Dr. Steinhart, you've had 30 plus years of experience in the emergency department.

This is our second best case ever in the best case ever series.

Let a rip.

Let us know what your best case ever is.

Well, there are too many to discuss in three or four hours, but with related to found down, again, there are several memorable cases, but I think

the one I'd like to talk about is that found down in shock and touch on the approach, the found

down patient in shock and shock NYD. So this relates to when I was working in the community. And one evening,

an elderly 70-year-old lady came in, highly functioning, was doing the dishes and collapsed

pressure of 70, encephalopathic, not responding, but awake, no focal findings, put on a monitor to sinus tachycardia.

So shock, NYD, next to upper airway obstruction and a difficult resuscitation.

It is my biggest dilemma, someone who's basically succumbing in front of you and you don't immediately

know what is going on. So you think of the differential of shock and immediately comes to mind

hypovolemic and in that is hemorrhage and didn't see any source of bleeding. There was

no GI bleed that was evident. So we rapidly

concluded that that wasn't an issue. Cardiogenic, normal sinus rhythm, no chest pain, no ischemic

changes on a 12 or 15 lead EKG. So likely not, but not ruled out. Distributive as one of the causes. So sepsis, certainly a consideration, a little fulminant in presentation, but it can be that these patients compensate and then just go over the deep end and crash to cause their presentation, but no obvious source of infection

on a quick survey. And then neurogenic, no, she's moving everything as highly unlikely

neurogenic. And anaphylactic, always a possibility. You don't have to have the flushing

and cutaneous manifestations for anaphylaxis, but we didn't get a

history of chewing on almonds or anything else. And then, constructive. And she was sating okay.

We were able to get a sat monitor with a readout despite the vasal constriction and it was showing

good sat. So highly unlikely of a saddle embolus and we did a chest

...