Medicine

For a physically small ER, we do get a variety of stuff: complete heart block with a ventricular escape rate of 37. Kept his BP reasonable, and his mentation good. Turns out we've got external pacing capabilities, but no pacer wire & box for transvenous. Would have been interesting if he'd been a little sicker and had to be urgently paced.

A flutter at 150 walked in to his GP's office asymptomatic - so no clue how long he'd been in it. But, he was already anticoagulated with a therapeutic INR, so we just cardioverted him. I didn't watch closely enough as the 1st year registrar gave the propofol, and he was "generous" with the dosage - the electrical cardioversion went smoothly, and respiratory status was OK, but took 12 minutes for him to wake up and for his BP to get above 60.

Great deal of interest in this: not sure that cardioversions had been done in the ER in recent memory, and no one had ever used a gloved hand to assure firm contact of the pad to skin.

Ortho was getting slammed, so for his Smith's distal radius fracture that he wanted just a reasonable reduction before admitting him for surgery in the AM, it was quicker to just put that guy down with propofol than to do a hematoma block. We do a lot of sedations here - all with no paperwork! He let our intern have a go at the reduction first, then, in disgust said "You pull like a girl" and then pulled like an ortho (I think they're all rugby players here), and away we went.

Quite a sick DKA with pH 6.93 but a K+ of only 2.7. So wanted lots of K+ on board before we started insulin. But, her precipitant was a submandibular and neck cellulitis and abscess, so put in a femoral line. Then opened the abscess - very little pus, but unusually awful swelling - wonder what the bug will be - presumably an anaerobe. Turned into quite a discussion/negotiation between medicine and ICU registrar as to who would take the patient. ICU/critical care is all done by anesthesia - no medical or pulmonary critical care here - so if the patient doesn't need a vent, ICU typically doesn't want them - treat them in the ER long enough to get them stable enough to go to the floor. Finally did go to ICU (well, sort of, there weren't any beds in ICU or on the floor, so she was staying in the ER for the foreseeable future).

Getting a bit of a feel for the practice styles of the various short term locums consultants - many or most come down and "turn the crank" - so see patients primarily, don't do much teaching, review cases with the junior residents, and on to the next. So, a bit more teaching, supervision, etc style that I'm used to, seems a distinct change and appears welcome.

Saw a "Jack Jumper" ant bite: Jack Jumpers are medium sized ants that grab you with their pincers, then curl their body in a half circle and sting. The sting is reportedly somewhat more painful than a bee sting and much more prone to anaphylaxis than a bee sting. So, there's lots of anaphylaxis from stings here.

The highlight of technology here is the POC (point of care) blood gas machine. Gives pH, pCO2, pO2, K+, glucose, Ca++, lactate, and Hemoglobin - all in a minute or so and gets used regularly. Fantastic when you're taking care of of a really sick patient (4 rounds of these numbers in the first 2 hours with the sick DKA - that let me see that our K and lactate were coming around and heading in the right direction). Further, It's a bit of overkill, but if you need any one of those numbers to get someone out the door - done in a minute instead of waiting an hour, to see if for example, the Hemoglobin is stable. I plan to unbolt it from the shelf and bring it home with me!

Anytime anyone gets near a patient, they put on a disposable plastic apron. Looks like cooking school!