Common ER Presentations
Dr. Zach, 2019
Today we’ll talk about some of the most common ER presentations, all of which I’ve seen in the last few days:
Working in the ER is great. You see whatever comes in the door, and you never know what that’s going to be. It is sometimes sad, sometimes funny, and often interesting. One of the best parts is the teamwork aspect. It takes a group of people working together closely and respectfully to take care of other people. NB it it nurses week — go nurses! Thank you for having my back.
The is an irreverent environment with plenty of humour and plenty of heart, as well. We some some fun things and some terrible things together.
In this short article I’ll talk about some of the most common presentations I’ve seen lately. For privacy reasons I won’t talk about any specific person, but all will be based on things I see often.
I work at 2 hospitals. One is a trauma centre which sees traumas from benign to life threatening. As such many people with injuries come in. In addition there is a psychiatry service, as well as other services including medicine, cardiology, and thoracic surgery. The other centre is a specialized cancer and transplant centre, so people with very complicated and serious medical illnesses go there. It also has cardiology and cardiac surgery, vascular surgery, and other surgical specialties. Both of these hospitals are open to the public. Therefore we see people with a host of problems that they decide to come in for. Below is a list of some common things I’ve seen recently (and in the past).
Example – 20 year old university student alone for the first time, very stressed about school, cuts herself and takes an overdose of acetamenophen. If she hadn’t come in she could have needed a liver transplant.
Example – 49 year old man with pain from left lower back to left thigh, worsening over the past 5 days. Can’t walk at all. No red flags. No imaging needed. Analgesia, physiotherapy.
Other example – 68 year old man with prostate cancer presents with severe back pain, leg weakness, urinary retention and fecal incontinence. Diagnosed with cauda equina syndrome — compression of the spinal cord — by a tumor metastasis to his spine — went for emergency surgery on his spine.
The story that we get is very important, and we supplement that with an examination and other tests, including blood tests, EKG’s, and imaging tests. The balance is doing enough testing to rule out the bad stuff without overtesting.
Example — 22 year old female comes in with chest discomfort, palpitations, and fainting. Diagnosed with Brugada syndrome, a genetic disorder that can cause sudden cardiac death. Treated with an implanted defibrillator. Family genetic testing.
Other example — 45 year old man, smoker, high blood pressure, with recurrent chest pain and shortness of breath at rest. Testing all negative — diagnosed with panic attacks.
Other example — 80 year old female with sharp pain in her right chest for 2 days. Diagnosed with pneumonia despite no cough or fever. Treated successfully with antibiotics.
In fact trauma is any injury, ranging from sprains to fractures and dislocations (a bone pops out of a joint), small cuts and bruises to massive internal or external hemorrhage, and mild head injuries to concussions to deadly intracranial bleeds.
The key is to see the patients quickly and recognize when their injuries are dangerous, and get them where they need to go. In many cases when the injuries are severe internal ones, the place they need to go is the OR with a trauma surgeon.
Example — 35 year old female, intoxicated, falls from 2nd story balcony. Multiple spine fractures, pelvic fractures with internal bleeding. Needed embolization (intervention to stop the bleeding) and surgery.
Other example — an 18 year old male is involved in a car accident. Very serious head injury requiring surgery.
Other example — 25 year old male falls playing basketball, anterior dislocation of humeral head (shoulder). Needs medication for pain and sedation and the ER doctor pops it back in place.
Once again the story is very important, as is the examination — checking the vision, looking in the eye, and perhaps doing an ultrasound of the eye. The eyes can also be injured.
Examples — a 35 year old man presents with eye pain after grinding metal. He has a piece of metal in his eye and this needs to be removed. Fortunately in his case it was superficial and could be removed in the ER. Remember safety goggles.
Other example — a 90 year old woman with no vision in her left eye presents because she is seeing flashes and floaters (dark spots moving around) from her right eye. She has a retinal detachment, and needed to be seen that day to try and save the vision in her eye that still had vision.
Other example — eye pain and redness in a 70 year old female. She also complained of pain in her jaw with chewing and pain on the side of her head. Diagnosis temporal arteritis, an inflammatory disorder that can lead to vision loss. Treated with oral prednisone.
There is an unlimited number of different presentations to the ER. These are 5 but we can cover more in future, including headache, abdominal pain, issues in early pregnancy, severe infections, and many more.