Record Setting Month

I’m glad August is OVER!  What is normally a shit month in my life was a shit month at work too.  Low census, poor staffing, sick-ass train-wrecks and all the goodies of a urban tele floor.

But truly I’ve had some records shattered.  We see far out and funky lab values all the time, but these were some doozies this month.

And the Winners are:

HbgA1C:  14.6!  Also had a 13.9 as a runner-up.  Both patients with Type I diabetes, both young, one with OK support, one with none.  We worked the diabetic educator to the bone trying  to teach these young’uns to not end up destroying themselves.  For those playing along with the home game, <6 is good control for diabetics.  And when you translate that to eAG (estimated Average Glucose) you get 372mg/dl and 352mg/dl.  Bad mojo.

Worst Case of Thrush EVER:  Candidal Esophagitis, from the oropharynx to just above the lower esophageal sphincter.  And in a twist, the patient was not immuno-compromised.

Highest WBC in a non-cancer patient:  68.8.  Yes, 68,800!  And it had jumped from 48,000 less than 12 hours earlier.

Lactate:  10.8.  Of course what do I say?  “Last time I saw a lactate that high we were coding the patient.”  Sure enough the patient did expire (they had the nasty white count).  They were sick with a capital “F”.

Dumbest idea of the month:  dude comes in drunk and complaining of nausea and vomiting.  After being triaged he goes to the bathroom and pops a couple of poppers, promptly turns grayish-blue with  a pressure of 50 and a raging onset of methemoglobinemia.  At least he was in the ED when he did it.

Oh, and for two Fridays in a row, had rapid responses at shift change…a helluva’ way to start the shift!

I hope September is better…

Observation Lovin’

Our observation unit is lovingly called the Hooper Annex (Hooper is our local detox unit) as not a day goes by that we don’t have at least 1 in with ETOH-related issues.  But we get dumped on, a lot.  Usually it’s because the docs can’t or won’t make up their mind and end up passing the buck.

Can’t figure out what to do with grandma, but there’s really nothing medically wrong with her?  Admit to obs.

Oh, you’re drunk and it’s cold outside?  Admit to obs.

Gastropareisis needing dilaudid?  Obs.

I know that an observation unit is a place to send the patient if they just a little too unsafe to send home, but not sick enough to be admitted.  And it can be a great thing.  Take for example uncomplicated chest pain.  No family history, no pain at rest, pain resolved PTA, but you’re male, age >50 and smoke.  OK, perfect obs admit.  Grab some serial enzymes, an EKG in the morning, maybe a stress test and off you go.  Or when your troponin I jumps to 5.0, we can start beta blockers, integrillin and call the cath lab.  Either way, we’ve done the right thing.

On the other hand you get a patient that needs a little IV antibiotics for an upper arm abscess.  The labs from their PCP are borderline icky, not enough to say definitively one way or the other if in-patient admission is warranted.  What to do?  Based on old labs, because why would we pull new ones, just plan to admit them to obs.  Then maybe grab a few new labs to direct therapy.

But if things had gone the right way, y’know like accurately triaging the patient, doing a complete workup before sending the patient out of the ED, like with labs and stuff, we wouldn’t be looking at this trainwreck patient rolling by the desk looking at each other going, “Uh, oh.”

If you had drawn labs first you would have been floored by the lactate of 2.2, the WBC >18, a H/H in the shitter, mult. 4+ accumulations of gram-positive baccili and cocci and gran-negative baccilli growing from the wound culture you just did the in ED or the raging case of rhabdomyolysis with a CPK of 96,000!  Yes, 96,000.

Luckily for you,we queried this lack of workup where you found all of these values.   We had a funny feeling, y’know that gut-level, spidey-sense feeling that this patient is not going to turn out well without a higher level of care.  Thankfully you ended up placing the patient in the ICU so they could run pressors and hang lots of lots of fluid on his septic self, instead of on observation where we would have had to rapid response them to get them to the unit as they crashed before our eyes.  Yeah, good call.

Summer Medblog Smackdown

In booming announcer voice…

“Ladies and gentleman, boys and girls children of all ages…welcome to the Interwebs Arena for our main event of the  Summer…”

“Fighting out of the Doctor’s Corner wearing the red trunks, the contender from a big hospital somewhere in America.  With a record of 200,000 and 0, years and years of residency training, thousands of sidebar ads and an ego a mile wide, Happy “I’m a Medical Doctor and have my own way of running a code” Hospitalist! …”

“And out of the Nurse’s Corner, wearing the blue trunks, the challenger from a big ER somewhere else in America.  With a record of a million saves, years of being at the front lines of American health care, a chip on her shoulder and Dr. Bloody Gloves in her corner, Nurse “The Snarkinator, can’t believe Happy runs a Code like this” K! …..”

crowd goes wild…

“Let’s get ready to ruuuuuuuumble…..!”


“OK you two, let’s have a clean fight.  No low blows, no crayzee talk…oh whatever, just come out swinging.”


Happy and Nurse K are at it again.  Sit back and enjoy the show.

Not going to say who’s right, who’s wrong (although Nurse K is right dude, either wake the patient up for fucks sake, hello, sternal rub ’em! or pull the cord for the code team), but it sure is turning out to be a real smackdown.  I mean between Happy’s smug aloofness and K’s snark attack, you’ve got a real read on your hands.

Happy’s Post: Michael Jackson May Have Died From Fibromyalgia

Nurse K’s Rebuttal: How to resuscitate a patient Happy-style

Happy’s Attempt to hide the fact he got pwned: Is It Reasonable to Stock Every Room With Emergency Resuscitation Supplies

Would you two just get a room or something…

Edit: K just posted up a rebuttal to Happy’s rebuttal (a double butt-al?)  Face it bro, you’re getting pwned.  Throw the towel.

One of Those Weeks

Since it was a full moon this weekend, oh yes, it was a full moon.  I remembered the fun and enjoyment derived from the last full moon.  Oh yes, time for “Fun With the ER Bigboard.”  The rules are simple:  each contestant, er…patient signs in with a “Chief Complaint” which is broadcast on the “Bigboard” that anyone with access to the charting system can see.  And it just so happens us charge nurses look at said Bigboard frequently to prepare for incoming…er, admits.  So here are the winners from the last full moon…

#5: Abdominal Pain/bloody urine (always a crowd favorite)

#4: Chest Pain/cocaine use (yes, Virginia, all that white powder causes your heart to beat really fast)

#3: Possible Labia Abcess (I kind of think this is a lot like pregnancy: it either is, or it ain’t)

#2: Right Buttock Abcess (evidently it was the second half of a matched pair…)

and our winner for this round:

#1: Penis caught in zipper* (ow, ow, ow, ow, ow…)

And now for the bonus round!

Guess which one got admitted?

I’ll give you a hint…think twins.

*Talking with an ER nurse I know, evidently he had a small lac on said member, then when he decided that instead of waiting for the ER doc to get the pliers to “gently” free said member, he tore it out.  Yes, tore it out.  With little bits still left clinging to the zipper was said to have utterd “I was just tired dealing with it, so I took take of it.”  Evidently, he had been imbibing just a little…


Sphincter-Clenching Case

via ER stories.  It’s pretty damn awesome.

I seem to forget that many times when you have an inferior infarct, odds are pretty good that there is RV involvement.  I remember having an intern literally babysit a patient on the floor one night because she though he was having a RV infarct and was kind of freaked out about it.  She just hung out at the nurses station for hours waiting for the shit to hit the fan, but it never did.  If I remember right, we did a right-sided EKG and it was benign as well.

What bugs me is that during our unit education/skills validation sessions, it’s all LV infarcts.  Which of course means that using nitro is pounded into our heads, but no one stops to ask, “What about RV involvement?”  Sure, it is relatively rare, but it is something that we need to know about.  Granted, LV infarcts are far more common and we need to know how to treat them (at least to keep them alive until they can get cathed…), but I wish the educators would look a little deeper.


Why would you come to the ER for a sunburn?  I guess I can stretch the imagination and come up with blistered, throbbing pustules, more in line with scaldings etc., but not really that far.  Really?  A sunburn?  You came in to the ER on a Saturday night at 1am for a sunburn?

I saw this on the ER screen in our system. I usually check it out a couple of times an hour when I’m charge to see if there is anything pending for admission, just so I can give a heads up.  But I couldn’t believe that “sunburn” was the chief complaint.  I mean, yes, it was a Saturday night, so it was mixed in with the psych holds/SI, ETOH, heroin OD, Alzheimers/AMS, Dr Referral and the typical “just not feeling well” but it blew me away.  I’ve had some horrible sunburns and will probably seeing a dermatologist frequently when I’m older anb never thought to go the ER for any of them.  Why can’t people just “cowboy up”?

I can’t wait to talk about the needle-phobic patient we had…but can’t right now.  I’m waiting for the wife so we can go celebrate our wedding anniversary.  I just had to get this off my brain; now I can relax.

Pass me a Rockstar

When energy drinks and teens collide: Energy drinks linked to risky behavior among teenagers

The trend has been the source of growing concern among health researchers and school officials. Around the country, the drinks have been linked with reports of nausea, abnormal heart rhythms and emergency room visits.

I think I too would have heart palpitations with 250+mg of caffeine.  What’s that?  A 12oz. cup of Starbuck’s coffee has the same?  Oh, never mind then.

I’m sorry, as a dedicated caffeine consumer (albeit on the road to recovery), I’m not sure what the deal is.  The article goes on the talk about risky behavior, like substance abuse and unprotected sex.  And you’re trying to tell me this is new?  Get a grip folks.

I’m not a fan of these, but I do enjoy my coffee.  I can’t see someone going to the ER for nausea or palpitations after 5 cups of coffee (which used to be my morning wake-up).   Just more scare tactics.  Funny though how they don’t mention anything about the tweens walking around the mall with grandé Frappuccinos in hand.

The best quote though comes from a company spokesman:

“We expect consumers to enjoy our products responsibly.”

Isn’t that the mantra of every company selling something that can effect your mind and body.  I think the chairmen of Anheuser-Busch and Phillip Morris console themselves with it every night before bed.

Race and Pain Meds

According to an article published in the Washington Post there appears to be large differences in prescription of pain medicine between blacks and whites.  They also go onto note that whites are more likely to abuse said prescription drugs.  In the immortal words of Rodney King,”Can’t we all just get along?”  Does it happen?  I’m sure it does.  I’ve found myself prejudging patients purely on the basis of their diagnosis and history, and feel like shit later about it.   It’s an interesting read and raises lots of issues and items for thought.

Read all about it here: Whites More Likely to Get ER Narcotics.