Scareway Case #2 - Blood, Vomit, MILS; with Yen and Minh

An hour into your morning shift at your community hospital, Canadian Janus General, 50yF is brought to your ED by paramedics. She was involved in a head-on MVC with a large truck that crossed over into oncoming traffic.

Canadian Janus General

Hi folks,

Been a while since I posted anything - sorry for the slow productivity...
This is a mini post.

Recently Scott Weingart of the EMCrit podcast had an episode on his new home hospital, Janus General. This is a virtual hospital inspired by the folks at St Emlyn's, a virtual hospital and blog site situation in the UK.

Why a virtual hospital? Because it allows you to retain patient confidentiality to a greater degree, and it allows flexibility with what your "hospital" provides.

Janus isn't the right fit for me, since I'm Canadian trained/insured/etc and we have a different level of litigation where I'm from. However, with Scott's blessing, I've opened a Canadian partner site to Janus. As of this post, unless otherwise stated, all cases presented on the Chart Review will Canadian Janus General hospital. Canadian Janus is a community ED in Canada, with Canadian policies. The goal is to provide a Canadian slant to emergency medicine and healthcare. We transfer out major traumas, STEMIs and neurosurgical cases.

If you wish to situate your cases at Canadian Janus General, feel free.

New post coming soon!

A clear-cut case of acute coronary syndrome (?)

Your shift is running smoothly. You’ve been applying all the fantastic FOAMed (what’s FOAM/FOAMed?) you learned this week and life couldn’t be better.  You pick up the next chart: a 50yF sent by her family doc to the ED - she presented to his office a few hours after a 10 minute syncopal episode at home preceded by chest pain. The note says: Please rule out cardiac ischemia.

She’s obese and has a history of diet-controlled DM. She’s never syncopized before and doesn’t recall previous episodes of chest pain. The event happened in the morning – 15-20 minutes of squeezing epigastric pain/pressure, followed by presyncope, followed by syncope. She hit her head and has a small lac over the eyebrow. Since the episode she’s felt generally unwell and so proceeded to see her FD.

On exam, vitals are a temp of 36, pulse 104 and regular, BP 140/90 at triage and then approximately 170/110 (all 4 limbs), RR 20, sat 94-96%. Normal glucose. She’s obese. She’s a bit anxious but otherwise in no distress, looks well. Breathing is not laboured. Her CVS exam is unremarkable, lungs clear and no edema.

The ECG, already done, is on her chart and this is what you see.

Acute Pulmonary Edema - Nitro vs Lasix?

A 75yF presents to your ED acutely short of breath. Two hours prior to ED arrival, she became suddenly short of breath. Her family tried administering her salbutamol (Ventolin) to no avail. She was driven to the ED. Her PHx includes hypertension and asthma, the former poorly controlled recently despite amlodopine, HCTZ and ramipril. She denies chest pain, N/V or diaphoresis. She had a minor surgical procedure a few days prior.

At triage her vitals included a RR of 45, pulse 100 and O2 sat 70%. BP is unobtainable. She is rushed to your resuscitation area. Her exam reveals an alert and oriented woman in extemis who is able to speak 1-2 word sentences with a lot of accessory muscle use. On a NRB mask she manages an O2 sat of 94%. The lack of BP makes you worry about a large PE with hypotension. The nurses try again. Her JVP cannot be seen. There are diffuse crackles to the scapulae and wheezes bilaterally. Heart sounds are normal and regular without murmurs. There is no peripheral edema or leg swelling. The BP finally registers – 280/150!

2 Difficult Cases to Swallow

A fairly frequent presentation to the ED is that of difficulty swallowing. By true definition this is “dysphagia” although commonly physicians and physicians-in-training use this word interchangeably with “odynophagia” (painful swallowing). Here are two interesting and unusual cases of dysphagia seen in the ED.

Pulmonary Embolism and the Chest X-ray

The diagnostic evaluation and management of pulmonary embolism (PE) is an ever-controversial and ongoing debate in emergency medicine. As emergency physicians (or med students, residents, others), we are constantly bombarded with questions and conflicting opinions on PE:

1)      Is gestalt equal to validated scoring systems like the Wells Criteria (or modified Wells) or the Geneva Score (or modified Geneva)? (see this paper)

2)      Can you “PERC” a patient or are they not “low-gestalt”?

3)      Do we order too many D-dimers?

4)      Do we scan too many chests, causing harm via excessive radiation or exposure to potentially harmful contrast dye?

5)      Do we need to even know about the tiny subsegmental “lung lint” (credit Casey Parker at http://broomedocs.com) or “pulmonary fluff” (See Andy Neil’s http://emergencymedicineireland.com/2013/01/is-pe-really-all-that-bad-again/?)

6)      VQ or CTPA in pregnant patients? (http://radiology.rsna.org/content/262/2/635.long)

The answers to all these questions can be found elsewhere (see links above and the fantastic Corey Slovis/Jeff Kline talk at Free Emergency Medicine Talks https://itunes.apple.com/ca/podcast/free-emergency-medicine-talks/id489694355).

I had a PE patient the other day who got me excited for another reason: the chest x-ray. That’s right, I still get excited when a patients with a PE has interesting chest x-ray findings

Open Letter to Influenza

Dear influenza,

I’m going to come right out and say it. I don’t like you.

I’m a nice guy, as most people will tell you. I don’t fight with consultants, I pick up shifts for colleagues in need and I take the extra 5 minutes to explain to new parents what is normal for a neonate or that their palpitations are common and benign.

But having been struck down by your might this weekend, I have had time to ponder about the life you live and the havoc you wreak upon your victims. And I thought you should know how I really feel about you:

I don’t like you.

I don’t care if you’re a type A or B, or what number comes after your H or after your N.

I think it’s vile and perverse that you sleep around with pigs and birds and then smudge us humans with your filth.

I think you’re a coward for being generally benign except when a pregnant woman, infant or elderly person crosses your path, at which point you deliver your rabbit punch. Bully.

I think it’s inconsiderate how you show up in full force during the Christmas holidays, filling my ED and hospital wards while so many of the walk-ins and family doctors' offices are closed. Sick patients wait longer because of you.

I barely eat on shift on a regular day, but when you’re around I have even less time and whatever I do eat tastes like sanitizer gel from all the compulsive hand washing I do.

I hate you for making me get chest x-rays on people who probably don’t need them, fearing that I may miss the complicated Staph pneumonia that rides shotgun with you.

I hate your deception. Why do you evade our best efforts at vaccines? Can’t you be like the H. flu and let us make a better vaccine? Eighty percent is okay, but we can do better.

Speaking of vaccines, I hate how you encourage public fear like this BS from 2009.

I can deal with fevers, coughs and myalgias but when you take me away from my wife and child when I finally have a weekend off, you cross the line. I’ve been quarantined and placed on isolation in my own home.

See you on the next shift, jerk. I'll be waiting.