Curbside Consult Thread

[ERCougar]

Once in a while, I've wish I had a medical discussion board--a place I can bounce ideas off of people, get unofficial opinions without having to bug a consultant, or just to discuss interesting patients. For example, I PM'ed Cardiac a while back about disposition of AFib patients after cardioverting them--just a question I had thought about but didn't have a patient to consult on. We have enough medical expertise here (surgery, cardiology, orthopedics, family medicine, pharmacy, physical therapy--am I missing any?) that I think we could pull this off. Obviously, anyone can post, but to distinguish this one from the medical question thread, this one's more for shop talk.

So...interesting patient the other day--30ish woman comes in completely gorked. Quick blood gas shows a pH of 6.95, pCO2 30ish. Sugar of 125. BMP comes back with bicarb "<5". Normal ETOH. Numbers look like a toxic alcohol, but the patient does not look at all the type. The serum osmolality is a send out, which makes me wonder why it even exists. Ethylene glycol and methanols are obviously send-outs (I haven't been anywhere where they aren't). Cr is 1.45, so this is really looking toxic alcohol. Started treating empirically with fomepizole (ethylene glycol Tx) and arrange for dialysis, still thinking there's no way this is ethylene glycol (I know the family well).

Anyway, just checked on the outcome--turns out she finally admitted to drinking a bottle of antifreeze in a suicide attempt. You just can't judge a book by its cover.

[ERCougar]

And some questions for the pharmacists:
1) What are Albuterol MDI's running these days? Are they coming down in price yet?
2) How about Zofran? I got Zofran ODT's for my daughter a while back for about $1/dose. Yet, sometimes, pharmacies call me for a substitution because their Zofran price is closer to $10/pill. Is it generic yet or not? Why the huge disparity? They have a generic ODT, don't they?

[CardiacCoug]

Interesting case. Nice diagnosis and you probably saved her by starting the fomepizole so cool.

Since 90+% of the stuff you ER docs see is totally routine I have always thought the main challenge of the ER is to stay motivated and alert for the unusual diagnosis that comes through.

We had a crazy case a few months ago. 70-ish lady with acute onset of left shoulder pain. Rules out for MI in the ER in AM. The discharge her and send her to us for a stress test which is mildly abnormal. So I admit her for a cath. She becomes progressively hypotensive, worsening shoulder pain.

Cath is normal but since she is crumping I run stat labs in the cath lab and her hemoglobin has gone from 14 to 6.5 or so. A bedside ultrasound in cath lab shows that her abdomen is full of blood. Goes to the OR emergently -- has a splenectomy for a spontaneous splenic rupture. Clearly that was her diagnosis all along with referred pain to left shoulder. She was discharged a few days later and is doing great.

[ERCougar]

Interesting case. Nice diagnosis and you probably saved her by starting the fomepizole so cool.

Since 90+% of the stuff you ER docs see is totally routine I have always thought the main challenge of the ER is to stay motivated and alert for the unusual diagnosis that comes through.

We had a crazy case a few months ago. 70-ish lady with acute onset of left shoulder pain. Rules out for MI in the ER in AM. The discharge her and send her to us for a stress test which is mildly abnormal. So I admit her for a cath. She becomes progressively hypotensive, worsening shoulder pain.

Cath is normal but since she is crumping I run stat labs in the cath lab and her hemoglobin has gone from 14 to 6.5 or so. A bedside ultrasound in cath lab shows that her abdomen is full of blood. Goes to the OR emergently -- has a splenectomy for a spontaneous splenic rupture. Clearly that was her diagnosis all along with referred pain to left shoulder. She was discharged a few days later and is doing great.

Funny--we had an almost identical M&M presentation in residency (she didn't die, but missed diagnosis).

[CardiacCoug]

Funny--we had an almost identical M&M presentation in residency (she didn't die, but missed diagnosis).

It was really lucky for her that her stress test was abnormal because otherwise I would have just sent her home to possibly bleed to death -- sometimes the most important thing is just to keep people with these unusual diagnoses in the hospital or ER long enough for the real problem to declare itself.

One of those situations where we all knew something bad was happening to this lady but of course since all I see is heart disease I have the blinders on and never think about anything else.

[wuapinmon]

If non-medical Cuffers read something in this thread, and would like to ask questions about what stuff means, is that cool, or do you want it kept free of clutter?

[ERCougar]

If non-medical Cuffers read something in this thread, and would like to ask questions about what stuff means, is that cool, or do you want it kept free of clutter?

Of course (you can ask anything). This is sort of like our needleneck wanker thread.

[San Juan Sun]

Two stabbings last night arrived at the exact same time. Injuries were almost mirror images of each other. One guy had a left chest wound hat game him a pneumothorax and a diaphragmatic laceration. The other guy had a left chest wound that gave him a pneumothorax, diaphragmatic laceration, but also bagged his liver. Each guy to go to the OR and get matching laparotomies and chest tubes.

[ERCougar]

It was really lucky for her that her stress test was abnormal because otherwise I would have just sent her home to possibly bleed to death -- sometimes the most important thing is just to keep people with these unusual diagnoses in the hospital or ER long enough for the real problem to declare itself.

One of those situations where we all knew something bad was happening to this lady but of course since all I see is heart disease I have the blinders on and never think about anything else.

SO true! There are an uncanny number of patients who code or have badness happen while they are waiting for their ride. It's really bizarre.

One guy I distinctly remember--mild posterior headache, mild vertigo, nothing else particularly alarming, so I didn't scan him. Wife goes to get the car and while she's gone, he codes. We resuscitate him and send him to the scanner--huge subarachnoid bleed. His son, who was with him, said he had a classic thunderclap headache right before coding, and in retrospect had had a similar headache a few weeks prior, which was likely a sentinel bleed.

I'm still pretty convinced we wouldn't have seen anything if we had scanned him when he initially presented--just happened to have his event while he was waiting to leave.

[ERCougar]

Two stabbings last night arrived at the exact same time. Injuries were almost mirror images of each other. One guy had a left chest wound hat game him a pneumothorax and a diaphragmatic laceration. The other guy had a left chest wound that gave him a pneumothorax, diaphragmatic laceration, but also bagged his liver. Each guy to go to the OR and get matching laparotomies and chest tubes.

LOL @ Detroit. I never spent time there outside of conference stuff (but spent plenty of time at Hurley), but the Ford residents always had the best stories.

[San Juan Sun]

LOL @ Detroit. I never spent time there outside of conference stuff (but spent plenty of time at Hurley), but the Ford residents always had the best stories.

We rotate at Hurley. I'll be there next month.

[wuapinmon]

It was really lucky for her that her stress test was abnormal because otherwise I would have just sent her home to possibly bleed to death -- sometimes the most important thing is just to keep people with these unusual diagnoses in the hospital or ER long enough for the real problem to declare itself.

One of those situations where we all knew something bad was happening to this lady but of course since all I see is heart disease I have the blinders on and never think about anything else.

A guy from my ward when I was a kid went to have a stress test done back in August as part of a followup to an insurance physical. He was in good shape. About 55 y/o.

He had a heart attack jogging on the treadmill and died in the lab.

Talk about bad luck.

[Viking]

I know two things about being a doctor:

1. I could never be one
2. Doctorcoug will not be one in ten years (he likes biz too much)

[doctorcoug]

Once in a while, I've wish I had a medical discussion board--a place I can bounce ideas off of people, get unofficial opinions without having to bug a consultant, or just to discuss interesting patients.

Heard of sermo? I love that site.

Just saw a trig level of 5000...

[San Juan Sun]

I was doing a low back lipoma excision today, which is maybe the easiest and least exciting general surgery out there. When I took the lipoma out, there was a bulb of fat left, which seemed to be coming from a deeper layer. I was able to palpate a small hole, and the next thing I know, my finger is in his pelvis. He had a lumbar hernia and I was seeing his retroperitoneal fat. Not a big deal to fix, but a good example of even the most simple-seeming case being more than you bargained for.