This place is getting boring, post something good.

[The Knife & Gun Club]

Cool case to share from the other day:
ED Case:
28yo F presents to the ED for 2 weeks of malaise, subjective fevers at home, chills, scant vaginal bleeding, chest pain, RUQ & RLQ abd pain, and palpitations. Arrived here from Guatemala 2 weeks ago, denies PMH/PSH/meds/allergies.

Triage vitals HR130, BP 91/45, O2 100, Temp 37.1, RR 16.

Got fentanyl and IVF 1L.

POC preg faintly positive.

US - no baby, ball looking thing in uterine wall, not sure what it is, FAST negative, IVC plethoric, RV strain with bowing of the cardiac septum.

Send labs, Trop in 0.2 (normal 0.034), BNP 2000, HCG 150 (so barely positive by our assay), WBC 13, AST/ALT 500s, elevated alk phos, normal Tbili. Hb 13. Urine is bloody, not infected. Lactic 1.3.

EKG is just sinus tachycardia wo RV strain pattern or stemi.

No idea wtf is going on - so decide risks outweigh benefits, CTA for PE and CT Abd with IV contrast - all completely negative. Again they see this ball thing in the uterus - they call it as likely a fibroid. So we get a transvaginal US, which is read as normal, but again they note an “intraluminal uterine fibroid, attention on followup”.

She responds well to IVF, gets a 2nd L and BP increases to 110/55.

Pelvic exam shows scant blood without discharge, fetal parts/tissue, or hemorrhage. Normal cervix.

We call OBGYN - not sure what’s going on but maybe it’s an ectopic somewhere? Is the ball really a fibroid? OBGYN resident signs off, says repeat bHCG in 48 hours, the ball is probably a fibroid, and the beta is likely from a completed spontaneous AB - possibly due to structural issues from fibroid.

Pt spikes fever to 38.5. At this point we surrender, cover with vanc and Cefepime, admit to medicine for septic workup without a source.

Inpatient course:
Blood cultures come back 2/2 positive for EColi. Super weird.

Formal echo shows mild RV strain, trended trops remain stable and modestly elevated at 0.2. Cards says likely a stress cardiomyopathy from sepsis, maybe with so pre-existing pulmonary HTN. No evidence of endocarditis or valve pathology. Nothing to do on their end.

Given the elevated transaminases surgery is consulted, they get a Hida scan, and it’s negative for biliary pathology. They sign off.

HCG at 48 hours is unchanged, still low 100s.

Repeat echo at 48 hours shows worsening global myocardial dysfunction. She’s still spiking fevers.

I’m curious and still following along, so at this point I decided to ask my wife - who’s the senior resident covering nights on GYN to look over her chart and see if there’s anything the other Day gyn resident missed.

Wife reads the TVUS and says that’s not a fibroid, that looks like retained products of conception. She goes at 3am to talk to the patient when her family is not there. The patient confesses to her that she actually had a surgical termination of pregnancy done in Guatemala 2 weeks ago immediately before coming to the US, but didn’t want her family to know so she didn’t tell anyone.

Wife gets a stat pelvis MRI at 3am (fancy toys at the womens hospital), they confirm a “loculated retained POC w/ signs of infection - most consistent with a septic abortion”. GYN team is with her in the OR now doing a formal dilation and evacuation.

So moral of the story, septic AB with stress cardiomyopathy from sepsis in a 28 year old.

---

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[Mount Asclepius]

Cool case to share from the other day:
ED Case:
28yo F presents to the ED for 2 weeks of malaise, subjective fevers at home, chills, scant vaginal bleeding, chest pain, RUQ & RLQ abd pain, and palpitations. Arrived here from Guatemala 2 weeks ago, denies PMH/PSH/meds/allergies.

Triage vitals HR130, BP 91/45, O2 100, Temp 37.1, RR 16.

Got fentanyl and IVF 1L.

POC preg faintly positive.

US - no baby, ball looking thing in uterine wall, not sure what it is, FAST negative, IVC plethoric, RV strain with bowing of the cardiac septum.

Send labs, Trop in 0.2 (normal 0.034), BNP 2000, HCG 150 (so barely positive by our assay), WBC 13, AST/ALT 500s, elevated alk phos, normal Tbili. Hb 13. Urine is bloody, not infected. Lactic 1.3.

EKG is just sinus tachycardia wo RV strain pattern or stemi.

No idea wtf is going on - so decide risks outweigh benefits, CTA for PE and CT Abd with IV contrast - all completely negative. Again they see this ball thing in the uterus - they call it as likely a fibroid. So we get a transvaginal US, which is read as normal, but again they note an “intraluminal uterine fibroid, attention on followup”.

She responds well to IVF, gets a 2nd L and BP increases to 110/55.

Pelvic exam shows scant blood without discharge, fetal parts/tissue, or hemorrhage. Normal cervix.

We call OBGYN - not sure what’s going on but maybe it’s an ectopic somewhere? Is the ball really a fibroid? OBGYN resident signs off, says repeat bHCG in 48 hours, the ball is probably a fibroid, and the beta is likely from a completed spontaneous AB - possibly due to structural issues from fibroid.

Pt spikes fever to 38.5. At this point we surrender, cover with vanc and Cefepime, admit to medicine for septic workup without a source.

Inpatient course:
Blood cultures come back 2/2 positive for EColi. Super weird.

Formal echo shows mild RV strain, trended trops remain stable and modestly elevated at 0.2. Cards says likely a stress cardiomyopathy from sepsis, maybe with so pre-existing pulmonary HTN. No evidence of endocarditis or valve pathology. Nothing to do on their end.

Given the elevated transaminases surgery is consulted, they get a Hida scan, and it’s negative for biliary pathology. They sign off.

HCG at 48 hours is unchanged, still low 100s.

Repeat echo at 48 hours shows worsening global myocardial dysfunction. She’s still spiking fevers.

I’m curious and still following along, so at this point I decided to ask my wife - who’s the senior resident covering nights on GYN to look over her chart and see if there’s anything the other Day gyn resident missed.

Wife reads the TVUS and says that’s not a fibroid, that looks like retained products of conception. She goes at 3am to talk to the patient when her family is not there. The patient confesses to her that she actually had a surgical termination of pregnancy done in Guatemala 2 weeks ago immediately before coming to the US, but didn’t want her family to know so she didn’t tell anyone.

Wife gets a stat pelvis MRI at 3am (fancy toys at the womens hospital), they confirm a “loculated retained POC w/ signs of infection - most consistent with a septic abortion”. GYN team is with her in the OR now doing a formal dilation and evacuation.

So moral of the story, septic AB with stress cardiomyopathy from sepsis in a 28 year old.

And here I was hoping for Chagas disease. Good ol’ Occam’s razor. Good case though.

 

[The Knife & Gun Club]

And here I was hoping for Chagas disease. Good ol’ Occam’s razor. Good case though.

I know I was really hoping for some neat tropical medicine stuff.

We actually sent Chagas. Our hospital has an in house Chagas immunoassay because we do see it here occasionally, but it was negative...good for the patient I guess but would’ve been cool. Also tested her for like dengue, chickengunya, malaria, and a host of other tropical crap that was all negative.

 

[Apollyon]

Carlos Chagas, of the massive ego: "Everyone looked, but I was the only one that saw."

 

[lucid_leprechaun]

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.

Yup. Young people get extraordinary measures. I don’t care if it’s a cric/thoracotomy/prolonged CPR I’m going to do whatever I have to do to sleep at night.

 

[WilcoWorld]

Cool case to share from the other day:
ED Case:
28yo F presents to the ED for 2 weeks of malaise, subjective fevers at home, chills, scant vaginal bleeding, chest pain, RUQ & RLQ abd pain, and palpitations. Arrived here from Guatemala 2 weeks ago, denies PMH/PSH/meds/allergies.

Triage vitals HR130, BP 91/45, O2 100, Temp 37.1, RR 16.

Got fentanyl and IVF 1L.

POC preg faintly positive.

US - no baby, ball looking thing in uterine wall, not sure what it is, FAST negative, IVC plethoric, RV strain with bowing of the cardiac septum.

Send labs, Trop in 0.2 (normal 0.034), BNP 2000, HCG 150 (so barely positive by our assay), WBC 13, AST/ALT 500s, elevated alk phos, normal Tbili. Hb 13. Urine is bloody, not infected. Lactic 1.3.

EKG is just sinus tachycardia wo RV strain pattern or stemi.

No idea wtf is going on - so decide risks outweigh benefits, CTA for PE and CT Abd with IV contrast - all completely negative. Again they see this ball thing in the uterus - they call it as likely a fibroid. So we get a transvaginal US, which is read as normal, but again they note an “intraluminal uterine fibroid, attention on followup”.

She responds well to IVF, gets a 2nd L and BP increases to 110/55.

Pelvic exam shows scant blood without discharge, fetal parts/tissue, or hemorrhage. Normal cervix.

We call OBGYN - not sure what’s going on but maybe it’s an ectopic somewhere? Is the ball really a fibroid? OBGYN resident signs off, says repeat bHCG in 48 hours, the ball is probably a fibroid, and the beta is likely from a completed spontaneous AB - possibly due to structural issues from fibroid.

Pt spikes fever to 38.5. At this point we surrender, cover with vanc and Cefepime, admit to medicine for septic workup without a source.

Inpatient course:
Blood cultures come back 2/2 positive for EColi. Super weird.

Formal echo shows mild RV strain, trended trops remain stable and modestly elevated at 0.2. Cards says likely a stress cardiomyopathy from sepsis, maybe with so pre-existing pulmonary HTN. No evidence of endocarditis or valve pathology. Nothing to do on their end.

Given the elevated transaminases surgery is consulted, they get a Hida scan, and it’s negative for biliary pathology. They sign off.

HCG at 48 hours is unchanged, still low 100s.

Repeat echo at 48 hours shows worsening global myocardial dysfunction. She’s still spiking fevers.

I’m curious and still following along, so at this point I decided to ask my wife - who’s the senior resident covering nights on GYN to look over her chart and see if there’s anything the other Day gyn resident missed.

Wife reads the TVUS and says that’s not a fibroid, that looks like retained products of conception. She goes at 3am to talk to the patient when her family is not there. The patient confesses to her that she actually had a surgical termination of pregnancy done in Guatemala 2 weeks ago immediately before coming to the US, but didn’t want her family to know so she didn’t tell anyone.

Wife gets a stat pelvis MRI at 3am (fancy toys at the womens hospital), they confirm a “loculated retained POC w/ signs of infection - most consistent with a septic abortion”. GYN team is with her in the OR now doing a formal dilation and evacuation.

So moral of the story, septic AB with stress cardiomyopathy from sepsis in a 28 year old.

Way to keep your eye on the "ball"

 

[RustedFox]

Way to keep your eye on the "ball"

AHHHHAHAHAHAHAHAHAAAAAAAAAAAAAAAAAAAAA!

You got me. You really did.

 

[MediCane2006]

Cool case to share from the other day:
ED Case:
28yo F presents to the ED for 2 weeks of malaise, subjective fevers at home, chills, scant vaginal bleeding, chest pain, RUQ & RLQ abd pain, and palpitations. Arrived here from Guatemala 2 weeks ago, denies PMH/PSH/meds/allergies.

Triage vitals HR130, BP 91/45, O2 100, Temp 37.1, RR 16.

Got fentanyl and IVF 1L.

POC preg faintly positive.

US - no baby, ball looking thing in uterine wall, not sure what it is, FAST negative, IVC plethoric, RV strain with bowing of the cardiac septum.

Send labs, Trop in 0.2 (normal 0.034), BNP 2000, HCG 150 (so barely positive by our assay), WBC 13, AST/ALT 500s, elevated alk phos, normal Tbili. Hb 13. Urine is bloody, not infected. Lactic 1.3.

EKG is just sinus tachycardia wo RV strain pattern or stemi.

No idea wtf is going on - so decide risks outweigh benefits, CTA for PE and CT Abd with IV contrast - all completely negative. Again they see this ball thing in the uterus - they call it as likely a fibroid. So we get a transvaginal US, which is read as normal, but again they note an “intraluminal uterine fibroid, attention on followup”.

She responds well to IVF, gets a 2nd L and BP increases to 110/55.

Pelvic exam shows scant blood without discharge, fetal parts/tissue, or hemorrhage. Normal cervix.

We call OBGYN - not sure what’s going on but maybe it’s an ectopic somewhere? Is the ball really a fibroid? OBGYN resident signs off, says repeat bHCG in 48 hours, the ball is probably a fibroid, and the beta is likely from a completed spontaneous AB - possibly due to structural issues from fibroid.

Pt spikes fever to 38.5. At this point we surrender, cover with vanc and Cefepime, admit to medicine for septic workup without a source.

Inpatient course:
Blood cultures come back 2/2 positive for EColi. Super weird.

Formal echo shows mild RV strain, trended trops remain stable and modestly elevated at 0.2. Cards says likely a stress cardiomyopathy from sepsis, maybe with so pre-existing pulmonary HTN. No evidence of endocarditis or valve pathology. Nothing to do on their end.

Given the elevated transaminases surgery is consulted, they get a Hida scan, and it’s negative for biliary pathology. They sign off.

HCG at 48 hours is unchanged, still low 100s.

Repeat echo at 48 hours shows worsening global myocardial dysfunction. She’s still spiking fevers.

I’m curious and still following along, so at this point I decided to ask my wife - who’s the senior resident covering nights on GYN to look over her chart and see if there’s anything the other Day gyn resident missed.

Wife reads the TVUS and says that’s not a fibroid, that looks like retained products of conception. She goes at 3am to talk to the patient when her family is not there. The patient confesses to her that she actually had a surgical termination of pregnancy done in Guatemala 2 weeks ago immediately before coming to the US, but didn’t want her family to know so she didn’t tell anyone.

Wife gets a stat pelvis MRI at 3am (fancy toys at the womens hospital), they confirm a “loculated retained POC w/ signs of infection - most consistent with a septic abortion”. GYN team is with her in the OR now doing a formal dilation and evacuation.

So moral of the story, septic AB with stress cardiomyopathy from sepsis in a 28 year old.

Dude. Your wife is a hero. Great catch!

 

[thegenius]

I participated in my first thoracotomy the other day. I've never done one on a person (only cadaver) and I've been an attending for 8 years and residency for 4 years. I told the trauma doc that "I've never done one" and he did most of it and I helped out a little on the fringes.

Pt made it to the OR but died there.

 

[BulgeDaTwine]

Cool case to share from the other day:
ED Case:
28yo F presents to the ED for 2 weeks of malaise, subjective fevers at home, chills, scant vaginal bleeding, chest pain, RUQ & RLQ abd pain, and palpitations. Arrived here from Guatemala 2 weeks ago, denies PMH/PSH/meds/allergies.

Triage vitals HR130, BP 91/45, O2 100, Temp 37.1, RR 16.

Got fentanyl and IVF 1L.

POC preg faintly positive.

US - no baby, ball looking thing in uterine wall, not sure what it is, FAST negative, IVC plethoric, RV strain with bowing of the cardiac septum.

Send labs, Trop in 0.2 (normal 0.034), BNP 2000, HCG 150 (so barely positive by our assay), WBC 13, AST/ALT 500s, elevated alk phos, normal Tbili. Hb 13. Urine is bloody, not infected. Lactic 1.3.

EKG is just sinus tachycardia wo RV strain pattern or stemi.

No idea wtf is going on - so decide risks outweigh benefits, CTA for PE and CT Abd with IV contrast - all completely negative. Again they see this ball thing in the uterus - they call it as likely a fibroid. So we get a transvaginal US, which is read as normal, but again they note an “intraluminal uterine fibroid, attention on followup”.

She responds well to IVF, gets a 2nd L and BP increases to 110/55.

Pelvic exam shows scant blood without discharge, fetal parts/tissue, or hemorrhage. Normal cervix.

We call OBGYN - not sure what’s going on but maybe it’s an ectopic somewhere? Is the ball really a fibroid? OBGYN resident signs off, says repeat bHCG in 48 hours, the ball is probably a fibroid, and the beta is likely from a completed spontaneous AB - possibly due to structural issues from fibroid.

Pt spikes fever to 38.5. At this point we surrender, cover with vanc and Cefepime, admit to medicine for septic workup without a source.

Inpatient course:
Blood cultures come back 2/2 positive for EColi. Super weird.

Formal echo shows mild RV strain, trended trops remain stable and modestly elevated at 0.2. Cards says likely a stress cardiomyopathy from sepsis, maybe with so pre-existing pulmonary HTN. No evidence of endocarditis or valve pathology. Nothing to do on their end.

Given the elevated transaminases surgery is consulted, they get a Hida scan, and it’s negative for biliary pathology. They sign off.

HCG at 48 hours is unchanged, still low 100s.

Repeat echo at 48 hours shows worsening global myocardial dysfunction. She’s still spiking fevers.

I’m curious and still following along, so at this point I decided to ask my wife - who’s the senior resident covering nights on GYN to look over her chart and see if there’s anything the other Day gyn resident missed.

Wife reads the TVUS and says that’s not a fibroid, that looks like retained products of conception. She goes at 3am to talk to the patient when her family is not there. The patient confesses to her that she actually had a surgical termination of pregnancy done in Guatemala 2 weeks ago immediately before coming to the US, but didn’t want her family to know so she didn’t tell anyone.

Wife gets a stat pelvis MRI at 3am (fancy toys at the womens hospital), they confirm a “loculated retained POC w/ signs of infection - most consistent with a septic abortion”. GYN team is with her in the OR now doing a formal dilation and evacuation.

So moral of the story, septic AB with stress cardiomyopathy from sepsis in a 28 year old.

I’d say moral of the story is patients and families, in their infinite wisdom, often withhold key details which if known would prevent much M&M and wasting of resources.

To paraphrase House of God:

-“Are you the patient?”
-“Nope - I’m on the other team, one of the doctors”

 

[Old_Mil]

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?

Did this case happen before or after 2020?

 

[MechEDoc]

Did this case happen before or after 2020?

Mid summer 2022.

 

[CajunMedic]

This was back in February, I was early into the 0600-1600 shift with just an attending at the "came out of the holler, damn near dead Center of Excellence", We had gotten 10" of snow overnight and it was still dropping flurries. EMS calls in on the bat phone and I hear "Wait, their tongue is in a bucket" from the charge nurse. "Hey Cajun, County medic 153 is about 10 out and they say the patient woke up and their tongue fell off"; "you're kidding me", "nope, had them say it twice", "guess we'll see when they get here"

Right on cue, County EMS rolls in 8 minutes later with a woman on the cot, pale white, with bright, red blood coming out of her mouth into a portable suction. The scars from a radical neck dissection and radiation are visible on the neck and mandible. She's clutching a small bucket with a bloody Wal-Mart bag in it (never a good sign). While she's getting triaged, we take a look in the bucket and see what looks like a piece of beef. The medics hand me a piece of paper with her history and where the surgery was (of course, Big State University Medical Center-3 hours away). She can only open her mouth about a cm, and I see what looks like skin with hair on it. She had had a brachioradialis/radial forearm flap reconstruction of a total glossectomy/radical neck dissection for cancer.

We get her roomed, and start ordering things: All the labs, TXA, 2 units of Blood-vitals are stable for now, but probably won't stay that way. Figure we need a head/neck soft tissue CT to figure out what the anatomy is and where the blood may be coming from. My attending gets the OMFS oncologist on the phone that performed the surgery who wants her intubated, CT scanned, and shipped ASAP. He hangs up and starts calling consultants: Surgery-for the trach if needed, ENT-for their expertise and likely airway complications, and anesthesia. I start working on transport: No helicopter until the weather clears. No ground ALS until the roads are clear-at least 3 hours.

Our ENT comes in, and calls the surgical attending and anesthesiologist himself after seeing the patient and she is whisked off to the OR. Comes back about 90 minutes later intubated and on minimal vent settings to wait for transport. ENT calls us and says "There is no way any of us could have probably gotten her tubed. Anesthesia did it fiber-optically, but the anatomy was a mess." Meanwhile, the accepting surgeon is calling to check on her status and has decided that she is going straight to the OR as soon as she arrives. Finally, the Critical Care ground unit arrives with the still grounded flight crew and gear and picks her up. Never did get to hear what the outcome was.

 

[Vandalia]

She's clutching a small bucket with a bloody Wal-Mart bag in it (never a good sign).

I feel morally obligated to tell the story of my first night as an MS-III. Not far, I am guessing, from this story.

I know I have probably told this several times before, but I am old.

This was back in the infancy of Emergency Medicine, so ward teams were often called down to see patients.

We got a call about a man who came in with an animal bite. No problem. Easy medical student case. As I leave to gather the supplies, and am at the doorway, I hear the patient say, "Oh, my brother is here. He must have it right here in this box. I know you would want to check the skunk for rabies ...." As he (apparently) opens the box, time slows to a crawl. I hear one of those loud, movie, "Nooohhhhs!" and see people diving for the door in slow motion.

Yes, it was a skunk.
No, it did not have rabies.

Surprisingly, the team did not receive many consults or admissions that night. Even more strangely, the floor nurses seemed to be able to handle every problem by themselves ....

I am not sure what was worse, being sprayed, or me not being sprayed but having to be around those people all night ...

That was always the barometer I always used for our residents on office service rotations. "I would give anything for a quiet night!" "Really, well, you know there is one sure way to guarantee that ...."

Nothing good has ever come from an ED patient (or their family) bringing something in a container ....

 

[RoyBasch]

Nothing good has ever come from an ED patient (or their family) bringing something in a container ....

I emphatically agree with this.

 

[Apollyon]

Nothing good has ever come from an ED patient (or their family) bringing something in a container ....

In the words of Andy Jagoda at Mt. Sinai, "when patients bring it, you always have to look in the jar!"

 

[Dred Pirate]

I feel morally obligated to tell the story of my first night as an MS-III. Not far, I am guessing, from this story.

I know I have probably told this several times before, but I am old.

This was back in the infancy of Emergency Medicine, so ward teams were often called down to see patients.

We got a call about a man who came in with an animal bite. No problem. Easy medical student case. As I leave to gather the supplies, and am at the doorway, I hear the patient say, "Oh, my brother is here. He must have it right here in this box. I know you would want to check the skunk for rabies ...." As he (apparently) opens the box, time slows to a crawl. I hear one of those loud, movie, "Nooohhhhs!" and see people diving for the door in slow motion.

Yes, it was a skunk.
No, it did not have rabies.

Surprisingly, the team did not receive many consults or admissions that night. Even more strangely, the floor nurses seemed to be able to handle every problem by themselves ....

I am not sure what was worse, being sprayed, or me not being sprayed but having to be around those people all night ...

That was always the barometer I always used for our residents on office service rotations. "I would give anything for a quiet night!" "Really, well, you know there is one sure way to guarantee that ...."

Nothing good has ever come from an ED patient (or their family) bringing something in a container ....

I have seen my fair share of copperheads in a bucket- one of them once was just stunned and then woke up as they were showing it to the RN- one of our crunchy granola types decided to take it and release it in the woods at a local park - sounds like a brilliant idea.

we used to have several in jars filled with formaldehyde we got from the lab.

 

[The Knife & Gun Club]

This was back in February, I was early into the 0600-1600 shift with just an attending at the "came out of the holler, damn near dead Center of Excellence", We had gotten 10" of snow overnight and it was still dropping flurries. EMS calls in on the bat phone and I hear "Wait, their tongue is in a bucket" from the charge nurse. "Hey Cajun, County medic 153 is about 10 out and they say the patient woke up and their tongue fell off"; "you're kidding me", "nope, had them say it twice", "guess we'll see when they get here"

Right on cue, County EMS rolls in 8 minutes later with a woman on the cot, pale white, with bright, red blood coming out of her mouth into a portable suction. The scars from a radical neck dissection and radiation are visible on the neck and mandible. She's clutching a small bucket with a bloody Wal-Mart bag in it (never a good sign). While she's getting triaged, we take a look in the bucket and see what looks like a piece of beef. The medics hand me a piece of paper with her history and where the surgery was (of course, Big State University Medical Center-3 hours away). She can only open her mouth about a cm, and I see what looks like skin with hair on it. She had had a brachioradialis/radial forearm flap reconstruction of a total glossectomy/radical neck dissection for cancer.

We get her roomed, and start ordering things: All the labs, TXA, 2 units of Blood-vitals are stable for now, but probably won't stay that way. Figure we need a head/neck soft tissue CT to figure out what the anatomy is and where the blood may be coming from. My attending gets the OMFS oncologist on the phone that performed the surgery who wants her intubated, CT scanned, and shipped ASAP. He hangs up and starts calling consultants: Surgery-for the trach if needed, ENT-for their expertise and likely airway complications, and anesthesia. I start working on transport: No helicopter until the weather clears. No ground ALS until the roads are clear-at least 3 hours.

Our ENT comes in, and calls the surgical attending and anesthesiologist himself after seeing the patient and she is whisked off to the OR. Comes back about 90 minutes later intubated and on minimal vent settings to wait for transport. ENT calls us and says "There is no way any of us could have probably gotten her tubed. Anesthesia did it fiber-optically, but the anatomy was a mess." Meanwhile, the accepting surgeon is calling to check on her status and has decided that she is going straight to the OR as soon as she arrives. Finally, the Critical Care ground unit arrives with the still grounded flight crew and gear and picks her up. Never did get to hear what the outcome was.

What would be your backup if you were at a hospital that didn’t have ENT/Anes? Was the anatomy even feasible for a cric? I’ve seen a handful of these reconstructed head/neck patients and their anatomy is always so deranged and unstable. That’s like a nightmare scenario where you need to tube to transport but also could potentially kill them with an intubation.

We had a case similar to this with a peds patient where they had a tracheal rupture with complete transection below the cords after some weird ENT surgery. Satting 90% and stridorous, but stablish. GS/ENT We’re not convinced they could even crash in a trach given the trachea was no longer attached to the larynx. Intubating from above could further destabilize whatever little passage they had left.

End result was actually genius - they cannulated the kid onto VV ecmo in the OR and then we’re able to open the chest cavity and retrieve the severed trachea.

 

[BoardingDoc]

What would be your backup if you were at a hospital that didn’t have ENT/Anes? Was the anatomy even feasible for a cric? I’ve seen a handful of these reconstructed head/neck patients and their anatomy is always so deranged and unstable. That’s like a nightmare scenario where you need to tube to transport but also could potentially kill them with an intubation.

We had a case similar to this with a peds patient where they had a tracheal rupture with complete transection below the cords after some weird ENT surgery. Satting 90% and stridorous, but stablish. GS/ENT We’re not convinced they could even crash in a trach given the trachea was no longer attached to the larynx. Intubating from above could further destabilize whatever little passage they had left.

End result was actually genius - they cannulated the kid onto VV ecmo in the OR and then we’re able to open the chest cavity and retrieve the severed trachea.

What ... the actual ... f***.

No thank you.

 

[alpinism]

What would be your backup if you were at a hospital that didn’t have ENT/Anes? Was the anatomy even feasible for a cric? I’ve seen a handful of these reconstructed head/neck patients and their anatomy is always so deranged and unstable. That’s like a nightmare scenario where you need to tube to transport but also could potentially kill them with an intubation.

We had a case similar to this with a peds patient where they had a tracheal rupture with complete transection below the cords after some weird ENT surgery. Satting 90% and stridorous, but stablish. GS/ENT We’re not convinced they could even crash in a trach given the trachea was no longer attached to the larynx. Intubating from above could further destabilize whatever little passage they had left.

End result was actually genius - they cannulated the kid onto VV ecmo in the OR and then we’re able to open the chest cavity and retrieve the severed trachea.

I obviously wasn't there but the few transections I've seen were surprisingly very straightforward intubations. Mostly from patients who've had their anterior throat cut with a knife that managed to spare the major vessels. Basically unless the distal segment is completely displaced the endotracheal tube just slides into the distal opening since it's the path of least resistance. You can also just push the segment back in position when its been displaced if needed. If that doesn't work I don't see how a rapid trach wouldn't be possible since you could just stabilize it with hooks and sutures to hold everything steady for when you're performing the cannulation.

 

[BoardingDoc]

I obviously wasn't there but the few transections I've seen were surprisingly very straightforward intubations. Mostly from patients who've had their anterior throat cut with a knife that managed to spare the major vessels. Basically unless the distal segment is completely displaced the endotracheal tube just slides into the distal opening since it's the path of least resistance. You can also just push the segment back in position when its been displaced if needed. If that doesn't work I don't see how a rapid trach wouldn't be possible since you could just stabilize it with hooks and sutures to hold everything steady for when you're performing the cannulation.

I love the nonchalant approach towards the topic. I suppose I would expect nothing less from someone who used to work EM in Joberg.

 

[Apollyon]

I love the nonchalant approach towards the topic. I suppose I would expect nothing less from someone who used to work EM in Joberg.

Busiest ED on Earth! LAC-USC is second (or was).

 

[Buckeye1992]

Had a recent 33yo found down in a hotel. Reported last know well days ago. Obtunded hypothermic hypotensive on arrival. Resuscitated, intubated, lined, pressors. Septic shock from pneumonia, initial pH 6.61. Lactic 20. ICU for about a week before extubated. Neuro intact and left the hospital the other day.

 

[RustedFox]

Had a recent 33yo found down in a hotel. Reported last know well days ago. Obtunded hypothermic hypotensive on arrival. Resuscitated, intubated, lined, pressors. Septic shock from pneumonia, initial pH 6.61. Lactic 20. ICU for about a week before extubated. Neuro intact and left the hospital the other day.

You are made of WIN.

 

[TooMuchResearch]

You heard me.

Cough. What's new here?

 

[CajunMedic]

EMS calls in with a cardiac arrest. 50ish male, found down bradycardic in the 20's, Air temp in the teens, wet clothes, and snow on the ground. Goes into V-Fib when EMS moves him, shocked to asystole. Bounces between V-Fib and asystole during transport. Has an IV, King-LT, and Lucas in place for compressions when he gets to us. EMS had been working him for at least 30 mins.

Rectal temp is less than 86 degrees. ETCO2 is 8. Keep compressions with the Lucas while actively warming the patient. 3-way-foley with warm saline and decided to put 2 chest tubes in and circulate warm saline to warm the core. Swap out the King for an ETT. After about 45 mins with 0 change in rhythm, Core is now 86 degrees. we tried amiodarone and lidocaine to no luck. I was doing my "anyone have any other ideas?" spiel when one of my interns speaks up. He's FM boarded but doing a second residency in EM. He suggested double sequential defibrillation (last month's journal club).....I'll be damned, it worked!. Sinus rhythm with J-Waves, trying to breathe over the vent, and systolic in the 120's. Labs aren't terrible. Call Big University Medical Center to transfer to ICU, and wait for ground transport (can't get a bird due to weather).

Near shift change, I get a call from the NP on the Cardiac Arrest team. EEG shows normal brain activity and a chance to recover. Clean heart cath 24 hours later. Got a message today from one of the medics that brought him in: Extubated, talking, and expected to make a full recovery

Chalk one up for the good guys!!

 

[RustedFox]

EMS calls in with a cardiac arrest. 50ish male, found down bradycardic in the 20's, Air temp in the teens, wet clothes, and snow on the ground. Goes into V-Fib when EMS moves him, shocked to asystole. Bounces between V-Fib and asystole during transport. Has an IV, King-LT, and Lucas in place for compressions when he gets to us. EMS had been working him for at least 30 mins.

Rectal temp is less than 86 degrees. ETCO2 is 8. Keep compressions with the Lucas while actively warming the patient. 3-way-foley with warm saline and decided to put 2 chest tubes in and circulate warm saline to warm the core. Swap out the King for an ETT. After about 45 mins with 0 change in rhythm, Core is now 86 degrees. we tried amiodarone and lidocaine to no luck. I was doing my "anyone have any other ideas?" spiel when one of my interns speaks up. He's FM boarded but doing a second residency in EM. He suggested double sequential defibrillation (last month's journal club).....I'll be damned, it worked!. Sinus rhythm with J-Waves, trying to breathe over the vent, and systolic in the 120's. Labs aren't terrible. Call Big University Medical Center to transfer to ICU, and wait for ground transport (can't get a bird due to weather).

Near shift change, I get a call from the NP on the Cardiac Arrest team. EEG shows normal brain activity and a chance to recover. Clean heart cath 24 hours later. Got a message today from one of the medics that brought him in: Extubated, talking, and expected to make a full recovery

Chalk one up for the good guys!!

1.) Wow. Just wow. STRONG work.
2.) WTF is "double sequential defibrillation"?
3.) How does one circulate warm saline thru chest tubes?
4. So many questions, here.

 

[MechEDoc]

EMS calls in with a cardiac arrest. 50ish male, found down bradycardic in the 20's, Air temp in the teens, wet clothes, and snow on the ground. Goes into V-Fib when EMS moves him, shocked to asystole. Bounces between V-Fib and asystole during transport. Has an IV, King-LT, and Lucas in place for compressions when he gets to us. EMS had been working him for at least 30 mins.

Rectal temp is less than 86 degrees. ETCO2 is 8. Keep compressions with the Lucas while actively warming the patient. 3-way-foley with warm saline and decided to put 2 chest tubes in and circulate warm saline to warm the core. Swap out the King for an ETT. After about 45 mins with 0 change in rhythm, Core is now 86 degrees. we tried amiodarone and lidocaine to no luck. I was doing my "anyone have any other ideas?" spiel when one of my interns speaks up. He's FM boarded but doing a second residency in EM. He suggested double sequential defibrillation (last month's journal club).....I'll be damned, it worked!. Sinus rhythm with J-Waves, trying to breathe over the vent, and systolic in the 120's. Labs aren't terrible. Call Big University Medical Center to transfer to ICU, and wait for ground transport (can't get a bird due to weather).

Near shift change, I get a call from the NP on the Cardiac Arrest team. EEG shows normal brain activity and a chance to recover. Clean heart cath 24 hours later. Got a message today from one of the medics that brought him in: Extubated, talking, and expected to make a full recovery

Chalk one up for the good guys!!

Awesome!

 

[southerndoc]

2.) WTF is "double sequential defibrillation"?

double sequential defibrillation - Google Search

Used it once with good results... but guy was brain dead.

 

[CajunMedic]

1.) Wow. Just wow. STRONG work.
2.) WTF is "double sequential defibrillation"?
3.) How does one circulate warm saline thru chest tubes?
4. So many questions, here.

2: 2 monitors and 2 sets of pads. 1 set anterior-posterior and one set anterior-lateral. Charge and basically hit the shock buttons at the same time. Ideally, the shocks are within milliseconds of each other. The DOSE-VF trial was started before COVID and was showing some promise. https://www.acc.org/latest-in-cardiology/clinical-trials/2022/11/05/02/59/dose-vf

3: We used 38 french, 1 near the axilla and one as low as possible without risk of cannulating the liver. The inferior one was hooked to a water-seal to suction as usual. A blood warmer was used with saline and plumbed into the superior one. We just kept an eye on the tube output to make sure it was reasonably close

 

[RustedFox]

2: 2 monitors and 2 sets of pads. 1 set anterior-posterior and one set anterior-lateral. Charge and basically hit the shock buttons at the same time. Ideally, the shocks are within milliseconds of each other. The DOSE-VF trial was started before COVID and was showing some promise. https://www.acc.org/latest-in-cardiology/clinical-trials/2022/11/05/02/59/dose-vf

3: We used 38 french, 1 near the axilla and one as low as possible without risk of cannulating the liver. The inferior one was hooked to a water-seal to suction as usual. A blood warmer was used with saline and plumbed into the superior one. We just kept an eye on the tube output to make sure it was reasonably close

So, you've got 2 chest tubes in one side... or 2 in each side?

 

[Dred Pirate]

2: 2 monitors and 2 sets of pads. 1 set anterior-posterior and one set anterior-lateral. Charge and basically hit the shock buttons at the same time. Ideally, the shocks are within milliseconds of each other. The DOSE-VF trial was started before COVID and was showing some promise. https://www.acc.org/latest-in-cardiology/clinical-trials/2022/11/05/02/59/dose-vf

3: We used 38 french, 1 near the axilla and one as low as possible without risk of cannulating the liver. The inferior one was hooked to a water-seal to suction as usual. A blood warmer was used with saline and plumbed into the superior one. We just kept an eye on the tube output to make sure it was reasonably close

Correct me if I am wrong but I thought there is some thought that the shocks should not be simultaneous, but sequential, with a very short delay between shocks. One person hits both buttons, but with like a fraction of a second delay between them.

But damn. Great story. Love those where victory is truly snatched from the jaws of defeat.

 

[CajunMedic]

So, you've got 2 chest tubes in one side... or 2 in each side?

2 in one side.

 

[CajunMedic]

Correct me if I am wrong but I thought there is some thought that the shocks should not be simultaneous, but sequential, with a very short delay between shocks. One person hits both buttons, but with like a fraction of a second delay between them.

But damn. Great story. Love those where victory is truly snatched from the jaws of defeat.

You're correct. There is supposed to be a fraction of a second delay

 

[Apollyon]

Not to throw cold water on anything (figuratively, and no pun intended), but, I recall being taught that you don't defib hypothermic VF, until they warm up. What that implies is a LOT of CPR. Maybe I'm wrong. Maybe times have changed.

But, nothing succeeds like success!

 

[thegenius]

Correct me if I am wrong but I thought there is some thought that the shocks should not be simultaneous, but sequential, with a very short delay between shocks. One person hits both buttons, but with like a fraction of a second delay between them.

But damn. Great story. Love those where victory is truly snatched from the jaws of defeat.

That's my understanding as well. I did it once (and it worked) and I recommended a 1 sec delay. Basically we had two zolls, the first RN pushed the button, counted 1 sec out loud, and the second RN hit the other button on the other zoll.

 

[WilcoWorld]

Not to throw cold water on anything (figuratively, and no pun intended), but, I recall being taught that you don't defib hypothermic VF, until they warm up. What that implies is a LOT of CPR. Maybe I'm wrong. Maybe times have changed.

But, nothing succeeds like success!

It's reasonable to shock at first, but don't just keep shocking a cold heart. If initial attempts at defibrillation are unsuccessful, move your focus to aggressive rewarming and then resume shocking if still in a shockable arrhythmia once warmer than 30C.

 

[Apollyon]

It's reasonable to shock at first, but don't just keep shocking a cold heart. If initial attempts at defibrillation are unsuccessful, move your focus to aggressive rewarming and then resume shocking if still in a shockable arrhythmia once warmer than 30C.

I'm trying to recall; I may be erroneous. I know for sure it was taught in ACLS in the past (before they dumbed it down) that, if you shock asystole that is the result of profound parasympathetic discharge, you've killed the pt. I thought it was similar for hypothermia - if you shock the VF, and they go into asystole, they're unlikely to recover. Of course, of course, ipso facto, not gospel, as to which this case attests.

 

[rokshana]

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

Funny…it seems to me that everyone wants to order a TSH /TPO ab on their pts and then refer to me…

 

[WilcoWorld]

I'm trying to recall; I may be erroneous. I know for sure it was taught in ACLS in the past (before they dumbed it down) that, if you shock asystole that is the result of profound parasympathetic discharge, you've killed the pt. I thought it was similar for hypothermia - if you shock the VF, and they go into asystole, they're unlikely to recover. Of course, of course, ipso facto, not gospel, as to which this case attests.

Oh, I didn't mean to recommend shocking asystole.

Did I do that?

 

[Apollyon]

Oh, I didn't mean to recommend shocking asystole.

Did I do that?

You did not.

 

[dchristismi]

Your mom shocks asystole.

 

[dchristismi]

Sorry, couldn't help it.
hehehe.

I did a double defib once on a really bad heart... hit her with esmolol too just trying to chill the VF storm. It didn't work. As it turned out, I called her PCP, told him the story - she'd just gotten in her car to drive home from a fast food joint if I remember right when she went unresponsive, rolled into a curb. We both agreed that with all her the cardiac history, it was certainly a massive cardiac event. And shocking miliseconds apart is just having two people try to hit the buttons at the same time, really. Especially if one is an amped up rookie medic who is going to jump the gun anyway.

Well, I got a call from the ME a couple weeks later nonchalantly letting me know she had somehow sustained a liver laceration in a 0 mph roll-into-parking curb mvc and had a belly full of blood. Crazy.

 

[The Knife & Gun Club]

3: We used 38 french, 1 near the axilla and one as low as possible without risk of cannulating the liver. The inferior one was hooked to a water-seal to suction as usual. A blood warmer was used with saline and plumbed into the superior one. We just kept an eye on the tube output to make sure it was reasonably close

I’m trying to imagine how logistically this would work in terms of getting all that equipment available to bedside quickly with CPR in progress.

Admittedly in Miami it’s pretty rare that we see that degree of hypothermia so maybe my hospital is just not set up for it but how the hell did you get a blood warmer to bedside in the span of minutes? Just announce it and someone brings one? Did it come from the OR?

In any case that’s a boss move, strong work.

 

[Rekt]

I’m trying to imagine how logistically this would work in terms of getting all that equipment available to bedside quickly with CPR in progress.

Admittedly in Miami it’s pretty rare that we see that degree of hypothermia so maybe my hospital is just not set up for it but how the hell did you get a blood warmer to bedside in the span of minutes? Just announce it and someone brings one? Did it come from the OR?

In any case that’s a boss move, strong work.

I would imagine most decent size places have some type of rapid infuser, like what's used for MTP, which can also warm IVF. I'm in fairly rural-ish area and all our trauma bays have one. There's many different ways to do it.

Can do one tube anterior 2nd intercostal area as a pigtail then an inferior chest tube to drain. Or use a single chest tube unit to infuse a few hundred warm saline for a few minutes then suck it back out through same tube - probably the more likely scenario in small EDs.

 

[The Knife & Gun Club]

I would imagine most decent size places have some type of rapid infuser, like what's used for MTP, which can also warm IVF. I'm in fairly rural-ish area and all our trauma bays have one. There's many different ways to do it.

Can do one tube anterior 2nd intercostal area as a pigtail then an inferior chest tube to drain. Or use a single chest tube unit to infuse a few hundred warm saline for a few minutes then suck it back out through same tube - probably the more likely scenario in small EDs.

Yea we have Belmont massive transfusers in the bay - I guess I never bothered to check if they are able to warm the blood. That would make a lot of sense now that you mention it.

I was imagining the blood warming contraption they use for ECMO/Bypass circuits, which I’d imagine is more challenging to get to the ED in a timely fashion.

My guess gun to my head would be surgical chest tubes rather than pigtails since there’s no pneumo or effusion to safely a stick the needle into…maybe like 2nd and 4th intercostal space, angle one up and one down?

 

[alphaholic06]

Sorry, couldn't help it.
hehehe.

I did a double defib once on a really bad heart... hit her with esmolol too just trying to chill the VF storm. It didn't work. As it turned out, I called her PCP, told him the story - she'd just gotten in her car to drive home from a fast food joint if I remember right when she went unresponsive, rolled into a curb. We both agreed that with all her the cardiac history, it was certainly a massive cardiac event. And shocking miliseconds apart is just having two people try to hit the buttons at the same time, really. Especially if one is an amped up rookie medic who is going to jump the gun anyway.

Well, I got a call from the ME a couple weeks later nonchalantly letting me know she had somehow sustained a liver laceration in a 0 mph roll-into-parking curb mvc and had a belly full of blood. Crazy.

You can’t make this **** up.

 

[The Knife & Gun Club]

Sorry, couldn't help it.
hehehe.

I did a double defib once on a really bad heart... hit her with esmolol too just trying to chill the VF storm. It didn't work. As it turned out, I called her PCP, told him the story - she'd just gotten in her car to drive home from a fast food joint if I remember right when she went unresponsive, rolled into a curb. We both agreed that with all her the cardiac history, it was certainly a massive cardiac event. And shocking miliseconds apart is just having two people try to hit the buttons at the same time, really. Especially if one is an amped up rookie medic who is going to jump the gun anyway.

Well, I got a call from the ME a couple weeks later nonchalantly letting me know she had somehow sustained a liver laceration in a 0 mph roll-into-parking curb mvc and had a belly full of blood. Crazy.

I would seriously question if the liver lac was a result of the CPR by either a broken rib or some other blunt mechanism, maybe in the setting of a blood thinner?

In any case I’m sorry that happened to you, that’s a huge bummer

 

[CajunMedic]

I’m trying to imagine how logistically this would work in terms of getting all that equipment available to bedside quickly with CPR in progress.

Admittedly in Miami it’s pretty rare that we see that degree of hypothermia so maybe my hospital is just not set up for it but how the hell did you get a blood warmer to bedside in the span of minutes? Just announce it and someone brings one? Did it come from the OR?

In any case that’s a boss move, strong work.

We assigned one of the nurses not active in the resuscitation to call the house supervisor and facilitate it. Pretty sure it was the only one in the hospital and it came from the OR.

 

[bravotwozero]

We assigned one of the nurses not active in the resuscitation to call the house supervisor and facilitate it. Pretty sure it was the only one in the hospital and it came from the OR.

And you placed said chest tubes with active chest compressions going on?

That’s impressive. I’ve never been in that situation, but I’m sure that’s not easy either.