sk732 Posted October 2, 2017 Share Posted October 2, 2017 Had an odd, atypical migraine in someone with known hydrocephalus...migraine cocktail #1 (litre R/L or N/S, 15mg ketorolac, 10mg metaclopramide and 25mg Benadryl) got rid of some of it - CT (-) for hydrocephalus and odontogenic abscess (poor dentition and had trismus). Person had a tender occiput and scalp- so I did a greater occipital nerve block with lido/bupi and 5 minutes later, eyes wide open in a lit room, talking and drinking. Told them to get a mouth guard for their bruxism and they walked out pretty happy. SK Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 16, 2017 Author Moderator Share Posted October 16, 2017 just had a fairly complex pt, don't know final dx yet. 75 yr old guy with literally hx of everything (copd, chf, type 2 dm, hypothyroid, htn, acs with stents, renal insufficiency, etc) found unresponsive by family 5 hrs after last known well. In warm house. no concern for OD, foul play, suicide attempt,etc. medics find pt hypothermic(31.9 foley probe), hypoglycemic (38) and in resp distress. no better with d50 or narcan. gcs9. insulin has recently been stopped due to good a1cs and dose of glucotrol cut in 1/2. pulse 60 paced. bp 110/70. R 32, initial sao2 on o2 92%, later down to 78% on NRB mask requiring intubation. Pcxr: chronic/stable chf, small RLL infiltrate vs prior study(given rocephin). CT head neg. unable to do mri brain for acute stroke due to presence of pacer. tsh elevated, gave IV sythroid, but nl free t4. was getting excited about ddx of myxedema coma, but apparently no. abg ph 7.25, pco2 55, po2 90% on o2 with npa airway in place. cbc, ua, lactate, cmp(other than glucose),mag, trop, ck nl. bnp stable with prior values. uds neg. blood sugars continue to tank into 30s despite multiple rounds of d50 and d5 drip. after 4 hrs of warmed iv fluids, bear hugger, warm blankets, etc core temp now nl. after intubation and confirmation of tube placement BPs tank to 80s. more fluids given and back to 100/p. pt on d5ns, fentanyl, and versed drips after vecuronium. transferred to distant hospital ICU. will get f/u tomorrow. receiving intensivist believes this is oral hypoglycemic OD, but spouse swears no tabs missing and no insulin given in weeks. other thoughts to explain this picture? we talked about antifreeze od , but no evidence for that. Quote Link to comment Share on other sites More sharing options...
sk732 Posted October 16, 2017 Share Posted October 16, 2017 I had a dude once that ate a 3 month supply of glyburide, initial presentation was Sz...and he continued seizing because his BG wouldn't get above 2.1mmol...literally was giving D50W through a central line q10 minutes to point we had none in our ER, resup area and were stealing from all the ALS ambulances to get them to MICU 75minutes away by road. It may very well be the antihyperglycemics - someone might have screwed the pooch and given the wrong dose OR the pt accidentally/accidentally on purpose took more than their kidneys could handle...and maybe had been saving stuff up. SK Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 16, 2017 Author Moderator Share Posted October 16, 2017 spoke with intensivist this am. no change. still intubated, still no clue as to etiology. Quote Link to comment Share on other sites More sharing options...
sk732 Posted October 16, 2017 Share Posted October 16, 2017 Weirdness. TRO (Time's Running Out)? SK Quote Link to comment Share on other sites More sharing options...
kargiver Posted November 10, 2017 Share Posted November 10, 2017 On 10/16/2017 at 3:18 PM, EMEDPA said: spoke with intensivist this am. no change. still intubated, still no clue as to etiology. My immediate thought was a sulfonylurea OD that has been down too long and now is in that quasi-life/death stage. If negative for volatiles (methanol, ethylene glycol), and remaining tox screen and tap is negative, I'd be sticking to that as a probable diagnosis. We both know if doesn't take much to overdue it with them... Interested to know what they find out, G Quote Link to comment Share on other sites More sharing options...
jbergenhartigan Posted November 14, 2017 Share Posted November 14, 2017 Suggestions for rural ED in Idaho/Montana/Wyoming? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 15, 2017 Author Moderator Share Posted November 15, 2017 Check on sempa website. generally a decent # of solo jobs in MT and WY. don't know that I have ever seen 1 in ID. Miles City, MT has frequent openings. most of the rural jobs tend to be ME, VT, upstate NY. very few on the west coast. 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 28, 2017 Author Moderator Share Posted November 28, 2017 On 1/4/2017 at 7:37 PM, EMEDPA said: I'm looking at 6 24s/mo in a few years at a very slow place with very high acuity and 1 weekend/mo at my fun coastal job (to be social and because I bought a condo there near the beach). so 8-9 days/mo. I'm only doing 12 now, but there is some unpleasant driving involved. Looks like this might actually happen. The rural job that switched everyone to 1099 contracts without benefits is realizing they want a regular full time PA for some consistency. They just asked to meet with me about transitioning to full time. I'm going to ask for $10/hr more to go to full time and also 6 24s/mo. will also keep my coastal job 1 weekend/mo if everything works out. I really hope this works. my current primary full time rural job is VERY slow and I much prefer the coast and the 1099 job. Quote Link to comment Share on other sites More sharing options...
sk732 Posted November 28, 2017 Share Posted November 28, 2017 I had a pt the other day I admitted with what appeared to be a bilat bacterial pneumonia or a viral pneumonia...started developing chest pain on the floor, TropT came in at 3000...no EKG changes. Got sent to the tertiary cardiac facility, clean angiogram, now admitted to ICU with ARDS...I admitted the patient on this Friday past, started developing fever on Sunday...not happy, since the patient's illness started the same way...hoping I'm not contact 1 of some new SARS thing. Seriously, just have a sinus infection - my Neil Med is cleaning it out. I hope. SK 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 5, 2017 Author Moderator Share Posted December 5, 2017 On 11/28/2017 at 9:52 AM, EMEDPA said: Looks like this might actually happen. The rural job that switched everyone to 1099 contracts without benefits is realizing they want a regular full time PA for some consistency. They just asked to meet with me about transitioning to full time. I'm going to ask for $10/hr more to go to full time and also 6 24s/mo. will also keep my coastal job 1 weekend/mo if everything works out. I really hope this works. my current primary full time rural job is VERY slow and I much prefer the coast and the 1099 job. They offered me the job today and I accepted! I have wanted this job for a decade. After 21 years as a PA I see this as a position that I could retire from. Very pleased! 6 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 5, 2017 Share Posted December 5, 2017 13 hours ago, EMEDPA said: They offered me the job today and I accepted! I have wanted this job for a decade. After 21 years as a PA I see this as a position that I could retire from. Very pleased! Congrats to you sir! I also finally obtained the retirement job two and a half years ago and am shooting for 2 1/2 more years. I’ll see you on the beach in Hawaii after retirement at my mai-tai shack. 1 Quote Link to comment Share on other sites More sharing options...
Annika Posted December 5, 2017 Share Posted December 5, 2017 That is just great! Congrats to you!!! 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 27, 2017 Author Moderator Share Posted December 27, 2017 so what do you do if your brand new 3000 dollar TV only works for an hr after you unwrap it? return it to the store? no. too easy. beat the living crap out of it with your fists. punch holes in the screen. show that TV who is boss!. wow, can you say impulse control issues? not even drunk or high....the ER visit will cost more than the TV replacement....complex lac repair, imaging, etc.... 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 12, 2018 Author Moderator Share Posted January 12, 2018 Met with an accountant today and set wheels in motion to set up an LLC S corp. for new full time(guaranteed 144 hrs/mo) 1099 job that starts in April. I know there are cheaper ways of doing a business startup with doing a bunch of it myself online, but I am going to have them handle all of this so I don't mess it up. Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted January 14, 2018 Share Posted January 14, 2018 On 1/12/2018 at 1:57 AM, EMEDPA said: Met with an accountant today and set wheels in motion to set up an LLC S corp. for new full time(guaranteed 144 hrs/mo) 1099 job that starts in April. I know there are cheaper ways of doing a business startup with doing a bunch of it myself online, but I am going to have them handle all of this so I don't mess it up. What was your accountants reasoning behind setting up an LLC instead of just doing a DBA? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 14, 2018 Author Moderator Share Posted January 14, 2018 7 hours ago, Boatswain2PA said: What was your accountants reasoning behind setting up an LLC instead of just doing a DBA? liability protection 1 Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted January 14, 2018 Share Posted January 14, 2018 1 hour ago, EMEDPA said: liability protection You should talk to an attorney about that instead of a CPA. Medmal lawsuits are always personal, so your LLC won't protect you at all from that. My CPA told me same thing, and it's good advice for other businesses, but won't work for practicing medicine. Quote Link to comment Share on other sites More sharing options...
sk732 Posted January 16, 2018 Share Posted January 16, 2018 Had to transfer someone to the cardiac referral center today - year long history of fatigue, syncope with seizure like activity x 3 this morning at home, hammers in again doing the CXR; EKG NSR with RBBB, (N) labs except for a TNT of 265 - (N)</= 14 - with (N) CK. Put him on telemetry, hammers in again and we catch a 6 second run of ventricular asystole. Starts going in and out of 3rd Deg AVB, Mobitz 2, ventricular standstill again, all sorts of shyte. Wouldn't capture on transcutaneous pacer until at 90 mAmps, so we transferred on a dopamine drip - that kept things around 50 odd bpm with a really weird arsed looking complete heart block. The pacemaker guys only work until 1600 and we don't float wires here, so had to go in to get a temp ahead of the real deal. I went from a non-thrilling Monday to having the most interesting patient in the hospital in one fell swoop :-D. SK 2 Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted January 30, 2018 Share Posted January 30, 2018 Why I love rural em: because you can go from being paid to sleep to cutting a hole in a chest, and getting that lovely rush of air and blood, in just a few minutes! 1 Quote Link to comment Share on other sites More sharing options...
sk732 Posted January 31, 2018 Share Posted January 31, 2018 Had two interesting things happen yesterday (the 2 OD's I was dealing with notwithstanding) - dude I admitted with unstable angina came down from the ward to say thank you for making him stay - he had pericarditis as well as a stent occlusion on his angio and the other was an AXR I did that showed not only a large poopoma, but an incidentaloma of what looked like four perfectly formed ice cubes in the RUQ... SK 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 11, 2018 Author Moderator Share Posted February 11, 2018 great case: 75 yr old male with " hypotension and abd pain after a fall" brought in by ems with bp 70/p and tachycardic looking like death. anticoagulated on Coumadin for afib. very tender abd with grossly + fast exam. fortunately surgeon already in dept admitting an appy. called to bedside for eval. agrees with need for emergent trip to OR. massive transfusion given. INR found to be 10 and reversed with vit k, platelets, ffp. surgical finding: isolated gastric tumor is bleeding source. resected for save and probable cure. not a trauma: blood loss...syncope....fall.....very cool. 5 Quote Link to comment Share on other sites More sharing options...
TrekkieByDay Posted February 13, 2018 Share Posted February 13, 2018 My face while reading all of these: https://giphy.com/gifs/popcorn-jon-stewart-E3xXqq617AaFW Quote Link to comment Share on other sites More sharing options...
sk732 Posted February 13, 2018 Share Posted February 13, 2018 (edited) Had another one of those episodes of why it annoys me that our triage nurses don't order CXR's for chest pain for some reason...20 yo kid with abrupt left sided pain going to neck - order all the ACS stuff but no CXR. The other part of this story is how you should listen to your neck hair when it stands up - first pass of the XRay was before I actually examined him. I did a second look because when I was charting an essentially normal exam with a bit of trap tightness, something was bugging me so I went back and just under his second rib was a pleural line so subtle I had to get a couple others to look at it to make sure I didn't have second hand crack smoke in my system...pneumothorax so small I wouldn't do anything, but there nonetheless. They're coming back today for a F/U CXR. This reminds me of a case that happened when I started working here where one of the more experienced RN's was trying to hustle a guy out that had been stabbed with a ice pick in the chest - no bubbling, as the wound was tiny and closed over (as they do) and didn't even think he warranted a CXR - he had a 60% collapse on that side and ended up with a pigtail for a bit. If there are triage generated protocols and CXR isn't included for some reason, these are good reasons to ensure they are. SK Edited February 13, 2018 by sk732 spelling oopie Quote Link to comment Share on other sites More sharing options...
lkth487 Posted February 13, 2018 Share Posted February 13, 2018 On 5/18/2017 at 8:29 AM, sk732 said: 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 On 5/23/2017 at 10:38 PM, sk732 said: 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 Haha I never assume anything when it comes to kids. I've had that happen to me - and I learned the hard way. I was like how can they not get an IV in such a big kid at outside hospital - and then when I couldn't either, there's a bit of humble pie involved. I'd be in favor of an IO for sure. Interestingly, in terms of the case, I wouldn't necessarily treat for PNA even if I saw a consolidation in a kid with RSV bronchiolitis. Although given the five month age, I'd probably be slightly more likely to treat. Quote Link to comment Share on other sites More sharing options...
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