Acebecker Posted May 4, 2016 Share Posted May 4, 2016 TPACODESTEMI.jpg have not given tnk in a code before, but figured with this rhythm before the pea arrest there was no downside. seemed to work ok. should know in a few days what neuro function is like... Cannot overstate the value of a bedside 12-lead. I have not read the recent literature on thrombolytics during arrest, but if they're low risk for hemorrhagic cause (no Hx leading to aortic aneurysm rupture, ICH, trauma, etc.) then it makes sense. I was just thinking of a case I'd heard about - young lady on exogenous estrogen with pleuritic CP on the way to have CTPA codes. With this Hx, why not try thrombolytics? Thoughts? It seems too simple. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 4, 2016 Author Moderator Share Posted May 4, 2016 Cannot overstate the value of a bedside 12-lead. I have not read the recent literature on thrombolytics during arrest, but if they're low risk for hemorrhagic cause (no Hx leading to aortic aneurysm rupture, ICH, trauma, etc.) then it makes sense. I was just thinking of a case I'd heard about - young lady on exogenous estrogen with pleuritic CP on the way to have CTPA codes. With this Hx, why not try thrombolytics? Thoughts? It seems too simple. I've seen this done before. I saw a guy with a cast on his leg who had shortness of breath and coded. one of my partners gave tpa for pea/presumed PE. didn't work, but it was a good thought. Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted May 6, 2016 Share Posted May 6, 2016 Is there going to be enough perfusion pressure to get the tPA to the site of the clot? 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 6, 2016 Author Moderator Share Posted May 6, 2016 maybe yes, maybe no. what is the downside to trying it on a patient who is pulseless and apneic with presumed PE or ACS? (aside from cost...) 1 Quote Link to comment Share on other sites More sharing options...
fishbum Posted May 6, 2016 Share Posted May 6, 2016 (aside from cost...) You stole my answer... Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted May 6, 2016 Administrator Share Posted May 6, 2016 maybe yes, maybe no. what is the downside to trying it on a patient who is pulseless and apneic with presumed PE or ACS? (aside from cost...) Definitely make sure the techs are going to town with continuous compressions if you're going to try ANY drug in an arrest situation. Forget 30:2, that's just asking for your patient to stay dead. 2 Quote Link to comment Share on other sites More sharing options...
sk732 Posted May 16, 2016 Share Posted May 16, 2016 Had an old dude (90) brought in by family today, Hx HTN and early (??!!) dementia, for " bad swelling and redness in the face,neck and head", getting worse over about 2 weeks. Slowly resolved when sitting and standing up. No real constitutional issues other than decreased PO intake and foul urine. He's also a lot less sharp than he usually is. One of my nurses (a very switched on and experienced one who is practically my work wife) figures "hey, can I get a urine and some blood on him - sure fire UTI"...so I said sure - had a GI bleed and a nasty teenage phimosis going on. Finally came in, dude's face was indeed almost livid in colour, seemed to have the IQ of a melted ice cube (not his norm), was badly hypertensive, bit of decreased AE in the RUL. No mediastinal nodes were noted. CBC was 14.0, 134 and 1935. Urine was stinky, but pretty boring except for ketone, which I expected. AP CXR - wicked looking goobers in the upper mediastinum causing a tracheal shift to the right plus something else high in the right apex. Last time I saw SVC Syndrome was on a CXR during grand rounds in, oh, I want to say 1997/98. Never saw it in person until today. The kids were saying this fellow first actually saw a doctor at the age of about 82 ish, being a typical farmer for this area. He's on an ER hold until he get's a CT noodle to tummy done tomorrow. Since I'm on in the am, I'll update y'all tomorrow. SK 1 Quote Link to comment Share on other sites More sharing options...
sk732 Posted May 16, 2016 Share Posted May 16, 2016 Grrr - dude's CT went late today, so won't have a result until start of shift tomorrow. SK Quote Link to comment Share on other sites More sharing options...
sk732 Posted May 21, 2016 Share Posted May 21, 2016 So part of this seemed to be a vascular issue - the sublacvian was getting congested due to a narrowing, no sign of tumour in chest...though the hospitalist is working up the 1935 platellet count. More to follow if I find out. SK 1 Quote Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted June 1, 2016 Share Posted June 1, 2016 Had a good one over the weekend. Working in a double coverage 10 bed ER. EMS call from adjacent (very rural) county. Head on wreck on rural highway. ETA essentially unknown. Basically a first responder service, so details are generally a little sketchy. After some time they make it to the hospital. 5 patients.... half of our total ER capacity. Not to mention all 5 were transported in one ambulance! It's the only one in the county. Members from both vehicles no less... The most sick patient had multiple rib fxs, sternal fracture, and a substernal hematoma. Other passengers had their own (thankfully and luckily) less substantial injuries. About an hour after they arrived... 2 chest pains simultaneously.... An hour later septic + chf + copd. Needed bipap and the whole works. Thankfully the helicopter was able to take off before the storm. Just another day in a sleepy little rural ER Quote Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted June 1, 2016 Share Posted June 1, 2016 Had a good one over the weekend. Working in a double coverage 10 bed ER. EMS call from adjacent (very rural) county. Head on wreck on rural highway. ETA essentially unknown. Basically a first responder service, so details are generally a little sketchy. After some time they make it to the hospital. 5 patients.... half of our total ER capacity. Not to mention all 5 were transported in one ambulance! It's the only one in the county. Members from both vehicles no less... The most sick patient had multiple rib fxs, sternal fracture, and a substernal hematoma. Other passengers had their own (thankfully and luckily) less substantial injuries. About an hour after they arrived... 2 chest pains simultaneously.... An hour later septic + chf + copd. Needed bipap and the whole works. Thankfully the helicopter was able to take off before the storm. Just another day in a sleepy little rural ER 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 13, 2016 Author Moderator Share Posted June 13, 2016 have had a few days like that. recently had a code and a pt with new chest pain with afib/rvr at the same time. lots of fun. Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 13, 2016 Share Posted June 13, 2016 Times like that in a rural setting you just want to pull out the ADLS cards and just tell folks "hold this", and that's while IN a bed in the ED! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 7, 2016 Author Moderator Share Posted July 7, 2016 after a month of negotiations I have finally landed my full time rural job. I'm going to be 1/2 time at 2 different facilities working for the same group. facility #1 is single coverage 12 hr night shifts. facility #2 is 12 hr day shifts, double coverage, alternating charts with a doc from the same rack. will also continue another per diem rural solo coverage job a few shifts/month. will now work 168 hrs/mo total instead of 212 without a change in pay. will also get rural health provider tax credit that I did not get before. very pleased all around. 5 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted July 7, 2016 Share Posted July 7, 2016 Good for you sir! 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 7, 2016 Author Moderator Share Posted July 7, 2016 thanks, 20 years as a PA and I finally have the job I wanted right out of school... Quote Link to comment Share on other sites More sharing options...
sk732 Posted July 7, 2016 Share Posted July 7, 2016 Much coolness :-) Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 15, 2016 Share Posted July 15, 2016 Why I love rural EM? Just got off 72 hour shift, at $85/hour = $6120 gross. Now I'm going to the lake for a week. Saw 22 patients. Admitted or shipped all but 3. Last two were back to back code blues. Achieved ROSC in both, and one was talking to us. 5 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 21, 2016 Author Moderator Share Posted August 21, 2016 ok, I know we all have " those pts, frequent flyers", etc but just keep an eye out for the day they are actually pretty sick. one of our less skilled(and I am being generous here) medics brought in a well known frequent flyer without really doing any assessment or tx at all. his report: : I"ve got xyz pt in bed 5. he's drunk or stoned or something". vitals? didn't check. cbg? nope. actual pt is elderly confused, smells of alcohol(likely chronically), but when I had his vitals checked here they are: temp 39.5 pulse 140 bp 72/40 sao2 90% Resp 28 mental status(normally a pleasant drunk, today totally out of it). a cursory exam reveals a foley bag full of pus. yup, uroseptic to the max with all the labs you would expect and an easy icu admit on pressors, multiple abx, etc. Just because you see someone every day doesn't mean you don't need to go through the motions of VS, H+P, etc. sure, they are often crying wolf until the day the wolf is chewing off their leg...that day they tend to be really damn quiet... rant over. 3 Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 21, 2016 Share Posted August 21, 2016 I second the thought that chronic folks can become acute. I am not even rural, so sometimes I have more access to rapid resources. My 75 yr COPD lady on chronic O2 has presented almost weekly SOB. I have learned to judge her eyes, her mood and her exam altogether to see where she is at. She is a pretty good judge. I can tell now when she is hinky. Most recent SOB took her to the hospital on a weekend. They checked her troponin and did an echo - negative. Ok - it's her lungs. Got her hospital admit yesterday from late at night this week - SOB again, but something bugged the ER doc and redid her troponin. It was normal. But he kept her long enough to do it again - It went up 2.5X and her enzymes shifted. So, nonSTEMI and not just SOB. The hardest for me are my psych hypochondriacs. They aren't immune to disaster whether self created or just bad luck. It gets tiring doing a million dollar workup on their every funky symptom - but they can crash too. Can't afford to miss it. They too deserve good care even when they make you crazy. Good work, EMED. I love hearing your stories. Quote Link to comment Share on other sites More sharing options...
sk732 Posted August 22, 2016 Share Posted August 22, 2016 Had an interesting case yesterday...22 yo female, PHx of Wegener's, not really following up once her rhematologist left (like almost 3 years), getting over injecting meth - 6/12 clean by her word - and LWBS/LAMA a week ago after having a CXR and not wanting to wait for her chest pain, now week plus Hx of ® CP. No real fever, but is not eating, weak, generally unwell and has a weak cough. Also noting some ® hip pain with walking. Old CXR had something brewing according to rad and yesterday's had a huge air bronchogram and some funky fluffy stuff in the RLL. wbc's 19.5 <shift, Pl 46 and Hb 118, ESR 70, urea 11.5 with (N) creatinine, some casts and protein in her urine. Her pressure was 95 syst and HR113, so I wasn't too worried - was a pain in the arse getting an IV and I was a little reticent about a central line just yet. Fluids, steroids and Abx got in, but clearly has to stay in...of course our ER is constipated and there are no beds here and in our region (big eye roller if you ever met me in person - this has me looking at my cerebellum) so called a tertiary facility in the city. Lo and behold, the head of internal medicine is on call and I'm told he's a knob...had that air about him on the phone too, but managed to successfully sell her - we have no internal med on site here, so I threw that out, along with the bed situation. "When is there ever any beds in (XYZ)?" he asks..."Infrequently in the last year" I reply. "What's in them?" "Old people awaiting placement and a paltry few young, actually sick people". "Send her in". "Thank you Sir". We often have a hard time selling folks out there when we need to...maybe he thought she was interesting too. SK 1 Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted September 15, 2016 Share Posted September 15, 2016 Nice peaceful morning interrupted with EMS call for truck vs RV on the interstate. Few minutes later EMS call for code blue at a nearby house. Few minutes later EMS call for another MVA on the interstate.NIce and peaceful to getting ready for $hitshow in 10 minutes. 30 minutes later, no transports at all and I'm getting ready to take a nap! I love rural EM. 3 Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted September 15, 2016 Share Posted September 15, 2016 Nice peaceful morning interrupted with EMS call for truck vs RV on the interstate. Few minutes later EMS call for code blue at a nearby house. Few minutes later EMS call for another MVA on the interstate. NIce and peaceful to getting ready for $hitshow in 10 minutes. 30 minutes later, no transports at all and I'm getting ready to take a nap! I love rural EM. Envying you right now. Medium size city suburban family practice - I am somewhere between the frantic phone call that "I have bladder cancer, I just know it" and "those meds are poison and I am not taking them". Considering a magic rain stick, a costume and ceremonial dancing as a method of treatment. Not putting the stick in my nose - just not gonna go there. Deep Sigh - full moon in a few days............................ Quote Link to comment Share on other sites More sharing options...
sk732 Posted September 20, 2016 Share Posted September 20, 2016 Had an odd weekend...two complaints about one of our smaller sister sites. Lady came in with a week long Hx of swollen painful toe with swelling extending into the foot. Toe is livid. Started on a ZPack for a skin infection (??!!) due to PCN allergy...doc failed to elicit a gout Hx with frequent recurrence in the past 5 months. Is on chlorthalidone...uric acidwell above acceptable levels with ESR 65. Another was essentially ignored by triage at the ER due to being in hysterics - had a tuft amputation with arterial bleeding, not even triaged there, no pain meds, barely had a pressure dressing applied. They then drove the 30min to get to us to get sorted out. SK Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted September 20, 2016 Share Posted September 20, 2016 The full moon was this past weekend........... How do you miss an arterial bleed????? The spurt spurt pattern should have been a clue. Never once used Zpak for skin anything. Gout is like the 900 lb Gorilla in the Room - kind of hard to miss. Glad they got to somewhere else - sounds like someone at the remote clinics will get a drug test and some discussion. Quote Link to comment Share on other sites More sharing options...
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