1). Sepsis paired with a thalamic sub-acute infarct

2) Sepsis deriving from an infected orthopedic surgical site

3) A chest wall abscess s/p pacemaker placement (it was really bad- one of the worst abscesses I have ever seen and it was going pretty deep into the chest wall)

4) Jet ski accident resulting in a splenic lac

5) Lumbar Chance fracture from a freak accident involving a ladder

6) 2 STEMIs

Here are the details of that GSW I was talking about on friday….

A middle aged man was at some sort of firing range and holstered his handgun in an improper fashion, which caused it to misfire. The bullet grazed over his right thigh, and then passed through the tip of his penis. 

Unfortunately, there wasn’t much to be done after the bleeding was controlled….

The ironic part of the story is the fact that the patient was a fire arm safety instructor and was teaching a class on gun safety… 

So about a month ago in the ER, on a really really slow day, we get a call from one of the Urgent Care physicians about a patient he was sending to the ER.

Apparently, this older gentleman came into the urgent care clinic complaining of Shortness of breath (SOB). He wasn’t obese but had a history of Hypertension and a random pneumothorax a year ago. (I bet you can see where this is going). His vitals were pretty stable when he got to the ER as well. His Oxygen saturation was a little low ( 95%, which is still the low side of normal), but that was about it.

Sure enough, this is what his xray looked like: 

I’m not sure if you can see it, but the left lung shows about a 30-40% pneumothorax. The way you can tell in this xray is there is a distinct absence of lung markings (I would suggest just comparing the difference between the left and right lung).

Anyway, a pneumothorax, also commonly called a collapsed lung, occurs when air escapes from the lung and fills the pleural cavity. This air puts pressure on the lung which prevents it from fully expanding. 

Some smaller pneumothoraxes can resolve on their own, but if they are big enough (as in this case) a chest tube needs to be put in fairly quickly to avoid any further complications.

So, the patient had an emergency chest put in and off he went off the the ICU.

Unfortunately, he spent several weeks in the ICU because his lung was not able to stay expanded every time his chest tube was removed and he kept getting a pneumothorax.

His risk factors I think would be (again this is just a personal opnion) his history of smoking, his previous pneumothorax, and the fact he was tall and thin. His old age probably didn’t help either. 

Among the many strange things I have seen, this has to be in the top 5.

Several months ago, an seemingly healthy 38 year old male came into the hospital complaining of intermittent bouts of shortness of breath that would only last for a few seconds of so for the past few weeks. He didn’t want to come into the emergency room, but when his wife found out about the shortness of breath, she made him come.

His exam was COMPLETELY normal. There was not a single abnormality in his physical exam. 

So,  the first thing we did was order a chest x-ray. That was normal too.

His labs were normal.

Finally, out of exasperation, the physician ordered a CT angiogram of the chest.

This is something similar to what we saw:

What that arrow is pointing to is what’s called a pulmonary embolism, more specifically a saddle embolus. 

A pulmonary embolism is a blood clot that blocks arteries to your lungs. Pulmonary embolisms are serious business. If not caught in time, it can most definitely be a fatal occurrence.  

A saddle embolus is even more serious. It straddles the bifurcation of the main pulmonary artery, the vessel that takes deoxygenated blood from the heart to both lungs. These will promptly lead to death unless treated.

What’s abnormal about this case?

Everything

The patient had no risk factors at all. He had no family history of blood clots, or even heart disease for that matter. He wasn’t overweight, he didn’t smoke, he had absolutely no previous medical history except for a appendectomy when he was 12. He hadn’t even done any recent traveling or long distance driving. His shortness of breath was even abnormal as it should have much more severe and his oxygen saturation should have been lower than he 95% he was saturating. 

I seriously don’t know how this man was in such good condition after having a saddle embolus as large as it was.

Needless to say, he was promptly admitted to the ICU and treated with blood thinners.

This guy was literally sitting on the saddle of death.

Note: his D-dimer ( a blood test that can sometimes indicate a blood clot) was normal in the ER. However, once he was admitted to the ICU and had another set of labs done, his D-dimer was ridiculously high. Whether it was another weird thing about this case or a laboratory error, I’m not sure

So, I used to have this nickname at the ER when I first started working there. I was referred to as “The Black Cloud”, because everytime I came into work, there was some extremely critical patient who was on the verge of death.

So one day I walk into the ER, and as soon as I got near my “office” that is in the middle of the nurse’s station, I see the paramedics bring in a somewhat older woman into one of the trauma bays. Normally you can guess the severity of a patient’s condition based upon the way the paramedics handle themselves. The paramedics looked more worried than usual, which surprised me because this was a group of the more jaded EMS people. 

After the physician and I went into the room, we learned that she had been found by her husband after a syncopal like episode with no evidence of trauma. She was still unconscious upon presentation in the ED and appeared basically in a sleep like state. The abnormal thing about her was that she would occasionally twitch and was semi curled up with her hands pulled up to her chest. She didn’t have any deep tendon reflexes in her lower extremities and hardly, if at all, responded to painful stimuli.

All the ED staff, even myself, were sure it was a stroke. She had a lot of risk factors including being non-compliant with her HTN (hypertension) medication, she was a heavy smoker and drinker, and while we couldn’t confirm this she did have the typical appearance of a meth user (The area I work in has a high level of methamphetamine abuse).

Even though we were pretty sure it was a stroke, the patient’s head CT was still pretty remarkable.

It looked something like this:

I’m not a doctor (obviously),but as you can see, there is a large abnormality in the head CT. That large white area is a severe hemorrhagic stroke that resulted in a midline shift due to very high ICP (intracranial pressure). While this isn’t the patients CT scan (I’d rather not get a HIPPA violation nor do I have access to them outside of the hospital) this was the closest I could find.

Unfortunately, the hospital’s neurosurgeon had moved across the country a few weeks previous and we had to transfer the patient via helicopter to the nearest hospital with a neurosurgeon.

Out of all the strokes I have seen, this one was probably the worst.

Also, if I made any mistakes on any of my personal opinions on the CT scan (I won’t call it an interpretation since that would imply that I am a physician/trained to read CT scans) please do correct me.

A few weeks ago, the police brought in someone to the ER for an emergency detention. An emergency detention prohibits a patient from leaving the ER if they are  mentally unstable who needs to get mental health treatment. It’s much more complicated, but that’s not the point of the story.

Anyway, this patient was extremely aggressive and non-compliant and was generally a pain in the ass. She had a few extreme mental health problems and she was very non-compliant with her medicine as well.

So, when the clinical psychologist came to evaluate the patient to see if they could be accepted at the mental health center, the psychologist accidentally got locked in the room with the patient.

Normally, we keep psych patients in rooms that are locked and can only be unlocked by scanning your hospital ID badge next to the door. Somehow, the door got shut behind the psychologist (it’s supposed to always be open when healthcare staff are in the room), and her ID badge malfunctioned and she couldn’t open the door. The patient saw this as an opportunity to practice their boxing skills and promptly began to assault the psychologist. Security managed to open the door somehow and rescued the psychologist, but not before she had acquired several injuries to her face.

Luckily, there were no bones broken and nothing required stitches. The psychologist was still fairly bruised all over her face. 

Overall, it was a pretty interesting night.

About a month ago, a woman presented to the ER via ambulance for complaints of vaginal bleeding after having sex for the first time in over 8 months. At first, the physician and I were pretty amused by this complaint because neither of us had seen someone come in via ambulance for vaginal bleeding after sex.

As soon as we went in to examine her is when things started getting crazy. She wasn’t just bleeding, she was essentially hemorrhaging blood from her vagina. I’m not even exaggerating. There was so much blood that we couldn’t find where she was bleeding from.  

So, we call the OBGYN surgeon on call and we get no reply. We ended up paging him three other times without a response. During this time, the patient blood pressure was steadily dropping and we had to move her to a “trauma room” so we could get more room to work with her. We got some blood to give her, but before it could get there she started going into shock, becoming unresponsive and she tachycardic (she had a fast heart rate).

We were able to just keep her stabilized, 4 units of blood later, until the OBGYN surgeon showed up and whisked her off to surgery.

There are two really crazy things that happened

 1) The patient ended up having a 4 inch laceration to her vagina. I don’t even want to know what she was doing that caused a laceration that big.

2) Why did the OBGYN take so long to show up? Because while he was watching tv with his family, his daughter took his iPhone and decided to play angry birds on it and turned off the ringer on his phone.

Angry birds can kill.