The Wire
Nursing home staff became concerned about a patient because he was “floppy.” He was a 59-year-old man with stage 3 chronic kidney disease, right ventricular heart failure, hypertension, cirrhosis, and insulin-dependent type 2 diabetes mellitus. He had been sleeping all day, according to his nurse, but he was not responding when she checked on him in the evening, and she could “drop his arm and it would just hit his face.”
He was hypotensive (90/50 mm Hg) and bradycardic (about 30 beats/min) in the ED. Respirations were slow and shallow. He was protecting his airway, but was hypoxic (SpO2 82%). IV access was es...
Source: Spontaneous Circulation - December 9, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Wire
Nursing home staff became concerned about a patient because he was “floppy.” He was a 59-year-old man with stage 3 chronic kidney disease, right ventricular heart failure, hypertension, cirrhosis, and insulin-dependent type 2 diabetes mellitus. He had been sleeping all day, according to his nurse, but he was not responding when she checked on him in the evening, and she could “drop his arm and it would just hit his face.”
He was hypotensive (90/50 mm Hg) and bradycardic (about 30 beats/min) in the ED. Respirations were slow and shallow. He was protecting his airway, but was hypoxic (SpO2 82%). IV access was esta...
Source: Spontaneous Circulation - December 9, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Techniques that May Actually Save Your V-Fib Patient
Winning teams have depth, and games are often won from the bench or deep in the batting order. That is certainly true when competing against ventricular fibrillation, and a few tools you might not know can help these patients.
A 55-year-old man with severe coronary heart disease and previous four-vessel coronary artery bypass surgery collapsed at a mall. He also had an unprotected left main atherosclerotic plaque. Bystanders immediately began chest compressions, and the available AED, unfortunately, advised no shock.
Paramedics started bag-valve-mask ventilation and high-quality mechanical compressions with a Lucas d...
Source: Spontaneous Circulation - October 1, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Techniques that May Actually Save Your V-Fib Patient
Winning teams have depth, and games are often won from the bench or deep in the batting order. That is certainly true when competing against ventricular fibrillation, and a few tools you might not know can help these patients.
A 55-year-old man with severe coronary heart disease and previous four-vessel coronary artery bypass surgery collapsed at a mall. He also had an unprotected left main atherosclerotic plaque. Bystanders immediately began chest compressions, and the available AED, unfortunately, advised no shock.
Paramedics started bag-valve-mask ventilation and high-quality mechanical compressions with a Lucas devi...
Source: Spontaneous Circulation - October 1, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Secrets Behind the Curtain
“Doc to the radio phone,” went the call over the PA. This is often just medics notifying about a diabetic refusing transport or stopping a futile code, though like most of emergency medicine, it can be anything.
Then we heard, “STEMI. Activating prehospital.”
EMS had been called to the house of a 54-year-old man. He had been experiencing chest pain on and off for several weeks. The most recent episode began about 30 minutes prior to ED arrival. He described 8/10 retrosternal pressure that radiated down his arms. He was tachypneic, but denied shortness of breath and was not hypoxic. Other vital signs were normal.
...
Source: Spontaneous Circulation - September 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Secrets Behind the Curtain
“Doc to the radio phone,” went the call over the PA. This is often just medics notifying about a diabetic refusing transport or stopping a futile code, though like most of emergency medicine, it can be anything.
Then we heard, “STEMI. Activating prehospital.”
EMS had been called to the house of a 54-year-old man. He had been experiencing chest pain on and off for several weeks. The most recent episode began about 30 minutes prior to ED arrival. He described 8/10 retrosternal pressure that radiated down his arms. He was tachypneic, but denied shortness of breath and was not hypoxic. Other vital signs were normal.
He...
Source: Spontaneous Circulation - September 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Pains of Separation
When a patient arrives to your ED fresh from karate class still in her uniform, you get a feeling about where the case is heading. This patient was 49, and reported that she always had some aches after karate. This evening, though, her pain was very different — and much more concerning. The pain had started about an hour into her class and worsened over the next 30 minutes. It was a severe achy pain over her left chest that radiated to her neck and was associated with pronounced diaphoresis. This prompted an expedited cardiac workup.
The ECG showed a sinus tachycardia with ST-elevation in V2-V3, I, aVR, aVL, with de...
Source: Spontaneous Circulation - August 5, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Pains of Separation
When a patient arrives to your ED fresh from karate class still in her uniform, you get a feeling about where the case is heading. This patient was 49, and reported that she always had some aches after karate. This evening, though, her pain was very different — and much more concerning. The pain had started about an hour into her class and worsened over the next 30 minutes. It was a severe achy pain over her left chest that radiated to her neck and was associated with pronounced diaphoresis. This prompted an expedited cardiac workup.
The ECG showed a sinus tachycardia with ST-elevation in V2-V3, I, aVR, aVL, with depr...
Source: Spontaneous Circulation - August 5, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Out of the Routine
Our patient was having an uneventful and ordinary day. He got his children off to school, and spent the morning at the office completing paperwork. By noon he had eaten lunch, and went to the company workout center. It was Wednesday, so it was arms day. He started as he always did with 20 minutes of cardio on the elliptical machine, then shoulders, biceps, triceps, forearms — big muscle to small muscle. It was at the end of his first rep of triceps that things changed.
He felt some dizziness, and the nausea began within 30 seconds or so. He couldn't hold himself upright, and slouched sideways off the bench onto the ...
Source: Spontaneous Circulation - July 7, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Out of the Routine
Our patient was having an uneventful and ordinary day. He got his children off to school, and spent the morning at the office completing paperwork. By noon he had eaten lunch, and went to the company workout center. It was Wednesday, so it was arms day. He started as he always did with 20 minutes of cardio on the elliptical machine, then shoulders, biceps, triceps, forearms — big muscle to small muscle. It was at the end of his first rep of triceps that things changed.
He felt some dizziness, and the nausea began within 30 seconds or so. He couldn't hold himself upright, and slouched sideways off the bench onto the gr...
Source: Spontaneous Circulation - July 7, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Unexpected Turns
She watched the Camry coming straight at her, obeying the laws that Newton laid out: a body in motion stays in motion until an external force intercedes.
Her husband, daughter, and the TV weatherman had told her not to go out. Ice had descended on the city earlier in the day, making even the walk to the garage precarious. But she needed milk to make a cake for the next day’s party, and the store was only three blocks away. Her plan was simple: store, milk, home. That might have worked if not for the Camry that became a hockey puck on the ice.
The next couple of hours were a blur but proceeded as readers would e...
Source: Spontaneous Circulation - June 4, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Unexpected Turns
She watched the Camry coming straight at her, obeying the laws that Newton laid out: a body in motion stays in motion until an external force intercedes.
Her husband, daughter, and the TV weatherman had told her not to go out. Ice had descended on the city earlier in the day, making even the walk to the garage precarious. But she needed milk to make a cake for the next day’s party, and the store was only three blocks away. Her plan was simple: store, milk, home. That might have worked if not for the Camry that became a hockey puck on the ice.
The next couple of hours were a blur but proceeded as readers would expec...
Source: Spontaneous Circulation - June 4, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Upstream Problems
He had been through this before. The patient, a 57-year-old man, had come through the doors of this emergency department many times. He had a favorite seat in triage. He knew what questions the nurse would ask him once he was in a room, and that the doctor would repeat those same questions. Then tests and labs, then moved upstairs for a couple of days before going home, hopefully feeling better. He knew all of this. Today, though, everything he thought he knew was wrong.
He had once considered himself lucky. He even survived a gunshot to the chest as a young man. But that notion had faded long ago. His health had been get...
Source: Spontaneous Circulation - May 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Upstream Problems
He had been through this before. The patient, a 57-year-old man, had come through the doors of this emergency department many times. He had a favorite seat in triage. He knew what questions the nurse would ask him once he was in a room, and that the doctor would repeat those same questions. Then tests and labs, then moved upstairs for a couple of days before going home, hopefully feeling better. He knew all of this. Today, though, everything he thought he knew was wrong.
He had once considered himself lucky. He even survived a gunshot to the chest as a young man. But that notion had faded long ago. His health had been gett...
Source: Spontaneous Circulation - May 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Narrow Gate
The patient first felt winded one night after doing the dishes. She was breathing so hard by morning that she was barely able to get out of bed. And a cough had started. “The flu” went through her mind. She stayed home from work to rest, but all day she just couldn’t catch her breath. The cough got worse and was making her chest hurt, and she felt her heart racing. She was exhausted by evening, but knew she wasn’t going to be able to sleep. The temperature was below 0°F outside, but she bundled up and drove herself the three miles to the emergency department. Barely able to speak by the time she stepped up to the ...
Source: Spontaneous Circulation - April 7, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
