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Archive for the ‘ER’ Category

General Treatment Strategies of the ICU

Posted by medliorator on April 20, 2009

Although care for each patient in the ICU is customized, there are general treatment strategies that are used by all trauma and critical care physicians in treating severely injured patients

On the transfer to the trauma bay, the patient would receive packed red blood cells. Upon arrival in the trauma bay, a series of diagnostic and therapeutic events take place.

The classic teaching for trauma surgeons upon arrival of a patient in the trauma bay is evaluating a patient using the protocol is known as the ABC’s  [airway, breathing, and circulation].

A patent airway is needed for the patient to be ventilated and oxygenated. …if the airway had not been placed in the field, it would be done immediately either by intubation or cricothyroidotomy.

The assessment of breathing is an assessment of the function of the lungs. …Loss of lung sounds in one or both lungs are a sign of pneumothorax, hemothorax, tension pneumothorax, and malposition of the endotracheal tube in one of the main stem bronchi.

Circulation is assessed by the heart rate of the patient and the systolic and diastolic blood pressure. …The blood pressure is taken initially manually by sphygomanometer (blood pressure cuff), with many trauma programs requiring the first three blood pressure recordings to be manual recordings.

The initial goal in the first 24 to 48 hours is to stabilize the patient in the face of any ongoing blood loss and the likely massive systemic inflammatory response (SIRS) patients that are severely injured undergo.

She would be continued on a ventilator and given pain medication and sedation. A typical regimen would be an around-the-clock infusion of the narcotic fentanyl (i.e., a fentanyl drip) and an around-the-clock infusion of midazolam (Versed).

Chimp Attack Victim Charla Nash Improving in the ICU [Inside Surgery]

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Cervical Spine Injuries in the ER

Posted by medliorator on February 14, 2009

Not everyone with a neck injury calls 911… and some of them walk in themselves. Such was the case of a high school football player whose coaches thought had suffered a “stinger” during a game. After a tackle, he developed neck pain and numbness to the left arm.

When someone walks into the ER on their own power, our clinical suspicion for serious injury is sometimes reduced. I can only assume this is why he wasn’t immobilized in triage. When I entered the room, I found him sitting upright in a wheelchair in mild distress from pain… He appeared to be holding his head very still so as not to move his neck at all. He was exquisitely tender to the lower midline of his posterior neck. He was slightly weak in his left upper arm but had normal grip strength.

I skipped the X-rays and sent him straight to the CT scanner, where he was found to have a burst fracture of C4 and some injuries to the posterior elements of C5.

The Stinger [Scalpel or Sword?]

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How to Ease Anxiety in the ER (Randy Pausch)

Posted by medliorator on July 28, 2008

As Jai was being rushed into surgery for an emergency C-section, she said to the doctor, “This is bad, isn’t it?”

I admired the doctor’s response.  It was the perfect answer for our times: “If we were really in a panic, we wouldn’t have had you sign all the insurance forms, would we?” she said to Jai.  “We wouldn’t have taken the time.”  The doctor had a point.  I wondered how often she used her “hospital paperwork” riff to ease patients’ anxieties.

A New Year’s Story [The Last Lecture by Randy Pausch]

Correlate: How to Give Bad News (Randy Pausch)

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How to Select the Best Residency

Posted by medliorator on June 18, 2008

The American Medical Association offers FREIDA, which provides the numbers on each program’s duration, residents, benefits and other factual information.

there are abundant resources available at most university bookstores that can be very helpful with thinking about various important criteria that go into selecting a residency…. At the very least, these books are worth checking out of the library.

Another invaluable resource in emergency medicine residency selection continues to be AAEM’s Rules of the Road for Medical Students.

if one is still feeling “information overload” the AAEM/RSA’s EM Select provides a great way to organize everything

Finally, if one has narrowed down his or her choices to a few programs and wants to get a closer look, most residencies offer “second look” opportunities. These low pressure shifts in the program’s emergency department provide a chance to see how residents and attendings interact, the type of patients seen and give a “snapshot” of life in that ED.

Comparing Apples to Apples: Selecting a Residency Program That is Right for You [Medscape]

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Removal of Foreign Body

Posted by medliorator on April 8, 2008

I recently treated a young patient with a cylindrical metallic foreign body in the ear canal …it was a tiny fuse. The smoothness and rounded edges of the object made grasping with alligator forceps impossible. The width of the object prohibited the use of a cerumen spoon since the object fit the canal almost perfectly. The only magnets we could find were [weak], and my lame attempt at using a suction catheter was entirely ineffective. Because I couldn’t tell how close the object was to the eardrum, I chose not to attempt the balloon-tipped catheter method

 

I removed the object by irrigating with Auralgan.

 

there was just enough room between the ear canal and the …object for the solution to pass by. The consistency of the Auralgan provided superior back pressure as well as excellent lubrication which made what was until then a frustrating procedure seem ridiculously simple.

Foreign Body Removal from the Ear [Scalpel or Sword?]

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Common Chief Complaints in the ER

Posted by medliorator on March 25, 2008

list of most common diagnosis codes used in our ER, in order:

  • 786.50 UNSPEC CHEST PAIN
  • 789.09 ABDOMINAL PAIN OTHER SITE
  • 465.9 ACUTE UPPER RESP INFECTIONS UNS
  • 847.2 SPRAIN/STRAIN LUMBAR REGION
  • 558.9 OTH NONINFECTIOUS GASTROENTERITIS
  • 486 PNEUMONIA ORGANISM UNS
  • 466.0 ACUTE BRONCHITIS
  • 780.99 OTHER GENERAL SYMPTOMS
  • 784.0 HEADACHE
  • 346.90 UNS MIGRAINE NOT INTRACT
  • 847.0 SPRAIN/STRAIN OF NECK
  • 079.99 UNSPECIFIED VIRAL INFECTION
  • 599.0 URINARY TRACT INFECTION UNSPEC
  • 724.2 LUMBAGO
  • 338.19 OTHER ACUTE PAIN
  • 780.2 SYNCOPE/COLLAPSE
  • 780.97 ALTERED MENTAL STATUS
  • 786.09 RESPIRATORY ABNORMALITY OT
  • 428.0 CONGESTIVE HEART FAILURE UNSPEC
  • 787.03 VOMITING ALONE
  • 381.00 UNS ACUTE NONSUPPUR OTITIS MEDIA
  • 491.21 OBSTRUCT CHRON BRONCHITIS W EXAC
  • 493.92 ASTHMA UNSPEC W ACUTE EXACER
  • 625.9 UNS SYMPTOM FEMALE GENITAL ORGANS
  • 780.4 DIZZINESS/GIDDINESS

There are no fewer than ten different “Chest pain” codes.

Why do people go to the ER? [Movin’ Meat]

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Intro to Emergency Medicine

Posted by medliorator on January 17, 2008

Panda Bear MD gives an excellent overview of his work in the emergency room.

I generally work 14 twelve-hour shifts in every 28-day block. I either work the 9 AM to 9 PM shift or the 9 PM to 9 AM shift, with seven consecutive days on one or the other. Next year I will work seven to seven instead of nine to nine which allows for some overlap between the third year and the second year residents. The most we ever work is three shifts in a row with at least two days off afterwards. Our schedule is set up so we work Friday, Saturday, and Sunday for two weekends in every block but get the other two off. It sounds like a pretty reasonable schedule and it is. We are allowed to trade shifts so if, for example, you need a bigger block of days off you can swap with another resident provided that you don’t violate the work-hour rules for Emergency Medicine.

 

During our first year we work mostly off-service (not in the Emergency Department) rotating on other specialties such as Trauma Surgery, Internal Medicine, Critical Care, Pediatrics, and Obstetrics to name a few. During second and third year we spend most of our time in the Department with a few months reserved for electives. Some programs mix it up a little more. The advantage of doing all the off-service training early is that by the start of second year, you are done with call forever. “Call” is the practice of spending the night in the hospital, in addition to your regular daytime duties, to take care of your existing patients, admit new patients, and handle emergencies. I did two intern years, approximately 150 nights of call, and got meaningful sleep on so few call nights that I can count them on the fingers of one hand. Considering that you may have call every fourth night for most of intern year and you cannot just go home in the morning afterwards but usually stay until one in the afternoon, you can imagine that intern year can wear you down.

 

In Emergency Medicine, we can see patients with complaints that are so idiotic they transcend idiocy and achieve a sort of moronic nirvana (”My ass is sweating”). We also see patients with some of the most serious injuries and medical problems that you can imagine… it’s a real mixed bag. Some nights you feel like a school nurse treating things that would have kept normal people home and some nights the trauma and serious medical complaints just keep rolling in and the minor complaints stew for hours complaining about the crappy sandwiches and the limited television stations.

 

The purpose of Emergency Medicine is two-fold. First, our job is to assess and stabilize injured or severely sick patients until they can receive definitive treatment… we often not only stabilize but make the diagnosis and initiate the definitive treatment.

 

For a practicing Emergency Physician, this means seeing at least four patients an hour to be considered a guy who pulls his weight. It may not sound difficult but while many complaints are minor, some are not and almost every patient we see is completely new, a Rossetta stone who needs to be deciphered. In fact, it is not unusual to get a “drop off,” a severely demented (senile) patient from a nursing home who hasn’t spoken a word since the Clinton Adminstration and for whom you have only a sketchy medical history (if that) and a chief complaint of “altered mental status.” If you’re lucky you can elucidate a reasonable list of her many, many medical problems from the medication list (if it was sent with the patient) but sometimes you have nothing to go on at all. Sorting it out takes time.

 

One of the biggest parts of our job is coordinating care which involves, among other things, arranging consults, calling on-call physicians to admit patients, talking to the medical examiner after a death, calling patient’s primary care physicians, and a myriad other tasks that keep us on the phone longer than any other specialty.

 

If you like multi-tasking you will like Emergency Medicine.

What I Do [Panda Bear MD]

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The Value of CPR

Posted by medliorator on January 4, 2008

Mr. and Mrs. John Q. Public are sitting on the couch relaxing after a busy Christmas. All of a sudden Mr. Public clutches his chest and falls over onto the floor.

 

Mrs. Public calls 911 and starts CPR. 10 minutes later, EMS arrives with their portable electricity and shocks Mr. Public’s VFib into asystole. Two rounds of drugs get him back. By the time he gets to the ER, he has a pulse of 80, a pressure of 120/50, and he’s trying to breathe.

 

Cardiac arrest with a 10 minute down time and no CPR prior to EMS arrival results in a funeral 99.9% of the time. Cardiac arrest with a 10 minute down time and immediate bystander CPR gives him a fighting chance.

Why you Should Know CPR [Highly Trained Monkey]

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How to Fix a Dislocated Jaw

Posted by medliorator on November 1, 2007

it was a jaw dislocation – the jaw slips out of socket, usually after a big yawn, and the end result is you can’t close your mouth. Even though it was the first time I’d actually seen it, it was an easy diagnosis to make, since the patient was staring at me like I’d just dropped my scrub pants and peed on the bed.

I quickly leafed through an emergency textbook, out of sight from the patient (who wants to see their doctor doing that?), to confirm what I thought I knew — wrap some gauze around your thumbs, put them on the back bottom teeth, and push down hard.

Gloves on, gauze wrapped, fingers in mouth, and I started pushing.

Hmm, the textbook didn’t mention what to do when the patient screams and grabs your wrists. I thought some medicines for pain and muscle spasm were in order.

4 milligrams of versed, 100 micrograms of fentanyl, and some beads of sweat on my part later, though, she was still sitting there mouth gaping open.

Time to bring out the big guns, a conscious sedation. Usually I use etomidate, but one of its side effects can be masseter spasm, which would make reduction all but impossible. So instead I went with propofol, a med I used extensively in residency but not since for a couple of reasons including I don’t think we’re really supposed to.

Usually you give a slug of this and people immediately go out, sometimes so deeply that they stop breathing momentarily. But with her, nothing, she just continued to stare at me as alert as if we were chatting at a coffee house. IV’s working, fluids are running wide open — what is it with this girl? Another big slug, and finally her eyes start to go heavy. And then they reopen, but her eyes are distant now, and looking around the room at me, the nurse, and the respiratory tech she says in a perfect stoner voice “hey ya’ll wanna get somethin to eat after this?”

I’d never seen anyone react to propofol like that before. I stuck my thumbs in her mouth one last time and clunk back in place it went, her mouth now closed. Stepping back to admire my work, she — with all of her sedating meds on board — started to unleash a giant yawn. No, I yelled, and quickly put one hand on the top of her head and the other under her chin, pushing her mouth back shut. Fortunately it didn’t pop out again, and I wrapped her head up in a bandage for good measure.

Shut my Trap [Ten out of Ten]

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Treating the Dead

Posted by medliorator on June 2, 2007

Consider someone who has just died of a heart attack. His organs are intact, he hasn’t lost blood. All that’s happened is his heart has stopped beating—the definition of “clinical death”

 

what has actually died?… the conventional answer was that it was his cells that had died…This process was understood to begin after just four or five minutes. If the patient doesn’t receive cardiopulmonary resuscitation within that time, and if his heart can’t be restarted soon thereafter, he is unlikely to recover. That dogma went unquestioned until researchers actually looked at oxygen-starved heart cells under a microscope.

 

once the cells have been without oxygen for more than five minutes, they die when their oxygen supply is resumed… cellular surveillance mechanism cannot tell the difference between a cancer cell and a cell being reperfused with oxygen.

 

When someone collapses on the street of cardiac arrest, if he’s lucky he will receive immediate CPR, maintaining circulation until he can be revived in the hospital. But the rest will have gone 10 or 15 minutes or more without a heartbeat by the time they reach the emergency department. And then what happens? “We give them oxygen,” Becker says. “We jolt the heart with the paddles, we pump in epinephrine to force it to beat, so it’s taking up more oxygen.” Blood-starved heart muscle is suddenly flooded with oxygen, precisely the situation that leads to cell death. Instead, Becker says, we should aim to reduce oxygen uptake, slow metabolism and adjust the blood chemistry for gradual and safe reperfusion.

 

A study at four hospitals, published last year by the University of California, showed a remarkable rate of success in treating …cardiac arrest with an approach that involved … “cardioplegic” blood infusion to keep the heart in a state of suspended animation. 80 percent of them were discharged from the hospital alive. In one study of traditional methods, the figure was about 15 percent.

To Treat the Dead [Newsweek Health]

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