"it's probably nothing"-fast track disasters

[medic25]

Had an interesting one recently while picking up some OT in Fast Track.

 

Middle aged male triaged to fast track as a "puncture wound". He had decided to go shooting with a rifle that hadn't been fired in 80 years (family heirloom) and didn't clean it first. Not surprisingly, the barrel exploded and he felt something "hot" sting his neck, which then bled for the next 15 minutes. Deciding this wasn't a good thing, he drove himself to our little free-standing ED ( 8 beds, no trauma designation)

 

After finding a 1cm wound just lateral to the trachea, I shot a quick plain film that revealed the bullet fragment sitting within his neck. My fast-track puncture wound quickly got moved out to the main ED, line/labs, and a rapid ambulance ride to our main hospital/trauma center for his Zone II penetrating neck wound.

[EMEDPA]

see this thread:

http://www.physicianassistantforum.com/forums/showthread.php/37235-another-cool-case

[katief262]

diabetic 50 yo m with "shoulder pain".... MI

85 year old htn male with atraumatic "neck pain" carotid dissection

30 yr old fe on o.c.'s with "blurry vision" .... stroke

75 year old male with worsening "leg pain" x weeks ....rhabdomyolosis (is he on statins?) or claudication

35 yr old fe with btl with "bad gas pains and dizzyness" ...ruptured ectopic pregnancy

17 year old fem with "yeast infection and fever" ... PID

18 yr old male iddm pt with" new onset asthma" ... DKA

50 yr old morbidly obese poorly controlled htn m with "heartburn" ... AAA or MI

45 yr old fe "bleeding gums" ... some kind of bleeding problem I hate hematology

22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v" ectopic pregnancy

 

I don't know I was just thinking worst case scenarios maybe...

[katief262]

Ok I'm late but I just wanted to try :) i'll go look at the answers now.

[Febrifuge]

And from the other side...

 

Early 30s woman has been having weird syncopal episodes, nothing involving falls or actual LOC, and not truly orthostatic by history or vitals in the Urgent Care. Also a dull but persistent headache. Exam is pretty damn benign. The story is just funky enough, and it's been going on long enough, that I send her to the ED for a better, more complete workup. (If nothing else, I figure they can page a Neuro resident to come and run through the gamut of tuning forks and filaments.) My Spidey-Sense tells me this isn't normal. She appreciates that I'm taking her seriously, at least.

 

A week later, she lets me know she was given NSAIDS, observed, and the EM guy was confident no imaging was needed or would help.

 

A month later, she lets me know the latest: it's an aneurysm. Somehow she got a neurology appointment and a scan of some sort. She was due to go in for an MR-A. Depending on size and exact location, it might need to be clipped.

[EMEDPA]

nice pick up feb.

I'm surprsied she didn't get at least a noncontrast head ct(which may have still missed it) at the first er visit along with a holter monitor.

[Febrifuge]

Yeah, honestly I'd been thinking they'd send her home with a Holter to wear. I always tell people "I have no sway whatsoever in the ER, and that's the way it should be," but I do print out a little summary for them to take with them -- it might help save some time, and it helps eliminate confusion. I don't like to flat out say stuff like "I think this patient would benefit from admission or a Holter," but on that one I almost feel like I should have.

[CAdamsPAC]

You know........something that needs to be added to the triage incompetence is a real biggie , ALL PATIENTS LIE! This doesn't mean they are malicious they just tell you what they think you need to know, what they don't want others to know and if they weren't asked they won't say!!

[nicuPAC]

Can you pick up aneurysms on a general CT scan? I've noticed that's the go to in the ED and if it came back negative my thoughts would be they'd be sent home and told they were fine. Would CTs show and if not what's the protocol if you're still suspicious?

[primadonna22274]

Can you pick up aneurysms on a general CT scan? I've noticed that's the go to in the ED and if it came back negative my thoughts would be they'd be sent home and told they were fine. Would CTs show and if not what's the protocol if you're still suspicious?

 

Only if they're bleeding or HUGE. Even plain MRI is not ideal for aneurysm--you need MRA--and nobody gets an MRA (let alone MRI) in the ED.

Still would be considered standard of care to do a screening non contrast head CT for funky HA in any ED I know.

[True Anomaly]

Can you pick up aneurysms on a general CT scan? I've noticed that's the go to in the ED and if it came back negative my thoughts would be they'd be sent home and told they were fine. Would CTs show and if not what's the protocol if you're still suspicious?

 

As primadonna said, you will pick up some aneurysms on non-contrast CT scan, but the accepted sensitivities are variable- anywhere between 80%-95% based on the study you read or the time frame in which the scan was done related to onset of pain. Remember, when it comes to aneurysms, we care if there's bleeding or not. And when it comes to subarachnoid hemorrhage (SAH), the classic teaching of the pattern of the headache is threefold:

 

- SUDDEN, thunderclap onset of headache

- Headache is WORST AT ONSET or within one hour

- A CHANGE in the pattern of previous headaches

If you document all of those on the chart, you better rule out a subarachnoid in the ED before they get sent home.

 

So then the question is, how does it get ruled out definitively? There is a study that's been gaining a lot of attention over the past year or so from the British Medical Journal from 2011 that showed with modern CT scanners, it had a sensitivity of 100% for subarachnoid hemorrhage within the first six hours of headache onset (after the first six hours, the sensitivity dropped into the 80's). There is also data showing that a CT head along with a CT angiography together may be enough to rule out SAH. However, this is not considered the "standard of care" for evaluation in the ED, and if you do the CT head which is negative, and even if you have a CT angiography showing a NON-bleeding aneurysm, the standard of care is still to do an LP. A CT combined with an LP is still the gold standard approach to ruling out a SAH in the ED. If I or the ED doc I'm working with can't get the LP, then we ask interventional radiology to do it.

 

Although it hasn't been updated since 2008, the American College of Emergency Physicians (ACEP) has a clinical decision paper outlining what is basically still considered the standard of care when it comes to evaluation of acute headaches in the ED. They also point out in here that when it comes to starting the evaluation, patients who get a CT scan are age > 50 with a new headache but a normal neuro exam. Here's a link to the paper: http://www.acep.org/Clinical---Practice-Management/Clinical-Policy--Critical-Issues-in-the-Evaluation-and-Management-of-Adult-Patients-Presenting-to-the-Emergency-Department-with-Acute-Headache/

Edited February 13, 2013 by True Anomaly

[EMEDPA]

TRULY A WINNER FROM TRIAGE:

3 week old with "runny nose"

no vs done (because they leave them for us to do in fast track....ALWAYS A BAD IDEA....).

the real story: poor feeding, no wet diapers for 24 hrs. bottle fed only but not taking bottle.

sao2 40-50% on RA with cyanosis to face + extermities, capillary refill > 4 seconds!

lethargic and febrile( 38.1 rectal).

put on o2 via portable tank, checked blood sugar(nl) and I personally hand carried kid over to the acute side and handed off to peds er docs...big septic workup now in progress...talk about lousy triage....kids legs were only twice as big around as my thumb. way too small for the IO needles I had on hand.

[rcdavis]

TRULY A WINNER FROM TRIAGE:

3 week old with "runny nose"

no vs done (because they leave them for us to do in fast track....ALWAYS A BAD IDEA....).

the real story: poor feeding, no wet diapers for 24 hrs. bottle fed only but not taking bottle.

sao2 40-50% on RA with cyanosis to face + extermities, capillary refill > 4 seconds!

lethargic and febrile( 38.1 rectal).

put on o2 via portable tank, checked blood sugar(nl) and I personally hand carried kid over to the acute side and handed off to peds er docs...big septic workup now in progress...talk about lousy triage....kids legs were only twice as big around as my thumb. way too small for the IO needles I had on hand.

 

How in the hell can triage triage w/o vitals??? That should ge changed immediately. 3 wk old with rectal temp 100.5 is emergent.. E, that hospital's policies are downright dangerous... And indefensible .

RC

[EMEDPA]

How in the hell can triage triage w/o vitals??? That should ge changed immediately. 3 wk old with rectal temp 100.5 is emergent.. E, that hospital's policies are downright dangerous... And indefensible .

RC

well aware that this kid was circling the drain...it's all about the #s. they want the fastest door to provider time possible to make their #s look good so "non-emergent" patients get triaged with VS in the area they are seen in by the primary nurse, not out front. This kid was hispanic so it wasn't as obvious that they were cyanotic just "dusky" at first glance which should set off warning bells in and of itself. I have been banging my head against the wall about this(as have others) because you don't know someone is non-emergent until you have VS. this wonderful plan has also sent folks in PSVT to fast track, etc

even worse, they want us to see the patients without VS and then have the VS done at d/c if it is busy. if the complaint is "ankle sprain" then ok, but if the complaint is cough/fever/sob, etc I just leave them in the rack until I get a set of VS. this was a physician and hospital admin. plan and it sucks. we have had numerous pts d/c home without vs ever being taken. frickin incredible and indefensible.

[CAdamsPAC]

well aware that this kid was circling the drain...it's all about the #s. they want the fastest door to provider time possible to make their #s look good so "non-emergent" patients get triaged with VS in the area they are seen in by the primary nurse, not out front. This kid was hispanic so it wasn't as obvious that they were cyanotic just "dusky" at first glance which should set off warning bells in and of itself. I have been banging my head against the wall about this(as have others) because you don't know someone is non-emergent until you have VS. this wonderful plan has also sent folks in PSVT to fast track, etc

even worse, they want us to see the patients without VS and then have the VS done at d/c if it is busy. if the complaint is "ankle sprain" then ok, but if the complaint is cough/fever/sob, etc I just leave them in the rack until I get a set of VS. this was a physician and hospital admin. plan and it sucks. we have had numerous pts d/c home without vs ever being taken. frickin incredible and indefensible.

 

E, you answered my unasked question about accountability and professional standards of performance.........EFFING Suites and PR a-wholes deciding how medicine should be practied so THEY can look good and pat each other on the back over how great they are at running and ED!!!!!!I can't stand even looking at these inept backstabbing selfpromoting SOBs! This is why I'm back in the Aleutians as far away from this behavior and these people as I can be!!! There is NO EFFING EXCUSE for this child to have been so mistriaged! Glad that you were there, someone competent and caring was the first need for this child!!!!!!

[EMEDPA]

next day f/u on septic baby:

still in PICU, doing better.:

rsv +. will be in ICU for at least 3 days until the results of all cultures are available.

[ajnelson]

next day f/u on septic baby:

still in PICU, doing better.:

rsv +. will be in ICU for at least 3 days until the results of all cultures are available.

 

 

I've had some really sick RSV babies this year. Think I've admitted at least a dozen and probably 2-3 have gone to ICU.

[Fat Albert]

EMEDPA: aren't most folks who present with PSVT (w/ no underlying pathology) non-emergent?

[EMEDPA]

EMEDPA: aren't most folks who present with PSVT (w/ no underlying pathology) non-emergent?

if your sx due to psvt are bad enough that they bring you to the er you need to have the condition addressed quickly: syncope, hypotension, chest pain, dizzyness, etc

it's hard to walk around with a heart rate of 200+ for very long and not be symptomatic....fast track is not the ideal location to be using adenosine and/or doing cardioversion.

[ajnelson]

The only way you are going to know if they are emergent vs non-emergent is to have monitoring of VS and cardiac monitor, EKG, etc. Which cannot be done in a fast track setting. Also, you don't want a patient that is potentially going to crash in a fast track type bed. The PSVT patients that show up in the ED are usually still in SVT and need semi-emergent treatment (adenosine vs cardioversion). If this is new onset PSVT, one does not know if there is underlying pathology until workup is done. And if the patient has known PSVT, they are not likely going to come to the ED until they tried Valsalva (or even meds) at home.

[jwells78]

I can add to this.

 

I call this one: "always look."

 

Had a guy come in a year ago at a different ER job, triage note said this: "burns to back."

 

This guy had been heating his living room with a propane stove and it caught his shirt on fire while his back was turned to it; 3rd degree burns to his ENTIRE back, shoulders and upper buttocks. He didn't complain of pain... why? Because he had NO SENSATION. He had been sitting in the WR for 4 HOURS.

 

Needless to say, that guy went to UC Davis.

 

 

And another one, same hospital (that I no longer pick up shifts at).

 

5 y/o boy with "weakness" as the complaint.

 

Ok, so I don't think it's that hard to tell a sick person from a well or AKA "not going to crump in the next 30 minutes" person, it's really more of a common sense thing... especially amongst ER peeps. So when I walk in and the kid is Altered, pale, febrile, won't answer questions, and cries out if I move him with positive meningeal signs, and the mother tells me he developed flu symptoms 2 days ago, and today they had to CARRY him everywhere... I see a SICK KID. JOE snuffy at Blockbuster Video would see: A SICK KID.

 

Moreover, I see a sick kid that someone out front should have maybe discussed with the team leader and not let sit in the rack for, I don't know- ANY amount of time before being seen.

 

Luckily, worked him up, sent him away to Davis with Niesseria Meng and he had full recovery last I heard. Glad he didn't sit in the WR.

[Corpsman2PA]

Jwells, Where abouts are you practicing?

[jwells78]

Still rocking in Redding, Norcal... The OTHER level II in town.

[ktcan10]

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.

 

I'm only a pre-PA EMT, but I had a similar 911 call. Young female spanish-speaking c/c lower abdominal pain and self-described "rectal bleeding" from "burst hemorrhoids". Vehemently (and I mean vehemently) refused to allow examination by EMS and possibility of pregnancy. Turned out to be a very unfortunately, very tragically deceased breech position delivery that got stuck on the shoulders and was about five hours old. Sad case.

[jdumoch]

37 y/o healthy female no medical history, no family history, no currents meds runs 3 miles per day. 12 hours of chest pressure and shortness of breath almost entirely relieved by leaning forward. ekg with minimal st elevations anteriorly. positive troponin. to cath lab with 100% clean cardiac cath. apical ballooning noted. dx stress cardiomyoapthy or "broken heart syndrome."