Guest Paula Posted November 27, 2015 Share Posted November 27, 2015 Good choice to let ortho handle that one. When I worked ER locums I had a guy come in with a 20 cm laceration to lower leg from having a ski-doo fall off the trailer onto his leg in the lake. The doc I worked with said go ahead and clean it up and suture. I had a med student with me who helped and did some of the work. It was a beautiful repair but a disaster overall. There was a tiny seashell that was imbedded that didn't get irrigated out. Initially when I saw the guy I considered calling surgery on call and wish I would've listened to gut. The guy was ok but got bad infection,dihescense of wound,IV antibiotics and surgical fix later. Happened on a July 4 holiday with ER crazy and everyone stressed. A good lesson learned to not let the pressure of getting patients in and out and then making a mistake like that. I had night mares for months afterwards and it was one thing that made me consider to stop working at that particular facility due to the pressure ..it was a toxic environment overall and I was too young in my career to figure out how to handle the personalities at that facility. But I learned a lot too and documented that the SP approved and delegated the repair to me and med student. It saved my buttons. Quote Link to comment Share on other sites More sharing options...
bigdawg1986 Posted November 27, 2015 Share Posted November 27, 2015 {style_image_url}/attachicon.gif dirtywound.jpg 12 cm x 4 cm lac just distal to knee of 30 yr old morbidly obese diabetic. full of gravel. almost took this one on myself but thought better of it. called ortho. guy spent about 2 hrs in the OR getting all the gravel out and closing it. Two hours for that? I'm in ortho and that just doesn't sound right... Considering that in 500 cases I've only had a longer than 2 hour case maybe less than 5 times. Even if there's a tendon lac that just sounds waaaay off. Sent from my SM-G900V using Tapatalk Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 27, 2015 Author Moderator Share Posted November 27, 2015 Two hours for that? I'm in ortho and that just doesn't sound right... Considering that in 500 cases I've only had a longer than 2 hour case maybe less than 5 times. Even if there's a tendon lac that just sounds waaaay off. Sent from my SM-G900V using Tapatalk you can't appreciate it from the picture but there was LOTS of embedded gravel that didn't irrigate out and needed to be removed a piece at a time. no tendon lac. that's why I was considering doing it myself. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 6, 2016 Author Moderator Share Posted January 6, 2016 a few pts from a recent rural shift. cxr 25 yr old male with dyspnea and chest pain. head ct 55 yr old female with gcs3, pulse 70 and bp 70/40. why? 1 Quote Link to comment Share on other sites More sharing options...
Guest Paula Posted January 7, 2016 Share Posted January 7, 2016 Subdural hematoma and fluffly cotton ball looking nodules in the RUL? Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted January 7, 2016 Moderator Share Posted January 7, 2016 Looks like a subtle pericardial effusion. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 7, 2016 Author Moderator Share Posted January 7, 2016 I guess the cxr didn't copy well. there is a 10-15% ptx L upper lobe. spontaneous. admitted for obs. no chest tube felt needed by surgery. anyone want to tell me specifically why the bp 70 and pulse 70 in the trauma pt with the head bleed( notice the lack of ventricle and midline shift)? Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted January 16, 2016 Share Posted January 16, 2016 Would expect low pulse d/t Cushing's, but would also expect elevated BP. If trauma, was there other major bleeding? What meds were the patient on - any anti-hypertensives, particularly beta blockers? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 16, 2016 Author Moderator Share Posted January 16, 2016 Would expect low pulse d/t Cushing's, but would also expect elevated BP. If trauma, was there other major bleeding? What meds were the patient on - any anti-hypertensives, particularly beta blockers? good. yes, brady due to head injury...hypotension makes you look elsewhere....like the belly where you find most of their blood volume and an h+h of 7/21. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 7, 2016 Author Moderator Share Posted February 7, 2016 never seen this before. fortunately the pt talked me through the reduction: Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 7, 2016 Author Moderator Share Posted February 7, 2016 here is the post reduction Quote Link to comment Share on other sites More sharing options...
cop to pa Posted February 7, 2016 Share Posted February 7, 2016 Anterior dislocation. At least, it looks like the humoral head is Anterior to the glenoid. Quote Link to comment Share on other sites More sharing options...
cop to pa Posted February 7, 2016 Share Posted February 7, 2016 Nope, never mind. Took a closer look. Belay my last. No idea, but I see some scapular involvement. Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 7, 2016 Moderator Share Posted February 7, 2016 never seen this before. fortunately the pt talked me through the reduction: scapula1.jpg Ouch.... Can't say I have ever seen a scapula in that position..... Wth?? Quote Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted February 7, 2016 Share Posted February 7, 2016 That's impressive.... And impressive is never something you never want to be as an ER patient Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 7, 2016 Author Moderator Share Posted February 7, 2016 http://shoulderelbow.blogspot.com/2015/02/locked-scapula-syndrome-rare-condition.html 2 Quote Link to comment Share on other sites More sharing options...
DiggySRNA Posted February 8, 2016 Share Posted February 8, 2016 But why....? I have so many questions. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 8, 2016 Author Moderator Share Posted February 8, 2016 But why....? I have so many questions. apparently typically due to trauma involving posterior ribs and supporting ligaments. Quote Link to comment Share on other sites More sharing options...
dmdpac Posted February 9, 2016 Share Posted February 9, 2016 Just to clarify what I'm seeing in the video. Anterior traction is placed on the extended arm while the thumbs are pushing along the lateral border of the scapula? Is that what they were doing? E, when you did the reduction was it similar to how it was presented in the video? That's pretty wild. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 9, 2016 Author Moderator Share Posted February 9, 2016 Just to clarify what I'm seeing in the video. Anterior traction is placed on the extended arm while the thumbs are pushing along the lateral border of the scapula? Is that what they were doing? E, when you did the reduction was it similar to how it was presented in the video? That's pretty wild. longitudinal traction on the affected arm by assistant. force applied to inferior aspect of the scapula straight up with both thumbs produced reduction. pretty much just like the video. IM dilaudid only for pain control. the guy said when he gets procedural sedation folks generally also dislocate his shoulder in the process. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 17, 2016 Author Moderator Share Posted February 17, 2016 27 yr old female with "cold sx x 1 week"....oh and bp 80/40, pulse 130, wbc 24k.....3l of pus in R chest via chest tube...after sitting in WR for 2 hrs.....untriaged.....maybe this should be in the fast track thread... Quote Link to comment Share on other sites More sharing options...
fakingpatience Posted February 17, 2016 Share Posted February 17, 2016 Wow! How did she manage to go 2 hours without triage? The x-ray is showing a massive pleural effusion, correct? What was the pathology behind it? Quote Link to comment Share on other sites More sharing options...
JDayBFL Posted February 17, 2016 Share Posted February 17, 2016 sepsisempyema.jpg 27 yr old female with "cold sx x 1 week"....oh and bp 80/40, pulse 130, wbc 24k.....3l of pus in R chest via chest tube...after sitting in WR for 2 hrs.....untriaged.....maybe this should be in the fast track thread... And I thought the 250mL of cloudy yellow pus I drained out of a post-op knee was bad today. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 28, 2016 Author Moderator Share Posted February 28, 2016 a few fun ones from last weekend (fun for me, not them). 1 Quote Link to comment Share on other sites More sharing options...
Evolute Posted February 28, 2016 Share Posted February 28, 2016 I had that same (well similar) elbow last week. that appears to be a thoracic aneurysm (descending). I had a pt last year that dropped 300 lbs on his chest and had a traumatic dissection of his ascending aorta involving the brachiocephalic artery. Not to mention pneumo, and multiple broken ribs as well as the sternum. Quote Link to comment Share on other sites More sharing options...
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