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"it's probably nothing"-fast track disasters


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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

 

 

 

 

I literally LOL when i read this. Elbow pain turning into a MI. I didnt see that coming!

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  • 1 month later...

My Two TRAUMA admits for 'The Track'

 

1) 88yo CC: forhead lac, yes but has a Bleed along with that, and huge hematoma to the forehead......

2) 36yo male, fell while riding his bike (pedal bike, not motorcycle etc), injuring left shoulder, was at another ER last night, xrays were normal and they sent him home, i see him the next day and he wants to know if he has a 'rotator cuff' injury to the shoulder.

P. Exam: Guy has obvious Sub-q emphysema around his neck and shoulder, and was sat'ing around 90-94% RA.

CT chest shows, pneumomediastinium and small pnemopercicardium. No pneumothorax..

 

both in the same day!

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92 yr old male c/c "tired for months"

looks a little pale but stable vs

cbc shows hemoglobin of 3.8....yes, 3.8...I double checked it.

mcv=50

ferritin= 2.8 (nl= >13)

 

sorry, don't remember serum iron or tibc but equally impressive.

admitted. given 4 units packed red cells over 8 hrs.

much more energy next am with h/h 8/24.....

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Gotta love the well-compensated anemia......

 

92 yr old male c/c "tired for months"

looks a little pale but stable vs

cbc shows hemoglobin of 3.8....yes, 3.8...I double checked it.

mcv=50

ferritin= 2.8 (nl= >13)

 

sorry, don't remember serum iron or tibc but equally impressive.

admitted. given 4 units packed red cells over 8 hrs.

much more energy next am with h/h 8/24.....

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Every geriatric who falls and gets a head/face lac is considered fast track if they *say* they didn't pass out. I've found a few head bleeds and cervical fractures that way, but had a new one this month: an open frontal sinus fracture in an anticoagulated, diabetic, renal transplant pt. That pt was transferred at the same time as two of my other "fast track" pts, a 29yo male with "painless scrotal swelling x 1m" (he did have a mild dull ache in his abd, where his testicular cancer had metastasized) and a 4mo with a uti who was vomiting (only 4 times, and she came in with her cousin who vomitted 4 times too, so it was assumed to be a viral stomach flu....)

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just a quick observation.

 

These cases are why one could argue very forcefully about staffing the fast track with your most senior, most experienced clinicians, whether PA or Doc.

 

And letting the newbies "cut their teeth" in the main where they learn workup and eval multi diseases and fine tune their diagnostic accumen.

 

Scares me to death to hear about fast tracks being staffed with new PAs unless close oversight for a good while.

 

The danger, of course, is the spiralling downward degree of concern when the triage nurse codes the complaint level 4 or 5.

 

just stating the obvious.

 

davis

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just a quick observation.

 

These cases are why one could argue very forcefully about staffing the fast track with your most senior, most experienced clinicians, whether PA or Doc.

 

And letting the newbies "cut their teeth" in the main where they learn workup and eval multi diseases and fine tune their diagnostic accumen.

 

Scares me to death to hear about fast tracks being staffed with new PAs unless close oversight for a good while.

 

The danger, of course, is the spiralling downward degree of concern when the triage nurse codes the complaint level 4 or 5.

 

just stating the obvious.

 

davis

 

Understandable statements that become an administrator's question and nightmare: how to retain senior, experienced providers for fast track? Many experienced providers want more than what fast track offers and new grads both PA and MD see fast track as a stepping stone to the main ED.

 

An entire systems approach is needed including patient delivery, triage, providers, etc. How to fix it, I don't know, but I don't expect any major changes soon.

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make sure pay/hours are same/better than ED. Not everyone wants the challenge/adreneline rush of ED. Been there, done that, don't want to do it again. I like my urgent care, even when I get the "cough for two days" who actually is in renal failure, CHF, and some pulmonary edema with a hemoglobin of 4.

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  • 1 month later...
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recently seen by one of my colleagues.

guy presents with c/c on chart of sore throat to fast track.

general assessment(from across the room):

middle aged asian guy in acute resp distress with stridor and drooling .

obvious large swelling to external neck.

o2 applied by mask. sats ok for now so my colleague grabs an ent guy he sees in the dept for a quick look with the nasopharyngoscope.

the guy has screws from a cervical fusion plate perforating the posterior wall of his esophagus.

emergent trach follows then removal of said plate by neurosurg and repair of tear by ent......

dart board triage strikes again!

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recently seen by one of my colleagues.

guy presents with c/c on chart of sore throat to fast track.

general assessment(from across the room):

middle aged asian guy in acute resp distress with stridor and drooling .

obvious large swelling to external neck.

o2 applied by mask. sats ok for now so my colleague grabs an ent guy he sees in the dept for a quick look with the nasopharyngoscope.

the guy has screws from a cervical fusion plate perforating the posterior wall of his esophagus.

emergent trach follows then removal of said plate by neurosurg and repair of tear by ent......

dart board triage strikes again!

 

So . . . I don't see the problem here. I bet his throat was sore wasn't it.:p

 

No, that was horrible. I hope he's ok.

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In the first four hours of my last fast track shift I saw a new dx hyperthyroid, new dx hypothyroid, a likely new dx long QT in an 8 yr old, new dx Raynaud's and a 7 yr old kid with RLQ pain x 4 hours w/ hx of colonoscopy with bleeding complications.

 

That is, in between the green-phleghm-in-my-throat-feeling-feverish-no-apap/ibu-zpack-worked-last-time folks that I'm sure no one else is seeing now.

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Memorable patient when I was working as an ED tech:

~60 y/o F

CC: abdominal pain (main ED was swamped...waited 4 hours for bed in fast-track)

Past Med Hx: Small Bowel Obstruction

During transport from waiting room to fast-track...vomited all over the floor.

Once I got her to the bed, she was diaphoretic.

Told to do a stat EKG : STEMI

What happened in triage?

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seen last week by one of my partners in fast track:

"ankle pain x 1 hr" (65 yr old pt with extensive cardiac hx)

pa:so tell me about your ankle

pt: well, I fell and twisted it

pa: why did you fall?

pt: I don't know, you see I passed out when the chest pain and rapid heart rate started and don't remember the rest until my son found me at the bottom of the stairs....

 

 

you know where there is going.....

 

 

and my "uti sx"pt last week....who was actually pyelo...with a temp of 104.....and no blood pressure...who was actually septic.....who went to the icu.....on pressors....

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recently seen by one of my colleagues.

guy presents with c/c on chart of sore throat to fast track.

general assessment(from across the room):

middle aged asian guy in acute resp distress with stridor and drooling .

obvious large swelling to external neck.

o2 applied by mask. sats ok for now so my colleague grabs an ent guy he sees in the dept for a quick look with the nasopharyngoscope.

the guy has screws from a cervical fusion plate perforating the posterior wall of his esophagus.

emergent trach follows then removal of said plate by neurosurg and repair of tear by ent......

dart board triage strikes again!

 

HOLY SCHNEIKY!!!:eek:

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I share a brief storyalong this line although it wasn't a Fast Track situation.

 

To prepared to get into PA school I took a job at a hospital during my senior year in college. I was a nursing assistant in the ER. I was barely getting use to gore when one night a guy walks in and checks in at the desk causally. He wasn't wearing a shirt and was holding a towel around his waist. He was complaining that he had "been in a fight and got cut."

 

To took him back to the room, took his vitals. We usually cleaned cuts in prep for the ER doc (who was often intoxicated btw) to come in and see the patient. After I finished the vitals, I said, "Let me see your cut."

 

He pulled the towel away and I could not believe my eyes. He had a clean cut (was done with a straight razor) across his abdomen and his small intestines were hanging out. I about passed out (hey, don't laugh, I was new at this). I gently placed the towel back over his wound.

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  • 1 month later...

I agree completely with the experienced peeps staffing fast track. I'm new, and feel like a ticking time bomb. I try to explain this to my attendings, but they just don't get it. The "chronic migrainer" with a BP of 250/120 "because of pain" is just not always the case -- admitted to the ICU for hypertensive emergency for that kind of stuff before. Terrifying. Here's hoping for the residency!

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Once again I agree with Davis that fast track should be staffed by the most seasoned PAs...as the triage nurses are generally the least experienced it seems....

 

I'm in total agreement. We at least require our new PA's to work in the main ED for several months before they are allowed anywhere near our Urgent Care section. I still remember one patient (thankfully not mine) who was escorted to Urgent Care by security at Triage's request, "because he was acting like a jerk". Turned out to be "acting like a jerk" because of the head bleed/c-spine fracture from his MVC; he was intubated in the trauma bay within the hour.

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