# Abdominal Pain scenario



## NysEms2117 (Nov 26, 2016)

To start off i'm going to say that I am the patient in this real case that happened. Now that i know the answer i will provide the case. I was taken 2 separate times for just about the same "case", and got 2 separate styles of treatment (both were fine with me).

You are called to  the residence of a 26 year old male, who is having debilitating abdominal pain. Background on the patient: seems to be physically in shape, is currently on the floor in the living area of the house curled into a ball. Patient states that he has been having moderate to severe pain for 2 days, on the left side of his abdomen, radiating to the lower left back. Pain on scale: 11/10. Pain described as: stabbing, stomach turning inside out, and burning. Last oral intake: about 4 hours ago/ few slices of bread, patient states he could  not eat due to pain increasing upon intake. 
FFW: patient is now in the ambulance, 20 minute transport time to a level 1 hospital has any capability (closest and obviously best choice). V/S BP:150/90 RR: 20 Sat:98% HR:96 SR
Patient also states he is not allergic to any medications to his knowledge. 

curious as to: 1. How do you transport this patient(LS or non emergent) 2. Pain control? 3. General impressions? 4. what other information would you try to gather?

this is my first scenario so  am probably forgetting things, lmk what you would need.


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## DesertMedic66 (Nov 26, 2016)

ABD distended? Rigid? How has urine output and color been?

1. No lights or sirens
2. I'd have to call for orders but I would try to get orders for 50mcg Fent every 5 minutes as needed for pain control. 
3. The first thing that came in my head is possible kidney stone.


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## NysEms2117 (Nov 26, 2016)

DesertMedic66 said:


> ABD distended? Rigid? How has urine output and color been?


urine output normal, no pain upon urination no blood, blood in stool, painful upon stool production.
Abd not distended, but slightly rigid.


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## SpecialK (Nov 26, 2016)

My diagnosis is "buggered if I know" which is not uncommon for abdominal problems.  If I have to pick I would say pyelonephritis but the blood in stool and painful stool makes me think of maybe a GI bleed or a bowel obstruction.

Analgesia: I would start with methoxyflurane if there was going to be a delay in getting IV access.  No entonox cos I can't rule out a bowel obstruction.  I'd give him some IV morphine; big strapping bloke in severe pain I'd give him 5 mg to start and after  his pain settled oral paracetamol, iburpofen and tramadol in combination.  Top up 2 mg IV aliquots of morphine as required.  With this combination he'll be well analgesed for a while so the hospital shouldn't have to worry about it immediately which is better for him.


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## ERDoc (Nov 26, 2016)

NysEms2117 said:


> painful upon stool production.



Rectal foreign body.  Next.  And the pt fails the intelligence portion of the exam for 11/10 pain.


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## NysEms2117 (Nov 26, 2016)

ERDoc said:


> Rectal foreign body.  Next.  And the pt fails the intelligence portion of the exam for 11/10 pain.


Nono that's too easy  this makes you think !. I never seem to pass intelligence tests for some reason, i can't quite figure it out either


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## ERDoc (Nov 26, 2016)

NysEms2117 said:


> Nono that's too easy  this makes you think !. I never seem to pass intelligence tests for some reason, i can't quite figure it out either


Well, you are an LEO so that explains a lot.


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## NysEms2117 (Nov 26, 2016)

ERDoc said:


> Well, you are an LEO so that explains a lot.


well ya know what they say... "we all can't be doctors" or something like that....probably not. At least you summarized me into the right category  guess you really are smart


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## StCEMT (Nov 26, 2016)

ERDoc said:


> Well, you are an LEO so that explains a lot.


Wait, I thought that was firefighters?


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## ERDoc (Nov 26, 2016)

NysEms2117 said:


> well ya know what they say... "we all can't be doctors" or something like that....probably not. At least you summarized me into the right category  guess you really are smart


If I get a ticket tomorrow, I'm blaming you so call off your friends.


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## VentMonkey (Nov 26, 2016)

ERDoc said:


> Rectal foreign body.  Next.  And the pt fails the intelligence portion of the exam for 11/10 pain.


First off: well played, sir.


NysEms2117 said:


> TV/S BP:150/90 RR: 20 Sat:98% HR:96 SR...Patient also states he is not allergic to any medications to his knowledge...curious as to: 1. How do you transport this patient(LS or non emergent)
> *Code 2 (non-emergent).* 2. Pain control? *Yes, and antiemetics titrated to comfort and tolerability (hemodynamically).* 3. General impressions? *The patient is in a great deal pain. Pylo is pretty high on my differential as well, but could be a slew of other diagnoses. *4. what other information would you try to gather? *Febrile? Honestly, there isn't much more digging on my end. As others have mentioned in this thread and another, abdominal complaints can yield many diagnoses. It's almost always supportive care in the prehospital setting, which at the ALS-level is typically antiemetics, analgesics, and IV(F) until they're transported to definitive care for lab work, and CT and/ or U/S.*


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## NysEms2117 (Nov 26, 2016)

ERDoc said:


> If I get a ticket tomorrow, I'm blaming you so call off your friends.


i dont control Michigan... especially after that loss, drive cautious friend . Tell them you know a NYS parole officer maybe they'll give ya a break.


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## VentMonkey (Nov 27, 2016)

NysEms2117 said:


> Tell them you know a NYS parole officer maybe they'll give ya a break.


Or a ticket based on this statement alone??...


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## NysEms2117 (Nov 27, 2016)

VentMonkey said:


> Or a ticket based on this statement alone??...


Do what EMS does pretty dam good . risk reward analysis?
If i actually was to send a PBA card it'd be a different story


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## ERDoc (Nov 27, 2016)

NysEms2117 said:


> i dont control Michigan... especially after that loss, drive cautious friend . Tell them you know a NYS parole officer maybe they'll give ya a break.



Maybe I'll mention I have an uncle who was a town police chief in Sullivan County also.  That should get me off the hook.


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## NysEms2117 (Nov 27, 2016)

ERDoc said:


> Maybe I'll mention I have an uncle who was a town police chief in Sullivan County also.  That should get me off the hook.


Eh NY PBA cards go a long way. Never needed to use one. But i suppose that could work. although broome and Delaware county sheriffs aren't the easiest folks in the world to deal with >.<


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## ERDoc (Nov 27, 2016)

NysEms2117 said:


> Eh NY PBA cards go a long way. Never needed to use one. But i suppose that could work. although broome and Delaware county sheriffs aren't the easiest folks in the world to deal with >.<



Gotta be better than troopers.  Hey wasn't there a scenario or something going on here?


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## NysEms2117 (Nov 27, 2016)

ERDoc said:


> Gotta be better than troopers.  Hey wasn't there a scenario or something going on here?


yeah, you sticking with your original diagnosis ?


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## VentMonkey (Nov 27, 2016)

If this is in fact pylo, then IVF is actually a highly recommended modality, IMO. Prime that (kidney) pump...


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## ERDoc (Nov 27, 2016)

Yup.


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## VentMonkey (Nov 27, 2016)

ERDoc said:


> Yup.


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## VentMonkey (Nov 27, 2016)




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## NysEms2117 (Nov 27, 2016)

Ouch that looks painful.


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## NYBLS (Nov 27, 2016)

How much do you weigh? Height? Figure out my dosing from there...


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## StCEMT (Nov 27, 2016)

ERDoc said:


> Yup.


I probably shouldn't say what my first thought to this was....


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## ERDoc (Nov 27, 2016)

StCEMT said:


> I probably shouldn't say what my first thought to this was....



If your first thought was maglite, then you are correct.


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## IanW (Nov 27, 2016)

EMT here.  NJ though so I can't do IV's.  This is a BLS call so honestly we can put you on the cot in your comfortable position and secure x3.   Transport as comfortably as we can .. this isn't really a medics situation for us, but they pay be interested in doing pain management ...otherwise they'll just release.  

*edit*-- would probably need medics for pain management -- missed the 20 min transport time, my l1 trauma center is 5 minutes away.

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## ERDoc (Nov 27, 2016)

IanW said:


> EMT here.  NJ though so I can't do IV's.  This is a BLS call so honestly we can put you on the cot in your comfortable position and secure x3.   Transport as comfortably as we can .. this isn't really a medics situation for us, but they pay be interested in doing pain management ...otherwise they'll just release.
> 
> *edit*-- would probably need medics for pain management -- missed the 20 min transport time, my l1 trauma center is 5 minutes away.
> 
> Sent from my LG-H810 using Tapatalk



Before we jump to treatment, what other things do you want to know?  What is on your differential?


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## NysEms2117 (Nov 27, 2016)

NYBLS said:


> How much do you weigh? Height? Figure out my dosing from there...


5'11-6' 180-185


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## StCEMT (Nov 27, 2016)

ERDoc said:


> If your first thought was maglite, then you are correct.


Not quite. It was they took the saying "anything is a dildo if you are brave enough" as a challenge.


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## ERDoc (Nov 27, 2016)

StCEMT said:


> Not quite. It was they took the saying "anything is a dildo if you are brave enough" as a challenge.



Good point but in this case it was "I was mad at my wife so I did it to show her how mad I was." 
"Sir, was there alcohol involved?"
"Yup."


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## Handsome Robb (Nov 27, 2016)

NysEms2117 said:


> 5'11-6' 180-185



No lights or sirens for you.

IV, 150 mcg of fentanyl q 10 PRN. 4-8 mg of zofran PRN. 25mg of da ketaminez if the fentanyl doesn't make you stop squirming and whining so I can chart in peace  

Pylo, ischemic bowel and obstruction are high on my list. 


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## NysEms2117 (Nov 27, 2016)

Handsome Robb said:


> No lights or sirens for you.
> 
> IV, 150 mcg of fentanyl q 10 PRN. 4-8 mg of zofran PRN. 25mg of da ketaminez if the fentanyl doesn't make you stop squirming and whining so I can chart in peace
> 
> ...


ahh.. close, but no cigar, And thank you for catering to my needs  lol


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## StCEMT (Nov 27, 2016)

ERDoc said:


> Good point but in this case it was "I was mad at my wife so I did it to show her how mad I was."
> "Sir, was there alcohol involved?"
> "Yup."


Because that always solves marital conflict. He must have been pretty mad....and well practiced lol


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## IanW (Nov 27, 2016)

ERDoc said:


> Before we jump to treatment, what other things do you want to know?  What is on your differential?


Normal sample history,what exactly the PT had before hand and when exactly the pain started and in what way.much of which was answered already but I can't do pain management IV's or anything. We do have is have abdominal pain,  previously treated,  id check for any masses but if I did find something it isn't any immediate relief to the pt. Just more info for the nurse. So transport is the best bet.  No lights. 

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## EpiEMS (Nov 28, 2016)

NysEms2117 said:


> You are called to  the residence of a 26 year old male, who is having debilitating abdominal pain.



This kind of call can go three ways: taxi ride, ALS intercept (ideally to the scene if it's hard to move the patient), or rapid transport to the nearest facility depending on the acuity of the patient and distance to the facility.



NysEms2117 said:


> Background on the patient: seems to be physically in shape, is currently on the floor in the living area of the house curled into a ball. Patient states that he has been having moderate to severe pain for 2 days, on the left side of his abdomen, radiating to the lower left back.



Differentials...appendicitis, pyelonephritis, pancreatitis, urolithiasis, peritonitis, bowel obstruction...

+ CVA tenderness? Is the abdomen rigid, supple? Rebound tenderness? Nausea? Vomiting? Normal ins/outs (eating/drinking and urination/defecation)? Any trauma? Has this happened before? I'd like to get a quick social history, too - ETOH, namely.

Not that these really change *my* management, honestly, it's more for my own education.



NysEms2117 said:


> Pain on scale: 11/10. Pain described as: stabbing, stomach turning inside out, and burning. Last oral intake: about 4 hours ago/ few slices of bread, patient states he could  not eat due to pain increasing upon intake.



Ideally, I'd get V/S in the house. Can the patient walk? Do we need to assist him to a standing position? Or do we have to lift him to the stretcher? If need be, I'd rather get ALS on scene for pain control prior to moving him. If this is too time consuming, it's easy enough to move this patient (not particularly heavy).



NysEms2117 said:


> FFW: patient is now in the ambulance, 20 minute transport time to a level 1 hospital has any capability (closest and obviously best choice). V/S BP:150/90 RR: 20 Sat:98% HR:96 SR
> Patient also states he is not allergic to any medications to his knowledge.
> 
> curious as to: 1. How do you transport this patient(LS or non emergent) 2. Pain control? 3. General impressions? 4. what other information would you try to gather?



Transport for this patient will be non-emergent. If traffic picks up and I don't have any pain control on board, I would consider an exceptionally easy L/S transport.

Pain control would totally be indicated, as far as I can tell. If I could, I'd get ALS on scene. They may not be happy with me, but they'll give this guy some sort of opioid, and probably Zofran for good measure.

With certainty, I can say that this call warrants ALS assistance (or, even better, BLS provision of some sort of effective pain control and an antiemetic) if the patient is really this uncomfortable.


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## NysEms2117 (Nov 28, 2016)

EpiEMS said:


> Differentials...appendicitis, pyelonephritis, pancreatitis, urolithiasis, peritonitis, bowel obstruction...
> 
> + CVA tenderness? Is the abdomen rigid, supple? Rebound tenderness? Nausea? Vomiting? Normal ins/outs (eating/drinking and urination/defecation)? Any trauma? Has this happened before? I'd like to get a quick social history, too - ETOH, namely.


Appendix is on the right side of the abdomen (i was taught to do rebound pain test on LRQ to test for appendicitis), if im not mistaken (i probably am..), abdomen is rigid to an extent, not rock solid, but not "normal" no nausea, no vomiting. Urination normal, stool present but bloody. no trauma, only the past day- to 2 days.


EpiEMS said:


> Ideally, I'd get V/S in the house. Can the patient walk? Do we need to assist him to a standing position? Or do we have to lift him to the stretcher? If need be, I'd rather get ALS on scene for pain control prior to moving him. If this is too time consuming, it's easy enough to move this patient (not particularly heavy).


Patient cannot move, cannot stand, can roll over, but causes agonizing pain.

What everything actually was will be put up later today.


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## EpiEMS (Nov 28, 2016)

NysEms2117 said:


> Appendix is on the right side of the abdomen (i was taught to do rebound pain test on LRQ to test for appendicitis), if im not mistaken (i probably am..), abdomen is rigid to an extent, not rock solid, but not "normal" no nausea, no vomiting. Urination normal, stool present but bloody. no trauma, only the past day- to 2 days.
> 
> Patient cannot move, cannot stand, can roll over, but causes agonizing pain.
> 
> What everything actually was will be put up later today.



Appendix is LRQ, yeah, I was just putting it on the list as a "thing that I can't definitively rule out, but doesn't seem likely" (assuming the patient doesn't suffer from situs inversus totalis ).

Pain control prior to movement would definitely be preferable, if it doesn't cause too much delay and as long as the patient is relatively stable (as he seems to be at this point).


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## NysEms2117 (Nov 28, 2016)

Solution: EMS could not solve the problem. My particular issue needed definitive care. This was an Infected Ulcer in the Descending colon(left side). Definitive care has shown, Ulcerative Colitis. This was compounded by a broken rib that was still in the process of healing. (left side as well), compounded further by  moderate- severe electrolyte imbalance, which was producing severe cramps.

My 2 ambulance trips produced severely different treatment routes. One group of medics gave pain control, until i was tolerable, but didn't snow me with analgesics. the other group did not give pain control, did just about nothing, and refused to transport my girlfriend with me for some reason.

Maybe this helped? if not sorry for taking up your time .


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## DesertMedic66 (Nov 28, 2016)

NysEms2117 said:


> refused to transport my girlfriend with me for some reason.


I very rarely transport anyone other than the patient. If your girlfriend is able to drive herself to the ED that is overall going to be the better option


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## EpiEMS (Nov 28, 2016)

NysEms2117 said:


> Solution: EMS could not solve the problem. My particular issue needed definitive care. This was an Infected Ulcer in the Descending colon(left side). Definitive care has shown, Ulcerative Colitis. This was compounded by a broken rib that was still in the process of healing. (left side as well), compounded further by moderate- severe electrolyte imbalance, which was producing severe cramps.



Oof, no fun. If you don't mind my asking, did you have surgery (bowel resection?) for the ulcerative colitis?



NysEms2117 said:


> My 2 ambulance trips produced severely different treatment routes. One group of medics gave pain control, until i was tolerable, but didn't snow me with analgesics. the other group did not give pain control, did just about nothing, and refused to transport my girlfriend with me for some reason.



Did the first medics medicate you prior to moving you?

On the latter point, I agree with DesertMedic66, transporting family is contraindicated in my mind, especially if they have their own car and the patient is a competent adult or teen.


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## NysEms2117 (Nov 28, 2016)

EpiEMS said:


> Oof, no fun. If you don't mind my asking, did you have surgery (bowel resection?) for the ulcerative colitis?


No sir, currently successfully medicated with a Mesalamine based medicine called Apriso. after a round of steroids antibiotics and the whole kit and kaboodle. 
https://www.aprisorx.com/


EpiEMS said:


> Did the first medics medicate you prior to moving you?


no, i was just kind of shuffled (with whatever assistance i could muster) onto the stretcher, started an IV within seconds of entering the ambulambs, pain control after that.


EpiEMS said:


> On the latter point, I agree with DesertMedic66, transporting family is contraindicated in my mind, especially if they have their own car and the patient is a competent adult or teen.


i suppose, i feel certain times its okay, especially if you put them up front.


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## DesertMedic66 (Nov 28, 2016)

NysEms2117 said:


> i suppose, i feel certain times its okay, especially if you put them up front.


Increased liability if we get into an accident, people steal things, people freak out, I don't want an unknown persons butt on my seat where I spend 12 hours a day.


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## NysEms2117 (Nov 28, 2016)

DesertMedic66 said:


> Increased liability if we get into an accident, people steal things, people freak out, I don't want an unknown persons butt on my seat where I spend 12 hours a day.


Fair points . I understand why.


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## EpiEMS (Nov 28, 2016)

NysEms2117 said:


> No sir, currently successfully medicated with a Mesalamine based medicine called Apriso. after a round of steroids antibiotics and the whole kit and kaboodle.
> https://www.aprisorx.com/
> 
> no, i was just kind of shuffled (with whatever assistance i could muster) onto the stretcher, started an IV within seconds of entering the ambulambs, pain control after that.
> ...



Whew. Glad it's going ok!

I don't know if I would have wanted to move! At least they started narc'ing you up as soon as they could.

I have no problems with a family member in the front, if they're capable of acting like an adult. All too often...they can't seem to.


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## NysEms2117 (Nov 28, 2016)

EpiEMS said:


> if they're capable of acting like an adult. All too often...they can't seem to.


I would've yelled at her . I get it but I also feel there's a patient benefit factor especially if they have never been in an ambulance or gone to a hospital before


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## VentMonkey (Nov 28, 2016)

DesertMedic66 said:


> I very rarely transport anyone other than the patient. If your girlfriend is able to drive herself to the ED that is overall going to be the better option





DesertMedic66 said:


> Increased liability if we get into an accident, people steal things, people freak out, I don't want an unknown persons butt on my seat where I spend 12 hours a day.





NysEms2117 said:


> Fair points . I understand why.


I have no issues with taking family members to the ED with me, within reason. Here, we're strongly encouraged to take them if they wish to come. Now, understandably there are family, and/ or friends that I would not want coming with me for several types of reasons; theses people are often "verbally judo-d" into taking their own vehicle, and/ or meeting up with said patient later at the ED.

As a parent, if I wished to ride with my child regardless of their age, you're damn right I would not be happy with someone telling me I can't, as would my wife. I think over the years I have begun to understand this firsthand. So, for me the average well-meaning family member who means no harm, and may be able to provide further history on the way to the ED (gotta love the "cubby holes") I take with me. If it's a small, scared child I let mom in back, and if anything I am leery of the patient's parent who _doesn't_ want to ride along, especially if they don't have other children to tend to at the time of the call. I do miss the days when we would slap baby of mom's lap, then on the gurney at times (talk about liability) as it made some things easier; clearly this was extremely unsafe though.

This is just my take, and reasoning as to why I would let a presumably reliable family/ friend ride in with us without hesitation. Obviously, they're belted in, but I guess I feel like who am I to tell them no? They're concerned, and again as long as they're fairly level headed they're welcomed to join in. 

To add to this, with critical calls, on scene or even en route I was taught by one of my paramedic proctors to invite them in if they so wish, which I do. If they're genuinely calm, and concerned and want to know what, and why we are doing what we are doing, why not allow them to see, and/ or know what it is their family member is being put through? I clump this into the "explaining the procedure" category; sometimes family wants to know, which is fine. This is no dig at @DesertMedic66's style, it's just what I have been taught, coupled what I have learned over the years from a "concerned family member's" point of view when my child/ wife is ill, and taken to the ED, or U/C for treatment. I have yet to take an ambulance, though.


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## DesertMedic66 (Nov 28, 2016)

VentMonkey said:


> I have no issues with taking family members to the ED with me, within reason. Here, we're strongly encouraged to take them if they wish to come. Now, understandably there are family, and/ or friends that I would not want coming with me for several types of reasons; theses people are often "verbally judo-d" into taking their own vehicle, and/ or meeting up with said patient later at the ED.
> 
> As a parent, if I wished to ride with my child regardless of their age, you're damn right I would not be happy with someone telling me I can't, as would my wife. I think over the years I have begun to understand this firsthand. So, for me the average well-meaning family member who means no harm, and may be able to provide further history on the way to the ED (gotta love the "cubby holes") I take with me. If it's a small, scared child I let mom in back, and if anything I am leery of the patient's parent who _doesn't_ want to ride along, especially if they don't have other children to tend to at the time of the call. I do miss the days when we would slap baby of mom's lap, then on the gurney at times (talk about liability) as it made some things easier; clearly this was extremely unsafe though.
> 
> ...


If I have a pedi patient (we don't get a lot of them) I will let mom or dad ride in, unless possible abuse by the parents is suspected. If the patient is an adult who is AOx4 and is able to provide me with accurate information then there is no need for family to come along. Unless the family does not have a working car then I will take one person and only one. Overall its better if the family takes their own car so that they have a move of transportation once at the hospital for when the patient gets discharged.


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## VentMonkey (Nov 28, 2016)

DesertMedic66 said:


> If I have a pedi patient (we don't get a lot of them)Overall its better if the family takes their own car so that they have a move of transportation once at the hospital for when the patient gets discharged.


Yeah, it's all circumstantial, you'd be surprised at the amount of patients that "look fine" to us then end up with admission orders.

I agree with asking if they have their own mode if they're an able bodied person so they don't get stranded. Also, if they're so distraught of the patients particular complaint, I may ask my partner, or fire to see they can get famiy or friends to drive them to the hospital.


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## BobBarker (Nov 28, 2016)

All depends on your department's policy. I remember a couple years ago I was over at a friend's house. His 85yo neighbor walks into his house with a 9 inch gash in her leg, dripping blood. We put pressure on it and when LAFD arrived, the ambulance allowed 3 of us to ride in the back with her. I think it was primarily because she had no family, the firemen liked our jokes and we didn't mind staying at the ER with her and drive her back home. As long as the patient wants the other person to come with them, they don't make the situation any worse and your department allows it, I don't see any reason why not.


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## Handsome Robb (Nov 28, 2016)

We'll take one rider and only one and they are belted in the front seat. Peds or special needs patients are the only times I'll let people in the back. 

9 times out of 10 we get people to driver themselves while we transport though. 


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## bakertaylor28 (Jan 23, 2017)

Mind you, having only read the initial scenario, My differential guess would be either A) a perforated Colon, B) Chron's Disease or C) An atypical presentation of appendicitis  (mind you without radiology to go on.)  My gut instinct leans toward A , however.


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