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You heard me.
Air embolism? Pneumo? Underwater seizure?Attempting to get scuba certification and having to do CPR on a dive boat sucks...
Now I just need a free weekend to do the 3rd and 4th open water dives.
Air embolism? Pneumo? Underwater seizure?
Dive/undersea medicine is probably one of the coolest niches of EM
Yeah, this gets a win.
My money is on air embolism.
Forgive me: ACS?I'm going to go with good ol' ACS, especially in an open water dive class.
I wish it was something as sexy.Air embolism? Pneumo? Underwater seizure?
Dive/undersea medicine is probably one of the coolest niches of EM
It’s never the cool sexy pathology. It’s always ACS.I'm going to go with good ol' ACS, especially in an open water dive class.
I love scuba -and have seen the cpr on a dive boat - not fun - if you want ideas of places to go - shoot me a message - heading to Bonaire for the 8th time in a month or soAttempting to get scuba certification and having to do CPR on a dive boat sucks...
Now I just need a free weekend to do the 3rd and 4th open water dives.
I wish it was something as sexy.
So this is a general dive boat that the open water class was on. It’s day 2, so open dive number 3 and 4. The boat has other groups besides the class.
There’s a fairly decent current, but that’s not abnormal and normally there’s no or minimal current on the sea floor. The class was on the lag line finishing our skills (surface marker buoy, clearing goggles, duffing/donning the BCD in the water) and about to go for the dive when I see a life ring float past. “Uhh, instructor, I don’t think that’s supposed to be out here…”
We get told to get back on board. As we get back towards the back of the boat they’re trying to recover a diver that’s unresponsive. 18 year old, certified (not what level, but at least open water). Apparently he never ended up diving to depth (so lung reexpansion injury shouldn’t be possible) and the depth (50 feet) and time would be a non-decompression dive anyways.
I realize what’s happening. Scramble on board, grab their o2 setup. Patient gets pulled out in arrest and it’s almost impossible to ventilate due to size (obesity, round face) and atelectasis from loss of surfactant. Coast guard was there in what felt like 10 minutes (nothing to add but manpower unfortunately). Fire rescue in 15. Got him on the LUCAS. Life pack showed asystole. Fire rescue then transported while the boat waited for 3 hours for the state law enforcement to come out and take pictures of the boat.
In the future I’m going to ask if I can ride with fire rescue and “help” if for no other reason than not be stuck on the boat for hours doing nothing.
An OPA would have been nice to have. I’m also sure that I have a deposition in my future (should have federal and state good Sam protection, so I shouldn’t be a named party).
My understanding is he didn’t actually start the dive and the entire event was at the surface.are you sure the lung injury/emoblism isn't a possiblity? I mean from 33 feet to the surface is one atm = doubling of the air size. if you hold your breath without doing a CESA from that depth you can definitely get a fatal injury - The greatest percentage increase is in that last atmosphere -
ahhh - gotcha - that makes more sense,My understanding is he didn’t actually start the dive and the entire event was at the surface.
Sure. You can get expansion injury from a relative short uncontrolled ascent.
everything prior to when he was pulled back on the boat is second hand. There was some comment that his regulator got entangled. However that’s what the octo is for.ahhh - gotcha - that makes more sense,
I figured to have an event at the surface for an 18 year old would be pretty rare,
ya- I live in NC - so we have some good off shore diving, but also can get into some sketchy situations pretty quick with heavy currents, and 8 foot seas coming out of nowhere.everything prior to when he was pulled back on the boat is second hand. There was some comment that his regulator got entangled. However that’s what the octo is for.
I was looking online to see if dive boats carried any airway gear. It was a little surprising to see no suction or OPAs on board as those would be low skill, high dividend tools. I subsequently came across this blog post relating what seemed to be a similar story of a young diver drowning on the surface. Essentially if you don’t have your reg in and grab onto a line in a current, you will be inhaling water.
011 Airway Control: What's All The Fuss? - ScubaGuru
In this episode of The Dive Locker podcast you’ll learn why airway control is such an important life saving skill for scuba divers.scubaguru.com
Oh man, you've gotta try the hail marry on that one. Can't let a 35 yo die an airway death without using all your tools. Good job.35 year old female, previously healthy-ish...I do wonder if the cric was truly indicated
That's a tough one. My first thought is deep space infection, followed by tetanus. I've seen some weird infections in my IVDU population. Unable to ventilate, even with an NPA sounds like maybe a retro-pharyngeal abcess? But the bilateral mandible swelling is odd as well.Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.
We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.
Yep. As said above, that's one you've got to use whatever you've got in the toolbox for the patient. Strong Work!I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)
Yea that’s the tough thing about IVDU, they really do manifest just the most bizarre infections even in healthy people.That's a tough one. My first thought is deep space infection, followed by tetanus. I've seen some weird infections in my IVDU population. Unable to ventilate, even with an NPA sounds like maybe a retro-pharyngeal abcess? But the bilateral mandible swelling is odd as well.
Yep. As said above, that's one you've got to use whatever you've got in the toolbox for the patient. Strong Work!
Maybe with a sprinkle of danger space infection.Yea that’s the tough thing about IVDU, they really do manifest just the most bizarre infections even in healthy people.
I’m sure where you’re located in the northeast/Appalachia you probably see more of it than I do. Even at our large tertiary center in Miami we don’t see all that much. People here tend to prefer drugs they can snort.
If I had to guess I’d put my money on something along the RPA/Ludwig’s/PTA spectrum.
Septic arthritis of TMJ maybe? Personally, I wouldn't put too much stock into jaw swelling-some people just look like chipmunks. I think you did the right thing cric'ing the patient, sounds like a resp arrest in a young patient--I never call codes w/o establishing an airway. (although I wouldn't criticize someone for just calling one in an unwitnessed asystolic arrest).Yea that’s the tough thing about IVDU, they really do manifest just the most bizarre infections even in healthy people.
I’m sure where you’re located in the northeast/Appalachia you probably see more of it than I do. Even at our large tertiary center in Miami we don’t see all that much. People here tend to prefer drugs they can snort.
If I had to guess I’d put my money on something along the RPA/Ludwig’s/PTA spectrum.
Ballsy move w/ a doac on board, good on you.I did a subclavian with a PGY-2 at my side, walking them through it (they don't do many of them).
I had a very similar case in a young guy a while ago, presumed to also be an IVDU. I gave benzos and even paralytics for fun just to see if it will relax his jaw with no success. So also ended up cric'ing him just to say I got an airway before calling it. Found some case reports afterwards that describe similar patients: Emergency cricothyrotomy for trismus caused by instantaneous rigor in cardiac arrest patients - PubMedSo here’s a case I would love some thoughts on:
35 year old female, previously healthy-ish but IVDU, came in as a cardiac arrest. Per EMS her jaw had “locked up.” Down time unknown and asystole on the monitor. No drug paraphernalia on the immediate scene.
Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.
We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.
We were trying to decide if it’s worth it to cric and establish a definitive airway. Likelihood of success is obviously exceedingly low but she’s a previously healthy-ish, and in a can’t intubate can’t ventilate situation with a presumed hypoxic arrest.
I decided to cric - got the airway, got ETCO2 and O2 sat went from undetectable to 95%. Ran CPR a few more rounds. Ultimately called it.
In the end I felt better talking to the family (her mom, husband, little kid at home) and being able to tell them we really did try absolutely everything to give her any shot and they were grateful. I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)
Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidismA woman goes to five different doctors with a complaint of palpitations. No one orders any labs on her. She was given mainly reassurances and discharged. One of the doctors even did a heart cath on her.
Woman still having symptoms, finally goes to the Cleveland Clinic, where she had lab tests done that showed hyperthyroidism. She was started on appropriate treatments and symptoms finally abated.
Woman's name: Oprah Winfrey.
Moral of the story: Outpatient medicine is dead?
A doctor told Oprah to 'embrace hunger.' How it changed her view of medicine forever
Ahead of a new documentary about racial inequities in healthcare, the TV host opens up to The Times about her own experiences.www.latimes.com
A surprising amount of scuba drownings occur at the surface. Strong current/waves, seawater in the face/mouth, panic sets in, irrational behaviors, more seawater aspiration, death spiral. That’s why they encourage regulator in your mouth at all times until back on the boat and establishing full buoyancy once at the surface.My understanding is he didn’t actually start the dive and the entire event was at the surface.
Sure. You can get expansion injury from a relative short uncontrolled ascent.
You did the right thing. Low likelihood of success but I think 35 yo relatively healthy you gotta pull out all the stops.So here’s a case I would love some thoughts on:
35 year old female, previously healthy-ish but IVDU, came in as a cardiac arrest. Per EMS her jaw had “locked up.” Down time unknown and asystole on the monitor. No drug paraphernalia on the immediate scene.
Initially when she came into resus we were thinking maybe early rigormortis but on exam the rest of her body was completely flaccid, warm, pink - just jaw locked shut and swelling/echymosis at the angle of the mandible bilaterally. Maybe some kind of deep space infection holding the airway closed? Unwitnessed isolated trauma? Maybe tetanus? Normal ACLS going in the background.
We were trying to bag but couldn’t get any air through the oropharynx even with a nasal trumpet. No ETCO2 return.
We were trying to decide if it’s worth it to cric and establish a definitive airway. Likelihood of success is obviously exceedingly low but she’s a previously healthy-ish, and in a can’t intubate can’t ventilate situation with a presumed hypoxic arrest.
I decided to cric - got the airway, got ETCO2 and O2 sat went from undetectable to 95%. Ran CPR a few more rounds. Ultimately called it.
In the end I felt better talking to the family (her mom, husband, little kid at home) and being able to tell them we really did try absolutely everything to give her any shot and they were grateful. I do wonder if the cric was truly indicated (given how long she’d been down and low likelihood of Neuro-intact survival.)
That reminds me of a sucidal ideation that was triaged to our fast track once. Pleasant middle aged woman, no obvious red flags. "So ma'am, the nurses tell me you want to kill yourself. Can you tell me what's going on?" "Well, I have these horrible headaches that started a couple if years ago and nobody can help me." "So tell me about your headaches.". She goes on to describe a classic space occupying lesion headache...which the CT scan confirmed.Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidism
For a minute I thought, how does an alpaca cause a STEMI, and what's one doing out on the water?!?STEMI from ALCAPA
But that is the whole thing. Most people with palpitations go to the ER or the PCP, not to the chair of cardiology at Mayo or whatever .. the chair of cardiology assumes the labs were already normal before the patient got to them…Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidism
Like for real. No one has heard of TSH?Too bad she didn't present to my ED with suicidal ideation - we'd have diagnosed her hyperthyroidism
Seems like an example of a person that is maybe too in tune with their body and can’t tough out a little pain leading to a bunch of downstream expensive testing that ultimate doesn’t change management. I’d suspect that anticoagulation for paraumbilical vein thrombosis would have limited efficacy. Did you end up doing anything about it? Did they also have liver disease?I have a relatively healthy, mid-30 something with a paraumbilical vein thrombosis, presented with pain on deep inspiration. D-dimer of 501 (threshold 500) lead to a CTA Chest, which lead to a CT abdomen which found the issue.
WTF?
And will of course lead to countless future visits and scans b/c of "i have a clotting disorder".Seems like an example of a person that is maybe too in tune with their body and can’t tough out a little pain leading to a bunch of downstream expensive testing that ultimate doesn’t change management. I’d suspect that anticoagulation for paraumbilical vein thrombosis would have limited efficacy. Did you end up doing anything about it? Did they also have liver disease?
What was the issue?I have a relatively healthy, mid-30 something with a paraumbilical vein thrombosis, presented with pain on deep inspiration. D-dimer of 501 (threshold 500) lead to a CTA Chest, which lead to a CT abdomen which found the issue.
WTF?
This was probably the second-most spinchter-clenching case of my entire medical career.
EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital
Gnarly case. Not fun to have, but great to add to your experience list.This was probably the second-most spinchter-clenching case of my entire medical career.
EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital
Perimortem c-section?I used to think - still kind of do - that the coolest part of an EM career would be if I got to do a resuscitative hysterectomy (perimortem C-section) with both the baby and mom surviving. I’ll likely never get to do one, and odds aren’t great that it will be a good outcome.
I did recently deliver a baby for the first time in many years involving reducing a nuchal cord and aggressively stimulating in the setting of fluid with light mec. Very normal patient/family that hadn’t expected me to be the one delivering, or for it all to happen in the ED. Probably quite routine for most OBs, but certainly out of my comfort zone given lack of doing for years. Felt very rewarding in a way that gives me a sense of peace if I never have that once in a career moment.
Makes me really value our skill set versus having subspecialty training. Also feels rewarding when we spend a lot of time doing nothing for all of the worried well that we deal with on the average shift.
Yes, in kids with unrepaired Tet squat/knee to chest will help. But it is also kids with Tet -a subset of them, at least- that will turn blue with crying/agitation, not transposition.Gnarly case. Not fun to have, but great to add to your experience list.
I think in Tetralogy of Fallot you put them in the knee-chest position or have them squat. In transposition of the great vessels isn’t the key supposedly to do everything to avoid making them cry even avoiding an IV?
Also sounds maybe more complicated given all their prior surgeries and atrial flutter with RVR.
I could be completely wrong, just vaguely remembering this from medical school and residency from the peds EM attendings.
Medicine or Edison? Looks like you went for medicine, but why not cardiovert?This was probably the second-most spinchter-clenching case of my entire medical career.
EMS is dropping one off when the other truck gets paged out for a 3 y/o with an HR of 240. They get on scene and they're cyanotic, diaphoretic, and lethargic. Kid has a history of transposition of the great vessels, double outlet right ventricle, and a total of 5 open-heart surgeries. When the get to us, they're pink, warm, dry, no distress with a rate of 140. As soon as they move them over, the HR shoots up to 280 and they get diaphoretic again. No IV access from EMS, Nursing is striking out, my senior resident gets an EJ as i'm prepping an IO if he fails. Adenosine slows them down enough to get A-flutter on 12 Lead. Second year resident is on the phone, trying to get their peds cardiologist for the transfer and treatment recs. Gave amiodarone, which improved the rate and pressure, but now, they're having 6-10 beat runs of V-Tach which eventually stop. Only lab abnormality is elevated trop. Gets helicoptered to the Childrens' Hospital
I hear what you are saying. Medmal is ridiculous and it’s certainly possible, but I disagree. I practice at times fairly defensively, but there are also times when you throw the kitchen sink at a problem in resuscitation and it’s exhilarating, especially with a good outcome. You just don’t get sued much when you do everything possible. It’s the missed diagnoses, bad discharges and incidental findings that get you. Not saving someone’s life. You just saved a young healthy life! Mom can have another baby even if you didn’t have the incredibly rare outcome of both surviving neuro intact.If mommy lives and that baby dies, regardless of care, just get ready for a monster lawsuit that will 100% settle because the optics of these of cases are always terrible and no jury is going to be able to think straight.