30 Y/0 M Sick Person

[Doczilla]

Remember that infections and bleeds can cause excessive vagal tone. The SA node can be depressed without seeing the effect on blood pressure, since there are a few vasoconstrictors outside the sympathetic arsenal.

 

[mycrofft]

When it comes to important stuff, always designate pulse as palp or apical, and whether it is regular, or irregular (regularly irregular or regularly irregular?), and add strength notes if it is not inotropically stable (all pulses same strength). I know this is "shake the magic rattles" stuff to most, but you can take a pulse and have that data while your partner is still untangling the 12 leads and etc., plus the EKG will not give inotropic info (effect of cardiac contractions). It may not be in the protocols but it can start focusing your attention and offer the ED some more info.

Rant over. Except for the vomiting thing I'd suspect acute gas or distress secondary to hard stool (dehydration,constipation). Renal or ureteral should be more "flanky" or even inguinal or scrotal, usually. Energetic vomiting can make your vitals go all to heck, especially if dehydration (and maybe electrolyte issues) are considered. Bowel sounds would have been helpful too, and a palpation. (Flatus? Tympany?).

Zebras: early appendicitis (it can initially present with nausea, and pain centrally then take a bit to "settle" into McBurney's point). A diverticulitis?

Treatment sounds like it was right on except maybe some pain meds and anti-emetic.

 

[Frozennoodle]

Yeah I understand that. I've been in that position plenty of times so I sympathise. My tone was probably a bit harsh. It wasn't directed at you, so much as the idea.

Many protocols in the states don't allow for administration of pain medications for abdominal complaints. My area is one of them.

 

[NYMedic828]

Many protocols in the states don't allow for administration of pain medications for abdominal complaints. My area is one of them.

As is mine, but the only standing orders I can give morphine on are for isolated extremity injuries and burns.

I can also give toradol standing orders for extremity injuries.

The docs are usually hesitant to give us morphine for chest pain or potential visceral pain for fear of changing the assessment for the receiving facility. I thought that mentality was done away with since the furthering of technologies like CT scans, MRIs and ultrasounds.

 

[Frozennoodle]

As is mine, but the only standing orders I can give morphine on are for isolated extremity injuries and burns.

I can also give toradol standing orders for extremity injuries.

The docs are usually hesitant to give us morphine for chest pain or potential visceral pain for fear of changing the assessment for the receiving facility. I thought that mentality was done away with since the furthering of technologies like CT scans, MRIs and ultrasounds.

Abdominal pain is our only restriction. We have fentanyl, morphine, and toradol. Morphine for chest pain. All standing orders. On-line med control for pediatric pain management.

 

[Handsome Robb]

As is mine, but the only standing orders I can give morphine on are for isolated extremity injuries and burns.

I can also give toradol standing orders for extremity injuries.

The docs are usually hesitant to give us morphine for chest pain or potential visceral pain for fear of changing the assessment for the receiving facility. I thought that mentality was done away with since the furthering of technologies like CT scans, MRIs and ultrasounds.

That's ridiculous. I'm sorry.

We have pretty liberal pain management protocols. I can give 2-5mg MS on standing orders to a max of 15 mg for abdominal pain.

Like you said, advanced imaging equipment *should* debunk the abdominal assessment problems at the ER.

 

[Melclin]

That is simply ridiculous.

Do you not have some sort of recourse where you can do a lit review or an argument and make an application for protocol change?

And isn't there room to bend those rules? Surely everyone agrees its ridiculous and would be in on a change, docs included.

 

[Veneficus]

Dog and pony show

That is simply ridiculous.

Do you not have some sort of recourse where you can do a lit review or an argument and make an application for protocol change?

And isn't there room to bend those rules? Surely everyone agrees its ridiculous and would be in on a change, docs included.

Lol.

I typed up a long reply detailing how US medicine with the exception of a handful of high profile centers is perhaps the worst in the world while ethnocentrically propagandizing how they are the best and one true faith.

But rather than post it here, I think I will go start a blog about it.

But if you are in pain forget pain meds, they are dangerous, lead to addiction, aren't needed, interfere with diagnostics, and all other manner of BS.

If it doesn't come on a radiology scan with a corresponding chart or scale on what treatment or how bad, the US medical establishment simply can't function.

There is no way this establishment is going to change no matter how much evidence is presented to whomever, by whomever.

The snake oil salesmen will continue pandering their leeches and hot pokers while pricing themselves out of the market charging exponentially higher costs than the rest of the world with end results you would have to go to Africa to find worse.

The only science or evidence they acknowledge is that which supports their postion. The exact same thing was done in the 19th century Europe to create scientific evidence white males were superior to all other humans including white females based on the volume of the cranial vault. (with all kinds of creative ways to alter the measurements, like using child skulls of Africans, or filling male skulls with metal shot and female skulls with seeds.)

Science to justify and enforce socialogical customs and norms.

 

[Melclin]

But rather than post it here, I think I will go start a blog about it.
....

Science to justify and enforce socialogical customs and norms.

Do. And do post a link. I like me a good blog to read so I do.

....

Yes well the US, as you point out, certainly doesn't have a monopoly on that.

The greater argument aside though, surely US EMS systems must have some mechanism by which people can suggest things. Its not the bloody magna carta. Its just a glorified suggestion box. Surely...

On the topic of bending the rules...surely you can say, well yeah I know it says 2-5mg q5 in the protocol, but this dude had 50%BSA burns so I gave the first two lots of ten pretty much just straight up and anyone auditing just says, well yeah...bloody hell he must have been in incredible pain...nice work.

 

[Veneficus]

The ultimate stawman argument

Do. And do post a link. I like me a good blog to read so I do.

....

Yes well the US, as you point out, certainly doesn't have a monopoly on that.

The greater argument aside though, surely US EMS systems must have some mechanism by which people can suggest things. Its not the bloody magna carta. Its just a glorified suggestion box. Surely...

On the topic of bending the rules...surely you can say, well yeah I know it says 2-5mg q5 in the protocol, but this dude had 50%BSA burns so I gave the first two lots of ten pretty much just straight up and anyone auditing just says, well yeah...bloody hell he must have been in incredible pain...nice work.

We might get sued...

While I was in the shower, where for some reason I get most of my clear and insightful philosphical thinking done, I think because nobody bothers me, but I digress.

I was pondering the realism of out of control litigation in US society. I have come to the conclusion it is grossly over exaggerated.

Not because it doesn't happen, but because medical culture has elevated it to the level of divine faith without reason or question. For reasons too long to discuss here and now.

You can offer your suggestion to the box, I have even worked for employers with groups paid to suggest better practices, you can present overwhelming scientific evidence.

But from field provider to Medical school professor, at the possibility of being the first to change practice, somebody in the chain will raise a voice as if starting the Lord's prayer at church on Sunday, and say:

"We might get sued"

Which will be follwed by much nodding of heads and a unanimous "Amen."

Gone are the days of American spirit of "We are doing the right thing, bring it on."

American medical graduates (doctor is too respecable of term) have lost control of their profession. (Which according to the standards applied to US EMS, should call into question if they still really are still a profession)

Plaintiff attorney who art in heaven,
hallowed be thy name.
Thy legal action come.
Thy will be done, in hospital as it is in University.
Give us this day our protocol and forgive us our logical thinking that deviates.
as we persecute them who trespass against it.
Lead us not into patient advocacy,
but deliver us our paycheque ungarnished.
For thine is the Kingdom of defensive medicine,
Forever and Ever.

Amen.

 

[NomadicMedic]

Did this scenario ever have a conclusion before we ran off down the pain management road?

 

[Handsome Robb]

Did this scenario ever have a conclusion before we ran off down the pain management road?

negative ghostrider

 

[mycrofft]

OP, what was outcome?

BTW, I reread this thread.
I never heard of heat stroke causing nausea and vomiting. Heat exhaustion: every time I've seen it.

 

[Doczilla]

Probably because by the time they've progressed into heat stroke, they're too busy seizing to vomit

 

[mycrofft]

But you can have both at the same time, right?

I think OP's who don't finish off their scenarios need to be made to clean the EMTLIFE restrooms with a toothbrush.

 

[musicislife]

i dont think is was an AAA. Sounds like a kidney stone. If it were an AAA, I would expect to see a blood pressure much lower, and the patient going into shock.

 

[Veneficus]

i dont think is was an AAA. Sounds like a kidney stone. If it were an AAA, I would expect to see a blood pressure much lower, and the patient going into shock.

That is not quite how a ruptured AAA works.

They either have a "slow leak" or the pt bleeds to death in a matter of seconds to minutes.

A grossly ruptured AAA carries a prehospital mortality rate in the high 90%s.

With the best centers of surgery reducing it to 87%, under the best of circumstances after emergent surgery and 30+ days in the ICU.

The "slow leak" may see initial compensation so the BP would likely be within normal or borderline ranges with tachycardia.

I have even seen a patient (who later died) who went to work at a factory with epigastric pain, did a 10 hour shift, and presented to the ED with "terrible pain" minutes before crashing.(never made it to surgery)

 

[musicislife]

but would abdominal pain come immediately at the onset of a slow leak? when would one start to notice the blood loss? (we were told we cant always determine the cause of abdominal pain...so I would just transport asap)

 

[Veneficus]

but would abdominal pain come immediately at the onset of a slow leak? when would one start to notice the blood loss? (we were told we cant always determine the cause of abdominal pain...so I would just transport asap)

In the above patient, he reported increasing pain all day.

I would think the pain would start with the irritation of the peritoneal cavity, however long that takes to develop in a given person.

y the textbook, it is always described as "tearing or stabbing pain radiating to the back" however, life does not always emulate textbooks.

There are 4 classes of blood loss.

In class I, it looks basically like dehydration. (estimated <15% blood volume loss)

In Class II, you start to see signs of compensated shock ( estimated 15-30%)

Class III starts decompensation (estimated 30-45%) and generally recognized as the last reasonably salvagable level and not responsive to chrystaloid. (water based iv fluid)

class IV is the complete decompensation (estimated >45% blood loss) it is only in the most rare circumsatnaces these patients are saved. Usually the ones who are, have some immediately identifyable and correctable surgical pathology and are in or very close to the hospital they need.

 

[Handsome Robb]

i dont think is was an AAA. Sounds like a kidney stone. If it were an AAA, I would expect to see a blood pressure much lower, and the patient going into shock.

I've seen kidney stones mentioned a couple different times in this thread.

I don't understand how this looks like a kidney stone. I guess it *could* be but generally it's going to be flank/back pain not abdominal pain.

Kidneys, bladder and ureters are all in the retroperitoneal space, not the abdominal cavity.

Well I guess technically the retroperitoneum is in the posterior portion of the abdominal cavity which is separated by the peritoneum.

Either way I don't see this being kidney stones, but that's just me.