A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

The Night Shift, episode 6

This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

Talking Points

Talking Points

Link your vision to action

As an ED leader, you must not only have a vision and plan, but you must communicate that vision effectively…

Toxic Liquid Nicotine

Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

Highly unregulated, the sale of toxic nicotine concoctions for e-cigarette refills pose a serious threat to children.

All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

Barriers to Admission

Barriers to Admission

Wait time is lost time

Nearly half the time a patient spends in ED is spent waiting for a bed.

The Storm Episode!

The Storm Episode!

Episode 5 of NBC's "The Night Shift"

It’s time for the passion that’s been building up between the two lead ED doctors for … the past few…

Strapped for Care

Strapped for Care

The changing definition of prudence

High deductible healthcare plans are altering EMTALA’s “prudent layperson standard” as patients triage themselves away from the ED based on…

That Ain't My ED

That Ain't My ED

"The Night Shift" is an embarrassment to us all

Having now watched the first two episodes, the only thing I can honestly do is beat my head into a…

Grace Under Fire

Grace Under Fire

EPM Reviews NBC's The Night Shift, Episode 4

This is the 4th episode of “The Night Shift” that I’ve endured watched. If you’ve seen it and you work in an…

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“Is it a full moon out?” your charge nurse asks as she takes the 5th EMS patch in the last hour. “We have two more traumas en route, and there are 4 patients that need to be seen at the door by our triage doc. Our beds are full and the hallways are getting awfully crowded…” You are all too familiar with the expectant look she just used to punctuate her statement, and you know that it is imperative for you and your team to start opening beds immediately. “All hail the full moon!” you chant as you walk briskly over to your ED team that night.

As you rally your department to start trouble-shooting patient dispositions, your senior resident approaches you with three cases he states are “ready to go”. The first two are a husband and wife who were in a low speed motor vehicle collision the day before. They came into today to get “checked out” and they both checked out just fine. The x-rays ordered through triage were completely normal, and the happy couple looks eager to be discharged. You help answer some of their lingering questions while your resident finishes up the discharge paperwork for the third patient he has for you.

After passing along a few teaching pearls, you tell your resident you are ready to hear about his next patient. His 3rd case is a 21 year-old female who came into the ED today for vaginal spotting, nausea, and mild abdominal cramping. She had normal vital signs and a benign physical exam. The labs he sent were normal except for a serum hCG of 91,000 mIU/mL. Her blood type is O+ and her wet prep looked normal. He got her abdominal cramping under control with PO Tylenol and she was able to drink plenty of fluid for her bedside ultrasound in the ED.

“I found her IUP without any problems and she’s about 9 3/7 weeks along.” he states as he pulls up her ultrasound images and videos for you to review. “The fetal heart rate measured at 167 bpm and her adnexae look great. She has no free fluid and the ultrasound went really smoothly.” He has her scheduled for an appointment with your OB clinic later this week and her discharge paperwork is burning a hole in his hand.

You review his bedside ultrasound images and video clips and pause to ponder over a couple of his images. 

What do you see in figures 1 and 2? Do you need to have a different discussion with your patient?


 


 

Dx: Forgotten IUD

As you review the resident’s images and videos, you note that there is a hyperechoic object adjacent to the gestational sac. At first, you thought it might just be some artifact but there is definitely an acoustic shadow farfield (posterior) to the hyperechoic object (Figure 3). You ask your resident whether or not he noticed the subtle finding during his scan and what he thinks it could possibly be. During your discussion, you see the light bulb turn on inside your resident’s head and you go with him back to the room to reassess the patient. You watch with pride as your resident sits down on the stool next to the bed and gently asks the patient if she has ever had an IUD before. It’s clear to everyone in the room that the patient had forgotten about that “minor detail” until that moment when she was prompted. On further review, the patient remembers having an IUD placed for her 16th birthday, but just thought that “they dissolve away after some time.” Your resident grabs the ultrasound machine and performs a transabdominal scan so he can show the patient what we are concerned about on her scan. He fans through the uterus and shows her the live IUP again. He then sweeps through the entire uterus and finds a clear transverse view of the IUD imbedded adjacent to the gestational sac (Figure 4). 


 


 

The OB team comes down to see the patient and explains the risks and benefits of leaving the IUD in place. They have arranged for close outpatient follow up and recommend a comprehensive ultrasound through radiology as an outpatient to follow the pregnancy and IUD. You debrief your resident and give him some pearls to use and pitfalls to avoid during his next patient encounter. “I guess I just stopped scanning once I found what I was looking for…” he contemplates out loud. You put a reassuring hand on his back, give him a comforting smile, and remind him that mistakes are the portals of discovery. Now go out there and enjoy all the mayhem we will be blessed with during this full moon. Just don’t let me see another anchor in our department tonight!


 

Pearls & Pitfalls for Pelvic Ultrasound

  1. Bedside ultrasound can provide you with valuable data to help you make critical diagnoses and expedite patient care.  Be careful not to fall into the common trap of using it just to find information that fits your clinical impression. Premature closure prevents you from considering other alternative possibilities.  Just because something fits doesn’t mean it’s right.  
  2. Novice sonographers may perform a cursory scan through a gallbladder and save images of an empty lumen because they don’t feel the patient has cholelithiasis, even when they might.  Their personal bias limits the usefulness of their scan results.  
  3. With experience, a seasoned sonographer may find those subtle gallstones or intraluminal polyps on that same scan that could have easily been missed secondary to anchoring heuristic error. 
  4. When you are performing pelvic ultrasound, make sure you scan through the entire organ of interest in multiple planes.  Often times, subtle and useful findings are seen in the periphery of a comprehensive scan.
  5. It is even more important to be comprehensive when you don’t know what you are looking for.  Patients and their presentations will surprise you.  Maintain an open mind and inquisitive nature during each patient encounter.  
  6. During the pelvic scan, always begin with a transvaginal scan to obtain a general overview of yout patient’s anatomy. Use a 3-5 MHz curvilinear or phased array transducer for transabdominal imaging.  Remember that a full urinary bladder provides a great acoustic window for the transabdominal scan.
  7. Have your patient empty her bladder for the endovaginal portion of the scan.  Apply a copious amount of gel over the intracavitary transducer (ICT) and then cover the probe and gel with a transducer sheath or condom.  Apply another layer of bacteriostatic surgical gel on the outside of the transducer sheath at the tip of the probe.
  8. Insert and advance the transducer with the indicator marker pointing anteriorly towards the patient’s pubic symphysis. Alternatively, you may let the patient insert the probe herself as this method is often less uncomfortable.  
  9. Scan through the entire pelvis in both the transverse and longitudinal planes.  Don’t prematurely terminate your scan just because you find the answer you are looking for early on.  Unexpected findings may lie in the periphery.
  10. Be consistent, comprehensive, and critical of the images you obtain.
Brady Pregerson manages a free on-line EM Ultrasound Image Library and is the author of the Tarascon Emergency Department Quick Reference Guide. For more information visit www.EMresource.org. 
 
Teresa S. Wu is the Associate Residency Director, and Director of Ultrasound and Simulation Based Training for the Maricopa Emergency Medicine Program in Phoenix, Arizona.
 

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