Kiwiology

Don't read the books, don't watch the TV shows ... nor do I have a hospital crash cart in my car and never have I shopped at Galls. Man I am just no fun huh? Oh, and MAST pants and terbutilyne aren't so bad, there was a time when if you were having other than a cardiac emergency and the Paramedics came they just looked at you and went "um .... yeah". Hopefully Emergentologist's crushing medical school debt has driven the enthusiasm out of him ....

I note there was a significant amount of pulmonary edema in these patients as well. Whilst my chemistry knowledge doesn't really extend to if there is any effect caused by the cold fluid, it certainly would seem like a less than good idea infusing a couple litres of fluid into somebody whose ticker probably ain't functioning too crash hot.

See here for the full, free article http://jama.jamanetwork.com/article.aspx?articleid=1778673 Yes, very interesting. In hospital they use an ice blanket and get the patient much colder (to about 32 degrees). I theorise that the relatively short time that pre-hospital people are with the patient (the vast majority would be < 30 minutes post ROSC) and isolated use of cold saline limits the benefit of something like this. While probably a little helpful, I am not sure if its practical to bring something more advanced into the pre-hospital space e.g. ice blanket or some sort of cutaneous based system, I know the London HEMS Doctors are using the Rhinochill nasal brain cooling system and a few places use ice packs. These reasons are most likely why we haven't yet introduced active pre-hospital cooling in NZ i.e. no real evidence of benefit for the costs.

It's because nobody can understand us, you are an Australian so by default you are barely understandable because you're pissed 24/7 and me, well I'm so bloody destroyed on lorazepams that I can barely contain my faculties .... I am curious as to the use of an alpha agonist like metaraminol vs a beta agonist like adrenaline as to which produces a better effect. I think we use adrenaline primarily because it's already in the toolbox ...

GRR! Kiwi quiere habla Espanol muy bien, estoy Espanol el tragedia, Kiwi aprendiendo en trabajo, aprendiendo Espanol es duro! es amigo de Cuba habla Espanol muy bien, el habla muy rapido, duro entiendo! Y yo estoy tambien mucho hambre, quien lo hara cocinar Kiwi cenar?

I miss my Jeep

Whilst you could not realistically be expected to diagnose meningococcal disease in this patient, It is not unreasonable to expect pre-hospital clinical people to make a diagnosis, even if that diagnosis is "I don't know what the hell is wrong", if you are going to treat something you must first of all form a diagnosis but like I said, the diagnosis in this case is less important than recognition that something here is awry. There are a number of signs that something is wrong and that this patient requires further evaluation.

We have a "critical operational check" which is a quick one minute check to make sure the defibrillator passes the self test/has pads, that suction works, there is a tank of oxygen etc in the ambulance and that is has wheels attached, enough fuel, lights work etc. This is completed at the start of each shift. Then there is the "vehicle readiness check" which is the larger, more encompassing check of things like quantities of consumables and drugs etc which needs to be completed once per day (which is usually at the beginning of a shift) And Doc, sure, make up some of them buttons, just be sure to put "ERDoc is not responsible for the care I provide you, by reading the text of my button you agree to indemnify ERDoc and ERDocs Inc, ERDoc's employing physician group as well as TheHospitalERDocPracticesAt Healthcare LLC from all liability" YEAH ... 'MURICA!

How interesting When I am a Resident, I want a button that says "Supervised by ERDoc"

We run it at two drops per second initially then titrate to effect So let's say we use a 20 gtt/ml set then that's be hmm let's see here, Kiwi math not so good ... 0.006 mg (or 6 mcg/min)

Nope. We do have adrenaline tho as a 1:1,000,000 infusion (i.e. 1 mg in 1,000 ml) provided after a minimum of 2 litres of fluid the patient is still hypotensive.

Our new rule is basically if you are less than an hour closer to hospital by air than road you should go by road unless the helicopter can bring specific skills you need that will be much faster by air than road (e.g. HEMS Doctor).

No recent family illnesses. Hard to tell really, she just wants to stay in bed, mum said previously when she wanted to go to the toilet that she had to physically pick her up and take her to the bathroom because she of how she felt. This is a real case (slightly modified). If you look at several of the findings thus far they should be telling you this is a person who is likely to be subtly very unwell. Fair enough mate, now hand me that thingamadongle there, this bloke looks like he's a bit crook, gonna have a fossick in his noggin .... What else would you like to know? I answered your questions. Oh stop it you You can skip an actual diagnosis I guess, it's less important than recognition that something is awry with this kid The photophobia is hard to pin down really; it could be photophobia or it could be a 3 year old kid who doesn't like being around strange ambos. The respiratory rate should be concerning. A raised respiratory rate in the absence of an obvious cause should be a flag for further investigation. I hypothesise it is often a sign of inadequate tissue perfusion and the beginnings of anaerobic respiration thus we get a raised respiratory rate in an effort to excrete excess CO2 when the lactate is converted into whatever lactate is converted into, help me out here Emergentologist, your BSc in Biochemistry (Cums a Lot) will mean you know far more about that than I do. The BGL is low, for us it is quite low, our normal is 4 mmol/l (80 mg/dl) and in children this is often sign of a significant underlying infection. Temperature is a little bit high as well but it's clinical significance is debatable until the cows come home. It is also significant that when she wanted to go to the toilet the mother had to carry her. Inability to mobilise normally (in the absence of an obvious cause) is probably not a good thing. I think the patient needs to be seen by a Doctor tonight, doesn't have to be immediately but should be with an hour of arriving at ED. I wouldn't give her any treatment in the pre-hospital setting. This is a real case (slightly modified) where the patient was left at home and died about 12 hours later of meningococcal septicaemia. While there was nothing immediately obvious in the history and exam that pointed to meningococcal septicaemia there were several signs (above) that the child was compensating for some significant underlying problem that needs further investigation. Many people would "explain this away" as the flu or a cold or even gastro. In the absence of diarrhoea some 16 hours after feeling sick then this isn't gastro and with no sore throat or cough after the same time period it's not the flu. Thanks for playing, pass GO, collect $200, go straight to ED, collect your refil for whatever chronic pain meds you are on then go wherever the hell you want.

Because not being able to would be a symptom of meningeal inflammation duh

I am greatly intrigued; every second person and their dog in US seems to have "chronic pain" of some sort and be on a bunch of narcs and it seems that it also includes adolescents/young adults plus their cat also has diabeetus and is metformin.

Want to evaluate her potential as a future stripper so they can reopen the Hooters on 29th? Um, I guess you can What else do people want to know, what are y'all thinking?

Yes what? OK so if the normal respiratory rate for a 3 year old is 30-35 then what does her RR being 40 mean to you? PMHx NAD Mum called because she doesn't know what to do No regular Rx Hard to tell, she wants to hide under her covers in general ... No neck stiffness that we can illicit but it's a crook 3 year old so .... Could be meningitis, could be anything ...

So, do you know what the normal respiratory rate for a 3 year old is? What if its 20? or 30? or 35? How will that change the way you look at it given the overall clinical picture? The BGL is in both mmol/l and mg/dl; the temp in F is 99.5, apologies. What do these numbers tell you? Just because mum called 911 doesn't mean the child needs to be seen by a doctor tonight. What I am asking is do you think she needs to be seen by a doctor tonight, and if so, how soon? i.e. how much of a threat to her life is your diagnosis?

Why? What is the normal respiratory rate for a 3 year old? So do you think that warrants the child being immediately referred to a Doctor? Do you see any other red flags here?

If you're using ketamine in combination with morphine (or fentanyl) you need to be giving a decent dose before deciding its not working; in an adult patient I'd be giving preferably at least 20 mg. I've had people we've put 20 mg into and they sort of blinked and gone "well, have you given me anything yet?" Ketamine can also be used as a sole agent and we do this a lot in patients who have burns or MSK pain e.g. long bone fractures (particularly femurs). As for anaesthesia it's just common knowledge that it wears off quickly (~ 15 minutes I think) so you need to be plugging the patient into your post intubation analgesia/sedation/paralysis regimen as soon as you've got them into the ambulance. We use fentanyl, midazolam and rocuronium here. Now, this whole "ambos give shit analgesia" thing seems to be purely an American thing; not sure about Canada but I've had a quick look at the AHS guidelines and you have up to 20 mg of morphine (or 250 mcg fentanyl) on standing order which is fairly decent, in line with what we have here (we have 40 mg / 200 mcg but that is only because we are physically limited by the amount carried).

You are called to see a three year old female child at home. It is 11.30 pm and mum states her daughter has been unwell for approximately 16 hours since 8.00 am this morning when she woke her to go to pre-school. HPI 16/24 generally unwell; has vomited once (stomach contents), no diarrhoea O/A In bed, awake, alert, orientated for age, not in obvious distress. She prefers to be in bed with blankets over her C/O “feels sick” – unable to be more specific O/E V/S: BP 100/70 PR 100 RR 40 T 37.5° SpO2 99% RA BGL 3.3 (~70) GCS 15 EXTREMITIES: Without cyanosis, clubbing or edema. Skin: WPD w/o purpura. NEURO: NAD HEENT: Denies sore throat, PERL (somewhat sensitive to pupillary light), otherwise NAD NECK: Supple w/o lymphadenopathy. CVS: NAD, normal S1/S2 w/o adventitious sounds RESP: Air entry clear/equal, no adventitia, no cough ABDO: Soft, non-tender, no distension, good bowel sounds. Inguinal area is normal. Consider … (1) What is your provisional diagnosis? (2) Are there any “red flags” which you think this child needs immediate referral to a Doctor? (3) If so, how quickly should she be seen by the Doctor upon arrival? Immediately? 10 minutes? 30? 60? 120? (4) What treatment would you provide right now and why?

Bah, ketamine is the best thing ever, hands down. The Australasian experience across thousands of patients have been overwhelmingly positive with no significant psychotropic problems and only a few isolated cases of hypertension or tachycardia. Of course we are talking "low dose" boluses (10-40 mg at a time) and not the massive infusions people get with CRPS/RSD. The most I have seen (or heard) of somebody getting was 100 mg in small boluses whereas I've seen people getting anywhere from 200-500 mg an hour infusion for CRPS. We are also using it only in a small group of critical care type paramedics. In hospital it is very popular down here in the same fashion for analgesia and is also used in higher doses for disassociation/sedation particularly now to get people on NIV who would otherwise have been tubed in the past. It's non Rx here in New Zed as well as the UK and Australia but you might need to buy it at the pharmacy (technically one step up from a GSM - general sale medicine - which is commonly known as "OTC" i.e. you can buy it anywhere). Some crazy guy tried to beat me up at the Port Authority Bus Terminal ...

How very interesting. I would be a bit dumbstruck if the hospital had a policy which prevented its use in analgesia, after all, its an analgesic, and a bloody good one. Ketamine has legitimate analgesic properties (as a u-and-mu-opioid receptor agonist) especially in low doses which do not produce a primarily sedating or anaesthetising effect so it has both properties depending on the dose you give. But in saying that, the mate in US went to an ED for excruciating toothache and they gave him, wait for it, nothing, because they did not have a "tooth pain protocol"; I sure hope that hospital has a stroke protocol because I damn near needed it after hearing that. A freaking Doctor has a license to practice medicine independent of some muppet protocol, or so I thought! No diss mate but if I get both my femurs shattered in a road crash or severe burns from my amaetur meth lab going ka-boom I want something a touch stronger than bloody morphine or fentanyl. What about midazolam, if somebody is in wretched agony and you've loaded them up on opiates without any great effect would you give them some small increments of midazolam for some anoxylysis? esp thinking about somebody with a fractured femur and who has skeletal muscle spasm?

And when that stops working or plain just doesn't work? It gives me acute severe pain to think about the people I've been to who we've loaded up on morphine who were still in wretched agony and viola a little ketamine and they're nicely analgised and disassociated. Ketamine is very, very popular in Downunderland, New Zed and UK. I'm not trying to be a dick; I am genuinely curious as to why you're not using it?

Panadeine (paracetamol 500 mg + codeine 8 mg) is available in up to 100 tabs here as a pharmacy only medicine i.e. can only be sold by a pharmacist but does not require an Rx. So Emergentologist if you're only using ketamine for sedation what do you use for acute severe pain e.g. patients with severe burns or multiple long bone fractures?