08 November 2007

Minor victories

Sad, but this really made my day: I just saw five patients, in a row, who all needed to be in the ER. Not for anxiety, or for alcohol and drug abuse, not for poorly controlled chronic illnesses, but for real, honest-to-goodness emergencies.

In no particular order there was:
An acute hemiplegic stroke
Acute Appendicitis
A fall with a head injury and moderate grade concussion
An acute arterial thromboembolism to the hand
(Most excitingly) a acute hemoperitoneum due to a ruptured artery in the abdomen (oddly enough, the splenic artery)

Wow. It's almost like I was working in a real Emergency Room or something.


  1. Did you give TPA to the stroke? Or has the genentech grand scheme to sell its snakeoil in medical-legal no-win either way left you unconvinced?

    From where and why the hand embolism? Afib? valve vegetations?

  2. I just saw five patients, in a row, who all needed to be in the ER.


    Here is a sampling of what I saw tonight: (1) Resolved chronic pain (pain 0/10 but it hurt earlier, relieved with taking home meds, wanted to be admitted in case it got bad again) (2) Pregnant girl who wanted ultrasound (3) "Painful nose pimple" (4) Foot pain, worse tonight (5) Actual migraine [resolved with Reglan/Benadryl, which is rare on night shift] (6) Chronic anxiety patient, out of meds, can't sleep by ambulance, anxious because he was out of meds (7) Frequent flyer with her 3rd visit of the DAY (8) "Hypoglycemic" patient with blood sugar of 118 and no history of diabetes--girlfriend checked his blood sugar and it was 118. She thought blood sugars were supposed to be at least 150 and we argued about this for 5 minutes, so better bring him in to be "checked out" for hypoglycemia in the middle of the night.

    I REALLY don't understand people. It's really getting disgusting.

    I'm jealous.

  3. No tpa. Ostensibly he might have been a candidate, but I search carefully for exclusionary criteria since I am in no way a tpa believer. In this case it was easy, since his symptoms were improving and resolving symptoms is a slam-dunk exclusion...


    Glad to see you're still around.

  4. It sounds like you had a better night than Nurse K.
    It must feel great when you can be there for someone who really needs your helps.

  5. Dude, you have got to be kidding me. I'm a radiologist in the southeast and I read a ct scan on a young guy with a RUPTURED SPLENIC ARTERY ANEURYSM WITH HEMOPERITONEUM 3 days ago!!! Too unstable for angio. Went to OR where aneursym couldn't be repaired and had a splenectomy. Guy's doing fine. So far no obvious explanation for the aneurysm as he is otherwise healthy (no pancreatitis, no evidence of arteritis). What a wicked coincidence.

    Like your blog. Very addictive.

  6. Mother J,

    You know, it wasn't just being there for someone who needs me that was so satisfying; the chronic folks need me as much or more in their way. It was the satisfaction of doing what I was TRAINED TO DO. I trained in acute care medicine, yet I find myself practicing chronic disease management and geriatrics. Frustrating (at best). And then of course half the patients we see have nothing discernibly wrong with them. So, to have real diagnoses, and acute ones at that, highly satisfying.

  7. Anonymous radiologist

    Cool -- odd coincidence. Apparently the splenic aneurysm is the third most common abdominal aneurysm (who knew?).

    The interesting thing about that case was how quickly it went south -- hmm ... Maybe a blog post there...

  8. Anon Radiologist here.

    We see incidental splenic artery aneurysms all the time on abdominal CTs. Most likely due to significant tortuosity of the artery with altered hemodynamics from HTN results in aneurysm formation at branch points. As long as they are peripherally calcified and generally less than 1.5 cm, there's nothing to do other than surveillance.

    Generally we see these aneurysms in older patients. They also pop up frequently due to chronic pancreatitis and in large vessel arteritis syndromes.

    In a setting of rupture of the artery, if the patient is stable (which yours and mine were not), angio could be considered as a covered stent could be placed across the aneurysm to protect it. You could also coil the aneurysm to thrombose it.

    Can you imagine that surgeon opening up that belly and seeing all that blood and having to find the source quickly? Sounds scary as shit.


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