ER Cases

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:

 

  1. Depression, anxiety, and suicidality
  2. Back pain
  3. Chest Pain
  4. Trauma
  5. Eye problems

 

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).

 

  1. Depression, anxiety, suicidal ideation, and suicide attempts.  Mental illness is a very common problem that we are just starting to appreciate the magnitude of.  So many people suffer. Some are alone, and some are our family and friends and coworkers who suffer in silence.  Many young adults suffer from anxiety and depression and it is difficult and/or expensive to see a therapist. Those in crisis come to the ER, and often they’ve either thought about or have actually made a suicide attempt.

 

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.

 

  1. Back pain.  This is very very common!  The good news is that the vast majority resolve with conservative management (meaning pretty much on their own, though sometimes people benefit from some analgesia).  Many people with back pain don’t need any kind of imaging, whether it be x-ray, CT scan, or MRI. Doctors worry when there is a “red flag” present, meaning something that could indicate that the back pain is not benign in nature.  Red flags include young or old age, a history of trauma, a history of cancer, fever, chills, night sweats, weight loss, iv drug use, immunosuppression, night pain, urinary retention, fecal incontinence, numbness and weakness in the legs.  The red flags are risk factors for worrisome conditions including infection and cancer. It is also incumbent upon the physician to consider and rule out other causes of back pain, such as kidney stones, and abdominal aortic aneurysm.

 

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.

 

  1. Chest pain.  Again, one of the most common reasons people come to the ER.  Most people come in because they are worried about their heart, which is a reasonable fear.  You need that to work. And, it being the ER, we see all causes of chest pain, from benign chest pain, shortness of breath, or palpitations caused by anxiety, to acute heart attacks, to blood clots in the lungs, to aortic dissections (tearing of the massive blood vessel that comes off the heart).  

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.

 

  1. Trauma — when we think of trauma, we think of major trauma, such as gunshot wounds, stabbings, etc.  This being Canada our volume of such trauma is blessedly low. But sadly it is still present.

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.

 

  1. Eye problems — When people have trouble with their eyes they often come to the ER.  Obviously our eyes are incredibly important, and so it makes sense that if there is a problem people want to get it checked out.  Problems range from a benign conjunctivitis (pink eye) to vision-threatening problems like retinal detachment (where the thin layer of tissue (the retina) at the back of the eye pulls away from its normal position) and everything in between.  Sometimes eye problems are associated with systemic issues, such as inflammatory conditions such as Lupus.  Two of the most concerning symptoms for eye problems are eye pain and significant vision loss.

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.

 

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