Motor Vehicle Accident and Chest Pain

A 50-year old man with no known medical history (“I don’t see doctors. I don’t like doctors.”) presents to the ED because he crashed his car into a pole after driving after a “wintry mix” weather event (#blizzard2015). There was no loss of consciousness. Airbags deployed. The car sustained damage to the bumpers and oneRead more

Small Bowel Obstruction Likelihood Ratios.

A 78-year old man presents with abdominal pain and decreased oral intake. His vitals are normal but he looks uncomfortable. After you introduce yourself, you palpate his abdomen which is diffusely tender. Your immediate gestalt is “Small Bowel Obstruction” but you’re not sure why. Frankly, you think, “I can do better than gestalt.” Can you?Read more

Ignoring Hiccups Lasting >48 Hours is a Bad Idea. Here’s Why and What to Do…

Chief complaint: Hiccups (i.e. “singultus”). Timing: 3 days. Diagnosis: Persistent hiccups. Etiology: Unknown. Who cares? You care. Why? Because persistent hiccups (>48 hours) and intractable hiccups (>1 month!) is likely indicative of an underlying illness that needs work-up/diagnosis. 1. What is the difference between a “bout,” “persistent,” and “intractable” hiccups? 2. What’s an ED-ready trickRead more

6 Month Old Wheezer. Trial of Saline and Albuterol Nebs, Right?!

PEM fellow Dr. Michelle Vazquez presents a case of: A 6 month old boy comes to the ED with an elevated respiratory rate and lots of wheezing on exam. He had a tactile fever at home and in the ED his temperature is measured at 100.4F. His oxygen saturation is 90% on room air. ThereRead more

How Many Chest X-rays Would It Take….

A young woman presents to the Emergency Department with chest pain of sudden onset while blowing up a balloon at her kid’s birthday party. Vitals are normal but due to slightly decreased breath sounds on the left, you are concerned for pneumothorax. ECG is normal. No other complaints. You order a chest x-ray but theRead more

Predicting and Dealing with Difficult Peripheral Iv Access.

Nurse: Doctor, this patient is a tough stick. I tried 3 times and I got nothing. Can you help? Doctor: Sure! I’ll grab the linear ultrasound vessel finder and get that line in for you, thereby potentially saving this non-critically ill patient from an unnecessary central venous catheter (free pearl #1). Nurse: Ok! Do youRead more

Wet Read on Lateral Knee Film

Your 14 year old male patient fails the Ottawa Knee or Pittburgh Knee clinical decision tool after gettting whacked in the knee with some object of some kind or another. He’s tender near the tibial tuberosity and he refuses to extend his leg. You can’t tell whether this is pain limited or whether something else is goingRead more

Stroke Alert! Wait, What Does Acep Want Me to Do?

A 75-year old man comes to your Emergency Department with an acute onset of left sided weakness and a facial droop. His NIH Stroke scale is 15. A stroke alert is called and the stroke fellow and her team race-walks to the Emergency Department. A vigorous discussion of whether to give tPA (alteplase) as aRead more

He Keeps Repeating Himself, Himself, Himself….

A 60 year-old male patient with a history of hypertension is BIBEMS with his spouse two hours of sudden onset memory loss. She noticed he began asking her if she wanted coffee every 3 or 4 minutes, apparently not remembering he had already asked.  He knows his name, where he is, and the date. He correctlyRead more

Femoral Nerve Blocks for Hip Fractures

by @benazan I have been surprised by the lack of pain in some patient with hip fracture. Most I have seen seem to be fine as long as the remain perfectly still. However, how often does that happen? After x-rays, multiple attending and resident exams patient will hate you if their pain is not wellRead more