"it's probably nothing"-fast track disasters

[medic25]

ah, triage...last week had a guy with new onset dm with dka. kusmaul resps around 60/min, blood sugar 696, ph 7.0, real case...triage note..."cold sx for 2 days with cough......."

 

Yes, the infamous "cold/flu sx"; triage's old fallback for anything they want to dump on urgent care. Flu symptoms cover everything from DKA to meningitis to AMI. I sometimes think triage is actually a French word for incompetent.....

[EMEDPA]

Yes, the infamous "cold/flu sx"; triage's old fallback for anything they want to dump on urgent care. Flu symptoms cover everything from DKA to meningitis to AMI. I sometimes think triage is actually a French word for incompetent.....

actually triage is the french word for "random assignment".....:D

[EMEDPA]

back to back:

 

triage note: "uri sx"

actual: elderly, febrile, stiff neck, fever, wbc=19,000, k=2.0.harrington rods and scoliosis so very tough LP...

 

#2

triage note:"cut on foot"

actual: significant cellulitis with multiple necrotic ulcerations in pt with adv peripheral vascular disease and renal failure, still smokes, no peripheral pulses, cold insensate foot(minimal arterial flow by u/s), s/p (failed) fem-pop bypass

[cdavis1409]

back to back:

 

triage note: "uri sx"

actual: elderly, febrile, stiff neck, fever, wbc=19,000, k=2.0.harrington rods and scoliosis so very tough LP...

 

#2

triage note:"cut on foot"

actual: significant cellulitis with multiple necrotic ulcerations in pt with adv peripheral vascular disease and renal failure, still smokes, no peripheral pulses, cold insensate foot(minimal arterial flow by u/s), s/p (failed) fem-pop bypass

 

 

EMEDPA,

 

Do you have the option to refer to Int. Rad. for difficult LP's? I receive them on at least a weekly basis and it makes it much kinder on the patient to do them under fluoro. Plus it frees up at least an hour for you.

 

CD

[EMEDPA]

EMEDPA,

 

Do you have the option to refer to Int. Rad. for difficult LP's? I receive them on at least a weekly basis and it makes it much kinder on the patient to do them under fluoro. Plus it frees up at least an hour for you.

 

CD

 

we do have this option but they like for us to try before we call them....

[ddrumm117]

I can now say i have been bit by the mistriage bug as well. I no longer trust ear pain triages. First case 62 year old female triage states left ear pain sent to fast track. patient spoke spanish, I don't asked her what's wrong she motioned to her left side of head and ears and says it hurts, got interpreter, turns out this patient is having left sided headache h/o b/l breast Ca, benign brain tumor removed in 1996, headache is same as pain she had with tumor. headache associated with dizziness, nausea. CT neg but admitted for MRI in morning, neuro consulted.

 

next patient, 58 year old female with ear pain, she doesn't speak english either, interpreted story reveals headache x 2 weeks with neck stiffness, dizziness no nausea, vommitting, blurred vision but BP 220/118. transfered her to Ed after ordering CT, atenolol 100mg (she was already on atenolol and missed her dosage). fast track closes at 11pm so don't know what happened after I left ct was still pending.

 

Note: These triages were all from the same nurse, both spoke spanish and motioned to the temporal region and ear. guess the nurse thought she was communicating well enough to triage the patient although this nurse doesn't speak spanish except for name, date of birth and how long.

[CAdamsPAC]

After reading and living these Triage nightmares, can anyone tell me if management has taken any action to address Triage Nurse incompetence/ignorance?

[EMEDPA]

After reading and living these Triage nightmares, can anyone tell me if management has taken any action to address Triage Nurse incompetence/ignorance?

 

 

nope,the nurses are too empowered. if the manager of the dept is an rn than rn's can do no wrong.

last week I had a 65 yr old guy with clear cut, new onset major cva sx x less than 3 hrs, multiple risk factors, no daily asa use, etc triaged to fast track. I got him the eval and tx he needed but then complained about the lousy triage(the guy waited 1 of his 3 hrs in our waiting room when we weren'tthat busy).

the nurse in triage turned around and yelled at me, told me she knew what a stroke was becuae she had worked at xyz busy hospital before and I was wrong, she said he "probably slept wrong" on his left side and that was why he couldn't move his arm or leg....when the neurologist admitted him and started anticoagulation she made herself really scarce really quick.....my chief was there, saw the whole thing and wrote her up as well....nothing will happen.....

it takes probably 10 major screw ups like this to get an rn disciplined, more to get them fired. we got 1 really bad rn fired a few yrs ago. took 3 yrs with multiple complaints from multiple providers....lots of dangerous stuff, drug errors, poor triage, wrong dose or route of med, subq epi given Iv, no iv fluids to obvious dka x 2 hrs despite orders for fluid resuscitation, etc

[CAdamsPAC]

nope,the nurses are too empowered. if the manager of the dept is an rn than rn's can do no wrong.

last week I had a 65 yr old guy with clear cut, new onset major cva sx x less than 3 hrs, multiple risk factors, no daily asa use, etc triaged to fast track. I got him the eval and tx he needed but then complained about the lousy triage(the guy waited 1 of his 3 hrs in our waiting room when we weren'tthat busy).

the nurse in triage turned around and yelled at me, told me she knew what a stroke was becuae she had worked at xyz busy hospital before and I was wrong, she said he "probably slept wrong" on his left side and that was why he couldn't move his arm or leg....when the neurologist admitted him and started anticoagulation she made herself really scarce really quick.....my chief was there, saw the whole thing and wrote her up as well....nothing will happen.....

it takes probably 10 major screw ups like this to get an rn disciplined, more to get them fired. we got 1 really bad rn fired a few yrs ago. took 3 yrs with multiple complaints from multiple providers....lots of dangerous stuff, drug errors, poor triage, wrong dose or route of med, subq epi given Iv, no iv fluids to obvious dka x 2 hrs despite orders for fluid resuscitation, etc

 

It seems that we all work in the same place! I've seen more bad nurses let go for calling out sick than being a threat to patients!!!!!!!!:eek:

[EMEDPA]

almost very bad.....

triage: abd cramping and vag bleeding(reasonable triage). pregnant, ?dates, no prenatal care

6 hr delay for u/s as tech took off to have dinner with family and did not respond to multiple calls until threatening phone call to home from u/s supervisor(who we called at home)...pt wants to leave ama on several occassions...convinced to stay....final u/s dx: ruptured ectopic with mod free fluid in the belly...direct admit to obgyn to go straight to o.r.

almost left, I basically had to threaten her with possible death, disability and infertility, etc....bad form, very bad form.....

[EMEDPA]

55 yr old male c/o itching all over after eating at taco bell just prior to arrival.

while I am talking to him over about 45 sec he develops generalized urticaria, wheezing/dyspnea, voice change, b/l hand swelling and facial edema....

subq epi 0.3 mg, benadryl 50/pepcid 40/solumedrol 125 mg iv mainline...doing much better...admitted to ed obs...glad this happened with me in the room instead of on the street or in our waiting room...another few min and I would have gotten a chance to try out our new glide scope.....

[CCPA]

I have heard many great things about the glide scope. I haven't heard that anyone dislikes them yet. We don't have one, but a nearby hospital does. I will be interested to hear your impressions and which model you have.

[EMEDPA]

I have heard many great things about the glide scope. I haven't heard that anyone dislikes them yet. We don't have one, but a nearby hospital does. I will be interested to hear your impressions and which model you have.

 

we have a peds, adult, and large adult handle with the regular size monitor, not the traveling"ranger" version that they are trying to sell to ems. it's really slick with difficult anatomy but probably still not terribly helpful with lots of blood, secretions, etc as the lens probably gets covered with gunk.

[kbreit]

I totally agree with staying sharp and on your toes at all time while in the "fast track" In the last 2 weeks alone I have seen Testicular torsion, a ruptured ectopic and a SAH.

[Guest pac4hire]

lets rebirth this thread so many of us are haunted by....

 

I bring this case up not to show my abilities, but rather my luck. this same 28 y/o female was seen at a fasttrack of a hospital in another hospital approx 3 days ago. A Cxr and ecg were completed and read as normal. she was diagnosed with pleuriisy.

 

 

 

Today she came in with complaints of substernal chest pain ,even taking ultram, worse with inspiration or coughing. she also said that change in positions made the pain her worse, AAhe has no associated antecedant illness, is afebrile, in no acute distress. but had no remitting factors. she has no risk factors, pmh is neg. family hx mom MI at age 55 Social: 1/2 ppd smoker quit 6 months ago

 

I obtained an ECG and CXR witch were both normal. I felt she may have had pleurisy also so i gave her a duoneb, 60 mg of toradol. 1 hour later she was pain free, as i was going over her plan she said the pain struck againand this time brought her to tears. I ordered 2 percocet PO . 1 our later she was still crying so i just bought the bullet and ordered an istat troponin and a d dimer. d dimer 0.10(neg) troponin 44 WTF??? i call cards after placing her on O2, ASA and 3 rounds of lopressor. Cards comes down and does a bedside echo which they read as nl.

 

Remainder of labs come back.

 

ESR 7

 

CRP<5

 

CBC Nl

 

CMP NL

 

CK 2167

 

mb 330

 

index 15.1

 

 

 

Second set of enzymes

 

troponin 47

 

ck 2890

 

MB 660

 

index 16

 

 

 

Duscussion: I actually thought that the patient was being historionic and was seeking stronger pain meds, Until there was no relief from three meds, Thats when i decided to lab her up. My gut feeling almost killed someone and made me a poor individual. Im just glad something in the back of my head told me to order those tests....

 

 

 

Sean

[Guest pac4hire]

Bump..............

[dreamin2baPA]

pac4:

 

............MB?

[primadonna22274]

Not my patient but....

Last night (July 4th) about 10pm healthy 20-something guy comes in with a head lac. Thinks he got hit in the head with a rock. There's something hard in his frontal scalp and he's got an open wound and bleeding. Also drunk. (Of course.) Yup, it's fast track.

My attending bops in to see the dude and he's like, there's something HARD in that scalp. Hard like a bullet. CT: bullet in the frontal scalp, skull intact, brain fine.

Call police. Fish out the bullet, label it, off to crime lab, sew up lac. Discharge the patient home in under an hour...how many times can YOU say you've identified, fixed and sent home a GSW to the head from fast track??

Sounds like in the local fireworks festivities some idiot decided to fire off bullets into the air and this guy's head was in the way when what goes up must decidedly come down.

Lucky bastard. His wife comes in with baby on her hip seriously P.O.'d and says "you know what this means--you'd better be praying HARD tonight!!"

:D

[EMEDPA]

how many times can YOU say you've identified, fixed and sent home a GSW to the head from fast track??

:D

 

twice(seriously).

[Guest pac4hire]

pac4:

 

............MB?

 

like 330 intialially with index of 15.1

 

 

turns out her cath was completely clean... cards called it clinical myocarditis without ecg changes.... whatever...she got better and went home, however her troponin finally peaked at 105.3

[EMEDPA]

60 yr old bk m with c/c on chart of " l elbow pain" x 2 weeks

me: so tell me about this elbow pain

pt: well it starts in my elbow and goes into my chest. I had pain like this before my last cath but I didn't think it was chest pain this time......( it was)

monitor lead II : 3 mm ST depressions

you know the rest.....cath lab, stents, etc

[d2305]

pac4:

 

............MB?[/quote

 

 

http://en.wikipedia.org/wiki/Creatine_kinase

[physasst]

60 yr old bk m with c/c on chart of " l elbow pain" x 2 weeks

me: so tell me about this elbow pain

pt: well it starts in my elbow and goes into my chest. I had pain like this before my last cath but I didn't think it was chest pain this time......( it was)

monitor lead II : 3 mm ST depressions

you know the rest.....cath lab, stents, etc

 

 

Yeah, I've had at least 2 STEMI's in the past several months in FT, also, just last week, saw someone who was listed as having "tongue swelling"....turned out to be the worst angioedema I've ever seen. Called anesthesia, but they couldn't get there in time, and I ended up doing a fiberoptic nasotrachial intubation with my consultant watching......guy got transferred up to the unit fast.

[HEENT]

I wanted to add this, even though it happened a long time ago, and was not such a big deal, but something I have been thinking about recently as my ED is attempting to implement a split flow model fast track, modeled after Banner Health in Az, everything is supposed to be 4 or 5, in and out, no admissions!!!

 

I digress, our FT is open 11 to 11, and nothing is really supposed to get brought back after 10, so we can close up...one evening I had an "ankle pain" and the triage nurse asked me if I could handle a quick ankle pain at 10:30, as well as a rash for my attending, I grabbed the ankle, he grabbed the rash. Classic "walking down loose dirt, rolled my ankle, felt the pop and came to the ER" I would assume the triage nurse at least looked at the ankle before asking me to be able to get them in and out in 30 minutes.... all I had to was take off her boot and sock to see the open fx.

 

Obviously there are sucky triage nurses and there are good ones, but it seems like sucky is the majority in my ED, and with my impending split flow model bounding down the pipe...I am very concerned these nurses will continue to give me TAA's which complain of back pain.... PE's which are "wheezy" and everything else I have had to admit from the fast track!!! Hope everyone has a great holiday season!

[EMEDPA]

THIS FOLLOWS THE WORST MEDIC REPORT OF ALL TIME-

REPORT IN IT'S ENTIRETY:

"WE GOT A GUY WITH RUQ PAIN TODAY, PROBABLY A GALL BLADDER, C'YA IN 5"

 

ACTUAL PT:(BRIEFLY)

96 YR OLD DIABETIC WITH ALTERED MENTAL STATUS, NORMALLY LIVES ALONE AND FULLY INDEPENDENT NOW A+OX1(NAME ONLY) C/O VAGUE R SIDED ABD PAIN TODAY. EMS CALLED BY VISITING FAMILY.....HAS NO DNR BY THE WAY....

VS: TEMP 102, P 122, R 26, BP 90/60

+ R CVAT ON EXAM

CATH URINE WHITE/CLOUDY URINE WITH > 100 WBC/HPF

WBC 22,000 WITH 15% BANDS

BLOOD GLUCOSE 300, CR 2 BUN 60

 

A: UROSEPSIS 2 TO PYELONEPHRITIS, DEHYDRATION, ALTERED MENTAL STATUS, DM, ETC

p: ADMISSION FOR IV ABX, FLUIDS, ETC