Continuing Education

A 55-year-old woman with a history of panic attacks, obesity, and untreated hypertension, experienced syncope after feeling flushed and lightheaded. On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of brain natriuretic peptide (BNP), and elevated troponin-I. Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation due to respiratory failure and subsequent cardiac arrest; cardiopulmonary resuscitation resulted in with return of spontaneous circulation. However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition to comfort care and subsequent death. The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated heart failure and appropriate treatment for hypertensive emergencies in the emergency department and intensive care unit. 

A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.

An older man underwent L4-5 decompressive lumbar laminectomy and discectomy, which was complicated by intraoperative durotomy. At a follow-up visit, he reported clear drainage from the surgical site and the surgeon suspected a cerebrospinal fluid (CSF) leak. Despite conservative management at home, his condition worsened over several weeks before being readmitted with discitis, osteomyelitis and sepsis, resulting in his death 50 days after the operation. The commentary provides an overview of the clinical manifestations of intraoperative durotomy, intra- and postoperative management strategies to address intraoperative durotomy and CSF leaks, and approaches to ensuring patient safety during spine surgery.

A patient in his mid-30s presented to the emergency department (ED) with three weeks of intermittent left-sided headaches, balance issues, and one brief episode of difficulty speaking and moving. On exam, the patient had normal vital signs, neurologic exam, and initial imaging; he was discharged from the ED without consultation from neurology. A few hours later, he suffered a stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading to severe neurological deficits after delayed treatment. The commentary highlights the importance of thorough neurological investigation of patients presenting with dizziness and other simultaneous neurological symptoms, the challenges of diagnosing transient ischemic attack (TIA) – particularly in a young, healthy adult, and the limitations of non-contrast brain CT for identifying TIA or early ischemic strokes in patients presenting with dizziness. 

A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without any specific treatment. Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache and was diagnosed with post-concussive syndrome and discharged without specific treatment. He was later diagnosed with a large frontal subdural hematoma requiring urgent surgery. The commentary discusses risk factors for delayed acute subdural hematoma and the importance of repeat brain imaging in patients with risk factors and persistent symptoms.

A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. Attempts to intubate him to manage his respiratory distress were unsuccessful and he underwent emergency cricothyroidotomy. Despite initial neurological evaluations indicating normal extremity movements, he developed progressive paralysis of his lower extremities over the hospital course. A delayed MRI revealed a significant epidural hematoma compressing his spinal cord from C3 to C7, prompting emergency surgery. Despite decompression, he suffered permanent paralysis. The commentary highlights the cognitive pitfalls associated with managing and processing large volumes of clinical information and the importance of effective communication and active engagement among all clinical team members.

A man presented at the emergency department (ED) after a motorcycle crash. He had superficial lacerations on his left elbow, where wood chips were noted on exam and x-ray but were not fully removed before discharge. He was discharged with antibiotic prescriptions, but returned three days later with worsening symptoms, including pain, swelling, and pus, leading to additional foreign material being removed and further antibiotic treatment, but without repeat x-rays. Ultimately, he developed osteomyelitis, requiring multiple surgeries and a long hospital stay due to the retained foreign bodies. The commentary highlights the importance of evaluating patient risk of wound infection and poor wound healing, the role of imaging modalities to help identify foreign material in wounds, and diligent follow-up to prevent complications.

During elective rhinoplasty, a patient became aware that she was awake. She heard the conversation among the surgical team members and felt that the breathing tube was pushed up against the inside of her throat, impeding her ability to breathe. She was unable to move but recalls making a “monumental effort” to utter a small groaning noise, which alerted the surgeon to the fact that she was awake. She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was almost over. During the first follow-up visit, the surgeon did not address the situation, so the patient brought it up at the end of the visit. The surgeon seemed surprised and embarrassed that the patient remembered waking up during the operation but could not explain what happened. The commentary discusses the risk factors for intraoperative awareness, approaches to prevent awareness, and the importance of validating and addressing the patient’s experience, including addressing symptoms of post-traumatic stress syndrome. 

A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety. 

Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading to dehydration and multiple outpatient treatments. Despite visiting an outpatient clinic and emergency department (ED) for ongoing symptoms and significant weight loss, the nausea and vomiting persisted. Eventually, she was admitted to the ICU with pancreatitis and dehydration. Subsequently, she exhibited neurological symptoms including difficulty walking, tingling sensations, and cognitive impairment. She was discharged with orders for total parenteral nutrition (TPN). Three days after discharge, she was readmitted for worsening confusion and profound motor weakness, which progressed to respiratory failure requiring mechanical ventilation. Laboratory tests revealed an extremely low thiamine level, and the patient was diagnosed with advanced Wernicke-Korsakoff Syndrome, exacerbated by a lack of proper nutrition, and resulting in permanent brain damage, necessitating ongoing care. The commentary discusses how biases associated with medical conditions, such as obesity and its treatment, can lead to poorer outcomes, as well as strategies to continually re-evaluate diagnostic reasoning in light of ongoing, intensive management and management reasoning