So, I thought I might post a series on fast track disasters. These are patients that presented with relatively mild complaints, and/or were overlooked by triage, and were put back into fast track, but ended up being pretty sick.
35 year old caucasian male with a complaint of "cellulitis". H/O Multiple Myeloma on immunosuppression. Patient states that his left elbow is quite reddened and swollen. Now, apparently triage was being manned by monkeys, as no one noticed his pressure of 90/45. OR his pulse rate of 126. Closer examination revealed full elbow ROM with only slight pain at the extremes of flexion. supination and pronation full without pain. Posterior elbow has a definitive infected Olecranon Bursitis, but looking closer, the rash encompasses his ENTIRE RUE. From the axilla down to his wrist, worse posteriorly, but present even circumferentially. I'm starting to get a little nervous now, but feeling at least a little better, after a BP recheck shows 100/50
I immediately order Zosyn, and a 1 liter bolus, look at our critical bed situation.....D*mn, only ONE bed left over there. Time to talk with my attending, I briefly discuss the case with her, and she is, as a new EM doc, a little scared as well. We talk to the charge nurse, and ask that another nurse come over for one to one care with q 5 minute vital checks, and while this is being arranged I am calling the Hem/Onc fellow. We chat briefly, and are both in agreement that he needs ICU care. I call the ICU, and speak with the fellow, and subsequently the attending there. They agree to accept the patient, with Hem/Onc being the primary service. We arrange for an Ortho consult when the patient reaches the floor. He was out of Fast Track within 45 minutes after arrival. Immunosuppressed Multiple Myeloma patient in early septic shock was how I coded that.
I thought briefly about taking the last critical bed, but the fact that his BP was climbing slightly, and that he was still mentating, and functioning okay, made me re-assured that with close one to one nursing care, and a rapid transfer to ICU care would be okay in FT. I simply didn't want to take the last critical bed from a level one MI (STEMI) or a level 1-2 trauma.
Anyway, that is just one of several postings to come about fast track disasters.