# Country Meddlin



## MrBrown (Jul 2, 2010)

It's 11pm and you are sent out into the middle of nowhere for an unwell.

After turning left at the General Store and continuing over yonder past the Johnson farm you locate at the address.  It's a rambling old country farm house where the patient lives with Nana and Pa.

O/A you are met by Pa who leads you into one of the bedrooms where a 21 yof is in bed with her boyfriend, the farm help, keeping her company.

Both the patient and her boyfriend are quite insistant she is fine and that you can go on back to where the city folk come from.  Pa is not convinced and is sure some meddlin is afoot so he called you as Nana was unable to reach ole Doc Shoemarker who ain't been since he went over range to go fishin yesterday.  The doctor did give her an Rx for, as Pa puts it, some of the robotics.

PMHx none

Hx/cc of felling unwell x 3 days with cough, mild SOB and pyrexia

O/E GCS 14 
BP 110/70
RR 22
PR 130
Temp 38

Meds amoxicillin and paracetamol po x 3 days

Now, those of you who think Brown is loosing his touch and that this case is potentially quite easy, you are correct, I blame 8 weeks of 6am starts.

You are 45 minutes from a small secondary level rural hospital where you might have a Post Graduate Year 2 junior doctor doing his rural rotation asleep in the lounge who can ring up the local GP for some orders and three hours to any sort of primary facility that has one or more of those funny Registered type doctors.

Oh, and no the HEMS jokers in thier funny orange getup are not avaliable, they are having a nap this evening.  They have to testify in court the following day about some funny bugger who was rolling around passing himself off as one of the helicopter doctors.


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## Simusid (Jul 2, 2010)

Why was she prescribed the amoxicillin?   The narrative says she's been on "robotics" for 3 days and been feeling unwell for 3 days.  But what was the cc 3+ days ago that made her see Ol' Doc Shoemaker?

skin color/temp/condition?  any rashes?


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## Smash (Jul 2, 2010)

Beats me. But congratulations on your Fellowship Brown.


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## mycrofft (Jul 2, 2010)

*Rashes? Discharges? Pain? Energy level?*

I know that place! It's the one where you turn left at the fork where the white barn with the tobacco ad painted on it used to be, go a piece past where the  big red bull lives and turn in where the gate is. Can't miss it.


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## Tincanfireman (Jul 2, 2010)

Has she been in close/repeated proximity to any farm animals (other than the one sharing her covers at the moment?) Everything seems to point to respiratory, and I wonder if this is a sheep farm or other type of livestock operation, which would raise my suspicions towards anthrax or something similar...


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## firetender (Jul 2, 2010)

MrBrown said:


> It's 11pm and you are sent out into the middle of nowhere for an unwell...



...and, rather than seeking an emergency where none exists, I'd do my best to get free and back to bed.


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## MrBrown (Jul 2, 2010)

Simusid said:


> Why was she prescribed the amoxicillin?   The narrative says she's been on "robotics" for 3 days and been feeling unwell for 3 days.  But what was the cc 3+ days ago that made her see Ol' Doc Shoemaker?
> 
> skin color/temp/condition?  any rashes?



Same CC of feeling unwell w cough, mild fever and some SOB

I guess Pa didn't quite get the pronounciation of "antibiotics" right 



Smash said:


> Beats me. But congratulations on your Fellowship Brown.



Brown is not a Fellow, heck, I'm a lowly part timey MBChB Year 1



firetender said:


> ...and, rather than seeking an emergency where none exists, I'd do my best to get free and back to bed.



Good thinking, thats pretty much what the crew did.  This patient died 24 hours later in Intensive Care.


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## MrBrown (Jul 2, 2010)

Tincanfireman said:


> Has she been in close/repeated proximity to any farm animals (other than the one sharing her covers at the moment?) Everything seems to point to respiratory, and I wonder if this is a sheep farm or other type of livestock operation, which would raise my suspicions towards anthrax or something similar...



No it's not anthrax or something whacky like that.  

Nana told Pa when she went out to get the milk fro Daisy the Cow the previous morning that the farm help was disposing of a number of heavily blood soked rags into the trash and when questioned said it was from cleaning the tractor where he hit a stray rabbit who ran infront of it.  

Nana also noticed that the patient spent a lot of time in the shower that morning.

Pa thinks something is a bit awry here and had planned to take the help out back and dump him down the old abandoned mine shaft but then he had to call you fellers coz his granddaughter didnt seem right.

I say something is afoot here in the country don't you Paramedic Joe Friday?


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## foxfire (Jul 2, 2010)

I am not a medic, and still quite green, but I would like to take a shot at this. 
Judging by the scene around, I would get nana, pa, and critter jr out of the room and question the granddaughter about last period and is there a possibility of pregnancy. I am suspisus of the bloody rags.
any ab pain? now or before?
any alergies? 
 pyrexia? 
Possibility of early stages of something toxic. 





These are my lowly basic thoughts.


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## MrBrown (Jul 2, 2010)

foxfire said:


> I am not a medic, and still quite green, but I would like to take a shot at this.
> Judging by the scene around, I would get nana, pa, and critter jr out of the room and question the granddaughter about last period and is there a possibility of pregnancy. I am suspisus of the bloody rags.
> any ab pain? now or before?
> any alergies?
> ...



Patient states her last period was three days ago and it was very heavy.

No abdo pain now, but did have some before when she menstrauted

No allergies

She does have a fever, her last temp was 38 degrees


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## PrincessAnika (Jul 3, 2010)

LMP Started 3 days ago or ended 3 days ago?  if started, is she still bleeding?  any clots? what color? how many pads/hr?

fever indicates infection which she is already on abx for 3 days (same as LMP...hmmm) so the abx aren't working, she at minimum needs a different abx or dose.  what was dx given by dr with meds?   what do lungs sound like?  whats her skin color/feel?  back to the prior abd pain...where? describe...

infection, possibly going septic; missed m/c; ectopic pg; pneumonia/other resp issue


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## MrBrown (Jul 3, 2010)

PrincessAnika said:


> LMP Started 3 days ago or ended 3 days ago?  if started, is she still bleeding?  any clots? what color? how many pads/hr?
> 
> fever indicates infection which she is already on abx for 3 days (same as LMP...hmmm) so the abx aren't working, she at minimum needs a different abx or dose.  what was dx given by dr with meds?   what do lungs sound like?  whats her skin color/feel?  back to the prior abd pain...where? describe...
> 
> infection, possibly going septic; missed m/c; ectopic pg; pneumonia/other resp issue



LMP ended 3 days ago and lasted for less than a day but was unusually heavy.

She states she had some abdo pain but that she normally has some pain associated with menstraution.  Described as a bloating/cramping feeling with some pain in the centre of her belly.

The doctor said she had a mild infection and gave her some ammoxicillin and acetamyophen.  He said she probably caught it from those city slicker realitives she had visit earlier in the week.

Skin is warm and dry.


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## mycrofft (Jul 3, 2010)

*Dunno.*

130/min to maintain ok BP suggests blood loss or other haemodynamic destabilizer. Cough...? Red herrring? Central belly...descending aorta, mesenteric circulation, possibly tail of liver..

Tularemia.


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## MrBrown (Jul 3, 2010)

mycrofft said:


> 130/min to maintain ok BP suggests blood loss or other haemodynamic destabilizer. Cough...? Red herrring? Central belly...descending aorta, mesenteric circulation, possibly tail of liver..
> 
> Tularemia.



Have you ever known 21 year olds who haven't been involved in severe trauma to get aortic ruptures?

Patient does not have any abdominal distention, rigidity or guarding nor does she complain of any abdominal pain.  No back pain.  Good pedal pulses.

Another set of vital signs 

GCS 14 
BP 108/68
RR 25
PR 138
Temp 38.4
SPO2 98
BGL 170


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## Smash (Jul 3, 2010)

MrBrown said:


> Brown is not a Fellow, heck, I'm a lowly part timey MBChB Year 1



Sorry. MBBS is a medical degree and FANZCA is Fellow of the Australian and New Zealand College of Anaesthetists. At least I thought they were. 

As for scenario, pt clinically has severe sepsis (temp >38C, HR > 90, RR >20 and altered level of consciousness). Origin could be respiratory (most common focus), could be something to do with the gynae issues (no signs of peritonitis though), could be somewhere else. Lung sounds?

Doesn't matter too much for a lowly ambologist though: oxygen, IV, crystallioids, keep an eye on BP, more crystalloids, have my inotropes drawn up, drive to the hospital.


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## MrBrown (Jul 3, 2010)

Smash said:


> Sorry. MBBS is a medical degree and FANZCA is Fellow of the Australian and New Zealand College of Anaesthetists. At least I thought they were.



You are correct, Brown *will* be a Fellow at some point before 2099, hence why it's coming soon! 



Smash said:


> As for scenario, pt clinically has severe sepsis (temp >38C, HR > 90, RR >20 and altered level of consciousness). Origin could be respiratory (most common focus), could be something to do with the gynae issues (no signs of peritonitis though), could be somewhere else. Lung sounds?
> 
> Doesn't matter too much for a lowly ambologist though: oxygen, IV, crystallioids, keep an eye on BP, more crystalloids, have my inotropes drawn up, drive to the hospital.



You are correct, I assumed somebody would pick it up soon enough.  To be exact it was a septic incomplete misscarriage.  

The crew that went to this patient left her at home, she was eventually taken into hospital with much of the fastness a few hours later and died the following day.

Not sure how they missed that one.


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## mycrofft (Jul 4, 2010)

*Aortic rupture in young adults...severe Marfan's.*

OK, and a punch in the belly.
Incomplete septic miscarriage. Sort of like a guy we had with a very large abcess riding up in the dome of his diaphragm. He was unruly, then very sick, then unruly, then sick, then unruly, then sick and then died after tyhree trips to the ER from which he was ejected each time after at most a flat plate xray of his abdomen. Needed at least a very good ultrasound to spot it and he was uncooperative. Yor pt wasn't assaultive, but maybe she didn't come clean with her recent hx.


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## foxfire (Jul 5, 2010)

I was starting to wonder if it was something along that line. But was not able to get back online for a few days. 

Wouldn't there be continued bleeding though, if it was a incomplete misscarrage?


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## Roam (Jul 5, 2010)

Wow, thank-you Mr. Brown!


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## firetender (Jul 5, 2010)

MrBrown said:


> Good thinking, thats pretty much what the crew did.  This patient died 24 hours later in Intensive Care.



Based on what you originally posted, especially with the pts insistence that all was well, what other conclusion could you possibly come to on-scene, other than doing a CYA and talking the pt. into taking a ride?

In terms of emergency, no alarms would have gone off. Based on what you described later on in the thread, perhaps I would have done a little more Sherlock Holmesing.


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## Smash (Jul 5, 2010)

firetender said:


> Based on what you originally posted, especially with the pts insistence that all was well, what other conclusion could you possibly come to on-scene, other than doing a CYA and talking the pt. into taking a ride?
> 
> In terms of emergency, no alarms would have gone off. Based on what you described later on in the thread, perhaps I would have done a little more Sherlock Holmesing.


How many alarms are needed? Tachycardic, tachypneic, febrile, altered mentation... Clinically this patient presents with severe sepsis which has a mortality rate of about 30% in that age group _when treated_. It doesn't even really matter what the history is or where the infection was originally located: even if you knew nothing at all about this patient except those vital signs, she is a very unwell young lady. Leaving her at home is inexcusable negligence.


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## firetender (Jul 5, 2010)

MrBrown said:


> Both the patient and her boyfriend are quite insistant she is fine and that you can go on back to where the city folk come from.



...so, because I saw nothing life-threatening, though I did note she had an elevated pulse, elevated respiration and elevated temperature consistent with a malady for which she was being treated, I restrained her and then, against her will, carted her off to the hospital.

She lasted a few days I understand. How many other offers of help did she refuse?


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## MrBrown (Jul 6, 2010)

I think people quite often overlook abnormal vital signs or fail to take them into consideration of a wider clinical picutre .... and people get left home and drop dead.


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## Aidey (Jul 6, 2010)

foxfire said:


> ...Judging by the scene around, I would get nana, pa, and critter jr out of the room...



Critter jr....I literally LOL'd

In my system someone with a GCS of 14 couldn't refuse, the whole ALOC and all.


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## MrBrown (Jul 6, 2010)

Aidey said:


> In my system someone with a GCS of 14 couldn't refuse, the whole ALOC and all.



Most people get around with a GCS of 14 as it was explained to me once by a Clinical Standards Officer.

I remember it was all to do with what sort of basis we go on to consider the patient is "orentaited" as Teasdale and Jeanette did not have a standard set of questions I don't think.


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## firetender (Jul 6, 2010)

MrBrown said:


> I think people quite often overlook abnormal vital signs or fail to take them into consideration of a wider clinical picutre .... and people get left home and drop dead.



I'm glad you started the VS thread. My reflection is up there.


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## CAOX3 (Jul 6, 2010)

MrBrown said:


> It's 11pm and you are sent out into the middle of nowhere for an unwell.
> 
> O/A you are met by Pa who leads you into one of the bedrooms where a *21 *yof is in bed with her boyfriend, the farm help, keeping her company.
> 
> *Both the patient and her boyfriend are quite insistant she is fine and that you can go on back to where the city folk come from.*  .



Shes twenty one I dont care what Ma or Pa said

Send Brown back to the truck to get the refusal.........

She may very well be sick but she still has the right to refuse medical treatment.


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## Aidey (Jul 7, 2010)

MrBrown said:


> Most people get around with a GCS of 14 as it was explained to me once by a Clinical Standards Officer.
> 
> I remember it was all to do with what sort of basis we go on to consider the patient is "orentaited" as Teasdale and Jeanette did not have a standard set of questions I don't think.



Yup, I know. The dementia and elderly with a decreased baseline are probably the biggest group. Even if they are alert and oriented to normal, they are still considered altered and unable to refuse. 



CAOX3 said:


> Shes twenty one I dont care what Ma or Pa said
> 
> Send Brown back to the truck to get the refusal.........
> 
> She may very well be sick but she still has the right to refuse medical treatment.



GCS of 14...technically ALOC.


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## MrBrown (Jul 7, 2010)

I think everybody just asks the standard time, date, place and person to determine if you get a 4 or a 5 for verbal.

My understanding is that is what Teasdale and Jenette might have had (not sure tho)


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## Sassafras (Jul 7, 2010)

Really?  I do the standard date time thing, but also introduce myself right away and ask them repeatedly if they remember my name.  I ask who the president is and do they know why we are here as well.  Generally the big tip off is not remembering my name 30 seconds after I told them the 3rd time.


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## MrBrown (Jul 7, 2010)

Sassafras said:


> Really?  I do the standard date time thing, but also introduce myself right away and ask them repeatedly if they remember my name.  I ask who the president is and do they know why we are here as well.  Generally the big tip off is not remembering my name 30 seconds after I told them the 3rd time.



What I say:  "Hello, I am _____, what is going on today/how can I help?"

What I really *want* to say: "Yeah hi, I'm ____, one of the helicopter doctors, what do you have guys got going on" followed by "yeah ok, get on a good drip and wheres that 20ml syringe gone? Whos got the ketamine?" 

Scoring an accurate GCS is so important I just can't stress that enough, one of the jumpsuited peoples told me if you give somebody E 4 who has thier eyes open but nobody is home and say a 5 for V when it should be a 4 or a 4 for M when it should really be a 2 then you are off by about .... 3, 1, 2 .... well between 4 and 6 points.

So lets say you put on 4 or 5 points that should not be there and wow thats a huge difference.  

In the past people who could tell me everything except what time it was got a 5 for V because even I can't tell you what time it is at any given time but heck now they get a 4 automatically.  I used to not think much of it to be honest, you know if they got one question wrong out of four or five it's not important, then I had a good run down from one of the Clinical Standards Officers who basically said people who have abnormal answers to fairly standards baseline questions and are not normally altered have a problem that needs to be looked at so its important to triage properly.


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## Sassafras (Jul 7, 2010)

Interesting stuff there Mr. Brown.  I don't worry so much about exact time but can you tell me if it's morning, afternoon or night, breakfast time, lunch time or dinner time?   I look for something close to what it should be.  If they tell me it's breakfast time at 20:00 hours I'm docking them a point.


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## MrBrown (Jul 7, 2010)

Obviously I don't give them a 4 if they say anything other than "____ hours GMT+12"  

If they can tell me WHERE they are but not WHY they are there or something eg if they say "I am at the mall" but dont know how they got there, how long they have been there etc or "I went out for some smokes" but can't tell me where they went then thats a 4.

The same goes for eye opening and motor; if the eyes are closed and they open when they hear us come up or something then thats a 4 for E.  Oh and if the patient gives you a bit of lip the V is not "inappropriate" (2 or 3 I think) just because you dont like what the said!

Motor is sort of the same; a bit of spastic flexion in the general direction or tugging at the oxygen mask upon painful stimuli is not 5 because they did not attempt to remove.  So now you have confused M5 with M2 or 3.

Hence you can bugger up a GCS a bit and it is important in a sick patient.  So if you loose a point for V and maybe 2 or 3 for M then you have lost 3 or 4 points.


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## Sassafras (Jul 8, 2010)

So you're telling me the time I was placed on 2 mgs of Ativan and called the best friend from the middle of walmart telling her "I can't find the front door and I'm lost" would land me with a 4V?  no I didn't drive that day thank goodness.


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## MrBrown (Jul 8, 2010)

Sassafras said:


> So you're telling me the time I was placed on 2 mgs of Ativan and called the best friend from the middle of walmart telling her "I can't find the front door and I'm lost" would land me with a 4V?  no I didn't drive that day thank goodness.


 
It depends in what context; if you weren't trying to get in the front door then it would have been V4 if you were able to carry out a partially normal conversation but you just slipped in that you were trying to get in the front door.

If I has said "hello I am with the Ambulance, what is wrong today?" and your answer was "hey man I can't get my keys to work!" then that would be V3.

We went to a guy who was pretty shockingly intoxicated the other night and somebody said oh leave him with me hes just pissed he will be fine ... sure OK so lets look at this guys GCS.  He would't open his eyes at all (E1), uttered incoherent words and slurred a lot of crap (V2) and would sort of have a bit of a swing at you if a sternal rub was done (M3).

This guy was just drunk we reckoned but with a GCS of 6 he was actually had the potential to be pretty crook.  Hence why he landed in the hospital.


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## Sassafras (Jul 8, 2010)

Oh I was good and properly lost in some department. I don't even remember the event. But the friend sure does like to remind me how out of it I was that day.


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## thatJeffguy (Aug 6, 2010)

MrBrown said:


> You are correct, I assumed somebody would pick it up soon enough.  To be exact it was a septic incomplete misscarriage.




The factors that had me thinking septis were the high pulse and the warm/dry skin.

What else here would lead to that conclusion?  What findings were red herrings?


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## juxtin1987 (Jan 11, 2011)

Another one of my I KNOW THIS IS OLD posts.

There's one thing that caught my eye immediately that noone mentioned.

Girl saying she's fine and doens't want transportation is a normal finding.

Girl AND Boyfriend both wanting her to stay sick at home is an abnormal finding, they're clearly hiding something that pertains to obtaining a ddx.


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