ohiovolffemtp Posted March 27, 2018 Share Posted March 27, 2018 Was your guy anticoagulated? Quote Link to comment Share on other sites More sharing options...
MrsGPAC Posted March 28, 2018 Share Posted March 28, 2018 Had a great "Not eating, drinking, taking meds. Confused" dropped off in my 5 bed solo ED this week. Recent flu admit, DC 4 days prior. Regular at this ED (I'm per diem, don't know all the regulars yet). Nurse (AMAZING nurse) says: "want an EKG?". Sure, weak old lady, sounds good. Brings me an inferior STEMI. Started c/o chest pain AFTER drop off. Go in to see the patient again, she is hypotensive, diaphoretic, writhing. Send EKG to nearest PCI center....because she's altered, wants CT head (in my tiny ER with no radiologist) prior to lysis and ship. Had lytics ordered since STEMI EKG. Choppers all out of range/at shift change. Locals won't transport without a nurse. Sup nurse won't let a nurse go. Patient lysed, into a-fib with RVR nearly immediately. Metop x 3 given with little change. Finally get a crew and my amazing nurse agrees to go. As they are wheeling her out the door she starts chatting away about grandkids and thrift stores...apparently talked the crews ears off the whole way down. Arrival EKG without ST changes, sinus rhythm. Unknown cath outcome. Alone in a small town, only provider in the hospital. Crazy stuff!! Makes me love ED more every day! 3 Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted March 28, 2018 Share Posted March 28, 2018 Awesome job! 11 hours ago, MrsGPAC said: Metop x 3 given with little change Why not dilt instead? 2 Quote Link to comment Share on other sites More sharing options...
MrsGPAC Posted March 30, 2018 Share Posted March 30, 2018 On 3/28/2018 at 0:38 PM, Boatswain2PA said: Awesome job! Why not dilt instead? I have been striking out with dilt recently so have used metop a bit more (with obviously not much luck this time) Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 30, 2018 Author Moderator Share Posted March 30, 2018 4 hours ago, MrsGPAC said: I have been striking out with dilt recently so have used metop a bit more (with obviously not much luck this time) You probably already know this, but for others: Sometimes the dilt requires a drip after the bolus to be effective. start at 5 mg/hr and gradually increase to 10 then 15. many places say rates > 5 require ICU monitoring. Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 30, 2018 Share Posted March 30, 2018 I’ve been away from REAL medicine for too long. Had to think what new acronym or drug I was missing when I glanced and saw “METOP and DILT”. Too much time spent at breakfast and Lowe’s this morning looking at landscaping. Took a couple of heartbeats to figure out. 1 Quote Link to comment Share on other sites More sharing options...
MrsGPAC Posted March 31, 2018 Share Posted March 31, 2018 11 hours ago, EMEDPA said: You probably already know this, but for others: Sometimes the dilt requires a drip after the bolus to be effective. start at 5 mg/hr and gradually increase to 10 then 15. many places say rates > 5 require ICU monitoring. Yes! And usually a dilt drip works splendidly! I have just apparently been grabbing the super stubborn a-fib recently!! Quote Link to comment Share on other sites More sharing options...
sk732 Posted April 20, 2018 Share Posted April 20, 2018 Had an interesting case that spanned yesterday and today when I came back on - mid 30's female, ~10/7 ish hx of increasing neuro symptoms. Dysarthria, right sided power deficit, contralateral CNIII palsy, dyequilibrium, all sorts of weirdness. Started varenicline about 1/12 ago, stopped after about 10/7 due to feeling weird and bad taste in mouth; serum sickness reaction in past to bupropion; 1 joint a day. CT shoed diffuse white matter damage - got her in for an urgent MRI last night that didn't get contrast (much to neuro's ire) showed several lesions scattered throughout the brain; contrast MR today showed enhancing lesions thought to be an acute demyelination disease. Re-consulted neuro - they're practically drooling on the phone. The one I talked to the night before is thinking blasto, dude today thinking wacked out MS OR blasto or TB or other odd infection, South African attending I'm with today thinking HIV or lymphoma...me, I'm just thinking "Journal Article" regardless. Alas, she got admitted in our urban tertiary care centre. Incidentally, this was triaged as a CAT 4... SK Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 1, 2018 Author Moderator Share Posted May 1, 2018 just had a pt come in by ems with c/c " I want a gatorade, a sandwich, and a bed". already d/c after signing ama. 1 Quote Link to comment Share on other sites More sharing options...
fishbum Posted May 2, 2018 Share Posted May 2, 2018 13 hours ago, EMEDPA said: just had a pt come in by ems with c/c " I want a gatorade, a sandwich, and a bed". already d/c after signing ama. A good reason that EMS should *sometimes* be allowed to refuse to transport. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 1, 2018 Author Moderator Share Posted December 1, 2018 Starting new per diem rural , solo coverage gig tomorrow in central WA. This place is a bit of a drive from anywhere so they provide housing on site if you want to show up the day before. Similar to full time job: 15 pts avg/24 hrs. nearest cath lab > 1 hr away, nearest trauma ctr farther than that. Hoping for a mellow day tomorrow so I can figure out where everything is, etc. They use electronic T-system , which is a fairly intuitive template-based system that I have used before. 2 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 1, 2018 Share Posted December 1, 2018 (edited) 50 minutes ago, EMEDPA said: Starting new per diem rural , solo coverage gig tomorrow in central WA. This place is a bit of a drive from anywhere so they provide housing on site if you want to show up the day before. Similar to full time job: 15 pts avg/24 hrs. nearest cath lab > 1 hr away, nearest trauma ctr farther than that. Hoping for a mellow day tomorrow so I can figure out where everything is, etc. They use electronic T-system , which is a fairly intuitive template-based system that I have used before. T-System; be still my beating heart. I have a confession to make. I’ve actually been squirrel hunting as a little kid. I remember watching one die on the step of an old Chevy stepside pickup in the early 60’s. I seem to recall actually tasting it also. THERE! I said it. I will never admit to having had kinfolk from southern Oklahoma near the Red River. Edited December 1, 2018 by GetMeOuttaThisMess Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 29, 2018 Author Moderator Share Posted December 29, 2018 rough recent case: 60 yr old very obese black female(350 lbs) alcoholic with hx of afib and rx noncompliance both to antiarrhythmic and anticoagulant therapy. call to EMS for near syncope. Found by them with afib w rvr rate to 180s. they gave dilt with pulse to 110. On arrival at ED pt alert/awake/pale(grey actually)/cool/diaphoretic with bp 200/120 and afib rvr at rate of 140(no stemi) with dyspnea. no chest pain. given additional dilt. rate to 110. dyspnea worsens(with clear lungs) bipap started and sats decrease from 95 to 70s on 100% o2. gcs from 13 to 5. intubated with ketamine and sux. BPs suddenly to 60s. ETCO2 and cxr confirms good tube. 2nd line started, fluids wide open, dopamine maxed, norepi maxed. bp 70. pulse 110. trop neg, d-dimer +( 4.2!!). case d/w hospitalist. decision to start heparin on way to scanner for probable PE with plan to give TPA if study +. . head ct neg, chest cta neg dissection or PE, but lower cuts show some blood around liver. heparin stopped, protamine given to reverse heparin, surgeon called. blood and cryo ordered. plts 50k. we have no platelets at this facility. initial h/h 11/33. dedicated ct abd/pelvis shows significant blood surrounding liver without obvious cause. abg ph 7.1. rate back to 150. cardioverted x 1 with return of rate to 110. To OR. liver is edematous/cirrhotic and weeping blood, most prominently from one location. surgeon oversews bleeder and 6l of blood suctioned. anesthesia continues 2 pressors and adds vasopressin.Fluids before OR 4L crystalloid, 2 units blood, 1 unit cryo. 6 additional units blood during OR tx. BP in ICU 110, Hr 110. pupils fixed/dilated. discussion with family to stop all pressors with death shortly thereafter. 90 min critical care time. this whole case sucked start to finish. I feel like I could use a drink, but that is probably not the right response to a death caused by alcoholic excess....sigh....maybe I will just spend some time yelling at newbies here on the forum who say PA is easy because you never have to make decisions on your own and it is a great lifestyle....as I work 6 out of 8 days, both holidays, with 2 24s and 4 12s because they could not find coverage other than me and apparently I am a glutton for punishment.... 2 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 29, 2018 Share Posted December 29, 2018 (edited) 7 hours ago, EMEDPA said: rough recent case: 60 yr old very obese black female(350 lbs) alcoholic with hx of afib and rx noncompliance both to antiarrhythmic and anticoagulant therapy. call to EMS for near syncope. Found by them with afib w rvr rate to 180s. they gave dilt with pulse to 110. On arrival at ED pt alert/awake/pale(grey actually)/cool/diaphoretic with bp 200/120 and afib rvr at rate of 140(no stemi) with dyspnea. no chest pain. given additional dilt. rate to 110. dyspnea worsens(with clear lungs) bipap started and sats decrease from 95 to 70s on 100% o2. gcs from 13 to 5. intubated with ketamine and sux. BPs suddenly to 60s. ETCO2 and cxr confirms good tube. 2nd line started, fluids wide open, dopamine maxed, norepi maxed. bp 70. pulse 110. trop neg, d-dimer +( 4.2!!). case d/w hospitalist. decision to start heparin on way to scanner for probable PE with plan to give TPA if study +. . head ct neg, chest cta neg dissection or PE, but lower cuts show some blood around liver. heparin stopped, protamine given to reverse heparin, surgeon called. blood and cryo ordered. plts 50k. we have no platelets at this facility. initial h/h 11/33. dedicated ct abd/pelvis shows significant blood surrounding liver without obvious cause. abg ph 7.1. rate back to 150. cardioverted x 1 with return of rate to 110. To OR. liver is edematous/cirrhotic and weeping blood, most prominently from one location. surgeon oversews bleeder and 6l of blood suctioned. anesthesia continues 2 pressors and adds vasopressin.Fluids before OR 4L crystalloid, 2 units blood, 1 unit cryo. 6 additional units blood during OR tx. BP in ICU 110, Hr 110. pupils fixed/dilated. discussion with family to stop all pressors with death shortly thereafter. 90 min critical care time. this whole case sucked start to finish. I feel like I could use a drink, but that is probably not the right response to a death caused by alcoholic excess....sigh....maybe I will just spend some time yelling at newbies here on the forum who say PA is easy because you never have to make decisions on your own and it is a great lifestyle....as I work 6 out of 8 days, both holidays, with 2 24s and 4 12s because they could not find coverage other than me and apparently I am a glutton for punishment.... Not taking meds didn't do her any favors but throw in the ETOH abuse and at that age I bet underlying CM is going to be the source of the AF (pulmonary disease is also a primary source for those who may not know or remember). Helps to have adequate clotting factors but with a jacked up liver that probably was off the table as well. I wonder why we don't routinely check INR's on folks with an ETOH abuse hx. (we already get the albumin on the CMP) on presentation lab workups if we want to actually know about liver function (not inflammation as one gets with LFTs)? In that age demo I wonder if Hep (B/C) was helping along the ETOH component in destroying the liver as well? Edited December 29, 2018 by GetMeOuttaThisMess 1 Quote Link to comment Share on other sites More sharing options...
kidpresentable Posted December 29, 2018 Share Posted December 29, 2018 From a few lines in, I was beginning to wonder if the post was in line with this thread’s title. Then I read your conclusion 9 hours ago, EMEDPA said: apparently I am a glutton for punishment.... Still sucks. Sorry to hear it 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 29, 2018 Author Moderator Share Posted December 29, 2018 2 hours ago, GetMeOuttaThisMess said: I wonder why we don't routinely check INR's on folks with an ETOH abuse hx. (we already get the albumin on the CMP) on presentation lab workups if we want to actually know about liver function (not inflammation as one gets with LFTs)? In that age demo I wonder if Hep (B/C) was helping along the ETOH component in destroying the liver as well? INR was 1.4 off coumadin for a month... Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 29, 2018 Share Posted December 29, 2018 Thank you sir. Quote Link to comment Share on other sites More sharing options...
JMann Posted January 6, 2019 Share Posted January 6, 2019 I was thinking PE from the start... Interesting case. Sucks though! 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 8, 2019 Author Moderator Share Posted January 8, 2019 same place last weekend, new doc on double coverage with me. full waiting room all day. at one point we had 2 stemis awaiting lifeflight and a gi bleed with perf/free air in the dept. never boring.... Quote Link to comment Share on other sites More sharing options...
sk732 Posted January 24, 2019 Share Posted January 24, 2019 Had a person yesterday I had to transfer to an ortho centre that was hobbling about on a bimalleolar fracture for > 1 month without an XRay...with almost 30 degrees of talar tilt. Person that initially saw them thought that inability to weight bear in a 60+yo didn't warrant an XRay... Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted January 28, 2019 Share Posted January 28, 2019 On 5/1/2018 at 6:10 PM, EMEDPA said: just had a pt come in by ems with c/c " I want a gatorade, a sandwich, and a bed". already d/c after signing ama. That doesn't sound very rural.... ?? Quote Link to comment Share on other sites More sharing options...
sk732 Posted February 23, 2019 Share Posted February 23, 2019 I saw shingles on the palm of someone's hand in the C8 dermatome 3 days ago...about 4 or 5 days after I saw them for cervical radiculopathy in the same dermatome (and what I thought was DSB). I have to confess I don't believe I've ever seen that before - anyone else? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 28, 2019 Author Moderator Share Posted February 28, 2019 at my regular job today. CRNA comes up to me and says" hey, it looks slow in the ED today, wanna do a difficult tube in the OR with me in 20 minutes". yes, yes I do. new pointer for big tongues: much smaller blade than you think you need so you have room for your tube in their mouth. easy peesy. 2 2 Quote Link to comment Share on other sites More sharing options...
JMann Posted March 1, 2019 Share Posted March 1, 2019 15 hours ago, EMEDPA said: at my regular job today. CRNA comes up to me and says" hey, it looks slow in the ED today, wanna do a difficult tube in the OR with me in 20 minutes". yes, yes I do. new pointer for big tongues: much smaller blade than you think you need so you have room for your tube in their mouth. easy peesy. Interesting. Kind of counterintuitive. Initially, you would think larger blade for more square inches to move more tongue out of the way. Really does make the viewing window smaller though. Good tip! Quote Link to comment Share on other sites More sharing options...
sk732 Posted March 10, 2019 Share Posted March 10, 2019 I was stuck in the minor treatment area a few weeks ago, saw someone with recurrent ear infections and increasing hearing loss - TM looked weird, so I ordered a CT an low and behold, there was the cholesteatoma I thought I was looking at... 1 1 Quote Link to comment Share on other sites More sharing options...
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