This place is getting boring, post something good.

[dchristismi]

Please tell me you nonchalantly replied "I am the airway team..." or "your secret airway team" or something like that...

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[The Knife & Gun Club]

Academically more interesting…

60yo M presents to ED as pedestrian hit by car. AO3/GCS15 on arrival but w/ BP 85/50, palpably widened pubic symphesis on survey. No other injuries. 2 units blood in the bay. BP doesn’t budge but he’s mentating fine and fast is negative. Place pelvic binder. Trauma scan with an open book pelvis and hematoma but nothing crazy.

Booked for the OR with ortho, ED/Trauma teams call me down to admit the guy to the unit post-op. He says he has a “problem with his heart and high pressure.”

Anesthesia goes to intubate the dude and he drops like a f*ing stone. Pressures in the 60/20 range. Ortho aborts the case and throws on an ex fix, he comes up to the unit with a BP of 50/— in RVR and having runs of pulseless vtach. ABG with a pH of 7.1, K 6.9, lactic 7. POCUS with RV completely blown out, LVEF looks fine. Bolus amio, then start epi—>norepi—>vaso and max then all. Push 3 amps of bicarb, calcium, mag and BP creeps up to 70/40. Dude starts hemorrhaging from his ex-fix site so call for blood, took quick clot and shoved in down holes for the ex-fix rods and pack it tight against the bone. Repeat fast negative. Optimize the vent with low tidal volumes and peep to try to unload the strain off the right heart. Maybe a PE?

Every time the vent delivers a breath his a-line flatlines.

Probably time to stop screwing around and call the adults, so call in my attending from home, and he suggests calling the CVICU in too. Luckily today the Trauma ICU attending is EM+surgical critical care and the CVICU attending is EM+medicine critical care. The cavalry arrives.

CV guy drops a TEE probe in while I float a swan with the trauma attending. PA pressures are 70/40. On TEE we can see he’s got a flail mitral valve. Hook up nitric to the vent to drop the PA pressure. Add on milrinone, dig load, 8 of bumex + 120 of lasix + drip, start to peel back the NE and the dude starts to turn pink again (from a robust shade of purple).

Lactic starts to come down and urine starts to flow in the foley. By morning the labs normalized and he’s being prepped for OR for a new mitral valve.

Personally convinced if it wasn’t for it being all EM people doing the resus the dude would have been dead as a rock.

 

[RustedFox]

Please tell me you nonchalantly replied "I am the airway team..." or "your secret airway team" or something like that...

I AM THE LAW!

 

[CajunMedic]

Academically more interesting…

60yo M presents to ED as pedestrian hit by car. AO3/GCS15 on arrival but w/ BP 85/50, palpably widened pubic symphesis on survey. No other injuries. 2 units blood in the bay. BP doesn’t budge but he’s mentating fine and fast is negative. Place pelvic binder. Trauma scan with an open book pelvis and hematoma but nothing crazy.

Booked for the OR with ortho, ED/Trauma teams call me down to admit the guy to the unit post-op. He says he has a “problem with his heart and high pressure.”

Anesthesia goes to intubate the dude and he drops like a f*ing stone. Pressures in the 60/20 range. Ortho aborts the case and throws on an ex fix, he comes up to the unit with a BP of 50/— in RVR and having runs of pulseless vtach. ABG with a pH of 7.1, K 6.9, lactic 7. POCUS with RV completely blown out, LVEF looks fine. Bolus amio, then start epi—>norepi—>vaso and max then all. Push 3 amps of bicarb, calcium, mag and BP creeps up to 70/40. Dude starts hemorrhaging from his ex-fix site so call for blood, took quick clot and shoved in down holes for the ex-fix rods and pack it tight against the bone. Repeat fast negative. Optimize the vent with low tidal volumes and peep to try to unload the strain off the right heart. Maybe a PE?

Every time the vent delivers a breath his a-line flatlines.

Probably time to stop screwing around and call the adults, so call in my attending from home, and he suggests calling the CVICU in too. Luckily today the Trauma ICU attending is EM+surgical critical care and the CVICU attending is EM+medicine critical care. The cavalry arrives.

CV guy drops a TEE probe in while I float a swan with the trauma attending. PA pressures are 70/40. On TEE we can see he’s got a flail mitral valve. Hook up nitric to the vent to drop the PA pressure. Add on milrinone, dig load, 8 of bumex + 120 of lasix + drip, start to peel back the NE and the dude starts to turn pink again (from a robust shade of purple).

Lactic starts to come down and urine starts to flow in the foley. By morning the labs normalized and he’s being prepped for OR for a new mitral valve.

Personally convinced if it wasn’t for it being all EM people doing the resus the dude would have been dead as a rock.

Jeezus. I thought I had put in some complex work. Holy hell, you rocked that one!

 

[Lexdiamondz]

Anesthesia nowhere to be found, just walked to the head of bed and popped a “difficult anatomy” ETT in the seconds. Nurse screaming “YOU CANT INTUBATE WITHOUT THE AIRWAY TEAM.”

Very few things infuriate me more than a non-physician trying to dictate what is within a physician's scope of practice.

 

[Apollyon]

Very few things infuriate me more than a non-physician trying to dictate what is within a physician's scope of practice.

When pts would say, "what are they going to do?", I would say, "I am 'they'."

 

[thegenius]

Academically more interesting…

60yo M presents to ED as pedestrian hit by car. AO3/GCS15 on arrival but w/ BP 85/50, palpably widened pubic symphesis on survey. No other injuries. 2 units blood in the bay. BP doesn’t budge but he’s mentating fine and fast is negative. Place pelvic binder. Trauma scan with an open book pelvis and hematoma but nothing crazy.

Booked for the OR with ortho, ED/Trauma teams call me down to admit the guy to the unit post-op. He says he has a “problem with his heart and high pressure.”

Anesthesia goes to intubate the dude and he drops like a f*ing stone. Pressures in the 60/20 range. Ortho aborts the case and throws on an ex fix, he comes up to the unit with a BP of 50/— in RVR and having runs of pulseless vtach. ABG with a pH of 7.1, K 6.9, lactic 7. POCUS with RV completely blown out, LVEF looks fine. Bolus amio, then start epi—>norepi—>vaso and max then all. Push 3 amps of bicarb, calcium, mag and BP creeps up to 70/40. Dude starts hemorrhaging from his ex-fix site so call for blood, took quick clot and shoved in down holes for the ex-fix rods and pack it tight against the bone. Repeat fast negative. Optimize the vent with low tidal volumes and peep to try to unload the strain off the right heart. Maybe a PE?

Every time the vent delivers a breath his a-line flatlines.

Probably time to stop screwing around and call the adults, so call in my attending from home, and he suggests calling the CVICU in too. Luckily today the Trauma ICU attending is EM+surgical critical care and the CVICU attending is EM+medicine critical care. The cavalry arrives.

CV guy drops a TEE probe in while I float a swan with the trauma attending. PA pressures are 70/40. On TEE we can see he’s got a flail mitral valve. Hook up nitric to the vent to drop the PA pressure. Add on milrinone, dig load, 8 of bumex + 120 of lasix + drip, start to peel back the NE and the dude starts to turn pink again (from a robust shade of purple).

Lactic starts to come down and urine starts to flow in the foley. By morning the labs normalized and he’s being prepped for OR for a new mitral valve.

Personally convinced if it wasn’t for it being all EM people doing the resus the dude would have been dead as a rock.

So this guy was hit by a car. He also randomly blew his mitral valve? You trauma scanned him and he had no thoracic injury.

Such a weird story. Well done though. haven't seen an acute flail leaflet in some time (years).

 

[thegenius]

Academically more interesting…

60yo M presents to ED as pedestrian hit by car. AO3/GCS15 on arrival but w/ BP 85/50, palpably widened pubic symphesis on survey. No other injuries. 2 units blood in the bay. BP doesn’t budge but he’s mentating fine and fast is negative. Place pelvic binder. Trauma scan with an open book pelvis and hematoma but nothing crazy.

Booked for the OR with ortho, ED/Trauma teams call me down to admit the guy to the unit post-op. He says he has a “problem with his heart and high pressure.”

Anesthesia goes to intubate the dude and he drops like a f*ing stone. Pressures in the 60/20 range. Ortho aborts the case and throws on an ex fix, he comes up to the unit with a BP of 50/— in RVR and having runs of pulseless vtach. ABG with a pH of 7.1, K 6.9, lactic 7. POCUS with RV completely blown out, LVEF looks fine. Bolus amio, then start epi—>norepi—>vaso and max then all. Push 3 amps of bicarb, calcium, mag and BP creeps up to 70/40. Dude starts hemorrhaging from his ex-fix site so call for blood, took quick clot and shoved in down holes for the ex-fix rods and pack it tight against the bone. Repeat fast negative. Optimize the vent with low tidal volumes and peep to try to unload the strain off the right heart. Maybe a PE?

Every time the vent delivers a breath his a-line flatlines.

Probably time to stop screwing around and call the adults, so call in my attending from home, and he suggests calling the CVICU in too. Luckily today the Trauma ICU attending is EM+surgical critical care and the CVICU attending is EM+medicine critical care. The cavalry arrives.

CV guy drops a TEE probe in while I float a swan with the trauma attending. PA pressures are 70/40. On TEE we can see he’s got a flail mitral valve. Hook up nitric to the vent to drop the PA pressure. Add on milrinone, dig load, 8 of bumex + 120 of lasix + drip, start to peel back the NE and the dude starts to turn pink again (from a robust shade of purple).

Lactic starts to come down and urine starts to flow in the foley. By morning the labs normalized and he’s being prepped for OR for a new mitral valve.

Personally convinced if it wasn’t for it being all EM people doing the resus the dude would have been dead as a rock.

What's frustrating about this case is that ultimately the patient will believe the CT Surgeon saved his life. Years later he will tell the story like "A car hit me and I had a broken pelvis, but they discovered I also had a ruptured heart valve. I was near death and the CT Surgeon saved my life!" And there won't be a single mention of the CCU doc.

I remember I had a 50s F w/ STEMI who coded, and I shocked her THIRTY TWO TIMES. The only thing that got her out of VT was actually pushing etomidate/roc. After the 15-20th time, the interventional cards was in the room too and suggesting stuff...but what stopped the incessant VT was sedation, much to my surprise. She got her LAD stent and resumed zumba classes a month later.

I, along with a few other docs and nurses, were honored at some yearly EMS Survivors event put on by the county EMS system. It's a cool event and we all get distingushed letters of commendation from the US State Representative from the district. Anyway....the pt said basically what I wrote above. On the microphone to the entire room she thanked the cardiologist who put in her stent and said he saved her life. I went up to her later that evening and said "do you remember me? I'm Dr. ER doc". She said no! I said I'm not surprised...because you were unconscious for most of those 32 shocks. I'm the one that pushed the button so many times, and you finally got out of it when I sedated you and intubated you. She was thankful for what I did, but didn't remember me at all.

 

[Radetzky]

So this guy was hit by a car. He also randomly blew his mitral valve? You trauma scanned him and he had no thoracic injury.

Such a weird story. Well done though. haven't seen an acute flail leaflet in some time (years).

more likely to be a chronic flail that decompensated in the setting of trauma from the sounds of it

 

[The Knife & Gun Club]

When pts would say, "what are they going to do?", I would say, "I am 'they'."

more likely to be a chronic flail that decompensated in the setting of trauma from the sounds of it

Yeah, our best guess is that he had some pre-existing structural problem with his mitral, and when he got hit by a car it just broke.

Weird mechanism, weird Pathology, but a good case

 

[Lexdiamondz]

Not nearly as cool as some of the other posts here but finally found a patient with too much adipose tissue for a standard central line kit needle to actually hit the femoral vein.

61 year old morbidly obese ESRD vasculopath with bilateral AKAs who decided he didn't want to go to HD anymore arrives peri-arrest after family calls 911 since he looked like death (literally)

Somehow despite not having legs dude still weighs over 400 lbs and the humeral IOs dislodge. EKG brady in 40s with a QRS >160 msecs

Try to go for a femoral CVL and the standard finder needle can't reach the femoral vein despite two nurses holding the pannus and a med student pushing down on the skin

Finally a grizzly older attending procures a not-so-sterile 18G spinal needle and by the grace of God it gets into the vein and I can thread a wire through it.

3g of CaCl, 3 amps of bicarb and RSI meds later nephrology actually agrees to dialyse this hot mess and I avoid running a ****show of a code.

 

[Mount Asclepius]

Not nearly as cool as some of the other posts here but finally found a patient with too much adipose tissue for a standard central line kit needle to actually hit the femoral vein.

61 year old morbidly obese ESRD vasculopath with bilateral AKAs who decided he didn't want to go to HD anymore arrives peri-arrest after family calls 911 since he looked like death (literally)

Somehow despite not having legs dude still weighs over 400 lbs and the humeral IOs dislodge. EKG brady in 40s with a QRS >160 msecs

Try to go for a femoral CVL and the standard finder needle can't reach the femoral vein despite two nurses holding the pannus and a med student pushing down on the skin

Finally a grizzly older attending procures a not-so-sterile 18G spinal needle and by the grace of God it gets into the vein and I can thread a wire through it.

3g of CaCl, 3 amps of bicarb and RSI meds later nephrology actually agrees to dialyse this hot mess and I avoid running a ****show of a code.

18g spinal needle will get you almost anywhere.

 

[Apollyon]

18g spinal needle will get you almost anywhere.

ALMOST.

 

[thegenius]

Not nearly as cool as some of the other posts here but finally found a patient with too much adipose tissue for a standard central line kit needle to actually hit the femoral vein.

61 year old morbidly obese ESRD vasculopath with bilateral AKAs who decided he didn't want to go to HD anymore arrives peri-arrest after family calls 911 since he looked like death (literally)

had the family only waited another 6 hours or so.

 

[TooMuchResearch]

What's frustrating about this case is that ultimately the patient will believe the CT Surgeon saved his life. Years later he will tell the story like "A car hit me and I had a broken pelvis, but they discovered I also had a ruptured heart valve. I was near death and the CT Surgeon saved my life!" And there won't be a single mention of the CCU doc.

I remember I had a 50s F w/ STEMI who coded, and I shocked her THIRTY TWO TIMES. The only thing that got her out of VT was actually pushing etomidate/roc. After the 15-20th time, the interventional cards was in the room too and suggesting stuff...but what stopped the incessant VT was sedation, much to my surprise. She got her LAD stent and resumed zumba classes a month later.

I, along with a few other docs and nurses, were honored at some yearly EMS Survivors event put on by the county EMS system. It's a cool event and we all get distingushed letters of commendation from the US State Representative from the district. Anyway....the pt said basically what I wrote above. On the microphone to the entire room she thanked the cardiologist who put in her stent and said he saved her life. I went up to her later that evening and said "do you remember me? I'm Dr. ER doc". She said no! I said I'm not surprised...because you were unconscious for most of those 32 shocks. I'm the one that pushed the button so many times, and you finally got out of it when I sedated you and intubated you. She was thankful for what I did, but didn't remember me at all.

If they don't remember you, they can't put on a complaint. Insert standard "thinking" gif.

 

[CajunMedic]

Here's another one of CajunMedic's spinchter-clenching patients,

29 Female, seizure history, comes in by EMS in status epilepticus. Had seized 7 times prior to EMS' arrival, twice with EMS, receiving a total of 10 mg Versed PTA. Normal person, takes their meds, follows with neuro at Big University system across the state line. Promptly seizes again as soon at EMS crosses into the room. Give 4 of Ativan as that's the quickest thing we can get our hands on, then the 1 gram of Keppra we have in the Pyxis. Still seizing and now Hypoxic. Pull the trigger and RSI. Have the PA call the pharmacy for the phenobarbital dosing. Call the nursing supervisor for the EEG machine, because it's going to be a while for transfer and transport, figure we'd need it. Can't get it, only 1 in hospital and no tech on call to set it up. Gets the Phenobarb, still seizing once the roc wears off. Lactic of 11. WBC 33K, labs otherwise OK. Give the remainder of the weight-based Keppra dose. Still seizing, but not as often. Transfer center finally calls back and puts me through to the ICU doc, recommends cranking the Propofol up, giving Valproic Acid, and starting Levophed if needed for the pressure after maxing out the Propofol. Finally stops seizing, core temp 102.9. Now cooling and giving IV tylenol. Central Line, Art line, and Levo on standby. Can't get a bird due to weather and no critical care ground assets for transport. At shift change, she's stable as I can get her and I sign her out to the day doc pending transport.

I came back on that night to find out, she stayed stable, but could never get a helicopter. At 10 AM, They wound up sending a local ALS truck with a new medic, an ER nurse, and a hospital RT to manage the vent and went an hour by ground.

Wishing I got an RVU Bonus! Level 5 patient, with 360 mins of CC time and procedures...

EPILOGUE: Working a night shift last week when a guy comes in with an infected chin lac. I walk in and introduce myself "Hey, I'm Dr. Cajun, what's going on tonight? The patient looks at me and says "You're Dr. Cajun? We'd never thought we'd see you again! You saved my wife's life!! and he points to her. She says "You probably don't recognize me, I'm not seizing!" She spent a month in the Neuro ICU, multiple specialists, EEG's, etc. wound up getting a whole new med regimen and hasn't had a breakthrough seizure since!


Here's one from the rural EMS medical director files.
I'm pretty active with my agencies and have scheduled work days where I'm running calls in my chase truck and doing "Hip-pocket" training with the on-duty crews, QA/QI, just being available to the crews and administration. I was sitting in an advisory council meeting for our in-house training center when a call comes in for the local clinic: 4 month old, distended abdomen. Don't think twice and go back to what I'm dealing with. I hear the crew go on-scene and a few minutes later ask for the status of our local helicopter. I figure it's bad, jump in my truck and get enroute. I pull up as they're bringing them outside. I introduce myself to mom and the clinic nurse and jump in the truck. Kid looks sick. Born at 26 weeks with a long NICU course. Abdomen so distended the veins are engorged, lethargic. Belly is hard as a rock with no bowel sounds. I pop my head out and ask if they did an x-ray. They did, but it isn't read yet. They brought me inside and let me look at it on the PACS. Massively distended bowel with what looks like a volvulus. About that time dispatch says that first flight service declined due to the mother's weight, and they're calling the next one. I key up and tell them that this is a surgical emergency and let HEMS know that. Next crew accepts with a 15 minute ETA to our helipad. Head that way and meet the crew there. Bird lands and I give report to the crew. I had looked for an IV, but mom said all the patient had ever gotten were central lines and umbilical lines. Flight nurse tried for an ankle, but couldn't get anything. They load up and head out.

A couple of weeks later, I'm working my regular job and get a phone call from the Pediatrician thanking us for our care, the clinic was impressed with the quality of the crew, and the fact that I showed up on scene. The patient did have a volvulus, went straight to the OR and was still in the PICU with an open abdomen, but minimal vent settings with plans to re-anastomose that week.

 

[BoardingDoc]

About that time dispatch says that first flight service declined due to the mother's weight, and they're calling the next one.

If being so fat that your weight is directly delaying transportation for your critically ill child to go to the OR isn't a reason to lose weight, I don't know what is.

That said, I'm also so utterly jaded from this job that I would bet money that it had no effect whatsoever.

 

[Apollyon]

If being so fat that your weight is directly delaying transportation for your critically ill child to go to the OR isn't a reason to lose weight, I don't know what is.

That said, I'm also so utterly jaded from this job that I would bet money that it had no effect whatsoever.

Well, Stat MedEvac in Western PA puts their flight crews on the scale periodically (I forget if it's quarter, half, or yearly), and, if even one pound over, you're off the flight line.

 

[CajunMedic]

If being so fat that your weight is directly delaying transportation for your critically ill child to go to the OR isn't a reason to lose weight, I don't know what is.

That said, I'm also so utterly jaded from this job that I would bet money that it had no effect whatsoever.

The problem was, she wasn't. she actually was a little person and was maybe 60kg.

 

[TeddyBoomBoom]

The problem was, she wasn't. she actually was a little person and was maybe 60kg.

Ooof 😞

 

[BoardingDoc]

The problem was, she wasn't. she actually was a little person and was maybe 60kg.

Whaaaat? I clearly don't understand critical care helicopter rules. How could that possibly have been a contraindication to flying? Mom plus baby must be what, 62kg then? I've definitely helicoptered out patients who weigh well over 100kg before.

 

[HemeOncHopeful19]

Whaaaat? I clearly don't understand critical care helicopter rules. How could that possibly have been a contraindication to flying? Mom plus baby must be what, 62kg then? I've definitely helicoptered out patients who weigh well over 100kg before.

Plot twist: the helicopter crew was superfat

 

[rokshana]

Like for real. No one has heard of TSH?

Said no one in an ED ever…