You have a patient with an anion gap of 30 and bicarbonate of 10 mEq/L. You also determine on VBG that the patient’s pCO2 is 25 mmHg. What trick of the trade can you use to quickly determine whether this low pCO2 is an appropriate compensation of the primary metabolic acidosis? Dr. Jeremy Faust and Dr. Corey Slovis explains the quick “Rule of 15”.
A 9 year-old patient presents with a headache and fever after swimming, along with subjective neck stiffness. Meningitis was of concern especially because the serum WBC count was 25,000 and other inflammatory markers were elevated. Because the patient’s mother had an unpleasant experience with an epidural during childbirth, she adamantly opposed the idea of a lumbar puncture (LP).
Money doesn’t grow on trees, and neither do simulation manikins, not even on simulated trees. So what to do when you are looking for a cheaper, more easily replicated solution to simulation dilemmas? This is the perfect time to fall back on skills developed in childhood during Arts & Crafts hour. Consider paper mache! So easy to use, and guaranteed to bring back childhood memories!
Simulations are routine now in medical training. But sometimes routine can start to get boring! All learners now know, especially for high fidelity simulations, to prepare for the unexpected. The stable patient will inevitably crash, maybe when your back is turned; the confederate in the room may or may not be a friend or a foe, you may never know! But these twists have become so integral to the simulation case that most learners know how to deal with it, or at the least know to anticipate it. But here is an idea for adding a new challenge to a stale simulation case. Blindfold the leader!
A 500-pound morbidly obese male presents to your ED complaining of mild shortness of breath and palpitations. A quick ECG shows SVT with a rate of 160 bpm. His BP is in the 130s systolic, and he is otherwise stable. You know you have a bit of time. Meanwhile, the nurses begin searching for veins to start an IV…
A fiberoptic nasopharyngoscope is a handy tool to check patients for suspected foreign bodies (e.g. fishbone stuck in throat) or laryngeal edema. Depending on the diameter of your fiberoptic cable, it may be fairly uncomfortable for the patient despite generous viscous lidocaine instillation through the nares and nebulized lidocaine. Alternatively or additionally, you can make your own lidocaine-oxymetazoline nasal atomizer which works well.
What if the patient is STILL not tolerating the procedure well?
A patient presents with an anterior shoulder dislocation on x-ray. Your ED just received 5 new patients via ambulance and you are trying to prioritize your patients as they come in the door. What can you do for your patient with the shoulder dislocation in the meantime? (more…)