The Mid-Shift Rush

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The Mid-Shift Rush

Working overnight in a busy community hospital, you’re starting to hit a mid shift wall.  There are some shifts in the ED where your job is glorious, where every patient has obvious pathology, where your interventions and treatments provide immediate relief of pain and suffering, and where the volume is steady though never overwhelming.  This is not one of those shifts.  Seemingly every patient has had a myriad of vague complaints to the point where you’re considering contacting the local health department to inform them of an exploding epidemic of “weak and dizzy” patients arriving in your ED.  Taking a breath between patients, contemplating whether or not to consume your 5th cup of coffee, you glance over to the triage desk to see 4 squads lined up.  Looking at the EMR you see all 4 of them carry the chief complaint of altered mental status…

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Grand Rounds Recap 12/30/15

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Grand Rounds Recap 12/30/15

Morbidity and Mortality Conference with Dr. LaFollette

Tracheoinnominate Fistula

One of the most dreaded days in the ED, a post-trach patient presents with a small bleed that stopped, is this one of 50% of patients with a TI fistula waiting to unleash?

  • 0.3% occurrence after routine tracheotomy
  • Incidence peaks 7-14 days after procedure

Once the patient starts massively bleeding - what's your next move hotshot?

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    The Approach to Shoulder Radiographs

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    The Approach to Shoulder Radiographs

    The first snowflakes of the year are falling as you head into your midday Minor Care shift.  Slipping on an icy patch of compacted snow and nearly falling as you head from your car to the ED entrance, you have a sneaking suspicion what the day will bring: falls, slips, and trips.  Indeed, you settle down to the computer, log in to your EMR and pull up the minor care screen to see 2 unseen patients with the chief complaint of “Fall”...

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    Global Health Case Files #3

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    Global Health Case Files #3

    Imagine:  you are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria.  You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics.  Your clinic does not have any power.   Your diagnostics include:  urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria.  You have 2 nurses, one of whom acts as a translator (from Swahili to English).  You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.

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    Annals of B-Pod: Mastering Minor Care

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    Annals of B-Pod: Mastering Minor Care

    Under Pressure: A Tonopen Tutorial

    Prepare

    1. Find your Tonopen. At our shop the Tonopen lives in the cabinet in the attending office.

    2. Adequate corneal analgesia is key. Instill tetracaine in both eyes prior to using the Tonopen.  

    3. If you are assessing the patient for corneal abrasions, perform the fluorescein exam prior to using the Tonopen as the Tonopen may inadvertently cause small abrasions.  

    4. Place a cover over the tip. It slides on like a condom and then roll the ridge into the grove.

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    Annals of B-Pod: Quick Hit Case

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    Annals of B-Pod: Quick Hit Case

    Open Globe and a Discussion about Traumatic Hyphema

    The patient is a male in his 40s who presents after sustaining an injury to his right eye with a fishing hook. He states that a three-barbed hook pierced his eye while fishing with his friend. On gross inspection, the hook was noted to have pierced the inferior eyelid causing an obvious right open globe and there was a large hyphema. While he was initially able to count fingers at four feet in his superior visual field, his visual acuity quickly deteriorated to light perception only. Extraocular movements were intact and caused movement of the hook. Ophthalmology was consulted and a CT was obtained. The patient was then taken to the OR for anterior chamber washout, open globe repair, and removal of the fish hook. He was discharged following the surgery with next day follow-up with ophthalmology.

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    Grand Rounds Recap 12/16/15

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    Grand Rounds Recap 12/16/15

    "IN JEOPARDY", AN ACS REVIEW - DR. FERMANN

    EKG Changes

    • According to the AHA, there are no diagnostic EKG changes for NSTEMI
    • ST elevations in II, III and aVF  with depression in V2 represents and inferior-posterior STEMI
    • ST depressions in the precordial leads may represent posterior MI
    • Continuous ST segment trend monitoring may pick up very dynamic ischemic changes (though this is almost never done anymore)
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    Annals of B-Pod: An Ocular Emergency

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    Annals of B-Pod: An Ocular Emergency

    A Case of Retrobulbar Hematoma

    The patient is a female in her 60s who presents by EMS after a fall in a parking lot approximately one hour prior to arrival.  She fell forward and landed on her face.  She believes she simply tripped and fell, but she did lose consciousness and does not know how she ended up on the ground.  Per family, she is unsteady on her feet and falls frequently, requiring a cane at baseline.  She reports feeling “weak” but no other symptoms preceding her fall.  She presents with significant right-sided facial trauma and is unable to open her right eye. She has no complaints of blurry vision in her left eye.  She has no headache or other areas of pain or trauma.

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    Dazed and Confused: The Approach to Altered Mental Status in the ED

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    Dazed and Confused: The Approach to Altered Mental Status in the ED

    We will all have the experience of taking care of a patient in the emergency department who is acting…different than they normally do.  Sometimes, the change can be subtle, maybe a family member will be the first to notice and bring the patient to be evaluated.  Sometimes the patient makes the change abundantly clear.  In either case it is essential to identify the underlying cause and treat any emergent conditions precipitating this dysfunction of the brain.  This month we hear from Dr. Erin McDonough on her approach to the patient with altered mental status (AMS). 

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    Grand Rounds Recap 12/9/15

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    Grand Rounds Recap 12/9/15

    Glucose Emergencies

    Remember the "I's" when looking for cause of DKA/HHS: Infection, Insulin lack, Infarction (MI, CVA, Ischemic gut), Indiscretion (EtOH, cocaine), Infant (pregnancy).

    After 2L NS fluid bolus in the hemodynamically stable patient, the corrected sodium should guide fluid choice for further therapy.

    Venous pH, HCO3 and base excess have sufficient agreement to be interchangeable with ABG in the ED.

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    You've Been Blocked!

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    You've Been Blocked!

    Case 1

    CC:  Laceration to Upper Lip

    HPI:  23 year old male presents to the ED with laceration to his upper lip.  Patient states he was “Minding his own business” when all of the sudden the ground came up and hit him in the face.   His friend alcohol might have been there.  Patient states he now has a cut on his lip and a bruise on his pride.

    Physical Exam:  Physical exam demonstrates a 2 centimeter full thickness laceration of the left upper lip that crosses the vermillion border.

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    Grand Rounds Recap 12/2/15

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    Grand Rounds Recap 12/2/15

    Air Care Ground Rounds

    Dr. Hinckley - Air Medical Resource Management

    Familiarity and complacency can lead to mistakes. Stay uncomfortable. A policy for preflight walk-a-rounds will be released shortly. 

    E-poc blood gas analyzer is now on AirCare. Think about using it for all patients, but particularly those who are intubated or may be in a state of shock.

    Dr. Powell - Minnesota Tube is coming to AirCare

    Everything you need will be in the Critical Care bag. You can bring all the gear with you into the hospital without having to gather supplies there. No football helmet required.

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    CSF Evaluation in Subarachnoid Hemorrhage

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    CSF Evaluation in Subarachnoid Hemorrhage

    So, what constitutes a “positive” tap when evaluating for subarachnoid hemorrhage?

    Traditional teaching is that a positive tap is Xanthochromia or blood in the CSF

    What exactly is Xanthochromia?

    The word xanthochromia is simply Greek for “yellow color.”  It refers to the yellow color that CSF can take in certain situations.  Some of these situations are listed below:

    • Elevated CSF protein            
    • Jaundice
    • Hypervitaminosis A
    • Rifampin Therapy
    • Elevated Bilirubin
    • Oxyhemoglobin

    What we are especially interested in when evaluating for subarachnoid hemorrhage is bilirubin and oxyhemoglobin.

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    Grand Rounds Recap - 11/18

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    Grand Rounds Recap - 11/18

    This week we recap the latest IOM recommendations on cardiac arrest management, evidence-based update on anaphylaxis management, management of the morbidly obese code and discuss the ins and outs of immunosuppressive agents.

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