emcases

[emcases]

A nursing-home patient was intubated in the field for respiratory distress and hypoxia. On arrival, breath sounds were decreased on the left during ETT (endotracheal tube) verification. His sat on 100% oxygen with the ETT is 98%. A CXR is done. What do we do next?

-- The CXR shows white-out of the left lung. There are four possible causes - (1) the ETT is malpositioned (right main-stem bronchus, typically) and the left lung isn’t aerated, (2) large pleural effusion, (3) complete infiltration of the left lung (pneumonia or bleeding), and (4) obstruction of the left airways by mucus, cancer / mass, or food. All four problems can happen at once.

The first thing to check is to see where the ETT is on the CXR. You can see that it is correctly positioned above the carina. If the ETT is in the right main-stem, pull the ETT back and repeat a CXR. You can also see an air bronchogram in the left lung field, suggestive of pneumonia. A CT scan shows bilateral effusions and alveolar infiltrates with partial collapse of the left lung. The patient needs a bronchoscopy, which showed severe mucus plugging. After removing the obstructions, a repeat CXR looks better.

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[emcases]

A young man is brought after falling from a height of 100 feet (30 m). His vitals are unstable. The FAST (trauma sonogram) shows free fluid in the abdomen. The patient is taken to the OR. His labs are shown. What do we do next?

Answer to 10/9 posted.

[emcases]

A young man comes in with a diffuse urticarial eruption after seafood exposure. He has a history of heavy alcohol use. His labs are shown. What do we do?

Answer to 8/15 posted.

[emcases]

A patient is found unresponsive by his wife. He has a history of hypertension. On exam, the patient is unresponsive with no spontaneous movements, but withdraws somewhat to pain. The patient is rushed to CT because of a suspected hemorrhagic stroke. The CT is shown. What do we do next?

Answer to 5/20 posted.

[emcases]

A patient is brought in for a single stab wound to the abdomen.  His vitals are HR 110, RR 12, BP 130/90.  There are no other injuries.  The abdominal exam is soft and non-tender.  He is intoxicated with alcohol.  During IV access, he didn’t feel any of the jabs.  What do we do next?

A different patient is brought in for a single stab wound to the abdomen (same location).  He is unresponsive and pulses are weak.  His vitals are HR 80, RR 16, ?BP 80/50.  The patient is lined and lab’d.  What do we do next?

[emcases]

Sometimes, I think the only reason I have a job is in case the internet goes down.

With the internet connection intact, it’s easy to look things up.  We have no books in the ED anymore and no one has Rosen’s or Tintinalli’s on their phone.  People tend to forget that Poison Centers can advise you with envenomations, so give them a call if you want some advice.  If the web and the phone go down, then you’re on your own.

We don’t have dangerous scorpions in our part of the country (and neither does most of the U.S.).  Like Covid, SARS-1, and Ebola, everyone is susceptible to diseases outside of their endemic flora because of airplanes.  It’s like a bizarre real-life medical version of the butterfly effect.

In general, scorpion stings are benign.  Everyone talks about pancreatitis, but that’s rare.  Serious envenomations come in two flavors: (1) neuro / cholinergic crisis (think SLUDGE) and (2) cardiac.  The treatment for SLUDGE is atropine.  There’s no antivenom, practically speaking.

There was no local reaction at the site of the sting.  The patient was observe for a couple of hours and then discharged home.  The scorpion was a nice break from the monotony of the ED.

[emcases]

A man is brought in after being stung by a scorpion.  He was unpacking groceries at a store when the critter popped out of nowhere.  What do you do next?

Answers to 2/12, 2/22 posted.

[emcases]

https://www.nytimes.com/2022/12/22/health/nyu-langone-emergency-room-vip.html

* Disclaimer - not a case, just an editorial

There was a recent article in the NYT about VIP treatment at NYU Hospital in New York City.  We would like to think of the ED as a level playing field; but like medicine in general, this is not the case.  All patients are equal, but some patients are more equal than others.  I think that if I do a survey, nearly all ED docs will say yes, they’ve been asked to give special treatment to a patient.

Another concern is the recurring theme of hospital v residents / residency and the issue of censorship.  The medical education system has always been a balance between service and education.  More than ever, hospitals have prioritized work over education.  Essentially, hospitals view their residents solely as employees.  Great teachers who speak out against hospital wrongs and fight for residents are forced out, and resident education suffers.  The ACGME seems to be the last and perhaps only line of defense.  CMS should grant the ACGME the power to impose financial penalties to hospital systems that abuse and neglect their residencies.  Without good Emergency Medicine residency training, patient care suffers.  It is a serious public health issue.

[emcases]

Elderly Head Trauma

An elderly woman tips over while reaching for something in her closet and hits her head.  She is on xarelto for afib.  She has a 4 cm mid-forehead lac that is oozing blood.  She denies headache or vomiting.  Her exam is normal.  She is pleasant and we have a good conversation, cracking jokes.  Her granddaughters are here with her.  Here are the “what am I thinking?” questions - what do we do first, and what is the only question I want to ask?

[emcases]

Weird-ish Labs

A woman with alcohol abuse and a history of pancreatitis comes in with pancreatitis.  Her lipase is 290 (normal is < 60).  Her chemistries are shown.  What are the abnormalities, and how do we treat them?

Answer to 1/4 posted.

[emcases]

A 50s M with hx diabetes, hypertension, and CKD comes to the ED because “my sugar is high”.  An EKG is done at triage and your co-worker activates a STEMI alert.  What do you do?

[emcases]

The short answer is to get the patient to the OR.  Call neurosurgery, pre-op the patient.

Epidurals require surgery.  There is a fracture, an injury to the middle meningeal artery, and it may not stop bleeding, causing the patient to herniate and die.  Subdural hemorrhages may be observed because they are venous.  Subdurals don’t always expand and kill the patients.

Virtually all of the epidural patients I’ve seen are breathing easily on their own, even the ones that are herniating.  I am often asked to intubate these patients electively for the OR.  Even though the intubation will delay the trip to the OR by at least 15 minutes, it’s irrelevant where I work because the neurosurgery attending will usually take that long to get to the patient.

Epidurals are distracting.  Frequently, these patients will have other brain injuries.  This patient also had a subdural (on the right), contusions, and skull fractures.  Sometimes, the co-existing subdurals, etc will also require surgical treatment.

Epidurals have good prognosis.  This patient walked out of the hospital a few days later.

A frequent theoretical question posed in the hospital is “would you rather have a subdural or an epidural?”  Most docs will say an epidural.  Epidural is mostly an arterial / bony injury, even though it’s often fatal.  Subdurals are associated with brain injury, so you won’t be the same even if you survive.

Answer to 11/29 posted.

[emcases]

A patient is BIB EMS with a gsw to his head.  There is vomit on his face.  What do you need to know?  What do you need to do?

[emcases]

Your resident calls you from CT and says the patient (that you just got sign-out on) has an epidural.  I go to CT to look at the image.  What do you do?

Answer to 10/15 posted.

[emcases]

Persistent High K

The sign-out: an ESRD patient comes in with high potassium (hiK) of 9.5 and fluid overload.  He received the potassium cocktail and he was dialyzed overnight, admitted to Tele.  The patient looks fine; he has a history of COPD / OSA and hypertension.  After sign-out, the repeat K after HD comes back at 9.2.  What do you do?

Answer to 9/5 posted.

[emcases]

Ped Struck

A 40s M arrives by EMS after being struck by a car.  Per witnesses, the patient ran out between two cars, was struck by the mirror, knocked down, and got up and ran back to the sidewalk.  EMS reports an initial sBP of 80 in the field.  On arrival, he complains of left shoulder pain.  His vitals are normal with a HR of 95, RR 12, BP 110 / 70.  His physical exam is normal.  There is no shoulder injury; he moves the shoulder perfectly well.  IV access is obtained.  Ten minutes later, his sBP is noted to be 60.  The patient appears well and the exam remains normal with good breath sounds, non-tender chest wall, non-tender abdomen.  What do you do?

Answer to 8/4 posted.

[emcases]

Rectal Pain

A 30s gay man comes in with rectal pain.  Triage vitals are normal.  What do you do?

Answer to 7/1 posted.