Author Archives: aramsey

Chest pain?

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Yesterday, 10 minutes before the end of a very busy shift in the middle of nowhere:
Nurse hand’s me an EKG for the mom of one of our best young medics. Ischemic STD in II, III, aVF, V5, V6. No STE. Maybe some LVH. No other EKG on file, she hasn’t been here before. I get up to see her right away.
In the room is a 50 yo lady in severe distress. BP 250/140. Describes “tearing” L sided CP radiating to her upper back. I ask her if she has a family hx of sudden death or aneurysms, her son says yes. No SOA. No N/V. Lungs are clear. Can’t palpate pulses in her feet. Slightly obese. She is sweating. There isn’t a CT surgeon in this county; I am sweating, too.
The nurse gets CT ready and I start the ball rolling for big IVs, blood, helicopter, etc. She gets dilaudid 1 mg then 0.5 then 0.5 again for pain and hopefully BP control. I tell everyone she’s now the ED’s top priority. The family of another patient grabs me twice in the hallway and asks why their mom, who fell, hasn’t gotten her home dose of lisinopril yet.
~30 minutes from door to imaging – CTAs = no dissection. Great, I have some time. Pain is well controlled now and BP 150s/80s. Repeat EKG w ischemia resolved completely, normal. Hypertensive emergency? She has a bit of a headache so I scan her head because we’re in CT, but it’s not useful due to the residual contrast. Trops, CBC, CMP, urine, tox, etc. all negative. Now looks great and feeling much better. Wants to go home.
Her son, her nurse, and I spend a long time convincing her she needs to stay overnight. She doesn’t want to be admitted, as she’s starting a new job Tuesday and can’t miss it. Eventually, she agrees to stay. Then we have to convince her to be transferred, since ED MD is the only MD in house overnight and she had me straight terrified. Reluctantly, she agrees to the transfer as long as her son will bring her home Monday night, no matter what. Hospitalist at the local mothership accepts readily. At that hospital, she’d had a negative stress 8 months ago and NES had placed her shunt (pseudotumor, she has a lot of headaches); hospitalist will consult cards and NES when she gets in.
I arrive back to work this morning to find out she’d made it upstate only to be transferred again overnight. She’d been flown to a bigger center after repeat CT head demonstrated SAH. She had 2 aneurysms, 1 was bleeding, both were definitively addressed. 24 hours after walking in the door, at the time of this writing, she is extubated and thriving.
Found this article from 1988 with a similar presentation, but I can’t say I’d ever heard of it before. Something else for your differential. Really consider that admission for observation when something seems wrong, even if you don’t know what it is.
Going to change my drawers now.

April Journal Club

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Hey, all,

There is multimedia for this month’s journal club, so I wanted to post it all in one place. The theme will be impossible decisions in the department (eg ED thoracotomy without surgery backup, but we’ve talked about that issue ad nauseum). In my mind, it’s best to think about how you’ll approach impossible decisions now, before they show up overnight on single coverage in the middle of nowhere. Other ideas for discussion are welcome.

Closing the emergency department: EP Monthly, Diversion 1, Diversion 2

Crashing VP shunt patient: Tapping a shunt article, Tapping a shunt video

Epidural hematoma: Burr hole for epidural hematoma article, Burr hole presentation, Video of a burr hole

 

Antibiotic review

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Maybe it’s because an overhead projector slide scanned and inserted into a powerpoint presentation comprised my medical school antibiotics curriculum (you know what I’m talking about if you went to U of L), but I’ve never really felt comfortable with the nuances of antibiotics. For those who want to understand them a little better, here’s a great review.

The bar is set, Chrissy!

Cardiology

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If you’re like me, and I know you are, you wish Martin Espinoza’s lectures were recorded and available. They are. You’re welcome.

Arrythmias

EKG concepts

A fib/flutter

Also, if you haven’t heard yet, the IM department just launched a FOAMed website called Louisville Lectures. It’s one of the first of its kind worldwide and it’s based out of ULH. Michael Burk, who is rotating with us this month from IM, is the founder and managing director. It got a shout-out on LITFL this month. Worth a look.

The competition

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It turns out that the Mayo EM program has a little room9er of their own… except it’s public… and updated frequently… and has a fellow generating content for it. Truthfully, it’s a great site. Quite a few reviews on topics that don’t pop up on the other FOAMed sites (the killer rashes, retroperitoneal hematoma, tumor lysis syndrome). Worth a look if you’re stuck at Jewish South with a broken CT scanner).

Mayo EM.

 

Expert central lines

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Fall: it’s that time of year when the PGY-1s start holding down the MICU.

If your MICU experience is like mine, you’ll get a few texts on the overnight from the medicine PGY-3s asking for help placing central lines. I’d put in a couple subclavians in the OR as a medical student and the venerable (legendary) Jason Mann had shown me some tricks, but I was definitely nervous being the go-to person.

Found these great videos for EM docs on central line placement. Most of the videos I’d seen before were showing you how to identify landmarks and such – these are a level beyond that and offer some great information and tricks for more expert line placement. Worth watching about once a year through residency.

Here’s part 1. Just search for parts 2-5 if it’s helpful.

Public health for adrenaline junkies

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Public health is associated with the least interesting courses of medical school (epidemiology and biostatistics). It has been linked to ED frequent flyers and psych hold patients (social and behavioral health). One might say it’s an integral part of vague clinical decision rules and flip-flopping society guidelines and Press-Ganey scores.

It’s also something us ED docs do every day, whether we want to or not. There’s no reason why we shouldn’t try to understand it and do it better.

Kiran and I have been developing a website dedicated to public health for ED personnel. It’s a FOAMed site. Our plan is to get it tied in with sites like EMCrit, ALiEM, LITFL, and the like. It’s still a very young project, but there’s a couple articles posted for you to glance at.

If anyone is interested in population health, there’s a ton of uncharted territory and we’d welcome the collaboration. Just let us know how you want to be involved. Also, tell your friends.