# Playtime Peculiarity



## MrBrown

It's a bright, sunny day; children are running round enjoying recess and all is quiet at the ambulance station allowing for much newspaper reading, sleep catching up on and telly watching.

You are sent to a local primary (elementary) school for an odd job.  The teacher reports that one of her students, a seven year old girl, came back into class after recess.  The child stated she felt unwell and about 10 minutes later became unconscious and began to sieze.

Although the siezure subsides with intranasal midazolam the girl is deeply unconscious and has vomited profusely.  There are no signs of trauma.  

BP 90/40
RR 8
PR 40
SPO2 93%
BGL 2.5mmol/l (~50mg/dl)
ECG sinus bradycardia

No history of illness lately the child has been well and nobody in the school or family can think of anything.  You are 90 minutes by road from a paediatric intensive care facility and the local hospital is having thier Christmas party so they are closed.

The teacher states she saw the child come out of the bathroom during recess.


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## Veneficus

MrBrown said:


> It's a bright, sunny day; children are running round enjoying recess and all is quiet at the ambulance station allowing for much newspaper reading, sleep catching up on and telly watching.
> 
> You are sent to a local primary (elementary) school for an odd job.  The teacher reports that one of her students, a seven year old girl, came back into class after recess.  The child stated she felt unwell and about 10 minutes later became unconscious and began to sieze.
> 
> Although the siezure subsides with intranasal midazolam the girl is deeply unconscious and has vomited profusely.  There are no signs of trauma.
> 
> BP 90/40
> RR 8
> PR 40
> SPO2 93%
> BGL 2.5mmol/l (~50mg/dl)
> ECG sinus bradycardia
> 
> No history of illness lately the child has been well and nobody in the school or family can think of anything.  You are 90 minutes by road from a paediatric intensive care facility and the local hospital is having thier Christmas party so they are closed.
> 
> The teacher states she saw the child come out of the bathroom during recess.



reply in PM so others may play.


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## jrm818

Clear case of simple hypoglycemia, give her some sugar, obtain refusal, back to TV.

What's that - not an interesting enough scenario?  Ah well, I guess there must be more to it than that.  Here's my whack at it...


I have a lot of questions initially, but a couple of things need to be worked on while we investigate.


Immediate tx: Everything's going a bit slow.  She needs some help in the respiration department, and I think I'd call her borderline hypotension and AMS constitutes "symptomatic" bradycarda (although the bradycardia I'm sure is a symptom itself).  Try some atropine?  Bp is a bit low, but I bet that's at least partially her insufficient HR to blame.

Her sugar is on the low side, but not so low that I'd think it's the source of all her woes.  Still, she should get some IV cake frosting.

Questions:

Any chance of getting a temp?

Lung sounds?  

Vomit color/consistancy?  Food particles in it (has she been eating?)

Pupils?  Any posturing?  Withdrawal to pain?  

no medical problems/allergies?

What did the seizure look like?  Tonic-clonic?

Any physical signs of medical problems?  Rash, obvious physical oddities, etc.

We don't happen to be near a farm/industrial area do we?  She vomited, but is there a lot of other fluid in the airway (salivation?)  With the bathroom hint/red herring, and depending on the rest of the assessment, cholinergic symptoms are jumping out at me...


DDx: no strong thoughts yet, so in no particular order:

occult head injury
non-traumatic acute intracranial event 
New onset very bad seizure disorder
infection
SLUDGE
something else entirely


Oh, and give her high flow O2


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## Veneficus

jrm818 said:


> Clear case of simple hypoglycemia, give her some sugar, obtain refusal, back to TV.




Test taking skills:

When one of the most knowledgable people on the forum posts a scenario, think zebras not horses.


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## MrBrown

jrm818 said:


> Any chance of getting a temp?



Normal



jrm818 said:


> Lung sounds?



Coarse, nasty sounding crackles; she has probably inhailed a lot of vomit



jrm818 said:


> Vomit color/consistancy?  Food particles in it (has she been eating?)



Watery brown consisting of bits of food (fruit and a partially digested sandwhich) and normal stomatch contents.  



jrm818 said:


> Pupils?  Any posturing?  Withdrawal to pain?



Sorry Brown did not post a GCS ... it is 3.



jrm818 said:


> no medical problems/allergies?



Are acute onset siezures, hypo and unconsciousness medical problems? 

None.



jrm818 said:


> What did the seizure look like?  Tonic-clonic?



Tonic-clonic siezure that lasted about 5 minutes until quelled with some intranasal midaz



jrm818 said:


> Any physical signs of medical problems?  Rash, obvious physical oddities, etc.



No



jrm818 said:


> We don't happen to be near a farm/industrial area do we?



Nope we are in Pleasentville 



jrm818 said:


> occult head injury
> non-traumatic acute intracranial event
> New onset very bad seizure disorder
> infection
> SLUDGE
> something else entirely



None of the above but what is SLUDGE?



jrm818 said:


> Oh, and give her high flow O2



But of course! 



Veneficus said:


> Test taking skills:
> 
> When one of the most knowledgable people on the forum posts a scenario, think zebras not horses.



Is that a crank pipe in your back pocket mate?


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## jjesusfreak01

Uncontrolled menstrual bleeding during early puberty, leading to loss of blood volume and hypovolemic shock. I would expect a lower BP and a higher pulse rate though if that was the case. Maybe this with mitigating factors...some sort of drug use?


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## MrBrown

jjesusfreak01 said:


> Uncontrolled menstrual bleeding during early puberty, leading to loss of blood volume and hypovolemic shock. I would expect a lower BP and a higher pulse rate though if that was the case. Maybe this with mitigating factors...some sort of drug use?



Brown thinks we have a candidate for the Parathinktheyare award 

No drugs.


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## vquintessence

SLUDGE: salivation, lacrimation, urination, defecation, GI distress, emesis

parasympathetic overdrive; vroom.


Me needs more time to mull over this scenario...


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## vquintessence

Any cleansers or other products in the bathroom?  What do the other kids or schoolyard monitors have to say about the pt during recess?

I liked the idea of menstruation initially, but I can't wrap my head around hypovolemia w/o physical signs & vitals to back it up.  The decline is too acute even for the "pediatrics hold until they don't" mantra.


My attempt to tack up a poster by using a monkey wrench would be:
SZ secondary to a toxic substance, followed by a nasty case of aspiration and yuckyness.  I'm leaning toward acute toxin exposure w/ some nasty neurological/gastrointestinal profiles.


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## kravturtle

It's a nice day, right? And they just got back from recess? I'm thinking some sort of snake/spider bite.


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## Sandog

Any signs of edema? I sure would like to get a blood pH?


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## jjesusfreak01

MrBrown said:


> Brown thinks we have a candidate for the Parathinktheyare award
> 
> No drugs.



Hey, I can have a little fun...the problem with scenarios is the EMT-B level ones are way too easy and the brown ones are crazy hard.



katherinemorris said:


> It's a nice day, right? And they just got back from recess? I'm thinking some sort of snake/spider bite.


Not a bad idea, snake bites can cause hypovolemia, but my problem with the vitals was the seeming lack of compensation in pulse rate, plus, when snakebites get bad enough to cause hypovolemia, I think there would be obvious visible swelling, but maybe not? That would be the case unless it was a neurotoxic venom and not a histamine inducing venom...we also have to remember this is a Brown scenario, and Brown is a kiwi, so they probably have all sorts of snakes and spiders that we don't have in the US. If not for the normal temp I would have guessed heat injury. 

Maybe Brown gave her a ride on the helicopter and she fell out and hit her head, inducing the seizures.


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## firetender

My vote is something in the realm of running while eating, a quick inhale and a partial obstruction, perhaps initiating a period of apnea from laryngospasm which brought on seizure activity and unconsciousness. Under such circumstances it would be transient, but vomiting would be likely. Could have been worse; children have been known to go into cardiac arrest from laryngospasm.


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## CAOX3

Hmmmmm.

Second pressure please?

Im going with a rough game of red rover come over (The other children will never admit to it because good little children dont play red rover), wacked her melon on the jungle gym somewhere in the hair line, its gone unoticed.

Stokes respirations, dropped her diastolic, she's herniating, boy oh boy its the triad.

Brown get the helicopter and get this young lady out of here.

Prize please.


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## MrBrown

vquintessence said:


> Any cleansers or other products in the bathroom?  What do the other kids or schoolyard monitors have to say about the pt during recess?



There are no cleaners in the bathroom, they are kept with the creepy loner seemingly disgruntled janitor who spends most of the day alone in his Unibomber style shack, the only place on the schoolyard that seems to defy all laws of nature, physics and mankind.



katherinemorris said:


> It's a nice day, right? And they just got back from recess? I'm thinking some sort of snake/spider bite.



Nope



Sandog said:


> Any signs of edema? I sure would like to get a blood pH?



Blood pH is normal and there is no edema.



jjesusfreak01 said:


> the problem with scenarios is the EMT-B level ones are way too easy and the Brown ones are crazy hard.
> 
> Maybe Brown gave her a ride on the helicopter and she fell out and hit her head, inducing the seizures.



Man if you think Browns ones are hard you should see some other peoples, like that crazy Ninja fellow .... 

No helicopter ride today .... except to the paediatric intensive care centre.



firetender said:


> My vote is something in the realm of running while eating, a quick inhale and a partial obstruction, perhaps initiating a period of apnea from laryngospasm which brought on seizure activity and unconsciousness. Under such circumstances it would be transient, but vomiting would be likely. Could have been worse; children have been known to go into cardiac arrest from laryngospasm.



Nope, not that.



CAOX3 said:


> Hmmmmm.
> 
> Second pressure please?
> 
> Im going with a rough game of red rover come over (The other children will never admit to it because good little children dont play red rover), wacked her melon on the jungle gym somewhere in the hair line, its gone unoticed.
> 
> Stokes respirations, dropped her diastolic, she's herniating, boy oh boy its the triad.
> 
> Brown get the helicopter and get this young lady out of here.
> 
> Prize please.



Second pressure with a half litre of saline is 100/60

No traumatic brain injury here.

The pilots are on thier union mandated 15 minute break, its going to take us at least that amount of time to decontaminate and secure an airway, package the patient, remove various small children that have clung to assorted appendages and pieces of clinical equipment and get her to the helichopper.

Perhaps a quick chat to the paediatric intensivest on the magic ambo phone?


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## Handsome Robb

I'll bite.

So no to the toxicity, febrile seizure, TBI, airway obstruction, venomous bite, doesn't seem to be compensating.

I was thinking an odd presentation of meningitis, but you said no to infection and with no fever that would be a very odd presentation. Did we ever give her any sugar to see if that helped? With no obvious trauma and a patent IV line it couldn't hurt. Dehydration? What are her skin signs? Pupils? I'm tired so I may have missed them.

Teacher said she saw her coming out of the bathroom during recess...is this recess after lunch? It'd be fast and wicked onset but food poisoning? But again no fever. Some sort of allergic reaction? Anaphylaxis can cause respiratory distress/arrest which can lead to cardiac arrest in peds, which this one seems to have the possibility of heading that way....compensate compensate compensate, crash, but again you said no to laryngospasm/airway obstruction. 

We can use the magic ambo phone but I feel like the man in the orange jumpsuit with DOCTOR across the back isn't going to let us get off that easily.

Just a thought though.


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## Aidey

Ruptured appendix? 

Heck, ruptured ectopic? Hey, crazier things have happened.


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## MrBrown

NVRob said:


> I'll bite.
> I was thinking an odd presentation of meningitis, but you said no to infection and with no fever that would be a very odd presentation.



A septic patient can be either hot or cold, they are most often hot but Brown has recalled at least one who was mildly hypothermic and very unwell. 



NVRob said:


> Did we ever give her any sugar to see if that helped? With no obvious trauma and a patent line D25 couldn't hurt. Dehydration? What are her skin signs, unless I missed them.



You could always try a bit of IM Glucagon or seeing as hoe we already have an good patent drip why not try some IV glucose



NVRob said:


> Teacher said she saw her coming out of the bathroom during recess...is this recess after lunch?



No, this was morning recess.  The teacher said she was the child go in and come out a minute or two later.

She has vomited up large amounts of watery , sludgy, off-colour thick yellow/green vomit.


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## Harvey

This was one is easy people. What we have here is your typical case of Cooties!


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## jrm818

MrBrown said:


> Are acute onset siezures, hypo and unconsciousness medical problems?



Well some people might say that's just a fun Friday night.  Maybe this girl is starting the partying early?


I assumed the glucose didn't work.  We should try it, but I'd still be surprised if it did any good.

I'm temporarily stumped.  After my total strike-out I was liking the toxin (ingested or injected) ideas, but if those are a no-no I'm not sure what we're left with.  I do like Aidy's appendix idea (and ectopic, but would be a major shocker at 7 y/o ), but as with all the hypovolemic scenarios I've been wondering how to explain bradycardia, and I wouldn't think of seizure activity typically either.

Still, how is her abdomen?  Rigid, distended, normal? 
How are her extremities?  Cold and pale, or nice and warm with strong pulses?  Cap refill?  The fluid helped her BP a bit, was she vasodialated before?  

Does the fluid change the HR at all?  Have we done anything else for the bradycardia?  Are we good enough to listen to heart tones?

Meningitis was among my thoughts in initially asking for the temp, and I don't think that a normal temp strictly rules it out, but with no other symptoms and a zonked patient I don't know how we can diagnose that clinically.  Plus, the Brown Sphinx said no to infection...

Do we know any more details about her complaint to the teacher?  In what way did she feel unwell?

I'd love to call the peds intensivist once we have time and have completed a thorough enough assessment that we have something useful to say other than "girl sick, no know what wrong, me give oxygen and stand on head, nothing better, what now?"  At this point, I wonder if this is beyond diagnosing with physical exam and we need some more intense lab testing/imaging.


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## uhbt420

BP 90/40  << not good, even at 100/60 it could use some improvment
RR 8  << very not good, get ready to ventilate
PR 40 << is tihs pulse rate?  if so she meets the criteria for chest comprs
SPO2 93%  << not awful but maybe have some 02 ready.  at least the resps aren't making her too hypoxic
BGL 2.5mmol/l (~50mg/dl)  << too low, correct w/ IV glucose

at this point i would be doing chest comps/ventilation, also suction the airway and drop a king



MrBrown said:


> IYou are 90 minutes by road from a paediatric intensive care facility and the local hospital is having thier Christmas party so they are closed.


that simplifies things...


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## MrBrown

It's not appendicitis.

Since when does a heart rate of 40 qualify for CPR? Is that a crank pipe in your back pocket mate? 

While correcting the hypoglycaemia won't fix the problem it will prevent secondary brain injury.  100ml of 10% glucose it is then.

The bradycardia is a manifestation of the CNS depression that made the child unconscious in the first place.  Bradycardia in children is rare, usually caused by hypoxia, complex to manage and not something Brown would be concerned about to be honest provided perfusion and oxygenation remain adequate in the short term/

What blood tests do you want?

There were no commercial cleaning products like bleach in the bathroom.

Brown will post the answer if y'all are stuck


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## abckidsmom

MrBrown said:


> It's not appendicitis.
> 
> Since when does a heart rate of 40 qualify for CPR? Is that a crank pipe in your back pocket mate?
> 
> While correcting the hypoglycaemia won't fix the problem it will prevent secondary brain injury.  100ml of 10% glucose it is then.
> 
> The bradycardia is a manifestation of the CNS depression that made the child unconscious in the first place.  Bradycardia in children is rare, usually caused by hypoxia, complex to manage and not something Brown would be concerned about to be honest provided perfusion and oxygenation remain adequate in the short term/
> 
> What blood tests do you want?
> 
> There were no commercial cleaning products like bleach in the bathroom.
> 
> Brown will post the answer if y'all are stuck




Completely stuck.  I've been watching all this time, and didn't even have a relevant question to add to the conversation.

Shock her!  It's bound to help, right?


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## jrm818

MrBrown said:


> It's not appendicitis.
> 
> The bradycardia is a manifestation of the CNS depression that made the child unconscious in the first place.  Bradycardia in children is rare, usually caused by hypoxia, complex to manage and not something Brown would be concerned about to be honest provided perfusion and oxygenation remain adequate in the short term/
> 
> Is she perfusing?  Nice warm extremities, or cold and pale?
> 
> side note for my benefit...what would be the potential management if oxygenation or perfusion fell perilously despite good airway management.
> 
> Also, was she acting pretty normally before her seizure?  Was this totally out of the blue?
> 
> 
> What blood tests do you want?
> 
> way out of my league here, but I suppose a good learning experience.
> 
> Start with CBC and BMP, I don't know what else would be called for.  I can't think what this could be besides toxicological, infectious, or mechanical so (raised ICP from something - bleed, hydrocephalus)  Head CT would be nice too I think.  If you hadn't told us it wasn't infection I'd be wondering about a LP as well.
> 
> 
> There were no commercial cleaning products like bleach in the bathroom.
> 
> Brown will post the answer if y'all are stuck
> 
> not yet!  That would ruin the challenge.  Much more educational I think if you hold off a bit.



10 characters


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## Pseudonymous

MrBrown said:


> Since when does a heart rate of 40 qualify for CPR?



Here, you start chest compressions on a child if the patient is:
A. not breathing 
and B. has a heart rate of <60.

So a heart rate of 40 would indicate a need for chest compressions, but since the patient is breathing, we would not start CPR.


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## abckidsmom

Pseudonymous said:


> Here, you start chest compressions on a child if the patient is:
> A. not breathing
> and B. has a heart rate of <60.
> 
> So a heart rate of 40 would indicate a need for chest compressions, but since the patient is breathing, we would not start CPR.



She has a blood pressure, though.  You might be mistaking a child for a neonate.  I can't think of a category of person that would need chest compressions for a rate less than 60 other than a neonate.


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## jrm818

I think the BP of 90/40 is a better reason not to start compressing this girl.  I have a hard time thinking that compressions unsynchronized with her heartbeat are going to be any benefit.

EDIT: Darn, scooped!  Well, I agree


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## Veneficus

I think I would estimate the developmental age of the child rather than a a number to determine if cpr was needed. 

I also believe in treating patients, not numbers. 

If this kid is 7+ 

Systolic 70+2(age in years) =84

Diastolic: systolic - 35-45 = 39

So the original vitals demonstrate average blood pressure by an acceptable form of clinical estimate that is within the normal range of a 7 year old even at a bradycardic rate.

Why again are we considering CPR?


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## Pseudonymous

abckidsmom said:


> She has a blood pressure, though.  You might be mistaking a child for a neonate.  I can't think of a category of person that would need chest compressions for a rate less than 60 other than a neonate.





jrm818 said:


> I think the BP of 90/40 is a better reason not to start compressing this girl.  I have a hard time thinking that compressions unsynchronized with her heartbeat are going to be any benefit.
> 
> EDIT: Darn, scooped!  Well, I agree





Veneficus said:


> I think I would estimate the developmental age of the child rather than a a number to determine if cpr was needed.
> 
> I also believe in treating patients, not numbers.
> 
> If this kid is 7+
> 
> Systolic 70+2(age in years) =84
> 
> Diastolic: systolic - 35-45 = 39
> 
> So the original vitals demonstrate average blood pressure by an acceptable form of clinical estimate that is within the normal range of a 7 year old even at a bradycardic rate.
> 
> Why again are we considering CPR?



Someone posted this:



uhbt420 said:


> BP 90/40  << not good, even at 100/60 it could use some improvment
> RR 8  << very not good, get ready to ventilate
> *PR 40 << is tihs pulse rate?  if so she meets the criteria for chest comprs*
> SPO2 93%  << not awful but maybe have some 02 ready.  at least the resps aren't making her too hypoxic
> BGL 2.5mmol/l (~50mg/dl)  << too low, correct w/ IV glucose
> 
> at this point i would be doing chest comps/ventilation, also suction the airway and drop a king
> 
> 
> that simplifies things...



So Brown posted THIS: 


MrBrown said:


> Since when does a heart rate of 40 qualify for CPR?



I was just saying that in my area, a heart rate of 40 in a child THAT young, would indicate the need for chest compressions if the patient was also *not breathing*. But this isn't an appropriate scenario for CPR (For multiple obvious reasons). I was simply pointing out that a heart rate of 40 CAN qualify for CPR in some places. Even if it's some crazy, improbable situation.


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## MrBrown

jrm818 said:


> Is she perfusing? Nice warm extremities, or cold and pale?



Unless she is in cardiac arrest or dead (not sure if the two are that much different lol) then yes, the question is whether or not said perfusion is adequate to provide adequate neurologic, cardiac, renal and hepatic function.

Limbs and other bits and pieces like the stomach and various odenums can go many hours without adequate perfusion before they die.  The heart, brain, liver and kidneys cannot and begin to die quickly which makes patients crook and various medicinos nervous.

Her perfusion is adequate for now, obviously there is something causing decreased respiration and cardiac output so we should be supporting them with the goal of avoiding any secondary injury as we are unable to correct whatever underlying problem caused her to get into this mess.  



jrm818 said:


> side note for my benefit...what would be the potential management if oxygenation or perfusion fell perilously despite good airway management.



Perfusion is a marker of cardiac output not ventilation and oxygenation.  Potentially if she began to become shocked then we could look at inotropic support and flogging the ticker along with an adrenaline drip however a Paediatric emergency or intensive care consultant Brown is not however in this case its more about supporting the pump to move fluid than lack of fluid itself (cardiogenic cause vs hypovolaemic).  What has caused this problem does have some vasodialatory effect so then you could look at things like levophed, noradrenaline and dopamine.  Brown would want to have a chat to the little people doctor types first on the telephone machine.

What size orange "DOCTOR" helicopter jumpsuit does Arizona Robbins take again?

Good airway management as far as Brown is concerned in this case would be for the first crew on scene to liberally suction/decontaminate the airway, place an LMA and ensure adequate artifical ventilation.  At the Intensive Care (ALS) level or if those funny sky cowboys rocked up out the stratus Brown would automatically be intubating, using RSI if required.

Invasive oxygenation techniques are the realm of those white coated people at the place known for its gaggle of Doctors.  



jrm818 said:


> Also, was she acting pretty normally before her seizure? Was this totally out of the blue?



No, she has Brown as a dad so how can she have been normal? 

There is no known PMHx



jrm818 said:


> Start with CBC and BMP, I don't know what else would be called for. I can't think what this could be besides toxicological, infectious, or mechanical so (raised ICP from something - bleed, hydrocephalus) Head CT would be nice too I think. If you hadn't told us it wasn't infection I'd be wondering about a LP as well.



CBC is normal as is the head CT .... man giving up our coffee machine for a portable CT was totally worth it

*Brown looks at his shaking hand .... 

If there was a significant serum Osm gap would that help any?



Pseudonymous said:


> Here, you start chest compressions on a child if the patient is:
> A. not breathing
> and B. has a heart rate of <60.
> 
> So a heart rate of 40 would indicate a need for chest compressions, but since the patient is breathing, we would not start CPR.



Either you are thinking of a newborn/neonate .... or is that a crank pipe in your medical directors back pocket?


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## Pseudonymous

Ah, upon further investigation, that <60 pulse for children if they are not breathing thing is in fact, *not* in our protocols.  Although, it's still in the current American Heart Association CPR course for Healthcare providers. And in that course, if there is a child age 1 to puberty, and they are not breathing, and have a heart rate of <60, you are instructed to start CPR.

I was confused, since I took my AHA CPR course IN my EMT-B class. But I crosschecked my American Heart association BLS book, against my state's protocols and it revealed that my protocols agree with the rest of you.


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## jrm818

MrBrown said:


> Unless she is in cardiac arrest or dead (not sure if the two are that much different lol)
> 
> "Whoo-hoo-hoo, look who knows so much. It just so happens that your friend here is only MOSTLY dead. There's a big difference between mostly dead and all dead. Mostly dead is slightly alive. With all dead, well, with all dead there's usually only one thing you can do."
> 
> CBC is normal as is the head CT .... man giving up our coffee machine for a portable CT was totally worth it
> 
> *Brown looks at his shaking hand ....
> 
> 
> you're shaking?  better hop in the scanner yourself!  Don't worry, the rep. told me they're perfectly safe.
> 
> If there was a significant serum Osm gap would that help any?
> 
> that depends.  How much hand sanitizer is left in the bottle in the bathroom?



10 characters


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## Sam Adams

Two quick questions and I'll get onto my rambling stream of thoughts. What are her pupils like? I don't think we've received a solid answer yet. Did her hypoglycemia resolve with the administration of Dextrose?

Now: What causes hypoglycemia in an apparently healthy child? growth on the pancreas stimulating an over abundance of insulin and an over abundance of and secretion of pancreatic digestive enzymes creating said disgusting emesis? Further, the release of those enzymes is controlled by parasympathetic nervous system and there appear to be other systemic parasympathetic s/s's....


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## MrBrown

Brown does not trust sales reps ... 

Nobody can find, and is unsure, if there was hand sanatiser in the bathroom


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## MrBrown

Sam Adams said:


> Two quick questions and I'll get onto my rambling stream of thoughts. What are her pupils like? I don't think we've received a solid answer yet. Did her hypoglycemia resolve with the administration of Dextrose?



There is no evidence of opiate ingestion or raised ICP

100ml of 10% dextrose has brought her BGL up to 5mmol (~100mg/dl) however as previously said, the hypoglycameia is a secondary problem and will not effect her 



Sam Adams said:


> Now: What causes hypoglycemia in an apparently healthy child? growth on the pancreas stimulating an over abundance of insulin and an over abundance of and secretion of pancreatic digestive enzymes creating said disgusting emesis? Further, the release of those enzymes is controlled by parasympathetic nervous system and there appear to be other systemic parasympathetic s/s's....



Hypogyclaemia in this case is secondary to the underyling problem and not a factor in the onset of symptoms


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## jrm818

MrBrown said:


> Brown does not trust sales reps ...
> 
> Nobody can find, and is unsure, if there was hand sanatiser in the bathroom



Pending further information I'm thinking there was and it can't be found now because it's all in her belly.  Google tells me her blood level would have to be pretty high to cause cardiovascular collapse, but she's little so I think it's plausible.


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## Handsome Robb

MrBrown said:


> Brown does not trust sales reps ...
> 
> Nobody can find, and is unsure, if there was hand sanatiser in the bathroom



h34r:


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## Sandog

How about an electrolyte check, how is Na/K?


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## MrBrown

Sandog said:


> How about an electrolyte check, how is Na/K?



Ca and Mg are a bit low .... Na/K seem OK


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## abckidsmom

Embolus to the mesentaric artery causing acute bowel infarction with profound vagal stimulation!


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## boingo

Wild mushrooms are delicious.


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## MrBrown

abckidsmom said:


> Embolus to the mesentaric artery causing acute bowel infarction with profound vagal stimulation!



Um, noooo not that but good guess!


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## abckidsmom

MrBrown said:


> Um, noooo not that but good guess!



Paging the smart people...how long do you get with a mesentaric artery failure before the bowel infarcts?  All I've ever seen are tears with ischemia, that slowly recover afterward.  

This is such a good scenario, I hate to hijack, but it's a little bit relevant since the author said it was a good guess, right?

Also, I'm going to do a reality check on the hand sanitizer notion.  There is no way on God's green earth a 7 yo would drink hand sanitizer.  It would take a psych pathology that was definitely not out of the blue.


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## jjesusfreak01

Warfarin poisoning from a rat trap in the bathroom...


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## MrBrown

abckidsmom said:


> Also, I'm going to do a reality check on the hand sanitizer notion.  There is no way on God's green earth a 7 yo would drink hand sanitizer.  It would take a psych pathology that was definitely not out of the blue.



Hey! Brown drank bleech when he was like 12.  It tasted yucky!


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## Veneficus

abckidsmom said:


> Paging the smart people...how long do you get with a mesentaric artery failure before the bowel infarcts?  All I've ever seen are tears with ischemia, that slowly recover afterward.
> 
> This is such a good scenario, I hate to hijack, but it's a little bit relevant since the author said it was a good guess, right?
> 
> Also, I'm going to do a reality check on the hand sanitizer notion.  There is no way on God's green earth a 7 yo would drink hand sanitizer.  It would take a psych pathology that was definitely not out of the blue.



Start a new thread on it. 

There are 2 mesenteric artieries, the superior and the inferior.

Infarcts

Because of the collateral circulation, it has to be a very major if not total occlusion before it starts to cause problems. But once it actually clots off, the collateral can no longer support it. It is an acute emergency as the bowel will suffer irreversable damage in hours. 

How soon depends on the location of the infarct, but it is usually right at the junction of the aorta and the respective artery.


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## Cohn

It's Lupus!



duhh


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## Sam Adams

Another Shot in the dark: Toxic Shock Syndrome?


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## abckidsmom

Sam Adams said:


> Another Shot in the dark: Toxic Shock Syndrome?



This kid is SEVEN, guys!  Have you ever seen a 7 yo?!  

Brown, for the record, can we have a look at the sexual maturity of this second grader?


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## skivail

Community acquired infection?


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## Veneficus

I think maybe it is time to put this out of its misery. 


My head is hurting from what I have been looking at.


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## abckidsmom

Veneficus said:


> I think maybe it is time to put this out of its misery.
> 
> 
> My head is hurting from what I have been looking at.



Please?  I'm so clueless my head hurts.  If this is especially time-sensitive, this kid is dead meat.


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## Handsome Robb

I give up as well


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## Sam Adams

abckidsmom said:


> This kid is SEVEN, guys!  Have you ever seen a 7 yo?!
> 
> Brown, for the record, can we have a look at the sexual maturity of this second grader?



Yes, yes I have seen a 7 year old. However, considering the author of this scenario, ANYthing AND EVERYthing is possible if not likely.

Half of me was kidding when I mentioned TSS, but kids do funny things. Often a result of watched and learned behavior from their parents... Could this child have put something someplace prematurely? Absolutely. If you haven't transported someone with something shoved somewhere it wasnt meant to be, you haven't worked in EMS long enough.


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## MedJPavlo

please, my head hurts from thinking about it


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## jjesusfreak01

Cohn said:


> It's Lupus!



It's never Lupus...


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## Sandog

A congenital disease like Arteriovenous malformation?


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## MrBrown

The child drank a whole bottle of hand soap, spent 48 hours in a medically induced coma in intensive care and walked out of hospital two days later

Her serum ethanol level was something like 400mg/dl


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## jjesusfreak01

MrBrown said:


> The child drank a whole bottle of hand soap, spent 48 hours in a medically induced coma in intensive care and walked out of hospital two days later
> 
> Her serum ethanol level was something like 400mg/dl



Wait, waterless alcohol-based hand soap? Didn't expect to see that in a permanent bathroom.


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## firetender

MrBrown said:


> The child drank a whole bottle of hand soap, spent 48 hours in a medically induced coma in intensive care and walked out of hospital two days later
> 
> Her serum ethanol level was something like 400mg/dl



If she was in a medically induced coma for three days, who induced it and why? Did I miss something?


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## firetender

MrBrown said:


> Brown does not trust sales reps ...
> 
> Nobody can find, and is unsure, if there was hand sanatiser in the bathroom



You laid what's called a "McGuffin" on us. Threw us off the trail. Hand soap, hand sanitizer, "Nobody's sure." Someone made the call. 

jrm818 



> Pending further information I'm thinking there was and it can't be found  now because it's all in her belly.  Google tells me her blood level  would have to be pretty high to cause cardiovascular collapse, but she's  little so I think it's plausible."


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## abckidsmom

MrBrown said:


> Hey! Brown drank bleech when he was like 12.  It tasted yucky!



I bet you didn't drink 6 ounces of bleach.  I've read a little on this, and the most (volume-wise) I've seen are a couple of mouthfuls by a toddler, which are enough to make them significantly altered.

This was definitely a zebra, Mr Brown.  I'm standing by the tastes-to-bad-to-be-real argument.


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## reaper

All bleach is going to do is clean out the GI tract. It will kill the bacteria and make you have a wonderful time in the bathroom. 

First time I ever dealt with it, was a drunk that drank a liter of it. Of course I thought the worse. Poison control and docs all agreed, that it is not fatal.


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## jrm818

abckidsmom said:


> I bet you didn't drink 6 ounces of bleach.  I've read a little on this, and the most (volume-wise) I've seen are a couple of mouthfuls by a toddler, which are enough to make them significantly altered.
> 
> This was definitely a zebra, Mr Brown.  I'm standing by the tastes-to-bad-to-be-real argument.



Well since it was my guess I guess I should defend it a bit.  I've never actually tasted hand sanitizer directly, and don't have any available at this second to sample.  Anecdotally my _hands_ taste awful after using the stuff, but I don't know for sure about the actual gel.

This guy claims to, however, and claims that its rather yummy:  http://www.thepoisonreview.com/2010/07/14/pediatric-hand-sanitizer-ingestions-not-always-benign/

Maybe some are tastier than others?  A service I used to work for had a frequent flier that seemed pretty fond of the stuff.  Any connoisseurs here?  There is a small but real population of children who suffer from Pica as well.  I know we had "no medical history," but perhaps it was new onset or previously undiagnosed.

More importantly there is _a _case report of major sequale after a pediatric ingestion of hand sanitizer: http://www.ncbi.nlm.nih.gov/pubmed/20622632.  I don't have access to the full text, unfortunately, but I assume the abstract is a good representation of the report. It sounds very similar to this case.

That said, I think overall you're right.  The case report claims that it is the first report (ever anywhere) of such a toxic ingestion, and _this _review of poison control records demonstrated only minor effects from hundreds of reported ingestions: http://www.ncbi.nlm.nih.gov/pubmed. 

 I'd say one case ever qualifies this as a zebra, and I think "unicorn" would be an even better label.  Still, it happened at least once, putting it into the universe of possibility.


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## Veneficus

*discussion*



MrBrown said:


> It's a bright, sunny day; children are running round enjoying recess and all is quiet at the ambulance station allowing for much newspaper reading, sleep catching up on and telly watching.
> 
> You are sent to a local primary (elementary) school for an odd job.  The teacher reports that one of her students, a seven year old girl, came back into class after recess.  The child stated she felt unwell and about 10 minutes later became unconscious and began to sieze.
> 
> Although the siezure subsides with intranasal midazolam the girl is deeply unconscious and has vomited profusely.  There are no signs of trauma.
> 
> 
> No history of illness lately the child has been well and nobody in the school or family can think of anything.  You are 90 minutes by road from a paediatric intensive care facility and the local hospital is having thier Christmas party so they are closed.
> 
> The teacher states she saw the child come out of the bathroom during recess.



If I could perhaps go over this case since there was an answer without an explanation or discussion? 

I always try to make a big deal out of treating patients and not numbers.

Starting with:, 

_"a seven year old girl, *came back into class after recess**."* 

If recess there is anything like what I had, the supervisors wouldn't know a kid got hit by a car even if it flew through the air in front of her. So really the kids are unsupervised just limited in movement.

The child stated she felt unwell and about 10 minutes later became unconscious and began to sieze."_

Apparently whatever happened at recess, caused an acute dysfunction of CNS.

_"No history of illness lately the child has been well and nobody in the school or family can think of anything."_

This is the clue to an acute event.

_"The teacher states she saw the child come out of the bathroom during recess"_

But not constantly going in an out of the bathroom or going to the bathroom/drinking fountain all day. Nor complaining of thirst and/or hunger.

This is why ddetailed historical information and pertinent negatives should always be listed.

Whatever caused an acute neuro dysfunction had to be found in or taken into the bathroom. I see a lot of people with the current prominence of bacterial phobia carrying around alcoholic hand sanitizers. Though not in amounts to get intoxicated from.

Teenagers are also a rather genious bunch when it comes to getting high. Glue, white out, and nyquil. But now popular alcohol based hand sanitizers. There is a learned behavior kids watching other kids are at risk for.

The disease also has to have initial or preferential symptoms manifesting in the brain/cns.

Vominting reflex is stimulated in both the stomach and brain, however there is usually immediate releif of symptoms when vomiting originating from the GI.

Seizure confirms neurotoxicity.

So the game becomes figuring out what the likely toxin is. 

Don't know about in the rest of the civilized world, but in the US, schools and churches are not held to commercial building code. (it would cost too much to retrofit, but strangley enough causes the largest loss of life from not having building codes)

My primary suspicion was lead because of the acute onset of seizure. However, without more findings no form of toxin could be settled on without doubt. 

There are also a few congenital enzymatic malformations that can make otherwise nontoxic substances toxic for those with the mutation. Some of which might go undiagnosed at birth.

Later on it was described that the hand cleaner was empty. Whether or not it tastes good or the kid was craving paint chips or whatever, is really irrelavent. Who knows why patients do the things they do? Maybe she had something to really hide in a game of truth or dare?

AV malformation manifests as bleeding, and this now nor later was presented with signs of acute stroke.  

numbers:

_BP 90/40
RR 8
PR 40
SPO2 93%
BGL 2.5mmol/l (~50mg/dl)
ECG sinus bradycardia_

Aside from the poster, many healthcare providers get caught up in dx by the numbers. But let us analyze it.

Would you expect somebody who was in DKA be breathing more or less to try and compensate for metabolic acidosis?

While the heart rate is slow, the blood pressure is within expected limits, further leading to a neuro pathology.

If you look at this without the blood sugar, you see somebody who has systemic depression. It is hard to come to a conclusion of other but toxin adding this to the already discussed findings. (I think so anyway.)

When you then add in the blood sugar, something must be causing it. Since the kid is listed as previously healthy and not on insulin, a decrease in blood sugar must be from something inhibiting metabolism. Like a toxin.

If the kid was an acute attack of undx diabetis, it would most likely be type I, and the finding would be DKA. The only things other than toxin or likely known from birth genetic condition that would account for the low blood sugar is a neoplasm or acute liver failure. (like from a female with an lower ability to metabolize alcohol) 

It is never lupus because while it has some outrageous findings it is relatively easy to dx.

TSS would be massive hypotension, _S. Aureus_ also needs fe, found in blood, to rapidly reproduce and secrete enough toxin to cause acute onset within hours. So even if the kid did put something from a learned behavior in the anus of vagina, without some respectable amont of blood for some time, I don't think an acute onset would be seen without a steady decline in the child's behavior.


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## abckidsmom

Thanks, I appreciate you spelling it out.  The thought process is helpful.


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## HappyParamedicRN

My guess is that this is neuro.

Brain tumor or she hit her head and now has a bleed.

Or maybe she vagaled?


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## Cohn

Was there ever a psych evaluation after this event?


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## Veneficus

Cohn said:


> Was there ever a psych evaluation after this event?



for a kid who ate soap?


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## Cohn

Veneficus said:


> for a kid who ate soap?



YES for a 7 YEAR OLD who ATE SOAP.


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## abckidsmom

Cohn said:


> YES for a 7 YEAR OLD who ATE SOAP.



This is completely where I'm sitting on this one.  One mouthfull, maybe...whole bottle, at 7 yo?  There's a problem.


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## Cohn

abckidsmom said:


> This is completely where I'm sitting on this one.  One mouthfull, maybe...whole bottle, at 7 yo?  There's a problem.



Not only that but the taste alone of a soap that contains alcohol would make any kid spit it out...

But for a kid even at seven to even think about eating soap is one of those Darwin moments.


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## kravturtle

I totally agree. But at the same time, if we knew why people did things, our jobs would be so much less interesting. B)


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## Veneficus

Developmentally challenged?

Maybe she was taking her HSV prophylaxis to the extreme?

Lost a bet?

Liked the taste?

Maybe she didn't do her homework and figured making herself sick would get her out of class?

I have seen a lot of crazy things, but a 7 y/o suicide attempt from drinking soap seems way far fetched to me. 

Figured cutting required too much pain?

Or perhaps felt that soap was the bulimic's best friend?

Is schitzo and trying to escape the matrix?

Sorry everyone, but I just don't buy psych.


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## Cohn

Veneficus said:


> Developmentally challenged?
> 
> Maybe she was taking her HSV prophylaxis to the extreme?
> 
> Lost a bet?
> 
> Liked the taste?
> 
> Maybe she didn't do her homework and figured making herself sick would get her out of class?
> 
> I have seen a lot of crazy things, but a 7 y/o suicide attempt from drinking soap seems way far fetched to me.
> 
> Figured cutting required too much pain?
> 
> Or perhaps felt that soap was the bulimic's best friend?
> 
> Is schitzo and trying to escape the matrix?
> 
> Sorry everyone, but I just don't buy psych.



So going along with a bet to eat soap or liking the taste of soap or even wanting to make her self sick does not make you wonder?


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## Veneficus

Cohn said:


> So going along with a bet to eat soap or liking the taste of soap or even wanting to make her self sick does not make you wonder?



stupid yes, psych. not really


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## Cohn

Veneficus said:


> stupid yes, psych. not really



But you would rule out psych?


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## abckidsmom

Veneficus said:


> Developmentally challenged?
> 
> Maybe she was taking her HSV prophylaxis to the extreme?
> 
> Lost a bet?
> 
> Liked the taste?
> 
> Maybe she didn't do her homework and figured making herself sick would get her out of class?
> 
> I have seen a lot of crazy things, but a 7 y/o suicide attempt from drinking soap seems way far fetched to me.
> 
> Figured cutting required too much pain?
> 
> Or perhaps felt that soap was the bulimic's best friend?
> 
> Is schitzo and trying to escape the matrix?
> 
> Sorry everyone, but I just don't buy psych.



I wasn't thinking psych as in suicidal.  Just psych like in sensory issues, autism spectrum issues, and developmental stuff. 

It would take a supreme overcoming of nature's design for a 7 yo to drink an entire bottle of alcohol-based hand sanitizer.  I really think that the take-home for people on this one is that just a mouthful can intoxicate, the bottle can kill, and neither are very common, even though sanitzer is ubiquitous.


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## HappyParamedicRN

Maybe she has Dysautonomia?  

Or ictal bradycardia... hmmm...


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## Veneficus

HappyParamedicRN said:


> Maybe she has Dysautonomia?
> 
> Or ictal bradycardia... hmmm...



I think it would be better to review the diagnostic criteria of those. Both present and require considerable history and there are far more accurate dx for dysautonomia.

As for psych, I guess we could just ask her why she did it?

I would think though that by 7 years of age, prior issues with developmental milestones were likely to be uncovered. Are we willing to accept that there was no other sign or symptom of a psychiatric or psychological illness until one day some girl drank some soap?

But it then gets into the realm of assumptions we cannot answer. Truthfully, if the girl basically admitted to an outside influence or stupidity, I would be satisfied.

We certainly don't send everyone who does something stupid for a psych eval.


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## Veneficus

Let us not forget: "I'll give you $5 if you eat a worm."

...Or a container of soap.


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## jjesusfreak01

Veneficus said:


> Let us not forget: "I'll give you $5 if you eat a worm."
> 
> ...Or a container of soap.



Related: I once replaced a container of soap in a school bathroom with pancake syrup.


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## uhbt420

jjesusfreak01 said:


> Related: I once replaced a container of soap in a school bathroom with pancake syrup.



can't... stop... laughing...


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## jjesusfreak01

uhbt420 said:


> can't... stop... laughing...



Was one of the wall dispensers, so there is no way you could see what you were putting on your hands ahead of time. This was of course for senior skip/prank day...one of the many ingenious things my class did.


----------

