ERDoc

If one of the other personalities were to shoot the one threatening to do the killing, would it be justified homicide or self-defense? Sorry, I guess it wasn't that funny.

Here's an article from emedicine: http://www.emedicine.com/emerg/topic486.htm Priapisms do not last a few minutes. Penile stiffening that lasts a few minutes is called an erection and can usually be treated with a little gentle massage.

Would this be considered a hostage situation?

Did her legs seem to be more affected than her arms? This sounds like serotonin syndrome to me. With all of the psych meds she was on, I'm sure there is something that is affecting serotonin levels. I once had a kid who OD'd on an SSRI and presented with what sounds like the same kind of symptoms. I called to tox people who work at the large teaching hospital and they said that he should go to the Peds ICU. I got a call later saying that he had the classic presentation of serotonin syndrome. The tox doc said that you couldn't ask for a more textbook presentation. Like I said, from what you are describing it sounds like serotonin syndrome to me. Have I mentioned the word serotonin enough? Serotonin.

That pulmonologist is a tool. Anyone can learn to listen to lungs sounds. Will we ever be able to discriminate the minute differences he is able to detec? No, probably not, but do we need to? No, probably not. Pneumonia is generally easy to differentiate from pulm edema, especially in your otherwise health person. Pneumonia will usually present with decreased sounds over a specific area when compared to the other fields. You may also hear some rales/rhonchi. Pulm edema will usually be more diffuse and will start at the bases and work their way up. Obviously the more comorbidities they have the more sounds you may have to differentiate. Also the more adiposely enhanced they are the more difficult they will be to assess. Pulmonologists have developed a special skill that helps them to be able to better assess the pt. It's called looking at the chest xray/CT scan first. Tniuqs, thanks for the praise and reminding me that I have no outside life. Seriously, I like coming here. You guys are all down to earth and afterall, EMS is where I started as one of the v-words (no, not that v-word. I started as a volunteer). It think it is important to

Slap the sh!t out of him and tell him, "Quick faking it, get back to class slacker!" I have a few questions, but after that I will stay out of it. Hopefully in my abscence someone else will get it. Does he respond to threatening stimuli from either side? Does he follow an commands? Any obvious paralysis or lack of movement in any area? Is there any loss of bowel or bladder control? Do the parents know of any recent hea trauma? Any recent significant streesors in the boys life?

Someone bordering on septic needs fluids. A pt in full sepsis can require liters of fluids in order to fill the space created by vasodilation. Obviously if they have a history of CHF you need to be careful, but that fluid is more likely to fill your increased peripheral capacitance before it will dump into the lungs. The ICU guys can worry about that, if they don't get the fluids they will not make it to that point. I have put almost 12 liters of fluid into a septic pt over 3 hours and still started them on pressors. In sepsis the key is antibiotics and then fluids. I would recommend giving so much fluid in the ambulance, but it is a good idea to start a hypotensive pt with a low BP some fluids.

I'm always up for a good challenge. I disagree that it would be hard to design a study. In fact, I argue that it would be just the opposite. The is no ethical or legal questions. An IRB would approve the study with very little difficulty. After a very brief pubmed search, I did find one article that showed an improved outcome for pts with severe asthma who were given MagSulf. The improvement was not as good for those with mild-moderate. The consensus seems to be that Mag is safe, but there is a paucity of studies supporting or not supporting it. Might be a great idea for a study. I got DIBS! http://www.ncbi.nlm.nih.gov/entrez/query.f...t_uids=12171821 Quick shout out to my hometown peeps on Long Island.

tniuqs, I agree with all of your points. However, aspiration pneumonia most commonly occurs in the RLL. The reason being is that the left mainstem has a sharper angle off the trachea than the right, so it is a more direct path to the RLL. This is also why most inhaled objects end up in the RLL. Then again, those north of the border may have a different anatomy. Giving lasix to a pt with pneumonia is bad. You want to keep them hydrated as dehydration can only make them worse. A problem I have with this scenario is that there was such a great improvement in her pulmonary status in less than 20 minutes after lasix. My guess is that there was some mucous plugging or just some excess mucous that was hanging around causing some rhochorus sounds that cleared in the 20 minutes via coughing or movement. This osunds like a case of aspiration pn to me. A good rule of thumb is that if you are not sure what the right answer is, it may be best to do nothing but monitor and transport. The way cases are generally presented in the hospitals: History of present illness : 54 y/o male with h/o MI presents with sharp substernal chest pain that radiates to his left arm. Started 20 minutes ago while the pt was running on a treadmill. Nothing makes it worse, but nitro makes it better. It is associated with diaphoresis, nausea and vomiting. He has never had pain like this before. Other pertinent history: Review of systems, PMH, PSH, fam Hx, soc Hx Physicial Exam: Vitals and head to toe Once this is done, the differential is usually discussed. Once a ddx has been made, you discuss the work up and treatment. After that you discuss work up results and response to treatment and then try to come up with your diagnosis. I have no problems playing Monday morning quarterback for any call that someone has a question about, but, as tnuiqs stated, be honest with what you are thinking and hoping to accomplish. Say straight out, "I had this call and got a major attitude from the nurse. I think I'm right, but let me know what you think." Just be prepared to hear that you might be wrong. If you are looking for opinions on what happened and what the diagnosis is, you've come to the right place. If you are looking for someone to make you feel better and tell you that you were right when you might have been wrong, you have come to the wrong place.

Here is a link to an OB website, but hey Mag on L&D is the same as Mag in the ER/ambulance. http://www.ismp.org/newsletters/acutecare/...es/20051020.asp

This case just reeks of something bad. Elderly people are not to be trusted. They will never present with the classic symptoms of anything. They do not mount the typical physiologic responses to anything. Obviously you can't force her to go, but she should have been exhaustingly encouraged. Elderly people are landmines waiting to be stepped on. Fear the elderly person with a fever or vague symptoms. Pick up a copy of Harwood-Nuss (Clinical Practice of Emergency Medicine) and read the chapters on the weak pt and abd pain in the elderly. They will scare the hell out of you.

I use it quite often for more severe asthma and COPD cases. I don't think it is used as much as it should for fear of Mag toxicity. Great little drug that works by smooth muscle relaxation, but you need to watch your pt for toxicity,

These pts that jam up the ER infuriate me. The sweetest revenge is when there is a perfectly good OTC med to treat their cold/runny nose/fill in bogus complaint here. The look on their face when you tell them that they are not getting a prescription when there is a perfectly good OTC alternative. Sorry, not everything little thing requires a prescription. I feel that I am just doing my part to keep down healthcare costs. Why should the insurance pay for something when there is an OTC equivalent. People need to understand that they need to take responsibility for themselves and their family to some degree. Don't ask me for a prescription for Motrin or for one of the $4 antibiotics from Walmart. Stop smoking for a day or two and you can afford your meds or your childs meds AND you will be on your way to better health. Sorry you have to give up your addiction, but it is not societies problem. OK, I'll get off my soap box.

LOL. Good to hear from you. Sorry, I just couldn't resist.

I didn't want to get involved with this discussion and I will not post my beliefs on homosexuality or the church at this point. To play devil's advocate, there is a large talk about the bible and how it denounces homosexuality. My question is, what gives the bible so much power? How is it any more than a book written by a bunch of guys looking to control a population who said that it was the work of god, their god specifically? How would it be any different if I wrote a book with a few guys and said that it was from god? Why would no one believe me (I would probably end up in a psych ward)? What makes it any different/

For the most part. I hope I am not taking away from your education (though I'm sure someone here will let me know if I am). A ddx is a list of diagnoses that you have after completing your H&P. Your workup will (hopefully) give you your provisional diagnosis, which is the one or two that you have narrowed it down to based on the workup.

A restaurant in Chicago recently started serving it. Guess the Chicago medics should brush up on it, if they don't know it already. :wink:

Wow, part 1 can be done adequately in less than 100 words. Part 2 could be a whole lot more than 1500.

I'm a little confused. Ar you supposed to define what a differential diagnosis and a provisional diagnosis is or are you supposed to develop a DDx and provisional diagnosis for those cases?

No problem. There is a Japanese says that goes something like this: Those who eat fugu soup are stupid. But those who don't eat fugu soup are also stupid. Care is basically supportive. Intubate and watch. Most statistics you find are from Japan, where people try to prepare them on their own. Mortality is fairly high because of this. Fugu is highly regulated here in the US. Any fugu that is sold in the US can oly be purchased from a single market in Japan (I don't remember the name, but it starts with an Sh). It is prepared there by chefs who have gone through 2-4 years of training exclusively on fugu. Their final exam is pretty simple, they have to eat a meal that they have prepared (pretty much pass/fail basis). It can only be flown into the US through JFK where it is inspected by trained inspectors (duh, who else would do some inspecting). It can then only be cooked by chefs in the US that have gone through the same training as those in Japan. Others have covered most of the pathophysiology so I will not go into the details. With a little modern medicine it is fairly survivable. Intubate, ventilate and let the tetrodotoxin clear out. This scenario was a little too easy (damn those Simpsons). I'll have to come up with a more difficult one next time. :twisted:

The owner tells you that they ordered edamame, tuna-goma-ae and sunomono for appetizers. The main course consisted of hamachi sashimi, tekka maki, spicy tuna roll, fugu and california roll. For drinks they had sodas and some sake. The pt denies any pain. He is not orthostatic. 12-lead is sinus with a rate consistent with the pulse. As you are sitting with him, he starts to tell you that he feels like he is having some trouble breathing.

The restaurant is Honshu Sushi. The pt is not sure what he ate. It is a dinner function for his job and the boss did the ordering. He looks well, just worried. He tells you, "Help me, I think I'm having a stroke! I'm too young to die!" Speech is OK and there is no stridor or other abnormal breath sounds. He is breathing a little fast (24-28 per min), but it could be from his anxiety. HR is 110 and BP is 138/90, SaO2 is 100% on room air. Grips are equal, but weak bilat. He has no known allergies and has never had anything like this before, however he has never eaten Japanese before. He has no handled any unusual substances. He describes the feeling in his hands as a tingling and weakness to the point that he was having trouble picking up his chop sticks. He is beginning to develop a similar sensation in his toes. He says that it seemed to start in his finger tips and has been progressing more proximally. No carpopedal spasms. He was not going to propose to anyone. As for his orientation, he insists he is straight despite his "I love Becksdad" tattoo on his lower back. He works for a computer company in the programming department. No family history. PERRLA at 4mm (seems appropriate for the ambient lighting). He is awake and alert. His ariway is patent and there is no swelling/angioedema. No rash and FS is 110. Your partner looks at the table and says that there is Sake and some stuff that looks like different kinds of fish (being the uncultured brute he is he does not know what kinds of fish). The restaurant owner comes out and says to you that you need to get out as quickly as possible as they have a new chef and you are making him and the other guests nervous. What do you want to know now and what is your next move?

You are called to a restaurant for a possible stroke. You arrive to find a 32y/o male c/o tingling around his mouth and in his tounge. He didn't think anything of it at first but started getting concerned when his hands were going numb and he seemed to have trouble picking things up. For those that will ask, yes the scene is safe.

:x So much goes on behind the scenes that people don't see and don't understand. There is not one MD and RN to cater to each pt. I cover 5-12 pts at any given time depending on how busy the dept is. Each one is waiting for something. CT scans can take some time to read, especially trauma scans. I don't know what parts were scanned, but I'm assuming at minimum, his chest was scanned. It can take a while to read all of the images, sometimes several hundred per pt. There is also monitoring time. We like to watch trauma pts for a while to make sure they stay stable. It really makes your day go bad when you send someone home who dies. Labs also take a while. I'm not saying that 8 hours isn't excessive, but the ER isn't McDonalds. Good pt care can take some time and just because you don't see things happening doesn't mean they are not. It only takes about 15 minutes to do a thorough H&P, but it doesn't end there.

There is no hard and fast rule. Even the A&OX3 or 4, depending on what you use, has no officialness (pardon the made up word). It is just jargon that we use to save time when trying to get a point across. It's easier than saying the pt is alert and oriented to person, place and time (and possibly event if you like). As someone before me said, document what you find and you can't go wrong.