Attention! New contender for most pathetic ER visit chief complaint

25 y/o M CC:

“I inhaled some water in the shower this morning and now I’m coughing”.

Is it just me or does bombing suspect Dzhokhar Tsarnaev look like Noel Redding from the Are You Experienced album from the Jimi Hendrix Experience?

Simple rule for all you triage nurses:
Don’t let people with abdominal pain sit for 45 min in the waiting room with a blood pressure of 76 systolic and a heart rate of 120. It’s bad form.
Thanks.

If you ask me, the most important thing you need to be able to do when working in the ER as a doctor or a nurse (and to only a slightly lesser extent, as a tech or a respiratory therapist), is to be able to recognize when someone is in cardiac arrest.

Sounds pretty basic, right? Then how can some people who should know better (ie BLS/ACLS trained) not realise that a pt who becomes unresponsive is in fact pulseless and apnoeic!

Come on people, feel for a pulse and check for respirations!

Throwing a pathetic pseudo-seizure on the floor of the ER in front of the Nursing Station is not going to get you Dilaudid any faster than faking back pain.

Ok, I know I’m not posting as much but I need to wait for something to inspire (or infuriate) me. Here  is a case that did:

78 y/o male with HTN and High Cholesterol but no other known cardiac disease presents with generalised weakness over about a 1 hour period. His family said he just said he did not feel well and went to lie down on the sofa. He soon was found to be semi-responsive so they called 911.  Medics found him with AMS but rousable and a HR of 140 and an SBP of 90. Fingerstick normal

In the ED his vitals and appearance were very similar.  He would rouse and described some vague abdominal discomfort but was more or less semi-conscious.  He had a temp of 100.8, was tachy and hypotensive.  Lungs clear abdomen mildly distended and slightly tender.  Skin pale.  EKG showed rapid Afib (pt had no prior history).

CXR normal, WBC 20K, lactate 5.8, Cr 2.0

What is it? I’ll tell you what I thought it was (and what I did for him) and what it turned out to be in the answers.

Too all ER doctors out there I give you this advice:
If you have a patient that is sick and a consultant over the phone tells you a specific way to manage it that you think is completely wrong, don’t just do what they say. Especially when it is out of their field of expertise.
I had a patient nearly die because a certain private MD refused to let me perform an intervention that I thought was entirely indicated. I held out because the patient was stable at the time and I didn’t want to create an argument.
Sure enough, several hours later,while the patient was languishing in the ER waiting for a bed he coded and almost died.
I’m still beating myself up over this poor decision.

Vtach>syncope>see me>Amiodarone 150mg>syncope>cardioversion>Vfib>CPR>Defibrillate>Amiodarone>NSR>wake up>IWMI>Vtach>syncope>cardioversion>Vfib>CPR>Epi>NSR>Wakeup>Vtach>Lidicaine>Cardiovert>Vfib>CPR>Defibrillate>Epi>NSR>Wakeup>Goes to CATH lab.

Whew!!

I think the most important aspect of being in emergency physician is being able to maintain one’s cool while stuff is crashing all around you.
Yes you need a broad knowledge base. Yes you need to be able to do procedures. Yes you need to be able to communicate well with patients and with other physicians. Yes you need to be able to multitask.
However all this is pretty moot if you can’t keep it together when someone’s going south. Is very easy to panic when you realize someone is having some unexpected situation and starts to become unstable. Is especially the case with young people since you don’t usually expect them to die unlike the ultra elderly.
Anyway, the other day I was called in urgently to see patient was only in his 40s who is complaining of shortness of breath. When I first walked in he didn’t look that bad. Not great but not bad. His blood pressure was a tad low and his heart rate was basically normal. However in for my icy begin to look worse he became more diaphoretic he had this look of impending doom on his face and his blood pressure dropped and his pulse rate dropped down into the low 40s. He complained of some vague chest discomfort. So quickly get the crash cart and get a repeat EKG. Turns out he was having a very large inferior wall myocardial infarction.
Bradycardia and hypotension can occur in the patient can look awful. Complicating this case was the patient’s recent history of lower intestinal bleeding. The low blood pressure meant he could not get nitrates and he could not get anticoagulated because of the bleeding. Lack of response to atropine further increased my pulse rate. Meanwhile all around were panicking family members. Finally I had to put him on a dopamine drip and send him off to the Cath Lab looking only marginally better (which for some reason took longer than usual time to get ready for the patient). He wound up doing well but that was a half an hour of some serious anxiety.

Happy new year everyone. Several musings on working overnight on New Year’s Eve.

First if you’re going to try to break up a fight between two people, try to avoid sticking your finger into one of the combatant’s mouths. Yes your finger will probably get bitten off.

Second, if you get stabbed 10 times it’s probably better to call the ambulance than to have your friend drive you in.

Third, if you’re diagnosed with the flu you can expect to have fever for 4-7 days. Tamiflu will not get rid of your fever three hours after taking it. There is no need to return to the emergency room for such things.

Fourth, always think twice about when you leave your 14-year-old off at a party with supposedly “good people”. He’s liable to end up intoxicated facedown on the roadside somewhere.

Me: “So sir, what brought you to the ER today?”

Mr Sarcastic: ” A car “

Sorry for the dearth of posts lately, I just have a lot of crap going on and little free time to sit and do them.  Kids will do that to ya….

Anyway, there is something to really be said for patients who come in having that “sense of impending doom” look.  Obviously, anxious people can have that look but there is something different about it than the typical panic-stricken person (who usually has nothing serious wrong with them).  Hard to describe but it’s more like they look like they saw a ghost. They may be nearly frozen in their tracks.  They just look seriously terrified.  When a middle aged man comes in with that look, it almost always means badness is going on.

Think MI, Aortic Dissection, Pulmonary Embolus, AAA leak, something potentially devastating.  Don’t blow these people off. They need extensive testing to rule out bad stuff when they have that look. It’s usually legit.

I want a sign posted in our ER waiting room that reads:

“Welcome to the Emergency Room. Please note if you have a non-urgent complaint you may need to wait to be seen. Hence the reason this is not called the Chronic, Annoying, and/or Minor Problem Room”

Top tip: if you’re an M.D. who does procedures on very entitled and rich patients who donate a lot of money to the hospital, it might be a good idea to actually return their phone calls when they contact your service to complain about something.
Having a nurse or PA just tell them to “come to the ER” and then still not be available when I call, is a surefire way to piss off the entitled patients, make them freak out and threaten to sue you even if technically you’ve done nothing wrong. You could’ve headed this off at the pass you dummy.

Sorry, been off my posting game lately.

Anyway, what always amazes me is when I see an elderly person coming in for drug OD or even just with a positive U-tox.  I guess Marijuana is not such a big deal in most cases but I’m shocked when I see Cocaine or Meth.  How does this happen? I imagine they are not just suddenly picking up a hard core drug habit when they are eligible for Medicare, but probably have done the drugs for a long time – and never put them down.

Then that always surprises me when I wonder how they survived that long while doing drugs that have such a high incidence of cardiac-related complications which are additive to the regular DM, HTN, and CAD that many people develop.

Still, they do die on occasion from it.  It’s sad when an old guy strokes out when doing blow or when he seizes and then has a v-fib arrest all because of something that should have been addressed years before.  Remember, not everyone is Keith Richards!

“Doc, it hurts when I breathe”

Repeat the test!

A). Vague symptoms but pt looks uncomfortable.

B). Same pt a little while later!

Or just a Moron.

Man who claims to be in the “Fitness” industry is on:

1). Anabolic Steroids
2). Yohimbine
3). Thyroxine-like hormones
4). Sugary Energy Drinks
5). Cocaine

Sorry, your actions are directly contradictory to your self-description.

Listen, if you’re the plastic surgeon on-call, you’ve got to take the good with the bad. Usually this means that you have to take the occasional significant, plastic surgeon-only case (like tendon lacs or parotid duct injuries) in an uninsured patient. In return, you get a bunch of simple insured, elective lacerations that you can charge a bajillion dollars for.
New take on this is an insured patient with a significant, multilayer, facial laceration that theoretically I could close ( albeit probably with a suboptimal cosmetic result) who specifically requests a plastic surgeon but happens to be 90 years old. If you piss and moan and refuse this case, guess what? I’m going to call in another plastic surgeon who will gladly take it and make plenty of money off it. Guess what you’re getting for the rest of my shift? Uninsured lacs that “I just don’t feel comfortable closing”. Most likely after 11 PM.

Payback is a bitch.

It is generally accepted that the very elderly are highly unlikely to go into tradition SVT (technically AVNRT or AV nodal reentrant tachycardia) because their AV node is so old and can conduct the signal very well. Typically they go into AFib or AFlutter.
Anyway, the other day I had someone who be damned went into AVNRT at a rate of 150 so it perfectly imitated AFlutter at 2:1 conduction. This was proven after a test dose of adenosine. Anyway, I felt bad for the old girl having to suffer through it but part of me was impressed. I told her, “Hey, people your age don’t usually have a heart that’s healthy enough to go into this arrhythmia! You should be happy!”. Well, maybe not happy but you know what I mean….

Some people can’t catch a break. They’re in and out of the hospital four times in the last two months with fevers and recurring sepsis that nobody can find the cause of. They get better each time on a cocktail of antibiotics.
After finally seeming to be better for several weeks they return again. This time with massive C diff colitis and a blood pressure 60.

Chief complaint winner of the Day:

“Diarrhea one time 20 minutes prior to arrival”

I actually did wait to see that he was breathing….

Listen, I know you said “I don’t eat no salt!!” when I asked you about your diet. Your leg edema and JVD contradict that statement however. Further investigation revealing that you don’t ADD any salt gives me the answer though. Your evening dinner of “Oodles of Noodles” contains a boatload of sodium so let’s sit and have a little talk about reading labels. K?

I have turned over a new leaf. No longer will I turn the other cheek when doctors talk down to me or are overtly rude. I’ve actually crossed the line a few times and have discovered lots of these bully doctors are do accustomed to being assholes that they are nearly dumbfounded when someone talks back and calls their bullshit.
They back down and don’t know what to do – just like schoolyard bullies.
You know what, if you are a dick to me, I’m giving it back. I don’t care if you are God’s gift to surgery or whatever. If you’re a tool, I’m calling you a fucking tool.
If I get fired (I doubt I will), it’ll be worth it. And there’re tons of other jobs out there.

Kids do some stupid things – like having a pica contest. Look! I can eat a penny! Oh yeah, I can eat a necklace!
*gulp*

I suggest the next time you try a flying kick to break a board during your karate practice, you might want to wait until you’re a higher belt.

This image is from an actual medical textbook. Provide an appropriate caption.