Kiwiology

Bro, I was taking the piss

How do you know my name? You've been looking in my window again haven't you! You're in luck, at 5.45am tomorrow you'll get to see me shower! Yes, infection, see below She could be, but it's easy to have a squiz and note a surgical scar Yes it's an infection. Interesting, are you not taught percussion as part of the physical exam? A resonant area is one is like hitting the side of a drum you don't get the dullness; I am not sure of the exact word but a hyper resonant area is one where it's more resonant. This can be used to test for free gas in the abdomen Sepsis from a perforated bladder caused by an improperly performed illegal abortion The five universal signs of inflammation are redness and warmth, tenderness (pain at site or surrounding it), swelling and um .. loss of function or reduced mobility of the part affected. Her abdomen has three of those signs (warmth, redness and pain) In the absence of a physical wound the cause of the five cardinal signs is infection. As for her obs, she is not yet septically shocked so blood pressure is really a poor indicator of anything She meets three of the criteria for SIRS (RR > 12, HR >= 90, temp > 36°) ETCO2 is low because oxygen demand is outstripped by supply and the beginnings of lactate production (a by product of the conversion of NAD+H and FAD into NADH and FADH2 I think) have been set in motion. That was more extra-credit information anyway. I think I put in there somewhere about lactaremia and leuckocytosis with a left shift but I might have edited it out; it was more extra-credit information anyway; again both are indicators of serious bad septicajuju Signs of infection (cardinal signs) + signs of severe inflammation (from an infection) (SIRS) = the flu infection In a female of child bearing age who presents "unwell" with signs of abdo/ ?pelvic infection and signs of SIRS by default she has some sort of gynae catastrophe until proven otherwise I don't actually care if you got the answer or not The two big things here were that she has signs of infection and meets SIRS criteria but presents in such a subtle way that she may very well have been left at home and be dead a day later or be written off as a "faker" or "BS". Obviously I couldn't expect you to figure out the illegal abortion thing but the reason she had it done illegally is as a solider in the Defence Force they will not pay for abortions so she has to get it done illegally. She forcefully denied being pregnant because she knew she'd had the abortion. Now obviously I can't expect you to be a mind reader. The two big things here were that she has signs of infection and meets SIRS criteria but presents in such a subtle way that she may very well have been left at home and be dead a day later or be written off as a "faker" or "BS". Are you serious? Did I ask you to "write it down" for possible use in court? Well fuck you too OK, you go and believe that ... I am not even interested in debating this with you.

no it is a gynae problem but it's not a uterine problem or ectopic pregnancy Kettymainz for teh win it makes my dates so much more complaint! You have a female crew partner, she takes a squiz down below and reports the perivaginal area is also very red and warm to touch and smells bad The patient once again forcefully denies being pregnant Without being really obvious and giving it away here's another clue; when you percuss the abdomen it is resonant however distal to the umbilicus it is hyper resonant; when you have the patient turn towards one side at about 45° angle the area of hyper resonance shifts What do hyper resonant areas indicate and what could it mean if it shifts?

Yes there is some muscular rigidity when palpating her lower tummy

Isn't thromboxane part of the haemostasis cascade? Are you suggesting I have some understanding of biomedical science and/or pathology? with encouragement like that I might just apply to medical school, oh look medical school applications open next week hmmm .... And under no circumstances am I to be referred to as a surgeon, I can barely cut fruit and am hopeless at sewing the hole in my jeans up; um yeah Ambreas Pare would be spinning in his bloody grave forever perturbed at the notion. I'd probably resort to hacking it off with a giant saw I stole from the orthopaedic registrar when he was not looking or something and be unable to close so the patient would die of nosocomial septicaemia; see if that happened I'd have Ignaz Semmelweis and that Baron Lister bloke come after me with their dead people powers ... So in short no operating for Kiwi; and yes I find medical history quite fascinating in case yo couldn't tell I think it's way too high; I was taught 220-age or 220+age or something as the maximum a person should be able to sustain (+/- clinical judgement) In September, 2011 Intensive Care Paramedics finally got adenosine for SVT

Good thinking mate, I suppose you could say there is non-specific pain upon palpation of McBurney's point And it was covered that she no longer has her appendix; a key factor to rule out before calling the Surgical House Officer or Reg to admit her (yes, it happens) You would think when the House Officer is on a surgical service it turns them into the House Surgeon but it does not ...

I'll do you one better sir, it's a good reason not to do it again That way you don't have to worry about getting caught And what is it with Pennsylvania (and those other places) being Commonwealths? Great, saying that make me think of Lara Flynn Boyle off The Practice, wasn't she a Commonwealth's Attorney? Now I'm going to have nightmares, great, thanks a lot, I'm blaming Penns...well in this case Massachusetts.

Yeah same here mate, if you're under 25 they won't even rent to you or you have to agree to pay like an extra thousand bucks excess (deductible) as part of the mandatory insurance cover the rental agency provides You also cannot rent on your restricted (P plates in AU) As far as Ambulance is concerned; in AU you need Class LR; Canada requires a Class 4 or Class F in Ontario; in the UK/EU you need Endorsement C1 (and maybe D1 depending on some UK NHS Trusts) so that means you must pass extra tests and be over 21 (usually) however in US doggon it you can roll up on a standard car license and drive with an 8 hour class and hey never mind if you've been suspended, had three at-fault fatal hit and runs and you're visibly intoxicated when you take your Ambulance driving class. OK I was kind of taking the piss on that last bit but you get the idea

I reckon we come off the southern coast of NSW, you can practically bloody see it; so that begs the question if we're a little bit of shit we must have broken off a bigger bit of shit (i.e. you) mwahahah The location is not important A common misconception. Based solely on knowledge of physiology and pathology with no access to lab tests or diagnostic imaging there are several huge clues in the information I have provided that should be screaming "really big problem". A Consultant Physician once told me that biochemistries and images help to augment what is found during the physical exam but are not an examination technique in and of themselves. I don't know, could she have an ectopic pregnancy? what would cause you to suspect that? (as an aside, I'm really dumb and cannot remember basic facts I learnt 20 minutes ago if my life depended upon it but for some strange reason one thing burned forever into my head are the risk factors for ectopic pregnancy; I can recite them off the top of my head cold and I have no idea why; it is truly bizarre) I'm not really into spanking, maybe a little, no whips or chains though y'know that's just creepy Nobody is expecting you to know exactly what is wrong with this person but bloody hell mate, these scenarios are clinical cases or situations we think interesting enough or out-of-left-field enough to post up and generate some discussion or ideas or debate; you know to get people thinking maybe a bit out of the box or something a bit different. This is not about an exacting diagnosis; you know these things never really are; how sick is this patient? how time critical is she? she has by all accounts "a sore tummy and fever" so do you take her to big surgical hospital or small hospital with no surgical capability and why? There are several huge red flags in the physical exam and trended obs provided that should be setting off the "time sensitive extremely sick person" flags but could just as easily be explained away to the satisfaction of the crew. None of the red flags are very advanced honestly. I'm not trying to put myself up on a pedestal as posting shit up that requires some bloody massively advanced knowledge of biomedical science (because I sure a hell don't have it ... oxidative phosporowhat? bloody Devil talk that is right there!) but you know patients who present subtly unwell but in fact have a time critical problem that will kill them in 24 to 48 hours are not extremely common; I can think of only two or three problems that can take a healthy young person such as this and turn them stone cold dead inside a short time span. Perhaps you yourself ran across such a patient; but all you did was take them to the hospital so it's not even important Why even post a reply to this if you're not interested in having a go because "it's not my job to know I only take them to the hospital" doesn't help; in fact all it does is exemplify what Skip Kirkwood and I were recently discussing. I could go on and on and have a massive bloody deconstructive rant but then I'd just look like that Semmelweis bloke and knowing my luck I'd probably end up like he did. Excuse me, I have to go wash my hands now. Bloody hell forget I ever posted the damn thing.

Very good point. So let's say the trend is below for the three sets of obs that have been taken 10 minutes apart BP 120/80 PR 90 RR 14 Temp 38°C SPO2 100 RA ETCO2 27 BP 120/80 PR 100 RR 16 Temp 38.2°C SPO2 100 RA ETCO2 27 BP 120/80 HR 100 RR 18 Temp 38.4°C SPO2 100 RA ETCO2 27 I'm trying really hard not to state the obvious here but what does this trend tell you and why is that important in a patient like this? Even if you cannot perform capnography what does it tell you if this patient is exhaling less CO2 than normal? Where does CO2 come from? Her abdomen is unremarkable except for the lower quadrant and pubis is very red and warm to touch The abdomen is soft except in the lower quadrants and pubis; that is firm to palpate and painful for the patient. Percussion of the lower quadrants and pubis illicit pain Pain about 3-4/10 and sharp No masses or organomegaly, the kidneys are not ballotable She has been vomiting for today only Urine is clear but it hurts to pee No this is not a acid/base imbalance; nor is it a KUB infection or a vascular catastrophe No, ew, hell no!

House Officers (aka House Surgeon) are first and second year Doctors; I should have said "the Doctor" or even "the Nurse" coz you know the Nurse sometimes asks too Are her obs "stable"? Which ones? All of them or only some? Have any changed? Which ones? What does that infer? There is a bit of "not seeing the trees in the woods" (which I am guilty of myself) ... her vital signs indicate significant underlying pathology which if left untreated means she will die within one to two days. With the information presented thus far, what could some possible pathologies be? What information or clinical observations would lead you to discount one over another? She is extremely, forcefully insistent she is not pregnant No current MP; states has not had one for some time

Sterile water shouldn't come in bags for IV infusion; its not the same as normal saline; the first contains only water (H2O) while the latter contains sodium chloride solution (NaCl) Now that I think of it, sterile water is more-than-likely relatively hypotonic compared to standard intravenous fluids (NaCl or Lactated Ringers) weird shit like Hexpan and gello excluded

whoops double post, silly kiwi

Six hours ago, big, well developed and smells like shit Quite correct So we've established her shit is normal, she has lower abdo/pubis is painful and warm to the touch and that she has vomited at least once Here are some repeat obs BP 120/80 PR 100 RR 16 Temp 38°C SPO2 100 RA ETCO2 27 GCS 15 BGL 5 (100mg/dl) If you want to take her to the hospital that's fine but when the House Surgeon asks "what do you think is wrong with her?" what are you going to say? Could her combined obs and physical exam be pointing toward a significant underlying pathology? They might not ... but they might be What could be the source of such serious pathology? ...

LOL @ Child Labour Act (sic) I think we have one or two volunteers who are qualified Technicians and they're only 19 or so, which is very much the exception here. It is good to see with the Degree that the average age is decreasing.

LMP and BM OK Yes, she says it hurts when she pees since she has been "feeling sick" No jaundice or piercings or foul odours that you smell Pain is central, lower abdo/ pubis Normal food, no diverticulitis, no history of abscesses or ovarian cysts What would you look for that would indicate a bowel obstruction? Um, points for recognising the limits of your knowledge or no points for not listing some pathologies you are considering? Hmm

You could try applying if that doesn't work get a Zoltar machine and wish upon it but don't turn into a creepy freak like Tom Hanks did and if that doesn't work hurry up and wait; use the time to go back to school and get some college A&P, chemistry, biology and microbiology done. It'll count towards an Associates Degree and will make you a better provider anyway regardless.

No - he shouldn't have a problem getting certified although he me may; it seems in US any Tom, Dick and Harry the Pisshead can roll up and take the course Yes - he will very likely have a problems finding a job or it will simply be impossible to find one; either because of his age (may be an insurance factor for any potential employer as he is under 21) or his suspended license or very likely both. Tough luck I say on the latter. I know in this part of the world a suspended license shows up for two years if suspended by the issuer or for seven years if suspended by the court; either of these will automatically disqualify you from not only the Ambulance Service (and many other jobs) but also the Paramedic Degree program.

It's one o'clock in the morning and you're called to assess a patient at home. The patient is a 20 year old well developed female who is found upstairs in the bathroom leaning over the loo having thrown up in it. She tells you that she is on two weeks leave from the Army and has felt generally unwell / flu-like for the past two days and it has come on gradually without provocation. Normally lives on base and eats in the camp mess with the other soldiers; nobody else has become sick; despite being in the Special Air Service she has not done anything out of the ordinary in the immediate past that she can think of which might contribute to her being sick and, as might be expected of the military, is up to date with all her immunisations. If you're interested, the New Zealand Defence Force does allow women in combat and in the Special Air Service. Complains of "feeling sick" with "tummy pain" Prior medical history of unremarkable, appendectomy at 10 years and some childhood asthma which also resolved about ten years ago. Takes no regular medicines. No family history that is remarkable. No remarkable social history; drinks occasionally either on-base or off-base in town but only two-three drinks and does not use recreational drugs. She sometimes spends social time with male soldiers off-base but denies being sexually active. Upon examination there is tenderness in her lower abdo which is warm to touch Obs; BP 120/80 PR 90 RR 14 Temp 38°C SPO2 100 RA ETCO2 27 GCS 15 BGL 5 (100mg/dl) You have the choice of leaving her at home or taking her to the hospital Pretty basic - what do you think is wrong, what other information do you want and does she go to hospital or stay at home?

Horses have been used once or twice here with medical gear in the saddle bags; Ambo Revere styles

I just said that. What we were discussing was more the "pseudo hyperkalaemia" in DKA; patients with DKA often require large amounts of potassium as they are infact relatively hypokalaemic (but I know you knew that already). If you push all the potassium extracellularly into a reduced intra vascular volume then remove a good portion of that volume through polyuric osmotic diuresis did you really have actual hyperkalaemia in the first place? I'm putting this in the same basket as patients with cardiogenic pulmonary edema actually being relatively hypovolaemic rather than "fluid overloaded" as the pulmonary edema fluid (often up to one litre) has come from the circulation.

I would highly suspect you are correct and that the polyuric osmotic diuresis contributes to the overall loss of potassium Should this patient need to be intubated then I'd be perfectly happy to use vecuronium in place of suxamethonium because it does not have the same risk profile for hyperkalemia and it's going to be given anyway once the tube is confirmed in the trachea. Now, if anybody here says "ZOMG we can't give people vecuronium because its a long acting neuromuscular blocker and we might not be able to intubate this patient!" is going to get slapped with a heavy object (like a piece of mining equipment) because if you do not think you can intubate then guess what, you shouldn't be bloody trying! Speaking from a local perspective such a modification (i.e. intubating with fentanyl, ketamine and only vecuronium) is called providing treatment not described in the guidelines but is within scope of practice so an Intensive Care Paramedic may do so but must send a note describing why they did it to the Medical Advisor.

Well you could always use Lactated Ringers

Could always mix coffee grounds into a one litre bag of NaCl and put it on the radiator for a lil' bit Kinda like reconstituting ceftriaxone, glucagon or penicillin but kinda not ...

Patients with DKA may appear hyperkalemic because the V H+/K+ ATPase swaps extracellular hydrogen (because of the acidosis) for intracellular potassium as one of the acid/base homeostasis mechanisms. I was taught (which does not mean it is correct) that this is only a "pseudo hyperkalemia" and that patients with DKA are often actually profoundly hypokalemic. It might be DIE WORDS DIE!