MediMike

Funny. I was going to Google that next but got a consult.

Tough right? I'm assuming you're talking in the outpatient world? There's still little data. If you are talking patients who have recovered then I agree with above regarding pulmonary function, there are some serious long term sequelae for these folks. And the if course all the coagulopathic issues, we don't really know what the incidence of DVT/PE/CVA is in non-admitted patients but there is more evidence coming out regarding the benefits of anticoagulation in the inpatient world, who knows if that translates into less severely ill patients.

Oooof @VeryOldPA, I'm afraid you're actually coming in at #20 https://en.wikipedia.org/wiki/List_of_U.S._states_and_territories_by_coastline

I use the TinyFax app... although now reading your post I don't know if you're old enough to consider a cell phone a phone line or not...

*heads over to SDN with popcorn to wait...*

@LT_Oneal_PAC great case man. There are definite challenges working out in the woods where you do. Couple of questions... 1.) Source for the lactate sensitivity? I've always learned a sensitivity of anywhere from 75% - 85%, clearly it will have a low specificity but I've never seen 30%. https://pubmed.ncbi.nlm.nih.gov/24238311/ 2) Your transfer system sounds terrible. Any way you can lean on your receiving facilities to change practices and make that a little easier? 3) Would have been great to be the one doing the adhesiolysis, slice it, stitch 'er up and send her home! 4) What criteria are you using in your practice to determine mode of transport? Clearly this lady had your gestalt all fired up, but when you've got crap weather what line are your drawing for ground versus air? Again, fun case. Always a challenge to hop into a different specialty and play in their sandbox, thanks for the opportunity!

@LT_Oneal_PAC Oh don't bother waiting on lil' 'ol me. Who doesn't love a little VitK? People who are already HTN at baseline..but if we assume her HTN is due to pain then it's a good call. Having done critical care transport in the past I understand where the medic is coming from...no one wants to drive that far, but while this lady is in obvious pain I'm not convinced it's worth the price/risk of a helicopter. Hemodynamics look good, she has normalized her lactate suggesting she is perfusing her gut, as long as we aren't in the midst of an icy blizzard I'd say ground-pound it. @GetMeOuttaThisMess nice thought on the angioedema! Edit: What IS the weather like?

Having an NG tube placed has consistently been ranked as one of the most painful procedures that occur in the hospital, unless I saw evidence of distension/dilation I'd probably hold off. If there wasn't a CT revealing no gaseous distention/dilated loops I'd be in total agreement. But I'm an upstairs guy, if you all want to stick the tube in before you send her up I'll gladly commiserate over how mean those ED people are

Of course it's not Thursday. It's never Thursday. Item One: Symptoms - No relief from anti-emetic, no relief from analgesia, let's combine the two into one form and try some haloperidol, 5mg. If it doesn't work for the pain maybe it'll make her a little wonky and relieve some of my caregiver guilt for being unable to manage her pain appropriately. Next step would be ketamine Item Two: Dispo I have a significant concern for an SBO w/ some relation to the possible malignancy vs an adhesion issue, although they didn't call a transition point the mesenteric/small bowel edema is consistent with that picture. With that being said, if she has an active malignancy you've got to be thinking of a potential hypercoag state which could predispose to venous thrombosis (although I just saw they excluded that on the read). Lactate is honestly not all that impressive for a enteric ischemia. I'd call the surgical service "Hey it's MediMike from Rural CAH. Now, I'm just a simple country PA but I've got a lady with intractable belly pain and a CTA demonstrating small bowel and mesenteric edema, happily there's no significant occlusive dz noted but unfortunately there's a likely active uterine malignancy. MY CLINICAL QUESTION FOR CONSULT is would this poor woman be best served receiving care at your facility as she will likely require an advanced workup? She is hemodynamically stable and has been resuscitated to a normal lactate."

Back! Sorry. Dog was super slow. Definitely wasn't me being slow. For sure not me. Well yay! Absolute immediate life threats of aneurysm/dissection are rules out in my mind. Thanks for the dimer btw, by the time I thought of it we were only a couple minutes away from out CT. She sounds like she's shaping up more along the lines of an SBO, unclear etiology, can consider adhesions from her two prior surgeries or there's the potential of an intraluminal metastatic bit from her possible uterine cancer. I don't suppose she vomited any of the oral contrast we gave her...? Issues at the moment are control of nausea and pain, await formal read followed by admission and likely surgical consult for SBO... depending on the final read of course. I would not decompress as there was no comment on gastric distension, distended loops etc. Labs in the elderly can be rough, will often not see them mount a robust response. This is fairly acute without significant vomiting (yet) so I'm not surprised there's normal renal function. Edit: 4mg Zofran, let's try a cautious 5mg of morphine for something a little longer acting. Have one of the medical hold a jaw thrust if need be. And how about 500 of LR for good measure.

Well I'm heading out for a run, but... Finish a physical exam: All peripherals pulses, skin signs, focused cardiac US exam, repeat the belly exam Labs: Nothing else really, can we switch anything from lab run to POC? Another 25mcg, with orders to admin another 25 if she's maintaining her airway ok. Repeat vitals after analgesia, is that BP still climbing? ...how fast can you shoot a KUB? (She's 83, gotten all the rads already in her life, plus she's probably on Medicare so I'll spot the bill on this one)

Well dangit. Big gal or twig? 50mcg of fentanyl to start with. Any change to my exam? Pulses still good? How's the belly NOW? Are we rigid yet? Edit: And was that "tearing" like boo hoo or "tearing" like a large blood vessel ripping sparo?

Most of my jam is above the diaphragm but i could probably find the aorta if (someone's) life depended on it. 83yo lady, concern for possible renal involvement if this IS a AAA/dissection... I'd hold the contrast and go for a regular old CT A/P

I think you might've missed an organ in there...wait...no...no guess not

Hx of smoking? Recent palpitations? Femoral pulses? Any imaging records (old CTs?) CBC/CMP/Lactate/Coags 12 lead Start the CT spinning up while you throw the probe on her belly, what do you see? (Don't say a fetus because I didn't order an HCG)