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"it's probably nothing"-fast track disasters


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he he good one angle, my point is that so many professionals saw this woman over three days--they actually kapt feeding her. Are these people stupid? Lazy? Ignorant? BLIND? did they simply not care? Was it the MR? Was it poor and black?

 

My own nurses gave up on the vitals and sent her to waiting. This woman was near death. Oh, and how long was she vertually anoxic? How do you quantify that as she was severly retarded to begin with?

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...my point is that so many professionals saw this woman over three days--they actually kept feeding her. Are these people stupid? Lazy? Ignorant? BLIND? did they simply not care? Was it the MR? Was it poor and black? ....

I go with "lazy and did not care" attitude. What a disservice to those truly in need.

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sorta makes you wonder HOW she became mentally challenged in the first place...cerebral hypoxia ignored as a consequence of prolonged birth, aspiration as kid, szs..medication overdose.

the medical community certainly failed her.

 

there is no crime in looking, but not "seeing".

 

there is plenty of guilt in not looking.

 

nice job on your part, bandit

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follow up to post #21

just heard from floor nurse that this guy ended up dying after going in and out of the o.r./icu over the course of a week or so.....so much for the probable recovery anticipated by the surgeon. apparently his gut just never recovered. lots of blood loss, ischemic bowel, "partial autodigestion by his own enzymatic processes"......end point was sepsis with prolonged hypotension leading to death.....young kid too...should have come in day 1......waited because he didn't have insurance.....

 

bandit-good to have you back-let us know how school is going......I haven't completely ruled out going yet and if you are breezing through that might make my eventual decision easier.....of course a 3 yr bridge without required mcats would make it a no brainer.....

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Guest yodau2

If you hear hoofbeats.......... is it a horse or a zebra........ or any number of hoofed creatures???

I like hearing about those zebras in horse suits cases....... it keeps us all thinking.

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  • 1 month later...
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high school football player still in pads(no helmet in er) sent to fast track for l shoulder pain after being speared to l side of chest with another players helmet minutes prior to arrival.

rn orders for cxr and l shoulder film attatched. no labs. no iv.

O: diaphoretic clutching l chest and abd, obvious distress

bp 110/70 p 120 r 24 sao2 100% temp not taken

heent: ncat

neck supple, nt

lungs clear with stable, nt chest wall

cv tachy, otherwise nl

abd: rigid, tender throughout with max tendersness to luq

ext: l shoulder : no deformity, full rom, clavicle nl

pelvis stable, nt

 

er course: transfer to acute/trauma side of dept as walk in trauma activation.2 iv's. trauma lab panel. fast u/s exam "nl." proceed to ct for high suspicion of injury. spleen is bisected with a 1 cm gap between the superior and inferior portion. direct to o.r. with trauma team.

 

rn after the fact : "thought it was a rib fx, fx clavicle, or shoulder dislocation"

 

take home message: don't believe the triage note.review the mechanism, look at the pt, their vital signs, pertinent trauma exam findings and make up your own mind. this guy was a trauma activation from across the room before looking at the chart or examining him.

fyi l shoulder pain resulted fron irritation of the diaphragm (presumably from blood) transmitted as a "pain signal " along the phrenic nerve as radiated pain into the shoulder. common with spleen injuries.known as kehr's sign.

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e:

are your triage nurses also experienced ED/Trauma nurses?

This is a bothersome triaging.

depends on the day of the week. sometimes they are top notch, other days they are agency new grads who were unit secretaries the week previous. we have something like 5-7 full time er rn jobs posted all the time. holes filled with agency rn's until jobs filled.....

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which serves (again) as a reminder to all of us: beware the slippery slope of "triaged minor ergo not sick" process. I try to avoid ALL triage comments except vitals until I have asked the patient what the problem is.

 

Which brings me to another observation:

 

if your hospitals are like mine: do you realize just how many times the patient has to repeat his complaint?

 

1. Enters hospital, meets greeter who asks "what is general nature of problem" (eg foot pain, chest pain, etc..-to enable some automatic "bring to the back immediately" processes.

 

2. Seen by the triage nurse: who sorts and goes thru some screening questions (TB, domestic risks, depression screens, etc)

 

3. Brought to ED. Met by receiving nurse who does more thorough Nursing assessment (to include almost complete medical ROS)

 

4. Seen by administration/registration: who (per insurance forms) ask: "what are you here for today? and "when did this happen? "" how bad is the pain?"

 

5. Then , finally, some hapless MD/PA walks in and asks: hey, what can I help you with today?"

To which the standard patient thinks (if not replies) "why are not you people communicating with each other," and "I have just told 4 other people this story" .

 

IMHO: I think that the detailed questioning should STOP after the greeter at best, primary triage nurse at worse...let me be responsible for my own history taking...

 

All I want from triage is vitals and 5 word chief complaint.

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RCdavis wrote:

All I want from triage is vitals and 5 word chief complaint.

 

Agree with rc... especially since you have to do it anyway...

because it is just "prudent" to do your own exam and gather all "pertinent" info yourself... since your name will be forever attached to the outcome...

 

DocNusum

 

recently had to go to the ED...kidney stones (MSK)... I had to tell my story to 4 people... the the MD comes in and says... Hi... your one of the Cardio PAs right... tell me why you are here...

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  • 5 months later...

The pt with a hx of asthma who presents for "acute asthma" and who ISN'T wheezing is much scarier than the asthmatic who IS wheezing.

 

Not a good time to assume that tachycardia is due to anxiety, and that tachypnea is just hyperventilation because the pt is a fruit loop. And while SpO2 is not the most accurate tool, don't completely blow off 88%. And just because they are young and otherwise healthy doesn't mean they are stable enough to sit in the waiting room for 2.5 hours.....

 

Especially if the pt has a history of multiple hospitalizations for asthma and says "I never had a breathing tube, but they talked about it a lot the last several times I was in the ICU for my asthma"

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...

 

All I want from triage is vitals and 5 word chief complaint.

 

Wow you need to work at my ED. This is all we are allowed to write down. If they are triaged 4 or 5 (5 tier system) they do not get vitals, do to the fact that or ED doc wants to get away from the funnel of triage and get them straight back. So as you would expect you get poor placement of pts to the fast track. Time to doc has dropped to 20min or less from arrival and the pts know this so are numbers have increased!

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...

 

All I want from triage is vitals and 5 word chief complaint.

 

Wow you need to work at my ED. This is all we are allowed to write down. If they are triaged 4 or 5 (5 tier system) they do not get vitals, do to the fact that or ED doc wants to get away from the funnel of triage and get them straight back. So as you would expect you get poor placement of pts to the fast track. Time to doc has dropped to 20min or less from arrival and the pts know this so are numbers have increased!

but don't you miss worrisome little trivialities(read sarcasm here) like a bp of 70/40 with a hr of 156 and an 02 sat of 72%...you need the vital signs in order to triage correctly....that is why they are called vital......."I feel dizzy" with a hr of 175( or 22 like a pt I had last week) is a lot different than "I feel dizzy" with a hr of 60......

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you need the vital signs in order to triage correctly....that is why they are called vital

 

Agreed! But tell that to the ED med director... All children get wts/ temp. If rooms/chairs full then vitals and assesments done before wait in lobby. If not brought straight back for PA/doc to start the ball rolling. I have had some nice discussions of how fast and easily vitals can be done, but the that always leads to "the pt didnt come to see a RN or registration, they came to see a doc". When he isnt there the tech vitals everyone at triage! :)

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Guest zulu62

right ureteral colic Imaged day before, sent back home to pass the stone.

"it still hurts" the next day. Re-eval: appendicitis besides the stone now.

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right ureteral colic Imaged day before, sent back home to pass the stone.

"it still hurts" the next day. Re-eval: appendicitis besides the stone now.

 

COOL- I had a pt with concurrent r pyelo and cholecystitis. I saw them day 2. the prior provider had tx for pyelo and disregarded anterior tenderness.

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  • 1 month later...

29yo mildly overwieght female smoker presents with "back pain" for one week. Had been to PCP and was Dxd with a back strain. She went to her chiropractor 3 times over the course of the week without improvement. Vitals 142/78, 84, 20, spo2 97%

PMHx-- neg, FmHx- denied

When queried, she states that the pain is intermittent--comes and goes 20mins at a time regardless of position or activity. She states that the pain is now staying longer -- now 2 hrs. I asked if the pain went elswhere-- she said "yeah, sometimes it comes through to my chest."

That was enough for me-- EKG (I almost soiled myself) tombstone ST elevation with reciprocal changes. Sent to cath lab within 20 min.= 99% occlusion of the LAD

Patient was put into quick care, although I don't fault triage--given her complaint of "back pain"

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29yo mildly overwieght female smoker presents with "back pain" for one week. Had been to PCP and was Dxd with a back strain. She went to her chiropractor 3 times over the course of the week without improvement. Vitals 142/78, 84, 20, spo2 97%

PMHx-- neg, FmHx- denied

When queried, she states that the pain is intermittent--comes and goes 20mins at a time regardless of position or activity. She states that the pain is now staying longer -- now 2 hrs. I asked if the pain went elswhere-- she said "yeah, sometimes it comes through to my chest."

That was enough for me-- EKG (I almost soiled myself) tombstone ST elevation with reciprocal changes. Sent to cath lab within 20 min.= 99% occlusion of the LAD

Patient was put into quick care, although I don't fault triage--given her complaint of "back pain"

wow...29?...had a similar pt in her early 20's with inferior changes but she had some help from meth and cocaine...clean arteries on cath...just lots of vasospasm.....

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  • 2 months later...
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40 yr old asian male sent in by pcp for "eval l leg cellulitis vs dvt" x 2 days

also complains of constant fatigue and h/a's for a few months

pmh none

sh no smoke/etoh/recreational drugs

vs nl

exam l leg cellulitis vs dvt: u/s shows superficial thrombophlebitis....

d-dimer 3200(nl less than 500)

cbc: wbc = 90,000 with 70% blasts.....acute leukemia.....admitted to oncology for further eval and workup.....

head ct neg(ordered to r/o bleed or possible primary or metastatic lesion)

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Just browsing thru the past posts. EMEDPA, any more thoughts for the CT abd/pelvis for appy/diverticulitis? Most of these studies done in our ED are with IV only, except for peds appy, which gets oral and IV (nobody gets rectal). Which is acceptable most of the time and the wait times are shorter, especially from a providers standpoint. From a RAD standpoint, the images are night and day difference.

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Just browsing thru the past posts. EMEDPA, any more thoughts for the CT abd/pelvis for appy/diverticulitis? Most of these studies done in our ED are with IV only, except for peds appy, which gets oral and IV (nobody gets rectal). Which is acceptable most of the time and the wait times are shorter, especially from a providers standpoint. From a RAD standpoint, the images are night and day difference.

 

I work at a few places. at one everyone gets triple contrast po/iv/rectal done as a 1 hr oral prep study. at another place they do double contrast po/iv; 2 hrs for appy, 3 hrs for diverticulitis. can't say the 3 hr study looks any better than the 1 hr prep triple contrast.....

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  • 2 weeks later...
Guest pac4hire

HERE IS A GOOD ONE GUYS....I caught this at an Urgent Care Center today.

 

81 y/o white female presents with Nausea and vommiting x 2 days. She denies any Diarrhea, flatus fever or appetite for 4 days. States her belly has relly began to hurt over the last 4 hours. She has a pass medical history of HTN, Hypothyroid and GERD. No surgical Hx. Lives with son and wife who are known to me and are good caretakers. He is a Rabbi. she a school teacher.

 

 

Exam found an ill appearing 81 y/o woman with poor skin turger, dry mucous membranes.

 

HEENT Dry tongue, otherwise nl

CV tachy but regular, no MRG

Lungs: CTA no resp distress

Abd: large distention of lower Abd. Gaurding, TTP absent Bowel sounds.

Remainder of exam Nl.

 

 

CBC, CMP could not get results till tomorow so i did not bother I assumer I was sending her to Hospital for admission to R/O SBO vs Bowel Ischemia

KUB shows large abnormality in pelvis

CT with minimal PO contrast ( have mobile scanner onsite) and rectal contrast ( did not use IV b/c of no BUN or Creat in an 81 y/o)

results: a 9.5 CM pancreatic MAss in the Head and proximal Body with a LARGE gallbladder that extends into the PELVIS. I HAD NEVER SEEN A GB THIS LARGE BEFORE!!!!!!!

 

 

Surgeon called, she was admitted and Perc Drainage of tumor/GB by IR completed.....METS CA with Stricture.

 

POOR LADY ( WHY DID SHE COME TO AN URGENT CARE WITH THIS?)

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