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 Post subject: WWYD - medical related
PostPosted: Sun Nov 13, 2016 4:22 pm 
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WWYD – Medical related.

Setup:
You are at a rural Alaskan summer camp. The camp is at the end of an old logging road. Parking for campers is at a trail head, about a 20 to 30 min walk from the camp area. This is by design to limit the amount of 'stuff' campers will bring. (You have no idea)
Campers use two-wheeled carts to carry their supplies in and out.
Camp supplies are delivered using a surplus Duce, trash removed after campers leave via the same truck. The Duce is always off site (in town) while camp is in session.

You are there with your daughter having volunteered to act as one of several bear guards. The camp (this cycle) is completely populated by women age 12 to 17 and their female camp leaders.

The situation:
At lunch, you are approached by a runner who asks that you to report to the main camp building. Returning with the runner, you are greeted by a woman you recognize from earlier meetings as the "Camp Nurse" – a friendly and very retired RN.

"I can use some help," she says. "I know you're a licensed EMT with a lot of ER experience. I could use your opinion…"

You are presented with a ~14Y/O girl, lying supine on the couch in the 'infirmary'. The nurse says the girl is complaining of 'non-specific' pain in the abdomen and has an elevated temp. Specifically "just under 100F". The nurse also says the girl just started on her period, and the nurse 'thinks' the abdominal pain is cramping. "What do you think?" is the million-dollar question.

You know from past experience the area is served by a volunteer EMT crew that takes upwards of 30 minutes to assemble - on a good day. Distance from the dispatch point to the trail head is about 35 minutes. So, an ambulance & crew is at least an hour or more, away.

So, What Would You Do?
Please post with some detail to show your thought process.

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PostPosted: Sun Nov 13, 2016 7:16 pm 
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Not a EMT so remind the nurse, I'm here as bear guard, not an EMT ;) , then ask patient if she normally ran a slight fever and cramping with periods. Ask the easy questions first - When did you poop last(You'd be surprised how many ppl will try to hold it a week or more with no 'real' facilities),new foods, homesick, eating wild berries, etc? . After some Q&A if warranted move to an abdominal quadrant check to see if it can be narrowed down. Otherwise observe and track patient, again if warranted give emt's a heads up just to be aware of a possible situation, but doesn't warrant an extraction yet...

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PostPosted: Sun Nov 13, 2016 9:38 pm 
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conduct a quick head to toe looking for any trauma that is life threatening, none, good lets move on

You are presented with a ~14Y/O girl, lying supine on the couch in the 'infirmary'. The nurse says the girl is complaining of 'non-specific' pain in the abdomen and has an elevated temp. Specifically "just under 100F". The nurse also says the girl just started on her period, and the nurse 'thinks' the abdominal pain is cramping. "What do you think?

SAMPLE and OPQRST history please

specifically:
When did the pain start?
Did the pain come on suddenly, or worsen over time?
can she point to where the pain is?
does the pain feel like its moving around?
can she describe the pain?
does it hurt anywhere else?
do you have any allergies?
are you on any medications? what are they for (if applicable)?
have you had this pain before?
when was your last toilet visit? fluid intake? meal? period? GP visit? did the GP visit show anything of concern?
What where you doing before the pain started?

Do I have monitoring equipment? can I feel her radial pulse? what does she look like? sweaty?, dry?, how hot is the day?

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PostPosted: Mon Nov 14, 2016 7:36 pm 
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taipan821 wrote:
conduct a quick head to toe looking for any trauma that is life threatening, none, good lets move on

You are presented with a ~14Y/O girl, lying supine on the couch in the 'infirmary'. The nurse says the girl is complaining of 'non-specific' pain in the abdomen and has an elevated temp. Specifically "just under 100F". The nurse also says the girl just started on her period, and the nurse 'thinks' the abdominal pain is cramping. "What do you think?

SAMPLE and OPQRST history please

specifically:
When did the pain start? "Recently" - I know but that's how some folks are.

Did the pain come on suddenly, or worsen over time? ""Gradual onset of pain"

can she point to where the pain is? "Pt indicates a 'dull' pain near her navel but also mentions the pain had been in upper, then lower abdomen. It really hurt as it moved to the lower right abdomen"

does the pain feel like its moving around? See above

can she describe the pain? see above

does it hurt anywhere else? see above

do you have any allergies? "Not that I know of"

are you on any medications? what are they for (if applicable)? "No medicine on board, the nurse requires parents ID any ongoing meds in advance"

have you had this pain before? "No"

when was your last toilet visit? "Last night"
fluid intake? "Two quarts water since breakfast. Camp leaders push fluid intake in a big way"
meal? "Breakfast - eggs and oatmeal - because they ran out of biscuits and gravy"
period? "last month"
GP visit? "Last year."
did the GP visit show anything of concern? "No"

What where you doing before the pain started? "Sitting and sewing on my hat"

Do I have monitoring equipment? Stethoscope and BP cuff. Right now, BP is 'normal' for thin 14 Y/O girl. can I feel her radial pulse? Good steady pulse

what does she look like? sweaty?, dry? Clammy, but with good color.

how hot is the day? It's Alaska - cool.


Very good question set. I use the SOAP method with younger folks.

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PostPosted: Mon Nov 14, 2016 7:43 pm 
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SCBrian wrote:
Not a EMT so remind the nurse, I'm here as bear guard, not an EMT ;) ,
Actually a good comment. I may be an EMT but I am not the [i]camp EMT - I have no indemnification. A much bigger dealt than many might think... [/i]


then ask patient if she normally ran a slight fever and cramping with periods. Ask the easy questions first - When did you poop last(You'd be surprised how many ppl will try to hold it a week or more with no 'real' facilities) - Spot on!

new foods,
homesick, Very good, this can be a real issue for first time campers.
eating wild berries, etc? Another good question

After some Q&A if warranted move to an abdominal quadrant check to see if it can be narrowed down.

Otherwise observe and track patient, again if warranted give emt's a heads up just to be aware of a possible situation, but doesn't warrant an extraction yet...
Okay, a safe enough approach for now. Do no harm, eh?



Good set of questions!

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PostPosted: Mon Nov 14, 2016 8:42 pm 
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TacAir wrote:

Okay, a safe enough approach for now. Do no harm, eh?[/i]


My Certs only go up to WFA + adult/child AED/CPR... Though I've carries them for years. The rest is just picking up over time and personal experience.
My next question is only based on a quadrant check and the response from Taipan's question - but I'd check for rebound tenderness and maybe heel jar. Though it doesn't rule out asking if she's sexually active. Could be an actopic (sp?) pregnancy...


If it's what I think, I presented asymptomatically when I had mine...

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PostPosted: Tue Nov 15, 2016 12:43 am 
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SCBrian wrote:
TacAir wrote:

Okay, a safe enough approach for now. Do no harm, eh?[/i]


My Certs only go up to WFA + adult/child AED/CPR... Though I've carries them for years. The rest is just picking up over time and personal experience.
My next question is only based on a quadrant check and the response from - but I'd check for rebound tenderness and maybe heel jar. Though it doesn't rule out asking if she's sexually active. Could be an actopic (sp?) pregnancy...


If it's what I think, I presented asymptomatically when I had mine...


Asking an unknown female (as a older male) about being sexually active is more than a loaded grenade. Be careful padowan.

However, the earlier brief seems to rule out a pregnancy....if no other signs of an active pregnancy are displayed. (such as AM nausea, painful breasts or a swollen abdomen )

An ectopic pregnancy is likely the scariest of all possible problems, IMO, given just how horribly fast a pt can exsanguinate if there is a major rupture. Esp if the nearest medical care is an hour out...

"My next question is only based on a quadrant check and the response from - but I'd check for rebound tenderness and maybe heel jar. " Logical next step.

Would you perform this set of checks or make a suggestion to the nurse?

"If it's what I think, I presented symptomatically when I had mine" More often than not, most folks present classic symptoms - except when they don't. And that is far too often.

Thanks for posting.

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PostPosted: Tue Nov 15, 2016 1:35 am 
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I'm going to alert local EMTs for an extraction, I'm having a gentle feel around the abdomen feeling for anything unusual,

Potential diagnosis...appendicitis, differential diagnosis, ruptured bowel? (unlikely)

reassure patient, monitor and await extract, possibly bypass local team and request aeromedical backup (its free here) in the form of a flight doctor/nurse/paramedic

and tacair, that's general questions for 'person feeling unwell' over here

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PostPosted: Tue Nov 15, 2016 7:35 am 
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I'd say check for a minor infection. The environment combined with the minor compromise of the immune system makes this a likely candidate. I have no medical provider training other than CLS. I just listen the the wife talk about and pick up what I can.

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PostPosted: Tue Nov 15, 2016 2:10 pm 
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TacAir wrote:

"My next question is only based on a quadrant check and the response from - but I'd check for rebound tenderness and maybe heel jar. " Logical next step.

Would you perform this set of checks or make a suggestion to the nurse?

That's where you start getting sticky. I'm not the on-site medical, and not in a position to determine. Me? I'd advise the RN to check explaining what my thoughts are. Even in the event of a bear attack, the standing orders are probably written to notify the on site medical, and let them do their thing. And normally they are that way for reasons, the least of which is insurance.
If I had to make the call. Based on the rebound test, heel jar, I'd call for the Duce to pick up at infirmary and meet the ambulance at the nearest access point. No need to helo, not good, but not immediately life threatening. No I wouldn't try to stretcher her for a 30 min walk, or make her walk out. If there was complications getting the duce in, the wheeled cart can move her to the trail head, probably faster and easier than a stretcher :( I've had to carry people out of the woods, it's not fun for anyone involved.


TacAir wrote:
"If it's what I think, I presented symptomatically when I had mine" More often than not, most folks present classic symptoms - except when they don't. And that is far too often.

Thanks for posting.

Yea, the on site intern decided it wasn't appendicitis because I walked in ( I have a high pain tolerance :/ Good & Bad). A number of hours later, some rude and invasive procedures and a gallon of barium, the lab tech diagnosed it. But I got to sit beside her and see the results as she was going through the images. And I couldn't keep it. I mean, I brought in in with me, Why cant I take it home in a jar, I mean really?? Silly medical waste procedures.. :lol:

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PostPosted: Tue Nov 15, 2016 8:10 pm 
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LOL
Everyone needs some piece parts in a jug of alcohol around the house to prove they are not an android....

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PostPosted: Tue Nov 15, 2016 9:44 pm 
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Why is a RN asking a EMT for advice?

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PostPosted: Tue Nov 15, 2016 11:00 pm 
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flybynight wrote:
Why is a RN asking a EMT for advice?


double checking, also RN might not have field experience, financial concerns, legal concerns...

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PostPosted: Tue Nov 15, 2016 11:13 pm 
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flybynight wrote:
Why is a RN asking a EMT for advice?


A very retired nurse with little to no recent trauma experience. Very nice woman, and she easily handled the normal run of the mill stuff that camps tend to 'produce' Minor cuts, wood-ash in the eye, small abrasions and so on. I think the fact that this was an internal issue may have spooked her.

As you have guessed - I had this very experience. After chatting with the nurse, I sent the runner back to camp and had the pt.'s designated leader some up. Not the girl's mother - but the leader was her legal guardian. I had to sign the same papers for my daughter.

I explained the situation and asked the leader for her permission to perform a couple of simple tests that required touching the young lady. This with two witnesses. There was marked rebound sensitivity, and that was enough for me to strongly suggest they pull the pin and get the girl to a hospital.

With 6 large males (other bear guards at camp with their daughters) it was an easy walk with a cart supporting a door to reach the trailhead. The local ambulance crew still hadn't launched, so the leader and the nurse escorted the girl to the nearest hospital in one of the autos at the trailhead - where she was admitted. Her appendix came out that afternoon. Everything turned out well.

The next year, the camp arranged for a local trauma RN to take a 'vacation' and act as the camp medico. Nobody was happier than me. Alaska had some quirky folds in it's Good Samaritan Law, which was updated years after this event. It is much less quirky now.

It would be a good thing for folks who plan on being helpful read their jurisdiction's current laws/rules on rendering aid. And then reinforce both their PPE and knowledge of infectious disease controls....

Thanks for playing/reading along.

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PostPosted: Wed Dec 14, 2016 1:16 am 
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The symptoms don't set off much warning bells for me, but an old RN being nervous does. Unless the RN had demonstrated dementia or gross incompetence, I trust their concern and would play it safe. Get the kid to a hospital.

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PostPosted: Sat Dec 17, 2016 11:17 am 
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TacAir wrote:
WWYD – Medical related.

Setup:
You are at a rural Alaskan summer camp. The camp is at the end of an old logging road. Parking for campers is at a trail head, about a 20 to 30 min walk from the camp area. This is by design to limit the amount of 'stuff' campers will bring. (You have no idea)
Campers use two-wheeled carts to carry their supplies in and out.
Camp supplies are delivered using a surplus Duce, trash removed after campers leave via the same truck. The Duce is always off site (in town) while camp is in session.

You are there with your daughter having volunteered to act as one of several bear guards. The camp (this cycle) is completely populated by women age 12 to 17 and their female camp leaders.

The situation:
At lunch, you are approached by a runner who asks that you to report to the main camp building. Returning with the runner, you are greeted by a woman you recognize from earlier meetings as the "Camp Nurse" – a friendly and very retired RN.

"I can use some help," she says. "I know you're a licensed EMT with a lot of ER experience. I could use your opinion…"

You are presented with a ~14Y/O girl, lying supine on the couch in the 'infirmary'. The nurse says the girl is complaining of 'non-specific' pain in the abdomen and has an elevated temp. Specifically "just under 100F". The nurse also says the girl just started on her period, and the nurse 'thinks' the abdominal pain is cramping. "What do you think?" is the million-dollar question.

You know from past experience the area is served by a volunteer EMT crew that takes upwards of 30 minutes to assemble - on a good day. Distance from the dispatch point to the trail head is about 35 minutes. So, an ambulance & crew is at least an hour or more, away.

So, What Would You Do?
Please post with some detail to show your thought process.


It would help to know other vital signs. That said, abdominal pain with fever is very concerning for a number of nasty problems that can be life threats. As a result, it would be desirable to get the child to a hospital with a CT scanner, to be able to rule out the life threats. Quickly, rather than slowly, is the way to go. If it's something bad, the girl could develop an aggressive form of septic shock known as Systamic Inflammatory Response Syndrome which is an acute life threat.

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