02 August 2007

Traveling

I'll be on the road for a few days. Talk among yourselves while I am away.

Suggested topic:

What's the scariest ER story you have ever seen - scary in the sense of bad diagnosis you missed or nearly missed or never would have expected?

18 comments:

  1. 50yo female with esrd goes to er for generalized weakness. she gets triaged (apparently vss) and then patiently waits for several hours in the waiting room. she got tired of waiting and went to another er across town. was immediately taken back....potassium was 8.9.
    not all weakness is bullshit.

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  2. Any ESRD patient that you see has something like a 25% overall 5 year mortality. Among ones that always come to the ER it is always higher. It seems like they are always just 1 hour away from full blown sepsis, AMI, cardiac arrest, etc.....


    20 y/o male drunk asshole involved in an MVA about 10pm. His whole friggin body hurts. Seen by the ER doc and trauma surgeon. Got the whole body scan read by Nitehawk radiology as "negetive". Cleared by the trauma surgeon to "go home". However doesn't have a ride so he sleeps it off in the ER. The day hospital radiologist calls about 9 am and says "I think the aortic arch looks a little funny"...........ends up in the OR an hour later to repair his aorta tear.

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  3. Please include the name and jurisdiction of the plainti... ur I mean patient.

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  4. A couple of years ago (but I still have nightmares):

    17 yo male attended at gone midnight with simple pneumothorax. Medical SHO (junior doc) decides to insert a chest drain (with trocar in situ) deep into his chest, despite my increasingly vocal protestations about the blood pouring into the collection bottle. "I'm the doctor, you're the nurse. I know what I'm doing. This happens all the time."

    Errr, not in my experience it doesn't.

    Enter stage left the SpR (senior doc), who I had bleeped to put an end to this madness - simply to remove the stiches holding the chest drain, push it further in, then re-stitch.

    I ended up phoning the consultant at home at about 2am but the damage was done and the kid still ended up in ITU for a week.

    Still makes me shiver just thinking about it...

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  5. 65 yo depressed Vet with usual comorbidities presented to triage complaining of fatigue and diffuse ill defined pain. Had been seen several times in the past 2 weeks in walk-in clinic and ED with no etiology identified. During triage says his pain is better and wonders if it is all in his head.
    I was a new triage nurse (not yet jaded by frequent flyers); since it was early AM, decided to draw routine labs and have him wait to be seen.

    CBC showed leukocytosis w/ blasts.

    His diffuse pain was bony pain due to his AML.

    Ultimately became septic and died in the ICU.

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  6. OK, so it's not ER, but L&D can be sometimes emergency medicine...

    26yo very pregnant female presents to L&D triage for acute calf pain & swelling x 3 days. Venous doppler shows occluding DVT "*superficial* femoral vein." Resident du jour says "*superficial*?... ok, heat, tylenol, discharge." I say "but femoral vein is deep. Call your attending, superficial is a misnomer." I heart UpToDate.

    She thankfully ended up staying for heparin - scary terminology error!

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  7. 30-something MVA driver comes in by ambulance at about 3AM oriented x3 normal neurological exam, just a headache. Head CT cleared by the ED attending, no other signs of trauma. On-call radiologist clears the CT, patient is sent home.

    Morning radiologist reads the film and finds significant right-sided sub-arachnoid hemmorage (I saw it later in the day fresh off of my neuro finals in MS1...it was pretty blatant). Patient contacted at about 8AM and made aware of the bleeding in his brain and that he should probably come back in for further treatment.

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  8. 30-year-old female in c/o headache, nausea, vomiting for 5 days; seen at two other hospitals and treated for "migraine." no CAT scans done. Came to us via ambulance, lethargic but A&Ox3. Was a little cranky, was taking prescribed percocets. MDs are wondering if she's a psych consult. I pass by her bed and she's unresponsive except to deep pain (stuck her with a #18 needle and almost no reaction). CAT scan ordered: HUMUNGOUS (15 CM) tumor in her brain, shoving her ventricles out of shape. EEEEP! Prepped for OR tout suite, shunt inserted, almost miraculous recovery--except then she had to have brain surgery later.

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  9. Also, just recently: 50-something chick who had been at Another Hospital earlier in the week with migraine, negative CT scan, treated with meds. Came in flailing around in melodramatic fashion, talking about her migraine.

    Then she goes potty and has seizure in the bathroom (1st time seizure). She was all over the place postictally, yelling, screaming, had to be 4-pointed. We gave her numerous benzos with no effect. Her CT scan showed a 1.5cm head bleed.

    CT scans don't diagnose aneurysms. I don't know that's what she had originally, but I can only assume.

    Poor thing was probably screaming because her head hurt like a mofo.

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  10. OK, you're all a bunch of med profs and I'm just a customer. But since this just happened three nights ago, to ME, I'll post it.

    39 year old female six months out of chemo for stage II breast cancer comes to ER complaining of severe abdominal pains, left side, and vomiting. She is told that even though she can't even sit up, her vitals are stable and is therefore left for five hours, on the FLOOR, in the HALLWAY, of good hospital in upscale neighborhood, while frantic husband tries unsuccessfully to get her at least a gurney. Finally said female tells husband to tell nurses that she can't breath. At that point she is reluctantly admitted. Cat scan reveals a 10cm "solid mass" in her abdomin. ER doc tells her that she most probably has a tumor, and admits her to hospital. He wishes her good luck.

    Patient spends the next several hours contemplating her impending death from metastatic BC.

    Luckily, patient's ob/gyn is atsame hospital, and immediately takes charge. Surgery reveals an ovarian tortion, probably secondary to a hemerrgatic cyst. Patient is relieved, but pissed that she had to deal with hours and hours of pain, on the floor, puking her guts out, while patients ahead of her in line with earaches and sprained wrists were seen.

    So, my question is, did the ER do anything incorrectly (don't worry, I don't sue)? If so, what?

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  11. First off, no one should touch an ED floor except with their shoes. In ED we don't see patients according to a "line." I'm the triage nurse, and I have to decide who is dying, who can't wait more than 10 minutes and who can wait for hours. We have a "fast track" so that all those earaches and wrist sprains can be seen, treated and released quickly, from the chairs in the back room. That way, they don't take up the beds we need for sick people. Females with abdominal pain get UA, IVHL, labs: hemog, CMP, lipase - and that's done before they see the doc. It's done while you are in the waiting room if there isn't a bed. If you are vomiting I can get an order from any doc for nausea meds in a hearbeat. This is all before the doc even gets to see you.

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  12. You'd be a triage score of "3" with abdominal pain and vomiting and normal vitals (heart attacks/strokes are '2', more acute). Some hospitals can do more extensive things from the lobby, ours can order ibuprofen, UAs and xrays only.

    You were probably in line behind a whole slew of other #3s and there were probably ambulances coming in through the back as well that you never saw. Most ER patients are a #3.

    What I would do if you find yourself in a similar situation is simply asked to be "re-triaged" or checked again by the triage nurse. Explain that your pain is getting worse and that you've never had this pain before, etc. This may get you moved ahead of the malingerers or drama queens that are #3s.

    This is an example of why people need to go to the ER for emergencies only. People with actual problems end up waiting.

    Your ER probably did nothing wrong specifically other than not have enough beds. You'd be surprised how many people come with those exact same symptoms. Abdomen pain/vomiting is probably half the lobby at any given time.

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  13. I am an experienced ER doc. A couple weeks ago I missed an ovarian torsion. Very obese lady with flank pain. It was extremely busy and chaotic as usual. The night radiologist (and day radiologist overreader) read the CT scan as entirely normal, even though in retrospect there is a 7cm pelvic mass. She came back later because the pain recurred and was worse. An ultrasound showed a complex ovarian mass without blood flow. I doubt the ovary was slavageable the first time around, but I still felt very bad about missing it.

    Our job is constantly humbling. Working the ER is very chaotic, high risk, with interruptions by the minute. No ER doc likes to hear "Remember that patient that........." On the other hand, we like to hear about those cases because it becomes part of "our clinical experience". The doc would probably fully appreciate a follow up letter as long as it is not venomous to cause anxiety of an impending lawsuit. (although I already feel that every shift is an impending lawsuit)

    On behalf of all who tolerate working ER, I apologize for your wait and suffering. It is certainly not ideal. However, because of EMTALA, hospital economics, ER boarding of admitted patients, nurse and hospital bed shortages, ER abusers, call panel malpractice crisis, the uninsured, and a variety of other reasons leading to ER overcrowding this is becoming the norm in neighborhoods all over the country.

    Unfortunately.

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  14. 9:41,

    Your type of presenting complaint suffers the most in the ER overcrowding crisis. That is - "not sick enough to require immediate resuscitation", and "too sick" to go to "fast track" and be seen by a PA in a chair.

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  15. Ovarian tortion here.

    Thanks for your comments.

    I feel that the only thing that was really wrong was making me lie on the floor for five hours.

    Pain meds would have been great, but if they have a policy against any treatment until a doc can see the patient, that at least makes sense.

    Although the waiting room was crowded, when I went inside I saw there there was plenty of available gurneys and even five empty beds in the triage area. I don't think there was any excuse for not putting me in one of them.

    The nurses apologized a lot. But I still don't understand why one of them couldn't have snuck me into a bed.

    My new motto: NO BED, NO BUCKET. If I'm on the floor, my vomit's on the floor. Maybe that would have gotten their attention.

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  16. One problem with "open gourneys" could be nurses unions or mandated nursing ratio laws.

    Not enough nurses to cover beds in the ER for the shift -- rules and laws mandate that a nurse can only be taking care of a certain number (BTW -- doctors have no such thing and have not choice to take care of 20 at a time if need be).

    Here in Northern Mexico (aka southern ca.) Arnold signed limited nursing:patient ratios into law and the nursing union will see to it that it is followed. If you tried to assign 8 patients to a nurse but then they would all quit and leave and then you would haven an even worse shortage.

    So patients lie on the floor instead of an open gourney.

    Sigh.

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  17. Another patient perspective story here...
    16yo female comes in late afternoon, complaining of diffused /right/ sided chest pain, lethargy and confusion. Somewhat tachycardic, temp raised very slightly.
    Pushed to fast track, and keeps getting ignored due to really, really sick people rolling in via ambulance doing terrible things like not breathing.
    About five hours after patient gets into the ER, her father wanders out of the room to go see mother (who also happens to be in the hospital, for an unrelated reason).
    Doctor wanders by. Stops. Looks. Comes over and says "Have you always had this rash on your chest?". Gets absolutely no response. Pokes patient. Nothing. Pokes patient with 18 gauge needle. Still nothing.
    Father wanders back to discover huge numbers of people freaking out over 150 pulse, strange EKG's and lack of consciousness.
    Final diagnosis - dehydration, mild (thankfully) meningitis, heart complication and a dislocated rib. Turns out, the chest pain was the rib.
    Go figure.
    One of the doctors from the ER popped up to see me later and admitted that she thought I was just having a panic attack over my mother being in the hospital.

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