# I promised a hard scenario, consider it delivered.



## Veneficus

Scenario

Dispatch/scene information:
You are called to an upper middle class residence for a 15 year old female feeling “sick for a couple of days.” Upon Arrival you are greeted at the door by the patient’s mother who claims her daughter has been feeling ill and spent the last few days in bed and is now difficult to arouse. On your way into the residence you notice a stack of bills on a bureau, a lack of furnishings and very limited amount of electronic devices. The dwelling is clean but the occasional damage to the drywall has not been repaired. 


You make your way up the stairs to a second floor bedroom where you notice a 15 year old female wrapped tightly in blankets despite the 85F temperature outside. You next remove the blanket to start your assessment. The female is wearing sweatpants and a t-shirt, she does not appear to be sweating, though she is pale in the face and has multiple purpuric lesions on her arms. While you expose her and perform a physical exam, your partner (a brand new, 1st call ever, provider of the lowest level allowed in your country. This one is all about you) gathers a history.

Vital signs:
Heart rate: 110 regular, central pulses present and weak. Distal pulses absent.
BP: 80/60
Respiratory rate is 24/min and shallow
Temperature is 40C rectal.
Capilary blood glucose: 60
Weight is 47kg height 5’5” 
Sinus tachycardia with occasional (<6 minute) PVCs that do not generate a palpable pulse wave. 
Spo2: 89 on room air
ETCO2: 30
GCS: E4 V4 M5

Physical exam:
Hair is oily and matted, skin is pale and cool to the touch, nothing noted about the ears. Pupils are dilated and sluggish.  Sclera has diffuse blood throughout, mucous membranes are dry, slight bleeding from the gum line, face and head is otherwise symmetrical with no obvious deformity or masses upon palpation. Trachea is midline without shift, JVD is noted and skin is also pale on the face/neck. Thyroid and lymph nodes are not enlarged carotid pulse is present and weak

Exposing her chest you observe multiple purpuric regions (>2cm in diameter), breathing is shallow and rapid at a rate of about 24/minute, breasts appear at stage 5 development. Breath sounds are diminished with crackles in the bases, Heart tones exhibit a gallop and sound distant. Apex of the heart is at the normal level, lungs also within normal topographic parameters. Back has similar purpura legions. Skin is cool to the touch.

The abdomen appears similar to the chest, however it is slightly distended, locally warm to the touch in the lower quadrants, involuntary muscle guarding is noted on palpation, you decide not to auscultate bowel sounds, liver in 2cm beneath normal margin, spleen not palpable. Diffuse echimosis in the gluteal region, constant trickling bloody discharge from the vagina, and subcutaneous emphysema in the mons pubis area .

There appears no indication of external trauma with an exhaustive exam.

Arms and legs are also cool to the touch, difuse purpura throughout. Capillary refill at +4. Femoral pulse is present and weak, distal pulses absent in all extremities.

History: Your partner (who is an exceptionally capable historian for a person green as grass) tells you the mother is extremely worried about the cost of all of this as they recently lost their health coverage. But he elicits:

Mother noticed her daughter had been sick the last few weeks with nausea and vomiting and warm to the touch. The girl continued to go to school despite the illness. She came home after hanging out with friends like usual 2 nights ago complaining of abdominal pain and went to her room. Next day pt told her mother she was too sick to go to school, was not hungry, but was drinking water and tea, vomiting had stopped. This morning mom came to check on the girl, who complained of epigastric pain. PT had spit up some gross red blood and then mom called 911. (aka: you)

The patient has been taking “femrelief” for menstrual cramps as needed for years, the dose of Nyquil on the bottle for the last 3-4 days and has no known allergies medical or otherwise. You notice no drug paraphernalia with a quick cursory search and no street drugs. You also do not notice track marks or venipuncture sites on the pt.

 The mother reports the female does not have a boyfriend, is not sexually active, started menstruating at age 10 and was not regular, LMP unknown. No history of pregnancy, miscarriage or abortion. 

The mother also reports that the patient uses no alcohol and does not smoke. You do not find anything in the environment that contradicts this information. 

The patient has not been eating the last few days but has been drinking a lot of fluids. The mother does not know about urination or defecation habits or frequency.

The Mother also reports the girl is a straight A student and is a starter on the high school volleyball and track teams, plays in the band and sings in the choir. (since 3rd grade.)

You are working in the US, but operate under your normal protocols or standard of care. So what are your thoughts and orders Captain? Your nearest hospital is a community hospital 10 minutes away. A major academic medical center is 30 minutes away. Anyone of 10 airmed providers are at your beck and call and frequently hand out pens and other marketing items but it will take them 40 minutes to respond at best.  You have anything you normally have on your responding unit. You can ask for any clarifications, repeat findings, more detailed findings, or the effect of your interventions. The only ambiguity in the scenario is what you do but I will do my best to respond accordingly and consistantly.

Hints to make your head hurt:
In this scenario there are 5 life threatening pathologies, some secondary to others.
All of the pathologies are readily identifiable by the information given except for the common primary pathology which is alluded to and can be reverse engineered from finding the others.  

PS. This is also my original work and not to be distributed without permission, which you have as long as you make no money from it and proper credit is given. 04/25/2010

This scenario is hypothetical and bears no relationship to any person known or unknown by the author.


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## 8jimi8

well... i don't have time to reply to this.

my initial wild stab in the dark....  (even though it seems you contradicted this with one of your later statements about the pt not being sexually active...)

anyway... initial thoughts went out to Peritonitis and Septic shock 2nd vaginal/uterine puncture (from her secret abortion) and DIC.

I'll come back to this... I just finished my work week at 9am this morning and i should not be awake right now.

I just wanted to post up those thoughts before everyone bloodied the water!


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## FLEMTP

Honestly.. sounds like Scurvy to me brought on by poor teenage nutrition.. which is more common than you think these days.. the poor nutrition, not the scurvy.

Id alert the closer hospital, start all ALS measures, give fluids, and get her to the ER for blood work to confirm the suspected diagnosis


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## Lifeguards For Life

It sounds like she may have a large cell vasculitis.

Takayasu's Arteritis occurs most often in teenage girls, and would account for a large portion of her symptoms.


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## Lifeguards For Life

Takayasu's Arteritis would also account for blood in the sclera.

What is this patients ethnicity?

any associated joint pain?

diplopia?

exactly how was she feeling sick for a few days?

Actually Takayasu's Arteritis fits less than i originally thought.


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## Lifeguards For Life

When the capillary BGL was taken, did she have an abnormal clotting time?


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## Veneficus

There is no large cell vasculitis nor takayasu’s.

The patient is a native born US Caucasian

Her GCS is 9 v4=confused she does not appropriately answer your questions. Her mother reports she only complained of nausea and vomiting prior to getting too sick to go to school. (go with “no” on the joint pain)

Diplopia is not assessable  

Mother reports feeling sick as: nausea and vomiting prior to being “too sick to go to school today”

Prolonged clotting time for sure. It appears infinite.


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## Lifeguards For Life

Veneficus said:


> There is no large cell vasculitis nor takayasu’s.
> 
> The patient is a native born US Caucasian
> 
> Her GCS is 9 v4=confused she does not appropriately answer your questions. Her mother reports she only complained of nausea and vomiting prior to getting too sick to go to school. (go with “no” on the joint pain)
> 
> Diplopia is not assessable
> 
> Mother reports feeling sick as: nausea and vomiting prior to being “too sick to go to school today”
> 
> Prolonged clotting time for sure. It appears infinite.



past medical history?

Is the patient anemic?

Von Willebrands?

is there any peripheral edema?


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## Veneficus

Lifeguards For Life said:


> past medical history?
> 
> Is the patient anemic?
> 
> Von Willebrands?
> 
> is there any peripheral edema?



I accidentally deleted the line about past medical history when editing...
sorry.

There is no prior medical history. 

The girl was born at term, without inducing, from a planned pregnancy with proper preconception and prenatal care. She has had a healthy childhood, meets all developmental benchmarks, has a yearly sports physical, and all vaccinations.


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## Lifeguards For Life

Thrombotic thrombocytopenic purpura secondary to a viral infection.

I considered Hep C, but with the given information, does not seem likely.

Am thinking the patient may also have ARF secondary to whatever the underlying condition may be.

May also have DIC as a secondary disorder as well.

The patient may also have a cardiac tamponade, as she meets criteria for becks triad, though JVD should be a normal variant while supine.

Does a hepatojugular reflux test show a deviation of 4cm or more?

Can you clarify what 





> liver in 2cm beneath normal margin


 means?

Are you advising the liver is distended, protruding 2cm lower than normal?

or the liver is displaced 2cm inferiorly?

I apologize for the random presentation of my thoughts...


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## MrBrown

septic shock and some sort of DIC is about the limit of my knowledge honestly


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## Veneficus

Lifeguards For Life said:


> Am thinking the patient may also have ARF secondary to whatever the underlying condition may be.



Not yet, but if somebody doesn't figure out what to do for her she will. 



Lifeguards For Life said:


> May also have DIC as a secondary disorder as well..



For certain. But what is the mechanism? (that will seperate the men from the boys so to speak)




Lifeguards For Life said:


> Does a hepatojugular reflux test show a deviation of 4cm or more?



That test is non specific, but I will throw you a bone and say there is an acute pathology causing right heart insufficency. 

Can you clarify what  means?



Lifeguards For Life said:


> Are you advising the liver is distended, protruding 2cm lower than normal?



yes



Lifeguards For Life said:


> or the liver is displaced 2cm inferiorly?



no


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## Lifeguards For Life

what region of the US are we in?

are oslers nodes present?

when you said the spleen can not be  palpated, is their evidence of a splenectomy?

history of possible tick bite exposure?

Meningococcemia seems a likely possibility given the non specific onset of symptoms.

maybe what i originally interpreted as becks triad and deduced as cardiac tamponade is actually endocarditis?


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## Lifeguards For Life

is the mother showing any signs or symptoms?


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## Veneficus

Lifeguards For Life said:


> what region of the US are we in??



Doesn't matter. Could happen anywhere.



Lifeguards For Life said:


> are oslers nodes present?



No



Lifeguards For Life said:


> when you said the spleen can not be  palpated, is their evidence of a splenectomy?



No splenectomy, I was trying to demonstrate it was not enlarged.



Lifeguards For Life said:


> history of possible tick bite exposure??



Always possible, but you find no evidence of it. No punctures with inflammation or tics. 



Lifeguards For Life said:


> Meningococcemia seems a likely possibility given the non specific onset of symptoms.



possibly but the patient will die before that.



Lifeguards For Life said:


> maybe what i originally interpreted as becks triad and deduced as cardiac tamponade is actually endocarditis?



There is ample evidence of bleeding into the pericardium.



Lifeguards For Life said:


> is the mother showing any signs or symptoms??



no, nor is the father or brother.


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## Veneficus

So far only one of my classmates has figured it out 

Where are you transporting to? Is this a medical or surgical emergency?


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## Lifeguards For Life

well if no one else in the house is displyaing signs or symptoms, i think i can rule out most viral causes.

acute pancreatitis resulting in DIC?

am also contemplating RMSV vs human ehrlichiosis, seems the differentiating factor would be purpural involvment in the palms and soles.

bacteremia of some origin?


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## Lifeguards For Life

Lifeguards For Life said:


> well if no one else in the house is displyaing signs or symptoms, i think i can rule out most viral causes.
> 
> acute pancreatitis resulting in DIC?
> 
> am also contemplating RMSV vs human ehrlichiosis, seems the differentiating factor would be purpural involvment in the palms and soles.
> 
> bacteremia of some origin?



would the absence of swollen lymph nodes rule out bacteremia as well?


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## Veneficus

Lifeguards For Life said:


> would the absence of swollen lymph nodes rule out bacteremia as well?



Not in such an acute case. Bacteremia is the final nail in this coffin.


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## Sasha

Oh LFL you are doing so well. I made Vene tell me the answers.


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## Lifeguards For Life

one thing still throwing me for a loop is the "constant trickling bloody discharge from the vagina" being a manifestation of an OB emergency vs. the patient having Disseminated Intravascular Coagulation.

And the patient having subcutaneuos emphysema in the mons pubis area.

I believe there are only a few pathologies that can cause this. one being blunt trauma, the other being a bacterial cause.

Clostridium perfringens could of caused the patient to have subcutaneous emphysema near the mons pubis.

but could that cause DIC?

And I still haven't seen how the patient could have gotten Clostridium welchii....

it has been isolated and found to culture near the perineum right?


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## EMTinNEPA

Has the patient been gaining or losing weight recently?

Any changes in behavior?  Has she been depressed?  Apathetic?  Socially withdrawn?

Has the mother noticed her daughter's voice becoming hoarse or deeper lately?

The patient is a starter for the volleyball team... does the team practice indoors or outdoors?


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## Veneficus

Lifeguards For Life said:


> one thing still throwing me for a loop is the "constant trickling bloody discharge from the vagina" being a manifestation of an OB emergency vs. the patient having Disseminated Intravascular Coagulation.



When in doubt choose both.



Lifeguards For Life said:


> And the patient having subcutaneuos emphysema in the mons pubis area.



How would you get air in there?

I believe there are only a few pathologies that can cause this. one being blunt trauma, the other being a bacterial cause.



Lifeguards For Life said:


> Clostridium perfringens could of caused the patient to have subcutaneous emphysema near the mons pubis.



near the mark with C perfringes.



Lifeguards For Life said:


> but could that cause DIC?



It can, DIC can be a complication of sepsis. However, in this particular scenario DIC is one of the earliest pathologies (prior to sepsis and promoting it)



Lifeguards For Life said:


> And I still haven't seen how the patient could have gotten Clostridium welchii....
> 
> it has been isolated and found to culture near the perineum right?



yes, but it is inconsequential to this case.


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## Veneficus

EMTinNEPA said:


> Has the patient been gaining or losing weight recently?



no.



EMTinNEPA said:


> Any changes in behavior?  Has she been depressed?  Apathetic?  Socially withdrawn?



No changes in behavior were noted other than the N/V for days. The mother tells you that the girl has such a busy schedule she is usually only home to eat, sleep and do homework. She spends most of her time on the internet in her room when awake at home.



EMTinNEPA said:


> Has the mother noticed her daughter's voice becoming hoarse or deeper lately?



no



EMTinNEPA said:


> The patient is a starter for the volleyball team... does the team practice indoors or outdoors?



Both, of no importance in this Dx.


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## Smash

It's late and I'm tired, but this sounds suspiciously like Toxic Shock Syndrome to me.

Treat for SIRS/Sepsis, to wit:  Oxygen, IV x 2 or 3 or something; large.  Lots of fluids, then inotropes of whatever flavour is in vogue in your area.  If things start looking worse intubate and provide 100% O2.
We don't carry an appropriate antibiotic for early empirical administration in this case, and it is probably too close to hospital to use anyway.  Remove (or get removed) the tampon, although there isn't really good evidence that this will help.

Drive to high level hospital with much of the fastness, this girl needs aggressive intervention with EGST and ICU admission and the local community center probably won't be up to caring for her.


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## EMTinNEPA

I agree... not much we're going to do pre-hospital except try to combat the shock long enough to get her to the hospital alive.  I seriously doubt the local community hospital will be able to appropriately manage her case without transferring her out.


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## Seaglass

The vaginal discharge might be a red herring, but I'd start wondering about TSS as well as general gyn history, and would see if there's a tampon to be removed. Sepsis in general seems like a solid guess, though I don't know what from. I'm also wondering about some kind of vasculitis. My zebra guess: Takayasu's?

Regardless, I'm a basic on a basic truck. I might not even be able to get several of the vitals you mentioned. I'd administer oxygen and gasoline. I'd either wait for ALS or get an intercept on the way to the higher-level hospital, depending on where the nearest intercept is. I'd get in touch with the intercept, the receiving hospital, medical control, or some combination of the above, depending on where I'm working.


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## Melclin

*This girl is sick.*

With the pupuric rash and septic shock, I'd be remiss not to pour ceftriaxone into her although I'm not entirely sure what it is off the top of my head. The septic shock and rash point to menningoccocal but the length of time she's been sick seems a little to long (It was a few days wasn't it?) so I'm not sure its that. Without some googling and "hittin' the Harrison's" I couldn't speculate what this might be. 

I think as paramedics, we wouldn't wanna sit around getting 15 years of medical history and trying to play noctor  she's seriously ill and seriously time critical. 

As a basic here:
- PPE. 
- rapid infuse normal saline 20mls/kg
- 1g ceftriaxone.
- ~100% oxygen
- Alert receiving hospital - we will be going to the major hospital. 

As ALS:
- All of the above
- titrate adrenaline if the blood pressure is refractory to the first..probably  500mls of NS. 
- another 20mls/kg as long as the lungs stay clear.
- Consult the clinician for dexamethasone dosage.


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## Aidey

The first thing I would have done after seeing that rash is put on a mask...it may be from the DIC, but it could also be from meningitis, and I'm not going to risk it. 

So we've got sepsis, DIC, and pericarditis so far correct? 

Maybe I'm over thinking, but she is technically underweight. She is also a 15 year old high achieving female, chance there is an eating disorder underlying all of this?


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## Veneficus

*Everyone did very well*

Many people here got part of the story. Without knowledge of the progression there are only a few subtle hints that point to the primary cause. It was given in the first reply, but nobody followed up on it.



Here is my walk through of the scenario with the key points and predetermined solution.


Though some treated more than others. I presented this same scenario to my classmates. As of this writing, 9 responded, and only one paid enough attention in class and reading to solve the puzzle. (though he did ask for lab values which I gave him because his primary scope is in hospital and limited only by his preceptor)


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## Veneficus

Scenario

Dispatch/scene information:
You are called to an upper middle class residence for a 15 year old female feeling “sick for a couple of days.” Upon Arrival you are greeted at the door by the patient’s mother who claims her daughter has been feeling ill and spent the last few days in bed and is now difficult to arouse. On your way into the residence you notice a stack of bills on a bureau, a lack of furnishings and very limited amount of electronic devices. The dwelling is clean but the occasional damage to the drywall has not been repaired. *(This is basic information and demonstrates and potential lack of financial means. In the US a person’s ability to pay for healthcare often directly equates to their priorities and health status. Many former middle class families that never used or discussed social programs are often at a loss for options when they find themselves economically struggling. Additionally, households with 2 working parents often do not have any idea what their teenagers lives are like.)*


You make your way up the stairs to a second floor bedroom where you notice a 15 year old female wrapped tightly in blankets despite the 85F temperature outside*.(subjective feeling of cold, often seen in shock)* You next remove the blanket to start your assessment. The female is wearing sweatpants and a t-shirt, she does not appear to be sweating*(could be distracting to heat injury, but also  a subtle sign of hypovolemia)*, though she is pale in the face*(pale cool skin indicative of shock)* and has multiple purpuric lesions on her arms*.(gross capillary permeability)* While you expose her and perform a physical exam, your partner (a brand new, 1st call ever, provider of the lowest level allowed in your country. This one is all about you) gathers a history.

Vital signs:
Heart rate: 110 regular, central pulses present and weak. Distal pulses absent. *(indicative of shock, tachycardia, weak central pulse, absent peripheral pulse)*
BP: 80/60 *(narrowing pulse pressure another easily identifiable sign of cardiovascular collapse)*
Respiratory rate is 24/min and shallow *(respiratory insufficiency)*
Temperature is 40C rectal. *(builds upon the differential of septic shock. Fever, hypotension, purpura)*
Capilary blood glucose: 60 *(she hasn’t eaten in days and bacteria often utilize glucose as a metabolite, a bigger problem still is the lack of glucose impairs mental function and causes breakdown of RBCs further complicating the hemodynamic picture )*
Weight is 47kg height 5’5” *(need weight for drug dosing, height demonstrates body proportion)*
Sinus tachycardia with occasional (<6 minute) PVCs that do not generate a palpable pulse wave. *(another sign of shock)* 
Spo2: 89 on room air *(respiratory insufficiency caused by some etiology)*
ETCO2: 30 *(lower than normal CO2 reading, indicating abnormal gas exchange or airway compromise)*
 GCS: E4 V4 M5 *(13, slightly impaired neuro function)*

Physical exam:
Hair is oily and matted *(recent lack of bathing), *skin is pale and cool to the touch*,(shock)* nothing noted about the ears. Pupils are dilated and sluggish*.(impaired neurological reaction, consider forms of insult like both forms of stroke)*  Sclera has diffuse blood throughout *(extravascular bleeding), *mucous membranes are dry*(dehydration secondary to volume loss), *slight bleeding from the gum line*(vascular permeability)*, face and head is otherwise symmetrical with no obvious deformity or masses upon palpation*.(eliminates lymphoid findings indicating early onset of sepsis)* Trachea is midline without shift, *(no pneumo)* JVD is noted *(physiologic in reclined position but does give a clue about potential insufficiency)* and skin is also pale on the face/neck. *(shock)* Thyroid and lymph nodes are not enlarged *(rapid onset sepsis)* carotid pulse is present and weak. *(shock)*

Exposing her chest you observe multiple purpuric regions (>2cm in diameter) *(sepsis or other form of capillary permeability like late DIC), *breathing is shallow and rapid at a rate of about 24/minute*,(acidosis compensation)* breasts appear at stage 5 development*.(stage of full adult breast development in female, not normally seen until 17 or older, breasts fully develop in pregnancy also)* Breath sounds are diminished with crackles in the bases*,(in this case from blood/fluid in the alveoli)* Heart tones exhibit a gallop and sound distant*.(new onset cardiogenic shock)* Apex of the heart is at the normal level*,(rules out hereditary cardiac malformations)* lungs also within normal topographic parameters*.(same with lungs)* Back has similar purpura legions. Skin is cool to the touch. *(by now you should get the sepsis/DIC picture)*

The abdomen appears similar to the chest, however it is slightly distended*,(blood, air, and swollen)*  locally warm to the touch in the lower quadrants*,(localization of inflammation)* involuntary muscle guarding is noted on palpation *(a very specific sign of a surgical abdominal pathology)*, you decide not to auscultate bowel sounds*,(because that would be useless in the current situation)* liver in 2cm beneath normal margin*,(liver edema from right heart insufficiency and/or liver malfunction)* spleen not palpable*.(Rule out pathology of splenomegaly)*  Diffuse echymosis in the gluteal region*(dependant sign of bleeding)*, constant trickling bloody discharge from the vagina*,(active bleeding from the internal genitalia which gives a clue to potential injury to highten index of suspicion but is nonspecific)* and subcutaneous emphysema in the mons pubis area . *(Trauma is the number 1 cause of air in the subcutaneous tissue if the trauma is not externally visible, this should be a clue of potential occult injuries)*

There appears no indication of external trauma with an exhaustive exam. *(Should raise index of suspicion on potential urogenital injuries)*

Arms and legs are also cool to the touch, difuse purpura throughout. Capillary refill at +4. Femoral pulse is present and weak, distal pulses absent in all extremities. *(reinforcing massive bleeding and shock)*


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## Veneficus

History: Your partner (who is an exceptionally capable historian for a person green as grass) tells you the mother is extremely worried about the cost of all of this as they recently lost their health coverage. But he elicits: *(clue about not seeking proper healthcare)*

Mother noticed her daughter had been sick the last few weeks with nausea and vomiting *(weeks of nausea and vomiting, what could cause that in a female of child bearing age?) *and warm to the touch*.(nonspecific sign meaning nothing)* The girl continued to go to school despite the illness. She came home after hanging out with friends like usual *(points to early morning N/V which resolves enough so school officials do not become suspicious)* 2 nights ago complaining of abdominal pain and went to her room*.(this is the key timeline for the acute pathologies)* Next day pt told her mother she was too sick to go to school*,(that is an understatement as it is the start of major prblems)* was not hungry, but was drinking water and tea*,(increase thirst from early shock)* vomiting had stopped*.(if you were thinking pregnancy and morning sickness, you are probably thinking miscarriage/abortion now)* This morning *(~48 hours post primary insult, late stages of progression)* mom came to check on the girl, who complained of epigastric pain. PT had spit up some gross red blood *(peptic ulcer secondary to traumatic injury or neurological dysfunction is a subtle sign, but also indicative of bleeding into the GI, like in DIC)* and then mom called 911. (aka: you) *(because there is no hiding this now)*

The patient has been taking “femrelief” for menstrual cramps as needed for years*,(potential to be pregnant, as a guidline all females between the ages of 8 and 55 are pregnant until proven otherwise)* the dose of Nyquil on the bottle for the last 3-4 days*(the night time sniffling, sneezing, coughing, achy head, fever so you can rest with 10% alcohol available to minors medicine)* and has no known allergies medical or otherwise. You notice no drug paraphernalia with a quick cursory search and no street drugs. You also do not notice track marks or venipuncture sites on the pt. *(IV drug use is the #1 cause of rheumatic fever, this should help rule out street drugs as well.)*

There is no prior medical history. 

The girl was born at term, without inducing, from a planned pregnancy with proper preconception and prenatal care. She has had a healthy childhood, meets all developmental benchmarks, has a yearly sports physical, and all vaccinations. *(there is no evidence of genetic or chronic illness undiagnosed)*

The mother reports the female does not have a boyfriend, is not sexually active, started menstruating at age 10 *(average age in the western world is 9)* and was not regular, LMP unknown. No history of pregnancy, miscarriage or abortion. *(because many parents would like to believe this if they  have no overwhelming  reason to think otherwise.)* 

The mother also reports that the patient uses no alcohol and does not smoke. You do not find anything in the environment that contradicts this information. *(further ruling out toxins)*

The patient has not been eating the last few days but has been drinking a lot of fluids. *(early symptom of shock)* The mother does not know about urination or defecation habits or frequency.

The Mother also reports the girl is a straight A student and is a starter on the high school volleyball and track teams, plays in the band and sings in the choir. (since 3rd grade.) *(is in very good mental and physical shape, which probably explains why she is still compensating. It also demonstrates the child is not at home very much compared to other activities)*

You are working in the US,(because there is no free universal healthcare that would preclude people from going to the doctor if they thought they were pregnant) but operate under your normal protocols or standard of care. So what are your thoughts and orders Captain? Your nearest hospital is a community hospital 10 minutes away*.(which is not up for this challenge)* A major academic medical center is 30 minutes away*.(which is where you need to go)* Anyone of 10 airmed providers are at your beck and call and frequently hand out pens and other marketing items but it will take them 40 minutes to respond at best. *(in otherwords its faster to drive)*  You have anything you normally have on your responding unit. You can ask for any clarifications, repeat findings, more detailed findings, or the effect of your interventions. The only ambiguity in the scenario is what you do but I will do my best to respond accordingly and consistently.

Hints to make your head hurt: *(these were hints, not a call to imply dx pathology, but your working dx should affect your treatments just like with any patient you see… I hope)*

In this scenario there are 5 life threatening pathologies, some secondary to others.

All of the pathologies are readily identifiable by the information given except for the common primary pathology which is alluded to and can be reverse engineered from finding the others.  *(you have to know your disease progression in order to get to root causes if you ever want to help with more than symptomatic treatments and make good transport decisions)*

PS. This is also my original work and not to be distributed without permission, which you have as long as you make no money from it and proper credit is given. 04/25/2010 *(because if you get paid for my work, I get paid)*

This scenario is hypothetical and bears no relationship to any person known or unknown by the author*.(I never saw this patient so they cannot complain I violated their privacy)*


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## Veneficus

The answer :

This scenario is an acute surgical emergency. *(because this uterus problem is going to have to be fixed and the surgical intensivist will probably manage this patient to the end.)* 

The pathology is textbook complications of an improperly performed abortion *( I took the progression right from published text)* when the placental layers are separated and not entirely removed.

In this case rest of the placenta was separated from the myometrial layer and the female was in a supine position during and after the procedure.* ( a very reasonable conclusion from incomplete removal/delivery of a placenta)*

1.Amniotic fluid sets off the coagulation cascade from protein interaction when it enters maternal blood causing acute DIC and causing systemic microinfarctions. Particularly manifest in the brain, heart, kidneys, and liver. (multiple organ dysfunction secondary to ischemia)

2. With the clotting factors depleted and liver impairment in the first 24 hours, uncontrolled hemorrhage results, both externally and in serous membranes.

3. When in the supine position this separation also allows clinically significant (greater than 100cc) air embolus to enter the maternal vascular system, most commonly resulting in massive PE. This manifests in the right sided heart insufficiency and respiratory findings.

4. With an opening and bleeding via the partially removed placenta, increased growth of normal bacterial flora (particularly S. Aureus or S.Pyogenes) multiply and their metabolites create a toxic shock syndrome resulting in gangrenous necrosis of the entire reproductive tract.

5. Finally acute sepsis from bacteremia .

*(the storyline that ties it all together)*The patient got pregnant. Scared and ashamed she feared her family would throw her out *( a fear of many teenage pregnancies in the US)* and without medical coverage in her desperation *(something we will see more of)* she opted to look up abortion on the internet and ask her boyfriend for help. *(to which he agreed because he saw it on House)*

Prognosis: Death *(most likely)* or major lifelong disability including infertility. *(after a lot of luck, herculean efforts, at a cost even Warren Buffet would probably regret losing)*


----------



## Aidey

So basically 5 seconds looking at her computer search history would have probably given us the answer?


----------



## Veneficus

Aidey said:


> So basically 5 seconds looking at her computer search history would have probably given us the answer?



Most probably. Do you do that regularly when you see a patient?


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## mycrofft

*Way above and beyond. Good mind exercise.*

Hot abd with late signs of sepsis. Giddyup, do NOT blow the veins with failed IV's or start little ones, oxygenate, document for rapid pass-off at closest ER. 

Unless you can resuscitate a crashing pt better in your rig?

Subcutaneous emphysema is not necessarily air, it can be products of baterial decomp.

What is your best IV solution for this?


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## Veneficus

mycrofft said:


> What is your best IV solution for this?
> [/FONT]



blood...

Giving this patient a chrystalloid infusion in my opinion would be like flushing the toilet to get what blood was left out of the bowl.


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## 8jimi8

well i'll take a little confidence boost out of my delirious field impression!

Although I did miss the PE... however, when originally presented the sepsis/dic and s/q emphysema seemed way more emergent than 89%on r/a and resprs at 24...

great scenario.


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## Lifeguards For Life

8jimi8 said:


> well i'll take a little confidence boost out of my delirious field impression!
> 
> Although I did miss the PE... however, when originally presented the sepsis/dic and s/q emphysema seemed way more emergent than 89%on r/a and resprs at 24...
> 
> great scenario.



agreed. great scenario


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## medic417

Veneficus said:


> Most probably. Do you do that regularly when you see a patient?



No because like House I send my people on wild goose chases to do that for me.  

To add things not done, how many that responded or even read but did not respond would have truly exposed this or any patients.  It amazes me how many will not remove patients clothes and actually look at the patient to truly evaluate them.


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## 8jimi8

I can't remember who said it on this forum....

someone mentioned about 8-9 months ago, that you should never auscultate breath sounds over any type of clothing...

i think they said something to the effect any breath sound can be mimicked by material between the scope and the patient.

I quickly amended my bad habits.  Everyone's top comes of for my shift assessments...
and yes...

gotta peek under the lower part of the gown too. and yup... roll over... let me check your bottom...


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## Lifeguards For Life

I also appreciated how you showed the proper thought sequence to arrive at the diagnosis.

The bold explanations, were especially helpful.

I feel I was able to learn a lot from this scenario


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## Aidey

Veneficus said:


> Most probably. Do you do that regularly when you see a patient?




Nope. I was thinking if the "do you know what your children are doing" aspect of it. Basically, if the mom and dad had been more aware, this situation probably wouldn't have progressed so far.


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## Seaglass

Good scenario. Thanks! 

It's easy to forget botched abortions as a possible cause. I live in an area where they're relatively easy to obtain without anyone knowing, and I don't know that my agency has seen any cases in the past few years. But I could easily see it happening... teenagers are stupid and scared, parents are strict, and so on.


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## mycrofft

*With subtle change could serve for tubal pregnancy,other closed abdominal problems*

Ruptured diverticulum, mesenteric embolus, tubal pregnancy, retained intrauterine foreign objects, delayed reaction to blunt trauma. Good to differentiate. Hard to change field responses except a good history while the mnother is there and (sometimes, not this time) while the pt is still lucid. 
Yeah not crystalines, but do ambulances carry blood now? Any colloids nowadays? (In WWII, plasma or some plasma subsitutes were used).


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## Seaglass

mycrofft said:


> Hard to change field responses except a good history while the mnother is there and (sometimes, not this time) while the pt is still lucid.



Often it's best to get parents out of the room with teenage patients. Even if they're not particularly lucid, sometimes they'll still be able to communicate something important. (Of course, they sometimes also give you total nonsense, but I'll check it out if it seems at all plausible.)


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## Aidey

^^^ That is one of the things many of our fire officers are good at. They are the ones who do the initial paperwork and they are pretty good about picking up on hints to get family members out of the room. Usually they do it by asking for insurance cards, medications, or doctor's names and then when they get the person away, they ask all the demographic info, which takes a few minutes.


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## Veneficus

mycrofft said:


> Ruptured diverticulum, mesenteric embolus, tubal pregnancy, retained intrauterine foreign objects, delayed reaction to blunt trauma. Good to differentiate. Hard to change field responses except a good history while the mnother is there and (sometimes, not this time) while the pt is still lucid.
> Yeah not crystalines, but do ambulances carry blood now? Any colloids nowadays? (In WWII, plasma or some plasma subsitutes were used).



Right on.

The reason I chose this scenario is because DIC as a primary pathology is rare. It usually results from massive trauma or more commonly like in this case, surgical intervention.

I also hope that people will be more specific on the findings when they present a scenario.


Medic417: I was once disciplined (unfairly in my opinion) for not properly exposing a patient who was later found to have a crack pipe in her vagina. (I left her underwear on) apparently the event was she managed to conceal the pipe from me and having nowhere else to put it in the hospital decided that would work. From that day on (many years ago) I don't care if the person is wearing a thong bikinni, the physical exam wll be completed on all patients.


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## Seaglass

Aidey said:


> ^^^ That is one of the things many of our fire officers are good at. They are the ones who do the initial paperwork and they are pretty good about picking up on hints to get family members out of the room. Usually they do it by asking for insurance cards, medications, or doctor's names and then when they get the person away, they ask all the demographic info, which takes a few minutes.



As a basic on a medic truck, that's often my job. If I think my partner will need some time, I can draw it out quite a bit. 



			
				Veneficus said:
			
		

> I was once disciplined (unfairly in my opinion) for not properly exposing a patient who was later found to have a crack pipe in her vagina. (I left her underwear on) apparently the event was she managed to conceal the pipe from me and having nowhere else to put it in the hospital decided that would work. From that day on (many years ago) I don't care if the person is wearing a thong bikinni, the physical exam wll be completed on all patients.



Under my protocols and local law, if a patient is competent to refuse treatment and not under police custody, they can refuse any intervention. Doing something against their will could be assault. I've never yet had a patient I couldn't talk into a physical exam, but I could see it happening.


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## Veneficus

Seaglass said:


> As a basic on a medic truck, that's often my job. If I think my partner will need some time, I can draw it out quite a bit.
> 
> 
> 
> Under my protocols and local law, if a patient is competent to refuse treatment and not under police custody, they can refuse any intervention. Doing something against their will could be assault. I've never yet had a patient I couldn't talk into a physical exam, but I could see it happening.



it's all about persuasion


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## Melclin

medic417 said:


> To add things not done, how many that responded or even read but did not respond would have truly exposed this or any patients.  It amazes me how many will not remove patients clothes and actually look at the patient to truly evaluate them.



I probably wouldn't have, or at least, not to the extent that was required to see the vaginal discharge. 

Very interesting case. I've more questions but they shall have to wait until I crawl out from underneath the many thousands of words of essays I have at the moment :unsure:


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## LucidResq

For once I knew what was going on, but alas, missed the boat. 

I'd like to reiterate the "get everyone else out of the room" point. You'd be amazed what important information patients will tell you once their partner/sister/mother/father etc isn't there. I've seen many a resident led astray on a hx by a patient's covering up infidelity, shame or fear of abuse. 

I'd also like to remind everyone that this scenario can easily apply to any age of woman. Many people think that undesired pregnancies are common to teenagers exclusively, but the majority of women I've seen terminate pregnancies are actually 20-40, often married and raising children. They may not have strict parents, but many lack access to health care, have abusive relationships, etc. 

Insurance coverage for abortion is about to take a radical hit due to health care reform (it's complicated, google it or something). This combined with recent violence at clinics, and the fact that few OB/GYN and family practice residents are receiving training in abortion, means we may very well see a drop in access to safe abortion over the next few years. Many of the abortion providers in the field today were around before Roe v. Wade, and therefore saw many patients such as the one posed in this scenario suffer and die, and many will tell you that is the reason why they provide the procedure today. Almost none of the doctors who will be replacing them over the next few years have this kind of emotional investment in the issue. 

Almost certainly this will lead to an increase in "back alley" type abortions and more complications such as this. One only needs to look at countries that ban or greatly restrict access to legal abortion to see that the number of abortions don't really decrease when doctors aren't providing them, they just shift to other "methods" and "practitioners." Septic pregnancy wards were once common in the US and Canada, and these patients are still very common in countries were access is banned or limited today. No matter what your ethical standpoint on abortion is, this is a reality. 

Thank you for posting this scenario and reminding us that this still happens today. I'll get off my soapbox.


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## medic417

Veneficus said:


> it's all about persuasion



Exactly just wine them and dine them and off they come.

But in all seriousness if you act like this is what you do and is expected most patients have no problems showing a professional acting person the so called "private parts".  Use proper terms and explain what and why even if you think they are unconscious.  You would be surprised how many mention me explaining what I am doing even though they were GCS of 3.


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## Commonsavage

Treat ABCs and life-threats first.  O2NC 4 lpm, Large bore IV w/ blood tubing NS bolus 500ml, titrate to SBP 90-100 (explanation to follow).
This kiddo appears to be suffering some kind of hemorrhagic event.  The DD ranges from viral to autoimmune/genetic.  I would don full PPE (Ebola?).  Purpura, bleeding, hepatomegaly indicate clotting disorder/factors diminished with probable profound enemia.  As such, she's unable to maintain perfusion and you want to bolus only enough fluid to maintain minimally acceptable SBP, with further dilution of H/H and clotting factors.
Rapid transport to that educational facility, to where any other facility would probably transfer this patient.  Request resus room to facilitate rapid response for possible Oneg transfusion.  This kid could crash at any moment.


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## Trayos

*Congrats!*

Managed to stump a 25 year experienced Commissioned corp officer, with history in both pediatrics and exhaustive diagnosis. Very well done!


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## nomofica

Got a friend of mine to take it on. She did real well. She managed to get a proper dx after about 15 minutes of talking on Facebook. 20 or so year veteren of 9-1-1 EMS and an instructor for NAIT as well as an examiner for the Alberta College of Paramedics (all levels of prehopsital care)


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## ChorusD

I was thinking retained dead fetus syndrome with the DIC but I suppose that's way off track... :wacko: that'd be why i'm a student though


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## MrBrown

I might try it on that chick I was with in high school and should be a dermatology registrar now


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## 8jimi8

ChorusD said:


> I was thinking retained dead fetus syndrome with the DIC but I suppose that's way off track... :wacko: that'd be why i'm a student though



not really way off track, you got the DIC part, but the creptius (crepitus lol) is what you didn't resolve.

i figured the crepitus was from a perforation, back on the very first post, but i think it was apparently from an amniotic fluid emoblus?


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## Veneficus

8jimi8 said:


> not really way off track, you got the DIC part, but the creptius (crepitus lol) is what you didn't resolve.
> 
> i figured the crepitus was from a perforation, back on the very first post, but i think it was apparently from an amniotic fluid emoblus?



air and amniotic fluid.


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## mcdonl

I love being a basic!!

I would get the taxi with a stretcher and lights going, call ALS and provide O2and Oral Glucose, treat for shock and leave the diagnosis for someone with a higher pay grade and training.

Administer diesel.


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## Veneficus

mcdonl said:


> I love being a basic!!
> 
> I would get the taxi with a stretcher and lights going, call ALS and provide O2and Oral Glucose, treat for shock and leave the diagnosis for someone with a higher pay grade and training.
> 
> Administer diesel.



why would you give this patient oral glucose?


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## mcdonl

Veneficus said:


> why would you give this patient oral glucose?



I wouldnt because she was not responsive and unable to swallow. :sad:


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## mcdonl

mcdonl said:


> I love being a basic!!
> 
> I would get the taxi with a stretcher and lights going, call ALS and provide O2and treat for shock and leave the diagnosis for someone with a higher pay grade and training.
> 
> Administer diesel.



Edited because I am an idiot.


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## Cake

mcdonl said:


> I wouldnt because she was not responsive and unable to swallow. :sad:



Protocols in MD allow oral glucose in unresponsive patients.  There's really no contraindication of it. At a basic level, if they're unresponsive/altered mental status, they're very likely to get a slab of goo in their cheek at some point during our care.  

To quote protocol: "Unconscious for unknown reason"

I probably would have given it to her too. :unsure:


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## Lifeguards For Life

Cake said:


> Protocols in MD allow oral glucose in unresponsive patients.  There's really no contraindication of it. At a basic level, if they're unresponsive/altered mental status, they're very likely to get a slab of goo in their cheek at some point during our care.
> 
> To quote protocol: "Unconscious for unknown reason"
> 
> I probably would have given it to her too. :unsure:



tsk tsk tsk:unsure:


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## Veneficus

Cake said:


> Protocols in MD allow oral glucose in unresponsive patients.  There's really no contraindication of it. At a basic level, if they're unresponsive/altered mental status, they're very likely to get a slab of goo in their cheek at some point during our care.
> 
> To quote protocol: "Unconscious for unknown reason"
> 
> I probably would have given it to her too. :unsure:



Are those protocols written on stone tablets? 

I remember the days of of "coma cocktails." Thiamine, narcan, and D50 for all unconscious unresponsive patients. It didn't really work out too well for the DKAs, HHNKs, and strokes.

Before giving oral glucose or IV glucose (dextrose) to an unconscious patient with no other information on why they are in such a state, I would encourage you to look up what the outcomes of such are.

Just because a protocol allows you to do something doesn't mean it is always a good choice.

conversely, I once worked for an agency that did not have a protocol to control bleeding. Should that be interpreted to mean we should not have?

"The rules are more actual guidlines than actual rules"


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## Cake

Not being a smartass here, I just got my cert so I don't know otherwise.  I understand they could aspirate on oral glucose, but whats the worst that could happen if given by IV?  or other than aspirating orally?


our protocols say the contraindications are "clinically insignificant" or something of that sort.


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## Veneficus

Cake said:


> Not being a smartass here, I just got my cert so I don't know otherwise.  I understand they could aspirate on oral glucose, but whats the worst that could happen if given by IV?  or other than aspirating orally?
> 
> 
> our protocols say the contraindications are "clinically insignificant" or something of that sort.



increased organ or tissue damage resulting in more profound disability or death.


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## Melclin

Cake said:


> Not being a smartass here, I just got my cert so I don't know otherwise.  I understand they could aspirate on oral glucose, but whats the worst that could happen if given by IV?  or other than aspirating orally?
> 
> 
> our protocols say the contraindications are "clinically insignificant" or something of that sort.



Glucose should be given on the basis of a cap glucose reading. There are a number of reasons why a person may be unresponsive and unfortunately the big one, esp in nursing homes, are stokes (its also not a great idea to be raising the blood glucose in a septic patient as far as I know, but I'm not sure if the amount we give would make a difference). 

When we start talking about cerebral insult glucose solutions are generally withdrawn from the batting line up. Other than the osmolar troubles you get from a solution with a bit of volume, like D5W, raising blood sugar in these patients causes the sugar to be metabolized to lactic acid (somebody correct me if I'm wrong). This lowers the pH and is associated with poorer outcomes. 

With IV admin, you take the risk of phlebitis just as with any other IV therapy. So as common as IVs are, you do still need a reason to stick them in the first place. Also there is the relatively rare but nasty risk of extravasation where the glucose makes its way into the tissue surrounding the IV access, causing necrosis. 

I've also heard about the possibility of it causing troubles in alcoholics, but I don't know much about that.

Aside from the head injury/stroke issue, I'm not sure what the risk of aspiration would be in the circumstances you mention, however, I would not say that any increase in the risk of aspiration is irrelevant.

Remember that your protocols are not an accurate summation of the nature of drugs and the best evidence based practice out there, its just the particular way in which your MD has chosen to dumb the material down. Saying that the risk is clinically insignificant just means he has accepted the risk, not that it isn't significant.


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## MrBrown

A fifteen year old with no history of diabetes .... are you really going to dish out glucose?.

I am not having a go at you personally mate but gah, non diabetics do not get hypoglycaemic, I mean seriously hypoglycaemic they might get a bit wonky after not eating for a day but thats not the same.

And be sure to administer D10 IV into a free flowing line that runs coz you know if you slip in a drip and extravasculate dextrose you end up with a black arm that doesn't work for very long after that.

That may lead to a change in orange jumpsuits to one that does not say 'DOCTOR' or 'PARAMEDIC' on the back but hey you MAS guys wear blue ones anyway right?


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## Melclin

MrBrown said:


> A fifteen year old with no history of diabetes .... are you really going to dish out glucose?.
> 
> I am not having a go at you personally mate but gah, non diabetics do not get hypoglycaemic, I mean seriously hypoglycaemic they might get a bit wonky after not eating for a day but thats not the same.
> 
> And be sure to administer D10 IV into a free flowing line that runs coz you know if you slip in a drip and extravasculate dextrose you end up with a black arm that doesn't work for very long after that.
> 
> That may lead to a change in orange jumpsuits to one that does not say 'DOCTOR' or 'PARAMEDIC' on the back but hey you MAS guys wear blue ones anyway right?



Is this at me? I wasn't suggesting glucose..just discussing its use.

EDIT: Looking back over the post, I see now "Glucose should be given..." I wasn't saying that it SHOULD be given in this scenario. I was responding to this talk about giving glucose to unresponsive patients...I was just saying, it should be given based on a BGL reading, not based on unresponsiveness in itself.


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## MrBrown

No not at you mate, at the other fella


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## Cake

Like I said, I'm a new EMT.   I vividly remember correcting someone in class giving glucose to an unresponsive patient, and having everyone jump down my throat about being able to do that, which is why I'm following through with this inquiry, because its the first time I've ever heard the other side of the argument.  

For this particular scenario in the thread, we had someone there to give us patient history, so we could rule out diabetes.  There were many signs presenting themselves that screamed more than diabetes, but at a BLS level, I would have requested ALS intercept, O2, def would have considered glucose, and load and go...

BUT

I understand the reasoning behind not giving her glucose- when my protocols dictate that an unresponsive person gets glucose, and i DONT give it to them, am I due to get reprimanded for not following protocols?   Someone mentioned that they're more like guidelines, but is that the feeling for every state's?  


In her condition, without a SAMPLE history, would it really have been that poor of a thought to give her glucose? (at a bls level)


----------



## thatJeffguy

Cake said:


> Like I said, I'm a new EMT.   I vividly remember correcting someone in class giving glucose to an unresponsive patient, and having everyone jump down my throat about being able to do that, which is why I'm following through with this inquiry, because its the first time I've ever heard the other side of the argument.
> 
> For this particular scenario in the thread, we had someone there to give us patient history, so we could rule out diabetes.  There were many signs presenting themselves that screamed more than diabetes, but at a BLS level, I would have requested ALS intercept, O2, def would have considered glucose, and load and go...
> 
> BUT
> 
> I understand the reasoning behind not giving her glucose- when my protocols dictate that an unresponsive person gets glucose, and i DONT give it to them, am I due to get reprimanded for not following protocols?   Someone mentioned that they're more like guidelines, but is that the feeling for every state's?
> 
> 
> In her condition, without a SAMPLE history, would it really have been that poor of a thought to give her glucose? (at a bls level)





If a patient can't protect their own airway, you can't administer oral glucose.

If you're talking about some D50 in an IV, it's above my level of training and I have no clue


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## Veneficus

Cake said:


> I understand the reasoning behind not giving her glucose- when my protocols dictate that an unresponsive person gets glucose, and i DONT give it to them, am I due to get reprimanded for not following protocols?)



You may want to talk to your medical director and get her input. That is the authority that can tell you what you may or may not get in trouble for.

Having said that. All the physicians I ever met would rather that a EMS provider use their clinical judgement before administering a medication.





Cake said:


> Someone mentioned that they're more like guidelines, but is that the feeling for every state's?



It is not even consistant within a state. However, a well written protocol will be able to make exclusions or additions for the benefit of the patient.   




Cake said:


> In her condition, without a SAMPLE history, would it really have been that poor of a thought to give her glucose? (at a bls level)



I would say that it would definately not help. It would be impossible to stipulate how much damage it might cause, the evidence suggests that it would likely be harmful. 

As was mentioned in the walkthrough. This patient is most likely to die. With such a remote chance for even a survival to discharge with major deficits, doing anything that may reduce the chances seems like a poor choice.

SAMPLE history or not, the physical findings alone suggest this is not diabetic in nature. I have never seen a hemorrhage or trauma protocol that directs the administration of glucose.


----------



## LucidResq

MrBrown said:


> I am not having a go at you personally mate but gah, non diabetics do not get hypoglycaemic, I mean seriously hypoglycaemic they might get a bit wonky after not eating for a day but thats not the same.
> D



Not saying this is what was going on... but I've heard of severely low BGLs in Addisonian crisis.


----------



## MrBrown

LucidResq said:


> Not saying this is what was going on... but I've heard of severely low BGLs in Addisonian crisis.



I think there are exceptions (chronic alcoholics are another) however I was taught those who are not diabetic will not become hypoglycaemic the same as a diabetic ... because they have a nroamlly functioning endorcine system.

Bloody hell I don't know this orange jumpsuit used to say "WHACKER" on the back, I just crossed that out and wrote "DOCTOR"


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## Sassafras

I was leaning toward miscarriage, or some form of obstetrical emergency, however, I'm not sure I would ever get all that information in an exam since we were told repeatedly that unless there is a serious reason to examine the genitalia we are to leave that up to the hospital to examine.  I would not have known if she was bleeding vaginally unless it was to an extent that it was obvious enough to observe.  Sort of makes me question our training.  And yet, I'm not so comfortable looking at an elderly patient and saying "excuse me mamm but can I look at your vajayjay?"


----------



## JTS

i enjoyed this scenario, thanks!


----------



## jjesusfreak01

Sassafras said:


> I was leaning toward miscarriage, or some form of obstetrical emergency, however, I'm not sure I would ever get all that information in an exam since we were told repeatedly that unless there is a serious reason to examine the genitalia we are to leave that up to the hospital to examine.  I would not have known if she was bleeding vaginally unless it was to an extent that it was obvious enough to observe.  Sort of makes me question our training.  And yet, I'm not so comfortable looking at an elderly patient and saying "excuse me mamm but can I look at your vajayjay?"



Ask the patient, "are you bleeding anywhere you know?". If they say "yes, my vajayjay", then get them a 5x9 or a trauma dressing to soak up the blood. If they don't know where it's coming from (which I understand in 99% of cases would end up being the vagina, because where else are you going to be bleeding from and not know it) then you have yourself a trauma and you need to see it yourself. Also, elderly patients very likely don't care what you see on their body. Of course you ask first, but those parts stopped being "sexually oriented" a long time ago for them.


----------

