#EMERGENCY MEDICINE

[emgoesmed]

10/18/2024

Officially completed my first ambulatory block, next up is the ED just as respiratory season is kicking in; I'm nervous but excited to learn a lot.

[drdessertfox]

It’s been really interesting to see the turn medicine has made with the public over the past several years. I would never advocate that you should trust any physician blindly, but it’s quite amazing that those with GED level education are trying to convince others glucola is evil, the vitamin K shot is unnecessary, and that doctors order certain medicines and tests because “big pharma” pays them to do so.

I want to be very clear- as an EM physician I am paid hourly, much like all other EM physicians. I do have an RVU component meaning I make more money if I am more efficient but that is only a minimal component of my pay. I want to have conversations with my patients and help address your emergencies, but it’s incredibly difficult when I’m met with antagonistic attitudes from the start that stem from misinformation and fear mongering of online crunchy mom influencers.

[studyblr-of-a-biomed-student]

Working in the emergency department is just:

- Seeing 5 people with colds who shouldn’t be here

- Someone with diabetes who just chugged a Big Gulp Soda

- Mystery Abdominal Pain

- An old person who fell and somehow broke every bone in their body

- Seeing the happiest healthiest baby ever with parents who look like they haven’t slept in 3 days because the baby sneezed (I don’t mind these patients - cute baby, knowing the cute baby is cared for, and easing people’s worry? Great time)

- Someone who got in a car accident 2 days ago and just now decided to get checked out and is about to learn about whiplash

- Someone who didn’t try any OTC medication for their symptoms before coming and is about to get the most expensive Acetaminophen & Ibuprofen of their lives

- An interaction that changes your life; that leaves you with a deep sadness but also hope and a certainty that despite everything, in their hearts people are good and want to love one another

- A 3ppd smoker with diagnosed COPD who decided today is the day to figure out that cough they’ve had for 5 years

- Homeless people who just want to get out of the elements and have a snack you want to help but can’t

- Someone who will scream at you for not prescribing antibiotics for a viral infection

- Someone with 13 heart stents who vehemently denies any heart problems because “they fixed it!”

- Someone who just invented a new way to take medication wrong

[justkidneying]

Why the Spleen Sucks

The spleen is a really shittily placed organ, making it prone to injury. This injury is usually severe and can lead to death if not properly managed. We're going to look at the function of the spleen, what happens when it is damaged, and how to write about.

Where is the spleen? It's in the upper left quadrant of the abdominal cavity, nestled right against the ribs (typically 9-11) at the midaxillary line. It's behind the stomach and is considered intraperitoneal. The main thing is that the spleen is very vulnerable. It is literally right up against the ribs without much protecting it. It's shaped like a little bean and is purple in humans. It is fed by the splenic artery, which comes off of the celiac trunk (which sticks off of the abdominal aorta).

What does the spleen do? Its main job is to filter out old and malformed red blood cells. It also holds immune cells. Certain diseases can cause the spleen to enlarge, including cirrhosis of the liver (it's connected to the hepatic portal system), sickle cell anemia (RBCs are stuck in it), and autoimmune disorders. The spleen also holds about 250 mL of RBCs in reserve in case you need them.

What happens when it is injured? The spleen can be ruptured and lacerated kinda easily. Blunt trauma to the ribs can cause it to rupture, and this is seen in contact sports and car accidents mostly. Because of those giant gaps between the ribs, it's also prone to injury from knife attacks. Gunshot wounds are another common cause, as well as broken ribs penetrating it (broken ribs are very sharp, like way sharper than you imagine). Rupture is more likely when someone has splenomegaly.

When the spleen is damaged, you're going to get a lot of intraperitoneal hemorrhaging. The spleen filters a lot of blood and has blood in it, so there's going to be a lot of blood in the abdomen (obviously). This will lead to distention, guarding (abs are tense), and hypovolemia. The left upper quadrant will be painful, and there can also be referred pain to the left shoulder (Kehr's sign).

If the patient has a small laceration, the symptoms aren't always as dramatic. Sometimes they'll just have low hemoglobin (which is on RBCs), maybe some thrombocytopenia (lots of platelets in the blood).

How do you fix this? If the injury is small and the patient is hemodynamically stable, they can usually be given a blood transfusion and the spleen can heal itself. Sometimes surgery is also performed to clamp a vessel or repair the outer layer of the spleen.

If the injury is major, then surgery will be performed. If the patient is less critical, they may go in and try to fix the problem. If it can't be fixed, they may do a splenectomy (remove the spleen). In a critical patient, they might forgo the nice pretty incision on the left side, and instead just split the patient down the middle. In these situations (in my experience), there isn't a lot of time to waste. One thing that we aren't going to waste time on is anesthesia, for example. This is with a lot of very critical surgeries, at least from what I have seen. Like the surgeon will start cutting as they are working on knocking out the patient, but usually they are in so much pain that they don't even register it.

If you remove the spleen, the patient is more at risk for infections, but with modern medicine and vaccinations, it's not as much of a big deal as it used to be. The patient will probably be fine.

Writing tips: (new section idea, hope you guys like it, lol) As with any injury, you have to make sure that you are giving them an acceptable mechanism of injury. With the spleen, this is either blunt trauma or penetration/laceration. Getting tackled, getting stabbed, getting shot, all great MOIs.

Second thing, present the appropriate signs and symptoms. A sign would be like bruising, hypotension, tachycardia, etc. A symptom would be LUQ pain, Kehr's sign, etc.

Next, figure out what you're going to do and where you're going to do it. In the field, there probably isn't much you can do. The most would probably be a laparotomy and clamping the splenic artery, but I mean, when I was an EMT, we were not doing this. There's a lot of stuff you can theoretically do, but never gets done. But I mean you can write it. If the patient makes it to the hospital, I think it would be more fun to do emergency surgery and just split them right down the middle. There's going to be a lot of blood in the greater omentum, very high stakes and exciting.

Anyways, hope you guys liked this, please let me know if I got anything wrong. I wrote this off of my personal experience and a few good textbooks, but there can always been mistakes in things.

[heardatmedschool]

“My tummy hurts…. Sorry, my right iliac region hurts.”

[heard-in-the-emergency-room]

[help-im-a-medstudent]

Never trusting a "can I handover my patients to you, there's no jobs to do" ever again

"He's having a ct head I'm sure it's going to be fine, GP just needs to refer to memory clinic" the CT head was not fine, had to do a referral to neurosurgeons and tell a man and his wife he had brain metastases and probably some cancer somewhere else in his body

"Waiting for a troponin if it's normal they can go home" the troponin was not normal

"Just waiting for a bed on the ward, everything's done" continued vomiting, required discussion with surgeons, ct had to be arranged

"Ortho are on their way to review" ortho were not on their way, because the day team had not handed it over to the night team

[er-cryptid]

Common Medical Emergencies

Patreon

[karmaalwayswins]

@quezify eggtober 2024

Nurse Kylie poked her head into the emergency department’s provider room. “Dr. T?”

“Yeah?”

“David wants you to come to room 12.”

“It’s a sprained ankle, he can handle that.”

“He already saw the patient, but he said you’ll need to see him too.”

Dr. T stood up from the computer and walked to room 12. David, the physician assistant, met her in the hallway across from the room. 

“Patient is Allen Spencer, age 29. He signed in for a sprained ankle. His xrays are fine, but when he opened up his bag… Well, see for yourself.”

The patient, a brown haired man wearing a sweatshirt and track pants, was sitting on the stretcher watching TV. Next to him was an approximately one foot tall egg with arms and legs. It was faceless. Neither the patient or the egg seemed to be in any acute distress. 

“That’s an egg who has arms and legs,” Dr. T said. 

“It is.”

On the TV screen, a football game was playing. A wide receiver caught a pass and started doing an end zone dance. The patient let out a little squeal and high fived the egg. The egg then stood up and started imitating the end zone dance. 

“It has no eyes but it can see.”

David passed her a notepad. “It asked for a pen and then wrote this.” 

On the notepad was a neatly written message in blue ink. Dr. T read it out loud in an annoyed voice. “Turn on the game.” She shook her head, then said, “This looks like an Institute problem. Did you check the guy for a chip?”

David answered, “I did. His scan flags for Spiceland Institute.”

“Did you call them?”

“Figured I should let you see him first.”

“Does he have any complaints other than his ankle?”

“He’s fine other than that.”

“OK. I’ll check his ankle just to say I did. Call the institute so they can come and get him and his egg. Get a sitter for the room until their team shows up.”

Dr. T. entered the room. “Hi Mr. Spencer, I’m Dr. T. They told me you hurt your ankle.”

“I twisted it in the woods.”

“I’ll take a look at it. Who’s your friend here?”

“He’s Buddy. He likes football.”

“Let’s have Buddy sit in the chair while I look at your ankle.”

The egg athletically jumped down off of the bed, walked over to the chair, turned the chair to face the TV screen, and then climbed into it to sit. Dr. T raised her eyebrows as this series of events occurred, let out a breath, and then started looking at Mr. Spencer’s ankle.

“I barely see any swelling here. Can you bend your foot up and down for me? Good. Wiggle your toes. Good.” She stood up. “I’m going to go talk to PA David. You can just rest for now and watch the game. OK?”

“OK.”

When she exited the room, a panda-man wearing scrubs was stationed in a chair next to the door, on sitter duty. His arms were crossed over his broad chest. He nodded his head and asked, “How you doing, Dr. T?”

“Depends on how much paperwork I have to do about this,” she said. 

She walked over to Helen, the charge nurse. “You’ve got Tai Shan doing sitter duty?”

Helen shrugged. “He’s trying to buy a house. He needs the extra hours.”

A couple of hours later, staff from Spiceland Institute arrived. Dr. T shook hands with the two men, who were wearing black baseball hats and black jumpsuits.

“I’m Dr. T.”

“Specialist Allen Kemper.”

“Specialist Dale Chavez. I gave your charge nurse the transfer paperwork. Can I get your name for our records?”

“First name’s Wendy, with a Y. I’ll just spell my last name. T-A-P-A-Z-O-C-L-O-L-I-N-E-A-B-E-U hyphen D-I-A-Z.”

“Got it. We’ll take him off of your hands.”

“And the egg?”

Specialist Chavez rolled his eyes. “We’ll take the egg too. The two of them are kind of a package deal. We've been looking for them for the past day and a half.”

Specialist Kemper cleared his throat.

Specialist Chavez shifted his eyes in response, then asked, "Which room are they in?"

"Room 12," Dr. T answered.

Specialist Kemper was helping Mr. Spencer into his coat when Dr. T went back into the room with the discharge paperwork.

Mr. Spencer was talking. “I watched the football game. And I had two cookies!”

“Two cookies are better than one cookie,” Specialist Kemper said.

Mr. Spencer asked, "Did you notice that it gets dark earlier now?"

"I did," Specialist Kemper answered.

On the floor, Buddy the Egg was enclosed in a carrier. By body position, he seemed forlorn. 

As the Spiceland Institute team walked out with Mr. Spencer and Buddy, Tai Shan glared at the specialists from his chair. 

Helen came up to Dr. T. “We’ve got a cardiac arrest coming in five.”

“What bed are you going to?”

“Thirty-four.”

“OK.”

[tumble-tv]

You know what sucks? Taking a six month class to become an EMT, becoming fully certified, the whole deal, just to watch my health plummet into being a barely functional person.

I got certified in May. My body doesn't work enough for me to be confident that I can save someone. It's been two months and it's only gotten worse.

My dream of being an EMT, of saving people, of finally being the person to help is crushed because my body doesn't work like it should, and it's tearing me apart.

I don't know what to do.

[emgoesmed]

11/2/2024

Tb to when I had time to read books for fun, just a month ago 🥲

Flipping back and forth from nights to days to nights in the emergency department while also trying to study for step 3 is not something I recommend 😭

[chasingmywhitecoat]

always fun to start working up a patient with the “could this be a dangerous cause of acute abdomen?” line of thinking and finish on “you’re just really (and I mean REALLY) constipated” lol

[studyblr-of-a-biomed-student]

So working in emergency medicine is going well…

[equinesandeducation]

Packed all my stuff for my first overnight/stand-by shift. Because I live far away from the faculty and you need to be at the clinic in 20 minutes for a stand-by, I get to sleep at the Farm Animal Clinic! Almost feels like a little holiday, with the exception of getting called in the middle of the night for emergency surgery.

[heardatmedschool]

“For new doctors, domestic violence should be like appendicitis. You are not the one that will solve the problem, but you have to suspect and also help contain the fire in the meantime.”

[lesbiansandgayssupporttheminers]

Mother, 39, collapsed under her coat and died after seven-hour wait at crowded A&E - LBC

This should not be happening.

We used to have a functional NHS - maybe there were issues but in emergencies it functioned.

The Tories have destroyed that.