Dr Poss Case

A 74 year old male presents to a rural ED with no CT. His wife came frantic to the triage desk as he was unable to get out of his car. As Dr Poss went out to see this person, he realized that he looked unwell, was presyncopal and pre-arrest. He was put onto a stretcher and into a resuscitation area of the hospital. He is somewhat relieved by this and provides a history of 2 weeks of exertional bilateral upper shoulder pain after using a treadmill for 5 minutes or so and is relieved with rest. Yesterday the pain was more severe and today it lasted from 7-9 pm. Today the same pain came back at 3 pm as well as diaphoresis and light-headedness. he then came to the ER where nearly fainted on the drive. He has had 4 hours of pain now. Vitals are HR 82, BP 161/101, RR 16, Sats 92 RA, Temp 36.7.

The ECG is below?

Thoughts? It is Dr Poss’s first shift here. Lab and Xray are here. There is no CT. Nearest Cath Lab is 1.5 hours away. Image-1


Can you just leave?

You are moonlighting in some rural ED. You have woken up as you did get some sleep. It is 8:30 am and the new MD should have just arrived. You make yourself a coffee, have a quick shower and head to the department. The day nurses have arrived and are chatting. They do look fresh and clean and the smell of coffee from their coffee cups makes you feel great. You crave the bagel that one of them has brought in but remember your diet. There is a patient registering but its not for the ED. They have to register at the ER desk for X-ray, US etc. You breathe a sigh of relief. You just want to go home. The nurses say there is nothing for you and Dr H who is supposed to be your relief is going to his office first to catch up on paperwork as he has a busy clinic in town. He may even have a patient to see who was not doing well overnight and has been booked in the clinic. He has asked to be called in if there is anything to see, but he didn’t give any handover instructions. He has asked not to be disturbed for anything else as he will be busy with the office. You suddenly remember the 80 year old you saw at 3 am who had some dyspnea and quiet crackles. Her oxygen sat was 79% with normal ECG and a mild degree of pedal edema. After some ventolin, oxygen, lasix and a dose of ceftriaxone, she is quietly sleeping, waiting for the myriad of tests you ordered for 9 am. You can’t believe you forgot to wake up and check on her at 6am, like you had hoped to do. Darn the night nurse for not waking you up. You have a quick look at her and decide its time to let Dr H know that he has one patient to assume care of. She has been stabilized and is looking good. The nurse calls Dr H for you and after speaking to him for all of 3 seconds she sheepishly hangs up and says “He said he will be an hour and doesn’t want to be disturbed. The patient he brought in to clinic is in a  crisis“…. You look exasperated and the nurses say “Just leave. We can tell him about the lady. If he wants he can call you to discuss it further. We do not expect you to wait. Plus, in our rural EDs we do not have a physician in the ED at all times“. You are happy with this plan. You do remember being told that rural EDs do not need a Doc in house 24 hours. You call your boyfriend, a surgical resident, and explain this to him. He listens patiently but then asks the quintessential question : “Can you just leave like that?” The doubts start to run through your head. What do you do now?

I am contracting for safety. Now let me go home

A health student who you know of has been having mental health issues. They have been doing an elective in your department and at least once or twice have been off. You have heard from your colleagues of this student. Upon starting a rather busy night shift, you see that they are back. Upon interrogation you find out that this is a qualified RN who is training in the N.P. program and has to do so many hours in the ED. They have been a qualified RN for a number of years and have worked for the Canadian Military where they served in Afghanistan and South Africa. After talking to them you recognize symptoms of PTSD stemming from experiences in the army as well as a sexual assault by another army officer which was never reported by this N.P. student. There is no drug use. There is no suicidality reported. They do cut their wrists. The student was supposed to work and decided to check in to be seen because they felt unable to work right now. After the interview, the student says “I am contracting for safety. Now let me go home”. What do you do?

I do not know what to do

A recent case highlights a common conundrum that happens to the best of us. You are presented with a situation where you simply do not know what to do.

A 23 yr old patient presented with tachyarrythmias following a night of heavy drug and alcohol use. Her presenting vitals are normal. Her toxidrome is clearing and her level of consciousness has improved. She however has chest pain and her heart rate remains 140 despite fluids, ativan and cooling. She had used some ecstasy and marijuana and a lot of alcohol. At one point she had an ECG that seemed to look like Atrial Fibrillation but the subsequent ones show a sinus tachy. You get a D-Dimer and a set of enzymes that are negative. Your chest X-ray is negative. You do a POCUS which is negative. Her parents then come to the department. You learn that her father is a family doctor in town and her mother is a radiologist in a rural hospital you have worked at. They have numerous questions about the chest pain that the young lady is experiencing and make some phone calls to their friends who include some cardiologists and internists that you know of. They all throw around some diagnoses that include PE, myocarditis and boor haves, none of which look like her current problem. She is rather chatty with her parents but very withdrawn with you and almost seems to dislike you. Her parents are equally frustrated with your lack of answers. They do not feel like they can take her home. You are past your shift being over and your very nice colleague hears your long winded talk with the parents and says “don’t handover me that”. You give cardiology a quick call and they say “please do not refer us these types of cases. She has a sinus tachy with a chest pain NYD”. You are now exasperated. What do you do?

Do we need to do it all?

A patient presented to an academic centre with hepatic encephalopathy and decompensated liver disease with a Hb of 54 and pancytopenia on a background of worsening NASH cirrhosis. She is febrile and tachycardic in addition to being confused. She has had multiple contacts with the GI service and several medical admissions as well, with the last admission being 6 weeks ago. There is concomitant hyponatremia and anemia from liver disease. After a few tests are back, a consultation is made to the Internal med service on call. The Resident asks if ammonia has been drawn, lactulose been given and a paracentesis performed. The platelet count is 39. The INR is 2.0. You have already given fluids, antibiotics and arranged for blood transfusion. You have even obtained some X-rays and a bedside US to document ascites worsening. All emergent bloodwork is either drawn or pending and resuscitative measures are well underway. A debate ensues that you may not have referred a well worked up patient as the paracentesis is missing, the lactulose is not given and the ammonia is pending. You kindly explain that this is normal practice to make a referral after you feel your job is done. The Medicine resident goes on to say that in his experience ER physicians do all these things and points out that you are the exception as most of the ones he has seen refer patients after all this is done. What would you do in this situation? A nearby nurse gestures you to hang up the phone and do what has been asked of you. Thoughts?

Who do you consult?

An elderly lady presented to an academic emergency department with a syncopal episode in her retirement residence. She has just been discharged from the same hospital following a subdural/subarachanoid hematoma sustained earlier that month. After receiving both neurosurgical and medical management, and convalescing as an inpatient, she was returned to the retirement facility. Upon arrival from the retirement facility a CT head shows further evolution of the intracranial bleed, an ECG demonstrates ST elevation and bloodwork indicates rhabdomyolysis from the fall. The Neurosurgery team has nothing to offer further and refuses to be admitting MRP. The cardiology service attributes the ST elevation to intracranial pathology as there is no chest pain prodrome and refuses to be the admitting MRP. The medical ward refuses to assume care either as there have been prior referrals made to Neurosurgery and Cardiology who should, in their opinion, assess the patient. As commonly happens in the ED, we have multiple services able to care for a patient, and yet they all sign off, leaving you a very sick patient who cannot be discharged and needs an inpatient team that you cannot seem to convince. What do you do?

To intubate and chest tube …. or not

Had to make a tough decision on a 88 year old cancer patient deemed to be DNR due to intra-abdominal cancer with liver mets but neurologically intact who presented with hypoxia and respiratory distress in the setting of no previous lung disease, lung cancer or COPD. He was a good 88 with functionality of a 65 year old who still road a bike daily for his groceries. He had signed a DNR because he was told he had incurable colon cancer. When he presented to us, there was an empyema with surrounding pleural effusion. It was pneumonia season and he had been visiting a nursing home where a few friends were residents. He had respiratory fatigue and if we were going to decompress this empyema and infected pleural effusion which had nothing to do with his malignancy we were going to have to intubate him and put in a chest tube. Would you cancel the DNR? The patient was not understanding all this due to his condition, PCO2 of 100, temp of 39.5 with tachypnea and altered level of cognition (related to infection). I was convinced that this man’s respiratory illness was curable and nothing to do with the malignancy from which he was slowly dying. What would you do?

Handover issues

A family doctor refers an elderly patient to your ED at 5 pm for admission for xray proven pneumonia with severe cough and oxygen saturation of 93% but rock solid vitals. The family doctor has admitting privileges and clearly tells the nurses to make arrangements for admission through the ED but he cannot come in and do the admission as his kids have activities that evening. He will come and see her at 8 am the next day once she is admitted. The patient arrives but because there are no admission orders done has to see the ED physician who receives all the instructions from the nurse. The ED physician refuses to admit the patient and disagrees that she needs admission. The family physician is unavailable now. The ED physician elects to treat her with antibiotics and suppress her cough and keep her overnight in the ED. At midnight you come on and hear the whole story from him as he politely disagrees with the need for admission and dismisses the oxygen saturation as not affecting her in any way and stating that she still looks pink and not cyanotic. He dismisses any of the family doctors recommendations and says he wants her to rest overnight and then she can go home and the nurses can update the family doctor when he is back.

Would you take this handover?

A case of a cystic mass

An 86 year old male presented to a community hospital with syncope. He had documented syncope in the past felt to be related to chronic orthostatic changes but still remained on beta blocker therapy. He suffered enough trauma to result in head injury, finger dislocation and rib fractures. Abdomen was quiet. After attending to his immediate injuries, reducing the finger dislocation and getting a CT head, we undertook a FAST scan. He had pristine vitals. On scanning the abdomen, there was a very small aorta but at the umbilicus no bifurcation was seen. More distally, though, at the pelvis, a cystic round structure appeared, somewhat contiguous to the bladder, but past the point where you would have expected the bifurcation to be. The patient was admitted overnight and the hospitalist was contacted to resume care in the morning. Would you have accepted this admission or would you have asked for AAA to be ruled out by CT, given the FAST findings? Screening labs were normal.

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Case presenting to a rural hospital

A keen aspiring CCFP-EM resident managed an interesting case the other day in a small town hospital. It was an unfortunate young lady, 9 years old, who had a straddle injury followed by copious vaginal bleeding. Unable to do a pelvic examination without the presence of conscious sedation, the resident chose to get pelvic xrays and observe the patient. Peds ER was contacted and were agreeable to see the patient but suggested direct referral to Gyne although the resident felt more comfortable if at least a better exam could be done before speaking to Gyne. In the end seeing, as the patients were anxious, the resident agreed to transfer the patient to Peds ER without a full exam or bloodwork. We felt a little sheepish initiating this transfer. What would you do in his place. Anything different?