Kiwiology

Isn't nitrate a vasodilator? Partial credit, we don't use all of them Trust Emergentologists with four years of post-graduate training to need a translation guide ....

Shit I'm too rooted to have a squiz at what Dwayne wrote, heaps rooted bro, time for a kip ....

Chur bro it's totally nunngered to buggery; I would seek refuge in the Great Mitten but I might get shot or stabbed by gangbangers then wait an hour for an ambulance then be seen by a Consultant Emergency Physician who only has four years of post-graduate residency training .... man I'd be one crook bloke then!

Bro I'm heaps nunngered .... especially since the House Surgeon is overworked, underfed and dangerously burnt out and the Registrar died last week from fatigue and MRSA. I'm never going to get my Consultantologist thingo now!

I note it says bacon is used because of "special circumstances" ; I would like to know what exactly counts as special circumstances?

Which is no different than any other patient The history is piss poor; did you ask for further information? No it's not, that is the bitches way out ... do you know that in South Africa, New Zealand, Australia and the UK there is no medical control?. What do you think we do? We use our brains Remind me again how adrenaline causes respiratory alkalosis? or how respiratory alkalosis causes cardiac symptoms? If you want to do no harm perhaps you need to seriously invest in a greatly expanded education of pathophysiology and pharmacology; in a very similar case the treating clinician was found to have acted without reasonable care and skill having inappropriately administered adrenaline to a patient he thought was having "anaphylaxis". Of all the drugs in the ambo bag of tricks adrenaline is one of the most dangerous but also the most life saving. You must use it wisely. .

The fail ... it is so strong. You state yourself this patient showed no signs of anaphylaxis and yet you jack her up with adrenaline, worse yet, IV adrenaline? Please don't use eponymous; I had to look up what Levine's sign was ... and if she is clutching her chest do you think it might have had something with that IV adrenaline you put into her? Sounds to me like a little bit of pseudo anaphylaxis and certainly not something that is a candidate for IV adrenaline or DPH; if the patient actually had angioedema with stridor but without systemic involvement (which is not unheard of) then some nebulised adrenaline is appropriate. There is good empirical evidence that adrenaline is overused in patients with asthma and anaphylaxis. Yes, early administration of adrenaline is critically important in patients with anaphylaxis but if you're giving this sort of patient adrenaline then I would very seriously hope you are not teaching this same clinical approach to your students. There was a case here a few years ago of a Doctor giving a patient adrenaline for "anaphylaxis", the patient ended up suffering myocardial damage and the case was referred to the Health and Disability Commissioner as a breach of the patient's right to receive care with appropriate care and skill.

Bro, missed opportunity to order lots of expensive tests and ca-ching cash in on those greedy money hungry HMOs! Haven't you passed the Part 1 Exam from the College of Kiwiologists yet?; I expect better from my Kiwiology Registrar bloody hell I need to pay for my private jet somehow! See, I told you the body was super smart; it's like hey man you don't want to feel what's happening up in your noggin right now because it's getting pretty buggered which means you're more than likely going to suffer and/or end up massively debilitated so hopefully if we keep it pain free and this ischaemia continues you'll just drop dead and never know what hit you! Oh, you gotta learn how to spell man seriously!

Love you too Dwayne now where the fuck is my Mongolian BBQ? I agree You know the people at the centre for the developmentally disabled tell everybody they turned out awesome right?

Ah yes you are talking about a General Practitioner, they're Consultant Physicians, I thought you were referring to the Doctors at the emergency department. Interestingly, no Physician has admitting rights except the particular service who is accepting the patient - if a GP wants their patient admitted they must call the hospital and speak with the particular service e.g. internal medicine or cardiology; and then it's usually the Registrar or more frequently, the House Surgeon attached to the particular tream.

Gosh I wish we had your medical system, here you only get a Consultant Physician if you are really crook; rest of the time it's the Reg or if they have died from fatigue then a dangerously underfed, overworked and chronically burnt out House Surgeon. Dear Jeebus, let me get into medical school so I can work in said system and earn enough money to buy a boat ...

Not sure what you mean by "narrative" but a medical note will look something like past history, current presentation, assessment, impression/diagnosis, treatment, plan and discharge information; for example here is one I prepared earlier ... PHx - hangs around internet forum frequented by Doctorates of Emergentology Hx - last 2/7 increasing anxiety ++ while on frequented forum, +++ when hassled about accent and funny speeling by Doctorate of Emergentology; SOB/hyperventilation/tight feeling in chest ... no LOC O/E - no sympts, resting comfortably, skin dry/warm, no CP, ECG SR, P70 S1/S2 OK nil added, lungs clear. CBC lipids lytes OK. Imp - ? psychogenic Plan - Counselled to stay away from bad, evil Doctorates of Emergentology on internet forums, PO diazepam PRN, d/w Consultant Forumologist, ref for O/P F/U 4/52 Rx - stat diazepam 2mg PO 1 x tab prn not to exceed three in 24 hours, 10 tabs no repeats /S/ Kiwi MBChB ED SHO NZMC 18789 Whacker We don't know if she had a history of hypertension and was on a bag of blood pressure lollies she left at home so 180 might have been normal for her; we picked up a bloke from medical centre who had BP of 220 and for him that was just normal. I do appreciate what you are saying tho in that a headache is one symptom of an acute neurological event or severe uncontrolled hypertension however if the hospital have had her glazed in that big donut machine and not found anything then hmm Medicine is both an art and a science; and is often times not that artsy or scientific .... if we can rule out serious pathology (stroke, cerebral haemmorhage, space occupying lesion, tumour etc) then we sort of default to the "we're not sure" diagnosis and provide appropriate symptom relief which in this case may have been appropriate or it may not have, she might be dead on the kitchen floor we don't know.

Snicker The solubility of a gas in a solvent (like carbon dioxide in blood whodathunkit?) is proportionate to temperature; so lower temperature = less soluble so there's your lower ETCO2 .. hmm I feel like I just stated the obvious right there? Other than that I have no idea and am going to leave now before that bloody emergentology doctorate fella comes in here complaining about how my pointing out basic science molested him once again sheez ...

It's very common for the Ambulance Service around the part of the planet that is ripe in Consultant Kiwiologists and some of those Aussieologists (although I don't trust them bastard Aussieologists ....always wanting to go to the beach) to transport people from home to hospital, hospital to home or to outpatient appoints where medically necessary. We have a separate branch called the Patient Transport Service (PTS) and in AU it's called Non Emergent Patient Transport (NEPT). It may have been part of their contract with the hospital if they're a private service or a private hire where the patient paid for it. UK House Surgeon: Hey did you hear the bloke in two screaming bloody murder? Me: Yeah, something about jelly; sounded a bit nunngered, I let the Reg handle it, jelly expert that bloke is Consultant: Why did you give him gelofusine for? Me: Where you from again mate? Consultant: Ketchum, Idaho Me: Nah bro you can't catch 'em, over your head they go, not gelofusine, jelly, like the wobbly desert y'know? I do hear it's pretty backwards in Idaho ....almost like upstate NY where volunteers don't have a blood pressure cuff Dramitisation - may not have happened True, seems pretty unusual

You are correct, I am a scary mother fucker and now I'm going to eat your children for your mistake ... I know for a fact you blokes have NEPT just like we have the Patient Transport Service ... some bloke in a van with three days training is a good money maker for giving Nana a lift home ... Hey come on now, you know I don't speak Spanish and the overworked, underfed and dangerously fatigued House Surgeon had to go on his Resident Medical Officer Association mandated break ... what, I can put on a pair of scrubs and wear this listening thingo around my neck and pass for a doctor? Bloody hell it's not my fault the Registrar died from fatigue last week and we haven't been able to get anybody else to cover. Shit man we are trying to provide healthcare for free-to-the-patient here! Correct. Isotonic fluid will not raise blood pressure in the normal person who is not volume depleted because the body has this awesome capability of maintaining pOsm 300mOsm/kg (well in reality it's (2[Na+] + (glucose/18) + (BUN/3)) but this isn't USMLE Step 1 here ... and if it were the answer would be "ask the Registrar who died last week from fatigue" and if you crazy American's did your bloods in mmol/l like we do it's just (2Na+) + Glucose + BUN)) so um yeah getting back from our chemistry lesson the extra fluid will just get sent to the kidneys and pissed out. Honestly if it were me I'd have had words with the Doctor, if need be speak to the Consultant Physician because in that state the lady is not in a fit state to leave the emergency department; she is an undifferentiated patient who needs further investigations. I would expect more, even out of an at-the-worst a dangerously overworked, underfed and chronically fatigued House Surgeon. Don't expect any more out of a Kiwiologist tho, those guys are really bad at killing people!

This is a pet hate of mine, really it is, it just fucks me off no end seeing people forcing oxygen down everybodies gob by non re-breathing mask and makes me want to hit them with a blunt object to the noggin ... *eyes oxygen tank, hmmm, well it would be of more benefit at least than it is to the patient! The whole issue is quite complex involving arteriolar and capillary tone regulation, chemoreceptors, oxygenation vs ventilation, hypoxaemia both chronic and acute, hyperoxaemia, the electron transport chain, hypoxaemia vs ischaemia, some basic physics and a bunch of other crap that I can't be arsed typing up now. The 20 on it is this: you can give somebody too much oxygen, it can be very harmful and the good ole ambo trick of "more is better" does not apply here; oxygen is a treatment for hypoxia not a 'general treatment'

Your drug shortage is because Kiwi can't break a glass ampoule properly .... so um goes through lots of them; oh and my finger is bleeding now, should I call the 911? Hydromorphine is good stuff, the UK use it but nobody down this end of the plant does.

I don't like those "Paramedics make intubation worse" studies and have some concerns about method and confounding variables But I do have a man crush on Gareth Davies from London's Air Ambulance (maybe Hank Scorpio too ssssh)

Stop stealing my funny spelling!

Several fold issue here; dosages used for RSI are much higher than for seizures and patients requiring RSI are often very unwell with low physiologic reserve and/or have lost the ability to auto-regulate their cerebral perfusion. Administering large dosages of a medicine which is known to cause hypotension and cardiorespiratory depression in a patient who is unwell is not a good idea. Midazolam can be used in combination with other medicines for intubation such as fentanyl (not the best idea but OK for somebody who is cardiovascularly stable) or ketamine (a much better idea especially for patients who are significantly shocked or unwell).

Midazolam assisted intubation ("sedate to intubate") has been banned by any self respecting ambulance service long ago; we had it in the 1900s but hell we had MAST pants and ideas that long spine boards and big volumes of crystalloid were good ideas too ... I know of only three jurisdictions globally that have what you could call a good RSI program; New Zealand, Victoria (AU) and Alberta (Canada). RSI done well is bloody brilliant, RSI done badly kills people. In each place mentioned RSI is available only to a group of highly educated, highly experienced practitioners with sufficient exposure to maintain competency; for example here and in AU you need five to six years of education and experience before you will be considered for the RSI program. In the UK there is much kerfuffle about RSI and the whole SECAmb CCP vs the BASIC Doctors thing ... I think Doctor-led RSI is appropriate for the UK If you don't have neuromuscular blockade you shouldn't really be intubating people who are not dead (very unconscious with GCS of 3); and then you shouldn't really intubate those people anyway ... prehospitally at least

From somebody who has been there; the NREMT want proof you have equivalent knowledge and skills as a Paramedic graduate attested from a US Paramedic program and you can take the test. Nobody I found was willing to give me such unless I completed their entire program. And throw that JRCALC book away, in most of California the standing orders not requiring "base hospital" contact with the medical control physician are like one page long! Tell you what, find me some 9 week trained ECA/ECSW to be my bitch and I'll take your spot in the UK; I might even be able to scoff down some fish and chips on the way to that suspended; nee naw nee naw mm good batter oi fella go left up here at the lights, red base november 100 on scene sort of thing ... (taking the piss)

with the federalisation of health practitioner regulation under the Australian Health Practitioner Regulatory Agency hopefully it sets a vehicle for ambo regulation in AU and it's been talked about for nearly 10 years here but only finally happening now BEorP are you at UQ mate, if so lets have words, i am srsly looking at the MBBS program there

or you could just put the recommended amount of air on the cuff into it? ... or is it only the LMA that has that? yes its a problem here too we put way too much air into the cuff of an endotracheal tube and y'know patients end up with tracheal stenosis n all that fun stuff oops looks like ima needed for a Kiwiology consult best nick off

True. Why because on the surface I appear unwieldy arrogant, impersonal, detached and cold? And that I cost five grand a consult?