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Trial & Error by Michael Mouw, MD

This blog is a collegial forum for emergency physicians to share lessons they learned from mistakes in practice. Submit your case, and we will publish it here with a brief analysis by Dr. Mouw. All cases will be published anonymously unless you choose to use your name, as Dr. Mouw has done. Submit to emn@lww.com.

A few rules:

  • No names (patients or otherwise) or identifying characteristics.
  • Don’t exceed 500 words. Cases will be edited for grammar, length, and clarity.
  • Photographs, clinical images, and lab reports are welcome, and should be 300 dpi and in jpg, tif, or gif format.
  • Authors are responsible for obtaining consent from patients, family members, and health care professionals depicted in images, and must attest to EMN that consent was obtained.Authors should provide their full name and contact information for verification purposes. This will not be published without permission.
  • Only post cases outside the statute of limitations. Pertinent references are helpful.
  • Comments about the cases are welcome. Submit yours to emn@lww.com. Word limit: 200 words.

Monday, August 3, 2020

I was about five years out of residency, working the pediatric ED. I walked into a room with a chart that said, "Vomiting, can't keep anything down," to find a pair of 3-year-old African American boys wrestling playfully on the stretcher. It wasn't obvious which one was sick, so after introducing myself, I playfully asked the boys: "Which one of you is throwing up?" Both hands shot up. Both giggled.

"Help me out, Mom, which one is here to see me? Can you hold him in your lap for me?"

His brother peeked out from behind their mom while we talked. Twin premies born at about 30 weeks, and my patient had a history of esophageal atresia that had required early dilation by surgery. They had done well, and were average-sized. But my patient had vomited multiple times soon after eating over the past eight hours. No diarrhea or fever. He tolerated liquids. His exam was normal: no stridor or drooling, and he looked great. She said there was no history of a foreign body ingestion, but my first thought was that he had swallowed a quarter.

I ordered a chest x-ray, and went to the next case.

The x-ray was normal. Still concerned about a nonradiopaque foreign body, I went back and asked again. No, she said he had not choked on anything. He also said he had not swallowed anything he wasn't supposed to. The pediatric surgeon on call that day was difficult to work with, and I knew he would resist seeing the child based on my suspicion alone.

They had been there an hour, he was still playful, and he hadn't vomited. I decided on a PO trial with two ounces of water. He grabbed it, quaffed it, and lifted the cup, pleading for more. Obviously thirsty. I waited for a couple of minutes, and gave him a bit more. No problem. I asked the mother about trying some graham crackers, and she approved. I gave him a couple of graham crackers and returned to the charting area, which was immediately adjacent to his room.

Ten minutes later, she burst from the room screaming, his unconscious form limp in her arms: My baby's choking! Help him, he's choking!

I jumped up, grabbed him, and sprinted to the crash room across the hall while yelling for help. "Code Blue STAT! I need suction and the crash cart!" He was apneic, limp, pale. I proned him over my left forearm in a football hold and gave two sharp back blows. He retched up graham cracker slurry. His chest heaved with inspirational effort, and he began to move air.

We laid him on his side and suctioned more slurry. Then he started to hyperventilate, retracting, honking like a goose. We gave him oxygen, and his color and oxygen saturation were normal within a minute, but he was still unconscious. He was rapidly improving, but I still didn't know what was going on, so I elected not to intubate. I had no difficulty convincing surgery to take him to the OR.

A couple of hours later, the pediatric surgeon, often critical of others, swung by to tell me he had extracted a 2 cm chunk of turkey hot dog from the boy's esophagus. He was uncharacteristically gracious, probably the nicest I ever saw him. "I spoke to mom afterward," he said. "And when pressed, she admitted she had fed him the turkey hot dog. She lied because she was afraid she'd get in trouble with child protective services."

Case Lessons

Apparently, the meat was impacted distally at the EG junction. The graham crackers caused him to vomit, causing the meat to move proximally, resulting in extrinsic compression and obstruction of the distal trachea. This wouldn't happen in an adult because of the calcification of the tracheal rings that occurs with age.

People of color face a different world. At first, I was angry with the mom for withholding information that almost cost him his life. Later, I realized that fear of child protective services was a reality in her world that I had never had to face.

Nonmetallic esophageal foreign body is one example of the most difficult diagnostic challenges we face—when decision-making is based on suspicion from the history alone, without objective clinical or ancillary findings

I dodged a bullet. This was the closest I had ever come to causing the death of a patient. After this case, I never hesitated to request endoscopy to rule out a foreign body in nonverbal patients, and I ended up being right more often than not.

Wednesday, July 1, 2020

The EMS radio crackled: "We are en route with an intubated trauma patient, prolonged transport, 20-minute ETA, and need sedation orders."

I gave orders for Valium 10 mg IV, and notified the ED team to prepare.

Things were otherwise slow, so I stepped out on the ambulance dock to get a jump on things.

The rig pulled up a few minutes later, and the rear doors opened to reveal a man in his 20s struggling against four-point restraints. As they pulled the stretcher out, I moved beside it to get a look. Although intubated, he appeared wide awake, making bug-eyed contact with me, imploring. No visible blood or other sign of trauma anywhere.

As we started moving inside, I asked the EMTs: "What's the story?"

"He crashed his car into the front wall of a 7-Eleven. We found him unconscious on the floorboard, so we protected his C-spine while moving him out of the vehicle, and intubated before loading him."

"How badly was the car damaged?"

"Minor. No interior damage."

Weird. Slow-moving parking lot frontal collision, minimal vehicular damage, unconscious at the scene, awake and responsive now, no signs of trauma.

A light bulb went off as we were rolling into the resuscitation room.

"Sir, do you have seizures?"

He nodded vigorously in assent.

"Do you hurt anywhere?"

Shook his head no.

"Would you like to get that tube out of your throat?"

Again, nodded vigorously. After a brief head-to-toe exam and a more detailed neuro exam, we successfully extubated him. Came to find out he was an epileptic who ran out of seizure meds.

Case Lesson

When receiving a patient from the EMTs, get all the details needed to make your own assessment while keeping in mind they could be wrong. If their assessment seems correct, all good. If not, think for yourself. Don't let an incorrect field assessment lead you down the wrong path.

Monday, June 1, 2020

"Doc, we need you in room nine stat!"

I dropped the phone at my workstation at this suburban freestanding ED (FSED) and hustled down the hall. The teenage girl I had just seen, whose transfer I had been arranging when I was interrupted, was lying unconscious on the floor in a growing pool of blood. On the floor near her right hand was an empty urine specimen cup.

On first contact in room nine a few minutes earlier, I had found her alone, sitting up on the stretcher, pale and diaphoretic, with a blood pressure of 70 mm Hg displayed on the monitor and a lot of blood in the bed. No nurse, no IV access. A brief history revealed she had started bleeding just a couple of hours before and had been having some moderate pelvic pain. She had missed a period, but had had no sexual activity. I went to the doorway and asked her nurse sitting at the desk to start IVs and get a pregnancy test. "I'm going to have to transfer her out since she's obviously in shock. If we don't get her pressure up with a liter bolus, we'll need to give her the O negative blood we have on hand. I'm going to enter her orders for you and get on the phone to arrange the transfer."

His look was one of surprised alarm. He had clearly mistriaged the severity of her situation. "OK, doc, but I can't get the saline out of the Pyxis until you put the order in."

This FSED had its own lab that performed urine hCGs (but not quants), as well as most other basic labs. I returned to my desk and ordered two IVs, a CBC, a type and screen, and a urine pregnancy test. I then got on the phone to the mother ship and asked to speak to an EP to arrange transfer. That's when I dropped the phone to return to room nine.

Apparently, the first thing her nurse did was give her a urine cup and instruct her to go across the hall to collect a sample! Once we got her back in bed, he called another nurse to help. While he started the IV, I went for the portable ultrasound. I returned to find them trying unsuccessfully to catheterize her bladder. I remembered a trick I had learned somewhere, so we dipped an hCG stick into the vaginal blood. It was positive. Her bedside ultrasound was positive for intraperitoneal blood.

The receiving EP accepted the transfer without a fuss. That FSED had a policy that required us to use their internal EMS for transfers, but they wouldn't be there for an hour, so I called 911. A county crew arrived 10 minutes later to take her. Total time in our department: about an hour (30 minutes of that before I saw her). They removed 3 L of blood from her abdomen and a ruptured ectopic. The next day, I was emailed by the medical director asking why I hadn't waited for their own ambulance!

Case Lessons

  • You don't have to wait for a urine specimen to get an hCG. It can be done on venous or vaginal blood.
  • If facility administrative policies are in obvious conflict with patient safety, do what's best for the patient.

Friday, May 1, 2020

The EM lecturer closed with: "So if you see a heavy-set person with nontraumatic muscle pain, think about hypothyroidism."

"Hmm," I thought, "Wonder if that might apply to that guy we saw a few days ago?"

A burly construction worker returned to the ED with persistent bilateral arm pain and swelling. He had been seen two days earlier for the same complaint, and had been worked up for rhabdomyolysis and compartment syndrome, which had revealed a creatine kinase (CK) in the 400s. He had been told to return for a recheck and trending of his CK. The resident on the case repeated his CK at his most recent visit, which was trending lower, so we let him go home to follow up in the clinic.

On my way home from that lecture, however, I swung through the ED, where the same resident was on duty again. "You remember that guy we saw with muscle pain who we repeated the CK on? We should call him back to test his thyroid function." He returned later that day, and the test showed a markedly elevated thyroid-stimulating hormone (TSH) level of 12 mU/L.

We researched the issue further and discovered that the incidence of clinical hypothyroidism in the United States isn't low: one in 300, which means most EPs will see at least one case in their career. My threshold for ordering screening TSH levels for patients with vague complaints definitely went down after this case. As did my threshold for calling a patient back if I may have missed something.

Wednesday, April 1, 2020

A 16-year-old football player presented to the pediatric ED with a severe headache. The attending physician was a first-year pediatric emergency physician.

The patient reported a constant, severe headache that he attributed to a hard collision in practice the day before. He had not lost consciousness, and his vital signs were normal.

A head CT was normal, and he was discharged with a diagnosis of post-concussion syndrome and given appropriate instructions.

The patient returned to the ED two days later (day three of symptoms), still alert and ambulatory. His headache had worsened, and was now severe. He presented with normal vital signs and was afebrile. He did report malaise and subjective fever.

He had taken ibuprofen an hour before ED arrival, and was still attributing his symptoms to the football collision. He said, however, that his headache had not started immediately after the collision but approximately 15 hours later. The collision itself didn't involve his head.

He had subjective posterior neck pain with flexion, but his neck was supple. Neurologic and skin exams were normal. I reviewed the initial head CT, and agreed that it appeared normal. I felt the presentation was more consistent with meningitis than a TBI, and after discussing my thoughts with the patient and his mother, they consented to a lumbar puncture.

An examination of cerebrospinal fluid revealed aseptic meningitis, and he was admitted for observation. Antibiotics were withheld because nothing suggested bacterial meningitis (afebrile, normal peripheral WBC count).

Case Lessons

The "consider the worst first" rule was broken. Anchoring on a TBI occurred when the physician followed the patient down the wrong path and didn't take a detailed history about symptom onset or consider alternative and potentially more dangerous explanations.

Although listening to patients and considering their ideas is good, it can lead to error if we take the path of least resistance and accept an incorrect self-diagnosis. In a case like this, thinking for ourselves and disagreeing with them is essential.

Absence of fever due to antipyretic administration can also lead to error. This patient endorsed subjective fever, but didn't have a fever in triage. A history of fever should be treated the same as an objective fever recorded in the ED.