Kiwiology

Attention fucked in the head Doctor - it is not acceptable to discharge my chest pain patient one hour after doing an ECG, furthermore, the fact I have had to specifically request you do cardiac enzymes and other biochemistry (e.g. leukocytes, ESR, bands, segs, CRP) makes me wonder if you are actually a doctor ... and furtherm0re, if I request a copy of said CXR, ECG, bloods and notes to have it reviewed by me and two Consultant Physicians well fuck you none of your lip just give it to me mmkay?

NAEMSP seem like a bunch of bitches; they have all these policy statements supporting cervical spine clearance, not using longboards. leaving people at home, RSI and one or two other things ... I think ketamine is in there somewhere ... but I do not see any of their members actively promoting or allowing them in the orginisations they are medical director for

I am an associate member of the Australasian College for Emergency Medicine or some near equivalent shit ... means I can jack off at some conferences if I should so choose ... at least I think I am, I do recall filling in some shit a while ago

The RANZCOG kicked me out; they found out the Gynae Reg post I was in was not accredited, and that um, I was not actually a doctor, apparently they were displeased by this .... bastards!

This sounds like a poor appreciation of basic physiology (love me physiology)

However, I was taught that the body will seek to maintain plasma normosmolarity and if too much free water is introduced then the body will sense hypo-osmolarity and expel the excess free water as urine?

In fact, here is what I wrote in a uni assignment about it

Atrial natriuretic peptide is an amino acid peptide released from atrial myocytes in response to distension; the most common cause being hypervolaemia and hypo-osmolar plasma (Klabunde, 2007). ANP increases urine output in an effort to achieve normovolaemia and normal extracellular fluid balance by

• Dilating the efferent arteriole of the nephron which increases glomerular filtration rate (Saladin, 2003),
• Acting upon the distal collecting tubule and duct in the nephron to decrease reabsorption of sodium (Guyton & Hall, 2011),
• Inhibiting anti diuretic hormone secretion from the posterior pituitary gland which … (Saladin, 2003) and,
• Decreasing aldosterone secretion from the adrenal cortex, lowering sodium reabsorption in the nephron thus increasing urine output (Rhodes & Tanner, 2003

​Thirst is awareness of the desire to drink water and intends to aid in restoring extracellular sodium balance (Rhodes & Tanner, 2003). Sodium balance is particularly important in ensuring correct extracellular osmolality which is calculated as ECF solute concentration / ECF volume (normal being 300mOsm/Kg or 2 (Na⁺) + (BUN/28) + (glucose/18)). The thirst centre is located in the anterolateral wall of the third cerebral ventricle and is activated by plasma and cerebrospinal fluid osmolality increases (osmoreceptor feedback) as well as increased release of angiotensin II (Guyton & Hall, 2011). When stimulated the thirst centre encourages drinking water by a reflex decrease in secretions from oral salivary glands. The ingested water will diffuse into the plasma through the gastrointestinal system and decrease extracellular fluid osmolality (Levitsky & Raff, 2011).

Anti-diuretic hormone (arginine vasopressin) is a small nine amino acid nonapeptide manufactured in the anterior hypothalamus and stored for release in the posterior pituitary gland. The principal factors influencing release of ADH is plasma hyperosmolality (osmoreceptors) or hypovolaemia (cardiovascular baroreceptors); in fact, the hypothalamus can detect a deviation as small as one per cent from the normal plasma osmolality of 300mOsm/kg (Rhodes & Tanner, 2003). Release of ADH allows for considerable water reabsorption in the renal collecting ducts by increasing permeability to sodium of the K⁺/Na⁺ ATPase (Levitsky & Raff, 2011)

So in theory would plasma hypo-osmolarity = decreased thirst, decreased ADH and increased ANP which would lead to > urine so < free body water, < ECF and cause > IVF to shift to ECF and lower pOsm thus normalising sodium levels in the plasma by increasing %age of Na to total volume?

I don't see a reason to need to do a nasotracheal intubation except in some things like dental or max/fac procedures

Damn you Emergentologist; I am going to have to chew down some more lorazepams now ... and just as I was getting them weaned ... oh who am I kidding, why in the fuck would I want to do that, lorazepams smooth out the day nicely especially when dealing with douchebag hospitals in US for patient records and things like actually wanting to speak to the Doctor, can take days to weeks or just never happen, you call some squalor hospital in Calcutta where the patient is having blood letting done for his dropsy and the Doctor is straight on the phone, telling me his symptoms, investigations, diagnosis, how many leeches he is using, what colour, size and wriggle factor they have, how much blood has been let, the lab values of that blood and what his plan is for the patient, then he gives you his cellphone number to call him if you need and then emails you as well, meanwhile in US you get somebody who just laughs at you when you ask to talk to the Doctor and offers to put you onto the RN, NP, PA, LVN, LPN or some other fucked up non doctor person if they can page them and that might take two hours and just never eventuate ... and its easier to just get fucked up on valiumz and deal with the health care system in India, Thailand, South Africa or honestly? ... any country that is not US! ... I do like the 40 page ED discharge notes though that contain what the patient did every day of their life prior to setting foot in the hospital, and what happened every second they were in the hospital and who was there, who was not there, why they were there, who ordered it, why they ordered it, and every other fucking excruciating detail imaginable and then tacked on the back is the $200,000 bill ... I am not even kidding you, last week I had a patient with a bill of over $100,000 for a 2 night stay and she didn't even have surgery or nothing ... Jesus H Shit on a stick Emergentollgist, if I need valiumz to just deal with the system from my level how is it you are not dead from some sort of massive chronic polypharmacy poisoning having to actually work there?

And lets not even get into the typical line of conversation when one of my patients is still being worked up in ED

"Hello this is Joe, you want to talk to me?"
"Yes, thank you for speaking, are you the House Surgeon or the Registrar?"
"No, this not surgery"
"OK, are you the House Officer or the Registrar?"
"The Registrar is sitting on the front desk"
"Can I speak to them about this patient please then?"
"Why?"
"Because I need to speak to the Registrar"
"Hang on"
"Hello Registrar?"
"Yes Registrar, thanks for speaking with me today, can you tell me about this patients presenting complaint, investigation, diagnosis and plan?"
"I don't know"
"Aren't you the Registrar?"
"Yes"
"And are you this patients Registrar?"
"Yes, well, I am for all the patients"
"So you have worked this patient up?"
"Um, I'm not the Doctor"
"Oh ... you said you were the Registrar, can I talk to the House Officer?"
"What?"
"The Doctor"
"You were just talking to him"
"Can I talk to him again please?"
"He is busy now, he will be free in five hours, let me transfer you to somebody else ...."

Hmmm * whips out that handy ERDoc to English Translator

"Can I talk to the Intern, Resident or Attending Physician please?"
"Sure let me find somebody!"

True story ....

I read her blood alcohol level was below the legal limit, so then how can they charge her if she was not committing a crime?

Awesome good luck mate, just stay the hell out of Bulletmore, Murderlandand you'll be fine

Did that make you feel better kiwi?........:-)

Nah I was being a little bit smug

I like to understand what's going on. Uncontrolled afib in a patient with a history of afib has me thinking differently from a patient with a new onset of vfib. I agree that the treatment protocols will have you treating both the same in regards to stable vs. unstable, medication vs electricity. Given hemodynamically stable yet symptomatic patients, I think a trial of a calcium channel blocker is indicated for the first patient before zapping them, whereas the second patient is getting amoidarone or possibly electricity first.(it depends). This has to to with sustainability of the first rhythm as opposed to the highly unsustainable vfib.

Maybe I'm off base here, but I like to know everything I feasibly can about what is going on with the patient, and in my simple mind, knowing where the dysrhythmia is originating is valuable information.

Smart people correct me. I always like to learn.

Nothing wrong with it but there are more important things to do if the patient is crook, get a look at the rhythm and determine that its very fast and the patient is having haemodynamic compromise and there's your sell on cardioverting him. Once you have fixed him up you can have a nosey I suppose.

Have to agree with my mate from across the dutch....

Winning

Interesting.

Not sure it makes a difference, since the 2011 CPG update all tachycardias causing significant haemodynamic compromise get cardioverted regardless of their origin but interesting none the less ...

Attention Physician who I can barely understand

(1) My patient has no history of HTN or cardiac disease

(2) He felt dizzy and was tachypnoeic

(3) He had a single, isolated episode of BP 160 systolic without symps of a hypertensive crisis, stroke or end organ dysfunction

(4) You started him on an ACE inhibitor and diltiazem (a calcium antagonist)

(5) He now feels unwell because his blood pressure is too low

(6) A Consultant Physician, a Registered Nurse and me all disagree with your management

(7) This comes as a surprise to you ....

(8) We think you're a fucking moron

That is all ...

The Rapid Response Unit here includes two BMW motorbikes

Damn it Emergentologist you are as bad as Trev, is not pericarditis!

The Rapid Response Unit uses Honda CRV and they are great! There are a few Hyuandi Santa Fe about and they are OK but the CRV is much better IMO

I have always wondered if CO2 itself is a vasodialator seeing as how most is carried in HC03/H2CO3 (if memory serves) with only a tiny amount actually dissolved in the blood plasma

Just had to evacuate somebody off a cruise ship I am jealous reminiscent of my cruise to Bahamas and wish I'd bought my trunks They wouldn't let me wear the flight suit that had DOCTOR written on it, poopyheads!

This is just absolutely terrible news.

I saw this on Facebook at work and I was thinking about this on the way home, my last patient tonight was sick, like he was going to die without us sick, he was really crook, we fixed him up (mad props to my R50) and I got off 20 minutes late but we felt like a million bucks then we were doing clean up I remember about this and now I feel really sad.

I suppose because it's Indianapolis and not some random nameless department where at best I've passed through the city or something random like that, never had the pleasure of meeting Tim, only met one crew from B Shift, but still ...

My heartfelt condolences to Tim, his family, B shift and entire IEMS family .. may something good come out of this.

Fire Control from Medic 302, we'll be out of service, gotta go attend to the flag

Attention doctor your decision to perform an appendectomy on my patient with tummy pain and raised leukocytes upon whom you have not performed a CT because the hospital does not have one is fairly dubious at best or so I think Also attention other doctor who cancelled the evacuation I spent eleven hours planning and then reordered it when the patient started spewing his guts out and you got freaked out and wanted him off your hands, you're a douchebag

I am old in the head

It comes from travelling at twice the speed of life

Sorry lads I kind of dropped the ball on this one, it was typhoid

I was very surprised, have not seen a lot of typhus carrying mozzies buzzing around Auckland, but apparently it can be transmitted by faeco-oral route as well so there you go.

or Chris' glowing ass ....

Agreed

Anybody who hires that lawyer is mentally ill

I don't really think there are any, they are all over-dramatised slop

I don't like Emergency! even tho I watched a few episodes, MJ&S was quite funny independent of any medical theme, I watched the pilots of both Trauma and Chicago Fire and they are awful.

Third Watch was OK, there was not a great deal of complex medical information in that show and again, it was good because the story line was good, independent of any medical theme.