"it's probably nothing"-fast track disasters

[EMEDPA]

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  

he was in my dept all of 5 min. I started the exam, got some lines, cleared his neck with plain films and removed his collar, then saw this huge scapular fx. didn't even do the pelvis view to finish the trauma series. just grabbed the medics and said": uh guys, this guy came to the wrong place" and shipped him to our local trauma ctr. he was actually much more comfortable on his padded backboard with blankets than he would have been off because of the nature of his fx. any movement caused a lot of pain. I tend not to board too many folks any more and get them off the boards fairly quickly, but this guy  just needed to be gone to a place with a surgeon and was relatively comfortable on the board, so I just got him on his way.

[fakingpatience]

he was in my dept all of 5 min. I started the exam, got some lines, cleared his neck with plain films and removed his collar, then saw this huge scapular fx. didn't even do the pelvis view to finish the trauma series. just grabbed the medics and said": uh guys, this guy came to the wrong place" and shipped him to our local trauma ctr. he was actually much more comfortable on his padded backboard with blankets than he would have been off because of the nature of his fx. any movement caused a lot of pain. I tend not to board too many folks any more and get them off the boards fairly quickly, but this guy  just needed to be gone to a place with a surgeon and was relatively comfortable on the board, so I just got him on his way.

 

Thanks for the explanation, thats great that they were able to pad the backboard so well he was comfortable there.  I was just curious since backboards seem to be one of those holdovers that many older/ stubborn providers still use simply "because this is the way we've always done it," regardless of the research, but you didn't strike me as that type. 

[sammedic]

Hey all. I laugh at these cases because with a change of age here or there they could all be my patient's. One of my more recent FT wonders: 80 something f,diabetic, PVD, cc "foot pain", nursing never looked at her foot. Long story short, admitted for SIRS/sepsis from raging bilateral lower leg cellulitis, oh yeah not to mention the new DVT in the R leg.

 

Everyone has similar stories, I have been trying to research triage guidelines to improve our system. We have discussed things like absolute age cut off (?85) and "soft" cut off of 65-70 if obvious minor extremity injury, etc. Anyone have any other suggestions or know any resources that might have some help? I can't seem to find anything from ACEP.

[sk732]

Was working ER last night and as my shift was in the later portions and we were getting slammed with no rooms, I went to our minor tmt area to take in some of the allegedly minor things.  Got a CTAS 4 (minor issue, 5 being an eye roller and 1 being a resus) abd pain.  Triage nurse wrote a terse note and likely didn't lay hands on her and drew no labs despite RN initiated protocols. 58 yo lady, generally healthy, increasing ® sided abd pain x 2/7.  Some anorexia, no fever, (+) constipation followed by what sounded like some over flow diarrhea, no bloody or melena stool, no dysuria or hematuria, some nausea without vomiting.  No prior surgeries.  AVS(N), decreased BS, (+) rectus push, hip shake, McBurney and psoas.  WBC 20.6 < shift and (N) chems, extended lytes and LFT's.  AXR showed fecal loading in descending colon and what appeared to be an egg shaped, large, calcified something that I took to be the GB  low in the RUQ.  I walked straight to the rad on call to get a CT and they started to seriously snivel...attached is a pic of the CT.  Due to the pic being too large, I shrunk down a lot...this is the gallbladder though and on CT it measured 15cm in length and the alien life form inside of it was about 4-5cm in diameter. 

[sk732]

Addendum to above - the surgical PA from our OR showed me a pic of the GB when it came out...15cm long and the stone was 7.5cm long by 3.5 cm wide/diameter.

 

OUCH.

 

SK

[bjmcell]

My second week working in fast track after taking the PANCE. 45 year old morbidly obese female who smokes and is on OCP's presents to triage. She speaks very broken english presents with "knee pain" with no history of trauma. Triage nurse quickly writes down the first thing that she can understand from the patient....."Pain in the back of my knee" and she orders a knee x-ray from triage. But she but did not wait to hear the rest of the pts' sentence...."that goes down my calf. It started on my flight back from Mexico."

[Nonlegit]

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 know this is an older post but it made me think about something I've been trying to be "zen" about recently. I get irritated at the weak traumas that get called mainly on criteria alone, but try to keep on my toes as...this is the result you don't want to have.

 

That lady meets trauma criteria even with the report of ambulation at the scene, much less triaged to fast track.

[PA-S Zoidberg]

Back when I was scribing in the ED I was working a fast track shift. 

 

Patient is a 54 year old male who presents four hours status post fall on ice at the top of his driveway. He reports a high velocity strike to the front of his head on the pavement with associated lac which he dressed himself. Patient presents via personal vehicle. 

 

Triage did not bother to soak and remove the bandage (which had plastered to his scalp). After the tech removes the dressing and irrigates the area following initial evaluation it appears he has a pretty deep lac. Some time into the encounter (prob total two hours from front door) he begins to complain of some dizziness and my doc notes some clear drainage from his nares. CT ordered and behind door number 2 we found multiple open skull fractures!

 

I though this was remarkable not just for the "we never looked" perspective but also the murky "sick vs not sick" impression that he put out (on that note I once saw a doc in the low acuity ED do full drawer/lachman's tests on a guy who fell off a porch after working on his deck while 'having a couple' prior to ordering the XR which revealed a full proximal tib fib, needless to say all the tests were positive for instability, odd that he wasn't jumping off the table. Later come to find that by 'a couple' he meant an 18 rack)

[RuralEDPA]

New Grad 3 months out working in Rural ER fast track.

Few days ago my first patient of the day was a 55 YO male with "cough and cold symptoms in dialysis patient" from triage. After walking into the room and seeing the patient came out and told my nurse that it was going to be one of those days. 

Start history realize this is a ESRD patient due to wegeners. Came in today because he feels "weak" and had an episode of SOB yesterday at rest along with non-productive cough, otherwise ROS cardiac and pulmonary negative. Last Dialysis was two days previously.

Vitals Signs Tachy at 109, BP 136/90, afebrile

Physical: Bibasilar crackles, No Peripheral Edema

EKG shows T wave inversion in anterior-lateral leads (new from previous)

CXRAY with my wet read (no radiology on weekends or night) stated compared to XRAY 5 months ago patient has increased pulmonary vasuclater and cardiomegaly (suspicious for CHF). 

 

CBC:WNL

CMP: elevated CR but not off of patients baseline, hyperkalemia

BNP: 800

Trop: not elevated (which honestly surprised me in an ESRD and ischemic changes on EKG)

 

Cough and cold symptoms--> New onset CHF and Ischemic EKG changes complicated by Hyperkalemia in ESRD patient.

 

 

-Same day had a 45 Y/O female with monoarthopathy, Febrile, triage note "requesting pain meds"... It was septic knee.

 

-Next day had a "wound check" that was previously septic elecronon bursitis S/P bursectomy. If only triage had looked at the bandage they would have seen that it was soaked in pus. Elevated HR, BP stable, BUT LA elevated with elevated WBC. After opening one of the stitches puss drained out and on exam fluctuanes went all the way up into the head of the triceps.

 

My new favorite Triage this last month has been "asthma exacerbation"  O2 stat no were to be found.........

[ohiovolffemtp]

One of the most important pieces of data on the triage note is the name of the person doing it.  That alone tells you lots about the quality of the information.

[MrsGPAC]

Wasn't a fast track case (but common fast track complaint).  Had a woman come in via EMS for "migraine x 24 hours" last night.  Typical migraine, typical aura, typical N/V.  No fever, no recent cold symptoms, urinary symptoms, abdominal symptoms.  No trauma.  Has had 3 episodes of vomiting in 24 hours.  Hasn't had a migraine in a while so doesn't have any abortive meds at home. BS at home have been "really good...between 150 and 180" for the last week or so (since discharge)

 

PMH of DM, CAD etc.  Brittle diabetic with multiple admissions for DKA.  In fact, in the past 6 months has had 8 or 9 admits.  Has not ever been discharged from the ED when she has come in.  Various presenting complaints--some "DKA", some "toe pain".  

 

EMS finger stick was 61.  They weren't able to get access so they tried oral glucose, which she spit out (not vomited per EMS) immediately.  No AMS. 

 

Shows up with no access and is a horrific stick--for who knows why, still doesn't have a port.  Neurologically intact, normal exam.  No fever, neck pain/stiffness.  ODT zofran given while trying to get access. She declined IM meds.

 

Once we get labs drawn (really only because of her low BS and history--I don't always get labs on migraines) and toradol/compazine/benadryl in she is not any better.  On ativan prn and says this often helps her headaches so this is given to her with some relief.  Does not want narcotics--history of polysubstance abuse.

 

Labs come back and BS 130.  Bicarb of 12.  Repeat FSBS at that point (30 min later) is 493.  Betahydroxy and VBG are ordered but because of her lack of access, pretty delayed.  She does have a midline on the other side and able to get fluids.  Flight guys finally got an EJ in her and these were drawn. 

 

Meanwhile she is getting more agitated, tachycardia to 145, tachypneic and Kussmaul breathing.  (In a matter of 45 min I think) VBG shows pH of 7.02 with bicarb of 6, glucose of 697.  K+ 5.3, Betahydroxy 5.6.  Lactate 2.4.  Insulin drip started with NS with q15 sugars.  These eventually go down to 215 but once she is switched to D5NS, jump back up to 600 pretty quickly.  

 

Anyway, ON insulin drip x 2h with 5 liters in, drops pH to 6.99 with bicarb < 5.  K+ still fine.  Lactate 4.5.  No ICU beds (but the intensivist was nice enough to see her and give recommendations--while he was down seeing a pt with a K+ of 8.5 with a sine wave--also cool).  The floor won't touch her so managed her in the ER for quite a while.  Had 3 amps of bicarb and 7-8 total liters of fluids.   

 

CXR, urine, EKG all normal.  

 

 

Ever seen someone come in hypoglycemic and go to the ICU for DKA with presenting complaint of "typical" migraine?? Super interesting case.  Thank goodness the usual migraine meds failed and her lack of vascular access slowed everything down.  High likelihood she'd have gone home and ended up in DKA there.  

[MrsGPAC]

CC: Shoulder pain

"Fell off snowmobile "at low speed"

PT: "My shoulder hurts and my collarbone is broken but my back hurts a lot worse--near my shoulder blade"

Otherwise stable, stable vitals.  Looks REALLY uncomfortable and you know this dude is tough. 

Comminuted clavicle fracture (knew that on exam)

CXR shows huge pneumo with blunting of costophrenic angle so likely hemopneumo

CT with 90% pneumo/small hemo component.  

In fast track (well, what we call PIT).  

Our triage situation is dire.  We are going to kill someone.  I have been screaming from the rooftops for years on deaf ears.  Anyone else been able to make headway on this at your shop? I gave my notice here today so ultimately my days are numbered, but this is my community and it terrifies me.  

[sk732]

Had something similar a few years back - doper hit a tree at 40mph snowmobiling (sled was going that fast and tossed him), found by EMS wandering, stoned on weed and c/o shoulder pain and a bit of  back pain.  No collar or board.  Fractured ribs and scapula - on XRays ordered by triage nurse without a real exam and based solely on C/C omitting circumstances surrounding; dude's got faint guarding in LUQ that worsens on reassessment and lumbar tenderness on exam while still stoned; labs showing something goofy so got a trauma CAP and Spine CT, which revealed a Grade V splenic lac (thankfully with contained hematoma) and L2-3 process #'s.  Trauma transfer not a good way to start morning...well it is, but not one so convoluted and messed up.  It's what happens when people are toasted, think they know everything or are just plain complacent...and can cause immeasurable grief.

SK

 

 

[MrsGPAC]

1 hour ago, sk732 said:

Had something similar a few years back - doper hit a tree at 40mph snowmobiling (sled was going that fast and tossed him), found by EMS wandering, stoned on weed and c/o shoulder pain and a bit of  back pain.  No collar or board.  Fractured ribs and scapula - on XRays ordered by triage nurse without a real exam and based solely on C/C omitting circumstances surrounding; dude's got faint guarding in LUQ that worsens on reassessment and lumbar tenderness on exam while still stoned; labs showing something goofy so got a trauma CAP and Spine CT, which revealed a Grade V splenic lac (thankfully with contained hematoma) and L2-3 process #'s.  Trauma transfer not a good way to start morning...well it is, but not one so convoluted and messed up.  It's what happens when people are toasted, think they know everything or are just plain complacent...and can cause immeasurable grief.

SK

 

 

Seriously.  This place is out of control.  Came in the other day to a pt 80/50 BP tachy to 140, 24 rpm who had been sitting in an empty pod FOR AN HOUR with no provider and no nurse.  Charge tells me "I've been keeping a close eye...blah blah blah".  My response is "it makes me really nervous for these patients to sit back here..."  Charge "well there are sick patients up front.  I put in the dehydration protocol".  I go in, the patient isn't on the monitor is basically just shy of extremis and the "dehydration protocol" (cbc/bmp) that was put in has not been drawn...  Patient with pancreatitis in DKA (new onset DM...A1c late Nov 5.1. Anion gap of 34, bicarb <5.  This particular pod is supposed to be 3's and soft 2's....  I've admitted more patients to the unit out of this place (in the 3 months we have used this system) than I have in 3.5 years here.  Oy.  I'm nearly bald now....

[sk732]

Seriously.  This place is out of control.  Came in the other day to a pt 80/50 BP tachy to 140, 24 rpm who had been sitting in an empty pod FOR AN HOUR with no provider and no nurse.  Charge tells me "I've been keeping a close eye...blah blah blah".  My response is "it makes me really nervous for these patients to sit back here..."  Charge "well there are sick patients up front.  I put in the dehydration protocol".  I go in, the patient isn't on the monitor is basically just shy of extremis and the "dehydration protocol" (cbc/bmp) that was put in has not been drawn...  Patient with pancreatitis in DKA (new onset DM...A1c late Nov 5.1. Anion gap of 34, bicarb

You need some violence therapy...like on “What About Bob?”, lol.


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[MrsGPAC]

8 minutes ago, sk732 said:

 

You need some violence therapy...like on “What About Bob?”, lol.


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Ha! Yes.  My resignation therapy (as of yesterday) is helping some.  I mean, for me.  :-)

[MrsGPAC]

CC: Flu

60 something female no medical care for years with cold symptoms (ST, runny nose) that have resolved.  Why she is really here is a rash and general weakness.  Rash started 6 months ago, weakness 4 months ago and worsening.  SOB x 2 months.  

Mildly tachy at 115, vitals otherwise stable.  Diminished lung sounds at the bases.  Her "rash"... her left breast is basically gone--no visible areola.  Open weeping wound with serosanguinous drainage.  Right breast is on its way to the same.  She has a massive fungating lesion from her sternal notch to umbilicus. Non-tender.  She also had some unilateral leg swelling

CTA shows multiple bony mets, liver mets, bilateral large pleural effusions

So yeah, metastatic breast cancer dx...in fast track

Hospitalists also noted 60 lb weight loss over the last several months (I never even asked...the diagnosis was pretty clear).  Malignant pleural effusions, adeno suspicious for breast primary on liver bx.  

Heartbreaking case.

 

[CJMO]

My first Fast Track patient EVER was a high speed mvc, unrestrained driver, +LOC, delayed ED presentation, with neck/back/shoulder and chest pain. Dx: C3 fx, T5 fx.

Triaged as a drug seeker because he had dingy clothes on and meth mouth. Clearly you could see signs of trauma (Abrasions on extremities and head, dried blood, etc). Plus the guy couldn't turn his neck at all.

Lmao. I'll never forget that.

[Eastcoast PA-C]

Both fairly recent
#1: 82F, belted passenger in MVC about 40 mph with “chest pain where the seatbelt was”. 9 broken ribs and a small bowel contusion and pressures in the 90s by the time transport to the trauma center arrived.

#2: “Left big toe pain” in a 50-something male. No pulses in the foot and “oh, I forgot to tell the nurse that my fem-pop was on that side.” Heparin and shipped to the nearest vascular surgeon an hour away.


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[Apriori]

Newer PA here, 2 months into EM. My favorite "fast track" patients so far:

1) 30 year old female. Triage RN puts in CC as "UTI complaints". When asked why she came to the ED,  she replies, "well I've been having really severe stomach pain that goes into my back and today I noticed blood in the toilet".  Ruptured ectopic.

2) 89 year old female with CC of back pain and inability to walk. Epidural abscess with compression.

3) 70 year old female with neck pain s/p "minor" MVC. Triage RN tells me, "She's being dramatic. She has a history of anxiety. She's fine". Multiple cervical fractures. 

I get a ton of patients that I don't feel are appropriate for fast track but I don't have the power to move patients to the main side. The attending has to agree to move them over and in most cases they don't want to because it means more work for them. Truly makes me want to jump ship...scared I'll miss something at this rate.

[ohiovolffemtp]

Could you present each of the fast track patients you're worried about to the attending?  Standard presentation:  age, gender, relevant hx /mechanism of injury , s/s, and exam findings.  Then "I'm worried about A, B, C and am doing X, Y, Z to evaluate for that.  Is there anything else I should do?  Would you like to see the patient with me?"  That way you can chart that you discussed the patient with the attending, including charting what you said to them.  Hopefully, even if they don't want to transfer the patient to the main ED, they'll help guide your workup.

[GetMeOuttaThisMess]

On 9/13/2015 at 11:11 PM, fakingpatience said:

 

Thanks for the explanation, thats great that they were able to pad the backboard so well he was comfortable there.  I was just curious since backboards seem to be one of those holdovers that many older/ stubborn providers still use simply "because this is the way we've always done it," regardless of the research, but you didn't strike me as that type. 

I would go so far as to say that they can be beneficial for extrication purposes on site and since they're on the backboard and now easily movable from stretcher in the box to stretcher in the ED, why not leave them on it (EMS perspective)?  I used to be the same way during my ED time.  Ambulatory on scene?  Yes?  Any other distracting injury?  No.  "Here's your board guys." as they were rolling the stretcher out of the room toward the unit.  Same with c-collars.  No step-off on palpation or pinpoint tenderness over spine and ambulatory?  Here's your collar as well.

[karebear12892]

Recently encountered my first "it's probably nothing" fast-track disaster as a practicing PA in a rural Southeastern community hospital. 

29 day old (delivered at 37 weeks) with reported chief complaint of "constipation." 

Saw on the tracker that the patient was afebrile and initially thought about picking up the chart, but my experience with neonates as a new grad is limited at best, and given that it was only my 3rd day of work, decided to pick up another chart and let the more seasoned provider handle this one. 

Thank goodness I did. His Na+ was 110. Turns out the parents were heavily diluting his formula and the child was H2O toxic. Ended up transferred to tertiary care center 30 miles away. 

Edited May 25, 2019 by karebear12892

[SB23]

Recently saw a 9mo with “nausea and vomiting” in fast track ESI level 4. Turns out the kid rolled off the bed, landed on the hardwoods and then developed nausea, vomiting and was “acting sleepy.” Well CT showed a large epidural bleed with shift. Had to send her out via helicopter to a children’s hospital.  

[EMEDPA]

one year old infant Bounce back yesterday, previously seen at another facility and dx as conjunctivitis. Funny, but I didn't think conjunctivitis involved vesicles all over the lids and periorbital area. Transferred emergently to peds ophtho at peds tertiary care hospital. Currently in ICU undergoing workup for disseminated herpetic infection +/- encephalitis. So Far LPs, blood cultures, etc done. Peds anticipates minimum 2 weeks inpt...