# Abd pain



## RedAirplane (Jun 12, 2015)

(Based on a scenario or two I have seen, scrubbed to prevent identification; I would like your thoughts).

It's a hot dry day without a cloud in the sky.

A family comes up to you asking for a bottle of water. You send your partner to grab some water and notice a male about 12 y/o who just doesn't look good. He is sweaty, flush red, in a slouching / tired posture, and has one hand on his abdomen. You offer him a seat and he takes it.

The parents advise you that their son was not feeling well so they wanted to get him some water. With their permission, you start asking a few questions. The pt is having a headache (3/10) and sharp abd pain (5/10) with nausea and dizziness. The headache is new and the abd pain, nausea, and dizziness have been worsening since morning. He had a hot dog to eat and hasn't drank much all day. The pt takes no medications and nothing like this has ever happened before. 

Examination of the abdomen reveals a diffuse pain, unable to be located by the patient. Palpation does not affect the severity of the pain. 

You suggest that the patient be evaluated by paramedics for possible transport, but they end up refusing care. You suggest that the pt be seen by his MD, but he does not have an MD. The parents say that they will take him to urgent care but don't want EMS/hospital because they don't have insurance.

How okay are you with this refusal? Your gut instinct wanted an ALS evaluation / transport unit to be called to the scene, but your partner and supervisor both seemed perfectly okay with this as an ordinary refusal.


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## NomadicMedic (Jun 12, 2015)

Minor with parents. Parents don't want a transport for a kid with a tummy ache.

End of scenario.

In the words of a famous talking lizard, "not my chair, not my problem."

#Bye Felicia.


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## RedAirplane (Jun 12, 2015)

DEmedic said:


> Minor with parents. Parents don't want a transport for a kid with a tummy ache.
> 
> End of scenario.
> 
> ...



Maybe EMT class scared me a bit much, but isn't sharp abd pain supposed to be worrisome?


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## Flying (Jun 12, 2015)

I would rather go with the parent's instinct.

It's a hot dry day, kid needs a break and some A/C.


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## LACoGurneyjockey (Jun 12, 2015)

Ishan said:


> Maybe EMT class scared me a bit much, but isn't sharp abd pain supposed to be worrisome?


What would you do if you had a stomach ache that was sharp? Call an ambulance? Or stop eating ****ty hot dogs that are giving you gas and drink some water?


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## ERDoc (Jun 12, 2015)

There is nothing specific about sharp pain.  It could be intestinal cramping, appendicitis, gas, etc.  Did you get a set of vitals?  That may sway things.


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## chaz90 (Jun 12, 2015)

DEmedic said:


> Minor with parents. Parents don't want a transport for a kid with a tummy ache.
> 
> End of scenario.
> 
> ...


That is one meme dense reply...I like it!


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## Tigger (Jun 13, 2015)

DEmedic said:


> In the words of a famous talking lizard, "not my chair, not my problem."


As we've discussed before, there may be no better reference. 

Topically,
What do you think ALS will provide for this patient? Have you ever had a stomach ache that was pretty brutal? What did you do?

What are your differentials? It is important to at least consider what could be causing the symptoms as opposed to "something is abnormal, therefore I call for ALS."


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## RedAirplane (Jun 13, 2015)

In my limited experience, I was thinking appendicitis or some bleeding internal organ. But it seems I'm way off base.


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## Gurby (Jun 13, 2015)

Do you guys ever suggest to patients that they go to an urgent care over the ED?  A lot of times, a patient will refuse transport after calling (or after their someone else calls for them) with something that seems non-acute.  I often want to say, "if it was me, I'd go get checked out at an urgent care", but always feel guilty about it, like I should always advise them to just go straight to highest level of care to CYA.


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## chaz90 (Jun 13, 2015)

Gurby said:


> Do you guys ever suggest to patients that they go to an urgent care over the ED?  A lot of times, a patient will refuse transport after calling (or after their someone else calls for them) with something that seems non-acute.  I often want to say, "if it was me, I'd go get checked out at an urgent care", but always feel guilty about it, like I should always advise them to just go straight to highest level of care to CYA.


I suggest this frequently and never feel any guilt about it. If requested, I'm happy to take a minor complaint to the ED or at least pawn it off to the BLS ambulance crew. If they're already refusing and ask for my advice though, I'm as honest as I can be with them. 

I would only go to the ED for myself if it were something fairly serious, unable to be dealt with at a PCP or urgent care, or all other facilities were closed and my complaint/pain was time sensitive or unbearable. If they're presenting with something that doesn't strike me as any of these, I give them my honest advice that going to their own doctor or urgent care might be a better idea than driving to the ED. 

We have a medical system that relies on more than just emergency treatment in hospital based EDs from emergency physicians. We in EMS aren't exposed to the alternatives quite as often, but we should be open to them when possible.


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## Brandon O (Jun 13, 2015)

Ishan said:


> In my limited experience, I was thinking appendicitis or some bleeding internal organ. But it seems I'm way off base.



Kids get abdominal pain with some frequency. You need to delve a bit deeper.

"Sharp" pain is more associated with peritoneal irritation than dull or vague pain, but in this case sounds diffuse rather than localized, so it may just be a youthful poverty of adjectives (or leading the witness). Is there constipation/diarrhea? Actual vomiting? Urinary complaints? Fever? Does the pain come and go in discrete phases (colicky pain), or is it steady or more vaguely fluctuating?

Is there any guarding? Rebound or other peritoneal signs (pain with walking, coughing, bouncing, heelstrike, etc)? Perhaps an obturator or psoas sign? Masses?

Most of all, does he look sick? Often that's the first question and you may not get too far past it.

Abdomens are hard, kids are hard.


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## DesertMedic66 (Jun 13, 2015)

Gurby said:


> Do you guys ever suggest to patients that they go to an urgent care over the ED?  A lot of times, a patient will refuse transport after calling (or after their someone else calls for them) with something that seems non-acute.  I often want to say, "if it was me, I'd go get checked out at an urgent care", but always feel guilty about it, like I should always advise them to just go straight to highest level of care to CYA.


I would like to however our urgent cares will call us out for any ABD pains regardless of what they find.


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## EMSComeLately (Jun 13, 2015)

ALS diagnostics aren't absolutely definitive for ABD pain especially with a likely inconsistent history that comes with children especially. With pediatric compensation, even vitals aren't enough until later stages.

I like heat stroke or exhaustion for this; however, and would like temps, find out if the child was sweating before and has stopped or slowed (though presented as "sweaty"), check manual pulse for tachycardia, etc.


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## NomadicMedic (Jun 13, 2015)

Not to single the OP out, but event EMTs and new basics seem to cry wolf over calls that more experienced providers don't get particularly excited about. 

At the end of the day, it's a kid with a belly ache. If he's not CTD and if mom and dad don't want him to go to the ED, you need to respect that. "Here's your water, find us if you need help."

Yes, it's a kid that doesn't feel well, but you don't know if he's tired because he was up playing video games all night, if he's been playing sick all day to get out of chores or he's wants to go home because he's missing his friends. It's the great unknown, and if the parents aren't particularly upset, you certainly shouldn't be. 

I worked at a water park as an EMS provider for a couple of seasons and would hand out water, band aids and the like all day without feeling the need to get involved at any EMS level with the patient. They didn't come to get an assessment, exam or play 20 questions. They came and asked for a bottle of water or to cool off in my EMS station's AC. If the kid passes out or they show up at the first aid point "looking for help/EMS/to get checked out", the situation changes. Til then, "here's a bottle of water, need anything else? No? Have a nice day."

That may make me seem like a ****, but at some point you need to draw the line on how much you insert yourself into other people's problems.


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## RedAirplane (Jun 13, 2015)

DEmedic said:


> Not to single the OP out, but event EMTs and new basics seem to cry wolf over calls that more experienced providers don't get particularly excited about.
> 
> At the end of the day, it's a kid with a belly ache. If he's not CTD and if mom and dad don't want him to go to the ED, you need to respect that. "Here's your water, find us if you need help."
> 
> ...



I can respect that philosophy but it is hard for me to follow. Working in an office Monday-Friday and doing volunteer standby BLS on nights/weekends came out of a desire to help people, so perhaps I'm more overzealous than the full-time EMS provider. Especially because in my role we look for people who may be sick, dehydrated, lost, needing a bathroom, walking unsteady (EtOH?), rather than just standing and waiting for a call. The question "is this person a patient" is a tough one to answer, because EMT school starts with the assumption that the person in front of you is a patient.

I know that anyone can refuse care, and I wouldn't kidnap the kid. My basic question was... is this something that should have gone to the ED per medical advice, or is this in fact something minor? Consent or refusal needs to be informed, the information needs to come from the EMT, and I'm the EMT... so I wanted some guidance on this situation.


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## RedAirplane (Jun 13, 2015)

Brandon O said:


> Kids get abdominal pain with some frequency. You need to delve a bit deeper.
> 
> "Sharp" pain is more associated with peritoneal irritation than dull or vague pain, but in this case sounds diffuse rather than localized, so it may just be a youthful poverty of adjectives (or leading the witness). Is there constipation/diarrhea? Actual vomiting? Urinary complaints? Fever? Does the pain come and go in discrete phases (colicky pain), or is it steady or more vaguely fluctuating?
> 
> ...



I thought he looked sick, moreso than the other hot, sweaty kids running around that day. You could see discomfort in his eyes, which is why I started asking questions in the first place. 

Not that a sample size of one person is great, but the one time I had similar S/Sx, I went to the campus clinic, got punted to urgent care, and from there got punted to the emergency room, because that's the only place where they could do the diagnostics necessary.


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## Ewok Jerky (Jun 13, 2015)

If the parents seemed more concerned, or had shown up at the ED I would be more thorough ala Brandon O. But in this scenereo I agree with those that are comfortable letting him go. Maybe even "person not a patient", definitely RAs not AMA.


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## NomadicMedic (Jun 13, 2015)

Until they (or someone else) call for EMS, or you come across an unconscious person, they're not a patient.


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## RocketMedic (Jun 14, 2015)

I respectfully disagree- although it is not ny legal duty, I think that it is in both our own and the child's best interest and ethically the right thing to do to attempt to provide a comprehensive assessment and at least some measure of treatment for their son. There is a line between "sick" and ill, and this scenario as presented seems to have significant potential to be more serious than we anticipate at present.

Financially, there are concerns, but I think we can at least attempt to mitigate them. I like to impress upon the recalcirant just how little money and debt actually matter as compared to health.


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## ERDoc (Jun 14, 2015)

I think this is probably one of those cases where a picture is worth 1000 words.  Seeing this kid may sway us one way or another.


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## RedAirplane (Jun 15, 2015)

ERDoc said:


> I think this is probably one of those cases where a picture is worth 1000 words.  Seeing this kid may sway us one way or another.



Unfortunately, my artistic abilities are terrible, or I'd draw you one. My instinct said he "looked sick" but my colleagues may have disagreed, leading to where we stood.


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## ERDoc (Jun 15, 2015)

I hear you.  The problem with internet forums, is that each one of us will form a picture of what this kid (or any other pt) looks like and it may be nothing close to what you saw.


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## RedAirplane (Jun 16, 2015)

ERDoc said:


> I hear you.  The problem with internet forums, is that each one of us will form a picture of what this kid (or any other pt) looks like and it may be nothing close to what you saw.



I'll ask a simpler question then. 

If you are a non transporting EMT, when does abd pain (pediatric, geriatric, male, female, whatever) warrant transport? When does it warrant ALS?


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## Chewy20 (Jun 16, 2015)

Ishan said:


> I'll ask a simpler question then.
> 
> If you are a non transporting EMT, when does abd pain (pediatric, geriatric, male, female, whatever) warrant transport? When does it warrant ALS?



The answer has already been given to you. When they request to be evaluated or when someone calls for them. Even then, they do not have to be transported and they can deny anything they feel like denying if they have the mental capacity to do so. If they are a minor, their guardian makes that decision, not you. If they have asked for help and it meets ALS requirements or it does not feel right to you, request ALS.

Not to be blunt (not that I really care) but almost all of your posts lead me to believe you are confused about this whole EMT thing. Its really not that hard, and it seems you are making it a lot harder then it is.

Take a step back, you don't and shouldn't be walking around events trying to make people patients. If they request your services, then by all means do what you need to do. But if all they do is request water or a bandaid, then just give them what they asked for. No need to start throwing coma/seizure/death lines at people who are a little dehydrated. 

If they come to you and request services and you take vitals and come up with some possible differentials and they deny being transported, inform them of some legitimate risks. If they still deny, explain to them your refusal form and say call or find us if anything changes. 

Being a basic is just that, basic. Treat it as such and life will be a lot easier.


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## Brandon O (Jun 16, 2015)

Chewy20 said:


> Being a basic is just that, basic. Treat it as such and life will be a lot easier.



Sounds extremely boring.


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## Brandon O (Jun 16, 2015)

Ishan said:


> I'll ask a simpler question then.
> 
> If you are a non transporting EMT, when does abd pain (pediatric, geriatric, male, female, whatever) warrant transport? When does it warrant ALS?



Can't really simplify this one down, unfortunately. Abdominal pain needs transport when you suspect it portends an illness that requires prompt care.

Same for ALS, although their role would typically be pain management (which a lot of them are reluctant to provide... 'nother story), supportive care if needed (fluids, airway management, anti-emetics, etc), and an ECG if there's any chance it's a cardiac etiology. Most abd complaints don't need ALS.

With all of that said, while there are many abdominal "urgencies" that need to be worked up in hours or "today," there aren't as many (especially in fairly well-appearing patients) that are life-and-death emergencies where minutes matter. A patient with reliable follow-up who's being driven by dad to the ED, or perhaps a PCP, is often a reasonable disposition.

YMMV and exceptions abound.

Edit: I was going to add that "medicine is hard," but as Chewy noted above, it doesn't have to be. However, you've chosen to try and function on a level where it is hard, which I applaud. So in your case: medicine is hard.


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## RocketMedic (Jun 16, 2015)

Ishan, putting aside the juvenile and condecending load of crap Chewy20 just laid down, I would say that the determination for ALS hinges on sentinel findings in assessment (vital signs, etc), observed levels of distress (pain, vertigo, nausea, vomiting) and skin tones. The original patient should have gotten an ALS assessment in my opinion.

To those on the "not-a-patient" bandwagon, I say this. For shame. We are advocates of the sick and injured. This person presents to us in a manner which appears to be distressed, and your answer is to shrug and point to a technicality (which appears driven by finances). DEMedic, I am disappointed in how cavalier you sounded there. No, he's not a "patient", but we ought to expend a little effort in seeing what ails him to this degree. Chewy, you come across as a condescending ambulance driver.


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## NomadicMedic (Jun 16, 2015)

Is every homeless person you see on the street a patient? I'd bet most of those guys have aches and pains and and an upset tummy. Do you stop and assess every one of them? Walk up and offer your services to all of 'em? How about every patient in a nursing home? I bet most of those folks look pretty sick. Hell, you'd need a city bus to transport all of them!

Be a patient advocate, WHEN THEY'RE ACTUALLY A PATIENT.

Until they come up and say "my son is sick, and I need help" they're NOT a patient. If you offer help when they DIDN'T ask for it and they decline your help, they're NOT a patient.

Don't be obtuse. Recognize that most sick people don't need EMS and certainly don't need some first aider with a hardon to be Mr. Richard Rescue insinuating themselves into their life.


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## RocketMedic (Jun 16, 2015)

....but is a visibly-ailing person who has been brought to your area a patient? I believe so.


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## Chewy20 (Jun 16, 2015)

Brandon O said:


> Sounds extremely boring.



It is. Which is why I continue to teach myself things and ask questions.


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## NomadicMedic (Jun 16, 2015)

RocketMedic said:


> ....but is a visibly-ailing person who has been brought to your area a patient? I believe so.



I don't believe I'm falling into your troll trap, but I'll say it one more time. This kid WAS NOT a patient. His parents didn't come seeking help, they wanted a bottle of water. The kid was sick, but NOT SO SICK that they came seeking EMS. They didn't want to go to the ED and said 'we'll take him to the urgent care later, if he needs to go". 

That is NOT a patient.


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## RocketMedic (Jun 16, 2015)

DEmedic said:


> I don't believe I'm falling into your troll trap, but I'll say it one more time. This kid WAS NOT a patient. His parents didn't come seeking help, they wanted a bottle of water. The kid was sick, but NOT SO SICK that they came seeking EMS. They didn't want to go to the ED and said 'we'll take him to the urgent care later, if he needs to go".
> 
> That is NOT a patient.



Because parents (fiscally-pressed ones at that) are clearly the best and only evaluators of a child's medical condition..


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## Chewy20 (Jun 16, 2015)

RocketMedic said:


> Because parents (fiscally-pressed ones at that) are clearly the best and only evaluators of a child's medical condition..



It does not matter what they think, they make the decisions for their child not you. What are you not getting about that? Just like people stroking out can refuse being transported against medical advice, these people can choose another route other than an ambulance.


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## RedAirplane (Jun 16, 2015)

Chewy20 said:


> The answer has already been given to you. When they request to be evaluated or when someone calls for them. Even then, they do not have to be transported and they can deny anything they feel like denying if they have the mental capacity to do so. If they are a minor, their guardian makes that decision, not you. If they have asked for help and it meets ALS requirements or it does not feel right to you, request ALS.
> 
> Not to be blunt (not that I really care) but almost all of your posts lead me to believe you are confused about this whole EMT thing. Its really not that hard, and it seems you are making it a lot harder then it is.
> 
> ...



Our role is specifically not that. If it were, it would be a lot easier.

With altered patients, we specifically are directed to intervene and convince them to come for treatment in a sobering area so that they won't get into trouble later.

When a chest pain patient refused, teams followed her around (discreetly) as part of 'regular patrol' on bicycles with AEDs in case she arrested.

Life would be so much easier if I were on an ambulance, went to calls only from people who specifically asked. That's about 1% of my role. The other 99% is public safety, and sometimes, if you see someone slurring their speech or walking unsteady, stepping in (without battering or kidnapping, of course).

So my question is not when can I legally transport or not, but rather, what medical criteria are going to lead me to drop this as a non-issue or proceed further.


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## RedAirplane (Jun 16, 2015)

Chewy20 said:


> It does not matter what they think, they make the decisions for their child not you. What are you not getting about that? Just like people stroking out can refuse being transported against medical advice, these people can choose another route other than an ambulance.



Not arguing that they make the ultimate decision. 

If someone presents with a laceration to the finger, we can bandage it up. If they are not on blood thinners, they can be on their way.

If someone asks for aspirin, we're going to ask some questions, and assuming no chest pain, blood thinners, etc, they can.

However, if someone presents asking for water because they're short of breath, they'll be told to sit, be given water. If they don't improve, then oxygen & ALS. These are clear and how we operate.

Abdominal pain is a gray area. And so I am asking, when is it more like a band aid, and when is it more like SOB/CP?

Obviously anyone can refuse, even a CP patient. And anyone (including finger guy) can choose to be evaluated/transported by ALS.


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## RedAirplane (Jun 16, 2015)

DEmedic said:


> I don't believe I'm falling into your troll trap, but I'll say it one more time. This kid WAS NOT a patient. His parents didn't come seeking help, they wanted a bottle of water. The kid was sick, but NOT SO SICK that they came seeking EMS. They didn't want to go to the ED and said 'we'll take him to the urgent care later, if he needs to go".
> 
> That is NOT a patient.



See my post above. 
If you see a guy walking past you clutching his chest...
Not intervening would be very bad in my role, possibly even negligent. 

Parents don't want to go to the hospital, fine.

I'm asking when I should strongly recommend it (a la Chest Pain or SOB) and when it is something that can be offered but not really needed (difficulty swallowing).


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## Chewy20 (Jun 16, 2015)

Ishan said:


> When a chest pain patient refused, teams followed her around (discreetly) as part of 'regular patrol' on bicycles with AEDs in case she arrested.



Wait...WHAT? hahaha



Ishan said:


> If someone presents with a laceration to the finger, we can bandage it up. If they are not on blood thinners, they can be on their way



Even if they are on blood thinners they can be on their way. 



Ishan said:


> However, if someone presents asking for water because they're short of breath, they'll be told to sit, be given water. If they don't improve, then oxygen & ALS. These are clear and how we operate.



You can not make them sit because they are SOB, nor can you force oxygen and ALS on people.

If you are not exaggerating about this place you work, it sounds down right ridiculous.


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## RedAirplane (Jun 16, 2015)

Chewy20 said:


> Wait...WHAT? hahaha
> 
> 
> 
> ...





Blood thinners... we'll request that they hang out for 5-15 minutes to ensure that the bleeding stops.

We cannot make anyone do anything. If they don't want something, they legally refuse and we don't do it. But if they are SOB, we'll politely have them sit in the cool shade, ask them if they have had asthma, if they use an inhaler, and if they're not improving, we will offer an ALS assessment which would confirm or deny txp ("before you go, I'd just like one of my colleagues in the fire dept to take a look at you...")

It sounds ridiculous because it's non-traditional first response, and it's more than one place that I volunteer, so it's not a one-off, or else I'd be a bit more suspicious.

In a regular ambulance, a call comes in and you go to it.

You don't have to think about whether the arena is too hot/cold given the weather, whether there are adequate water supplies, etc.

Our mission is the health and wellbeing of all who take part in the event, so noticing people turning pink and politely asking if they want some sunscreen is very much part of the expectation.


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## NomadicMedic (Jun 16, 2015)

Chewy20 said:


> If you are not exaggerating about this place you work, it sounds down right ridiculous.



This isn't work, it's a volunteer gig. Sounds like Red Cross FAST.

And it's certainly not that way any event medical I've ever done works. We don't go looking for patients, nor do we try drum up patients by following around people who "look sick" or keep someone with a cut sitting in a tent for 15 minutes to make sure the bleeding stops. 

It's ridiculous to the Nth degree.


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## Chewy20 (Jun 16, 2015)

Yeah I'm done posting in this one. You keep on keeping on brother.


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## RocketMedic (Jun 16, 2015)

Ishan, don't let the ambulance driver drag you down. Risk mitigation on-site is a fairly important part of event medical, and no one wants to make the news for a public medical catastrophe.

As medical professionals, it is part of our responsibility to analyze people who present to and around us for help. A sick-looking kid certainly fits that description, and I would feel far better if I at least attempted to assess and discern potential causes of a problem rather than a simple dismissive Ambulance Driver handwave. Sure, it might be nothing, but it could be something too...and it doesn't hurt us to put forth the effort, it doesn't hurt the patient to be assessed and it doesn't hurt the parents to be approached about it.


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## RocketMedic (Jun 16, 2015)

Chewy20 said:


> Wait...WHAT? hahaha
> 
> 
> 
> ...



This may surprise you, but some places are slightly more professional and expansive than "you call, we haul, that's all".


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## RocketMedic (Jun 16, 2015)

Ishan said:


> (Based on a scenario or two I have seen, scrubbed to prevent identification; I would like your thoughts).
> 
> It's a hot dry day without a cloud in the sky.
> 
> ...


To me, this looks like dehydration, heat exhaustion, and a potential electrolyte deficiency at the very least.


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## ERDoc (Jun 16, 2015)

Here is my concern with this scenario.  This place is hiring people that are expected to be able to determine if someone is sick and make a recommendation about treatment/transport, yet they are hiring people that lack the education/experience to make such decisions.  This is no offense to the OP, but this is a bad/dangerous set up for you as the provider and for the patients.  It makes me wonder what kind of medical direction they are operating under.


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## RocketMedic (Jun 16, 2015)

ERDoc said:


> Here is my concern with this scenario.  This place is hiring people that are expected to be able to determine if someone is sick and make a recommendation about treatment/transport, yet they are hiring people that lack the education/experience to make such decisions.  This is no offense to the OP, but this is a bad/dangerous set up for you as the provider and for the patients.  It makes me wonder what kind of medical direction they are operating under.


 Similar to most 911 systems in this regard.


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## ERDoc (Jun 16, 2015)

True, but at least in that situation the default is usually to transport when called.


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## Brandon O (Jun 16, 2015)

ERDoc said:


> True, but at least in that situation the default is usually to transport when called.



Not always our most intelligent moments in the field, but it does cover a multitude of sins.


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## Handsome Robb (Jun 17, 2015)

Gurby said:


> Do you guys ever suggest to patients that they go to an urgent care over the ED?  A lot of times, a patient will refuse transport after calling (or after their someone else calls for them) with something that seems non-acute.  I often want to say, "if it was me, I'd go get checked out at an urgent care", but always feel guilty about it, like I should always advise them to just go straight to highest level of care to CYA.



We transport people to urgent cares as well as refer them to go POV to them or their PCP pretty often.


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## Ewok Jerky (Jun 17, 2015)

ERDoc said:


> This place is hiring people that are expected to be able to determine if someone is sick and make a recommendation about treatment/transport, yet they are hiring people that lack the education/experience to make such decisions



Have you ever met an EMT? We get 240 hours of education and then tossed onto the street.


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## ERDoc (Jun 17, 2015)

I've met plenty of EMTs and was one for 10 years.  I only got 110 hours of training.


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## JPINFV (Jun 17, 2015)

LACoGurneyjockey said:


> What would you do if you had a stomach ache that was sharp? Call an ambulance? Or stop eating ****ty hot dogs that are giving you gas and drink some water?


I had a patient who was coming in with sharp epigastric pain after eating a gas station burrito. He had an aortic aneurysm. Of course being meth positive could have contributed.


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## RedAirplane (Jun 17, 2015)

BLS standing orders?


Ewok Jerky said:


> Have you ever met an EMT? We get 240 hours of education and then tossed onto the street.



You got 240 hours?
I got closer to 160.


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## Brandon O (Jun 17, 2015)

JPINFV said:


> I had a patient who was coming in with sharp epigastric pain after eating a gas station burrito. He had an aortic aneurysm. Of course being meth positive could have contributed.



Still alive, I hope. That's like an EM final exam.


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## RedAirplane (Jun 17, 2015)

Brandon O said:


> Still alive, I hope. That's like an EM final exam.



Was that the ultimate Dx by the MD, or was there some clue in the field that told you that?
(The "pulsating mass" that the textbook talks about...)


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## Brandon O (Jun 17, 2015)

Ishan said:


> Was that the ultimate Dx by the MD



JP's a doc nowadays, although wrong initials.


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## JPINFV (Jun 18, 2015)

Ishan said:


> Was that the ultimate Dx by the MD, or was there some clue in the field that told you that?
> (The "pulsating mass" that the textbook talks about...)


The CT scan that the senior resident threw on because something didn't feel right. Also with that hospital's patient population, patients are assumed to be meth positive until proven otherwise.

We know he was meth positive because it became a, "Well, admit to surgery and pre-op labs." He was treated medically and ultimately discharged. Not all aneurysms need surgery.


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## BOS 101 (Jun 18, 2015)

Ishan said:


> Maybe EMT class scared me a bit much, but isn't sharp abd pain supposed to be worrisome?


 nah, honestly how they describe pain half the time is completely inconsistent with what they have (not just kids)
Dont be worried just cause its sharp, and you do have to think not just from an EMT stand point, but like many others have said, from a regular every day stand point
He just has a upset stomache with no big fuss needed, and his parents may know if this happens every now and again to him or what have you
No reason to feel bad about asking questions, but you might be trying too hard to find an issue, you know what I mean? Odds are, hes hot maybe dehydrated, and its giving him a headache and a stomache ache, water and rest will work
and i like what was said about the urgent care, i would suggest it if it was appropriate


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## ERDoc (Jun 18, 2015)

Here's a good article looking at the sensitivity/specificity/likelyhood ratios of classical signs and symptoms associated with appendicitis.

http://www.aafp.org/afp/1999/1101/p2027.html#afp19991101p2027-b7


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## Brandon O (Jun 19, 2015)

ERDoc said:


> Here's a good article looking at the sensitivity/specificity/likelyhood ratios of classical signs and symptoms associated with appendicitis.
> 
> http://www.aafp.org/afp/1999/1101/p2027.html#afp19991101p2027-b7



While I appreciate this sort of thing to help demystify bedside examination, I am always a little wary of trying to pin sensitivity/specificity figures on physical exam findings (or even components of the history). These are inevitably skill-dependent tools, just like interpreting an ultrasound or an ECG.

As Sapira put it, it's never particularly hard to find somebody who can't do something. (I had a roommate, for instance, who couldn't seem to wash dishes -- yet dishes are intrinsically washable.) This is probably increasingly true nowadays when few clinicians have serious training or experience relying upon their exam in isolation. You don't want to "validate" the sensitivity of Skodaic resonance in the Facebook generation; you want some old crusty fellow who drives a Cadillac and is still skeptical of CAT scans.

Of course, it's easy to take this to the other extreme and pull the old "I don't care what the RCTs say, I've seen this drug work!" Some areas just aren't very amenable to study.


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## Clare (Jun 19, 2015)

Nothing is medicine is ever 100% but given we are dealing with a child, we're not going to be thinking atypical myocardial ischaemia, leaking aortic aneurysm, pancreatitis, cholecystitis etc.  An important point to note is there have been case reports of children spontaneously dying suddenly from aortic aneurysms from undiagnosed connective tissue disorders such as EDS or Marfan's syndrome (although I don't think undiagnosed Marfan syndrome is very likely!).  FMHx here is the kicker given both are inherited (if I remember correct).  Like most things in medicine, this goes to show that diagnosis usually hinges on the history. 

I'd recommend the child is reviewed by a Doctor, preferably his own GP who knows him well provided this can happen today.  If it cannot, he should go to an Accident and Medical Clinic (urgent care) provided this can happen the same day.  If neither of these options is available, he should be seen in an ED today.  It is likely that he will be referred there anyway for an opinion by the duty surgical registrar.  I would contact his GP or an A&M to see if they are comfortable seeing him there, no point sending him there if he's just going to go to ED to be s/b the surgical reg!

If the parents do not want this to happen then there is very little we can do it about it, as in nothing.  Not really at the level where we could involve the Police or Child, Youth and Family for something this simple.  If it was a case of neglect or abuse or something then yes.  

At the end of the day his parents have the right to make a informed choice regarding their child's healthcare until the child is at an age he can do it himself. 

I wouldn't feel that uncomfortable leaving a kid with a tummy ache with mum and dad.  

Nothing to get bent out of shape about.


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## ERDoc (Jun 19, 2015)

Brandon O said:


> While I appreciate this sort of thing to help demystify bedside examination, I am always a little wary of trying to pin sensitivity/specificity figures on physical exam findings (or even components of the history). These are inevitably skill-dependent tools, just like interpreting an ultrasound or an ECG.
> 
> As Sapira put it, it's never particularly hard to find somebody who can't do something. (I had a roommate, for instance, who couldn't seem to wash dishes -- yet dishes are intrinsically washable.) This is probably increasingly true nowadays when few clinicians have serious training or experience relying upon their exam in isolation. You don't want to "validate" the sensitivity of Skodaic resonance in the Facebook generation; you want some old crusty fellow who drives a Cadillac and is still skeptical of CAT scans.
> 
> Of course, it's easy to take this to the other extreme and pull the old "I don't care what the RCTs say, I've seen this drug work!" Some areas just aren't very amenable to study.



I was just putting it out there to show that despite the dogma that is taught in EMT class, things are never black or white.  Not all pts read the textbooks and not all are built the same.  Some people have retrocecal appendices and can have llq tenderness.  The large majority of pts I have seen with acute appy have not been febrile.


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## Brandon O (Jun 19, 2015)

ERDoc said:


> I was just putting it out there to show that despite the dogma that is taught in EMT class, things are never black or white.  Not all pts read the textbooks and not all are built the same.  Some people have retrocecal appendices and can have llq tenderness.  The large majority of pts I have seen with acute appy have not been febrile.



I guess that's my point. When someone tries to do a study showing that "X finding is Y sensitive/specific for Z!", it's inevitably by trying to dichotomize it into a binary result. Very little of anything we do (that works) is binary; it's a constellation of mutually-interacting spectra of data, and much of the task of interpreting it has to be learned experientially, as it's rather difficult to put down on paper.

As you said, this is why this thread is so unanswerable; we'd have to put our eyes on the actual patient, and even then we might disagree.

This is also the only reason our jobs haven't been replaced by computers yet...


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## AcadianExplorer1910 (Aug 23, 2015)

RedAirplane said:


> (Based on a scenario or two I have seen, scrubbed to prevent identification; I would like your thoughts).
> 
> It's a hot dry day without a cloud in the sky.
> 
> ...


i guess since the patient is a minor and the parents say no then do as told but to me it sounds like he ate something that upset his stomach then if he gets even more sick (vomiting) he could get extremely dehydrated


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