Why I love rural EM

[EMEDPA]

My double coverage rural job is in a vacation destination with several major access roads so lots of potential for mvas, also as Steve mentioned above there are the rural farming accidents, etc.
being a double coverage facility, if there are 2 major trauma pts (or 2 major anything) at the same time I get one. a few years ago we had 2 guys who fell 30 feet off scaffolding. the doc and I each got one. both needed to got out by lifeflight to the local level 1 120 miles away. I ran the whole thing start to finish.
when I was there last month we had 2 medical codes at the same time. we each ran one. at this particular facility there is a large # of pts > 70 yrs old as it is both a vacation and retirement destination. lots of bad chf, sepsis, etc in that population. almost every shift there I put folks in the icu. last month we had 7 icu admits in 12 hrs. I was starting folks on bipap and putting in IOs in the hallway. at my regular job these folks would all be seen by the er docs and the intensivists only.

[EMEDPA]

Back at my 1 weekend/mo rural job.

anyone else do this( take a working vacation somewhere away from home on a regular basis?). I have friends who do this both in Hawaii and Alaska. at this point I only go 3 hrs from home but it is enough change of pace to be relaxing.the place I stay at has a pool/jacuzzii/sauna and ocean views for $80/night with an included breakfast. walking distance to the hospital and multiple nice restaurants. sometimes I bring the family, sometimes I come alone. this tends to be my most relaxing weekend every month despite working a 12 hr shift sat/sun/mon.

I drive here friday and have friday afternoon free. sometimes see a movie at the local theater fri night. always some good wine after shift every night. despite just going from dictation to EPIC this is still a great job. I hope to end up here full time in a few years when the kids go to college.

The theme today is end of summer alcohol binges....most recent blood alcohols for my last 3 pts: 357, 309, 402.

it's a nice little drinking town with a serious fishing problem...

[Hemegroup]

just started a clinic which is about an hour from town and it turns out that wow ... this is rural medicine lol. i worked solo last Friday and took a bolt out of a leg and rearticulated a shoulder. it's a very small community where ive been placed, about two to 400 people spread out over a very large region. many are 'off the grid', it's all loggers and growers. went to the hunting raffle last night (you shoot your dinner here) and church this morning where all 25 attendees insisted on hugging me. signed a 5 year contract. town is a burger trailer and a post office with 200 PO boxes. and a meat shop connected with a small bar. all local grass fed meat. hunting, fishing, pulling rods out of people ... i'm home. time to brush on some atls, it seems, altho half the clinic is ems.

[Derbingle]

the next step is aspirating out all the excess blood with a butterfly needle and 20cc syringe...seen it done once.

...............i did this in a guy with priaprism for 12 hours.....after terbutaline and levophed mixture, injected, I used a long 18 guage and 20 cc syringe, get a good grip for control and go in between 1 and 3 o'clock on right and 10 and 9 on the right, the middle of the spngy tissue on the sides. Give the penis wings (syringes) ha! withdraw slowly, move it a bit, and the blood flowed out. Just like doing a femoroal artery blood gass. Withdraw needle.......had do 3 x on each side, then doc grabbed the junk like a pair of socks and wrang it out- yes like a rag, then had me wrap in ace banadage and pack ice on it. The guy was better. Observed for four hour until urology transfer arranged. Most intrtrsting thing in ER so far. Its def not boring!

[rcreek]

...............i did this in a guy with priaprism for 12 hours.....after terbutaline and levophed mixture, injected, I used a long 18 guage and 20 cc syringe, get a good grip for control and go in between 1 and 3 o'clock on right and 10 and 9 on the right, the middle of the spngy tissue on the sides. Give the penis wings (syringes) ha! withdraw slowly, move it a bit, and the blood flowed out. Just like doing a femoroal artery blood gass. Withdraw needle.......had do 3 x on each side, then doc grabbed the junk like a pair of socks and wrang it out- yes like a rag, then had me wrap in ace banadage and pack ice on it. The guy was better. Observed for four hour until urology transfer arranged. Most intrtrsting thing in ER so far. Its def not boring!

 

It's funny you bring this up, as that is one of the most interesting things I have seen as well. Guy walked awkwardly into our ER really embarassed after using caverject that was prescribed to him unresponsibly by his oncologist. It had been about 5 hours and was getting painful. ER Physician tried phenylephrine injection but it didn't help. On-call Urologist came and I was assigned to help him do the same process you described above with 18g needles and syringes, only he also flushed the cavernosa with a copious amount of saline. Aspirated a good amount of blood. Wrapped it up with coban. Patient was informed to see a urologist for his erectile issues from then on.

[medic25]

You really do get some fun cases in the country.  We had a good zebra shift last week in my satellite ED; in our 8 bed ED we had a guy with an SMA dissection, a elderly patient with a gastric volvulus, and a teenager with a spontaneous pneumomediastinum, all within an hour of each other.  Too bad we don't get PA or medical students!

[EMEDPA]

pulling a 24 for the holiday at one of my rural jobs....

Sometimes gastroenteritis isn't straight forward.....

lady in her 50s with n/v/d x 3 days. family with same. dizzy, etc. no blood in stool, no travel, no recent abx..Easy right? not so fast....did I mention she has a hx of afib and has taken no meds x 3 days. oh, she's also a chronic alcoholic and has had no etoh x 3 days but that's ok because she is still using her meth....oh boy....

ok, exam and labs c/w with dehydration, bp ok, pulse 140ish, vomiting controlled with zofran, diarrhea improving with loperamide...heart rate still 140-150 after 1 l ns and 1 l banana bag with 2 gms of magsulfate. ok, time to address the afib. INR subtherapeutic so added lovenox. given cardizem IV with minimal improvement and metoprolol IV(pts regular med) with slowing to 110 or so. troponin neg.

oh yeah, what about etoh withdrawl? added ativan in addition to banana bag.

admitted to hospitalist service(they were not pleased as I had just admitted a 55 yr old copd exacerbation also on meth.....)

[primadonna22274]

Sounds like any southern patient lol

[EMEDPA]

another interesting rural e.d. pt.

95 yr old male. known dnr for multiple issues(ca, cad, etc). got gastroenteritis, vomited, aspirated and became sob and febrile. brought in by medics in resp. distress. P 145, bp 160/100, RR 50, sao2 90% on 4l, T 101.5. disucssion with wife re dnr and she is ok with bipap. bipap started with dec in resp rate from 50 to 25 and inc in sao2 from 90% to 96% on 50% o2. abg on bipap ok(pco2 36, o2 139, ph 7.48). influenza A +. cxr b/l infiltrates R>L c/w aspiration + influenza.. concern for sepsis so iv fluids, early iv abx x 2 after bc x2. lactate later ok at 1.5.

cbc ok. cmp mild renal insufficiency otherwise ok. admit icu on bipap for abx, tx of influenza, hydration and resp. support.

wife of pt is retired crna and son is ICU RN. no pressure there....

[primadonna22274]

I love love love BiPAP for those folks I don't want to or can't intubate...even had it turn around an overdose with resp depression and hypoxia last weekend. Lady had taken 4.5x the upper 24hr limit of tramadol in <18 hr...thankfully no APAP. And cocaine. She had a positive UDS for PCP which I very much doubt (nothing thAt looked like PCP toxicity, certainly no nystagmus, although she was hypertensive, febrile and tachycardic--possible serotonin syndrome). Poison control told me many OTC cough syrups can give a false positive PCP result. I didn't know that and thought other folks might want to tuck away that little factoid.

[primadonna22274]

Dangit tapatalk crashed.

Anyway, more than 1650mg tramadol in less than 18 hr. Thankfully no APAP or ASA.

UDS positive for cocaine, benzos and amphetamines also. Family denied hx drug use and I'm kinda inclined to agree except for rx drugs. She did have an appropriate amount of temazepam remaining and no other BZ rx--not excluding some Xanax scored surreptitiously though. She was the well-dressed housewife type, makeup done, fully dressed BEFORE her 10 yo son found her unresponsive on the couch.

Now here's where it gets interesting: she was tachycardic, tachypneic, febrile 101.4 and hypertensive. Serotonin syndrome? Maybe. But she only barely responded to Narcan 1mg x 2...what actually did the trick was Romazicon 0.2 mg x1. Sitting up and talking kind of stuff.

Oh and her UDS was also positive for PCP which I very much doubt. Have never seen it here and she didn't have nystagmus. Poison control told me many OTC cough syrups can cause a false positive PCP result. I didn't know that and thought it a useful factoid to tuck away.

You did good E :) I love it when EM guys practice palliative medicine in the ED. :)

[EMEDPA]

IPoison control told me many OTC cough syrups can give a false positive PCP result. I didn't know that and thought other folks might want to tuck away that little factoid.

did not know that. thanks!

[EMEDPA]

anyone using relenza for influenza? my pt above does not tolerate PO meds so I called the pharmacy about an IV alternative and they recommended relenza for oral inhalation 10 mg twice daily x 5 days.

[primadonna22274]

anyone using relenza for influenza? my pt above does not tolerate PO meds so I called the pharmacy about an IV alternative and they recommended relenza for oral inhalation 10 mg twice daily x 5 days.

I've never used it.

In fact using very little Tamiflu this past 2 seasons with CDC recommendations to reserve it for those with chronic disease, the very young and very old, and pregnant women 2nd trimester or later.

Writing LOTS of work notes, Motrin, the good cough syrup and educating about the importance of hydration and rest. So far so good here in rural SC.

[EMEDPA]

this is the first antiviral I have written this year. I figure a hospitalized 95 yr old with pneumonia counts as immunocompromised....I usually write 2-3 max/yr and only babies and frail elderly, or pregnant with + rapid flu test.

[primadonna22274]

this is the first antiviral I have written this year. I figure a hospitalized 95 yr old with pneumonia counts as immunocompromised....I usually write 2-3 max/yr and only babies and frail elderly, or pregnant with + rapid flu test.

Oh absolutely. I would want to treat this patient too. Nothing PO? Does he have a PEG? Use that. Can he tolerate liquid?

I'm still a bit leery about Relenza since its release days and the caution against using it in those with asthma and bronchospasm. I would worry with this guy because of the pneumonia. Does he not meet admission criteria?

[EMEDPA]

Oh absolutely. I would want to treat this patient too. Nothing PO? Does he have a PEG? Use that. Can he tolerate liquid?

I'm still a bit leery about Relenza since its release days and the caution against using it in those with asthma and bronchospasm. I would worry with this guy because of the pneumonia. Does he not meet admission criteria?

he's in the ICU. he meets sirs criteria. tachypneic, hypoxic, tachycardic, febrile, etc.

where doing npo for now both because he has been aspirating his own vomit and becuase the tylenol I tried to give him on arrival resulted in projectile vomiting( so used tyl. supp instead). no peg. no foley. he's dnr so nothing uncomfortable. just comfort care which at this point means iv abx, antivirals, bipap, and hydration. I think the wife would likely refuse any type of artifical feeding at this point, even an ng tube. hopefully they can get on top of the vomiting/aspiration issue and slowly advance his diet over the next 24 hrs to fluids and stuff like jello. I'm the only in house provider tonight after the hospitalist goes home so I am hoping he does ok overnight. if he gets worse not much else to do as allowed by his dnr.

[primadonna22274]

I see. I know he's in good hands with you E. This may be his easy exit, you know? Comfort care is always appropriate.

[medic25]

Now here's where it gets interesting: she was tachycardic, tachypneic, febrile 101.4 and hypertensive. Serotonin syndrome? Maybe. But she only barely responded to Narcan 1mg x 2...what actually did the trick was Romazicon 0.2 mg x1. Sitting up and talking kind of stuff.

 

 

Are many of you folks using Romazicon much for ingestions/AMS?  I have always been taught that the risk of inducing seizures/BZD withdrawal outweigh the benefits of potentially reversing AMS.  Outside of having it handy for conscious sedations, I can only think of one case in our ED that I've seen it used (ETOH'er given midazolam by EMS for combativeness, attending reversed her rather than tubing her).

[EMEDPA]

Are many of you folks using Romazicon much for ingestions/AMS?  I have always been taught that the risk of inducing seizures/BZD withdrawal outweigh the benefits of potentially reversing AMS.  Outside of having it handy for conscious sedations, I can only think of one case in our ED that I've seen it used (ETOH'er given midazolam by EMS for combativeness, attending reversed her rather than tubing her).

agree. that has been my practice as well. only use it to reverse benzos I have given.

[EMEDPA]

same shift. next pt: 87 yrs old with chest pain via ems. chronic afib now @ 150. on dialysis. dialyzed today. pain 4/10. bp 110/p. no ready IV access ( L arm fx in cast, R arm has shunt and edematous, both legs edematous). pt really in nad so hesitated to IO. not sick enough for cardioversion. thought about PE workup but can't give IV contrast and can't get VQ scan here. will let accepting hospitalist at transfer facility r/o that ddx.

tiny 22 g IV started R hand, minimal blood drawn from IV, lab tech attempts x 2 for a bit more blood. Trop #1 surprisingly <.02 even with renal failure on dialysis. given fentanyl 25 mcg and metoprolol 5 mg iv x 2. rate controlled to 110, pain free. transfered as we have no dialysis capability and pt needs second set of enzymes, etc.

at same time relatively spry 85 yr old with gastroenteritis and n/v/d x 4 days. k=2.8, bun 30, cr 1.6. tuned up and admitted.

have only seen 7 pts so far in 13 hrs but admitted 1 to icu, 1 to tele, and transfered 1. 11 hrs to go. hope to get some sleep.

[primadonna22274]

Are many of you folks using Romazicon much for ingestions/AMS? I have always been taught that the risk of inducing seizures/BZD withdrawal outweigh the benefits of potentially reversing AMS. Outside of having it handy for conscious sedations, I can only think of one case in our ED that I've seen it used (ETOH'er given midazolam by EMS for combativeness, attending reversed her rather than tubing her).

First time I've EVER used it. I was very cautious but she wasn't coming around and was on the verge of intubation. My attending was like "just do it..." He's done this 35 years and I trusted him. Worked like a charm. Nurses curse you though cuz they wake up fighting and really really have to poop ;)

[primadonna22274]

Also has anyone else seen a tramadol OD like mine? The physiology of it was insane. The more I think about it the more I think she DID have serotonin syndrome. Might be worth some data mining and writing her up. Very little that I could find in the literature on this non-opioid when overdosed. We figured she probably had some cross-saturation of GABA receptors when the Romazicon did more good than then naloxone.

[EMEDPA]

Also has anyone else seen a tramadol OD like mine? The physiology of it was insane. The more I think about it the more I think she DID have serotonin syndrome. Might be worth some data mining and writing her up. Very little that I could find in the literature on this non-opioid when overdosed. We figured she probably had some cross-saturation of GABA receptors when the Romazicon did more good than then naloxone.

tramadol toxicity is usually szs so likely serotonin syndrome.

as an aside for those who think tramadol is not addictive - I recently saw someone on suboxone to get them off tramadol.

[medic25]

Sounds like a great case; I can't say that I've ever seen a significant tramadol overdose.  Interestingly enough, when I did a quick lit search on this, I found an article stating that tramadol OD can also cause a false positive for PCP on urine drug testing.

 

http://www.ncbi.nlm.nih.gov/pubmed/22944551

 

This might help explain the positive PCP on this patients UDS.  Definitely jealous that you don't have PCP in your neighborhood; we see a ton of it here, and it is not a lot of fun to deal with!