chbare

"Rommel... you magnificent bastard, I read your book!" On of the best movies I have ever seen, a classic IMHO. Take care, chbare.

MAP measurements can be used in many situations; however, like any measurement, it is just a number and must be taken into context to the patient's condition. An example of one situation where you can use MAP's to help guide treatment is a head injury. A MAP of 70-100 or more may be helpful with the maintenance of CPP. If you remember the formula for CPP, then you see how MAP can be an important factor in head injury management. On common mistake I see is people treating the HTN associated with head injuries and reducing the MAP. Take care, chbare.

Yep, should have used the esophageal bulb and capnograhy immediately following the initial intubation. After a few minutes of arrest, I would not expect great end tidal readings. The tube may have been in proper place and we were simply looking at the end result of AAA that decided to rupture; however, I would still pull the tube. Take care, chbare.

As I stated in my post, this condition must be ruled out. It is often found in young otherwise healthy people. I would not be surprised to find out this is some kind of conduction or congenital anomaly. Take care, chbare.

It is now under the Department of Homeland Security. I think the branch is Protective Medicine. Take care, chbare.

Better obtain a dig level. Would not suprise me if it is a dig problem. Take care, chbare.

In addition, we need to rule out congenital conduction problems and various other syndromes such as early repolarization, WPW, and Brugada syndrome among others. Any info as to the specifics of his "heart history?" Perhaps electrophysiology/cardiac mapping would be helpful? Take care, chbare.

I am sorry to hear about your needlestick. It does sound like a lower risk and the decision to take the HIV cocktail ultimately comes down to you. I had a needle stick several years ago and decided to take the cocktail. I had allot of diarrhea during the two weeks it took for the ELISA results; however, I felt it was still the proper decision. Take care, chbare.

I am with Ridryder911. No major problems with what I saw. Could have had him on the monitor a little sooner. I am not sure they had the ability to do 12 lead ECG's. Take care, chbare.

rut row raggy!! The lesion must have been a little on the proximal side? Nice, atypical presentation. Take care, chbare.

I am all for shotgunning with labs and diagnostics. CBC, SMA-12, PT, PTT, INR, CK, Troponin, UA with urine drug screen, a 12 lead was already covered (did not see any specific findings for the 12 lead), portable chest, and CT head w/o. Consider an ABG, ETOH, ASA, and APAP. I will take what I can get however. Take care, chbare.

My response was directed at your question. It was one of the key parts of the puzzle. In fact, she ended up getting a whole lot of IV contrast. Take care, chbare.

It looks like somebody pretty much answered the scenario while I was typing my last post. Several events led up to a possible disaster: 1) Upon the initial scan, the hospital staff missed the renal issues and metformin use. 2) After the first scan, the staff still did not identify the problem and the patient continued taking metformin. 3) The following day, the patient was scanned with IV contrast again and still continued on metformin. 4) The prior events were not identified upon the patient's second pesentation to the ER. As is the case in the real world, a chain of several events let to this problem. So, can anybody explain why (physiology) she developed the lactic acidosis? Take care, chbare.

So close I should not say a thing. Simply having a CT scan while taking metformin will not cause lactic acidosis. However, sometimes we do something to help with the view during a CT scan. Say this was done when we CT'd the the chest, then the abd, then the pelvis. Then, we did it all over again the next day. Add in the fact that we are on metformin and continued taking metformin in addition to pre-existing renal issues. This can add up to disaster. I know it is a long shot, but it can happen at Oz General Hospital. What was done durng the CT and how do we explain the pathophysiology of this situation? Take care, chbare.

We are very close to the answer. I agree that it is not common for people to simply develop lactic acidosis from metformin therapy. However, the patient was taking metformin and had known renal compromise. Then, something happened during her stay at the hospital that derailed the train so to speak. It not only happened once, but twice. This is something that should have never happened. What threw her kidneys over the edge? Carefully read the prior posts. Just as in real life, attention to detail can save the day. ERDoc, it was worth a try. Take care, chbare.

this scenario was actually created from scratch. The hospital is sending the patient to a facility that can provide a higher level of care. This is their reason for the transfer. She does have +1 pitting edema to her feet bilat, but this is a baseline finding. No facial droop and the crainial nerves are assessed with unremarkable findings. The patient is very lethargic however. I think a couple of people are very close; however, we need to put the pieces together and come up with a working hypothesis for what happened. Let me know if you need a hint, but I bet if you study the previous posts and do a little research, you will arrive at the answer. Take care, chbare.

Good, we are headed in the proper direction. The question to ask is why indeed. Something acute happened during her stay at the hospital. The question is what. Allow me to throw in an ABG to further muddy the water. PH: 7.29 CO2: 20 O2: 108 Bicarb: 12 Base Deficit: -8 Take care, chbare.

From her prior history you gather the following: -She has a long history of NIDDM. -She has a long history of elevated lipids. -She has a long history of obesity. -She has a long history of HTN and GERD. -She has had a diagnosis of renal insufficiency in the past couple of years related to her diabetes. Her home medications include: -Lisinopril 20 mg po q day. -Ranitidine 150 mg po q day -Metformin 1000mg po bid -Atorvastatin: 10 mg po q day Take care, chbare.

As I remember, there were medication lists and past medical history progress notes in the pile of paper work. :scratch: Take care, chbare.

EMSGeek, do not think I will let you off of this case so easily. :twisted: In the land of Oz, provider level matters not. You will end up having to care for this patient and you along with all of the other participants of this scenario will produce a diagnosis. This is not about being an EMT-B, this is about solving a problem with your knowledge of physiology and research ability. Take care, chbare.

ERDoc, I will take you to the prom. My mother would be so happy if I hooked up with a Physician! Of course, there would be the minor issue of my wife. :-k You have your SMA-7: NA+: 130 K+: 5.8 CL-: 99 CO2: 20 BUN: 80 Creat:20 Glu:288 You place an 18 fr Foley without difficulty and note a scant amount of dark urine. I think the labs may help to explain the lack of a UA prior to your interventions. No rashes or joint pain. Pt has been dizzy however. Vital signs: R: 23 non labored, P: 105 regular, B/P: 178/98, SPO2: 95% on 2 lpm NC, Temp: 99.1. She received Levaquin 500 mg IVPB times 3 during her stay at the hospital along with her home meds. EMSGeek, ERDoc is correct regarding the labs. So, her WBC is a little on the elevated side. Just a side note for the new faces. This is more typical of my scenarios. Some of what will or has occurred may not actually occur in the world as we know it. You see, in many of my scenarios, we live and work in the magical land of Oz where bizarre and magnificent things can occur. More to the point, I try to set you up for a specific learning experience that would be difficult to replicate under typical circumstances. I want people to look at labs, Goggle, and really think about the physiology of the patient in question. Sure, this may not reflect reality; however, I hope the learning experience will help you in your practice as a provider. Now, where do we go from here? Take care, chbare.

No UA, she has not given a sample. The WBC is 12.8. Take care, chbare.

ERDoc, I agree. This is simply a way of making everybody dig a little deeper in their thinking and history gathering. From the chart you note that she was worked up in the ER and also had CT scans of her chest, abd, and pelvis. From the notes, nothing significant was noted, so she was admitted. The following day, she was feeling a little better and had repeat CT scans of her chest, abd, and pelvis with negative findings. She was discharged that HS and continue on her home meds. The following day, her husband brought her back into the ER with complaints of lethargy. She has had lab work up and IV therapy only for her current ER course. It looks like there are a few old progress notes from her primary care provider with past history and medications. Take care, chbare.

The ER is a zoo and the patients nurse is a travel nurse that just came on shift. She has no idea what is going on with the patient and the patients prior nurse is long gone. The only report you receive is that the patient was discharged home yesterday with a dx of gastroenteritis and was brought back in by her husband because she was not feeling well. The nurse takes off into another room with the other ER staff and the ER doc. It looks like they are working on a bad patient and are preparing to RSI. There is a jumbled stack of copied paperwork in the patients room. The BGL performed today was noted as 288mg/dl. Initial presentation and assessment: Lethargic 56 year old female patient with a patent airway supine in bed. Neuro: Lethargic, moans with verbal stimuli, opens eyes and moves all extremities with verbal command, only answers questions with simple yes no answers. HEENT: PERRL, EOM's intact, atraumatic unremarkable exam. CX: Unremarkable atraumatic exam, lung sounds clear with equal bilat excursion. Cardiac: No gallop, murmur, or muffled tones noted, sinus tachycardia at 103 on the monitor without ectopy. Abd: Unremarkable atraumatic exam, soft and non tender to palp times 4. Pelvis: Unremarkable atraumatic exam. Back: Unremarkable atraumatic exam. Extremities: Unremarkable atraumatic exam, cap refill 2-3 seconds distally, moves all extremities, patent 18 ga IV to right FA with NS at KVO. Skin: Pale, warm, non-diaphoretic. History (HPI) from the husband: Patient was sick for a couple of days with nausea and vomiting. Went to ER and was worked up. Admitted with "gut infection." The following day she was feeling a little better and worked up again. She was sent home that night and started to "act strange" and was taken back to the ER today. Past Medical History from the husband: NIDDM, HTN, Elevated lipids, obesity, and GERD. Medications per husband: "Sugar pills," "blood pressure pills," "cholesterol pills," and "stomach pills." Take care, chbare.

Perhaps a Helical/Spiral CT to look for PE? Unfortunately, the problem with altered renal function is impaired ability to clear certain types of contrast media. What was the differential on the WBC? This can at least give you a general idea of the organism involved. (Bacteria, virus, parasite.) Take care, chbare.