sk732 Posted September 20, 2016 Share Posted September 20, 2016 The only thing they cared about was the fact the patient was in hysterics and woudln't calm down...we initiated an incdent report at our end, hopefully someone does something about it. SK Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted September 20, 2016 Share Posted September 20, 2016 A brown paper bag can calm hysterics most times. We gave one adult a child's pinwheel to blow on (we use it for vaccines). Told her to blow on the pinwheel till it spun and that was her ONLY job while we took a look at her. It worked - just long enough to find out the extent of damage. Or - pretend it is a screaming 9 mos old and do the exam anyway - you have to learn to block out the sounds and focus the exam. Paramedics can still somehow take BP and assess a patient going around a corner at 90 with sirens wailing and gunshots......................... It takes a lot not to get all bent sometimes but a little focus can go a long way. Hope the incident gets some attention. Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted September 21, 2016 Share Posted September 21, 2016 New hospital for me today. Never even been in this town before. Show up this morning (after a long drive) and find out I'm not only covering the ED (average of 6 visits a day) but I'm also covering the attached walk-in-clinic. Crap....I hate clinic. Oh well... Then I find out one doc is sick, one PA is on vacation, and the remaining doc & PA are heading to next town over for satellite clinic, so I'm on my own. Already seen 15 patients in the ED and I'm only 12 hours into my 48 hour shift! I love rural EM. Quote Link to comment Share on other sites More sharing options...
sk732 Posted September 21, 2016 Share Posted September 21, 2016 A brown paper bag can calm hysterics most times. We gave one adult a child's pinwheel to blow on (we use it for vaccines). Told her to blow on the pinwheel till it spun and that was her ONLY job while we took a look at her. It worked - just long enough to find out the extent of damage. Or - pretend it is a screaming 9 mos old and do the exam anyway - you have to learn to block out the sounds and focus the exam. Paramedics can still somehow take BP and assess a patient going around a corner at 90 with sirens wailing and gunshots......................... It takes a lot not to get all bent sometimes but a little focus can go a long way. Hope the incident gets some attention. Preaching to the choir - used to be an army medic and also worked in flight and diving medicine - C130's and recompression chambers are freaking loud sometimes...and we talk funny at depth, especially if we're using heliox. SK 3 Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted September 21, 2016 Share Posted September 21, 2016 Preaching to the choir - used to be an army medic and also worked in flight and diving medicine - C130's and recompression chambers are freaking loud sometimes...and we talk funny at depth, especially if we're using heliox. SK I just get frustrated when folks bail and take an out because something might take some ingenuity to assess a patient. No excuse for lazy. Should be legal to head slap those folks. Quote Link to comment Share on other sites More sharing options...
sk732 Posted September 21, 2016 Share Posted September 21, 2016 It's more likely they didn't know how to deal with a hysterical patient WITH an arterial bleed...seen alot of folks that don't understand pressure dressings at all, much less use of indirect pressure bleeding control. It ws a fingertip - pile of gauze and some Coban and voila...or even just the Coban at the base of the finger. I remember well a few years ago having to show a nurse and a doctor (EM at that) how to apply a pressure dressing on a surgically amputated toe stump that popped its clot...after using a pressure point to gain control of the bleeding and clean the area up a bit. My actual SP is an ex-South African Defense Force surgeon...we at least speak the same language this way. SK Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 24, 2016 Author Moderator Share Posted September 24, 2016 Just took care of a WW2 vet who was on active duty at pearl harbor 12/7/41 and later served on multiple vessels in the pacific. not a lot of these guys left. had a minor fall and ortho issue while at car dealership BUYING HIMSELF A NEW CAR. fellow is totally independent, lives alone, etc. med list 81 mg asa daily. Colace 100 mg daily. wow. God bless him and those like him. 5 Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted September 24, 2016 Administrator Share Posted September 24, 2016 Just took care of a WW2 vet who was on active duty at pearl harbor 12/7/41 and later served on multiple vessels in the pacific. not a lot of these guys left. had a minor fall and ortho issue while at car dealership BUYING HIMSELF A NEW CAR. fellow is totally independent, lives alone, etc. med list 81 mg asa daily. Colace 100 mg daily. wow. God bless him and those like him. I did a new-onset Afib workup at the Portland VA ED for a similar gentleman (not the same guy: mine was army air force). I consider myself blessed to have been able to help him, and listen to his story in the process. He became a preacher after the war, and had been doing that ever since, and wanted to make sure I knew Jesus more than he wanted to tell me war stories. 2 Quote Link to comment Share on other sites More sharing options...
sk732 Posted September 25, 2016 Share Posted September 25, 2016 Had an old dude I'd see frequently for heart issues that was a Korean War vet that served on HMCS Cayuga, a destroyer that became kinda infamous because the medical officer on board was not a doctor, but a complete imposter. He operated on and saved a number of men's lives - after reading some books - before he was found out. Tony Curtis played him in "The Great Imposter". SK Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted October 5, 2016 Share Posted October 5, 2016 Another reason to love rural EM: Every day I go to work I get to see two people (they work at the hospital) who are alive because of my team. One young lady with a very, very rare disease that was caught and treated, and a middle age lady who came into my ED in full arrest. Nothing beats the smile these two women give me when we pass in the hallways. 4 Quote Link to comment Share on other sites More sharing options...
sk732 Posted October 31, 2016 Share Posted October 31, 2016 Up side of small town medicine - youngster that plays next door came in with a hot appendix and sent him to the Peds facility to get it out and did a transfer on a failed thrombolysis for a STEMI for rescue PCI. Downside, kid from down the street in O/N after misadventure with crustal meth... SK Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 2, 2016 Author Moderator Share Posted November 2, 2016 Sometimes the obvious dx is the right one...elderly woman from nursing home with altered mental status. cbg nl. any narcotics? " nope" and none on med list. exam shows multiple 100mcg fentanyl patches on back. rapid return to nl mental status with removal patches and gently titrating narcan 0.1 mg IV at a time x 4. Quote Link to comment Share on other sites More sharing options...
sk732 Posted November 3, 2016 Share Posted November 3, 2016 Had one of those not long ago...couldn't figure out why Grandad wasn't talking or breathing all that well...hmmm, old guy with decreased renal function and a buttload of hydromorphone on board. Tried a sniff of Narcan and VOILA!!!, dude is very interactive...and somewhat upset about all the pain he's in. Had to shake my head so hard I almost concussed myself. SK Quote Link to comment Share on other sites More sharing options...
sk732 Posted November 8, 2016 Share Posted November 8, 2016 Had two cases of folks with diverticulitis in the past month or so that were under age 35...one last night with atypical symptoms at age 29. The other was 34 with recurrent disease, presented with yet another abscess that perfed. Surgeons ried conservative tmt, failed and he ended up with a Hartmann's done. Had a boat load of folks with appendicitis lately, all with normal labs and no fever except one...out of about 12 cases in a month. Weirdness...though as I always say, the only person with a textbook case of anything is usually malingering. SK Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 8, 2016 Author Moderator Share Posted November 8, 2016 youngest diverticulitis I have ever seen was 17. weirdest appy was in the LUQ with malrotated bowel. Quote Link to comment Share on other sites More sharing options...
sk732 Posted November 9, 2016 Share Posted November 9, 2016 Had a dude come in yesterday with what a few of us swore was a retropharyngeal abscess or early epiglottitis...calcific tendonitis of the longus colli. I've seen one case study online prior to this, the two rads on call and my attending had not seen it ever. Was kind of cool - especially since he's improving and it's pretty easily treatable. SK 1 Quote Link to comment Share on other sites More sharing options...
ruralem Posted November 14, 2016 Share Posted November 14, 2016 Ill join in. Had an interesting cardiac case yesterday. Pt came in with wide complex tachycardia. Adenosine 6, 12 mg PTA. Hr of 170, BP 80/40. Tried second dose of 12 mg adenosine while prepping ketamine just for kicks. Nothing. Conscious sedation with ketamine, 100 j cardioversion did the trick back to NSR. Admitted for tele, and about 2 hrs later, went into new onset afib RVR at about 130. Bolus 20mg dilt brought her down a bit ... started drip and PO dilt, increased beta blocker, lovenox. HR in high 90's today. Trop peaked at 3, then dropped. Pt came in right after with persistent ventricular bigeminy. Increased beta blocker and it went away overnight. Cards day.. 2 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted November 19, 2016 Share Posted November 19, 2016 Mid 30's patient wakes up after 8 mg Narcan. Looks up at one of the medics in tears and says, "Mrs. Marshall?". 70ish medic who was the crew lead drove his school bus when he was a kid. Medic does fine job of telling patient he's lucky and she really wants him to get help. 3 Quote Link to comment Share on other sites More sharing options...
sk732 Posted December 5, 2016 Share Posted December 5, 2016 My hospital is right next door to a large in patient psychiatric facility and they send over a poor soul that had to be taken off of clozapine due to their WBC hammering in...they've been started on loxapine instead and now come in stiff as a board, not eating or drinking, making no effort to respond and according to the triage nurse, catatonic...they ain't catatonic. They're warm, really stiff with hyperreflexia and clonus, a heart rate in the 130 range and drooling. I had to hand off to the attending because my shift is over, but we're thinking neuroleptic malignant syndrome or serotonin syndrome...not one of the head shrinkers seem to have thought of this, since they pawned the kid off on the facility GP and by them to us. Back in tomorrow, we shall see what the verdict is... SK 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 5, 2016 Author Moderator Share Posted December 5, 2016 SK- do let us know. find out if they gave dantrolene. Quote Link to comment Share on other sites More sharing options...
sk732 Posted December 6, 2016 Share Posted December 6, 2016 So we talked with the psychiatrist attending this patient - NMS. He wanted us to just stick with fluids and benzos...Cogentin if she got really stiff. Doing well through the day - stuck in our OU though since no in patient beds, as per our normal right now :-(. The head shrink said there wasn't a lot of advantage of using the dantroline vs benzos alone...though if her temp had gone up really high I'd have had to really consider it. Intuitively it makes sense, since the benzos relax the muscles and that will help keep a lot of the thermogeneration down. SK 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 18, 2016 Author Moderator Share Posted December 18, 2016 ok, "poor form" issue from my local medics. these guys are usually rock stars , but this left me speechless. older guy in obvious resp distress, GCS 7ish, strapped to gurney sitting up, gray in color, receiving a neb tx through a mask WHILE TOLERATING AN ORAL AIRWAY. needless to say, RSI intubated immediately(ketamine, etomidate, sux,)....cool case. had some torsades that responded well to mag too. Quote Link to comment Share on other sites More sharing options...
sk732 Posted December 21, 2016 Share Posted December 21, 2016 49 yo dude comes in, severe chest and epigastric pain, vomiting - I thought for sure he was having an inferior MI...exam, not so much - RUQ guarding, distention and ileus like presentation. Lipase came back at a whopping 76,280...highest I've ever seen in person, and I saw a lot on Gen Surg in school, since one of my attendings was a ERCP/Whipple guy. To be sure to be sure, (N) EKG's and TNT's ;-D SK 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 24, 2016 Author Moderator Share Posted December 24, 2016 rural holiday 24. apparently everyone and their mother has been saving up ailments. saw 12 pts in the first 4 hrs here, which is a busy day around these parts. walked into a stemi at 0745. didn't wake up the doc I was relieving, just dug in fast. ekg, ntg and heparin drips, fentanyl, consult, and transfer to cath lab. 2 hrs of chest pain. 50 yr old guy. drove himself in. pale and diaphoretic. no prior cardiac hx. 4 mm of lateral st elevation with reciprocal changes everywhere else. anyone else having a rock and roll rural day or am I just lucky... 1800: up to 15 pts in 10 hrs. nl 24 hr shift = 12-15. 1 Quote Link to comment Share on other sites More sharing options...
sk732 Posted December 25, 2016 Share Posted December 25, 2016 I had my first real break at 1830 yesterday after starting at 0800...nobody in our MTA, the am doc got hung up with a critical patient that had to be airlifted, so I got the waiting room, which seemed to be like the Oak Island flood tunnels - we scoop a few people out, more came in. I wish I could say more than a few were in fact actually sick - most felt they had conditions that would be amenable to some sort of silver bullet...and not clear crème de menthe and tequila unfortunately. Our Wall of Shame of regional facilities on diversion was at about 75% into the red. Did admit one appendicitis though, and casted an actual fracture. Hope today is better... SK Quote Link to comment Share on other sites More sharing options...
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