Have you ever accidentally flicked a drop of blood while disposing a straight guidewire into a rectangular sharps bin? The bins just don’t quite fit the wire easily. That’s just an occupational exposure just waiting to happen to yourself.
The electrocardiogram can pick up all sorts of electrolyte abnormalities. The most common abnormalities revolve around high and low levels of potassium and calcium. Magnesium derangements typically have nonspecific findings. How do you keep things straight? To make things more complicated, multiple electrolyte derangements can occur at the same time, making ECG interpretation challenging.
Having you had trouble seeing a pediatric patient’s tympanic membrane because of impacted cerumen? Scared from that last time you used a rigid curette and caused bleeding in the ear canal? The parents are worried that you hit the brain…
In U.S. academic emergency departments, decisions to accept patients is typically easy, because you have ready access to on-call physicians. When in doubt, accept transfer patients and sort things out later.
As a general rule, the liability falls upon the transferring site and physician. So be sure that your patient won’t decompensate in the ambulance during transfer. So, don’t transfer that CP patient who is getting ruled-out for an MI or ACS no matter how good they look. Patients need to be stable for transfer.
Anyone with pearls to share?
Thanks to @EMurgentologist for tweeting me the idea!
Go to ALiEM (PV) Cards for more resources.
Further Reading:
A 41 y/o m presents to your ED after an occupational exposure to 30% hydrofluoric acid (HF). The thumb and index finger of his right hand were affected. Upon visual examination, the site of exposure looks relatively benign but the patient is complaining of extreme pain. Beyond giving opioids, what can you do?
Industrial accidents sometimes involve hot coal tar stuck to a patient’s skin. Coal tar is notoriously challenging to remove once it has cooled and adhered to the skin. The tradition teaching is to apply large quantities of petroleum jelly to the black tar, let it sit for at least 60 minutes, and then diligently try to rub away the tar. Repeat as needed. What if you don’t have any petroleum jelly or petroleum-based products?
A 40-year-old man presents with significant agitation and severe respiratory distress from a COPD exacerbation. His oxygen saturation is 75% on room air, and he has diffuse, tight wheezes on exam. You prepare to intubate the patient using a rapid sequence induction protocol: etomidate, succinylcholine, 8-0 endotracheal tube.
Or do you?
This pocket card discusses the delayed sequence intubation (DSI) protocol made famous by Dr. Scott Weingart and Dr. Rich Levitan.1 Thanks to Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob (Intermountain Medical Center in Utah) for designing this helpful card. Rob has even implemented a DSI protocol in his ED.
The card breaks down the reasoning and steps behind DSI. Anecdotally, ketamine has often calmed patients down enough during the preoxygenation phase to enhance oxygenation/ventilation so much so that intubation is not required.
Go to ALiEM (PV) Cards for more resources.