12 hours later so now it's out of hours again, Damn. Except for consultants
in Emergency Medicine of course.
We did some work here with the venometer and it is an Irish piece of kit so
I am prepared to accept that he doesnt have a horrible DVT which has caused
a PE as the cause of his moribundness. Interestingly the venometer involves
inflating a pressure cuff over his most tender area the medial part of his
thigh, wonder how he tolerated that. But I remain concerned as to why an
alcoholic has to call an ambulance for this at 4 am. Lets not be
perjorative and call him a tosser beacuse he is an alcoholic, I am more
concerned that there is a red flag Rowley which is someone presenting in an
atypical way. Suely it begs a more decent look when someone does something
seemingly stupid like calling an ambulance at 4 am for a 'trivial' problem.
Like, surely someone who does that something that stupid must have a good
reason ? So what's his good reason ? It seems to be pain ? What sort of
pain makes you do this ? Fluid in a confined space does, ie: an abscess or
sometimes a haemarthrosis (not here though).
And now back to ? 18;00 hours. So is his shock Septic ? Cardiovascular ?
Hypovolaemic ? Neurogenic ? Spinal ? Respiratory ? etc
Maybe just maybe he bled from an AV fistual or anuerysm, hmmmm unlikely.
I don't think this is vascular unless something was tracking down the psoas,
blood or TB ?
I suspect it's septic shock and would go down that route, antibiotics,
fluids, inotropes, +/- blood, +/- steroids, mind the glucose and all the
other surviving sepsis bits and pieces. No doubt lactate is well up, Hb is
down, renal function has gone off and INR is elevated. Maybe even
pulmoanary oedema picture on CXR ? Simultaneous multidisciplinary
resuscitation of course, intubation and prepare for ICU if not theatre to
debride the leg (need more than electronic data now Rowley, this is where
the experience and the art of medicine comes in, how he looks, feels,
sounds. An ED ultrasound of the leg might be revealing. Urine tox in case
he is has been injecting cocaine and don't forget to ask someone to send
some tissue off at some stage for Clostridium Novyii Type A if you do get
necrosis. We found it in Brighton before. I suspect this chap has missed
the boat though and on current info I am not to hopeful of a positive
outcome.
John
PS who is heading to Halifax on Saturday ? At the Syndey ICEM in 96 we had
a great acad-ae-med bash in Doyle's of Watson's bay. Maybe we might have a
10 year re-union and international acad-ae-medders get together ? Have I
really been running this list for 10 years ?
----- Original Message -----
From: "Rowley Cottingham" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, May 31, 2006 9:11 AM
Subject: Re: A sore leg
> Well, of course, Adrian was the closest; in all honesty WHO would be
> around at 4am to see a patient like that? So the answer is you manage it
> by delegation, and wait for the delegatee(s) to pick up any red flags,
> as John puts it. And, frankly, there aren't any. The man is apyrexial
> with local tenderness. He has no signs of systemic infection, so the
> person who sees him decides to rule out a DVT. We don't use D-dimers at
> this site, we use a plethysmographic device called a venometer, which is
> supposed to be 100% sensitive (SnNout) although as we know, never should
> you say never in medicine.
>
> The venometer is negative, so the man is allowed home with advice and
> painkillers.
>
> He is brought back 12 hours later moribund with a temperature of 35, a
> pulse of 140 and an unrecordable blood pressure. His leg now looks
> bruised and the rest of him is mottled. What has happened and what would
> you do now?
>
>
>
> /Rowley./
>
>
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