"it's probably nothing"-fast track disasters

[skyblu]

I have a couple of recent gems from my recent Fast Track shifts.

 

1) A 23 yo Hispanic female is put in an RME room (not even fast track!) with her boyfriend for a "small lac on L breast".

 

She's pale, diaphoretic, tachycardic, hypotensive. Triage did no vitals (because she's RME), and didn't look at the "lac", just took patient's word for it. Didn't bother with interpreter, patient pointed to general area of left thorax and said "a cut".

 

Sure enough, she does have "a small lac". But not on her breast, but on her LUQ. Except its not a lac, but a stab wound with an underlying splenic lac.

 

When I endowed the RN with a brand new anus, his answer was "she said the cut was only this big!" (holding fingers an inch apart)

 

Lengthy lecture on penetrating wounds followed. And language barriers. And the fact she was evasive of the exact mechanism because it was her boyfriend who stabbed her and he's standing in the room.

 

2) 63 yo guy with left "ribcage" pain after falling off a ladder.

 

He's tachypneic, SUPER sick looking, can barely speak. Was in the waiting room for a couple hours...

 

With a traumatic dissection to a AAA THAT WAS IN HIS CHART UNDER PMHx!

 

I ultrasounded him at the bedside myself while literally screaming for help. He made it to the OR with a pressure of 40/palp after norepi.

 

Sure, triage couldn't know the guy was dissecting his triple A. And he did also have a couple of rib fractures. But he looked way sick. Besides, a traumatic chest or abdominal pain with a decent mechanism (8 ft fall) should not be fast track!

[Just Steve]

I love those little cuts... medic working the streets, called to bar sp altercation, police on scene, one in custody for an eval. Everyone is doing the peacock strut on scene, including the perp in hand cuffs. "just got nicked, needs a wash and dressing" says the cop. "Ain't nuthin, leave me the *&^% alone" says the perp. "That's a stab wound that may have reached your liver, you're going to the trauma center" says me the medic. "Ef you" says the cop, who doesn't want the hassle of riding to the ER. "Ef you" says the perp, who doesn't want to go to the ER. "Ef you both" says me the medic. My scene, my patient, my call. Get in the rig, we're rolling.

 

15 minutes by land to the Trauma bay. Last 5 minutes the perp turns ashen, diaphoretic, starts to tach even more than he was. His adrenaline from the fight finally wore off and he stopped compensating so well. Straight to the OR we went for his liver lac.

 

not a fast track find, but one that could, and did with the above poster, walk into your ER.

[peaceloveandPA]

Nice call!

 

 

Let food be thy medicine

[Leeg]

38 yo female presents ambulatory for evaluation neck pain s/p mva the previous night. Admits to ETOH use as cause of the single car accident. Spent night in jail "sleeping on concrete floor". Mild TTP midline lumbar spine. CT show burst fracture L1 with protrusion into spinal canal. Patient walked in and left via EMS to larger hospital for surgery.

[TheDude]

As a PA student, I still work the helo and the rig some (in between my weekly floggings from professors), and also goofing off in the ER between flights.  The hospital for the flight program I work for is a level 1 trauma center and teaching hospital with other "areas of excellence" as they call it.  I can not hold a stone to the types of assessments and such as you seasoned PA's do, but here is a good one.  

 

Working the helo, waiting on weather to pass so my partner and I mosy over to the ED out of sheer boredom and to hit on the cute nurses.  A nurse asks us if we can do an IV start and draw some labs, do an ECG on a lady that was there for foot/leg pain.  Of course we look at each other and roll our eyes being the smart-asses we are, and we head to the patients cubicle....this is similar to a fast track unit.  Knocking on the door (curtain) the patient, a well fit and trim 40ish something y/o female bolts out of the room says she has to go to the bathroom bad....makes it 10 steps equivalent to a sprint....little to say the browns didn't make it to the super bowl, and she bites the dust...literally.  As we walk down to where she landed, we noticed she wasn't moving...figured she got knocked cold.  So over the stench of liquid death we went to assess her....FULL ARREST.  Got her onto a gurney (C-spine in mind), wheeled her into the nearest room and did the code, with everyone and their damn dog...(remember...teaching hospital).  ROSC after tube and some drugs and good CPR for 5 mins.  EKG showed a global MI, off to cath lab.  Had been in fast track for a couple of hours, no other symptoms or complaints other than intense right foot and occasional knee pain.     

[bgdog]

and also goofing off in the ER between flights. 

 

 Of course we look at each other and roll our eyes being the smart-asses we are,

 

 so my partner and I mosy over to the ED out of sheer boredom and to hit on the cute nurses. 

 

Goof off in the ER, hit on the cute nurses and roll your fricken eyes when asked to do a job by someone senior to you??

 

Really dude, serious.

 

I know you're cool with your flight helmet and fancy jumpsuit, goofing off in the ER and hitting on the cute nurses, but these are patient's lives we are talking about and that includes a modicum of respect and professionalism. 

 

I, and the other physicians, nurses and techs work really hard in the ER.  The last thing WE need is someone standing there goofing off, hitting on the cute nurses AND ROLLING YOUR EYES, when asked to do something that you think is beneath you.

[TheDude]

Goof off in the ER, hit on the cute nurses and roll your fricken eyes when asked to do a job by someone senior to you??

 

Really dude, serious.

 

I know you're cool with your flight helmet and fancy jumpsuit, goofing off in the ER and hitting on the cute nurses, but these are patient's lives we are talking about and that includes a modicum of respect and professionalism. 

 

I, and the other physicians, nurses and techs work really hard in the ER.  The last thing WE need is someone standing there goofing off, hitting on the cute nurses AND ROLLING YOUR EYES, when asked to do something that you think is beneath you.

 

 

First off I am sorry that you can not find humor nor satire in my post.  My attempt to be funny and/or sarcastic obviously slipped past you.  You see, in the ER, we help out between flights, we are a team, as half the flight crews also work the ED/ICU/Cath labs/EMS on the days away from flying.  We work closely with the trauma surgeons and PA's, even taking them on flights as CREW members, not passengers.  When we work, we work well, as a team, we work HARD.  The last thing I or damn near the majority of staff needs is a stuck-up pompous ass that can not have humor or let loose a little bit.  When the shit hits the fan, we work like a fine swiss watch...  I am sorry that you seem to think that my flight suit or helmet makes me a lazy horny guy out looking for a piece of ass...btw I am happily married ;)

 

When I say goof off, our helipad and crew quarters is next to the ED, we often times go and pick up some of the slack....making beds, cleaning things, you know...things beneath us....to help out the staff when times are busy, matter of fact, last night I even went and mopped a room so one of the housekeepers could grab some dinner.  My professionalism and respect for others was a major reason why I got into PA school, at least thats what the nurses, attending, techs, PA's, and NP's tell me.

 

So the next time you decide to ride a high horse or high chair like a child and bash a post, don't take it too seriously, you might get a hemorrhoid or something.   

[EMEDPA]

Okie- I liked your original post and caught the humor.

[TheDude]

Thanks EMEDPA, I am suffering through GI pathophysiology right now...makes me all gassy and sensitive.

[bgdog]

  I am sorry that you seem to think that my flight suit or helmet makes me a lazy horny guy out looking for a piece of ass...

It wasn't the flight suit, it was your post that made me think that.

[bgdog]

...btw I am happily married ;)

 

so.....you goofing off in the ER hitting on all the cute nurse was bull@#$%

 

OR...

 

You're a happily married guy that hits on all the cute nurses.

 

I'm confused, which one is it?

[TheDude]

The post was meant to be humorous, I think the majority of people got it.  And the hitting/flirting/talking/smiling at/taking orders from on the ER nurses part, that was "sarcasm."  Plus, the scenario that happened was way before I met my wife, so I am sure I was guilty of hitting on a nurse or two, maybe even an attending, resident, PA, clerk, paramedic, lunch lady, police officer, mortician, even hit on a female chaplain once, ok maybe twice!  

 

I will not respond to anymore of the "your post, my post" BS anymore, I do not want the thread to be hijacked into a pissing match. 

[skyblu]

Bumping up the thread (and getting away from the flirting debacle)

 

A text from one of my coworkers during their UC shift:
 

"Triage: Wound check.

 

Patient: I've been unconscious for two days and I think my dog was scratching at me trying to wake me up."
 

[medic25]

Fun shift yesterday due to freezing rain; after falling hard myself on the way to work, came in to 20 patients registering in the first 90 minutes of my shift (8 bed satellite ED).  Fast track was closed, so the Level 4's and 5's were triaged to us in the main ED.  Had a level 4 triaged as a "fall, back pain"; one of 19 other falls, so he waited a while and then was triaged to a back hallway bed.  After examining him, find a 70yo on plavix who slipped and fell down his stairs, exquisitely tender in the LUQ and left chest who can't take a deep breath.  One pan-scan later, CT showed 5 rib fractures and a hemothorax!

Pretty amazing shift; never seen so many ice related patients/injuries; my other ice related patients yesterday included:

 

- intracranial bleed s/p fall on ice

-thoracic vertebral fracture s/p fall on ice

-multiple sacral fractures s/p fall on ice

-angulated humerus fracture s/p fall on ice

-plus multiple bad concussions from falls on ice/ice blocks falling from roof onto head!

 

I think it time to move to a sunnier climate...

[just_nelle]

Here's a gem from this week.

 

Working in fast track for the first time in months.

 

First patient of the day, triaged with CC: "rib pain"

 

Triage note: 68 healthy male. Left sided lateral rib pain x4 days after bumping into door hinge. Afebrile P: 90 RR: 20 O2: 95% RA

 

Easy enough I thought, until I saw the patient. Turns out he has no past medical history *other than* glioblastoma, last chemo 6 days ago (minor details, right?). He did bump his left ribs against the door hinge 4 days ago and he thought he might have broken a rib. Pain worse with deep breath, mild dyspnea. No extremity pain/swelling. No cardiac or VTE history. My exam: Speaks in full sentences, splinting due to pain, borderline tachy reg rhythm, decreased but clear breath sounds throughout, tender to left lateral chest wall without ecchymosis/crepitus, no LE edema/tenderness. Popped the oximeter on him during my evaluation, HR ranging from 90-105, O2 ranging from 90-96%.

 

I thought to myself, this guy very well might have rib fractures or some atelectasis/PNA from shallow breathing; maybe even small PTX…but I'm more worried about PE. 

 

Got him moved to a monitored bed (after some head to head combat with ED resource nurse who didn't want to "waste" the valuable real estate on a "guy with rib fractures"), ordered labs, EKG, CXR, PE CT, passed off to colleague working in monitored area, and got back to tending to my lacs and FOOSHes in fast track. 

 

Checked in on the guy at end of shift. Sure enough…saddle embolus. No heart strain on bedside cardiac u/s, bnp and trop nonelevated. Anticoag was initiated, and patient was admitted. One left sided, non displaced rib fx. 

[KMD16]

Good you insisted and stood your ground. I saw a pt w/ similar presentation. Weeks ago in UC. Stand alone UC. Saw a 72 to F formal smoker. No signif PMHx. Very active. Doesn't looks her age. Came in ambulating. Only complain was L sided ribs pain s/p fall from standing stool changing battery in her smoke detector. On exam. VSS. HEENT unremarkable. CV/Lung wnl. Spine cleared. Moving all 4 extremities. Skin intact. Portal CXR demonstrates bursted 8 th rib fx w/ bone fragment & unstable.. 9 th rib fx 50% displaced. 10th rib fx but stable. No evidence of pneumothorax. Dispo: on 2L suppl o2 via EMS. Stable at discharge. Next day, i accessed the ED system and found that At the ED CT chest/Abd shows multiple ribs fx 6th thru 12th w/ small Anterior apical pneumothorax s/p thoracostomy. Pt was admitted.

[ventana]

Here's a gem from this week.

 

Working in fast track for the first time in months.

 

First patient of the day, triaged with CC: "rib pain"

 

Triage note: 68 healthy male. Left sided lateral rib pain x4 days after bumping into door hinge. Afebrile P: 90 RR: 20 O2: 95% RA

 

Easy enough I thought, until I saw the patient. Turns out he has no past medical history *other than* glioblastoma, last chemo 6 days ago (minor details, right?). He did bump his left ribs against the door hinge 4 days ago and he thought he might have broken a rib. Pain worse with deep breath, mild dyspnea. No extremity pain/swelling. No cardiac or VTE history. My exam: Speaks in full sentences, splinting due to pain, borderline tachy reg rhythm, decreased but clear breath sounds throughout, tender to left lateral chest wall without ecchymosis/crepitus, no LE edema/tenderness. Popped the oximeter on him during my evaluation, HR ranging from 90-105, O2 ranging from 90-96%.

 

I thought to myself, this guy very well might have rib fractures or some atelectasis/PNA from shallow breathing; maybe even small PTX…but I'm more worried about PE. 

 

Got him moved to a monitored bed (after some head to head combat with ED resource nurse who didn't want to "waste" the valuable real estate on a "guy with rib fractures"), ordered labs, EKG, CXR, PE CT, passed off to colleague working in monitored area, and got back to tending to my lacs and FOOSHes in fast track. 

 

Checked in on the guy at end of shift. Sure enough…saddle embolus. No heart strain on bedside cardiac u/s, bnp and trop nonelevated. Anticoag was initiated, and patient was admitted. One left sided, non displaced rib fx. 

 

 

Cancer patients on chemo showing up in the ER is almost NEVER a good thing...

 

they usually HATE accessing more care so they are almost never simple (4 and 5)

 

well done!

[EMEDPA]

seen last week in Haiti(ok, not fast track but still fun).

18 month female infant

c/c "my child's nails are too white"

yup, and so were her conjunctiva, skin tone, and gingiva.

That's what happens when your H+H are 3.6/11 (!!!).

very remote location. transfer/transfusion not an option. RX double dose iron + iron to breastfeeding mom. will recheck in 2 months at next mission.

[cinntsp]

seen last week in Haiti(ok, not fast track but still fun).

18 month female infant

c/c "my child's nails are too white"

yup, and so were her conjunctiva, skin tone, and gingiva.

That's what happens when your H+H are 3.6/11 (!!!).

very remote location. transfer/transfusion not an option. RX double dose iron + iron to breastfeeding mom. will recheck in 2 months at next mission.

Oddly enough, I had a 20yo pt last week with a 3.7hgb. She came in because she has been having palpitations while walking.

 

Sent from my Nexus 5 using Tapatalk

 

 

[EMEDPA]

Oddly enough, I had a 20yo pt last week with a 3.7hgb. She came in because she has been having palpitations while walking.

 

Sent from my Nexus 5 using Tapatalk

any idea why? gi bleed? malignancy?

in my pt ( and several similar pts with hgb 2.5-5 in Haiti) it is purely nutritional. They don't get enough iron and have MCVs around 40-50.

[cinntsp]

any idea why? gi bleed? malignancy?

in my pt ( and several similar pts with hgb 2.5-5 in Haiti) it is purely nutritional. They don't get enough iron and have MCVs around 40-50.

Duodenal ulcer. I was off when she got the egd and she was dced by the time I got back so I don't know all the fine details unfortunately.

 

Sent from my Nexus 5 using Tapatalk

 

 

[GetMeOuttaThisMess]

How does one not have sx ischemia at such a level? Perfusion has to be horrible. Wonder if there is such a thing as a compensatory mechanism with the diffused low level O2 in the plasma...

[EMEDPA]

How does one not have sx ischemia at such a level? Perfusion has to be horrible. Wonder if there is such a thing as a compensatory mechanism with the diffused low level O2 in the plasma...

bingo. most folks with anemia in Haiti have either always been anemic or got that way over years.

[ventana]

How does one not have sx ischemia at such a level? Perfusion has to be horrible. Wonder if there is such a thing as a compensatory mechanism with the diffused low level O2 in the plasma...

 

 

yes, and interestingly enough I have seen a few research articles recently that seriously call into question the benefit of transfusion under the current guidelines (7-8 hg)   There is also some interesting data on the Jehovah's Witnesses who don't accept transfusions - and do fine.

[skyblu]

How does one not have sx ischemia at such a level? Perfusion has to be horrible. Wonder if there is such a thing as a compensatory mechanism with the diffused low level O2 in the plasma...

Yes. Very chronic anemics can be astoundingly low. I have a patient who regularly comes in with a crit of 19. We are all like "How are you sill standing?", but he doesn't usually require a transfusion unless she's at 16.

 

This was triaged as UC today. 90 yo F with "fatigue". Anticoagulated on Coumadin, Plavix, AND asa. Almost didn't scan her, she looked so good! Minimal left sided motor deficits which she says are chronic since a CVA a few years ago.

 

This is why I have very low threshold to do a CT in the elderly. No trauma, no real symptoms, this scan: