CAdamsPAC Posted March 11, 2019 Share Posted March 11, 2019 On 12/29/2018 at 2:02 AM, 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.... Strong work, the late RC Davis would call it "studly". Quote Link to comment Share on other sites More sharing options...
MrsGPAC Posted April 20, 2019 Share Posted April 20, 2019 Fellow rural EM folks--I have just (FINALLY) landed a solo coverage rural critical access gig that I thought I'd have to hold out for a few more years. I've been doing per diem shifts here for a while now but will be starting full time in July. I am super excited to finally have this opportunity. What courses have you felt were particularly helpful for this setting? (I've done ATLS, Bootcamp, Essentials, difficult airway). I have 5 years under my belt working a variety of high autonomy positions so have decent experience but limited solo coverage, so would like to expand my skill set. For context: It's a 5 bed ED in a critical access hospital, 24 hour shifts with hospitalist backup (around during the day/close to hospital but offsite at night). No surgical call on the weekends...(yikes) Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted April 21, 2019 Share Posted April 21, 2019 Difficult airway course Quote Link to comment Share on other sites More sharing options...
MrsGPAC Posted April 21, 2019 Share Posted April 21, 2019 9 minutes ago, Boatswain2PA said: Difficult airway course I've done the "official" one. Are there other ones that you've done that you thought were helpful? (Not that any airway practice is unhelpful...) Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted April 21, 2019 Share Posted April 21, 2019 Whoops! Missed that in your op. You've done the courses, now just stay paranoid and you'll do fine! Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted April 22, 2019 Share Posted April 22, 2019 Was on the edges of a very weird case a few weeks back: a 23 y/o/f came in to the critical access hospital on 2 successive days with complaints of worsening nausea, vomiting, and headache. She was approximately 18 weeks pregnant with twins. On her second visit her sister who is an RN reported that over the preceding 4-5 days the family had begun to notice behavioral changes. The sister also related that the patient previously had had gestational trophoblastic disease after a molar pregnancy. The patient had been treated with chemo and had had 2 successive non-detectable HcG's. The patient had been advised not to get pregnant, but had. The doc ordered a CT of the head which was read by radiology as multiple hemorrhagic mets. This poor lady was transferred to our tertiary center and passed away about 5 days later from a head bleed. Very sad and very rare. The gyn/onc said they couldn't even find a case report anywhere for a similar case. Quote Link to comment Share on other sites More sharing options...
MrsGPAC Posted April 22, 2019 Share Posted April 22, 2019 23 hours ago, Boatswain2PA said: Whoops! Missed that in your op. You've done the courses, now just stay paranoid and you'll do fine! I love it! Definitely no lack of paranoia here! Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted April 23, 2019 Share Posted April 23, 2019 Comprehensive Advanced Life Support (CALS) out of the University of Minnesota directed towards those out in Critical Access Hospitals. Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 23, 2019 Share Posted April 23, 2019 I'm surprised that I never see folks note that they have taken the disaster trifecta. CDLS, BDLS, ADLS. I always found it interesting, though way too many pneumonics. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 21, 2019 Author Moderator Share Posted July 21, 2019 love my little ER....nothing for hours then an svt and an acute resp failure presenting 5 min apart. both went well. Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted July 22, 2019 Share Posted July 22, 2019 My ED: person brought in for clearance for incarceration after being intoxicated & flipping his vehicle. CT head, cervical spine, chest, abdomen, and pelvis. Gee: what's that highly opaque circular object in the pelvis. Talk to the reading radiologist: it's not in the rectum, but between the buttocks. What wonderful news: I don't have to deal with a rectal FB. The nice state trooper gets to retrieve it. Weed in a baggie is hard to pick up on CT vs. clothing. Meth in a glass vial - very easy. We were nice to the trooper, helped him double bag the evidence. Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 15, 2019 Share Posted August 15, 2019 Had a new experience this morning. Narcotic OD biba, was stable and protecting airway so didnt narcan him until after we got head CT. Considered half-dose, but went full dose. He woke up pissed off and cursing at us as expected. But then he took out his keyring and frantically opened up his two pill-fobs searching for his next hit right in front of us! Fortunately they were both empty. Dont know what I would have done had he poured out a hit of fentanyl and snorted it in front of us. 1 1 Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted September 5, 2019 Moderator Share Posted September 5, 2019 I tubed, lined, and started a epi drip on a patient with hepatic encephalopathy, possible sick sinus syndrome, and urosepsis, then slept the last 8 hours of my shift. Best job ever. 3 2 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted September 20, 2019 Share Posted September 20, 2019 This morning at the end of my shift while I was BiPap'ing a COPD'er the EMS crew brought me a plate of home made biscuits and gravy, with the sausage coming from a hog the medic had raised. Makes you feel wonderfully welcome. 2 2 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted November 13, 2019 Share Posted November 13, 2019 (edited) Last night, did a physical exam with 1 hand on a LOL who fell while in the other armI was holding and rocking to sleep the sibling of a neonate in for an ALTE. The nurses (all 2 of them) were very busy with everything they had to do. Dad and grandpa experience augments PA experience I guess. Edited November 13, 2019 by ohiovolffemtp 2 3 Quote Link to comment Share on other sites More sharing options...
sk732 Posted April 13, 2020 Share Posted April 13, 2020 On 8/15/2019 at 6:20 PM, Boatswain2PA said: Had a new experience this morning. Narcotic OD biba, was stable and protecting airway so didnt narcan him until after we got head CT. Considered half-dose, but went full dose. He woke up pissed off and cursing at us as expected. But then he took out his keyring and frantically opened up his two pill-fobs searching for his next hit right in front of us! Fortunately they were both empty. Dont know what I would have done had he poured out a hit of fentanyl and snorted it in front of us. Ask to share? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 16, 2020 Author Moderator Share Posted April 16, 2020 On 4/13/2020 at 11:02 AM, sk732 said: Ask to share? chase it with intranasal narcan Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted April 17, 2020 Share Posted April 17, 2020 On 9/5/2019 at 9:12 AM, LT_Oneal_PAC said: I tubed, lined, and started a epi drip on a patient with hepatic encephalopathy, possible sick sinus syndrome, and urosepsis, then slept the last 8 hours of my shift. Best job ever. No lactulose enema? Quote Link to comment Share on other sites More sharing options...
wamucc Posted June 29, 2020 Share Posted June 29, 2020 @EMEDPA Do you mind sharing what state you're in? Working in a rural ED is in my long-term plan and what you described sounds amazing. If you'd rather not, I understand! Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted July 1, 2020 Share Posted July 1, 2020 We have a fire/EMS/police radio always on in our ED - gives us good notice of what's coming our way, plus it permits us to talk directly to EMS crews. Earlier tonight, listened to police being dispatched for a "chicken at large" running across US 52. Bird described as large and white. While telling each other, "you can't make this stuff up", we did speculate as to the bird's motive...... 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 1, 2020 Author Moderator Share Posted July 1, 2020 On 6/29/2020 at 3:22 PM, wamucc said: @EMEDPA Do you mind sharing what state you're in? Working in a rural ED is in my long-term plan and what you described sounds amazing. If you'd rather not, I understand! Live in OR, work in both OR and WA 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted July 17, 2020 Share Posted July 17, 2020 Over the past 2 shifts at my CAH I've: coded a 46 y/o/f diabetic (non-compliant) dialysis patient along with the doc - unsuccessful caught an acute appy on a 13 y/o/m clamshelled a cast on a 36 day old female's leg packed a bleeding dental socket on a screaming 6 y/o/f s/p tooth extraction eaten a tomato harvested from a plant I'm growing beside the house where we stay when we're working caught a bat flying around our radiology suite (happens often enough throughout our hospital we have a net on a 5' pole for this) besides the other more routine patients. Truly blessed with the variety and the work environment. 2 Quote Link to comment Share on other sites More sharing options...
MediMike Posted July 17, 2020 Share Posted July 17, 2020 15 hours ago, ohiovolffemtp said: Over the past 2 shifts at my CAH I've: coded a 46 y/o/f diabetic (non-compliant) dialysis patient along with the doc - unsuccessful caught an acute appy on a 13 y/o/m clamshelled a cast on a 36 day old female's leg packed a bleeding dental socket on a screaming 6 y/o/f s/p tooth extraction eaten a tomato harvested from a plant I'm growing beside the house where we stay when we're working caught a bat flying around our radiology suite (happens often enough throughout our hospital we have a net on a 5' pole for this) besides the other more routine patients. Truly blessed with the variety and the work environment. This...is amazing. I mean the tomato and bat thing. The rest whatever, EM is real hard and smells bad and is loud. But fresh tomatoes are awesome, as are flying nice! What region of the country you in? PNW if I remember right? 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted July 18, 2020 Share Posted July 18, 2020 Rural Indiana, near the Illinois border, on the banks of the Wabash. Got 2 more tomatoes in my lunch box for later: San Marzanos. Quote Link to comment Share on other sites More sharing options...
sk732 Posted July 18, 2020 Share Posted July 18, 2020 23 hours ago, ohiovolffemtp said: Over the past 2 shifts at my CAH I've: coded a 46 y/o/f diabetic (non-compliant) dialysis patient along with the doc - unsuccessful caught an acute appy on a 13 y/o/m clamshelled a cast on a 36 day old female's leg packed a bleeding dental socket on a screaming 6 y/o/f s/p tooth extraction eaten a tomato harvested from a plant I'm growing beside the house where we stay when we're working caught a bat flying around our radiology suite (happens often enough throughout our hospital we have a net on a 5' pole for this) besides the other more routine patients. Truly blessed with the variety and the work environment. I delivered a 2 x 0.5cm pencil lead from the sole of a 5 yo' s foot yesterday...thought was just going to be a little tip, but no, this dude went pretty big. Had been there for about 5 days and was suppurating. Mummy's eyes bugged out...kid was scarfing a popsicle while I was milking the thing out. Sent an 11 yo to urban plastics with a wicked thumb fx at the MCP just above the growth plate last week...the resident on the phone was kinda no fuss until she saw the dedicated thumb view and audibly gasped because the MC was almost overlaying the scaphoid...gave me the heebee jeebees actually, was likely going to need a few wires. No bats here though...though we do have a breeding pair of red foxes that live nearby and patrol the parking lot regularly. 1 1 Quote Link to comment Share on other sites More sharing options...
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