Moderator EMEDPA Posted October 23, 2014 Author Moderator Share Posted October 23, 2014 I think triage should 1) have to look at a physical injury ALWAYS with out any clothing blocking view 2) listen(yup actually listen) to the chest with a stethoscope..... these two things would help but then I wouldn't get hemopneumothoracies in fast track with a c/c of "wants pain meds". sure he did. he was ejected from his car when he rolled it, sustaining a flail chest...I'm sure that hurt.... 2 Quote Link to comment Share on other sites More sharing options...
medic25 Posted October 23, 2014 Share Posted October 23, 2014 but then I wouldn't get hemopneumothoracies in fast track with a c/c of "wants pain meds". sure he did. he was ejected from his car when he rolled it, sustaining a flail chest...I'm sure that hurt.... Exactly. I had a patient triaged to me once as "ankle laceration" that I ended up putting a chest tube into. Older woman who fell from her attic; her laceration turned out to be an open calcaneus fracture, along with multiple rib fractures and a large pneumothorax. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 23, 2014 Author Moderator Share Posted October 23, 2014 best/worst fast track case ever: 2 month old triaged as "poor feeding". yup, that often happens when you are septic....we had no peds ICU bed and this kid was CRASHING. only lifeflight case from fast track to local peds tertiary facility ICU that I am aware of. the only freeway between the 2 facilities had a big mva at the same time and was closed. Quote Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted October 23, 2014 Moderator Share Posted October 23, 2014 Exactly. I had a patient triaged to me once as "ankle laceration" that I ended up putting a chest tube into. Older woman who fell from her attic; her laceration turned out to be an open calcaneus fracture, along with multiple rib fractures and a large pneumothorax. At least the last old woman who fell onto her side I had in our "fast track"-equivalent area only had a small hemothorax with her rib fractures :D Quote Link to comment Share on other sites More sharing options...
RRivas2004 Posted November 25, 2014 Share Posted November 25, 2014 Another great one from Fast Track this week.... 53 Yo A.A Male with hx of DM2, HTN, presenting with a complaint of "Rash". States that he has had a very itchy rash that covers his entire torso, arms and legs. Has appearance of uticaria / drug eruption. He did take a course of tetracycline last week for an URI, He is not known to have any allergies to antibiotics. Initially exam appears benign..Rash looks typical for that of drug eruption. Luckily his eyes caught my attention.. Jaundice.. Wife at bedside confirms that this is not the usual color for him. CBC, CMP, Amylase, Lipase ordered. CT abd/pelvis ordered. Endorses feeling somewhat ill last week with a bout of vomiting and flu like symptoms but today no belly pain, no fevers, no chills, no nausea, vomiting, headaches, diarrhea, cough. Zip zilch. He feels fine, thinks testing may be overkill..Decide to proceed with workup either way... Initial V/S Temp - 99.2 HR - 18 BP - 113/72 O2- 98% LABS: WBC-4.3 11% Bands Cr-2.33 ( Up from 1.5) BUN 35 Total Bili - 4.6 AST - 461 ALT - 522 ALK Phos - 877 Amylase - 125 Lipase - 98 CT abd/pelvis: FINDINGS: Lung bases appear clear. The heart size is within normal limits. No pericardial or pleural effusion is seen.There is contraction of the gallbladder with subtle pericholecystic stranding. No radiopaquestones are seen. No intrahepatic biliary ductal dilatation is identified. Further evaluation ofthe liver is limited due to lack of IV contrast. Gallbladder US: IMPRESSION 1. Cholelithiasis with evidence of acute cholecystitis.2. Prominence of the portal vein. Clinical correlation is recommended. The patient was then admitted, seen by GI who did an ERCP with stone manipulation of obstructing stone in the common bile duct with placement of stent. He was also seen by Gen surgery and ID. Gen surgery is planning for Lap chole. He developed fevers and chills soon after admission and has been tachycardic to the 120's and hypotensive. All the specialists have concluded that the rash was a separate entity from the obstructing bile duct stone and cholecystitis, as the itch of the cholestasis is generally not associated with a uticaria. Has anyone encountered such a patient with true cholestasis WITH rash and associated itching? Quote Link to comment Share on other sites More sharing options...
RRivas2004 Posted November 25, 2014 Share Posted November 25, 2014 Edited. Post was made twice... Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 25, 2014 Author Moderator Share Posted November 25, 2014 Rivas- good pick up. painless jaundice had me thinking pancreatic CA from the initial presentation... 1 Quote Link to comment Share on other sites More sharing options...
RRivas2004 Posted November 26, 2014 Share Posted November 26, 2014 I definitely had Cancer at the top of the list. I've had 6 shifts in a row in fast track this week and it's been grueling. Quote Link to comment Share on other sites More sharing options...
RRivas2004 Posted December 3, 2014 Share Posted December 3, 2014 Another great one, granted this was in the main ED side but I am responsible for all the Fast track patients in the morning until the fast track side is officially open at 11am... 31 yo A.A male with history of Ehler Danlo's syndrome, who smokes 1 PPD. He was seen 3 days earlier in fast track with complaint of left shoulder pain that was thought to be muscular skeletal in nature. No imaging studies done, given dose of steroid and sent home with flexeril... When he returns 3 days later he is triaged as a level 4 and with C/C of "Muscle spasms". So now his actual complaint is left sided chest and back pain, and shortness of breath and cough that has been getting worse. Physical exam: Dyspneic, absent lung sounds on the left, hyper resonant on the left. Bed side ultrasound, no sliding of pleura on left. CXR: Immediate chest tube placement. Lung expanded very well. He is admitted and feels much better. Likely to be discharged soon. Lots of red flags with this patient, I'm glad he came back to the hospital in time before he had a bad outcome. 2 Quote Link to comment Share on other sites More sharing options...
delco714 Posted December 4, 2014 Share Posted December 4, 2014 You had me going on the track of a dissected thoracic aortic aneurysm! Quote Link to comment Share on other sites More sharing options...
winterallsummer Posted July 16, 2015 Share Posted July 16, 2015 Great fast track case the other day. Previously healthy, obese teenage female. Tachy at 112, otherwise VS normal. Complaining of rash on b/l palms of hands (petechia-like), "red rash" on face, emesis, and a couple falls. The RN tells me the rash on the face just looks like acne / acne scars. Was seen in the ED a week ago, sent home with anti-emetics, dx of viral syndrome. Went to PCP before coming to our ER this second time, had blood work done and sent home. Mom not happy with this, so shows up in our ER. Patient threw up some water, basic labs showed transaminitis, Cr around 1.5, thrombocytopenia, neutropenia, no anemia but possibly hemoconcentrated. Blood cx sent along with ANA. Sent out to peds, I did not tap the pt as I did not suspect an infectious etiology and the accepting doc was ok with this being deferred. Few days later (pt transferred out), blood cx return normal, ANA grossly positive. New onset lupus with likely pancytopenia and renal failure. Those were not acne scars, folks! 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 16, 2015 Author Moderator Share Posted July 16, 2015 Great fast track case the other day. Previously healthy, obese teenage female. Tachy at 112, otherwise VS normal. Complaining of rash on b/l palms of hands (petechia-like), "red rash" on face, emesis, and a couple falls. The RN tells me the rash on the face just looks like acne / acne scars. Was seen in the ED a week ago, sent home with anti-emetics, dx of viral syndrome. Went to PCP before coming to our ER this second time, had blood work done and sent home. Mom not happy with this, so shows up in our ER. Patient threw up some water, basic labs showed transaminitis, Cr around 1.5, thrombocytopenia, neutropenia, no anemia but possibly hemoconcentrated. Blood cx sent along with ANA. Sent out to peds, I did not tap the pt as I did not suspect an infectious etiology and the accepting doc was ok with this being deferred. Few days later (pt transferred out), blood cx return normal, ANA grossly positive. New onset lupus with likely pancytopenia and renal failure. Those were not acne scars, folks! pretty adv. lupus if they presented with renal failure... Quote Link to comment Share on other sites More sharing options...
winterallsummer Posted July 20, 2015 Share Posted July 20, 2015 pretty adv. lupus if they presented with renal failure... Agreed. Unfortunately it was missed in the ER a week ago and also arguably by the PCP that same day. She had emesis which may have contributed to her lupus nephropathy. A good case for us, but the patient has a potentially difficult life ahead. Quote Link to comment Share on other sites More sharing options...
spensj Posted August 25, 2015 Share Posted August 25, 2015 A "fasttrack" beauty last night. 30 yo arrived in the department after MVA. Was in a high speed head on collision. Airbag deployment.Wearing seatbelt. EMS reports patient was AMBULATORY on scene. C/o chest tightness, hip pain. Vitals signs: T98.3, P67, RR18, POx99RA. Etoh on board. Diminished breath sounds on R. No tracheal deviation. No respiratory distress.Pelvis feels stable. She's just hanging out in wheelchair looking very stoic. Order a CXR to eval for PTX and R hip w/pelvis. Try getting her to xray multiple times but she can't walk from wheelchair to xray table. Of course I got upset with her and informed her of the EMS report - She denied ever being able to walk - reports she was extricated from the car. Immediately get her on a bed and over to main ED with the help of multiple staff members - has 90% R sided PTX, After chest tube done, Pelvic XR shows multiple pelvic fractures. Doing well in the ICU. Lesson: listen to your patient once in a while :) - hopefully doesn't remember "the mean PA who tried to make me walk on multiple pelvic fractures." Triage RN was quite defensive about it. Remember, sometimes EMS reports can cause bias! 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 25, 2015 Author Moderator Share Posted August 25, 2015 A "fasttrack" beauty last night. 30 yo arrived in the department after MVA. Was in a high speed head on collision. Airbag deployment.Wearing seatbelt. EMS reports patient was AMBULATORY on scene. C/o chest tightness, hip pain. Vitals signs: T98.3, P67, RR18, POx99RA. Etoh on board. Diminished breath sounds on R. No tracheal deviation. No respiratory distress.Pelvis feels stable. She's just hanging out in wheelchair looking very stoic. Order a CXR to eval for PTX and R hip w/pelvis. Try getting her to xray multiple times but she can't walk from wheelchair to xray table. Of course I got upset with her and informed her of the EMS report - She denied ever being able to walk - reports she was extricated from the car. Immediately get her on a bed and over to main ED with the help of multiple staff members - has 90% R sided PTX, After chest tube done, Pelvic XR shows multiple pelvic fractures. Doing well in the ICU. Lesson: listen to your patient once in a while :) - hopefully doesn't remember "the mean PA who tried to make me walk on multiple pelvic fractures." Triage RN was quite defensive about it. Remember, sometimes EMS reports can cause bias! I'm guessing if you track down the ems report it doesn't say anything about the pt walking. you are just dealing with a lazy triage nurse who knows she will rotate back to main in 20 min and doesn't want to deal with another pt...more common that you think...main can be empty and they give every single pt to fast track and intermediate despite 2 hr waits....how does that make any sense? Quote Link to comment Share on other sites More sharing options...
RealityCheck Posted August 25, 2015 Share Posted August 25, 2015 One time look between patients at work - did not cheat or look at other posts................................. diabetic 50 yo m with "shoulder pain" -- MI85 year old htn male with atraumatic "neck pain" - hmmmm - vertebral fracture or impending vascular event30 yr old fe on o.c.'s with "blurry vision" - VTE, stroke75 year old male with worsening "leg pain" x weeks - spinal stenosis35 yr old fe with btl with "bad gas pains and dizzyness" - ectopic pregnancy17 year old fem with "yeast infection and fever" - PID18 yr old male iddm pt with" new onset asthma" - pneumonia50 yr old morbidly obese poorly controlled htn m with "heartburn" - MI again45 yr old fe "bleeding gums" - NSAIDs - not sure on this one22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v" - pregnant Quote Link to comment Share on other sites More sharing options...
FfIghter23 Posted August 31, 2015 Share Posted August 31, 2015 Not mine, but a PA colleague from this morning... CC: 9 y/o Sore throat for 3 hours woke up with it. Febrile, Tachy, but no tachypnea per nurse. Kid tripoding and drooling when PA enters room and mom playing on iPhone. In the OR within ten minutes and intubated (fairly difficult per ENT/anesthesia). Side note: up to date vaccinations including HiB. Quick gram stain of epiglottis reveals Strep pyogenes... It can happen to anyone. Quote Link to comment Share on other sites More sharing options...
RealityCheck Posted August 31, 2015 Share Posted August 31, 2015 I want to flush the parents' phones down the toilet!!!! If you can't do 24 hour dietary recall on a toddler but can tell me your high score or your Facebook status - we have a parenting problem. When I am seeing a teenager - I put my palm out and take the phone and place it face down on the cabinet in plain view. Most parents congratulate me. The others don't notice because they are playing Candy Crush................... I wish I had some device - jammer - in the room that would shut their phones down. I don't bring mine in the rooms at all unless I am semi-patiently awaiting a specialist to call me back about a same day emergency. Sheesh! 1 Quote Link to comment Share on other sites More sharing options...
sk732 Posted September 4, 2015 Share Posted September 4, 2015 Came on shift one morning - EMS had just brought some young guy in, had smashed into a tree 3 hours previously after being thrown from his snowmobile at about min 40mph. +MJ and EToH. NO collar...C/O (L) shoulder pain; nurse initiated XRay at triage for shoulder only. The off going Doc suggests I check the film - his scapula is in 2 pieces, 3 ribs fractured. Go to examine him, still no collar. Get one on, CSpine XRays were piss poor, so went to order a CT - I'd noted a tiny bit of guarding in the LUQ but no distention or ecchymosis and some lumbar tenderness. Still drunk and stoned. Labs came back - (N) Hb, but the LDH was pushing 1000, so wandered down to the nukes and switched the CSpine to a full trauma scan - several fractured ribs, a couple of vertebral body fractures and a contained Grade V splenic fracture later had him screaming off to the trauma centre. One of my SP's is the medical director for the Regional EMS - she got an ear full later that day when she came on...as did the paramedics shortly thereafter. Dude lucked out in that he had a nice hematoma formation containing the bleeding - the surgeons did watchful waiting with him for about a week. SK 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 4, 2015 Author Moderator Share Posted September 4, 2015 Came on shift one morning - EMS had just brought some young guy in, had smashed into a tree 3 hours previously after being thrown from his snowmobile at about min 40mph. +MJ and EToH. NO collar...C/O (L) shoulder pain; nurse initiated XRay at triage for shoulder only. The off going Doc suggests I check the film - his scapula is in 2 pieces, 3 ribs fractured. Go to examine him, still no collar. Get one on, CSpine XRays were piss poor, so went to order a CT - I'd noted a tiny bit of guarding in the LUQ but no distention or ecchymosis and some lumbar tenderness. Still drunk and stoned. Labs came back - (N) Hb, but the LDH was pushing 1000, so wandered down to the nukes and switched the CSpine to a full trauma scan - several fractured ribs, a couple of vertebral body fractures and a contained Grade V splenic fracture later had him screaming off to the trauma centre. One of my SP's is the medical director for the Regional EMS - she got an ear full later that day when she came on...as did the paramedics shortly thereafter. Dude lucked out in that he had a nice hematoma formation containing the bleeding - the surgeons did watchful waiting with him for about a week. SK STRONG WORK!. shoulder pain after trauma should always make one think about splenic injury (Kehr's sign/phrenic nerve irritation). 2 Quote Link to comment Share on other sites More sharing options...
sk732 Posted September 8, 2015 Share Posted September 8, 2015 Yes indeed...of course the fractured scapula wasn't helping that, lol. SK Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted September 9, 2015 Share Posted September 9, 2015 The old medic and ATLS person in me says bad mechanism of injury plus chemical impairment = pan-scan. Do other folks agree, or am I spoiled by my easy access to CT in my ED? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 9, 2015 Author Moderator Share Posted September 9, 2015 The old medic and ATLS person in me says bad mechanism of injury plus chemical impairment = pan-scan. Do other folks agree, or am I spoiled by my easy access to CT in my ED? yes and no. if the mechanism is clear cut (baseball bat to the head, witnessed) you don't really need to CT head to toenails, although many services do. I agree that if the mechanism is vague or has the potential for multiple injuries(rollover mva, assault by multiple assailants, etc) then pan-scan is a must. I had a pt with a bad bike accident over the weekend who we scanned head to pelvis because he was so altered he needed to be intubated and the event was unwitnessed. he was found down in a gas station bathroom, apparently trying to clean himself up. probably should have called 911 instead. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 9, 2015 Author Moderator Share Posted September 9, 2015 Yes indeed...of course the fractured scapula wasn't helping that, lol. SK agree- although it's amazing how folks blow this off. I had a guy I transferred recently based on mechanism (fell off motorcycle at high speed, c/o chest pain) who had a large L scapular fx on cxr. Didn't even bother to get the CT, just sent him because I figured he would need a huge trauma work up, trip to the OR, etc and I didn't have a surgeon immediately available. A scapular fx implies a high energy impact with concerns for vascular injury, etc in my mind Receiving doc at trauma ctr took him off backboard. gave him pain meds, looked at my plain film and sent the guy home without a CT, still complaining of pain and tachycardic, with a dx of "uncomplicated scapular fx". glad I didn't sign that d/c. I would have scanned his entire spine, chest, and pelvis. don't know what ended up happening to him after that. may have bled out in the back seat of his buddy's car going home for all I know. Quote Link to comment Share on other sites More sharing options...
fakingpatience Posted September 13, 2015 Share Posted September 13, 2015 Receiving doc at trauma ctr took him off backboard. Out of curiosity, what was your rational for sending the patient out for transport still on a backboard? Many of the more progressive EMS systems around the nation are moving away from using backboards entirely, in favor of c-collar and securing the patient directly to the stretcher, even when spinal injury is suspected/ possible. Here is a link to the position statement by NAEMSP http://www.naemsp.org/Documents/Position%20Papers/POSITION%20EMS%20Spinal%20Precautions%20and%20the%20Use%20of%20the%20Long%20Backboard.pdf Quote Link to comment Share on other sites More sharing options...
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