My goal with this 3 part post is to discuss a particular disease state focusing on the pathophysiology and the current treatment guidelines and their rationale. Let's start with the presentation:IntroductionYou are the medic working with with an EMT on a 12 hour shift in an urban low income, mixed race neighborhood. You have been running non-stop for 9 hours, doing two BLS and 5 ALS trips, and you are hungry, tired, and have 4 PCRs to type up yet (while your partner only has two). It is a typical cold winter day with snow flurries. The heater is on to not only warm you guys but as a half hearted attempt to keep your food warm that is sitting on the dash over the defroster duct. You have been nibbling at your sandwich over the past couple of hours. Just as you take a bite, you get a call for a 9 YOM"sick and vomiting". Your partner slams her hand on the steering wheel while you yell out a few expletives. "This kid better be sick!" Your partner yells out,"Who calls an ambulance for vomiting?" Why ask? We get these calls everyday, and will continue for a long time.You pull up to an old row house in this old mill town and see a somewhat neat front porch atop a flight of stairs with bikes in the front yard. You are already thinking you aren't carrying someone down these stairs for just feeling sick. This kid is going to walk. You grab the clipboard while your partner grabs the jumpbag and you ascend the stairs to the house. The door opens and an overweight but neat appearing woman in her late 20s opens the storm door. She appears concerned and tells you it is her son who is sick. She holds the door open as you and your partner pass through. She tells you he is upstairs in bed and scurries past you to lead the way to his room. Great. More steps. This kid is definitely walking.Chief ComplaintAs you climb the stairs, you try to illicit a history of present illness. She tells you he has been sick the past few days, progressively getting worse. "So why now are you calling?" You ask. She turns around to see the expression on your face as she senses a slight sarcasm in your voice. You quickly add, "I mean, what prompted you to call now? What is worse this evening?""He has been throwing up all day and now and is weak, laying in bed all day," she says as she turns the corner and heads down the hall. "He won't even play his video games.""Has he had a recent fever?", you ask. She tells you she didn't notice and does not have a functioning thermometer. "Do you think it is the flu?" she asks. You shrug your shoulders. You ask about his medical history. He has none other than a T&A (tonsillectomy/ Adenoidectomy ) done last year.Your partner asks, "Did you call your PCP for guidance?" and the woman answers that she thought she should just take her child to the ER. Yeah, the ER-the abused modern day clinic. Your partner asks if she has a car to drive him to the hospital and the woman says no. Of course not. If she needed a ride to Walmart she would have no problem getting one, but to the hospital, the ambulance is always free. Or so it seems to many. You keep those thoughts to your self. You are used to this.General ImpressionAs you walk in the room, you see the thin child, of normal size for his age, laying in bed. He shares the room with his younger brother and it is expectedly messy. Though it is a boy's room, you can smell someone was painting nails or something similar. He makes eye contact with you but gives a half hearted smile, showing signs he is tired of being sick. Looking at him makes you overcome with pity. You have forgotten you are a health care provider, often called to replace the MD who did house calls in the past. Despite how busy you are, it is not this kid's fault he is sick. He did not plan this. Despite whether a patient needs transport or not, you have a responsibility to alleviate pain and suffering, and this kid appears to be suffering in some way. This family called you for help and you have an obligation to help them.AssessmentYou talk to the kid and he is alert and oriented but appears slightly pale and tachypneic. Actually, he appears to be hyperventilating at 28 and regular but he denies any SOB and you have seen much worse on healthier patients. His skin is warm and dry and he tells you he is thirsty and hungry but cannot keep anything down.In the meantime, your partner get vitals:P=110, S/RBP =90/58, manuallyR=28, deep and regularT=37.6Pulsox =97% RAYour partner asks you if you want to make this ALS or BLS and how do you want to get him to the truck. What is your answer? What is your general impression of this patient? Are the vitals within normal limits for a 9 year old. Does he need to go the hospital or should you call his pediatrician about scheduling an urgent office visit the next day? Would you refer the child to bee seen at the local urgicare center or clinic in the morning? Are there any additional isolation precautions you should consider? What other assessment information would you like (or need) to guide your treatment plan for this patient?
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Introduction
You are the medic working with with an EMT on a 12 hour shift in an urban low income, mixed race neighborhood. You have been running non-stop for 9 hours, doing two BLS and 5 ALS trips, and you are hungry, tired, and have 4 PCRs to type up yet (while your partner only has two). It is a typical cold winter day with snow flurries. The heater is on to not only warm you guys but as a half hearted attempt to keep your food warm that is sitting on the dash over the defroster duct. You have been nibbling at your sandwich over the past couple of hours. Just as you take a bite, you get a call for a 9 YOM"sick and vomiting". Your partner slams her hand on the steering wheel while you yell out a few expletives. "This kid better be sick!" Your partner yells out,"Who calls an ambulance for vomiting?" Why ask? We get these calls everyday, and will continue for a long time.
You pull up to an old row house in this old mill town and see a somewhat neat front porch atop a flight of stairs with bikes in the front yard. You are already thinking you aren't carrying someone down these stairs for just feeling sick. This kid is going to walk. You grab the clipboard while your partner grabs the jumpbag and you ascend the stairs to the house. The door opens and an overweight but neat appearing woman in her late 20s opens the storm door. She appears concerned and tells you it is her son who is sick. She holds the door open as you and your partner pass through. She tells you he is upstairs in bed and scurries past you to lead the way to his room. Great. More steps. This kid is definitely walking.
Chief Complaint
As you climb the stairs, you try to illicit a history of present illness. She tells you he has been sick the past few days, progressively getting worse. "So why now are you calling?" You ask. She turns around to see the expression on your face as she senses a slight sarcasm in your voice. You quickly add, "I mean, what prompted you to call now? What is worse this evening?"
"He has been throwing up all day and now and is weak, laying in bed all day," she says as she turns the corner and heads down the hall. "He won't even play his video games."
"Has he had a recent fever?", you ask. She tells you she didn't notice and does not have a functioning thermometer. "Do you think it is the flu?" she asks. You shrug your shoulders. You ask about his medical history. He has none other than a T&A (tonsillectomy/ Adenoidectomy ) done last year.
Your partner asks, "Did you call your PCP for guidance?" and the woman answers that she thought she should just take her child to the ER. Yeah, the ER-the abused modern day clinic. Your partner asks if she has a car to drive him to the hospital and the woman says no. Of course not. If she needed a ride to Walmart she would have no problem getting one, but to the hospital, the ambulance is always free. Or so it seems to many. You keep those thoughts to your self. You are used to this.
General Impression
As you walk in the room, you see the thin child, of normal size for his age, laying in bed. He shares the room with his younger brother and it is expectedly messy. Though it is a boy's room, you can smell someone was painting nails or something similar. He makes eye contact with you but gives a half hearted smile, showing signs he is tired of being sick. Looking at him makes you overcome with pity. You have forgotten you are a health care provider, often called to replace the MD who did house calls in the past. Despite how busy you are, it is not this kid's fault he is sick. He did not plan this. Despite whether a patient needs transport or not, you have a responsibility to alleviate pain and suffering, and this kid appears to be suffering in some way. This family called you for help and you have an obligation to help them.
Assessment
You talk to the kid and he is alert and oriented but appears slightly pale and tachypneic. Actually, he appears to be hyperventilating at 28 and regular but he denies any SOB and you have seen much worse on healthier patients. His skin is warm and dry and he tells you he is thirsty and hungry but cannot keep anything down.
In the meantime, your partner get vitals:
P=110, S/R
BP =90/58, manually
R=28, deep and regular
T=37.6
Pulsox =97% RA
Your partner asks you if you want to make this ALS or BLS and how do you want to get him to the truck. What is your answer? What is your general impression of this patient? Are the vitals within normal limits for a 9 year old. Does he need to go the hospital or should you call his pediatrician about scheduling an urgent office visit the next day? Would you refer the child to bee seen at the local urgicare center or clinic in the morning? Are there any additional isolation precautions you should consider? What other assessment information would you like (or need) to guide your treatment plan for this patient?