The 1997 write-ups

“ER Patients” From the 1997 Physiology Class

Case # 1
(from "Something New")
by Igor Schwartzman and Kendra Ward

Scenario:

A young male, Ernesto Ruiz, an approximated age of late twenties early thirties, was rushed into the Emergency Room with a GSW to the right chest at the 6th intercostal space. As soon as he was brought in he was put on 2L of saline. The doctors who were on duty were informed of his condition. His BP was 100/60, he was tachy at 120, his pulseox was 95 on 10L. One of the doctors noted to the patient that he had a large hole near his nipple. The assessment of the patient began all over, from the basics by performing a primary survey by assessing the airway and respiratory effort. The patient showed no sign of tension pneumo or cardiac tamponade. The auscultations of the heart and lungs were then performed with the palpations of the carotid pulse. The palpable carotid pulse indicated the systolic BP of at least 60. No evident muffled heart sounds were present, however, the patient then had diminished heart sounds on the right side. He needed a chest tube, 32 French is what the doctors used on the patient. The doctor's evaluation was that the patient was shot with a nine millimeter bullet.

Symptoms:

GSW - gunshot wound
Intercostal space - the space between the ribs
2 Liters of saline - given 0.9% NaCl through an IV
Tachy at 120 - high heart rate of 120 bps (1)
Pulse-ox - oxygenation of the blood, 95 or greater is desired (1)
Primary survey - controlling for major life-threatening problems, ensuring ABC's (Airway, Breathing, and Circulation)
Assess airway - making sure the airway is unobstructed
Respiratory effort - assessing the patient's respirations patterns
Tension pneumo (pneumothorax) - a collapsed lung (2)
Auscultations of the heart - listening to the heart beat using a stethoscope
Carotid pulse - the pulse of the principal neck artery
Muffled heart sounds - irregular heart beat
Chest tube - is inserted into the chest cavity to relieve pressure
32 French - the size and the type of the tube

References:

1. Nordberg, J. & Aronson, R. (1997). Ambush.

Case # 2
(from "Ground Zero")
by Jean Campbell and Jannelle Parent

Scenario:

An approximately 40-year old caucasian male was brought into the emergency room with a gun shot wound to the left knee. The artist was in a production when an apple was supposed to be shot out from between his legs but missed and he received a gun shot wound to his left knee. The emergency room doctor ordered a lateral X-ray of the knee. A "ten of morphine" was also ordered to be administered, but the patient refused to accept the morphine so he could experience the pain of the moment. Eventually the morphine was given. When the X-rays were examined the doctor observed complete imploded cartilage to the medial distal femoral condyle. A revolutionary technique was used after "trolling the morgue" for a donor femur match, patient consent was granted and cultures of the cells were started. The new surgical procedure that was done on this patient was osteochondral allograph. This was the first osteochondral allograph done in the county and certain sections of the operations were shown on the Sci-Tech section of the nightly news.

Terms:

lateral- relating to or situated on one side. (A)
X-ray(radiograph)- an X-ray beam is passed through the knee to produce a two dimensional picture of the bone.
"ten of morphine"- the amount of morphine given to the patient. Morphine is the best known narcotic analgesic(pain killer). To relieve severe pain usually from a heart attack, major surgery, serious injury or may be used to prepare a patient for surgery. (B)
cartilage-the three bones in the knee are covered with articular cartilage, which is tough elastic material that helps absorb shock and allows the knee joint to move smoothly. Cartilage is a type of connective tissue that forms an important structural component of many parts of the skeletal system.(A)
medial- a medical term meaning situated toward the middle line of the body. Less commonly the work is used to refer to the middle layer of the body structure particularly of a blood vessel wall. (B)
distal- describing part of the body that is farther away from a central point of the reference such as the trunk of the body.(B)
condyle- a rounded pertuberance on a bone. Condyles of the femur give width to the knee.(B)
osteochondral-bone and cartilage(C)
allograph-or graft in medicine, is a portion of the body or complete organ artificially removed from its natural site and transferred to a separate site or to a different individual.(C)

Surgery:

In an osteochondral (bone and cartilage) allograft a donor with a similarly sized subchondral bone is matched to the patient. The cells from the femur of the donor are cultured and then grafted into the patient's cartilage. These grafted cells are used to help reconstruct the damaged cartilage of the patient. Osteochondral cells are used to repair large defects of the articular cartilage. Sufficient autologus cells can be grown to initiate the repair of articular cartilage and the reformation of the subchondral bone. The tissues that have been repaired appear to be undergo the same developmental transitions that originally led to the formation of articular tissue in embryos.(C)

Sources:

A-The Medicine of the ER
B-American Medical Association Encyclopedia of Medicine
C-http://www.nih.gov/niams/healthinfo/kneeprobs/kneeqa.htm

Case # 3
(from "Ambush”)
by Joshua Nordberg and Rachel Aronson

Scenario:

A 37 year old male presents in the Emergency Room with respiratory distress. His neighbor reports that his friend was diagnosed with esophogeal cancer six months ago. The man had also had laser surgery in the past to enlarge his esophogus. He began having trouble breathing and then began choking. The paramedics informed Dr. Green that he was tachycardic at 120 with a b.p. of 130/100. He had lots of secretions and his resps were increased at 30. He was put on high flow O2 and an intubation tray was prepped. He was given 2 liters of saline and a blood gas test was ordered. His pulse-ox was down to 87. After trouble intubating the man, Dr. Green decided to "crike" him. First he had to confirm that the man did not have a D.N.R. (do not resuscitate) order. Unable to give a clear answer, they went for the crike. He was prepped by receiving a 600 clindamycin I.V. He was given a crichothyroidectomy. The man was able to breath. Dr. Green had mentioned to the man's girlfriend that there was an option to help keep his nutrition level up using a J-Tube, but there was no conclusion to the man's condition in the show.

Terms:

Tachy at 120 - abnormally high heart rate of 120 beats per minute.
Pressure 130/100 - a blood pressure of 130 (systolic) / 100 (diastolic).
Resps - respirations. (D)
High flow O2 - a flow of oxygen that exceeds the patient's respiratory demand. (F)
2 Liters of saline - given two liters of a 0.9% NaCl solution intravenously.
Blood Gas Test - a test to determine pH of the blood, and its concentrations of oxygen, carbon dioxide and bicarbonate. (A, 187)
Pulse-Ox - a measure of how oxygenated the blood is; a 95 or greater is desired. (B)
Crichothyroidectomy - cut a hole in the neck and place a breathing tube directly into the trachea (windpipe). (C, 104)
Crike - the short name for a crichothyroidectomy.
Intubation - placing a breathing tube into the trachea through a patient's mouth. (C, 3).
Clindamycin I.V. - an antibiotic drug used to treat serious infections that have not responded to other antibiotics. Used to treat bacteria such as staphylococcus and pneumococcus that are resistant to more commonly used antibiotics. (A, 284)
J-Tube Option - a jejunal tube used for feeding. It is a permanent tube placed just past the stomach into the jejunum or small bowel. (E)

Sources:

A - American Medical Association Encyclopedia of Medicine - Ref.RC.81.A2.A52.1989
B - Case #2 Lotterman and Schumacher
C - The Medicine of ER - Stacks.RA.645.5.R68.1996
D - Medical and Scientific Abbreviations Ref.R.123.L8.1987
E - http://crossroads.gower.net / gtubehome.html
F - http://www.hsc.missouri.edu/shrp/rtwww/rcweb/aarc/othefcpg.html

Case # 4
(from “Freak Show”)
by Dory Lev, Shawn Bates

Scenario:

Henry, an intern, is in the process of assisting Dr. Carter with a chest tube, when he starts having symptoms of labored breathing and nausea. He faints and becomes cyanotic. He is taken into a trauma room where he has wheezes bilaterally and a pulse ox of 86. Dr. Cater immediately orders a chem 23, cbc, and tox screen. Dr. Carter then intubates with a laryngoscope. His pulse ox falls to 82. Not knowing the cause of the collapse Carter took Henry's gloves off to reveal his hands red and edematous. They discovered that he was having an allergic reaction to the latex in his gloves, that caused him to go into anaphylactic shock. Henry then went into asystole. They gave him an amp of epi, iv push, and since he was allergic to the latex gloves, all medical personnel working on him had to change to non latex gloves. They then extubate the et tube because the cuff of the tube was latex. Another intubation was done with a non latex tube. It was difficult to intubate due to laryngeal edema. A mg of atropine and 50 benadryl to prevent further allergic reaction. A high dose of epi 7 ccs was administered.

Medical Terms:

cyanotic - blueness of the skin and mucous membranes due to an increased concentration of reduced hemoglobin in the superficial capillary circulation. (2)
wheezes bilaterally - various sounds produced on both sides of the chest, when bronchial tubes are narrowed . (4)
pulse ox - a measure of how oxygenated the blood is. Normal is 95 or better. (5)
CBC - complete blood count, tallies up the number of rbc's, wbc's and platelets. (1)
chem 23 - chem 7 and sixteen other chemicals found in blood. (1)
tox screen - identifies if patient has taken and drugs. (1)
intubate - simple operation consisting in the introduction, through the mouth into the larynx, of a tube designed to keep air passage open. (4)
edematous - the presence of edema. (4)
edema - abnormal accumulation o fluid beneath the skin, or in one or more of the cavities of the body. (4)
asystole - cardiac arrest, lack of heart beat. (2)
epi - epinephine or adrenaline, stimulates symphatheic nerves, contracts blood vessels to increase blood pressure, inhibits the release of histamines, and dilates the bronchial tubes. (3)
iv push - injecting drug introvenously. (1)
atropine - antispasmodic drug used for its affects on spasmodic disorders. (3)
benadryl - antihistamine which reduces the intensity of an allergic response, by blocking the action of histamine. (3)
anaphylactic shock - acute form of anaphylaxis, the patient is hypersensitive to foreign material entering their tissues, characterized by severe shortness of breath and decrease of blood pressure. (4)

Reference:

1) The Medicine of ER: or, How We Almost Die, by A.D. Ross & H. Gibbs
2) Oxford Medical Companion - REF. RC. 41.084.1994
3) The Essential Guide to Prescription Drugs- REF. RM.300.L64.1992
4) Black's Medical Dictionary - REF.121.B53.1992

Case # 5
(from "Fear of Flying")

by Menard & Wright

Scenario:

Dr. Green and Dr. Lewis respond to a motor vehicle accident out in Boone County, via med-flight helicopter. Upon entering the scene they began to triage a family of four who have been in the accident. The oldest child Zach, eight years old, stopped breathing due to an obstructed airway. Dr. Lewis began to administer treatment but was unable to see the obstruction because of an excess of blood in the airway. She tried to suction off the blood with a 6.0 tube and then a 5.5 tube, but there was not enough suction to clear the passage. They decided to transfer the boy to the hospital via med-flight. On the way to ER, Zach began to show signs of shock. Once he was brought in, he was cross-tabled, typed and crossed for 4 units, and a blood gas kit was ordered. A cath-urine was dipped, and a saline flush was ordered. At this point his BP was only 65 palp, and his pulse was 163. A lavage was ordered and drained, and came back positive. To sedate Zach, Dr. Ross ordered one milligram I.V. of Versed, explaining to Zach that this would help him sleep. Saline was orderd to be injected into his I.V. There was a close brush with tragedy as a replacement nurse accidentally injected him with a quarter c.c. of potassium. Insulin and glucose were ordered immediatley to counteract this mistake, but they were not needed. The amount of potassium injected was not enough to stop his heart. Dr. Keaton, a pediatric surgeon, then came in to prep for surgery, Dr. Carter gave the briefing. He said that Zach had a hypotensive intraperitoneal hemorrhage, R.S.I. was given at the scene, and that Zachs H and H was 11, 32. Zach was brought into surgery.

Terminology:

c-spine: cervical spine
6.0 tube and 5.5 tube: guage of tube used for suction
'shocky': showing signs of shock
cross table: an x-ray that is shot across the table or gurney in order to view a side angle of the upper (cervical) spine
type and cross for 4 units: test for blood type; and the mixing of the patients blood with a sample of the blood the hospital is planning to transfuse into the patient. This is done to make sure the 2 different bloods are compatible. 4 units refer to how much blood is ordered.
Dip a cath urine: cath stands for catheter which is a tube. In this procedure, the catheter is placed into the urethra, the opening from which you urinate, it is pushed all the way into the bladder. Here it collects a sterile sample of urine. This is useul for a urine analysis, which test for impurities such as blood in the urine.
Saline flush: used in a lavage to flush the body cavity
lavage: washing of a wounded body cavity or hollow viscous with a stream of water, saline or other liquid
bloody-tap: a positive result in a lavage; indicates that there is internal bleeding in the cavity tested
blood gas kit: used for blood gas analysis; analysis of blood concentration of oxygen, carbon dioxide, hydrogen ions, and hemoglobin.
Versed: central nervous system depressant, often used with patients in respiratory distress.
hypotensive: in shock, low blood pressure
intraperitoneal hemmorhage: dramatic and sudden blood loss in the peritoneal cavity.
R.S.I.: short for R.S.I.C.U., which stands for Respiratory Surgical Intensive Care Unit.
H and H 11, 32: hemoglobin and hematocrit, hemoglobin test tells doctors how well your red blood cells can carry oxygen throught out your body-normal is 15. Hematocrit is the percentage of red blood cells in blood-normal is 40%.

Case # 6
(episode title not known)

by Maria

Scenario:

A man, who was in a helicopter crash, was bought in with his crew who were critically injured and had severe burns. He had a fractured ankle and did not seem to have as many complications as his crew members. He and Dr. Greene's father started talking to eachother when, all of a sudden, Dr. Greene's father noticed that the patient stopped talking. Dr. Greene checked to see if the patient was still breathing and checked his pulse; there was no carotid pulse. He immediately called the medical staff to bag the patient and started pumping his chest (CPR). The patient was crashing and was said to have tension pneumo. A 14-gauge is inserted in the upper chest area. Afterwards, they prepared for a chest tube, and they used a 36-French and 20cc's of Xylocaine.

Symptoms:

carotid pulse- pulse of two arteries on both sides of the neck which supply blood to the head (3)
crashing- going under cardiac arrest (1)
tension pneumo- (pneumothorax) damage to the lungs due to major trauma which has caused the lung to collapse. This is due to presence of air in the pleural cavity. As the pressure builds up within the cavity, the structures of the mediastinum (i.e. trachea) are dislocated to the opposite side. The air in the chest also constains the blood circulation, not allowing the blood to be pumped (1,2)

Treatments:

Bag (him)- an ambu-bag is placed over the person's mouth and nose in order to simulate respiration (goes along with pumping of the chest) (1)
14-gauge- a specific size hypodermic needle, which, in this case, was inserted in the upper chest area allowing the tension of air to be released and for the trachea and other structures to move back to the middle (3)
chest tube- a tube which is inserted into the chest cavity and into the pleura by making an incision (in this case specified at 5th intercostal space, mid-axillary line). This tube re-inflates the collapsed lung and gets rid of any blood and air from the chest (1)
36-French- ?the size of the chest tube. Size is on French scale, in which 1mm=3fr (therefore, a 12mm tube) (3)
Xylocaine- a local anesthetic agent which is administered by injection (4)

Sources:

1. The Medicine of ER
2. The Oxford Medical Companion
3. Stedman's Medical Dictionary
4. Pysician's Desk Reference 1997

Case # 7
(from "The Long Way Around")
by Seth Lotterman

Scenario:

Duncan Stewart, a man in his late 20's is brought into the ER with multiple gun shot wounds in the chest and thigh. When he arrived he had already been given 2 liters of saline, and high dose epinephrine for PEA. The doctor then ordered 2 more liters of saline, and 4 units of O- blood on the rapid infuser. However, The patient regained spontaneous breathing so CPR was stopped. Soon afterwards the patient's pulse was then lost again, he was then intubated, and CPR was performed. In addition, a portable chest was ordered, and a chest tube done. A blood gas test was also ordered, and H and H crossed for eight, type specific. Suddenly the patient went into asystole, and the doctors quickly opened his chest. Using a rib spreader to keep the heart exposed, internal compression was then performed. Epinephrine and atropine were immediately given, but after the patient had been down for 25 minutes he was declared dead.

Symptoms:

GSW- gun shot wound (2)
Asystole-cardiac arrest, absence of a heart rate. (1)

Diagnostic Tests:

Portable Chest-portable x-ray machine used to take x-rays of the chest. (2)
H and H-hemoglobin and hematocrit tests. Hematocrit measures the percent of RBC's in the blood, 40% is normal, under 10% is critical. Hemoglobin is usually around 15, under 10 critical. These tests are used to indicate the amount of blood lost. (2,3)
Blood gas-test that uses an arterial blood sample to test content of oxygen and other gases in the blood. (2)

Treatments:

Saline- A solution of 0.9% NaCl per 100 ml. It has the same electrolyte strength (osmotic pressure) as blood, referred to as isotonic saline. (1)
O- blood- type O blood, that is Rh negative; also the universal donor's blood.
Intubation-Insertion of a tube into the patient's trachea to assist in breathing. (2)
7.5 ET tube-endotrachial tube, 7.5 refers to the width of the tube in millimeters. (2)
Chest tube-tube inserted into upper chest via incision. It is hooked up to a suction device which removes excess air and blood, which allows the lung to reinflate. (2)
Epi-Epinephrine, a drug and a neurotransmitter which stimulates heart rate and raises blood pressure. (2)
Atropine-drug that increases heart rate by blocking the inhibitory effect of the parasympathetic nerves on the heart. (2)

Sources:

1. Oxford Medical Companion
2. The Medicine of ER
3. Logan's Medical and Scientific Abbreviations

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