This place is getting boring, post something good.

[RustedFox]

You heard me.

---

Members don't see this ad.

 

[HemorrhagicShock]

Life is short

Life can also be long

 

[bravotwozero]

Anyone read the brothers karamazov, by Dostoevsky? I'm in a book club, and that's what's up next...

 

[Tenk]

 

[Siggy]

Attempting to get scuba certification and having to do CPR on a dive boat sucks...

Now I just need a free weekend to do the 3rd and 4th open water dives.

 

[PikminOC]

Does it really make sense to travel outside the US with how terrible medical care is in the rest of the world?

 

[The Knife & Gun Club]

Attempting to get scuba certification and having to do CPR on a dive boat sucks...

Now I just need a free weekend to do the 3rd and 4th open water dives.

Air embolism? Pneumo? Underwater seizure?

Dive/undersea medicine is probably one of the coolest niches of EM

 

[RustedFox]

Air embolism? Pneumo? Underwater seizure?

Dive/undersea medicine is probably one of the coolest niches of EM

Yeah, this gets a win.
My money is on air embolism.

 

[DeadCactus]

Yeah, this gets a win.
My money is on air embolism.

I'm going to go with good ol' ACS, especially in an open water dive class.

 

[RustedFox]

I'm going to go with good ol' ACS, especially in an open water dive class.

Forgive me: ACS?

I'm so bad at anagrams.

 

[DeadCactus]

Sorry, acute coronary syndrome.

 

[Siggy]

Air embolism? Pneumo? Underwater seizure?

Dive/undersea medicine is probably one of the coolest niches of EM

I wish it was something as sexy.

So this is a general dive boat that the open water class was on. It’s day 2, so open dive number 3 and 4. The boat has other groups besides the class.

There’s a fairly decent current, but that’s not abnormal and normally there’s no or minimal current on the sea floor. The class was on the lag line finishing our skills (surface marker buoy, clearing goggles, duffing/donning the BCD in the water) and about to go for the dive when I see a life ring float past. “Uhh, instructor, I don’t think that’s supposed to be out here…”

We get told to get back on board. As we get back towards the back of the boat they’re trying to recover a diver that’s unresponsive. 18 year old, certified (not what level, but at least open water). Apparently he never ended up diving to depth (so lung reexpansion injury shouldn’t be possible) and the depth (50 feet) and time would be a non-decompression dive anyways.

I realize what’s happening. Scramble on board, grab their o2 setup. Patient gets pulled out in arrest and it’s almost impossible to ventilate due to size (obesity, round face) and atelectasis from loss of surfactant. Coast guard was there in what felt like 10 minutes (nothing to add but manpower unfortunately). Fire rescue in 15. Got him on the LUCAS. Life pack showed asystole. Fire rescue then transported while the boat waited for 3 hours for the state law enforcement to come out and take pictures of the boat.

In the future I’m going to ask if I can ride with fire rescue and “help” if for no other reason than not be stuck on the boat for hours doing nothing.

An OPA would have been nice to have. I’m also sure that I have a deposition in my future (should have federal and state good Sam protection, so I shouldn’t be a named party).

 

[The Knife & Gun Club]

I'm going to go with good ol' ACS, especially in an open water dive class.

It’s never the cool sexy pathology. It’s always ACS.

 

[Dred Pirate]

Attempting to get scuba certification and having to do CPR on a dive boat sucks...

Now I just need a free weekend to do the 3rd and 4th open water dives.

I love scuba -and have seen the cpr on a dive boat - not fun - if you want ideas of places to go - shoot me a message - heading to Bonaire for the 8th time in a month or so

 

[Dred Pirate]

I wish it was something as sexy.

So this is a general dive boat that the open water class was on. It’s day 2, so open dive number 3 and 4. The boat has other groups besides the class.

There’s a fairly decent current, but that’s not abnormal and normally there’s no or minimal current on the sea floor. The class was on the lag line finishing our skills (surface marker buoy, clearing goggles, duffing/donning the BCD in the water) and about to go for the dive when I see a life ring float past. “Uhh, instructor, I don’t think that’s supposed to be out here…”

We get told to get back on board. As we get back towards the back of the boat they’re trying to recover a diver that’s unresponsive. 18 year old, certified (not what level, but at least open water). Apparently he never ended up diving to depth (so lung reexpansion injury shouldn’t be possible) and the depth (50 feet) and time would be a non-decompression dive anyways.

I realize what’s happening. Scramble on board, grab their o2 setup. Patient gets pulled out in arrest and it’s almost impossible to ventilate due to size (obesity, round face) and atelectasis from loss of surfactant. Coast guard was there in what felt like 10 minutes (nothing to add but manpower unfortunately). Fire rescue in 15. Got him on the LUCAS. Life pack showed asystole. Fire rescue then transported while the boat waited for 3 hours for the state law enforcement to come out and take pictures of the boat.

In the future I’m going to ask if I can ride with fire rescue and “help” if for no other reason than not be stuck on the boat for hours doing nothing.

An OPA would have been nice to have. I’m also sure that I have a deposition in my future (should have federal and state good Sam protection, so I shouldn’t be a named party).

are you sure the lung injury/emoblism isn't a possiblity? I mean from 33 feet to the surface is one atm = doubling of the air size. if you hold your breath without doing a CESA from that depth you can definitely get a fatal injury - The greatest percentage increase is in that last atmosphere -

 

[Siggy]

are you sure the lung injury/emoblism isn't a possiblity? I mean from 33 feet to the surface is one atm = doubling of the air size. if you hold your breath without doing a CESA from that depth you can definitely get a fatal injury - The greatest percentage increase is in that last atmosphere -

My understanding is he didn’t actually start the dive and the entire event was at the surface.

Sure. You can get expansion injury from a relative short uncontrolled ascent.

 

[Dred Pirate]

My understanding is he didn’t actually start the dive and the entire event was at the surface.

Sure. You can get expansion injury from a relative short uncontrolled ascent.

ahhh - gotcha - that makes more sense,

I figured to have an event at the surface for an 18 year old would be pretty rare,

 

[The Knife & Gun Club]

So here’s a case I would love some thoughts on:
35 year old female, previously healthy-ish but IVDU, came in as a cardiac arrest. Per EMS her jaw had “locked up.” Down time unknown and asystole on the monitor. No drug paraphernalia on the immediate scene.

Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.

We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.

We were trying to decide if it’s worth it to cric and establish a definitive airway. Likelihood of success is obviously exceedingly low but she’s a previously healthy-ish, and in a can’t intubate can’t ventilate situation with a presumed hypoxic arrest.

I decided to cric - got the airway, got ETCO2 and O2 sat went from undetectable to 95%. Ran CPR a few more rounds. Ultimately called it.

In the end I felt better talking to the family (her mom, husband, little kid at home) and being able to tell them we really did try absolutely everything to give her any shot and they were grateful. I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)

 

[Siggy]

ahhh - gotcha - that makes more sense,

I figured to have an event at the surface for an 18 year old would be pretty rare,

everything prior to when he was pulled back on the boat is second hand. There was some comment that his regulator got entangled. However that’s what the octo is for.

I was looking online to see if dive boats carried any airway gear. It was a little surprising to see no suction or OPAs on board as those would be low skill, high dividend tools. I subsequently came across this blog post relating what seemed to be a similar story of a young diver drowning on the surface. Essentially if you don’t have your reg in and grab onto a line in a current, you will be inhaling water.

011 Airway Control: What's All The Fuss? - ScubaGuru

In this episode of The Dive Locker podcast you’ll learn why airway control is such an important life saving skill for scuba divers.

scubaguru.com

 

[Dred Pirate]

everything prior to when he was pulled back on the boat is second hand. There was some comment that his regulator got entangled. However that’s what the octo is for.

I was looking online to see if dive boats carried any airway gear. It was a little surprising to see no suction or OPAs on board as those would be low skill, high dividend tools. I subsequently came across this blog post relating what seemed to be a similar story of a young diver drowning on the surface. Essentially if you don’t have your reg in and grab onto a line in a current, you will be inhaling water.

011 Airway Control: What's All The Fuss? - ScubaGuru

In this episode of The Dive Locker podcast you’ll learn why airway control is such an important life saving skill for scuba divers.

scubaguru.com

ya- I live in NC - so we have some good off shore diving, but also can get into some sketchy situations pretty quick with heavy currents, and 8 foot seas coming out of nowhere.

always have the reg in your mouth before leaving the boat, seen people jump in over weighted with their snorkle in their mouth, and then a frantic few moments while they struggle to not die. We are all just a bad decision or two from getting ourselves in a world of ****. And every new diver is over weighted.

 

[WilcoWorld]

35 year old female, previously healthy-ish...I do wonder if the cric was truly indicated

Oh man, you've gotta try the hail marry on that one. Can't let a 35 yo die an airway death without using all your tools. Good job.

 

[Kryptocoin]

A woman goes to five different doctors with a complaint of palpitations. No one orders any labs on her. She was given mainly reassurances and discharged. One of the doctors even did a heart cath on her.

Woman still having symptoms, finally goes to the Cleveland Clinic, where she had lab tests done that showed hyperthyroidism. She was started on appropriate treatments and symptoms finally abated.

Woman's name: Oprah Winfrey.

Moral of the story: Outpatient medicine is dead?

A doctor told Oprah to 'embrace hunger.' How it changed her view of medicine forever

Ahead of a new documentary about racial inequities in healthcare, the TV host opens up to The Times about her own experiences.

www.latimes.com

 

[CajunMedic]

Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.

We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.

That's a tough one. My first thought is deep space infection, followed by tetanus. I've seen some weird infections in my IVDU population. Unable to ventilate, even with an NPA sounds like maybe a retro-pharyngeal abcess? But the bilateral mandible swelling is odd as well.

I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)

Yep. As said above, that's one you've got to use whatever you've got in the toolbox for the patient. Strong Work!

 

[The Knife & Gun Club]

That's a tough one. My first thought is deep space infection, followed by tetanus. I've seen some weird infections in my IVDU population. Unable to ventilate, even with an NPA sounds like maybe a retro-pharyngeal abcess? But the bilateral mandible swelling is odd as well.

Yep. As said above, that's one you've got to use whatever you've got in the toolbox for the patient. Strong Work!

Yea that’s the tough thing about IVDU, they really do manifest just the most bizarre infections even in healthy people.

I’m sure where you’re located in the northeast/Appalachia you probably see more of it than I do. Even at our large tertiary center in Miami we don’t see all that much. People here tend to prefer drugs they can snort.

If I had to guess I’d put my money on something along the RPA/Ludwig’s/PTA spectrum.

 

[maxxor]

Yea that’s the tough thing about IVDU, they really do manifest just the most bizarre infections even in healthy people.

I’m sure where you’re located in the northeast/Appalachia you probably see more of it than I do. Even at our large tertiary center in Miami we don’t see all that much. People here tend to prefer drugs they can snort.

If I had to guess I’d put my money on something along the RPA/Ludwig’s/PTA spectrum.

Maybe with a sprinkle of danger space infection.

 

[CajunMedic]

I didn't get eased into attendinghood. 3 of my first 4 night shifts I had major traumas that my community hospital is not used to, nor has much capability to care for.

#1- Teen gets thrown from ATV that subsequently lands on their unhelmeted head, gash from nasolabial fold, to corner of mouth, to angle of mandible. Almost completely through to buccal mucosa. Full trauma workup and helicopter ride to peds trauma center with OMFS standing by.

#2- Old enough to know better, intoxicated on Fireball, jumps from ATV, with the ATV running their foot over. Open bi-mal fracture/dislocation. conscious sedation, reduction, and our ortho won't touch it. Ground to trauma center for ortho

#3- Trauma code with ROSC and intubation in the field. This was the impressive one. EMS decided to come to us because the bird was going to take a while. I had a solid PGY-3, 2 PGY-2's, and 1 intern who hadn't taken ATLS yet. Plus, we actually had enough nurses who were experienced. Elderly patient on NOAC, found at bottom of stairs in pool of blood, actively exsanguinating from where the stairs effectively scalped them. Got blood, TXA, Keppra loading, Trauma scans, KCentra (despite the pharmacist telling me on the phone "umm, I can't order this under my name, it's kinda expensive.", "Well, put it under mine then"). Wound up on Levophed. I did a subclavian with a PGY-2 at my side, walking them through it (they don't do many of them). Had the goals of care conversation with the family multiple times, they wanted the transfer despite knowing the likely outcome. At least they agreed to DNR. They had a a skull fx, multiple spinal fx, broken ribs, SAH, SDH, you name it. Got a lucky break in the weather to get the helicopter to pick up the patient. Despite not having a true trauma team or trauma bay, it was one of the smoothest running traumas I have participated in. Everyone performed exceptionally well. Unfortunately, even with everything we did, they died the next day.

 

[turkeyjerky]

Yea that’s the tough thing about IVDU, they really do manifest just the most bizarre infections even in healthy people.

I’m sure where you’re located in the northeast/Appalachia you probably see more of it than I do. Even at our large tertiary center in Miami we don’t see all that much. People here tend to prefer drugs they can snort.

If I had to guess I’d put my money on something along the RPA/Ludwig’s/PTA spectrum.

Septic arthritis of TMJ maybe? Personally, I wouldn't put too much stock into jaw swelling-some people just look like chipmunks. I think you did the right thing cric'ing the patient, sounds like a resp arrest in a young patient--I never call codes w/o establishing an airway. (although I wouldn't criticize someone for just calling one in an unwitnessed asystolic arrest).

I did a subclavian with a PGY-2 at my side, walking them through it (they don't do many of them).

Ballsy move w/ a doac on board, good on you.

 

[Mofasa]

So here’s a case I would love some thoughts on:
35 year old female, previously healthy-ish but IVDU, came in as a cardiac arrest. Per EMS her jaw had “locked up.” Down time unknown and asystole on the monitor. No drug paraphernalia on the immediate scene.

Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.

We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.

We were trying to decide if it’s worth it to cric and establish a definitive airway. Likelihood of success is obviously exceedingly low but she’s a previously healthy-ish, and in a can’t intubate can’t ventilate situation with a presumed hypoxic arrest.

I decided to cric - got the airway, got ETCO2 and O2 sat went from undetectable to 95%. Ran CPR a few more rounds. Ultimately called it.

In the end I felt better talking to the family (her mom, husband, little kid at home) and being able to tell them we really did try absolutely everything to give her any shot and they were grateful. I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)

I had a very similar case in a young guy a while ago, presumed to also be an IVDU. I gave benzos and even paralytics for fun just to see if it will relax his jaw with no success. So also ended up cric'ing him just to say I got an airway before calling it. Found some case reports afterwards that describe similar patients: Emergency cricothyrotomy for trismus caused by instantaneous rigor in cardiac arrest patients - PubMed

 

[WilcoWorld]

A woman goes to five different doctors with a complaint of palpitations. No one orders any labs on her. She was given mainly reassurances and discharged. One of the doctors even did a heart cath on her.

Woman still having symptoms, finally goes to the Cleveland Clinic, where she had lab tests done that showed hyperthyroidism. She was started on appropriate treatments and symptoms finally abated.

Woman's name: Oprah Winfrey.

Moral of the story: Outpatient medicine is dead?

A doctor told Oprah to 'embrace hunger.' How it changed her view of medicine forever

Ahead of a new documentary about racial inequities in healthcare, the TV host opens up to The Times about her own experiences.

www.latimes.com

Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidism

 

[RoyBasch]

My understanding is he didn’t actually start the dive and the entire event was at the surface.

Sure. You can get expansion injury from a relative short uncontrolled ascent.

A surprising amount of scuba drownings occur at the surface. Strong current/waves, seawater in the face/mouth, panic sets in, irrational behaviors, more seawater aspiration, death spiral. That’s why they encourage regulator in your mouth at all times until back on the boat and establishing full buoyancy once at the surface.

That being said, I have no idea what happened, could have been an unrelated rare medical event in a young thought to be healthy person (massive PE from unknown clotting d/o, STEMI from ALCAPA, VF from underlying sodium channel-opathy, etc.)

 

[RoyBasch]

So here’s a case I would love some thoughts on:
35 year old female, previously healthy-ish but IVDU, came in as a cardiac arrest. Per EMS her jaw had “locked up.” Down time unknown and asystole on the monitor. No drug paraphernalia on the immediate scene.

Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.

We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.

We were trying to decide if it’s worth it to cric and establish a definitive airway. Likelihood of success is obviously exceedingly low but she’s a previously healthy-ish, and in a can’t intubate can’t ventilate situation with a presumed hypoxic arrest.

I decided to cric - got the airway, got ETCO2 and O2 sat went from undetectable to 95%. Ran CPR a few more rounds. Ultimately called it.

In the end I felt better talking to the family (her mom, husband, little kid at home) and being able to tell them we really did try absolutely everything to give her any shot and they were grateful. I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)

You did the right thing. Low likelihood of success but I think 35 yo relatively healthy you gotta pull out all the stops.

 

[Old_Mil]

Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidism

That reminds me of a sucidal ideation that was triaged to our fast track once. Pleasant middle aged woman, no obvious red flags. "So ma'am, the nurses tell me you want to kill yourself. Can you tell me what's going on?" "Well, I have these horrible headaches that started a couple if years ago and nobody can help me." "So tell me about your headaches.". She goes on to describe a classic space occupying lesion headache...which the CT scan confirmed.

 

[WilcoWorld]

STEMI from ALCAPA

For a minute I thought, how does an alpaca cause a STEMI, and what's one doing out on the water?!?

 

[CoolDoc1729]

Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidism

But that is the whole thing. Most people with palpitations go to the ER or the PCP, not to the chair of cardiology at Mayo or whatever .. the chair of cardiology assumes the labs were already normal before the patient got to them…

During residency a patient signed in for SI and was triaged to our locked psych area. When I went to see him no one had gotten him undressed yet … he had a self inflicted GSW to the abdomen .. “I told them I was going to kill myself!” 🤦🏻‍♀️

 

[wholeheartedly]

and threads like these are why i love this forum…

 

[Kryptocoin]

Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidism

Like for real. No one has heard of TSH?

 

[MechEDoc]

I have a relatively healthy, mid-30 something with a paraumbilical vein thrombosis, presented with pain on deep inspiration. D-dimer of 501 (threshold 500) lead to a CTA Chest, which lead to a CT abdomen which found the issue.

WTF?

 

[Mount Asclepius]

I have a relatively healthy, mid-30 something with a paraumbilical vein thrombosis, presented with pain on deep inspiration. D-dimer of 501 (threshold 500) lead to a CTA Chest, which lead to a CT abdomen which found the issue.

WTF?

Seems like an example of a person that is maybe too in tune with their body and can’t tough out a little pain leading to a bunch of downstream expensive testing that ultimate doesn’t change management. I’d suspect that anticoagulation for paraumbilical vein thrombosis would have limited efficacy. Did you end up doing anything about it? Did they also have liver disease?

 

[RustedFox]

What I want to know is what was the CTA finding that led to the CT Abd/Pelvis.

 

[turkeyjerky]

Seems like an example of a person that is maybe too in tune with their body and can’t tough out a little pain leading to a bunch of downstream expensive testing that ultimate doesn’t change management. I’d suspect that anticoagulation for paraumbilical vein thrombosis would have limited efficacy. Did you end up doing anything about it? Did they also have liver disease?

And will of course lead to countless future visits and scans b/c of "i have a clotting disorder".

 

[WilcoWorld]

I have a relatively healthy, mid-30 something with a paraumbilical vein thrombosis, presented with pain on deep inspiration. D-dimer of 501 (threshold 500) lead to a CTA Chest, which lead to a CT abdomen which found the issue.

WTF?

What was the issue?

 

[MechEDoc]

No liver disease, some portal vein extension (non-occlusive), so anticoagulation with Coumadin (insufficient NOAC evidence). CTA PE showed some weird inflammation below the diaphragm -> CT abd/pelvis -> Dx -> lots of phone calls.

 

[CajunMedic]

This was probably the second-most spinchter-clenching case of my entire medical career.

EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital

 

[RustedFox]

This was probably the second-most spinchter-clenching case of my entire medical career.

EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital

Damn.
You're getting trial by fire early in your young attendinghood.

I don't think there's anything you're gonna do there beyond what you did.

 

[Mount Asclepius]

This was probably the second-most spinchter-clenching case of my entire medical career.

EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital

Gnarly case. Not fun to have, but great to add to your experience list.

I think in Tetralogy of Fallot you put them in the knee-chest position or have them squat. In transposition of the great vessels isn’t the key supposedly to do everything to avoid making them cry even avoiding an IV?

Also sounds maybe more complicated given all their prior surgeries and atrial flutter with RVR.

I could be completely wrong, just vaguely remembering this from medical school and residency from the peds EM attendings.

 

[Mount Asclepius]

I used to think - still kind of do - that the coolest part of an EM career would be if I got to do a resuscitative hysterectomy (perimortem C-section) with both the baby and mom surviving. I’ll likely never get to do one, and odds aren’t great that it will be a good outcome.

I did recently deliver a baby for the first time in many years involving reducing a nuchal cord and aggressively stimulating in the setting of fluid with light mec. Very normal patient/family that hadn’t expected me to be the one delivering, or for it all to happen in the ED. Probably quite routine for most OBs, but certainly out of my comfort zone given lack of doing for years. Felt very rewarding in a way that gives me a sense of peace if I never have that once in a career moment.

Makes me really value our skill set versus having subspecialty training. Also feels rewarding when we spend a lot of time doing nothing for all of the worried well that we deal with on the average shift.

 

[Groove]

I used to think - still kind of do - that the coolest part of an EM career would be if I got to do a resuscitative hysterectomy (perimortem C-section) with both the baby and mom surviving. I’ll likely never get to do one, and odds aren’t great that it will be a good outcome.

I did recently deliver a baby for the first time in many years involving reducing a nuchal cord and aggressively stimulating in the setting of fluid with light mec. Very normal patient/family that hadn’t expected me to be the one delivering, or for it all to happen in the ED. Probably quite routine for most OBs, but certainly out of my comfort zone given lack of doing for years. Felt very rewarding in a way that gives me a sense of peace if I never have that once in a career moment.

Makes me really value our skill set versus having subspecialty training. Also feels rewarding when we spend a lot of time doing nothing for all of the worried well that we deal with on the average shift.

Perimortem c-section?

No thanks! I could be perfectly happy never performing that procedure. If mommy lives and that baby dies, regardless of care, just get ready for a monster lawsuit that will 100% settle because the optics of these of cases are always terrible and no jury is going to be able to think straight. They'll get focused on the 30-90 seconds worth of nursing note timestamps that make it seem like you delayed the procedure.

That's probably the worst part of OB/peds...the almost guaranteed threat of suit if you screw it up. I don't envy OB at all with their monstrous malpractice premiums. I probably spend more time on defensive documentation in OB/peds cases than I do during anything else.

 

[PTPoeny]

Gnarly case. Not fun to have, but great to add to your experience list.

I think in Tetralogy of Fallot you put them in the knee-chest position or have them squat. In transposition of the great vessels isn’t the key supposedly to do everything to avoid making them cry even avoiding an IV?

Also sounds maybe more complicated given all their prior surgeries and atrial flutter with RVR.

I could be completely wrong, just vaguely remembering this from medical school and residency from the peds EM attendings.

Yes, in kids with unrepaired Tet squat/knee to chest will help. But it is also kids with Tet -a subset of them, at least- that will turn blue with crying/agitation, not transposition.

But, yeah, DORV with TGA who has had 5 surgeries is likely single ventricle physiology and something hasn't gone well to get to 5 surgeries...

 

[MechEDoc]

This was probably the second-most spinchter-clenching case of my entire medical career.

EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital

Medicine or Edison? Looks like you went for medicine, but why not cardiovert?

 

[Mount Asclepius]

If mommy lives and that baby dies, regardless of care, just get ready for a monster lawsuit that will 100% settle because the optics of these of cases are always terrible and no jury is going to be able to think straight.

I hear what you are saying. Medmal is ridiculous and it’s certainly possible, but I disagree. I practice at times fairly defensively, but there are also times when you throw the kitchen sink at a problem in resuscitation and it’s exhilarating, especially with a good outcome. You just don’t get sued much when you do everything possible. It’s the missed diagnoses, bad discharges and incidental findings that get you. Not saving someone’s life. You just saved a young healthy life! Mom can have another baby even if you didn’t have the incredibly rare outcome of both surviving neuro intact.

You literally just sit on the stand and say, “She was dead. I was able to restart her heart. I’m so sad that her baby didn’t survive while their mom was dead.” I can live with that outcome all day if I had been able to keep the mom alive.

Lastly, it’s just as important to communicate well with family in these situations. You have to discuss how dire the situation is, everything you did, and most importantly provide empathy. Won’t stop you from ever being sued, but I think these things mitigate the risk.