You are working an overnight shift at a Level 3 Trauma Center Emergency Department in a community hospital with most subspecialties available by telephone when EMS calls the charge nurse to report they are inbound with a new patient. As they roll through the ambulance doors, you note that the patient “looks” to be acutely ill and is immediately rolled into your resuscitation bay…
Read MoreWho do we RSI? What do we use? We can be better than etomidate and succ and the protocol in development will drill into the details - here is an overview:
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…
Read MorePatients typically present to the Emergency Department with one complaint. The chart says “Headache” or “Abdominal Pain” but B-pod implores us to look closer. B-pod teaches us that it is our job to sit down, take a few extra minutes, and look at the entire patient in front of us...
Read MoreTracheoinnominate 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?
Once the patient starts massively bleeding - what's your next move hotshot?
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”...
Read MoreImagine: 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.
Read More1. 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.
Read MoreThe 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.
Read MoreEKG Changes
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.
Read MoreWe 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).
Read MoreRemember 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.
Read MoreCC: 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.
Read MoreDr. 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.
Read MoreSRU (pronounced "shrew") = Shock Resuscitation Unit
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
Check out AI contexted information from this and other great FOAMed sites via FOAMCortex
