A 80s M presents with a brisk nose bleed. He is bleeding from both nares, the left more than the right. He has been bleeding for about two hours at home before coming in. His vitals are normal. What do you do?
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(1) It helps to have a fresh set of eyes.
(2) Know what you’re not good at.
The ED is a chaotic place with limited resources, and there’s no way anyone can get it right the first time, every time. Sometimes, you just need a little more time to figure out what’s going on. Sometimes, it helps to have a fresh set of eyes. Thus, you should re-evaluate your sign-out at times.
After sign-out, I reviewed this patient. It looked like acute pulmonary edema (from heart failure) to me. I changed course on the patient.
I did a bedside echo on the patient. The heart was pumping fast and the squeeze looked good to me, casting doubt on my diagnosis. However, I know that I’m inexperienced with echo and I get it wrong sometimes. I stuck with my clinical diagnosis. The patient’s Ef on the official echo (done the next morning) was 25% with diffuse hypokinesis. I was disappointed by my echo skills but happy with my clinical diagnosis. (On a related note, we tried to echo a patient recently and we couldn’t even find his heart [not kidding]. Fortunately, the pt was still there the next morning when I came back, and I put a probe on the pt and saw everything rightaway. I think it was the probe.).
The patient did fine. She was treated for her heart failure and was successfully extubated after a couple of days.