Your patient is a well appearing, otherwise healthy 22 year old female who presents with lower abdominal pain x3 days. She is unsure of her LMP, but thinks she had some spotting about a month ago. Vital signs: Temp 99.3F, HR 92, BP 102/70, RR 20, 98% on RA. She has a benign, non-gravid abdomen. Urine pregnancy is positive. You fire off a quantitative hCG and don’t expect that result to come back for a while. What do you do next?Read More
Simulation with Dr. Hill
Transitions of care can be a high risk time for our patients, especially amidst the chaotic environment that can be the SRU.
Pre-planning sign out is an effective strategy to make the transition smooth. One to two hours out from the shift's end, take them time to start getting things in order for the end of the shift.
As emergency medicine physicians we have the tendency to want to wrap up our patients at sign out as nicely as possible. This is a good habit, realizing that it can predispose to premature closure, and, particularly in the case of an unpredictable SRU, should be applied with caution...Read More
It's been a busy Monday night shift. 2 hours in and it seems like all you've seen is belly pain after belly pain. You hesitate and think maybe it's just a figment of your imagination but a quick look at the track board tells you nope, 5 patient's with abdominal pain in your 10 bed pod and a new patient arriving to C40 with, of course, abdominal pain. You meet the squad and get report...Read More
Elbow injuries account for 2-3% of all emergency department visits across the nation (1). Yet, because of the elbow’s complex anatomy and the presence of numerous ossification centers in children, elbow fractures are the third most commonly missed fracture group in the ED (1). Here are some tools to help ED physicians read elbow x-rays more effectively and hopefully identify abnormalities more easily...Read More
It is late on a blustery grey and rainy day in November and you are the dedicated flight doc on Air Care One (the “UH”) nearing the end of your shift. Your pilot has had to turn down two flights already due to high winds and reduced visibility as bands of storms moved through the area. Against your better judgment, you are standing in the sushi line in the hospital cafeteria to grab dinner when you hear “Air Care One Pilot, weather check for a patient coming back to the U” squawk out over your portable radio. Your excitement rises as “we can do that” echoes over the radio and you hear the tones drop for your flight. You grab the blood cooler and meet your crew for takeoff on the roof...Read More
It’s true that sometimes critical care transport missions to transport STEMI patients to PCI are fairly uneventful. But if we allow ourselves to get lulled into a “Milk Run” mindset, it will most definitely come back to bite us. The jovial, normotensive, fairly comfortable-appearing STEMI patient may be only a couple of minutes away from V Fib arrest or florid cardiogenic shock. When that occurs, if we have expected and prepared for such a complication, it’s likely that we’ll be able to manage it successfully.Read More
You settle in to your 6th of 6 shifts in a row in B Pod in your tertiary referral center when you sign up for your first patient. Ms. Circling is an 86 year old female who presents with abdominal pain and altered mental status. She presents with her family who gives most of the history that for the last 2 days the patient has been complaining of abdominal pain and has not been eating or as active as normal...Read More
M&M with Dr. LaFollette
Modified Sgarbossa Criteria to aid in diagnosing STEMI in the setting of LBBB
- Can be used in the setting of induced (paced) LBBB
- Unweighted scoring (any of the following indicates STEMI equivilance)
- Concordant ST elevation
- Concordant ST depression in V1,V2,V3
- Inappropriate discordance of >25% ST elevation / S wave amplitudes
- Improves your test metrics from the original criteria from sens/spec of 36%/96% to 80%/99% respectively in a new validation study
It’s late on a Saturday night and you are moonlighting as the single provider at a community hospital about 15 minutes from UC. You’re trying to disposition five current patients when a new patient is brought in by EMS with a complaint of vomiting blood. The patient smells of alcohol and states that he drinks daily, though he may have “overdone it” the last 2-3 days since he has had friends in town...Read More
Both the diagnostic and therapeutic thoracenteses are performed using a similar technique. The major difference is the amount of fluid removed. The proceduralist may also choose to only use the needle technique as opposed to the needle-catheter unit when obtaining fluid for diagnostic purposes only.
It is generally recommended that needle size be limited to 18-gauge or smaller to minimize risk of pneumothorax and damage to nearby structures.
US-guided thoracentesis is associated with a significantly lower rate of complications and has become the standard of care. (1) Real-time ultrasound (US) guidance is recommended for small or loculated effusions when there is concern that the diaphragm or lung tissue is <10mm from the pleural surface. It is also recommended in patients with relative contraindications such as coagulopathies and the mechanically ventilated patient.Read More
Spring is here and new beginnings are right around the corner. Step-ups are looming and we will find out the names of our new interns any day. It is time for interns to polish their efficiency, for the R2s to finish their off-service rotations in anticipation of the great variety of the SRU, the R3s to finishing refining their ability to run an effective team. The R4s #fillintheedges of their careers as residents so they can go forth as prepared attendings. In anticipation of these new beginnings, this issue of Annals of B Pod focuses on cases that #fillintheedges.Read More
Back Pain with Dr. Summers
Of the more than 2.5 million ED cases of back pain every year, roughly 5% of these actually have an emergent cause. Conventional red flags include:
- Age >50 or <20 yo
- History of cancer
- Steroid use
- IV Drug Use
- Known aortic aneurysm
- Motor neurologic deficit
- Urinary retention, bowel incontinence, or saddle anesthesia
OB-GYN Emergencies with Dr. McKinney
Case 1: 18 wk patient with vaginal spotting who is Rh- but antibody+
Bedside U/S shows fetal abnormality due to Rh alloimmunization with fetal hydrops. Positive antibody screening on gravid female should warrant obstetric consultation. Rhogam administration within 72 hours of bleeding is important.
Case 2: 40 wk female with gestational DM present with crowning fetus who fails to immediately deliver secondary to shoulder dystocia.
Treatment: stop pushing and avoid traction. Initially attempt hyperflexion of legs and suprapubic pressure to release (McRoberts maneuver). Then consider episiotomy because subsequent maneuvers involve twisting the baby to get shoulder into a different plane.Read More
Think about gravity: fluid will collect in most dependent region (down); air tends to collect towards the least dependent regions (up)
Air does not reflect sound waves well. Lungs are filled with air. Rather than getting most of our information from visualizing the anatomy (as in a RUQ ultrasound, for example), much of our information comes from “artifact” or ultrasound waves being affected by phase changes.Read More
While many wounds are adequately repaired with simple interrupted sutures, not infrequently we are confronted with wounds that require more specialized suturing methods. One such method is deep sutures. Here to answer some questions regarding deep sutures is our wound management guru, and author of the book “Wounds and Lacerations: Emergency Care and Closures,” Dr. Alexander Trott.Read More