Country Meddlin

[Smash]

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.

How many alarms are needed? Tachycardic, tachypneic, febrile, altered mentation... Clinically this patient presents with severe sepsis which has a mortality rate of about 30% in that age group when treated. It doesn't even really matter what the history is or where the infection was originally located: even if you knew nothing at all about this patient except those vital signs, she is a very unwell young lady. Leaving her at home is inexcusable negligence.

 

[firetender]

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.

...so, because I saw nothing life-threatening, though I did note she had an elevated pulse, elevated respiration and elevated temperature consistent with a malady for which she was being treated, I restrained her and then, against her will, carted her off to the hospital.

She lasted a few days I understand. How many other offers of help did she refuse?

 

[MrBrown]

I think people quite often overlook abnormal vital signs or fail to take them into consideration of a wider clinical picutre .... and people get left home and drop dead.

 

[Aidey]

...Judging by the scene around, I would get nana, pa, and critter jr out of the room...

Critter jr....I literally LOL'd

In my system someone with a GCS of 14 couldn't refuse, the whole ALOC and all.

 

[MrBrown]

In my system someone with a GCS of 14 couldn't refuse, the whole ALOC and all.

Most people get around with a GCS of 14 as it was explained to me once by a Clinical Standards Officer.

I remember it was all to do with what sort of basis we go on to consider the patient is "orentaited" as Teasdale and Jeanette did not have a standard set of questions I don't think.

 

[firetender]

I think people quite often overlook abnormal vital signs or fail to take them into consideration of a wider clinical picutre .... and people get left home and drop dead.

I'm glad you started the VS thread. My reflection is up there.

 

[CAOX3]

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

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. .

Shes twenty one I dont care what Ma or Pa said

Send Brown back to the truck to get the refusal.........

She may very well be sick but she still has the right to refuse medical treatment.

 

[Aidey]

Most people get around with a GCS of 14 as it was explained to me once by a Clinical Standards Officer.

I remember it was all to do with what sort of basis we go on to consider the patient is "orentaited" as Teasdale and Jeanette did not have a standard set of questions I don't think.

Yup, I know. The dementia and elderly with a decreased baseline are probably the biggest group. Even if they are alert and oriented to normal, they are still considered altered and unable to refuse.

Shes twenty one I dont care what Ma or Pa said

Send Brown back to the truck to get the refusal.........

She may very well be sick but she still has the right to refuse medical treatment.

GCS of 14...technically ALOC.

 

[MrBrown]

I think everybody just asks the standard time, date, place and person to determine if you get a 4 or a 5 for verbal.

My understanding is that is what Teasdale and Jenette might have had (not sure tho)

 

[Sassafras]

Really? I do the standard date time thing, but also introduce myself right away and ask them repeatedly if they remember my name. I ask who the president is and do they know why we are here as well. Generally the big tip off is not remembering my name 30 seconds after I told them the 3rd time.

 

[MrBrown]

Really? I do the standard date time thing, but also introduce myself right away and ask them repeatedly if they remember my name. I ask who the president is and do they know why we are here as well. Generally the big tip off is not remembering my name 30 seconds after I told them the 3rd time.

What I say: "Hello, I am _____, what is going on today/how can I help?"

What I really want to say: "Yeah hi, I'm ____, one of the helicopter doctors, what do you have guys got going on" followed by "yeah ok, get on a good drip and wheres that 20ml syringe gone? Whos got the ketamine?"

Scoring an accurate GCS is so important I just can't stress that enough, one of the jumpsuited peoples told me if you give somebody E 4 who has thier eyes open but nobody is home and say a 5 for V when it should be a 4 or a 4 for M when it should really be a 2 then you are off by about .... 3, 1, 2 .... well between 4 and 6 points.

So lets say you put on 4 or 5 points that should not be there and wow thats a huge difference.

In the past people who could tell me everything except what time it was got a 5 for V because even I can't tell you what time it is at any given time but heck now they get a 4 automatically. I used to not think much of it to be honest, you know if they got one question wrong out of four or five it's not important, then I had a good run down from one of the Clinical Standards Officers who basically said people who have abnormal answers to fairly standards baseline questions and are not normally altered have a problem that needs to be looked at so its important to triage properly.

 

[Sassafras]

Interesting stuff there Mr. Brown. I don't worry so much about exact time but can you tell me if it's morning, afternoon or night, breakfast time, lunch time or dinner time? I look for something close to what it should be. If they tell me it's breakfast time at 20:00 hours I'm docking them a point.

 

[MrBrown]

Obviously I don't give them a 4 if they say anything other than "____ hours GMT+12"

If they can tell me WHERE they are but not WHY they are there or something eg if they say "I am at the mall" but dont know how they got there, how long they have been there etc or "I went out for some smokes" but can't tell me where they went then thats a 4.

The same goes for eye opening and motor; if the eyes are closed and they open when they hear us come up or something then thats a 4 for E. Oh and if the patient gives you a bit of lip the V is not "inappropriate" (2 or 3 I think) just because you dont like what the said!

Motor is sort of the same; a bit of spastic flexion in the general direction or tugging at the oxygen mask upon painful stimuli is not 5 because they did not attempt to remove. So now you have confused M5 with M2 or 3.

Hence you can bugger up a GCS a bit and it is important in a sick patient. So if you loose a point for V and maybe 2 or 3 for M then you have lost 3 or 4 points.

 

[Sassafras]

So you're telling me the time I was placed on 2 mgs of Ativan and called the best friend from the middle of walmart telling her "I can't find the front door and I'm lost" would land me with a 4V? no I didn't drive that day thank goodness.

 

[MrBrown]

So you're telling me the time I was placed on 2 mgs of Ativan and called the best friend from the middle of walmart telling her "I can't find the front door and I'm lost" would land me with a 4V? no I didn't drive that day thank goodness.

It depends in what context; if you weren't trying to get in the front door then it would have been V4 if you were able to carry out a partially normal conversation but you just slipped in that you were trying to get in the front door.

If I has said "hello I am with the Ambulance, what is wrong today?" and your answer was "hey man I can't get my keys to work!" then that would be V3.

We went to a guy who was pretty shockingly intoxicated the other night and somebody said oh leave him with me hes just pissed he will be fine ... sure OK so lets look at this guys GCS. He would't open his eyes at all (E1), uttered incoherent words and slurred a lot of crap (V2) and would sort of have a bit of a swing at you if a sternal rub was done (M3).

This guy was just drunk we reckoned but with a GCS of 6 he was actually had the potential to be pretty crook. Hence why he landed in the hospital.

 

[Sassafras]

Oh I was good and properly lost in some department. I don't even remember the event. But the friend sure does like to remind me how out of it I was that day.

 

[thatJeffguy]

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

The factors that had me thinking septis were the high pulse and the warm/dry skin.

What else here would lead to that conclusion? What findings were red herrings?

 

[juxtin1987]

Another one of my I KNOW THIS IS OLD posts.

There's one thing that caught my eye immediately that noone mentioned.

Girl saying she's fine and doens't want transportation is a normal finding.

Girl AND Boyfriend both wanting her to stay sick at home is an abnormal finding, they're clearly hiding something that pertains to obtaining a ddx.