Kiwiology

I agree with Wendy but thank you anyway for an interesting case, we don't do paeds or gynae much

Polymorphic VT?

*facepam This brother is a sister

Of course, for I am Kiwi! ... and you're just a Consultant Physician, the two pale in comparison Love you Doc ... now make with teh kettymainz

I dno mate I'd rather rock up in the GSA-HEMS helicopter and make you my bitch, because I would be uncomfortable at being the Registrar's bitch so need to make myself feel big by hassling you. I would rather go up to Queensland and work with Care Flite; the bro up there is a Aeromed Reg who is like "yeah I'll just sign things, you can do the thinking" ... works well for me. Oh, and you expect me to drive a Vanbasprinterulance? *shakes head sadly

On reflective thought, our local hospital does not have a Radiologist on duty after 5pm (must call one in from home to get a CT scan) and the surgical service is probably provided by the Surgical House Officer with an on-call Registrar (who is likely on-site asleep in the call room). The Emergency Department will be (now as it's > 10pm) staffed by a House Officer who is probably going to have kittens when we take this lady through the doors. Based on the immediate facilities available (we have 24 hour theatre, anaesthesia, diagnostic microbiology, ICU, radiology and obstetrics/gynae but several Consultants will have to be woken) I will call this lady status one and place an early RT call to the hospital (before leaving scene) that they need to wake people up. Happy now?

Here ya go Nat; just for you, it's the most appropriate thing I could think of seeing as how you make this place great! Great stuff, way to go, I'm proud of you!!!!

The nattle is correct; I am so proud (*tear); atrial fibrillation is the only irregular irregular rhythm on the face of the earth (my EEG excluded) I know I'm stating the obvious but atrial fibrillation is caused by multiple ectopic atrial foci whereas atrial flutter is caused by only one ectopic foci Why did I state the obvious you ask? it's not because I like demonstrating my knowledge (seriously, its not) it's because atrial flutter can easily be distinguished if we think of it in terms of where the electrical impulses are coming from; it has polymorphic sawtooth waves (like giant P waves) compared to messed up bizzare fibrillatory waves Atrial flutter is regularly irregular whereas AF is irregularly irregular If you want some of my ECG ebooks you know where to find me (hiding in the corner with a toil foil hat to keep the aliens away and trying to bike lock up my soul because the sermon at church on Sunday was about how Satan wants to steal my soul, wait, does Satan have bolt cutters? poo ... bloody Satan who gave him bolt cutters?) This is atrial fibrillation, notice the polymorphic fibrillatory waves? This is atrial flutter, notice the monomorphic waves?

I'm not trying to be an ass and am quite aware that 38mmol/l is about 800mg/dl (doing a quick mental conversion of 40x20) whereas normal is 80-120mg/dl Several times it was stated that the blood sugar was in mmol/l and that should have fired off some neuronal activity with the bloke to go "what in the bloody hell is that thing I've never seen it before!" before going "all I've ever been taught is mg/dl so it must be the same" because one day he might land himself in hot soup doing that. I could say to you "ZOMG WTF this bloke's Trop-T is 100!" and you'd probably keel over and die in horror when in fact I meant 100mcg/L which is 0.1mg/L which is normal. If you're referring to me I was basing my thoughts on the limited information I had at the time. I'd be more than happy to manage her airway with an LMA and would prefer to do this than RSI. A patient who is poorly oxygenated despite adequate ventilation is not the best candidate for RSI because ventilation is a separate physiologic process and not mutually exclusive to oxygenation. You can be ventilating perfectly but if I come along and take out all your Hb then your oxygenation is going to be a bit nunngered because what, about 2% of oxygen is transferred in the blood as dissolved oxygen? I would certainly consider RSI in this patient if she was poorly oxygenated with an LMA, if her unconsciousness did not rapidly improve and we had suitable resources available. Her SPO2 is 93% at the moment which is quite low. I am more in favour of just taking her to the hospital rather than trying to bugger around tubing her. You are correct that in DKA the high respiratory rate and increased tidal volume is an attempt by the body to buffer off the excess acid being produced by the beta oxidation of free fatty acids that have been released from the adipose tissue into Actetyl CoA which is then transformed into ATp, NAD+ and FAD(H2)... blah blah blah gluconeogenesis and kreb cycle oh look my eyes are bleeding in disgust at having written something about biochemistry. I'd really rather not cannulate this baby if we can avoid it; oral fluids as tolerated and if not then I guess it's a drip and 10cc/kg This is why I am not a paediatrician

I initially considered this as well but discounted it because of the whole c-section thing; I think I might have been a bit premature in doing so perhaps If she had POC retained she'd easily turn septic; most likely she has severe sepsis rather than septic shock; *puts ceftriaxone back in hip pouch, one day friend... one day I am still keen to call this lady status one (super crookTM) but I have not quite convinced myself that she has an immediate threat to life

We use a numerical scale between zero and four to describe the threat to life the patient has. Status 0 is dead; status 1 is immediate life threat; status 2 is potential life threat; status 3 is unlikely life threat and status 4 is no life threat What are the patients vital signs including SPO2? what is her work of breathing? I want to call this lady status one but she doesn't quite seem to be sick enough If indicated by SPO2 I'd put her on some oxygen, put a drip in (doesn't have to be a big one) and look at moving towards hospital Is there somebody to look after baby at home? i.e. dad or auntie or neighbour? I want to begin to get her moving toward hospital if she is this crook

No this patient is not "stable"; based solely on your information she is right now what we call status two or potentially life threatening problem It could be any one of 400 things but right now my suspicion is high for a post-operative infection (specifically pneumonia/RTI) or another surgical complication could be anything from the sniffles to a bloody great DeBakey clamp left inside her. General impression? (by which I mean well perfused etc or does she look "crook" (sick) i.e. shut down?) What is her obstetric history? why did she have the c-section? When did this fever start; did it just "turn up" or did it come on gradually? has she taken anything for it? What has precipitated the SOB? has she been coughing up any sputum (if so what colour) or anything else? How do her lungs sound? What is meant by "shaking" i.e. any seizure activity (I'm thinking it's just because she is in the latter stage of fever and is feeling "cold") How does her surgical wound look? is it pink and nicely sutured up or is it oozing and smelly and discoloured? Observations including SpO2? I'd be inclined on transporting to a hospital with gynae capability even if we have to get the Consultant out of bed.

No I did not, I never made it out to NYC again; I did recieve a huge package of patches and such like from Robert; one of them is a desk ornament My summahz workn at camp upstate i gawt real gud at tawkn like dis yo?

LMA is the laryngeal mask airway aka lesbo lolly or fanny on a stick; it is what is used at the sub-ALS level (ACP/ICP/SRP/ECP) around the world for airway management. They were first introduced here in early 2005 and generally speaking perform very well; in fact outside of RSI if a patient is ventilating and oxygenating well via an LMA it is being discouraged that it is swapped for an endotracheal tube in the field. Equivalent in US EMS would be the King airway which some places have; it pains me greatly that supraglottic airways were included in the EMS Agenda for the Future as an "Advanced EMT" intervention; I can teach a bloody 5 year old the critical thinking and skill require to put in an LMA and it has been a bottom-tier thing here for at least 5 and probably closer to 7 years.

I'm not being an ass, you said it was quicker to stick in a drip and infuse some sugar than to put in an LMA in this patient So naturally my next question is why suggest it if you don't think it's a good idea?

Yeah but that priority 1 rush on the bus for the RTA with entrapment confirmed pin is just going to turn into another turf war between FDNY and NYPD ESU. As for the FDNY*EMS Lieutenant boss for the bus he can come help clear c-spine or click both halves of the scoop stretcher together strap the patient to a long board with head blocks and tape Man it's sooz difficult to tawk authentic yo?

Right, but you think it's a good idea to give somebody D50 when they have a BGL of 38 mmol/l? Your use of the term "sugar problem" leads me to wonder if you understand the pathogenesis of DKA and why D50 (or 10% glucose) is not appropriate in this situation?

I was taught milk as well I was also taught the NREMT tests do not test complex cognitive information processing and require only simple behaviouristic based responses to standardised stimuli Pass in Adult Teaching class for the win

Well you just proved you're not competent. Giving somebody with DKA who has a blood sugar of 38 mmol/l dextrose is bad glycolojuju Oh, and D50 went out of fashion with MAST pants and long spine boards; 10% glucose is where its at increasingly worldwide

Potentially yes, but in the mean time ... Oh and I don't really consider the LMA an "advanced" airway, its so bloody simple you can teach a firefighter volunteer Technician to put one in and maintain competency.

fur suvun nine hundheld calls Sudney, one male patient, appears to huv bun assulted with a bunt objuct ....

LOL, this. 10 Zebra for assignment k? 10 Zebra, negative, assessing walk up at Starbucks, will advise condition Central calls 11 Young, for the assignment? 11 Young, negative, also assessing a walk up at Starbucks, conditions mochalicious! I so crazy

Sigh! *puts suxamethonium back in hip pouch, sorry bro not today my friend! Mum has DKA Sounds like baby is just dehydrated, change diaper and see if oral fluids or milk (have a look in the fridge for some) is tolerated

I hear getting sent to the Bronx is worse than getting fired ...

For right now mum is status 1 (immediately life threatening problem) Need back up on a 1; two Technicians will do but an Intensive Care Paramedic would be ideal Put in an LMA and ventilate, if her SPO2 improves I'm happy to manage her airway with the LMA if not I'd be inclined toward RSI however in saying that I'm keenly aware we are only a two person crew and there is another patient plus I don't know if the cause for unconsciousness will rapidly improve e.g. GHB or alcohol poisoning, post seizure. If her lungs are clear then stick in a big bore drip and give one litre of fluid as a bolus Secondary survey and a full set of observations please My impression for mum is either a neurogenic insult (e.g. stroke) or a drug overdose but possibly something environmental if we have two crook patients in the same home As for baby I'm really crappy with paeds so I'm going to be guided here more by clinical guidelines than actual knowledge ... um, general impression? work of breathing? activity? cry/grimace? a few basic obs; heart rate, SpO2, AVPU?