This is why I love EM!
I left my ED shift yesterday feeling so great from the mix of pathology and opportunity to be involved, and I just wanted to share a few learning points from yesterday with my fellow applicants:
Mid 30s male with aortic dissection, from a proximal point just distal to the origin of the subclavian, all the way down into the SMA, and all the way down into one of the iliacs
-This was a valuable learning experience for me. All you had to do was look at the dude from the door and you could tell some badness was happening. He wasn't complaining so much, but the look on his face was of a man trying to conceal his pain and fear in front of his fiance. He looked very uncomfortable, sorta like a kidney stone but more subtle. Kept shifting his weight in bed. He wasn't my patient initially, so I didn't take the history, but when I saw the CT I went in the room to get a look at him. He described his pain as being pretty classic, substernal but radiating to the back, and he said he developed some abdominal pain since he arrived. Equal pulses, neurologically intact. They scanned him based on chest pain with a history of uncontrolled HTN, I don't even think he mentioned the back pain at that time. I'll have to find out what happened to him today, as CVS took him up to the CVICU, and I expect he would be medically managed based on having a Type B/III. They were starting an esmolol gtt in the ED.
40yo male, motorcycle vs. ?, of the extremities only his RUE was spared from nasty fractures, also had a fracture of the transverse process of C6 and so needed a CTA. Crepitus over the thorax, multiple broken ribs, CXR looked like pulmonary contusions to me but I didn't read the official report. Got a L-sided chest tube for a small pneumo. Initial FAST performed by trauma resident was negative and vitals were stable, but on CT he had a sufficient splenic lac with enough bleeding to get him to the OR for a splenectomy.
The attending asked if I knew what a Maisonneuve fracture was, and I did not.
http://lifeinthefastlane.com/education/who-was/eponymous-fractures/
Main teaching point in that conversation was that if you have a proximal or distal fracture of the lower leg that disrupts the interosseus ligament, that ligamentous disruption can spread proximally or distally to affect the other joint (knee or ankle depending on where it started).
70ish woman who fell on her porch, had a dislocated elbow. We did "conscious" sedation with propofol for the reduction, which went well, until after her elbow reduced and that painful stimulus subsided. ETCO2 and pulse ox alerted us, we tried stimulating her, I gave her a jaw thrust and bagged her for a couple minutes.
The lesson here is really to make sure you always have ETCO2 for "conscious" sedation, and to be well-versed in what it means and what it can tell you. There's a great EMCrit podcast on the use of ETCO2, and I highly recommend it. There's also a lot of online articles.
We also had an ischemic stroke in a 70yo man with a history of a prior stroke leaving him weak on his right side. His grandson said he was seeming confused and talking funny, and it started abruptly. He has able to call his grandson by name, but on arrival, he was unable to tell me his name, the year, our location, or the president. He couldn't give me the name of my watch or my pen. He was articulating his words well, just not making much sense, saying "that's, uh, that's the name, the name? I have, yeah, it's that..." When asked to open his eyes, he opened his mouth. I was the first person to see him in the room, and when I asked his name and he couldn't tell me, but was still pronouncing things correctly without slurring, I went down that avenue of language deficits. He had no increased weakness on his good side. CT was negative, MRI showed a CVA in the left posterior temporal area. No TPA due to h/o recent GI bleed with hemoccult positive and no obvious hemorrhoids. The lesson here was to remember that the neuro exam isn't just motor, sensory and coordination.
Hope you're all having fun on rotations and learning a lot!