# Foaming At The Mouth



## Tigger (Dec 26, 2015)

I've temporarily removed a thread that I recently created that would totally give this away, so if you already read that maybe don't spoil this immediately.

Your ALS ambulance and two person BLS fire unit are dispatched on a 31D2 Subject Unconscious--Severe Respiratory Distress, patient is a 16 year old female. You are responding to a residence that is about 15 minutes away, and while enroute dispatch advises that the patient is "foaming at the mouth." You and fire arrive on scene at the same time, where you are met by the father who beckons you into a holiday rental home that is well kept and rather pricey looking. He brings you into the ground level bedroom where you find your patient supine in bed where other, borderline hysterical family members are trying to wake her up.

Your initial assessment reveals the following: Pt is breathing at approximately 30 times per minute with normal depth and occasional snoring respirations. Heart rate of 130. 

Mental Status: Pt responsive to painful stimuli only, which causes her to open her eyes, no verbal response. Skin: Well-perfused, hot, and dry. HEENT: Significant amount of saliva is present in the oropharynx, pt appears "almost trismused" (2 cm gap between teeth, jaw is fixed). Pupils open during painful stimuli to reveal that they are somewhat dilated, equal, and reactive. Pt has an obvious leftward gaze with occasional nystagmic movements through all fields. Chest: Equal rise and fall bilaterally with clear lung sounds throughout. Abdomen: Soft, palpation does not elicit pain responsive. CTLS: Unremarkable. Pelvis: No incontinence or other abnormalities noted. Extremities: Decorticate posturing noted with both feet and wrists. No signs of trauma noted anywhere on patient. 

Vitals: BP: 110/70, HR: 130 Sinus Tach, RR: 30, SpO2: 94% RA, EtCO2: 25, BGL: 81. 

Family states patient does not take any medications aside from Emergen-C. Patient has no diagnosed history, though family stated that patient has had frequent nosebleeds over the last few weeks. No drug or food allergies. They stated that patient flew in from Arkansas yesterday, which is a 6000 foot change in elevation and twoish hour flight. Once she arrived pt went sledding but did not appear to suffer any trauma during that. No one in the house takes prescription medications. Patient went to bed at nine last night, and mom came in at 730 this morning to wake her up, pt smiled then went back to sleep. At nine they were unable to wake her and called 911.

So what are you going to do? What are your differentials? There is a six bed critical access ED 15 minutes away and a Level II, pediatric accepting facility 1 hour by ground. Flight is not available due to low cloud cover and occasional snow showers.


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## Gurby (Dec 26, 2015)

Slap on a NRB, extricate, suction, 12 lead, call med control.

See what med con says, but probably running in saline (possibly chilled), ice packs under arm pits and groin.  We don't have RSI but this seems like a good candidate.


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## MS Medic (Dec 26, 2015)

I assume where this is going would be HACE. (I live in an area that is slightly below sea level, so I had to look this up to confirm my memory wasn't faulty.) 

Treatment without specialization is to remove the pt from altitude. Since the local hospital is a level II, I'll assume the specialization isn't available there. That means load her up and roll. Since it isn't mentioned, can I assume that peds facility has said decrease in elevation?


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## Tigger (Dec 26, 2015)

MS Medic said:


> I assume where this is going would be HACE. (I live in an area that is slightly below sea level, so I had to look this up to confirm my memory wasn't faulty.)
> Treatment without specialization is to remove the pt from altitude. Since the local hospital is a level II, I'll assume the specialization isn't available there. That means load her up and roll. Since it isn't mentioned, can I assume that peds facility has said decrease in elevation?


You are at 7500 feet and the peds facility is at 6000. That hospital also has a hyperbaric chamber incidentally.


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## Summit (Dec 26, 2015)

Sxn, 4l nc, npa, 2 ivs
Left lateral recumbent (but first lift knees to see of head lifts)
Focused assessment head for evidence of trauma
Focused assessment nose arms for evidence of drug use.

How long has this been going on?
Temperature? Ekg?

Consider rsi but not sure we need this right now.

Ddx: sx, drugs, closed head injury, meningitis

I do not suspect altitude related illness. 

Tp to peds facility


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## MS Medic (Dec 26, 2015)

Without any indications causing me to suspect trauma based on family history of events and a lack of evidence of toxidromes, coupled with the mentioned rapid rise in elevation, I'm going to suspect HACE until it is ruled out by the ED. Going to administer Narcan simply to rule out that possible cause of AMS but transport to the Peds center, providing supportive care.

But as I stated earlier, I live where I have absolutely no experience with altitude illnesses so I accept that I might be way off base.


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## DesertMedic66 (Dec 26, 2015)

MS Medic said:


> Without any indications causing me to suspect trauma based on family history of events and a lack of evidence of toxidromes, coupled with the mentioned rapid rise in elevation, I'm going to suspect HACE until it is ruled out by the ED. *Going to administer Narcan simply to rule out that possible cause of AMS* but transport to the Peds center, providing supportive care.
> 
> But as I stated earlier, I live where I have absolutely no experience with altitude illnesses so I accept that I might be way off base.


Are people still giving Narcan to patients just to rule something out? Pupils are not pinpoint, respiratory drive clearly has not been depressed, and really nothing about this patient is making me think a narcotic overdose unless I am missing something...


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## NomadicMedic (Dec 26, 2015)

I saw the original post, so I won't comment... But this is not what you think it is ... And there's a couple of important questions you'll be asking as soon as Tigger spills the beans on this.


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## MS Medic (Dec 26, 2015)

DesertMedic66 said:


> Are people still giving Narcan to patients just to rule something out?



Not as a matter of rote form, but there is an hour long Tx that will consist primarily of supportive care and since there isn't any harm in the administration or any way to completely confirm the pt isn't on an opioid, I would in this case.


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## Tigger (Dec 26, 2015)

Summit said:


> long has this been going on?
> Temperature? Ekg?


Sinus tach, no 12 lead. No thermometer, patient felt hot in bed. Enroute skin felt pretty normal. 

Patient went to bed normally last night, awoke briefly at 7 (smiled at mom who left her to keep sleeping). At nine patient found unresponsive.


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## MS Medic (Dec 26, 2015)

DEmedic said:


> I saw the original post, so I won't comment... But this is not what you think it is ... And there's a couple of important questions you'll be asking as soon as Tigger spills the beans on this.



Then I reserve the right to be wrong.


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## DesertMedic66 (Dec 26, 2015)

MS Medic said:


> Not as a matter of rote form, but there is an hour long Tx that will consist primarily of supportive care and since there isn't any harm in the administration or any way to completely confirm the pt isn't on an opioid, I would in this case.


But there is no indication for Narcan in this patient. How do we know the patient didn't overdose on narcotics? Because the patient is not presenting at all of an OD.


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## MS Medic (Dec 26, 2015)

If you wouldn't, that's fine. I agree that it probably won't make a difference and I don't want to derail this thread.


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## Summit (Dec 26, 2015)

What does the capno look like?

So does pt tolerate npa? Can we Opa?  If extended then et and nasal intubation if needed.

I reserve the right to add sepsis to ddx to explain tachypnea and type 2dcs too but only because tigger mentioned hyperbaric chamber. Have extreme trouble believing that is the case since she was asymptotic on the flight.

Hace is extraordinarily unlikely less than 24 hours in and below 14000


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## Tigger (Dec 26, 2015)

Summit said:


> What does the capno look like?
> 
> So does pt tolerate now? Can we Opa?  If extended then et and nasal intubation if needed.
> 
> ...


There is no way to open her mouth open enough to get an OPA in. There is obvious an pain response to NPA insertion but you are able to pass it which lessens but does eliminate snoring respirations. Capno waveform shape is unremarkable at 25.


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## MS Medic (Dec 26, 2015)

Since this pt has a RA SPO2 of 94%, I would consider her self maintaining an airway. I'd probably put her in fowlers with a canula.


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## redundantbassist (Dec 26, 2015)

Any family history of seizure disorders or diabetes? Last oral intake? Also, any possible way to suction and visualize the mouth?


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## Summit (Dec 26, 2015)

Tetnus shot? Kernigs  and bridninskis signs?


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## MS Medic (Dec 26, 2015)

Do have a question. What is CLTS? That's a new anacronym to me.


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## Tigger (Dec 26, 2015)

redundantbassist said:


> Any family history of seizure disorders or diabetes? Last oral intake? Also, any possible way to suction and visualize the mouth?


No to all. Ate dinner last night with family.


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## Tigger (Dec 26, 2015)

MS Medic said:


> Do have a question. What is CLTS? That's a new anacronym to me.


Cervical Thoracic Lumbar Sacral


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## DesertMedic66 (Dec 26, 2015)

Almost sounds like a CVA/brain bleed to me. Not unheard of in a 16 year old.


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## CALEMT (Dec 27, 2015)

DEmedic said:


> I saw the original post, so I won't comment... But this is not what you think it is ...



Same here.


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## CALEMT (Dec 27, 2015)

You know @DesertMedic66 is desperate when he texts you asking for the answer. Better not spill the beans Desert!


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## DesertMedic66 (Dec 27, 2015)

CALEMT said:


> You know @DesertMedic66 is desperate when he texts you asking for the answer. Better not spill the beans Desert!


I don't know what you're talking about..


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## Tigger (Dec 27, 2015)

Summit said:


> Tetnus shot? Kernigs  and bridninskis signs?


For lack of a better word the patient's neck could be called floppy and was easy to manipulate in all fields. Did not really manipulate her legs, though they were straight and rigid with decorticating feet.


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## Clare (Dec 27, 2015)

My diagnosis is intracerebral bleed until proven otherwise. 

I see nothing to indicate seizure, ischaemic stroke, meningitis, meningococcal septicaemia, traumatic brain injury or poisoning which are on my differential list.

Treatment? Well, regardless of cause, from the pre-hospital perspective it's fairly straightforward:

1.  Suction airway, attempt NPA, if unsuccessful, jaw thrust and reservoir mask oxygen
2.  Call for RSI Officer

I would go directly to a major hospital unless her airway was unmanageable and no RSI Officer was available, or it was quicker to perform an intermediate stop to get her airway managed then continue, although in practical reality it is probably going to be faster to meet RSI Officer en-route


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## Summit (Dec 27, 2015)

DesertMedic66 said:


> Almost sounds like a CVA/brain bleed to me. Not unheard of in a 16 year old.


It just doesn't feel like an ICH although blowing an AVM seems like a decent cause. Presentation is just not quite right...

Wish I had labs.


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## MrJones (Dec 27, 2015)

Not going to hazard a guess, but why is it that apparently no one uses Endotrols for nasal intubation these days?


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## reaper (Dec 28, 2015)

MrJones said:


> Not going to hazard a guess, but why is it that apparently no one uses Endotrols for nasal intubation these days?


Use them all the time. Most smaller services won't carry them, due to cost.


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## zzyzx (Dec 28, 2015)

Coming to this late...

Meningitis/encephalitis
CVA
Status seizure
Drugs/toxic ingestion

But I'm sure it's going to be some other zebra.


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## NomadicMedic (Dec 28, 2015)

reaper said:


> Use them all the time. Most smaller services won't carry them, due to cost.



We still have them. It's been forever since I even thought about nasaly intubating someone though. That's a low frequency procedure that I'm not nearly comfortable enough with.


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## Seirende (Dec 28, 2015)

Sounds laik that hydrophoby to me.

Which would be rather sudden onset, but it's in my differential diagnoses. Any recent animal contact?


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## chaz90 (Dec 28, 2015)

reaper said:


> Use them all the time. Most smaller services won't carry them, due to cost.


We carry them, but no one uses them. If I'm at the point of wanting to intubate a conscious and breathing patient, I'd much rather do a standard RSI. My medical director hates nasal intubations, and I have never done one and am completely uncomfortable with the procedure.


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## Summit (Dec 28, 2015)

Seirende said:


> Sounds laik that hydrophoby to me.
> 
> Which would be rather sudden onset, but it's in my differential diagnoses. Any recent animal contact?


I'll buy it, but I've never seen a case myself so I fear I'm buying it in the same way non-altitude folks would buy HACE. But it is a fair question.

Also, who even calls it that anymore? Rabies!


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## Seirende (Dec 28, 2015)

Summit said:


> Also, who even calls it that anymore? Rabies!


I'm honoring my old school film and television upbringing.


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## Tigger (Dec 28, 2015)

reaper said:


> Use them all the time. Most smaller services won't carry them, due to cost.


We actually do carry them so that the non-RSI qualified folks will have an option. That said, when I start working as a medic (non-RSI), I think I would rather just call for someone to come and do an RSI for me, be that by air or ground.


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## Tigger (Dec 28, 2015)

In any case, we elected to transport the patient to the pediatric facility. Enroute the patient was RSIed without difficulty and and an OG tube placed, with nothing of note suctioned with that. The patient was sedated with Fentanyl and Versed with minimal changes in vital signs. 

She was quickly taken to CT, which was completely clear. After that she was admitted to the PICU and eventually they got around to drawing blood gasses, which apparently were not particularly abnormal. CO-oximety was then used and some very high (they didn't pass along numbers) values were found. The hospital called us, we called fire, they went out and their meter pegged at 1500ppm as soon as they walked into the house. 

No one in the house ever had any symptoms since they were all staying upstairs (patient had the only ground floor bedroom). It's still unclear to me how my partner and I did not develop symptoms given those levels, perhaps levels were lower in the bedroom itself. 

As for whether we use CO-oximetry ourselves: The LP15s were placed in service last winter with zero in service training on them aside from "it's got a color screen, everything else is the same as a 12." I asked if we had ordered them with spCO, which the supervisors and supply guy answered with either "no, too expensive" or "I don't know." In any case, every now and again the spO2 would switch to CO when someone had a reading over 10. How could this be if the monitors don't have them I asked???

"Well it probably doesn't work," was the answer. Oh it worked on this call alright. Values of 35 to 38 pre RSI. But as I had been told to discount it, we ignored it (my partner had no idea such a feature even existed on LPs). My supervisor then proceeded to ask us why I "blew off that reading since it made sense." It made absolutely no sense given presentation and environment and he was not aware that the monitors could that either. 

I like where I work, but the lack of in service training has always irked me, and yesterday that was reaffirmed. It would not have changed much except that she probably would have ended up in the hyperbaric chamber quicker.


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## Summit (Dec 28, 2015)

Ah... so that is why you needed hyperbarics!


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## EMSComeLately (Dec 28, 2015)

MrJones said:


> Not going to hazard a guess, but why is it that apparently no one uses Endotrols for nasal intubation these days?



We carry them as well as the BAAM device.


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## Tigger (Dec 28, 2015)

Summit said:


> Ah... so that is why you needed hyperbarics!


Totally by luck that she ended up at Memorial Central in the Springs, if she was 17 we would have likely ended up Penrose, which does not have that.


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## reaper (Dec 28, 2015)

chaz90 said:


> We carry them, but no one uses them. If I'm at the point of wanting to intubate a conscious and breathing patient, I'd much rather do a standard RSI. My medical director hates nasal intubations, and I have never done one and am completely uncomfortable with the procedure.


I make sure all new medics are comfortable with NTI. Just like RSI, they are a tool in the box. RSI is not always a good choice or even able to be done. You need to have that back up available to you.

Any medical director that hates NTI does not have a good grasp of airway management. You need to be comfortable in all airway management.


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## chaz90 (Dec 28, 2015)

reaper said:


> I make sure all new medics are comfortable with NTI. Just like RSI, they are a tool in the box. RSI is not always a good choice or even able to be done. You need to have that back up available to you.
> 
> Any medical director that hates NTI does not have a good grasp of airway management. You need to be comfortable in all airway management.


I'm not certain I quite agree with this. Being comfortable and competent in airway management should mean one is capable of using a variety of tools, rescue devices, and adjuncts to manage a patient's airway as is appropriate for them. That doesn't mean I have to be comfortable or familiar with every single airway device or technique that has ever been devised. 

I've never used an iGel or many of the dozens of types of video laryngoscopy devices. That doesn't mean that they don't have a role in airway management, certain advantages, or that I couldn't learn to use them effectively, but I would use my preferred techniques over something unfamiliar if I had both in front of me. 

Being comfortable in "all of airway management" should mean you have a plan and backups available along with the skill and clinical acumen to know when to proceed to the next step. In my case, I know enough of my unfamiliarity with NTI and have enough other tools available that I don't plan on ever using it barring exceptional circumstances. If I had a compelling argument as to why it would be beneficial in certain patient populations over some other way I had of managing them and had opportunities to learn how to properly place them in live patients, I would be happy to add it to my skill set. As it stands now though, I would be very reluctant attempting it for the first time on a patient in extremis.


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## teedubbyaw (Dec 28, 2015)

Good case, Tigger. Do you know her outcome?


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## ERDoc (Dec 28, 2015)

Great case that is definitely not straight forward.  I might have missed it but any idea where to CO was coming from?


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## chaz90 (Dec 28, 2015)

Absolutely, cool case Tigger, and thanks for sharing.


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## Tigger (Dec 29, 2015)

I'm on vacation right now so I won't know till the new year. We suspect the furnace or water heater, the utility room was adjacent to her bedroom.


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## Tigger (Jan 15, 2016)

Finally got some followup. It's still unclear if they placed her in the hyperbaric chamber while intubated or just under sedation, but she received three of five intial treamtents. Initial neuro assessment was positive and as sedation was lifted the patient was found to have an "age appropriate fund of knowledge" and something about a snarky 16 year old attitude. The patient continued to suffer from extreme nausea and could not walk farther than 15 feet without vomiting. The patient was given additional hyperbaric treatments and apparently responded well enough to be discharged on a cannula. She'll be followed by her local children's facility in hopes of additional improvement.

We're all pretty stoked on that, needless to say.


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## johnrsemt (Jan 22, 2016)

Didn't see it on first or follow up posts:  was her skin flushed?


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## meatanchor (Jan 23, 2016)

I understand that CO poisoning will invalidate an SPO2 reading, so good call on  immediately placing her on O2.   Our team does underground rescue and we've been considering the purchase of a  Carboxyhemoglobin oximeter (SPCO) device.  Does anyone have a recommendation for something that isn't thousands of dollars and is relatively portable?  I understand a lot of fire services have these for use in the "rehab" area during a fire.


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## NomadicMedic (Jan 23, 2016)

meatanchor said:


> I understand that CO poisoning will invalidate an SPO2 reading, so good call on  immediately placing her on O2.   Our team does underground rescue and we've been considering the purchase of a  Carboxyhemoglobin oximeter (SPCO) device.  Does anyone have a recommendation for something that isn't thousands of dollars and is relatively portable?  I understand a lot of fire services have these for use in the "rehab" area during a fire.



Is there anything other than a rad-57?


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## Tigger (Jan 23, 2016)

DEmedic said:


> Is there anything other than a rad-57?


As far as I can tell only Masimo makes such a device. 


johnrsemt said:


> Didn't see it on first or follow up posts:  was her skin flushed?


Not in the slightest. 


meatanchor said:


> I understand that CO poisoning will invalidate an SPO2 reading, so good call on  immediately placing her on O2.   Our team does underground rescue and we've been considering the purchase of a  Carboxyhemoglobin oximeter (SPCO) device.  Does anyone have a recommendation for something that isn't thousands of dollars and is relatively portable?  I understand a lot of fire services have these for use in the "rehab" area during a fire.


I don't think the NC did much good, but the ET tube certainly helped as per the SpCO on the monitor. That's a 40k device though and not practical for your uses.


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## meatanchor (Jan 24, 2016)

I understand that the half-life of CO in the body is approximately halved once the Pt. is breathing 100% O2.  When we go into mines, one of our protocols is that we must have at least 1 hour of high-flow O2 available and radio, phone or satphone contact with our dispatch from the entrance.  We also have two 4-gas monitors with each team.

A lot of old mines have experienced fires at some point, and it is possible that we could open a door and release a trapped pocket of smoke/gas, or discover that something had burned more recently than estimated.  The SPCO wouldn't change my treatment, but might help with decision to call for air transport to a hyperbaric facility.


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## wilderness911 (Feb 8, 2016)

Great case, OP. Thanks for taking the time to share this one!


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