u/tallyhoo123

Example case: mid 30s female presented as anaphylaxis.

States acute onset of throat tightening without known precipitant - maybe some itching to chin but no rash and no angiooedema.

Took own epi but called ambos who gave another and came to ED.

Similar hx few weeks before.

Apparently under immunologist for years but no cause found.

BG of depression, acute on chronic headaches and presented once with multiple syncope but normal ED investigations and discharged against medical advice.

Important to note - never any obvious objective findings apart from a hoarse voice in last 2 admissions.

I (as a consultant doing what we call VMO work I.e locum work) assessed and something didn't add up to me and my treatment plan was to hold any further treatment I.e. no steroids or further antihistamine or adrenaline as the patient was well without any stridor/swelling/rash and normal obs.

I wanted to do a nasoscope to investigate paroxysmal vocal cord pathology.

Another consultant (who works in the place full time) also reviewed and instead decided on IV hydrocort + further antihistamine.

I then decided to do a nasoendoscopy anyway, due to ongoing hoarse voice, and found no oedema or anatomical abnormality at the cord level but did find paradoxical movements which was confirmed by ENT review of the video.

I personally think this lady is suffering from PVCD and not anaphylaxis but the other consultant has written notes basically just stating it was another anaphylaxis again.

The reason I am a tad annoyed is the failure to consider other pathologies which unfortunately will continue the mismanagement of the patient.

Granted I am aware it is often safer to treat for anaphylaxis than not but in this situation I felt we could have observed and not rushed to enforce a potential misdiagnosis.

I am tempted to call the patient tomorrow and explain my thoughts to guide her to see an appropriate speech/ENT specialist.

In the future if this similar interaction occurs how would you handle it - as 2 senior doctors.

I have had similar interactions with this consultant who has failed to act quickly enough (in my opinion) resulting in poor outcomes.

Elbow dislocation techniques

How do you relocate your elbows?

For some reason I keep coming across other Docs who find it difficult using rhe traction / counter traction technique and often I come in an use my own technique which has worked 100% of the time and is easy peasy.

I've looked up different techniques and the one I use hasn't been described - I would love to have a technique with my name on it! But before I try and do that I wanted to see if anyone else does it.

Without giving the game away, how do you guys relocate the elbow?

Edit: people getting snarky in the comments - thid is supposed to be a bit of a light hearted discussion so keep the negativity away, I am just asking how others do it.

Also apparently me not knowing the formal pathway to get a technique described means I can't be a consultant ?!? I'm sorry but I'm not a researcher/academic - I work hard on the shop floor and I'm not interested in these things.

Edit: OK so I'll just describe my technique as I still haven't seen anyone describe theirs and even with a post detailing 7 different techniques it's not written.

It's a single operator, double handed technique similar to the double thumbs.

Have the patient sat down and you are facing them.

The arm is held in a position of comfort- likely partially extended with palm upwards.

You use your hands to "grip" the elbow.

Your 2 middle fingers "hook" the olecranon posteriorly and your 2 thumbs are positioned on the anterior distal humerus.

Then you push with your thumbs and pull with your fingers in a rotating fashion to pull the olecranon down and your thumbs push the distal humerus backwards.

As you do this you will notice the elbow tends to flex abd then "clunk" it's back in place.

I've done it with sedated and non sedated patients and, for me anyway, it's as easy as putting a patellar back into place.

Mid 50s female batcall sepsis, obese, no neck.

DC recently with large purulunt ascites and new Malignancy.

Re attended 2 days post DC SoB and agitated.

- BP 80

- Tachycardia 130

- Sats 100% on 15LNRB

- Pale clammy

- Periarrest

- No IV access.

- non compliant with positioning / monitoring

- Able to get some poor IV access

- Fluid resus and BP >100

- A line inserted

- Abx given

- Pocus = reaccumulation ascites (?loculated) and bilateral large pleural effusions, heart hyperdynamic nil effusion.

- hyperglycaemia but ketone 1.5

Taken for CT but IVC lost enroute so noncon CT completed = large pleural effusions, ascites, nil obstruction or perf.

Back to resus.

Attempted NGT for large stomach and further IVC.

Managed IVC but pt non compliant for NGT.

Attempted CVC but pt non compliant agitated needing more sedation with ketamine / midaz.

Looking worse.

Unable to get non-invasive BP due to Agitation.

A line poor trace but sometimes reading 100 systolic.

Blood gas at this time = 7.295, lactate ~ 4, K5.6 rest unremarkable, ongoing IVF.

Decision for tube to facilitate management/transfer/likely IR drainage of ascites/effusions.

- RSI ramped with Roc and Ketamin (reduced dose)

- Gentle bagging.

- rescue drugs ready and Cric kit on hand.

- Sats 100% BVM prior and last reading a Line 100 systolic

- Grade 1 CMAC.

- large vomit during ett and aspiration but tube secured.

- sats dropped to 69% but bagged back to 78% post some inline suction.

- became Brady and arrested.

CPR commenced.

-repeat Gas showed K6 and hypercapnia.

- multiple coached rounds and at 24 mins brief rosc

- adrenaline infusion and boluses commenced plus calcium chloride provided and insulin.

- cpr ongoing for 45 mins and all rhythms non shockable.

- repeat gas worsening acidosis, K7 and lactate 8.

- decision to stop at 45mins.

Just thinking if anything else could have been done.

Could we have pressed on for NGT? She was agitated and non-compliant so would need more sedation and risk of losing airway with this hence decided not to press it.

It was overall a pretty shitty case and from the start she was cold as ice/clammy/agitated/delirious etc

I am trying ti find an alternative route to what we did but I am struggling to justify any other management at this time.

Any suggestions for future learning?

Hot debrief at the time- no other suggestions

What are your techniques for removing difficult FB from ear canal.

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Generally I use analgesia + alligator forceps or flushes depending on the FB.

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However there is always that one case where pain becomes too much of an issue and it's difficult to get to so I send to ENT.

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My question is what analgesic methods are you using to help with ear canal pain and what do the ENT guys do differently apart from deeper sedation as needed?

We are having more and more patients arrive with this combo and my God are they a difficult bunch.

I know the standard at the moment is symptomatic management - maybe some IVF, laxatives, analgesia and then back to community followup.

I have been doing a deep dive into these conditions and one paper hints that MCAS may provide a unifying diagnosis. It can cause multiple physical and neuropsychiatric issues which are common in this population with some evidence of resolution of symptoms after managing the MCAS with histamine blockers / mast cell stabilisers etc.

Does anyone have any evidence / anecdotal reports on whether or not providing these patients with H1 / H2 receptor meds or steroids may reduce their symptoms burden and hopefully reduce their ED presentations in the acute setting?

The more common this becomes the more issues in regards to ED workflow develop and I am trying to find some sort of quick fix that actually works as I'm getting tired of the arguments / the lack of trust / the difficult conversations.