Final 3 Days
Ah, been on a hiatus for some time! Partly because I've been so caught up with studying and seeing cases, it just seems so ... inappropriate, to continue thinking about e med-related stuff during free time at home.
Yesterday, though, has to be recorded down. It was my ambulance day shift, and honestly the first part was so bad. I just couldn't clique with the medics on that shift - for some reason they were the exact type of medical personnel who were there just because they had to, and I was not enthused. And secondly, (I say this with no intention of discrimination whatsoever) most of them were Malay, and during the whole time they were speaking in Malay. Granted, I could understand quite a bit of their conversation (usually frivolous stuff involving under-aged schoolgirls), I still felt rather left-out and the whole thing seemed a nasty waste of time.
A very strange point of note though. The senior medic, an Indian lady, was at first rather non-communicative. It wasn't until our 2nd case when I met some classmates who were in proper ED "uniform" that she started being friendlier. Perhaps she initially thought I was some secondary schoolboy there for a school visit? Thereafter she started letting me take full histories and handing cases over to the staff nurse, how odd.
The best and most woeful part was the handover of duties late at night. I was SO pissed, since the next batch were just plain wonderful!! If I thought my night posting people were good, these had to be 3 times better. 2 ladies, 2 men who were all so amiable I couldn't stop chatting. What a waste though - I really *would* have stayed on for night rounds, if not for the fact that I was totally zonked from reading the entire e med text one more round, and that there's an upcoming test. The female junior paramedic was most interesting. She kept asking me questions (regarding the cases of course .. I wouldn't have minded PERSONAL questions however - she was cute in her own way and less gung-ho than the one during my night duty) and paying rapt attention to my talk on septic shock. Strangest part was, she was TAKING NOTES. OMG. I really do hope I didn't give her any wrong info. If someone with septic shock comes along and she does something wrong cos of me, I'll really be on my head.
And now for the cases proper:
1) From a certain polyclinic near Aaron's, an Indian gentleman presenting with right iliac fossa pain, colicky, no nausea/vomitting, no fever, faeces normal. On examination, marked tenderness over all areas of abdomen, voluntary guarding but no rebound tenderness. Polyclinic personnel's differential was acute abdomen, appendicitis. However, I thought he behaved in a manner consistent with ureteric colic - just rolling about in pain. I was right! =D Ah, one of those classic times where it's a first-look diagnosis. Don't even have to take a history.
2) OK, I need help with this one. Old lady with past history of ESRF presents with lethargy and weakness for 1 week, and 3 days of productive cough. No fever. No signs of urinary tract infection. P/E revealed abdominal catheter used for peritoneal dialysis, but she has not started on it yet - due to be this Fri. Any idea what this is? Differentials so far could only include sepsis and uraemia.
3) Secondary schoolgirl (NS medics went NUTS when the com announced we're going to Crescent) who "collapsed" (according to their teachers - these people have NO IDEA what a real collapse is) after a dance competition. Difficulty breathing, with rigors and chills. P/E revealed dypnoea (RR=25) and generalised weakness. So. Young girl, stress from competition, hyperventilation anyone? Hah ... The senior paramedic was positively rolling her eyes ...
4) Yet another secondary schoolgirl who fell off her monkey bar, bled and fainted. I was starting to get excited - haven't really seen hypovolemic shock. However, another paramedic on a bike arrived there before us and said .. no need to go hospital. She fainted cos she saw blood .. vasovagal syncope. No fractures, no nothing.
5) On our way back from the abovementioned school we routed over yet again to that first polyclinic to pick up a Malay woman who had non-vertigous giddiness for 2 days. History of DM x 2 years, defaulted meds (was on traditional Malay medicine - for goodness' sake!!) and recently started back on meds. I'm suspecting anaemia. Initially the top of my list was hypoglycaemia due to new meds, but hypocount was 7.7.
6) Oooh this one was interesting. Somewhere in a NUS hostel, married couple. Husband was frantic, the wife was suicidal and blabbering nonsense and absolutely delirious. History of past cervical CA on chemo, had first shot last Friday. Sudden onset of delirium and suicidal tendencies (kept going for the kitchen knives) this morning. We had to restrain her in the alpha, and boy, was she strong!! It's amazing how much gust these thin fragile women can have when agitated. Ended up tying her down on bed, and she was spouting nonsense with big staring eyes. Kept wanting to scramble out of the alpha.
I have absolutely no idea what that was about.
7) Once again went back to the polyclinic, this is an Indian gentleman with left hypochondrial pain, constant since this morning. CGS 14: E4 V4 M6. Claimed to have vomitted stuff that looked like strong tea or coffee, no history of cofffe ingestion. Faeces was normal, no fever, no rebound, no history of alcohol ingestion, no radiation, no pulsatile mass. Known DM, hypocount 26.6. Might have been a DKA? Probably a BGIT. Vomitted again in ED and ah .. yes. It was clearly coffee grounds vomit. Very large pulse pressure 180/80, managed in P1.
Now at that time they had another 2 interesting patients in the ED. One was a female who went into asystole for almost 1 hour and they brought her back, WOW! BP was still poor but started on dopamine. Another one was Mr. LL who showed me this ECG - narrow complex tachycardia (HR=200) with no p waves. Anyone? First impression was VT, until you realise on closer inspection that the QRS complexes are actually only very slightly irregularly irregular. Yep, it's an atrial fib with rapid ventricular response. =D Patient looked remarkably well but was managed in P1 anyway.
Yesterday, though, has to be recorded down. It was my ambulance day shift, and honestly the first part was so bad. I just couldn't clique with the medics on that shift - for some reason they were the exact type of medical personnel who were there just because they had to, and I was not enthused. And secondly, (I say this with no intention of discrimination whatsoever) most of them were Malay, and during the whole time they were speaking in Malay. Granted, I could understand quite a bit of their conversation (usually frivolous stuff involving under-aged schoolgirls), I still felt rather left-out and the whole thing seemed a nasty waste of time.
A very strange point of note though. The senior medic, an Indian lady, was at first rather non-communicative. It wasn't until our 2nd case when I met some classmates who were in proper ED "uniform" that she started being friendlier. Perhaps she initially thought I was some secondary schoolboy there for a school visit? Thereafter she started letting me take full histories and handing cases over to the staff nurse, how odd.
The best and most woeful part was the handover of duties late at night. I was SO pissed, since the next batch were just plain wonderful!! If I thought my night posting people were good, these had to be 3 times better. 2 ladies, 2 men who were all so amiable I couldn't stop chatting. What a waste though - I really *would* have stayed on for night rounds, if not for the fact that I was totally zonked from reading the entire e med text one more round, and that there's an upcoming test. The female junior paramedic was most interesting. She kept asking me questions (regarding the cases of course .. I wouldn't have minded PERSONAL questions however - she was cute in her own way and less gung-ho than the one during my night duty) and paying rapt attention to my talk on septic shock. Strangest part was, she was TAKING NOTES. OMG. I really do hope I didn't give her any wrong info. If someone with septic shock comes along and she does something wrong cos of me, I'll really be on my head.
And now for the cases proper:
1) From a certain polyclinic near Aaron's, an Indian gentleman presenting with right iliac fossa pain, colicky, no nausea/vomitting, no fever, faeces normal. On examination, marked tenderness over all areas of abdomen, voluntary guarding but no rebound tenderness. Polyclinic personnel's differential was acute abdomen, appendicitis. However, I thought he behaved in a manner consistent with ureteric colic - just rolling about in pain. I was right! =D Ah, one of those classic times where it's a first-look diagnosis. Don't even have to take a history.
2) OK, I need help with this one. Old lady with past history of ESRF presents with lethargy and weakness for 1 week, and 3 days of productive cough. No fever. No signs of urinary tract infection. P/E revealed abdominal catheter used for peritoneal dialysis, but she has not started on it yet - due to be this Fri. Any idea what this is? Differentials so far could only include sepsis and uraemia.
3) Secondary schoolgirl (NS medics went NUTS when the com announced we're going to Crescent) who "collapsed" (according to their teachers - these people have NO IDEA what a real collapse is) after a dance competition. Difficulty breathing, with rigors and chills. P/E revealed dypnoea (RR=25) and generalised weakness. So. Young girl, stress from competition, hyperventilation anyone? Hah ... The senior paramedic was positively rolling her eyes ...
4) Yet another secondary schoolgirl who fell off her monkey bar, bled and fainted. I was starting to get excited - haven't really seen hypovolemic shock. However, another paramedic on a bike arrived there before us and said .. no need to go hospital. She fainted cos she saw blood .. vasovagal syncope. No fractures, no nothing.
5) On our way back from the abovementioned school we routed over yet again to that first polyclinic to pick up a Malay woman who had non-vertigous giddiness for 2 days. History of DM x 2 years, defaulted meds (was on traditional Malay medicine - for goodness' sake!!) and recently started back on meds. I'm suspecting anaemia. Initially the top of my list was hypoglycaemia due to new meds, but hypocount was 7.7.
6) Oooh this one was interesting. Somewhere in a NUS hostel, married couple. Husband was frantic, the wife was suicidal and blabbering nonsense and absolutely delirious. History of past cervical CA on chemo, had first shot last Friday. Sudden onset of delirium and suicidal tendencies (kept going for the kitchen knives) this morning. We had to restrain her in the alpha, and boy, was she strong!! It's amazing how much gust these thin fragile women can have when agitated. Ended up tying her down on bed, and she was spouting nonsense with big staring eyes. Kept wanting to scramble out of the alpha.
I have absolutely no idea what that was about.
7) Once again went back to the polyclinic, this is an Indian gentleman with left hypochondrial pain, constant since this morning. CGS 14: E4 V4 M6. Claimed to have vomitted stuff that looked like strong tea or coffee, no history of cofffe ingestion. Faeces was normal, no fever, no rebound, no history of alcohol ingestion, no radiation, no pulsatile mass. Known DM, hypocount 26.6. Might have been a DKA? Probably a BGIT. Vomitted again in ED and ah .. yes. It was clearly coffee grounds vomit. Very large pulse pressure 180/80, managed in P1.
Now at that time they had another 2 interesting patients in the ED. One was a female who went into asystole for almost 1 hour and they brought her back, WOW! BP was still poor but started on dopamine. Another one was Mr. LL who showed me this ECG - narrow complex tachycardia (HR=200) with no p waves. Anyone? First impression was VT, until you realise on closer inspection that the QRS complexes are actually only very slightly irregularly irregular. Yep, it's an atrial fib with rapid ventricular response. =D Patient looked remarkably well but was managed in P1 anyway.
posted by R. at 4:05 PM
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