Travelling Soldier

[Eydawn]

Seriously? The information you've given me indicates need for a full pelvic workup and lab draws. She's got a fever, trending upwards, pain, and indication of infection. I have no idea what hyper-resonant areas mean, as that's not part of my standard physical assessment.

So, smartarse, what is it already? Seriously, these signs are so vague/broad as to be of almost no help to the average prehospital provider...

Wendy

CO EMT-B

[Chief1C]

I asked if there was any problems urinating, discharge, or odors - you said no. I may have finished the EMT course, prior to taking hundreds of hours of additional courses, about 159 months ago.. But I do recall that our duty isn't to diagnose. Sure, you can rattle off a definitive diagnosis sometimes and be right on the money. But will I write it down? Absolutely not. B/c if.. IF.. I were to end up in a court room, what do I say, when they ask for my medical background, to base my diagnosis on? It makes for good and inappropriate conversation during dinner, and that's about it.

This isn't a scenario, this is a little twenty question mind-fuck-game of yours. And I'm no longer interested. A good scenario has a curve ball, but you're just dropping the ball in the storm sewer, before you even pitch it.

[Pavehawk]

I have to agree with Wendy, although the clinical picture paints PID (and or associated complications) you say she says she is NOT being sexually active (again is she being truthful?). She needs a work up that includes labs (and an HCG cause Im still going to R/O ectopic), a pelvic, ultasound (especially if the HCG is up), etc. Does she have an IUD in place? Does she douche frequently? History of STD? As I said earlier the differential for this is long. She may even have developed a tubo-ovarian abcess secondary to salpigitis and require surgery. Bottom line she needs a hospital and a work up.

I also have to agree with 1C. Kiwi I think you have a lot of knowledge and are passionate about your job. You do come across as a bit of a "clinical bully" trying to beat people up with your impressive array of knowledge and playing "I know this you don't therefore you're a poor medic" You copped an attitude with me... "a common misconception" well that's your opinion and you can certainly voice it but your bedside manner, so to speak, sucks. I don't like condecending attitudes and I would bet most other folks here don't either.

Anyway like 1C Im done playing Kiwi's "Look how smart I am" changing scenario of Gyn doom. Thanks for the scenario bud have a good day!

[craig]

kiwi

question........guarding and pain on palp of abdo..correct?

the trends on the vitals that you have listed are stable except the increases in the temp of the patient..........is this an amnomially or is the patient getting warmer? ie infection

[Chief1C]

I said PID!?

Extensive knowledge my white Irish ass. I may "only" be an EMT, but at least I have thirteen-plus damn years of effort behind each one. You're looking this stuff up in books and on websites.

[Kiwiology]

kiwi

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!

question........guarding and pain on palp of abdo..correct?

the trends on the vitals that you have listed are stable except the increases in the temp of the patient..........is this an amnomially or is the patient getting warmer? ie infection

Yes, infection, see below

Of course, she could be lying about that too.

She could be, but it's easy to have a squiz and note a surgical scar

Seriously? The information you've given me indicates need for a full pelvic workup and lab draws. She's got a fever, trending upwards, pain, and indication of infection. I have no idea what hyper-resonant areas mean, as that's not part of my standard physical assessment.

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

So, smartarse, what is it already? Seriously, these signs are so vague/broad as to be of almost no help to the average prehospital provider...

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".

But I do recall that our duty isn't to diagnose. Sure, you can rattle off a definitive diagnosis sometimes and be right on the money. But will I write it down? Absolutely not. B/c if.. IF.. I were to end up in a court room, what do I say, when they ask for my medical background, to base my diagnosis on? It makes for good and inappropriate conversation during dinner, and that's about it.

Are you serious? Did I ask you to "write it down" for possible use in court?

This isn't a scenario, this is a little twenty question mind-fuck-game of yours. And I'm no longer interested. A good scenario has a curve ball, but you're just dropping the ball in the storm sewer, before you even pitch it.

Well fuck you too

I also have to agree with 1C. Kiwi I think you have a lot of knowledge and are passionate about your job. You do come across as a bit of a "clinical bully" trying to beat people up with your impressive array of knowledge and playing "I know this you don't therefore you're a poor medic" You copped an attitude with me... "a common misconception" well that's your opinion and you can certainly voice it but your bedside manner, so to speak, sucks. I don't like condecending attitudes and I would bet most other folks here don't either. Anyway like 1C Im done playing Kiwi's "Look how smart I am" changing scenario of Gyn doom. Thanks for the scenario bud have a good day!

OK, you go and believe that ... I am not even interested in debating this with you.

Edited March 27, 2012 by Kiwiology

[Just Plain Ruff]

I for one Kiwi definately do not want to see you shower so keep the video or the pics to yourself.

[Eydawn]

You most certainly did edit out the info about lactaremia and leukocytosis shift. I would like to know, in the absence of a blood pressure drop, how we were to determine prehospitally that this woman was septic without blood cultures? Her rising fever, to me, indicated an infectious process, but I was also more trending along the lines of abdomen-focused infection, as that is where all your s/sx were currently clustered. The CO2 changes are so subtle as to be non-diagnostic in the absence of actually knowing what's going on with her. You knew, therefore your brain went "Oh, it's obvious! So X should indicate Y" when in reality, all we see is Y, with no real idea of the X causative factor...

You can get a spiking, high fever with endometritis and PID, as well as with a severe enough UTI (the vomiting made me think kidney infection secondary to untreated bladder infection) that could be secondary to a vag infection of some sort. The lower abdo tenderness and redness to me doesn't scream perforated bladder and sepsis, it says "STD" and/or "vaginal infection" and/or "PID" and/or "untreated bladder infection."

There's a reason GYN problems are such a fustercluck. There's too much crap clustered down there that, when affected, presents with some pretty damn similar presentations.

I would say the important things for prehospital providers to identify in this scenario are as follows:

1. There is an active infection that is worsening as evidenced by the rapidly increasing fever, pain and redness.

2. This woman needs to be transported for further evaluation pronto.

3. This woman is in a precarious position with regard to occupation and may not be totally forthcoming about pertinent medical history, and needs a nice, safe, quiet room with a social worker or RN that has good patient rapport to ask those questions if we've any hope of getting an honest answer.

Forest for the trees, my arse! Things are obvious to you when you know the answer. Sorry, man, but those symptoms don't scream sepsis to me. Especially without blood cultures.

Wendy

CO EMT-B

[Just Plain Ruff]

i've got to say that with the soldier adamantly denying the sexual activity that would have crossed illegal abortion off my list and I would not have pursued that line of questioning any further and still have transported her and let the ER deal with it.

I would have also told the ED when they asked me the question about what I thought was wrong with her I would have told them "I don't have a bloody clue, that's what I brought her to you to figure out" which is why they have the Ultrasounds and all that fancy labs, xrays and all that other megadollar equipment that has yet to grace the insides of the ambulances yet in the convenient Dr. McCoy tricorder sized boxes.

There was no way we were going to guess a botched abortion in a million years.

[ERDoc]

This is why any woman of child bearing age that still has a uterus and ovaries is pregnant until proven otherwise. Anyone with a fever, abd pain and rigidity needs further evaluation.