July 2016

Case 1: SOB with Multiple Medical Problems

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Sean G., M.D. -

I know this was live...but that is irrelevant. In my residency T the old MCP(Medical College of PA) now Drexel/Hahnemann we had Grand Rounds every week. Part of that was the chief resident of the month(we had 12 residents per year so we had each take a month at chief) would present a case just as these. An intern would be chosen at random to basically do what Stu and Billy are doing....as the intern faltered guys like Jim Roberts, Bob McNamara, and Dave wagner would chime in with their wisdom. Well the mantra of my residency was "Vital signs are vital" . I believe it was one of the best lessons they taught me. I teach my residents NP's and nurses as well as medics....you don't have to know everything....no one is going to sue you if you miss a rare variant of GBS...or an odd presentation of Botulism. But you damn well may get sued if you fail to emergently treat a hypoxic or hypotensive or crashing patient with good basic EM principles....I tell them start with the vitals....if they are all normal and the patient looks well, the chance you are missing something legit is minimal. If you have an abnormal vital sign....and there are 5...including the pulse ox...if they are abnormal, and you can not prove it is benign....like a PO of 88% on RA in a well appearing advanced COPD pt....then you WILL be held accountable to address and begin to remedy that vital sign.
In our case presentations every week for my 3 years, if a resident jumped into lung exam or diff dx or US or even hx without knowing a FULL set of vitals they would get slammed by the attendings. This is an important lesson even for seasoned ER docs...esp if you are like me and see pts often before the nurses have triaged them...sometimes that pulse is unexpectedly 120...or BP 90 syst, or temp 101, or RR 24....or PO 82%.... In my 20 years of career I have seen a very seasoned ER doc get sued successfully for missing one of these abnormal vitals....someone who will remain nameless but has lectured countless times and is considered one of the top EM docs in the biz. It can happen to the best of us. So my shock here is that both Billy and Stu would have FAILED utterly if they were the intern getting pimped on one of these cases. No one asked the pulse ox on the first patient, but went on to lung exam and discussing imaging modalities...the woman presenting even prompted them...."what about the pulse ox?" AND STILL neither asked! Now if this had happened with one of our interns the Chief resident was instructed to make the pt hypoxic and go into resp failure(for about 10 minutes until the intern acknowledged their mistake) even if the pulse ox was normal. The point is....u HAVE TO KNOW THE VITAL SIGNS before you start looking for zebras. I was shocked when the presenter asked Billy "what do you want to know History or vitals?" and Billy responded..."well history of course!" I beg to differ....I want to know the vital signs first. That's why they are called "Vital".

Mel H. -

Sean you are right of course...this was not meant to be exactly how you would run a "real" case or do an oral exam. We will make that a little clearer next time...but I TOTALLY agree...vitals are vital. All life and death starts there!

Sean G., M.D. -

Joe Lex always told me that you and I thought alike....maybe it was my Russian accent when calling consults, or my Aussie one....who knows...I would like to think it clinical skills....but it was probably the silliness. Anyway...thanks for re igniting my desire to practice EM. What you do matters Mel.

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