ERDoc

I will try to address everything that has been suggested. MRI, not going to happen in the ER, "No paralysis, no analysis." Blood cultures will take 5 days (what is the indication?). CT neck and chest, expensive tests. Please justify these $1000 tests on someone with a headache. ABG, why do such a painful test on someone with goods sats and no c/o resp distress? TSH will not come back in a reasonable time. FSH, not going to happen. ER docs are simple folks and this is too complex for them to understand (I wouldn't know what to do with it if I did order one) and will probably take a while to get back. UA good thought, but negative (I'll even tell you that the HCG is neg). CBC and chem 10 wnl. LFTs, although not indicated, are also normal. Pituitary and adrenal testing not practical in the ER. Cardiac enzymes (again, not indicated) are wnl. From an ER standpoint, the only workup this pt warrants is a head CT, and you could make an arguement for CBC, chem, UA, HCG. Although I am will to argue otherwise. Obviously if you find something in those you may need a further workup.

Attention all passengers, the captain has abandoned ship. This is no way to stop the sinking of this one. To try to answer all questions in one reply: No snake bites. House built 3 years ago, electric stove. It never seems to wake her up, but is present when she wakes up. It goes away after she has been headache up for a few hours. The only nightmares she has is the ones of becksdad (man I feel bad for beck, if only he knew what his dad was doing) in her leather. No palpitations, memory seems intact. VS are pretty much the same as they were. So to recap this is a middle-aged woamn with h/o htn dx one year ago who seemed to be well controlled on atenolol who is c/o a right sided headache when she wakes up every morning for the past week. No other headache history. Pain is nonradiating and is usually relieved after she has been up for a few hours. She has some nauseousness, but no vomiting or visual distrubances. The is no neuro deficit on exam and the exam is otherwise unremarkable. You arrive at the ER and the doc says he's too busy for someone that sounds like something so benign. He tells you to write the orders and he'll cosign them. What do you want to order?

No garage, driveway only. Really good thought though. Line is in. You start to take the pt out to the ambulance with one of the police officers. Suddenly over the officers radio you hear the one inside call for backup. Apparently he needs help getting becksdad out of the closet (in more ways than one) since becksdad has now found the pts leather collection and has taken to trying the samples on.

TMI, please keep your disturbing fantacies to yourself.

Grips are 5/5 b/l, reflexes 2+ throughout. No leg pains, drowsiness, dreams or dizziness. She has tried some Motrin with minimal relief. The pain is about the same. EKG NRS no blocks. Chest wnl "Now that you mention it, I do need to use the potty. Can you wait two minutes for me to go?" Otherwise no interesting facts about her urine.

She called today because it is a little worse today and she was watching a 20/20 special on SAH last night and got a little nervous. No meds contracts. She has been on the atenolol for about a year, when she was dx with the htn. Last time she was at her MDs her BP was 110/64 and this was 2 months ago. She states she is compliant with the meds.

Always on the right. No change with caffeine. At this point, becksdad sneaks off to the bedroom while his partner does the work. He is later found by PD snooping through her lingerie collection :shock:

PERRLA. No signs of trauma. No smell in the house or on the pt. No one else in the house at the time. Husband left for work a while ago.

I think I would like to meet some of the pts that you transport. O2 placed with no relief.

She replies, "Listen civil servant boy. I pay your salary. Do your job and take me to the hospital in your metal chariot."

No wierd odors. Denies any signifiacnt stress. She works at a bank as a teller. She woke up with this headache about 30 minutes before calling you. No photophobia, some nausea no vomiting. The pain does not radiate. She is adopted and doesn't know her family history. No tobacco or drugs.

Skin is warm and dry with good color. She states she has been having these headaches in the morning for the past week or two, on occasion they wake her up from sleep. They usually go away after she has been up for a while. No fever or neck pain. She states she had a can of Bud before going to sleep, otherwise has not had anything to drink since last Christmas. NKA. Last meal was about 7pm last night. BGL is 102. This is not the worst headache she has ever had, rates is about a 3-4.

153/88 66 RR14 100%RA Atenolol 25mg PO bid She's about 5'8", 135lbs, brown wavy hair down past her shoulders, sea foam green eyes, the perkiest... oh wait, I don't think that's what you are asking for. She looks pretty normal. As stated previously, no facial droop.

Recently dx with htn, on meds. States, "It's under control." Right sided. No droop.

It is 0630 and you are called to the house of a 45y/o female who was woken by a severe headache. Scene is safe, blah, blah, blah. She appologizes for calling but says that her husband just took the car and left for work. What do you want to know?

I have no problems with any field personel staying around and watching to see what happens, as long as they don't get in the way. If you are still around when it is over and have questions, feel free to ask. As for Asys's comment, yeah, watch out for the Badge-Bunnies. They'll go polish someone else's badge just as quickly as they polished yours, if you know what I mean.

As one of my attendings drilled into us during residency: When you have a pt with AMS the first three things that need to be done are finger stick, pulse ox and rectal temp. Can't tell you the number of times I have seen near misses because one of these was not checked (usually the rectal temp).

I agree that I would treat this as VT, but I have to disagree about the ERAD. There are a few other causes other than VT (albeit not many). You can also see it in hyperkalemia, COPD and with a pacemaker.

Don't wait for the 5th drunk, bring chocolate STAT! You will make the nurses very happy right off the bat. If you go to a hospital with residents, bring pizza, chinese food or heros (that are always looking for a free handout). That should get you off to a good start. Professional appearence helps (a lot). You aren't going to be seen as a professional if you don't look like one. Be confident and competent, but don't ever step your bounds or try to act like you know more than you really do. Most of us that work in an ER have been involved in EMS in some way and know what your limits are. We can smell lying from the parking lot. Don't question us, especially in front of a patient (unless it is something that is going to kill the pt in the next 30 seconds). Ask questions (if it is not too busy). I'm always glad to answer any question, "Hey doc, what do you make of this on the EKG?" But don't do it when I am up to my knees in melena from a hypotensive GI bleeder or have 2 codes going at the same time. Even if you know the answer to the question, don't be afraid to ask it just to break the ice. We doctors are very type A/narcisistic and love to get the chance to share our knowledge with anyone who wants listen (and sometimes those who don't). It is always worth points to help out the nurses when they are trying to get a pt settled in, but don't get in the way. These are just a few thoughts. Hope they help.

Just figured I'd add my 0.02(USD). It doesn't sound to me like you did anything wrong. This guy doesn't necessarily need a stroke center and he IS NOT a candidate for thrombolytics. As long as he ends up at a hospital with a CT there is not much else to do.

I think I have found my future wife. I've got dibs when she's 18!

One word can sum that video up: Idiots. People that do that need to get a real life. It's totally fake. Who is going to sit there and let someone smash flourscent bulbs over their bare back.? I don't care how tired you are. Basic instinct is going to kick in and you're going to get your arse up. As for the spurting blood, it seems convenient that the bleeding is coming from a spot right next to his elbow pad (where a supple of fake blood could conveniently be hidden). I can't say for sure, but if I had to put my money on it I would place it on a fake bleed.

MD=Massive Debt

Why do you think I spent so much time and money on medical school. I have mastered the art of cut and paste!!! By the way, anyone know what MD REALLY stands for?

I would be careful with active rewarming if you don't have an IV established. Yes, you can cause a bad case of vasodilation, which you can compensate for with fluids. Pressors would be good too if you have them. You do need to be careful with the fluids. If the pt is too hyponatremic you can cause CPM (I'll let you Google it if you don't know what it is).