ohiovolffemtp Posted January 12 Share Posted January 12 When you exhaust your hospital's supply of phenergan, droperidol, and pseudaphed .... But not your community's supply of EtOH, weed, COVID, and flu .... Also, just had my highest ever acetaminophen level: by pt's report took approximately 125 500 mg tablets as a suicide attempt. Showed up 5.5 hours after ingestion - drove himself in after fiance nagged him into coming in. NAC right away, initial acet level 229, wound up needing levo to keep his pressure up. Thank heaven the winds dropped enough for the helicopter to come and take him to the tertiary center. Pt tried to refuse because that was too far away. At 13 hours into a rough 12 hour shift I "explained" to him that he didn't have a choice and liver failure was a particularly unpleasant way to die. 2 3 Quote Link to comment Share on other sites More sharing options...
SedRate Posted January 12 Share Posted January 12 5 hours ago, ohiovolffemtp said: At 13 hours into a rough 12 hour shift I "explained" to him that he didn't have a choice That was me yesterday when I discussed smoking cessation for a hip fracture patient who just had surgery, can barely move, and wants to discharge home so she can smoke. 1 1 Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted January 13 Share Posted January 13 6 hours ago, SedRate said: That was me yesterday when I discussed smoking cessation for a hip fracture patient who just had surgery, can barely move, and wants to discharge home so she can smoke. But it's " their right". Questionable decision making as demonstrated by their circumstances! I am sick of hearing about the rights of the dumdasses keeping me and many others awake so many nights! 1 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted January 13 Share Posted January 13 I always explain to patients that it's their body and they have a constitutional right to choose what to do with it. (except for folks on mental health holds...) I then tell them that I have a professional obligation to tell them when they are making a stupid choice. I usually phrase it exactly like that. 1 1 1 Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted January 13 Share Posted January 13 So true but when their family and friends jump in supporting the stupidity, it brings on another layer of bovine scatology! 1 Quote Link to comment Share on other sites More sharing options...
SedRate Posted January 13 Share Posted January 13 6 hours ago, ohiovolffemtp said: I always explain to patients that it's their body and they have a constitutional right to choose what to do with it. (except for folks on mental health holds...) I then tell them that I have a professional obligation to tell them when they are making a stupid choice. I usually phrase it exactly like that. Definitely. I say something like, "As you might already know, smoking causes lung cancer. It can also cause a stroke, vascular and blood flow problems, bone health and healing problems, and wound healing problems. So my medical recommendation is zero cigarettes and smoking." And I give them a zero and pause for them to acknowledge. One guy responded saying he has nothing better to do than smoke. I told him he needs to find a better hobby. 1 Quote Link to comment Share on other sites More sharing options...
SedRate Posted January 13 Share Posted January 13 1 hour ago, CAdamsPAC said: So true but when their family and friends jump in supporting the stupidity, it brings on another layer of bovine scatology! Definitely. I shut it down real quick. But if the friend/family member continues to cause issues, I state that I need to ask them to leave as they are not contributing to a healing and healthy environment and I open the door for them. 1 1 Quote Link to comment Share on other sites More sharing options...
sk732 Posted February 5 Share Posted February 5 Had a weird case the other day - came in presenting with syncope, complaining they couldn't breath...recent UTI, initial labs largely normal, HR in 130 range, sats 94%, BP 76/50 something...felt a bit better with O2, BP bumped a bit with fluid, but went down quickly. Nil really of note on exam other than diaphoretic/tachycardic, EKG was STach. Started aggressive fluids and Abx, because it was early morning, handed over to the day person awaiting airevac. Evacuated them either expecting a PE or Urosepsis...turned out to be an 8x10cm liver abscess, despite no abdominal tenderness on exam. Had someone yesterday that was likely having a crack cocaine crash (I didn't know anyone still did that anymore, what with the advent of meth around here) and had been hallucinating for 5 days or so, but also had a wicked HHS happening...bright side, with their sugar unrecordable high on the iStat, and a Hx of heart failure coupled with complete medication non-adherence, they were at least auto-diuresing... Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted February 6 Share Posted February 6 My weird one: 60's y/o/f presents with 3 days of N/V & malaise. Pt alert & oriented, but complaining of feeling very weak & nauseous no active vomiting, mild belly pain.Dx with COVID 3 days ago & started on Paxlovid, N/V started right after starting the Paxlovid. Started on NS bolus, Reglan, Benadryl. Routine labs ordered. Results anything but routine (also delayed because lab said the blood was "turbid" and they were having analyzer issues: Na+ 108 K+ 2.2 Cl 96 Mg 0.63 Thought that had to be a lab error but repeat labs (this time drawn by lab) essentially unchanged. Stopped the IVF, gave PO K+ 80 meq, IV mag. Normal EKG. Asked pt for more history. She has Sjogren's - says she drinks 4-5 bottles of water/day to keep her mouth moise, maybe a "bit more" now because of the N/V. Family says it's more like 8-10 bottles/day, so 4-5L/day. No ICU beds or nephrology available at my facility so worst hyponatremia I've ever seen treated with a JP4 bolus. Pt's minimal s/s likely d/t the fact that she's probably gotten that way slowly d/t her heavy water consumption. So, no hypertonic given and TX deferred to experts. K+ resolved and mag close to normal by the time the flight crew arrived. 1 Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted February 6 Share Posted February 6 Cool, so those hoof beats were a zebra! 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted February 7 Share Posted February 7 My best friend from PA school pre-reqs became a veterinarian. We often trade stories and pictures from our interesting cases. Recently I had an interesting angioedema patient who responded to FFP, but not to steroids, benadryl, or TXA. I sent her a picture: Angio edema 1.jfif She proceeded to go one better with her case: Angio edema 2.jfif Quote Link to comment Share on other sites More sharing options...
sk732 Posted February 7 Share Posted February 7 On 2/6/2024 at 5:45 AM, ohiovolffemtp said: My weird one: 60's y/o/f presents with 3 days of N/V & malaise. Pt alert & oriented, but complaining of feeling very weak & nauseous no active vomiting, mild belly pain.Dx with COVID 3 days ago & started on Paxlovid, N/V started right after starting the Paxlovid. Started on NS bolus, Reglan, Benadryl. Routine labs ordered. Results anything but routine (also delayed because lab said the blood was "turbid" and they were having analyzer issues: Na+ 108 K+ 2.2 Cl 96 Mg 0.63 Thought that had to be a lab error but repeat labs (this time drawn by lab) essentially unchanged. Stopped the IVF, gave PO K+ 80 meq, IV mag. Normal EKG. Asked pt for more history. She has Sjogren's - says she drinks 4-5 bottles of water/day to keep her mouth moise, maybe a "bit more" now because of the N/V. Family says it's more like 8-10 bottles/day, so 4-5L/day. No ICU beds or nephrology available at my facility so worst hyponatremia I've ever seen treated with a JP4 bolus. Pt's minimal s/s likely d/t the fact that she's probably gotten that way slowly d/t her heavy water consumption. So, no hypertonic given and TX deferred to experts. K+ resolved and mag close to normal by the time the flight crew arrived. My trial week up north had a lady come in with K unrecordably low on iStat - asked the RN to repeat it like I usually do, comes back the same. Hx T2DM, chronic diarrhea, some CHF...came in with Tachy-Brady stuff. Gave her 60 or 80mEq po stuff (have no liquid K on the Formularies . Flew them out, inital K was 1.2 at the ED. 1 Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted February 7 Share Posted February 7 6 hours ago, ohiovolffemtp said: My best friend from PA school pre-reqs became a veterinarian. We often trade stories and pictures from our interesting cases. Recently I had an interesting angioedema patient who responded to FFP, but not to steroids, benadryl, or TXA. I sent her a picture: Angio edema 1.jfif 45.85 kB · 2 downloads She proceeded to go one better with her case: Angio edema 2.jfif 150.03 kB · 3 downloads Your friend's picture beats yours! Quote Link to comment Share on other sites More sharing options...
SedRate Posted February 8 Share Posted February 8 9 hours ago, sk732 said: Flew them out, inital K was 1.2 at the ED. I'm no smarty pants but that seems low. 1 Quote Link to comment Share on other sites More sharing options...
sk732 Posted February 8 Share Posted February 8 1 hour ago, SedRate said: I'm no smarty pants but that seems low. Kinda wondering how low it was before we gave her the oral replacement... Quote Link to comment Share on other sites More sharing options...
DiggySRNA Posted February 8 Share Posted February 8 22 minutes ago, sk732 said: Kinda wondering how low it was before we gave her the oral replacement... Holy crap... 1.2 after repletion with 80 mEq? *based on 1:1 assumption in a perfect environment* for every 0.20 repletion, you expect your serum K+ to raise +/- 0.2 points....so with 80 mEq; I assume their original K was 0.4 and that sounds like cardiac stand still. Then again iStat vs SST. 1 Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted February 8 Share Posted February 8 4 minutes ago, Diggy said: Holy crap... 1.2 after repletion with 80 mEq? *based on 1:1 assumption in a perfect environment* for every 0.20 repletion, you expect your serum K+ to raise +/- 0.2 points....so with 80 mEq; I assume their original K was 0.4 and that sounds like cardiac stand still. Then again iStat vs SST. Ah, the art of medicine, not science this demonstrates there are no absolutes....... 1 2 Quote Link to comment Share on other sites More sharing options...
SedRate Posted February 8 Share Posted February 8 1 hour ago, sk732 said: Kinda wondering how low it was before we gave her the oral replacement... Definitely. Surprised she was alive... 1 Quote Link to comment Share on other sites More sharing options...
sk732 Posted February 8 Share Posted February 8 50 minutes ago, SedRate said: Definitely. Surprised she was alive... Yo're not the only one... Quote Link to comment Share on other sites More sharing options...
sk732 Posted February 8 Share Posted February 8 2 hours ago, Diggy said: Holy crap... 1.2 after repletion with 80 mEq? *based on 1:1 assumption in a perfect environment* for every 0.20 repletion, you expect your serum K+ to raise +/- 0.2 points....so with 80 mEq; I assume their original K was 0.4 and that sounds like cardiac stand still. Then again iStat vs SST. I'm not sure what our low cut off is for the iStat...I'll tell you her EKG would have made a med student's case study wet dream... 1 1 Quote Link to comment Share on other sites More sharing options...
sk732 Posted March 29 Share Posted March 29 So got called in 0 Dark OMFG for an overdose and a second person with a laceration that fell outside scope of practice of the RN. OD was relatively straight forward...I thought the lac would be - smoked some meth, fell down, hit face. Stair laceration to lip though vermillion border, had some contralateral jaw pain - so, I arranged to send them out. Going through the chart, find they're diabetic and have evolving nephropathy. Pt noted that they've been fainting a lot lately, not just when smoking their meth...to close the loop, ordered some labs prior to transfer...Na 112, K 2.3, Cl <65, BG 26.7 mmol (Canada here), so corrected Na~118. Cr went from baseline 178 to 775 and BUN 7.5=>22. pH was 7.60'ish. Dude's awake, talking, vitally (N) save mild tachycardia at 106...called the receiving ER back and we had a good little chuckle, and called the IM o/c to let them in on the joke as well, to get some advice on how to deal with this ...as did my doc that I handed over to at 0800. My call Kharma lately is getting to the point that the RN's are threatening to get a collection together to pay me my call stipend to not take call and let out a universal groan at report yesterday morning when they hear I was on . We were doing slow correction/hydration when I went back to bed for a few hours, and likely has been shipped out by now (well hoping anyway). 1 2 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted March 30 Share Posted March 30 Has anyone else noticed that meth seems to be getting stronger and it's harder to sedate meth patients? I had a ~50 kg female that 150 mg of ketamine, 15 mg of valium, and a precedex drip just barely kept still enough to CT her exquisitely tender belly. She wound up having a perf'd viscous and got a fixed wing out. 3 Quote Link to comment Share on other sites More sharing options...
SedRate Posted March 30 Share Posted March 30 18 hours ago, ohiovolffemtp said: Has anyone else noticed that meth seems to be getting stronger and it's harder to sedate meth patients? I had a ~50 kg female that 150 mg of ketamine, 15 mg of valium, and a precedex drip just barely kept still enough to CT her exquisitely tender belly. She wound up having a perf'd viscous and got a fixed wing out. No, but I've had a couple like that over the years. Essentially maxed out and still moving on a drip. One was meth, the other an alcoholic. 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 31 Author Moderator Share Posted March 31 On 3/29/2024 at 7:33 PM, ohiovolffemtp said: Has anyone else noticed that meth seems to be getting stronger and it's harder to sedate meth patients? I had a ~50 kg female that 150 mg of ketamine, 15 mg of valium, and a precedex drip just barely kept still enough to CT her exquisitely tender belly. She wound up having a perf'd viscous and got a fixed wing out. Yup. Generally polysubstance involved. we recently had to give a 120kg + drunk/meth fellow in an mva 500 of ketamaine to get him in the scanner. Quote Link to comment Share on other sites More sharing options...
sk732 Posted April 1 Share Posted April 1 I've had discussions with medical directors about getting dart guns for ED use for standoff Ketamine or olanzapine/haldol use so all concerned are less likely to get injured in a fight to subdue/restrain them...apparently the optics of shooting someone in the ED/Nursing Station are poor, but the admins are of course just fine with people and facilities getting the living Bejeezus beat out of them. I'm not sure if the meth is getting stronger or if there is some other adulterant in it or what...I'm hoping to not have to go the ketamine route, since we've only got a BS 10mg/10ml concentration of the stuff ...and the Rez "police" aren't sworn peace officers and the nearest Mounties are 20 minutes away IF the ice road is open on the lake...longer if they have to boat it or chopper over in spring/summer. Quote Link to comment Share on other sites More sharing options...
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