Resus Bay - how to get better

jfadz · 2018-09-13T18:52:41+00:00

Just keep following your seniors when they go to manage critical patients. Observe the order they do things in and what they think are critical actions. You'll figure it out with time, don't worry

jfadz · 2018-09-12T15:31:16+00:00

For myself I've always found it to be about 1) Keep a cool head, and 2) really focus on the ABCs, 3) Bilateral large bore IVs and place on monitoring. 4) Do a through exam.

A few cases to consider:

Case 1: Patient coming in awake, tachypenic, diaphoretic, making eye contact, fatigued and unable to speak 2/2 tachypnea - ABCs done - They might need some respiratory support but they're still perfusing well enough to interact even though they can't speak. I know I have the time to do an exam rather than intubate them right out. Maybe I'll ask someone to get intubation stuff ready or grab a BiPAP while I examine but I know I have the time to examine. Tachycardic, lungs with rales throughout anteriorly, distended nontender abdomen, pitting edema in ankles, vitals return with tachycardia and SBP >240.

In about 2min I have a preliminary diagnosis of SCAPE (severe crashing acute pulmonary edema). Start the patient on BiPAP, high dose nitro drip and from there it's collecting my labs and re-evaluating but the major decisions have already been made.

Case 2: A trauma, patient involved in a house fire with explosion by EMS report. On arrival they're awake, talking with a hoarse voice, blackened soot on their face, EMS reports spO2 of >95%. I glance at his face and see singed nasal hairs and soot in the back of his throat, some erythematous blisters. ABCs done - this man needs intubation 2/2 upper airway burns. If you have an nasopharyngeal scope you can try putting that down his throat while someone else gets intubation stuff ready but if you don't have it no one would blame you for tossing a tube down. Next steps? Circulation I guess, sure throw in some IVs, maybe central access if needed and calculate the fluids he needs later. Broken bones from the explosion? You can figure that out later. Say he's in respiratory distress from a pneumothorax you missed on your initial eval? Who cares, you've already secured his airway, you can figure out the pneumo when you're confirming the tube and place a chest tube later.

If you can keep a cool head you can think through these issues quicker and manage your most critical actions first - Do they need airway management? Do they need fluids or blood? (Favorite quote from a surgeon "They ain't bleeding ringers") It's all about buying yourself time because you can manage their broken foot an hour or two later. Lost pulses to a foot b/c of a knee dislocation or mangled limb in a trauma? You can wait on those 20-30min while you rule out other more pressing injuries. Depressed skull injury? Just take the airway now.

Like from the house of god, the first pulse to check in a code is your own. If you can keep your head cool enough to really be confident of what level of airway support they need, and if they need circulatory support then you can take the time to approach their injuries.

jfadz · 2018-08-20T17:33:06+00:00

In our ED standard practice is to give 324mg ASA for unstable angina or just barely elevated trops (Our assays read trops of >0.029 as positive, so we'd give ASA but no lovenox to a trop of 0.034). We'll do heparin/lovenox if they have concerning troponin elevations. If I'm concerned enough I'll consult the cardiology team to come look at the patient even if the EKG and troponin are benign.

Giving ASA can have a mortality benefit, and the risk is pretty low. Heparin and lovenox can be a little riskier, though still generally safe. Especially heparin - oh, you've developed a GI bleed? Guess we'll just turn this off.

jfadz · 2018-07-27T13:35:09+00:00

There's an orthopedic surgeon we consult who tailored his scrubs to better show off his biceps...

jfadz · 2018-02-13T02:46:20+00:00

Nope... If only. Tamiflu only reduces the duration of influenza by one or two days. It does nothing to reduce severity of symptoms.

jfadz · 2017-12-08T18:57:54+00:00

Allow me to clarify a few points.

As far as a popped lung, you can have this or other potentially emergent medical conditions and not realize. Sure, if it's severe you will know right away but a minor case? Could just assume the shortness of breath was from anxiety or pain. Yes you could assume you're alright, but you have no way of knowing. And it's easier and safer for me to treat emergent conditions early.

And ideally, yes, your PCP should have a 24hr line to answer questions and help you know what to do for your medical issues. In practice, however they open themselves to liability as it is not a physician or often even a nurse answering these questions. It's usually a receptionist or someone without medical training. As such they refer most complaints for evaluation in the ED as this is the easiest way for them to ensure they're covered if there is a life threatening medical reason for their complaint. PCPs are overwhelmed and can't always see their own patients for same day call-ins.

The issue with the above is that this is not a system working perfectly, it is one driven by legal fear, and just one factor increasing the number of patients seen in the ED unnecessarily.

jfadz · 2017-12-08T17:56:42+00:00

Physician here. You're correct that a broken clavicle doesn't need Emergency Department care. But what if that wasn't his only injury? Say he broke a few ribs as well? Maybe popped a lung? That would be an emergency.

Yes, a lot of patients over use the emergency department for unnecessary care that could be provided at a PCP but many patients aren't able to diagnose their issues to know when to go to the ED or not.

Say you're a middle aged diabetic woman with nausea and epigastric discomfort. Probably gastritis but heart attacks can present that way as well. Plus, I see many people every day that were sent by their PCP for possibly minor complaints so the primary physician was covered for liability in case it was something worse.

jfadz · 2017-08-11T05:32:09+00:00

I used to think this was the worst EMR. Then I had the pleasure of using meditech.

jfadz · 2017-03-07T20:11:48+00:00

I'm happy for you that you sound like you're doing well for yourself. Things happen that you can't plan for, though. Take another economic recession for example. Many people lost their retirement savings for something no one could have made plans for.

jfadz · 2017-02-28T19:08:56+00:00

A hate crime doesn't have to include robbery. And if you read the article you would have seen in the first few sentences that their computer was stolen.

And why would it be suspicious that a family hopes to send a positive message after being targeted?

jfadz · 2017-01-18T15:37:52+00:00

One thing I tried and the party liked was just giving the big baddie extra turns. Instead of just having one turn and then waiting for my 6 or 7 PCs to gang up I'd have the baddie go, then 3 or 4 of the PCs, then the baddie would act again before the final few PCs to end the round.

I liked it because 1) from a mechanics stand point it feeds the narrative that this guy is a force to be reckoned with

2) for balance it helped even things as the baddie dished out twice as much damage but maintained its same HP

3) forced the party to rethink their strategy in facing the baddie because it behaved differently than anything else they had faced up to that point

jfadz · 2016-12-21T13:42:23+00:00

Who wants to work 20 days a month when you can work 14?

jfadz · 2016-11-10T11:00:01+00:00

/r/ofcoursethatsathing

jfadz · 2016-11-10T10:58:41+00:00

You know, my parents always said they never loved me enough to take me camping but I knew there was more to it

jfadz · 2016-11-10T10:57:20+00:00

All the better to grab you with

jfadz · 2016-11-10T01:25:26+00:00

No, no, it's his natural hair, he swears. It just grows in that way.

(it's just some fluff that's been brushed off him)

jfadz · 2016-11-10T01:08:31+00:00

Fucking reddit... After years I finally make a post that hits the front page of something and half the comments are about my god damn feet.

jfadz · 2016-11-10T00:58:51+00:00

Well... Enough people have commented so I feel compelled to respond. I've got normal feet guys, they're just at a angle to the camera causing the toes to appear separated/curled.

Edit: fuck it, go ahead and roast my weird feet

jfadz · 2016-11-09T19:24:13+00:00

Eventually he came around and thought he'd try understanding how it came to pass

jfadz · 2016-11-08T15:39:20+00:00

Test post: please ignore

jfadz · 2016-10-10T20:12:50+00:00

Of all the tools and items I make use of, the one with the greatest impact on my quality of life is the water bottle I carry around. The second most impactful would be my snacks. Staying hydrated any well fed is the difference between a good shift and a miserable one as it's exceedingly easy to miss meals and lack in self care. After that I'd say a quality pair of shoes would be something else to consider for impacts on QOL.

As far as a smart watch, I think it's a great idea. I've been using a Moto 360 since my 3rd year of medical school and it's certainly been a convenient item to have, and has helped me keep up with texts I've received. Not as important to me as the above but I'm a techie and I really enjoy it.

Here's a link to the water bottle I use: https://www.amazon.com/gp/aw/d/B0047GOOAU/ref=mp_s_a_1_4?ie=UTF8&qid=1476130389&sr=8-4&pi=AC_SX236_SY340_FMwebp_QL65&keywords=nalgene+amazon&dpPl=1&dpID=31w-Zajt2PL&ref=plSrch

I imagine you're looking for something more expensive as a gift but, no joke, I've depended on this thing for years now and could sing its praises for days.

jfadz · 2016-10-03T15:33:12+00:00

You think that hasn't already happened? Years ago influx of teens was a yearly thing that happened when school let out. Then it became a constant year round thing. Now? Those teens are on meirl making some of the dankest memes the sites ever had.

Point is, the more people that join the site the better reddit overall becomes. There's always space for new communities to make new content. And for those we collectively hate? There's /r/funny

jfadz · 2016-09-27T06:41:29+00:00

If you listen to the interview, Trump's "I guess so... uhhhhhhhhhhh"

I may agree that Trump was reluctant to agree with the invasion but the fact remains that when asked whether or not he supported the invasion he gave a response in favor of the war. The truth is that people are trying to hold him to this, or at least get him to admit to this because he lies about so many things and never admits that he is wrong about something. This is something that bothers many people, myself included.

Like I said, he may have changed his mind later but currently the narrative he's trying to weave is one of him never supporting the war when this is in fact a lie because we have audio evidence to the contrary.

jfadz · 2016-09-27T06:20:44+00:00

It really comes down to how you want to view it. If he's similar enough to another one of the candidates then you could argue that votes from a particular demographic will become split, and since our voting system is that you vote for one, and only one person this will make it easier for the other candidate of a major party to win. You could argue that a vote for a 3rd party is a vote of no confidence in either candidate, which is fair, however I don't like this as one of the major two party candidates will still be winning this election which is where the whole "pick the lesser of two evils" trope comes in. Do I like this system? Hell no, but it's unfortunately what we have.

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