The labs have all come back on a 38-year-old female who you suspected
had pyelonephritis. She had presented with 24 hours of flank pain and
fever but no vomiting, abdominal pain or dysuria. Her last menstrual
period was 2 weeks ago and she denies any possibility of pregnancy.
“Seeing is believing” you mutter as you shake your head in amazement.
You can’t believe your good luck tonight. You ordered a CT scan on a
patient with pleuritic right-sided chest pain looking for a pulmonary
embolism, and instead you found her leaking thoracic aortic aneurysm.
And then, your senior resident performed a bedside abdominal ultrasound
on a 40-year-old male with chronic back pain and discovered a 5 cm
abdominal aortic aneurysm.
A 21-year-old male bicyclist is brought to the ED, fully immobilized by
EMS, after being struck by a car at moderate speed. The patient was
found on the ground a few feet from the road with an obvious deformity
to his right lower extremity (RLE).
Your last patient of the evening is a 42-year-old veterinarian who
recently returned from a trip to Mexico where he injured the dorsum of
his right hand on a cactus spine. He states that he was able to remove
the entire spine and the site subsequently became infected.
“I can’t believe I missed that airway!” she says. “I haven’t had that
happen in years!” You reiterate how difficult the airway was, and you
compliment her on changing her approach between attempts. “You know, Richard Branson once said, ‘Opportunities are like buses…there’s always another one coming’
You breathe a small sigh of relief when your senior resident begins
presenting his next case to you. The patient is a 17-year-old G1P0 who
found out she was pregnant via a home pregnancy test last month. She presents to the ED
at 6 AM because she has been vomiting all night and can’t sleep.
You are about to start your shift after a somewhat lengthy department
meeting where one of the main topics discussed was utilization review
with a special emphasis on cutting down the number of unnecessary
advanced imaging studies. The physician champion for cutting down on
unnecessary imaging had a lot of valid points.
“We have 6 traumas coming our way, Doc. ETA is 15 minutes. We’ve
mobilized backup. The ultrasound machines are in the rooms, and the
residents are gowned and ready to roll. Is there anything else you need
help preparing?” You give your favorite charge nurse a thankful smile
and start preparing yourself for the organized chaos that is about to
Your next ED patient is a 47 year old male with a history of diabetes, hypertension, coronary arterial disease and CHF who presents with 2 weeks of gradually worsening leg swelling, abdominal swelling, and trouble sleeping due to orthopnea. He states that he has had the leg swelling and trouble breathing in the past from his CHF, but he has never had a “jelly belly” before. He denies any change in his medications or dietary indiscretion.
You find yourself working in a small - I’m talking very small - rural hospital in South America for your summer “break”. The only imaging modalities available are plain X-ray and a small portable ultrasound machine your group-of-four brought along for the trip. There is no MRI, no CT, and no formal ultrasonography. It might not help much if there were any of these however, as the are no radiologists, or any other specialists for that matter, in the hospital. It’s just you and your three friends: a general surgeon, an OB/GYN, and an orthopedist. The two local doctors who are general practitioners have taken the week off. There is, however, a much larger hospital in the nearest city, but it is over a day’s journey away.