone turning left in front of them at about 80km/h (~50mph). I get the lady, who's got sternal/retrosternal pain. Hx is lupus, "lung infection", HTN, hypothyroid and cognitive decline/outright dementia. Here are the problems - no CT tech after 1600, CXR is equivocal, CP not improving with small aliquots of hydromorphone. Chemistry analyzer is down...CBC shows WBC of 29.1 /c <shift, Pl 650, Hb 126 (something normal). EKG has decreased voltages, sinus arrhythmia and she has wandering O2 sats (even before 0.5mg of HM). U/S was US (unserviceable). Had to send for trauma team assessment at the trauma centre...still waiting back (on a day off and don't want to go in to find out).

 

Had another on Saturday that came in with a brutal radial styloid fracture - hardest part was calming them down enough that they'd stop clamping down so we could get an IV in to sedate and reduce...2 hours of skilled nurses trying and I managed to float a 24g in a tiny wrist vein (go Army training!!). I was a hair's width from just giving a buttload of ketamine and midazolam IM when I got it...problem of course is the SP I was with is scared of ketamine for some off reason (and their own shadow and of being wrong and of screwing up and you can see where I'm going), so that might not have flown...also, some of the RN's had that same odd ketamine phobia. I'm seriously considering an Ortho job that's opening up in the city south of here...despite the ortho program likely getting shunted elsewhere due to the mentally challenged restructuring going on there, I actually wanted to do ortho when I got out of the Regular Army, but no jobs available at the time, so had to settle for FM and EM.

 

Watch and shoot.

 

SK

Sternal fractures I've seen from MVAs are always female. Cardiac contusion would give you S/S you describe.

[Simplify]

Had an interesting pt at shift change(20 min before end of my shift) on the floor. older lady with multiple issues admitted for psych stuff. should have been DNR, but wasn't. nurses call me for SOB x 3 hrs. find her hunched over in bed looking like death with sao2 74% on simple mask at 5L(WTF). other VS : R40, P 120, bp 170/95, T 97.4 Temporal, monitor ST without ectopy.

a little positioning, removing pillow that was flexing neck, insert nasal airway, switch to nrb mask at 15L, ok 90%. gcs in the toilet. responds to pain by moaning only. intubated. chart review shows chf hx. has rales b/l,  nl temp, +JVD, no edema, and bedside lactate of 0.5. PCxr big heart, but nothing different than prior studies so ddx chf vs basilar pneumonia vs flash pulmonary edema, etc. stated abx and Lasix and KVO fluids and placed ntg paste on chest, which tanked bp. initial procalcitonin and BNP nl but next several procalcitonin trend upwards. intensivist opted to tx as likely aspiration pneumonia. 6 hrs later required more fluids and pressors. I'm thinking this lady was sick for more than 3 hrs at the point they called me.

(side note: this is a new solo rural job . this was the first PA-performed intubation without a physician present in this ED as far as I can tell).

CHF vs pneumonia can be harder than you might think if the pt is afebrile and can't give an adequate hx.

 

 

Do you have POC US available?  I have been getting in the habit of walking into the room w/ US at the ready when I pick up geriatric SOB patient.  It's actually pretty slick.  A few windows over the anterior chest looking for diffuse B lines (not hard to spot once you have seen a few although can see localized B lines w/ lobar pneumonia) and bam, you are done. 

[sk732]

Sternal fractures I've seen from MVAs are always female. Cardiac contusion would give you S/S you describe.

 

No bruising suggestive of fracture...I got into it with EMO at the other end because he thought the accident wasn't high energy enough - oddly enough, I did a paper on myocardial contusion for grand rounds on my trauma rotation - the subject of the case study was a 70 odd yo dude, restrained by seat belt, 80km/h into bottom of ditch.  I just shook my head - they have to take any high energy referrals regardless.  My neck hair was standing up over this though...which I think is just as important.  I'll find out later I'm sure what happened.

 

Simplify, our U/S wasn't up - mentioned it was unserviceable. 

[EMEDPA]

Do you have POC US available?  I have been getting in the habit of walking into the room w/ US at the ready when I pick up geriatric SOB patient.  It's actually pretty slick.  A few windows over the anterior chest looking for diffuse B lines (not hard to spot once you have seen a few although can see localized B lines w/ lobar pneumonia) and bam, you are done. 

At some places, not at this one.

[GetMeOuttaThisMess]

No bruising suggestive of fracture...I got into it with EMO at the other end because he thought the accident wasn't high energy enough - oddly enough, I did a paper on myocardial contusion for grand rounds on my trauma rotation - the subject of the case study was a 70 odd yo dude, restrained by seat belt, 80km/h into bottom of ditch. I just shook my head - they have to take any high energy referrals regardless. My neck hair was standing up over this though...which I think is just as important. I'll find out later I'm sure what happened.

 

Simplify, our U/S wasn't up - mentioned it was unserviceable.

Last one I saw was a driver making a left turn and not going wide enough thus running up onto center island and striking base of turn signal. Certainly not high impact and no ecchymosis, but was certainly tender to light touch. Wall motion anomaly on initial echo that later resolved. EKG low voltage throughout. Always told students, biggest concern is not always the most obvious, i.e.-fx sternum, look at heart/lungs. Same with rib fx(s).. Focus on lungs!

[sk732]

Went and looked up the trauma CAP...turns out that, despite how roughly I checked the spine (thrice actually - once on primary/secondary assessment, twice at request of the RN and once again because of a complaint of back discomfort by the patient and no midline bony tenderness), there was a T11 fracture...no heart, lung, great vessel or even sternal damage.

 

My neck hair was standing up for something :-).

 

SK 

[sk732]

5 mo male brought by parents due to increasing cough, fever and decreased PO intake over about 4 days - LWBS after a (relatively) short wait the other day, came back yesterday.  Kid is pale, breathing about 60/min, HR pushing 200, sats low 90's, low grade temp, pale as a ghost, crackly in lo/mid right and not a lot of fight.  CXR showed a RLL pneumonia...3 of us couldn't get an IV into the kid, so we stuck him with high dose ceftriaxone IM (which got him squaking), bundled him up for a transfer to the Children's hospital 35 minutes away...a bit of a disdainful look on the face ot the EM resident and nurses  there when we told them about not being able to stick the IV (the attending I called was ok with no IO as the kid was still awake)...I'm waiting in the rig for the return trip and the paramedics told me the expert baby handlers were having trouble doing it themselves, so got to gloat a little.  Something I learned from my army days - don't get your nose up in the air if someone can't get a line in and decides to scoop and run, as Monday morning quarterbacking without all the facts will bite you in the arse.

 

SK

[sk732]

So an interesting follow up - said kidlet above was kept for 4 days in hospital and released - Dx of bronchiolitis.  Brought back today by mom, increasing fever, still crackly in ® lung...new XRay showed some RUL consolidation, so back to Kidlet Hospital...at least they were able to get some blood out of him this time.

 

SK