G. Davenport Posted July 21, 2011 Share Posted July 21, 2011 Hey E, Were you following me around on my last shift at the ER? Miss you brother. G. Quote Link to comment Share on other sites More sharing options...
G. Davenport Posted July 21, 2011 Share Posted July 21, 2011 Hey E, Were you following me around on my last shift at the ER? Miss you brother. G. Quote Link to comment Share on other sites More sharing options...
icthus13 Posted August 18, 2011 Share Posted August 18, 2011 The other day: 75 y/o female to fast track after a fall. Triage RN notes obvious deformity of left wrist. Apparently the RN missed the huge hematoma on her forehead. Admitted with subdural hematoma and distal rad/ulna fracture. Quote Link to comment Share on other sites More sharing options...
jmj11 Posted August 18, 2011 Share Posted August 18, 2011 Okay, this is an old one and before I was a PA. I was in college and had just gotten a job at the local hospital's ER to explore my interest in medicine. Our ER had sort of a fast track, straight back to the trauma ward, and the routine, where novice nursing assistants like me would bring them back, get their history, take their vitals and put their chart in the slot for the physician . . . who may see them an hour later. So I'm called up to the front to bring back a guy with a cut hand. He has a bloody white towel that is between his hand and his belly. I took him back to the exam room. He wasn't in any distress or too excited. So when I was done getting his vitals I asked, "So let me see your little cut . . . is it your hand or finger?" He looks at me and calmly says, "Hey dude, it's my belly. Got in a fight and he had a razor." He pulls away the towel and his small bowel loops are hanging out through a 30 CM slice from his umbilicus over to his right flank. Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted August 18, 2011 Moderator Share Posted August 18, 2011 jmj11 we feel your over worked stressed out life right now.... your post #153 is the same as #121 (I think anyways) how is the clinic going?? Quote Link to comment Share on other sites More sharing options...
jmj11 Posted August 18, 2011 Share Posted August 18, 2011 jmj11 we feel your over worked stressed out life right now.... your post #153 is the same as #121 (I think anyways) how is the clinic going?? I didn't read it but would be surprised. I feel, after this year, that I'm teetering on the edge of exhaustion. But I can't slow down until we are completely solvent. Quote Link to comment Share on other sites More sharing options...
Superfundee Posted August 18, 2011 Share Posted August 18, 2011 we have new fast-track guidelines. anybody over 65 who fell or any ortho issue is going to the Main ED. Simple abscess with Job's syndrome is going to the Main ED. Quote Link to comment Share on other sites More sharing options...
icthus13 Posted August 19, 2011 Share Posted August 19, 2011 Just had another one today... 16 month old male to fast track, triaged a 4. CC "mouth sores" and rash. I get in the room and he's drooling and in respiratory distress. Diagnosis: acute epiglotitis. Yikes. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 19, 2011 Author Moderator Share Posted November 19, 2011 1ST PT LAST WEEKEND: triage note: "fever at home..." T=106.6...the minor details....breast cancer pt on chemo...wbc=1.0...neutrpenic fever...great..... next pt. c/c "drank too much"...yes he did, etoh =371....elevated serum ammonia also an issue since he stopped taking his meds(lactulose) for alcoholic hepatic encephalopathy over a week ago....Grade 3 of 4 symptoms(care of wiki): The severity of hepatic encephalopathy is graded with the West Haven Criteria; this is based on the level of impairment of autonomy, changes in consciousness, intellectual function, behavior, and the dependence on therapy.[1][7][8] Grade 1 - Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction Grade 2 - Lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behaviour Grade 3 - Somnolence to semistupor, but responsive to verbal stimuli; confusion; gross disorientation Grade 4 - Coma (unresponsive to verbal or noxious stimuli) Quote Link to comment Share on other sites More sharing options...
medic25 Posted November 20, 2011 Share Posted November 20, 2011 The severity of hepatic encephalopathy is graded with the West Haven Criteria; this is based on the level of impairment of autonomy, changes in consciousness, intellectual function, behavior, and the dependence on therapy.[1][7][8] Thanks for the info E. This caught my eye since West Haven is one of the bigger cities in my hospitals catchment area. Turns out the name came from a study our medical school ran at the large VA hospital in West Haven. I'll have to use this as some medical trivia for pimping students :) Quote Link to comment Share on other sites More sharing options...
medic25 Posted December 13, 2011 Share Posted December 13, 2011 Interesting case tonight; not true fast-track, but the "low-acuity" section of the ED designed for stable, quicker dispo-type patients. Triage note lists CC as "Hemorrhoids/rectal pain x 1 week". Older male with a history of ESRD, HTN. Turns out that because it was so painful to sit, the patient skipped his hemodialysis for the last 5 days; you can probably guess where this is going.... EKG shows peaked T waves with widened QRS complexes; potassium comes back at 8.8! We give him insulin/dextrose, calcium gluconate, sodium bicarbonate, albuterol, and admission to the MICU for emergent dialysis, and I think the thing the patient appreciated most was the lidocaine jelly for the rectal pain! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 13, 2011 Author Moderator Share Posted December 13, 2011 cool case...had a few sent to FT last week that I just sent back to main without starting because they looked ugly from across the room....baseball sized lateral neck abscess in febrile IV drug user, c'mon now! febrile, elderly out of control diabetic with orbital cellulitis..."well, there was eye d/c..isn't that conjucntivitis?" me: "what about the bright red swelling all around her eye and complaint of worst pain ever?" "well, I thought she was being dramatic" ...uh, ok. Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted December 14, 2011 Share Posted December 14, 2011 Interesting case tonight; not true fast-track, but the "low-acuity" section of the ED designed for stable, quicker dispo-type patients.Triage note lists CC as "Hemorrhoids/rectal pain x 1 week". Older male with a history of ESRD, HTN. Turns out that because it was so painful to sit, the patient skipped his hemodialysis for the last 5 days; you can probably guess where this is going.... EKG shows peaked T waves with widened QRS complexes; potassium comes back at 8.8! We give him insulin/dextrose, calcium gluconate, sodium bicarbonate, albuterol, and admission to the MICU for emergent dialysis, and I think the thing the patient appreciated most was the lidocaine jelly for the rectal pain! I'm sure the Renal Fellow appreciated another PIA case hyperkalemia induced by missed HD sessions in the middle of the night!!!! Quote Link to comment Share on other sites More sharing options...
medic25 Posted December 14, 2011 Share Posted December 14, 2011 I'm sure the Renal Fellow appreciated another PIA case hyperkalemia induced by missed HD sessions in the middle of the night!!!! LOL; apparently mine was the third severe hyperkalemia that night. He said he was dreading telling the on-call dialysis nurse that she needed to stick around and dialyze yet another ED patient :) Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted December 15, 2011 Share Posted December 15, 2011 LOL; apparently mine was the third severe hyperkalemia that night. He said he was dreading telling the on-call dialysis nurse that she needed to stick around and dialyze yet another ED patient :) The good part is ESRD patients have a greater tolerance for elevated K+ so there some good wiggle room as opposed to "normal host" patient. Yeah the HD nurses can get slammed sometimes they just get home and it's time to gome back in for another session!!! It never ceased to amaze me that these patients seem to appear in the middle of the night! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 16, 2011 Author Moderator Share Posted December 16, 2011 not really a disaster and not really fast track as I was working a shift at our affiliated urgent care center but suffice it to say it wasn't a kidney stone, it was a baby in a young woman who "couldn't possibly be pregnant" and had "regular periods every month". started pelvic exam and baby was crowning. ok then. easiest delivery ever. Quote Link to comment Share on other sites More sharing options...
CAdamsPAC Posted December 17, 2011 Share Posted December 17, 2011 not really a disaster and not really fast track as I was working a shift at our affiliated urgent care center but suffice it to say it wasn't a kidney stone, it was a baby in a young woman who "couldn't possibly be pregnant" and had "regular periods every month". started pelvic exam and baby was crowning. ok then. easiest delivery ever. What was her presenting complaint? How did she get past triage? Quote Link to comment Share on other sites More sharing options...
primadonna22274 Posted December 17, 2011 Share Posted December 17, 2011 Sure am glad I never encountered THAT in my urgent care! not really a disaster and not really fast track as I was working a shift at our affiliated urgent care center but suffice it to say it wasn't a kidney stone, it was a baby in a young woman who "couldn't possibly be pregnant" and had "regular periods every month". started pelvic exam and baby was crowning. ok then. easiest delivery ever. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 17, 2011 Author Moderator Share Posted December 17, 2011 What was her presenting complaint? How did she get past triage? FLANK PAIN AND HEMATURIA. lg lady, didn't look pregnant. Quote Link to comment Share on other sites More sharing options...
showard873 Posted December 19, 2011 Share Posted December 19, 2011 Glad I got to be a part of that with you, E :) What an experience! I'll definitely be talking about this for a long time! I'm sure it will be a topic of conversation in PA school! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 19, 2011 Author Moderator Share Posted December 19, 2011 Glad I got to be a part of that with you, E :) What an experience! I'll definitely be talking about this for a long time! I'm sure it will be a topic of conversation in PA school! you could have done it without me. I just caught the kid, suctioned, dried him off and handed to mom. it really doesn't get easier than that. next one is yours. Quote Link to comment Share on other sites More sharing options...
nebero Posted May 26, 2012 Share Posted May 26, 2012 Almost a diaster. Last week I had a middle aged guy with laceration from temple through the ear to the neck and he was sent to fast track. I noticed profuse arterial bleeding and fought with the charge nurse to find him a room on the main side because I need a bigger room and overhead light to do the lac. When I went to the room in a little bit, I noticed the whole bed soaked with blood. I immediately started working on him and about half way through, pt felt very light headed and BP went down to 60/40. We had to push 2 liters NS immediately before I continue with the lac. Note for triage nurse: because it is a lac and the PA has to do it, do not put that pt in fast track where we have no monitor, no enough space to do any thing if pt codes. In this case, the triage nurse did't even take the dressing off and look at the lac. "oh it is a lac. Fast track pt" Quote Link to comment Share on other sites More sharing options...
sunny2spot Posted July 30, 2012 Share Posted July 30, 2012 So 3 days ago I was working Fast Track and had a 25yr old febrile female with a confirmed inevitable miscarriage of a 12 week pregnancy. The patient could not have cared less about this, though. She couldn't walk due to extreme atraumatic knee pain and was 100% more concerned about the knee saying she'd go to Planned Parenthood later to take care of the miscarriage. IV drug user, last heroin use 4 days prior. Heart murmur (OB-GYN told us this was probably due to the pregnancy) "I've lost 16 pounds in the last 2 weeks" Notably diaphoretic. Three serial blood cultures all came back positive the next day. (We have a Physician in Triage (PIT) at all times. It still happens.) Quote Link to comment Share on other sites More sharing options...
jen0508 Posted July 30, 2012 Share Posted July 30, 2012 try to guess the ADMITTING dx for each of these recent fast track complaints. let's see who can get them all first. some are easy, some aren't....gotta stay on your toes even in fast track folks.... diabetic 50 yo m with "shoulder pain" 85 year old htn male with atraumatic "neck pain" 30 yr old fe on o.c.'s with "blurry vision" 75 year old male with worsening "leg pain" x weeks 35 yr old fe with btl with "bad gas pains and dizzyness" 17 year old fem with "yeast infection and fever" 18 yr old male iddm pt with" new onset asthma" 50 yr old morbidly obese poorly controlled htn m with "heartburn" 45 yr old fe "bleeding gums" 22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v" so as an ER newbie i'll take a stab at this without lookking at the answers diabetic 50 yo m with "shoulder pain" MI 85 year old htn male with atraumatic "neck pain" carotid artery dissection 30 yr old fe on o.c.'s with "blurry vision" hmm.. stroke? 75 year old male with worsening "leg pain" x weeks ...DVT? 35 yr old fe with btl with "bad gas pains and dizzyness" hmm not sure on this, dont kno what btl is, but with dizziness id guess shes bleeding so ectopic 17 year old fem with "yeast infection and fever" PID 18 yr old male iddm pt with" new onset asthma" not sure what iddm is, but im guessing pneumothorax 50 yr old morbidly obese poorly controlled htn m with "heartburn" MI, but this seems too easy.. 45 yr old fe "bleeding gums" ITP 22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v" upper GI bleed now i'll go back and read the answers... fun stuff :-) Quote Link to comment Share on other sites More sharing options...
jen0508 Posted July 30, 2012 Share Posted July 30, 2012 by the way i know i'm 7 years late, just entertaining myself :) Thanks for the post EMED, i'll be browsing through this thread for the rest of the night. Hopefully soon I can add to it. Quote Link to comment Share on other sites More sharing options...
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