EPs share first-hand accounts of train wrecks, close calls & potentially-disastrous errors
30ish male presented after being involved in a low speed MVA. He arrived by ambulance with multiple contusions and abrasions and scattered muscloskeletal complaints but nothing apparently serious. Wounds were treated and needed X-rays were obtained. Patient was given discharge instructions. Had some difficulty walking out so tech got him a wheel chair (did not advise nurse or doctor of the patients difficulty walking). Came back the next day with gross weakness of both legs and a spinal cord injury that resulted in patient permanently disabled.
A 62-year-old male is brought to the ED by family/private car with right-sided chest wall pain after he fell 8 feet to the ground while attempting to clear snow off his garage roof. Patient denied any other injuries, specifically no head/neck/back pain, no LOC. Patient placed in ED room with initial VS at triage all nl, including POx = 96% on RA although patient was mildly tachypneic, RR=20 (for real, not the usual triage 20). A few minutes later, the family came out stating that the patient was feeling like he couldn’t breathe. He was then in distress with absent breath sounds on right. EP called for chest tube set up stat and did quick explanation of need for CT due to collapsed lung. As patient deteriorated rapidly and became more agitated, the chest tube was placed under less-than-ideal circumstances. Instead of a rush of air, the doc got a return of blood/dark tissue in the tube. With the patient now in respiratory distress, a second tube was placed higher on the anterolateral chest wall. With a large rush of air the patient’s respiratory status improved. First tube still drained bloody fluid . . .
A 78-year-old male arrived with anaphylaxis from ibuprofen (he had taken it for the first time after developing muscle aches after helping dig a grave for a dear friend). He was inadvertently given epi 1:1000 IV instead of IM. He became tachycardic, diaphoretic, nauseated, and presyncopal. He developed ST depression on his EKG. He was admitted and fortunately recovered without recourse.
A 45-year-old female restrained passenger in MVC came in by EMS, no backboard or C-collar and was speaking in triage. She coded immediately. Resuscitation began, trauma signed off, patient had rosc on massive pressors but expired. On autopsy found to have liver lac.
I had a middle-aged gentlemen, approximately 35 years old, obese with horrible pulmonary hypertension causing liver disease and esophageal varices. He had just had an EGD a few days earlier and had received eight bands and came in after an episode of hematemesis. He was doing well in the ED, HD stable, and had not had any further emesis. As he was an expected difficult airway, we decided to just sedate for the EGD. So after he was sedated and positioned (sitting up) for the EGD which was about to start, he began to have massive hematemesis requiring intubation. Luckily I was able to partially make out my landmarks and got the airway but quite easily could have been a disaster.
I received a sign-out as follows: “She is a Sudanese female with a headache and chest pain that developed while in the ED. Her headache is resolved and if her second set of enzymes are negative she can go home.” Her repeat troponin was 1.8, and she was admitted by the resident physician. The pharmacist was the only one to notice that she was being started on heparin after undergoing several attempts at an unsuccessful LP. I was neither aware of the LP nor the order for heparin. We then received a call from the lab that the troponin actually belonged to a patient in the ICU. This patient barely escaped anticoagulation after an invasive procedure for an incorrect lab value. As an added bonus, she spoke no English, had no family with her, and we were unable to locate an interpretor in order to explain what had happened.
48-year-old female brought to ED by EMS after the patient was found unresponsive in their bathroom at home. Per EMS, patient was intubated but they were unable to obtain IV access in field due to patient’s large body habitus. CPR was in progress on arrival to ED with estimated down time of 30 minutes. Patient was in asystole on arrival with no spontaneous respirations/response to stimuli. Lungs sounded grossly symmetrical but distant with bagging by RT. ETCO2 detector with equivocal purple/yellow change, presumably due to prolonged down time. IV established by ED staff, Epi/Atropine/Bicarb/IVF given per ACLS protocol with no response. After another 10 minutes of CPR with no response the ED doc was ready to call code, but asked code team for any other suggestions/concerns. RT stated that the patient was getting harder to bag. ED doc attempted direct visualization – difficult due to short neck/excess oropharyngeal soft tissue. Visualization with fiberoptic scope showed ETT in esophagus. The patient was reintubated with fiberoptic scope, but remained unresponsive with no Return of Spontaneous Circulation (ROSC). The patient was pronounced dead.
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