Country Meddlin

[MrBrown]

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

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

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

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

PMHx none

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

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

Meds amoxicillin and paracetamol po x 3 days

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

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

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

 

[Simusid]

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

skin color/temp/condition? any rashes?

 

[Smash]

Beats me. But congratulations on your Fellowship Brown.

 

[mycrofft]

Rashes? Discharges? Pain? Energy level?

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

 

[Tincanfireman]

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

 

[firetender]

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

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

 

[MrBrown]

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

skin color/temp/condition? any rashes?

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

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

Beats me. But congratulations on your Fellowship Brown.

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

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

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

 

[MrBrown]

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

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

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

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

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

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

 

[foxfire]

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





These are my lowly basic thoughts.

 

[MrBrown]

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

These are my lowly basic thoughts.

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

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

No allergies

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

 

[PrincessAnika]

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

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

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

 

[MrBrown]

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

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

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

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

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

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

Skin is warm and dry.

 

[mycrofft]

Dunno.

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

Tularemia.

 

[MrBrown]

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

Tularemia.

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

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

Another set of vital signs

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

 

[Smash]

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

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

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

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

 

[MrBrown]

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

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

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

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

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

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

Not sure how they missed that one.

 

[mycrofft]

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

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

 

[foxfire]

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

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

 

[Roam]

Wow, thank-you Mr. Brown!

 

[firetender]

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

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

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