An ER Victory?

[docB]

What's a victory in the ER? The big saves are cool. Tension pneumo you needle, diagnosis you make that no one else did, etc. But these are few and far between. Many of my ER victories aren't really victories at all. The code that you bring back that has anoxic injury and never leaves the ICU, the frail elderly with resp failure that you tube but who will never get off the vent. I had a case tonight with a 70 yo F came in with dead bowel. Made the diagnosis right off, intubated, fluids, she coded twice bu I got her back and she went to surgery alive. Surgeon found a mass of dead bowel. Nothing to do. Is that a victory? Sometimes in the ER you have to take what you get.

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[DrDre']

I think the "victories" are resuscitating 50 yr old MIs who have kids, fixing up injured kids, alleviating suffering of the elderly. I used to think it was the traumas and codes. they are usually futile efforts that offer no benefit to the family, pt, or society.

 

[DrQuinn]

Transfer from an outlying hospital:

60some year old gentleman, fall from 8 ft... injury happens at 10AM, we get a call from Aeromed (our air service)... the guy is diagnosed with a "fractured kidney" on CT, apparently 1 L of blood in retroperitoneum. No CBC, no c-spine films, no fluid resuscitation. Apparnetly the sending facility gave him labetolol becuase his HR was 130s... becasue "he's probably got release of his renin-angiotensin system."

I'm glad he came to us.

A little investigative work and it was a smaller (not dinky) ER with an FP attending.

Save? Maybe. Scary, yes.

Q

 

[Sessamoid]

Transfer from an outlying hospital:

60some year old gentleman, fall from 8 ft... injury happens at 10AM, we get a call from Aeromed (our air service)... the guy is diagnosed with a "fractured kidney" on CT, apparently 1 L of blood in retroperitoneum. No CBC, no c-spine films, no fluid resuscitation. Apparnetly the sending facility gave him labetolol becuase his HR was 130s... becasue "he's probably got release of his renin-angiotensin system."

I'm glad he came to us.

A little investigative work and it was a smaller (not dinky) ER with an FP attending.

Save? Maybe. Scary, yes.

Q

Labetalol? Geez, if the transferring facility had a general surgeon, wouldn't it have made more sense to stabilize his bleeding before transfer? Then again, if they're giving labetalol for hemorrhagic shock, then maybe even an active abdominal bleed should have been transferred. I assume the flight staff did a better job than the transferring facility.

 

[spyderdoc]

Labetalol? Geez, if the transferring facility had a general surgeon, wouldn't it have made more sense to stabilize his bleeding before transfer? Then again, if they're giving labetalol for hemorrhagic shock, then maybe even an active abdominal bleed should have been transferred. I assume the flight staff did a better job than the transferring facility.

What Sessamoid? You don't give labetalol for hemorrhagic shock?

I guess in FL, where anybody can become "board certified" to practice EM (BCEM), that very well may be the standard of care...
Whoops, there goes my Tourette's again...

 

[banner]

I'm not in ER but victory is when that paycheck is deposited in my account.

 

[margaritaboy]

Victory:

2 yr old male run over by a vehicle comes to the trauma bay with agonal respirations, poorly responsive to pain. Resident tubes the kid, CT, mannitol, admission to PICU.

2 weeks later and I see this kid in the follow up clinic. Talking, walking, the whole deal. He has a small area of residual burn on his leg that we expect heal up, over the next few weeks.

Amazing.

 

[Sessamoid]

Victory:

2 yr old male run over by a vehicle comes to the trauma bay with agonal respirations, poorly responsive to pain. Resident tubes the kid, CT, mannitol, admission to PICU.

2 weeks later and I see this kid in the follow up clinic. Talking, walking, the whole deal. He has a small area of residual burn on his leg that we expect heal up, over the next few weeks.

Amazing.

I'm repeatedly impressed by the ability of the young to recover from seemingly fatal physical injuries. At times, I'm equally impressed by the susceptibility of the very old to a mere change in the wind.

 

[Seaglass]

Personally I don't try to track victories. IMHO there aren't many in any field of medicine--we're all fighting a losing battle against time. I just like the temporizing that I do and the people I meet and leave it at that.

 

[mikecwru]

Transfer from an outlying hospital:

60some year old gentleman, fall from 8 ft... injury happens at 10AM, we get a call from Aeromed (our air service)... the guy is diagnosed with a "fractured kidney" on CT, apparently 1 L of blood in retroperitoneum. No CBC, no c-spine films, no fluid resuscitation. Apparnetly the sending facility gave him labetolol becuase his HR was 130s... becasue "he's probably got release of his renin-angiotensin system."

I'm glad he came to us.

A little investigative work and it was a smaller (not dinky) ER with an FP attending.

Save? Maybe. Scary, yes.

Q

The labetolol was ******ed, but the guy probably should have been sent to you without a CBC or imaging per ATLS. If the guy was showing signs of shock, he should have just been transferred with the time spent on fluids/blood if necessary.

mike

 

[srlondon]

Or, as The Fat Man says in the House of God (excellent book...should be required reading in med school), we practice on the GOMERs so that when somebody comes in who we might actually "save", we'll know how and know what to do with them.

I think the "victories" are resuscitating 50 yr old MIs who have kids, fixing up injured kids, alleviating suffering of the elderly. I used to think it was the traumas and codes. they are usually futile efforts that offer no benefit to the family, pt, or society.

 

[DrQuinn]

The labetolol was ******ed, but the guy probably should have been sent to you without a CBC or imaging per ATLS. If the guy was showing signs of shock, he should have just been transferred with the time spent on fluids/blood if necessary.

mike

THe patient got to the outside ED at 10AM, we get a call at 2PM that Aeromed is ready to transport but they have a question about spine immobilization. That's when we find out that he had a CT scan, no CBC, Labetolol for his HR. He wasn't a trauma alert, more of a trauma transfer, but if he had been sitting in that ED for four hours he probably should have had some labs and some fluid/blood resus, IMHO.
SCARY!

 

[WakeMedHeel]

A 17 year old found down, no pulse, body temp of 88 degrees, coded for 45 minutes, (because they're not dead til they are warm and dead)...got pulse back...sent to PICU...talking a day later.

 

[Annette]

20 someyear old mother of two, coded from septic shock. Chest cracked by an aggressive ER resident over many objections from surgery. In MICU for 1 1/2 months, with no corneal reflexes at first. Now at home, with few residual problems, taking care of her children.

vs (A medicine sucks type) 47 yr smoker/drinker found blue and "seizing" by 16 year old daughter. Vfib when paramedics arrive. Episodes of asystole. Had an hour and 20 minutes of no perfusing rythym, then transfered to us.

Did you know that you can't go through DT's if you have no functioning cortex?

You just never know. I really hate that.

 

[Sessamoid]

What Sessamoid? You don't give labetalol for hemorrhagic shock?

I guess in FL, where anybody can become "board certified" to practice EM (BCEM), that very well may be the standard of care...
Whoops, there goes my Tourette's again...

Yeah, that whole BCEM thing in Florida chaps my hide. How did the Florida Chapter of ACEP miss the boat on that one? I was paying my freaking dues for a reason dammit!

 

[A little elf]

I know up here at Hennepin, we are only a select minority of the cowboys that actually do indicated thoracotomies (along with our bros in Denver), had a guy who came in a few months back after running his semi into a concrete bridge after avoiding another car, lost vitals in front of us. Placed chest tube, put femoral cordis, cracked chest, put finger in LV until OR, all in under 30 min, guy left 1 month later neuro intact...BUT last week had crack-head spit at me...give and take.

 

[leviathan]

A 17 year old found down, no pulse, body temp of 88 degrees, coded for 45 minutes, (because they're not dead til they are warm and dead)...got pulse back...sent to PICU...talking a day later.

And thank goodness for that rule that resusc. takes place until reasonable efforts have failed with a normal core temp. Certaintly saved this kid.

 

[ekydrd]

Recently had a 28 yo male with metabolic acidosis and respiratory alkalosis, petichial rash, fever, and altered mental status. Outside fac treated him for meningitis and kept him for almost 8 hours with NO LABS at all!!! When he got worse they x-ferred him to our facility where we correctly Dx'd him with ASA overdose 30 minutes before he died.

 

[docB]

60 yo M, no medical problems presents by ambi with sudden onset severe belly pain, hypotension, tachycardia. AAA right? Wrong! Large bore x 2, IVF, stat scan (I went with 'cause I was worried about him). Guy had a tennis ball sized liver primary that had opend up and bled ~3 liters into his belly. Goes stat to angio for embolization which was successful and the guy's still alive. Problem is he still has liver CA with some small lung mets and mediastinal adenopathy. He's still hosed. I just prevented him from having a quick, painless death. Now he'll spend his last months as a chemo-irradiated organic pain collecter. Wheeeee!

 

[mikecwru]

60 yo M, no medical problems presents by ambi with sudden onset severe belly pain, hypotension, tachycardia. AAA right? Wrong! Large bore x 2, IVF, stat scan (I went with 'cause I was worried about him). Guy had a tennis ball sized liver primary that had opend up and bled ~3 liters into his belly. Goes stat to angio for embolization which was successful and the guy's still alive. Problem is he still has liver CA with some small lung mets and mediastinal adenopathy. He's still hosed. I just prevented him from having a quick, painless death. Now he'll spend his last months as a chemo-irradiated organic pain collecter. Wheeeee!

I did a similar thing for a guy with nec fascitis to his arm, saved his arm, problem was that he had end stage prostate ca. Being septic and dying from hypotension is probably less painful than constant bone pain.

mike