What is the most interesting case you've seen in the ER?

brainkandy87 · Feb 17, 2012

My nursing career has been far too short to top any of the crazy stuff here, but so far, this is my most interesting pt:

Forty-two year old female comes in with CP radiating to her back 8/10, with no prior cardiac history, or any history really. BP in the 170's. Give her three SL nitro, no pain relief. Morphine helps resolve the pain to a 4/10. Get her to the floor, she's feeling much better. Pain about 3/10, looks good, feels good, sounds good. Doesn't even want any pain medicine. This was about 6 am. At about 11 am, her CP starts back up, but not severe. The doc sends her down for a CTA w/ contrast. She gets rolled back up about noon and the MD gets her results back... she's dissected from her right carotid to her right femoral. Right about this time she gets back from CT, her pressure drops from 150's to 80's. Life flight her out and she ends up in surgery for eight hours. Somehow, she survived. Absolute miracle.

sapphire18 · Feb 18, 2012

dissected from her right carotid to her right femoral. Right about this time she gets back from CT, her pressure drops from 150's to 80's. Life flight her out and she ends up in surgery for eight hours. Somehow, she survived. Absolute miracle.

:eek: WOW. She is so lucky to have survived!!!

chansen · Feb 18, 2012

20' and above tends to be the height at which falls get ugly. Had a construction worker fall 60' off a roof, landing feet first on the hood of a car. L1 and up on the CT were pristine. Some minor damage to L2-L4 (never found out if there was cord involvement), no pelvic damage, and some lower limb breaks. Medical hx received in report? Past trauma history of pedestrian vs. train and pedestrian vs. car. I honestly wondered if he fell from the building or jumped. . .

EDRN10 · Feb 21, 2012

Had a good one last wk. Pt came from nsg home hx of dementia complaining of being more confused and low b/p. Pt initial b/p was 70/50. Bolus-ed the pt with no rise in pressure. Pt placed on dopamine drip and pressure slowly came up. In the meantime, ekg, labs, foley, x-ray, and head CT were all performed. Labs started coming back and everything was abnormal. EKG was normal but triponin was elevated. Renal function was crap. CT showed a bleed. On top of it all pt had a UTI. So NSTEMI, Acute Renal Failure, CVA and UTI all occurring at once. One of the sickest patients I've seen in a while for sure.

brainkandy87 · Feb 22, 2012

Had a good one last wk. Pt came from nsg home hx of dementia complaining of being more confused and low b/p. Pt initial b/p was 70/50. Bolus-ed the pt with no rise in pressure. Pt placed on dopamine drip and pressure slowly came up. In the meantime, ekg, labs, foley, x-ray, and head CT were all performed. Labs started coming back and everything was abnormal. EKG was normal but triponin was elevated. Renal function was crap. CT showed a bleed. On top of it all pt had a UTI. So NSTEMI, Acute Renal Failure, CVA and UTI all occurring at once. One of the sickest patients I've seen in a while for sure.

Any idea if it was r/t poor care at the nsg home?

EDRN10 · Feb 22, 2012

I didnt suspect it at the time and still don't considering his symptoms at the time. I cannot remember how long the patient had the worsening confusion, but had it been more than 24hrs I'd would suspect poor care or lack of attention to the pt at the nsg home.

dirtyhippiegirl, BSN, RN · Feb 22, 2012

We always go down to assess major burn patients.

My last major burn was a "stable" pt who was walky/talky at the scene and in the ambulance.

He ended up a 70%+ third-degree'r with circumfential burns to the neck, arms, and chest.

DixieRedHead, ASN, RN · Feb 22, 2012

I didnt suspect it at the time and still don't considering his symptoms at the time. I cannot remember how long the patient had the worsening confusion, but had it been more than 24hrs I'd would suspect poor care or lack of attention to the pt at the nsg home.

Why would you think that? Had the increase in confusion been addressed that the facility? U/A? Vital signs, labs?

Twenty four hours is not a long time in the nursing home setting.

It seems no matter what goes wrong with a nursing home resident, it's always "poor care".

Heaven help us.

morte, LPN, LVN · Feb 22, 2012

I know what you mean, gee, it couldn't just be advancing of underlying disease?

Why would you think that? Had the increase in confusion been addressed that the facility? U/A? Vital signs, labs?
Twenty four hours is not a long time in the nursing home setting.
It seems no matter what goes wrong with a nursing home resident, it's always "poor care".
Heaven help us.

EDRN10 · Feb 22, 2012

As I stated previously I did not suspect poor care in this instance from the nsg home. In this particular case the nursing home if i remember correctly had not addressed the confusion as the symptoms onset had been fairly recent (ie less than 24hrs) and they felt it was warranted to have the pt sent to the ED.

While I agree with you that 24hrs in a nsg home setting is a short amount of time, however in this particular case had the symptoms been going on for more than 24hrs I most certainly would has suspected poor care. If a patient had unstable vital signs and stroke like symptoms for greater than 24hrs wouldn't you?

resumecpr · Feb 24, 2012

Thanks for ruining a really fun topic EDRN10. I once had a 20 something female come in with a GSW to the buttocks. Upon X-ray, learned that she was actually a he because of the member taped to his inner thigh!!! The patient had female ID and everything! Thank goodness we didn't have to give any emergency release blood!

EDRN10 · Mar 9, 2012

Thanks for ruining a really fun topic EDRN10.!

Sorry was not intentional just trying to defend my position.

Now to move on I had an awesome pt last week. Pt is in their 70's but appears to be a very healthy and lean individual, comes in by EMS with complaints of dizziness and back pain. Pt's skin color is extremely pale. Symptoms started approx 1hr prior to arrival. EMS reports pts b/p is 80s/50s and they started an IV and was giving fluid bolus. Began to triage pt and placed them on automatic b/p cuff. Cuff wont read. So I attempt a manual and all I hear is the systolic thump and nothing else it is 78. Right now I'm thinking something is not right. I run out and grab an EKG even before triage is finished. Run the EKG shows NSR. Take the EKG to the doc and tell them to please come see this pt ASAP. I go back in the room, lay the pt flat and place auto b/p cuff back on pt and it finally reads 105/56. Doc comes in the room and begin to assess the pt and as she does feels the pt's abdomen and gets a strange look on her face and tells me to get this pt to CT now. Doc has the secretary paging CT to come get the pt as I start as second IV and draw labs. I grabbed the biggest IV in our IV cart because of the frantic look on the docs face which is a 14g and pt did not even flinch. CT tech arrives and I go with the pt to CT as the doc wants them on telemetry. We do a CT abdomen/pelvis on the pt with contrast and as the scan is running I hear the CT tech who is very experienced state "oh ****." Pt has a ruptured AAA on the scan. I tell the CT tech to make sure the radiologist reads this scan right now and I call the ED MD before leaving CT and tell her that the CT tech thinks the pt has a ruptured AAA. We get the pt back in the ED and by that time the ed doc has already paged the vascular surgeon and they are on their way down. By this time first set of labs are coming back and pt's hgb is 10.0 and b/p is starting to drop so I place pt in trendelenburg. Vascular MD gets to the ED and tells the pt that he has a ruptured AAA and that he is going to surgery. We pressure bag in 1L NS and give the pt 2 units of blood as the vascular MD inserts a central line. Pt's b/p is still dropping is now 60s/40s but pt is still alert and talking to us. Vascular MD finishes up the line and we rush the pt to the OR. As soon as we get there repeat labs are drawn and pt and pts b/p had dropped even more and is now 52/30. I stay with the pt until the vascular MD opens them up and was able to see the massive amount of blood pour out of the pt's abdomen. As I walk out I hear one of them say that the pt's repeat hgb was 7.5 when they first arrived in the OR after the 2 units of blood given in the ED. Pt miraculously makes it through surgery I find out later that day. 6 days later I see the vascular surgeon in the ED and he tells me he just d/c'ed the pt that morning and he had been up walking around without assistance for the past 2 days. Also turns out pt works as a delivery driver and was out driving a route when EMS picked him up. One of the people at his regular stops noticed the pt stumbling as his walked and his skin color off and called EMS for the pt. This was one lucky pt.