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Excellent, am arriving Halifax on the Friday (for the EDTU course on Saturday). We must catch up on one of the non-ICEM evenings, put together an ACAD group as you say, or failing that just an irreverent Irish group. That is, assuming you're still talking to me since the RTE fall out! AF ----- Original Message ----- From: "John Ryan" <[log in to unmask]> To: <[log in to unmask]> Sent: Wednesday, May 31, 2006 9:49 PM Subject: Re: A sore leg > 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./ >> >>