Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 make that *much* more common in relatively young Asian females. this is a real zebra, almost a unicorn. I recall seeing *one* patient with this disease in 35 years of practice. ck In a message dated 6/12/2010 01:43:07 Central Daylight Time, ExLngHrn@... writes: Caucasian. However her underlying medical history is more common in Asian females. Wes Sent from my iPhone On Jun 12, 2010, at 1:33, _krin135@..._ (mailto:krin135@...) wrote: > what is the ethnic background of the patient? > > ck > > > In a message dated 6/11/2010 22:42:45 Central Daylight Time, > _ExLngHrn@..._ (mailto:ExLngHrn@...) writes: > > Alas, no. > > Wes > > Sent from my iPhone > > On Jun 11, 2010, at 21:41, " Brad Sattler " __bradsattler@..._ (mailto:_bradsattler@...) _ > (mailto:_bradsattler@..._ (mailto:bradsattler@...) ) > wrote: > > > Yeah, I was working toward lymphoma Wes, but we're trying to > > differential diagnose here. > > > > Her possible demyialation (sp?) might be causing stroke-like > > symptoms, but it's also possible that engorged lymph nodes are > > blocking peripheral circulation and causing increased vascular > > pressure system-wide, leading to a brain bleed. > > . > > Is that getting close? > > > > -Brad > > > > Sent via BlackBerry, the office that follows you. > > > > EMS challenge > > > > > > > > Since it's been a while since Professor Gandy offered a > challenge > > > > (and the > > > > prize-winner's trip to Ladonia), I present the following brain- > > > > teaser for > > > > all of y'all. Alas, there are no prizes since the half-star > hotel > > > > resort > > > > in Ladonia is closed for fumigation. > > > > > > > > On to the challenge...... you are dispatched to an altered > mental > > > > status > > > > call. Upon arrival, you find a middle-aged female laying on the > > > > floor of an > > > > office. She is semi-coherent and semi-combative, with slurred > > > > speech. Her > > > > co-workers know that she has an extensive medical history, but > > they > > > > can't > > > > remember what it is. > > > > > > > > Oddly, while the patient is breathing and speaking (although > > > > abnormally), > > > > you cannot obtain a radial pulse or a blood pressure. You do > > find a > > > > palpable carotid pulse at 72 bpm. > > > > > > > > What is happening to the patient and what is the underlying > > etiology? > > > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > > -Attorney at Law/Licensed Paramedic > > > > -Austin, Texas > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 make that *much* more common in relatively young Asian females. this is a real zebra, almost a unicorn. I recall seeing *one* patient with this disease in 35 years of practice. ck In a message dated 6/12/2010 01:43:07 Central Daylight Time, ExLngHrn@... writes: Caucasian. However her underlying medical history is more common in Asian females. Wes Sent from my iPhone On Jun 12, 2010, at 1:33, _krin135@..._ (mailto:krin135@...) wrote: > what is the ethnic background of the patient? > > ck > > > In a message dated 6/11/2010 22:42:45 Central Daylight Time, > _ExLngHrn@..._ (mailto:ExLngHrn@...) writes: > > Alas, no. > > Wes > > Sent from my iPhone > > On Jun 11, 2010, at 21:41, " Brad Sattler " __bradsattler@..._ (mailto:_bradsattler@...) _ > (mailto:_bradsattler@..._ (mailto:bradsattler@...) ) > wrote: > > > Yeah, I was working toward lymphoma Wes, but we're trying to > > differential diagnose here. > > > > Her possible demyialation (sp?) might be causing stroke-like > > symptoms, but it's also possible that engorged lymph nodes are > > blocking peripheral circulation and causing increased vascular > > pressure system-wide, leading to a brain bleed. > > . > > Is that getting close? > > > > -Brad > > > > Sent via BlackBerry, the office that follows you. > > > > EMS challenge > > > > > > > > Since it's been a while since Professor Gandy offered a > challenge > > > > (and the > > > > prize-winner's trip to Ladonia), I present the following brain- > > > > teaser for > > > > all of y'all. Alas, there are no prizes since the half-star > hotel > > > > resort > > > > in Ladonia is closed for fumigation. > > > > > > > > On to the challenge...... you are dispatched to an altered > mental > > > > status > > > > call. Upon arrival, you find a middle-aged female laying on the > > > > floor of an > > > > office. She is semi-coherent and semi-combative, with slurred > > > > speech. Her > > > > co-workers know that she has an extensive medical history, but > > they > > > > can't > > > > remember what it is. > > > > > > > > Oddly, while the patient is breathing and speaking (although > > > > abnormally), > > > > you cannot obtain a radial pulse or a blood pressure. You do > > find a > > > > palpable carotid pulse at 72 bpm. > > > > > > > > What is happening to the patient and what is the underlying > > etiology? > > > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > > -Attorney at Law/Licensed Paramedic > > > > -Austin, Texas > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 then set your subscription to 'digest' version. Or, you might decide that you want to be more medic than Fire Captain and contribute to the discussion. Based on your email addy, I'd guess that your medics have a better chance than most folks on this list of seeing a patient with this diagnosis (since there is a large Asian community in Dallas), and it would make an interesting CME case for them. You'd do better to invite Wes up to give your medics a class than to complain about what's going on the list. ck In a message dated 6/12/2010 01:46:55 Central Daylight Time, luis.cardenas@... writes: LP. Big urban FD Captain Who has better things to do than hit " delete " every 2 minutes so you can annoy every other user of this site. Have fun boys. ________________________________ From: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > To: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > Sent: Fri Jun 11 22:44:36 2010 Subject: Re: EMS challenge Makes me wonder where this person is a medic and what their certification level is. Further affiant sayeth not. Wes Sent from my iPhone On Jun 11, 2010, at 22:17, " Cardenas, " _luis.cardenas@..._ (mailto:luis.cardenas@...) > wrote: > Then answer the ? And stop clogging up the site. > > ________________________________ > > From: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > > To: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > > Sent: Fri Jun 11 21:59:05 2010 > Subject: Re: EMS challenge > > > > > Senor Cardenas: > > What game? > > a good paramedic is offering a case scenario (and doing a decent job > of > it), practicing his teaching skills while trying to get other folks > to think > outside the paramedic cook book. This is the sort of thing that we > need more > of on the various paramedic groups. I can assure you that there are > similar cases being presented on the 'real' medical groups all the > time, albeit > frequently being posed in search of other treatment options for really > screwy (read zebra or even unicorn) cases. > > ck > > > In a message dated 6/11/2010 21:55:09 Central Daylight Time, > _luis.cardenas@..._ (mailto:luis.cardenas@...) %40dallascityhall.com> writes: > > Can you play this game somewhere else. > > ________________________________ > > From: __texasems-l _ (mailto:_texasems-l ) %40yahoogroups.com> _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) > __texasems-l _ (mailto:_texasems-l ) > _ (mailto:_texasems-l _ (mailto:texasems-l ) %40yahoogroups.com> ) > > To: __texasems-l _ (mailto:_texasems-l ) %40yahoogroups.com> _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) > __texasems-l _ (mailto:_texasems-l ) > _ (mailto:_texasems-l _ (mailto:texasems-l ) %40yahoogroups.com> ) > > Sent: Fri Jun 11 21:41:09 2010 > Subject: Re: EMS challenge > > Yeah, I was working toward lymphoma Wes, but we're trying to > differential > diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but > it's also possible that engorged lymph nodes are blocking peripheral > circulation and causing increased vascular pressure system-wide, > leading to a > brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > [Non-text portions of this message have been removed] > > > > > > ------------------------------------ > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 then set your subscription to 'digest' version. Or, you might decide that you want to be more medic than Fire Captain and contribute to the discussion. Based on your email addy, I'd guess that your medics have a better chance than most folks on this list of seeing a patient with this diagnosis (since there is a large Asian community in Dallas), and it would make an interesting CME case for them. You'd do better to invite Wes up to give your medics a class than to complain about what's going on the list. ck In a message dated 6/12/2010 01:46:55 Central Daylight Time, luis.cardenas@... writes: LP. Big urban FD Captain Who has better things to do than hit " delete " every 2 minutes so you can annoy every other user of this site. Have fun boys. ________________________________ From: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > To: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > Sent: Fri Jun 11 22:44:36 2010 Subject: Re: EMS challenge Makes me wonder where this person is a medic and what their certification level is. Further affiant sayeth not. Wes Sent from my iPhone On Jun 11, 2010, at 22:17, " Cardenas, " _luis.cardenas@..._ (mailto:luis.cardenas@...) > wrote: > Then answer the ? And stop clogging up the site. > > ________________________________ > > From: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > > To: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > > Sent: Fri Jun 11 21:59:05 2010 > Subject: Re: EMS challenge > > > > > Senor Cardenas: > > What game? > > a good paramedic is offering a case scenario (and doing a decent job > of > it), practicing his teaching skills while trying to get other folks > to think > outside the paramedic cook book. This is the sort of thing that we > need more > of on the various paramedic groups. I can assure you that there are > similar cases being presented on the 'real' medical groups all the > time, albeit > frequently being posed in search of other treatment options for really > screwy (read zebra or even unicorn) cases. > > ck > > > In a message dated 6/11/2010 21:55:09 Central Daylight Time, > _luis.cardenas@..._ (mailto:luis.cardenas@...) %40dallascityhall.com> writes: > > Can you play this game somewhere else. > > ________________________________ > > From: __texasems-l _ (mailto:_texasems-l ) %40yahoogroups.com> _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) > __texasems-l _ (mailto:_texasems-l ) > _ (mailto:_texasems-l _ (mailto:texasems-l ) %40yahoogroups.com> ) > > To: __texasems-l _ (mailto:_texasems-l ) %40yahoogroups.com> _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) > __texasems-l _ (mailto:_texasems-l ) > _ (mailto:_texasems-l _ (mailto:texasems-l ) %40yahoogroups.com> ) > > Sent: Fri Jun 11 21:41:09 2010 > Subject: Re: EMS challenge > > Yeah, I was working toward lymphoma Wes, but we're trying to > differential > diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but > it's also possible that engorged lymph nodes are blocking peripheral > circulation and causing increased vascular pressure system-wide, > leading to a > brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > [Non-text portions of this message have been removed] > > > > > > ------------------------------------ > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 not *that* much of a unicorn. Moyamoya syndrome (yes, it *is* a real syndrome) also does not involve the peripheral circulation in general. ck In a message dated 6/12/2010 02:07:38 Central Daylight Time, aggiesrwe03@... writes: Moya moya syndrome On Jun 12, 2010, at 1:45 AM, _krin135@..._ (mailto:krin135@...) wrote: > make that *much* more common in relatively young Asian females. > > this is a real zebra, almost a unicorn. > > I recall seeing *one* patient with this disease in 35 years of > practice. > > ck > > > In a message dated 6/12/2010 01:43:07 Central Daylight Time, > _ExLngHrn@..._ (mailto:ExLngHrn@...) writes: > > > > > Caucasian. However her underlying medical history is more common in > Asian females. > > Wes > > Sent from my iPhone > > On Jun 12, 2010, at 1:33, __krin135@..._ (mailto:_krin135@...) _ (mailto:_krin135@..._ (mailto:krin135@...) ) > wrote: > >> what is the ethnic background of the patient? >> >> ck >> >> >> In a message dated 6/11/2010 22:42:45 Central Daylight Time, >> __ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) writes: >> >> Alas, no. >> >> Wes >> >> Sent from my iPhone >> >> On Jun 11, 2010, at 21:41, " Brad Sattler " ___bradsattler@..._ (mailto:__bradsattler@...) _ > (mailto:__bradsattler@..._ (mailto:_bradsattler@...) ) _ >> (mailto:__bradsattler@..._ (mailto:_bradsattler@...) _ (mailto:_bradsattler@..._ (mailto:bradsattler@...) ) ) > > wrote: >> >>> Yeah, I was working toward lymphoma Wes, but we're trying to >>> differential diagnose here. >>> >>> Her possible demyialation (sp?) might be causing stroke-like >>> symptoms, but it's also possible that engorged lymph nodes are >>> blocking peripheral circulation and causing increased vascular >>> pressure system-wide, leading to a brain bleed. >>> . >>> Is that getting close? >>> >>> -Brad >>> >>> Sent via BlackBerry, the office that follows you. >>> >>> -----Original Message----- >>> From: ___ExLngHrn@..._ (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) ) _ > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) ) >>> Date: Fri, 11 Jun 2010 21:34:11 >>> To: ___texasems-l _ (mailto:__texasems-l ) _ (mailto:__texasems-l _ (mailto:_texasems-l ) >>> ) > _ (mailto:texasems- >> __l _ (mailto:_l ) _ (mailto:_l _ (mailto:l ) ) ) > >>> Subject: Re: EMS challenge >>> >>> Very close. It's a CVA. But is the CVA caused by the Enbrel? Or is >> it >>> more likely that the CVA is caused by a condition she's taking >>> Enbrel for? >>> (BIG HINT THERE) >>> >>> -Wes >>> >>> >>> In a message dated 6/11/2010 7:22:55 P.M. Central Daylight Time, >>> ___drdugud@..._ (mailto:__drdugud@...) _ (mailto:__drdugud@..._ (mailto:_drdugud@...) ) _ > (mailto:__drdugud@..._ (mailto:_drdugud@...) _ (mailto:_drdugud@..._ (mailto:drdugud@...) ) ) writes: >>> >>> CVA from Enbrel use. Enbrel is a TNF inhibitor. This drug class is >>> known to >>> cause demyelinating CNS disorders. >>> >>> Close? >>> >>> Neil >>> >>> >>> >>> >>> >>> >>> >>> On Thu, Jun 10, 2010 at 10:54 PM, Brad Sattler >>> ___bradsattler@..._ (mailto:__bradsattler@...) _ (mailto:__bradsattler@..._ (mailto:_bradsattler@...) ) _ > (mailto:__bradsattler@..._ (mailto:_bradsattler@...) _ (mailto:_bradsattler@..._ (mailto:bradsattler@...) ) ) > >wrote: >>> >>>> >>>> >>>> Wes, >>>> >>>> Would you describe this patient as " thin " by any chance? >>>> >>>> -Brad >>>> >>>> Sent via BlackBerry, the office that follows you. >>>> >>>> -----Original Message----- >>>> From: Wes Ogilvie ___ExLngHrn@..._ (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) ) _ > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) ) >> > >>>> Date: Thu, 10 Jun 2010 19:35:27 >>>> To: ___texasems-l _ (mailto:__texasems-l ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ (mailto:__texasems-l _ (mailto:_texasems-l ) _ > (mailto:_texasems-l _ (mailto:texasems-l ) ) >> ) >> < >>>> ___texasems-l _ (mailto:__texasems-l ) _ (mailto:_texasems- >>>> _l _ (mailto:l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> > >>>> Subject: Re: EMS challenge >>>> >>>> Nope. >>>> >>>> Wes >>>> >>>> Sent from my iPhone >>>> >>>> On Jun 10, 2010, at 19:06, >>> ___rick.moore@..._ (mailto:__rick.moore@...) _ (mailto:__rick.moore@..._ (mailto:_rick.moore@...) ) _ > (mailto:__rick.moore@..._ (mailto:_rick.moore@...) _ (mailto:_rick.moore@..._ (mailto:rick.moore@...) ) ) >> > >>>> wrote: >>>> >>>>> Since Enbrel can cause demyelinating cns disorders I am going to >>>>> guess neuro issues from the Enbrel >>>>> Rick >>>>> Sent via Blackberry >>>>> >>>>> ________________________________ >>>>> From: ___texasems-l _ (mailto:__texasems-l ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ >> (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) >> ) > ) < >>>> ___texasems-l _ (mailto:__texasems-l ) _ (mailto:_texasems- >>>> _l _ (mailto:l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> > >>>>> To: ___texasems-l _ (mailto:__texasems-l ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ (mailto:__texasems-l _ (mailto:_texasems-l ) _ > (mailto:_texasems-l _ (mailto:texasems-l ) ) >> ) >> < >>>> ___texasems-l _ (mailto:__texasems-l ) _ (mailto:_texasems- >>>> _l _ (mailto:l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> > >>>>> Sent: Thu Jun 10 18:35:40 2010 >>>>> Subject: Re: EMS challenge >>>>> >>>>> >>>>> >>>>> Your scene is a fairly normal office building. Blood sugar is >>> 128 mg/ >>>>> dL. >>>>> Pupils unequal. Obvious weakness left side when you check a >> stroke >>>>> scale. >>>>> No medical alert tag. No obvious signs of trauma. The only >>> medicine >>>>> you find on scene is a box containing a drug called Enbrel. >>>>> >>>>> -Wes >>>>> >>>>> >>>>> In a message dated 6/10/2010 6:29:32 P.M. Central Daylight Time, >>>>> ___lrichardson@..._ (mailto:__lrichardson@...) _ > (mailto:__lrichardson@..._ (mailto:_lrichardson@...) ) _ >> (mailto:__lrichardson@..._ (mailto:_lrichardson@...) _ > (mailto:_lrichardson@..._ (mailto:lrichardson@...) ) ) >> %40ci.duncanville.tx.us> >>>> >>>> %40ci.duncanville.tx.us> writes: >>>>> >>>>> Ok Professor Wes! >>>>> >>>>> Some clues please! scene findings? other VS's? Blood Sugar? >> Stroke >>>>> Scale? Pupils? Obvious trauma? medical alert tags? meds on >> scene? >>>>> ________________________________ >>>>> From: ___texasems-l _ (mailto:__texasems-l ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ >> (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) >> ) > ) >>> >>> texasems-l >>>>> %40yahoogroups.com> >>> [___texasems-l _ (mailto:__texasems-l ) _ (mailto:_texasems- >>> _l _ (mailto:l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> >>>> >>>> %40yahoogroups.com>] On Behalf Of >>>>> ___ExLngHrn@..._ (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) ) _ > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) ) >>> > %2540aol.com>> >>>> >>>>> [___ExLngHrn@..._ (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) ) _ > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) ) >>> > %2540aol.com>>] >>>> >>>>> Sent: Thursday, June 10, 2010 6:14 PM >>>>> To: ___Paramedicine _ (mailto:__Paramedicine ) _ > (mailto:__Paramedicine _ (mailto:_Paramedicine ) ) _ >> (mailto:__Paramedicine _ (mailto:_Paramedicine ) _ (mailto:Paramedici > _ne _ (mailto:ne ) ) ) >>>> >>>> %40yahoogroups.com>; >>> ___texasems-l _ (mailto:__texasems-l ) _ (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> >>>> >>>> %40yahoogroups.com> >>>>> Subject: EMS challenge >>>>> >>>>> Since it's been a while since Professor Gandy offered a >> challenge >>>>> (and the >>>>> prize-winner's trip to Ladonia), I present the following brain- >>>>> teaser for >>>>> all of y'all. Alas, there are no prizes since the half-star >> hotel >>>>> resort >>>>> in Ladonia is closed for fumigation. >>>>> >>>>> On to the challenge...... you are dispatched to an altered >> mental >>>>> status >>>>> call. Upon arrival, you find a middle-aged female laying on the >>>>> floor of an >>>>> office. She is semi-coherent and semi-combative, with slurred >>>>> speech. Her >>>>> co-workers know that she has an extensive medical history, but >>> they >>>>> can't >>>>> remember what it is. >>>>> >>>>> Oddly, while the patient is breathing and speaking (although >>>>> abnormally), >>>>> you cannot obtain a radial pulse or a blood pressure. You do >>> find a >>>>> palpable carotid pulse at 72 bpm. >>>>> >>>>> What is happening to the patient and what is the underlying >>> etiology? >>>>> >>>>> -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. >>>>> -Attorney at Law/Licensed Paramedic >>>>> -Austin, Texas >>>>> >>>>> [Non-text portions of this message have been removed] >>>>> >>>>> ------------------------------------ >>>>> >>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 not *that* much of a unicorn. Moyamoya syndrome (yes, it *is* a real syndrome) also does not involve the peripheral circulation in general. ck In a message dated 6/12/2010 02:07:38 Central Daylight Time, aggiesrwe03@... writes: Moya moya syndrome On Jun 12, 2010, at 1:45 AM, _krin135@..._ (mailto:krin135@...) wrote: > make that *much* more common in relatively young Asian females. > > this is a real zebra, almost a unicorn. > > I recall seeing *one* patient with this disease in 35 years of > practice. > > ck > > > In a message dated 6/12/2010 01:43:07 Central Daylight Time, > _ExLngHrn@..._ (mailto:ExLngHrn@...) writes: > > > > > Caucasian. However her underlying medical history is more common in > Asian females. > > Wes > > Sent from my iPhone > > On Jun 12, 2010, at 1:33, __krin135@..._ (mailto:_krin135@...) _ (mailto:_krin135@..._ (mailto:krin135@...) ) > wrote: > >> what is the ethnic background of the patient? >> >> ck >> >> >> In a message dated 6/11/2010 22:42:45 Central Daylight Time, >> __ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) writes: >> >> Alas, no. >> >> Wes >> >> Sent from my iPhone >> >> On Jun 11, 2010, at 21:41, " Brad Sattler " ___bradsattler@..._ (mailto:__bradsattler@...) _ > (mailto:__bradsattler@..._ (mailto:_bradsattler@...) ) _ >> (mailto:__bradsattler@..._ (mailto:_bradsattler@...) _ (mailto:_bradsattler@..._ (mailto:bradsattler@...) ) ) > > wrote: >> >>> Yeah, I was working toward lymphoma Wes, but we're trying to >>> differential diagnose here. >>> >>> Her possible demyialation (sp?) might be causing stroke-like >>> symptoms, but it's also possible that engorged lymph nodes are >>> blocking peripheral circulation and causing increased vascular >>> pressure system-wide, leading to a brain bleed. >>> . >>> Is that getting close? >>> >>> -Brad >>> >>> Sent via BlackBerry, the office that follows you. >>> >>> -----Original Message----- >>> From: ___ExLngHrn@..._ (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) ) _ > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) ) >>> Date: Fri, 11 Jun 2010 21:34:11 >>> To: ___texasems-l _ (mailto:__texasems-l ) _ (mailto:__texasems-l _ (mailto:_texasems-l ) >>> ) > _ (mailto:texasems- >> __l _ (mailto:_l ) _ (mailto:_l _ (mailto:l ) ) ) > >>> Subject: Re: EMS challenge >>> >>> Very close. It's a CVA. But is the CVA caused by the Enbrel? Or is >> it >>> more likely that the CVA is caused by a condition she's taking >>> Enbrel for? >>> (BIG HINT THERE) >>> >>> -Wes >>> >>> >>> In a message dated 6/11/2010 7:22:55 P.M. Central Daylight Time, >>> ___drdugud@..._ (mailto:__drdugud@...) _ (mailto:__drdugud@..._ (mailto:_drdugud@...) ) _ > (mailto:__drdugud@..._ (mailto:_drdugud@...) _ (mailto:_drdugud@..._ (mailto:drdugud@...) ) ) writes: >>> >>> CVA from Enbrel use. Enbrel is a TNF inhibitor. This drug class is >>> known to >>> cause demyelinating CNS disorders. >>> >>> Close? >>> >>> Neil >>> >>> >>> >>> >>> >>> >>> >>> On Thu, Jun 10, 2010 at 10:54 PM, Brad Sattler >>> ___bradsattler@..._ (mailto:__bradsattler@...) _ (mailto:__bradsattler@..._ (mailto:_bradsattler@...) ) _ > (mailto:__bradsattler@..._ (mailto:_bradsattler@...) _ (mailto:_bradsattler@..._ (mailto:bradsattler@...) ) ) > >wrote: >>> >>>> >>>> >>>> Wes, >>>> >>>> Would you describe this patient as " thin " by any chance? >>>> >>>> -Brad >>>> >>>> Sent via BlackBerry, the office that follows you. >>>> >>>> -----Original Message----- >>>> From: Wes Ogilvie ___ExLngHrn@..._ (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) ) _ > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) ) >> > >>>> Date: Thu, 10 Jun 2010 19:35:27 >>>> To: ___texasems-l _ (mailto:__texasems-l ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ (mailto:__texasems-l _ (mailto:_texasems-l ) _ > (mailto:_texasems-l _ (mailto:texasems-l ) ) >> ) >> < >>>> ___texasems-l _ (mailto:__texasems-l ) _ (mailto:_texasems- >>>> _l _ (mailto:l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> > >>>> Subject: Re: EMS challenge >>>> >>>> Nope. >>>> >>>> Wes >>>> >>>> Sent from my iPhone >>>> >>>> On Jun 10, 2010, at 19:06, >>> ___rick.moore@..._ (mailto:__rick.moore@...) _ (mailto:__rick.moore@..._ (mailto:_rick.moore@...) ) _ > (mailto:__rick.moore@..._ (mailto:_rick.moore@...) _ (mailto:_rick.moore@..._ (mailto:rick.moore@...) ) ) >> > >>>> wrote: >>>> >>>>> Since Enbrel can cause demyelinating cns disorders I am going to >>>>> guess neuro issues from the Enbrel >>>>> Rick >>>>> Sent via Blackberry >>>>> >>>>> ________________________________ >>>>> From: ___texasems-l _ (mailto:__texasems-l ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ >> (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) >> ) > ) < >>>> ___texasems-l _ (mailto:__texasems-l ) _ (mailto:_texasems- >>>> _l _ (mailto:l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> > >>>>> To: ___texasems-l _ (mailto:__texasems-l ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ (mailto:__texasems-l _ (mailto:_texasems-l ) _ > (mailto:_texasems-l _ (mailto:texasems-l ) ) >> ) >> < >>>> ___texasems-l _ (mailto:__texasems-l ) _ (mailto:_texasems- >>>> _l _ (mailto:l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> > >>>>> Sent: Thu Jun 10 18:35:40 2010 >>>>> Subject: Re: EMS challenge >>>>> >>>>> >>>>> >>>>> Your scene is a fairly normal office building. Blood sugar is >>> 128 mg/ >>>>> dL. >>>>> Pupils unequal. Obvious weakness left side when you check a >> stroke >>>>> scale. >>>>> No medical alert tag. No obvious signs of trauma. The only >>> medicine >>>>> you find on scene is a box containing a drug called Enbrel. >>>>> >>>>> -Wes >>>>> >>>>> >>>>> In a message dated 6/10/2010 6:29:32 P.M. Central Daylight Time, >>>>> ___lrichardson@..._ (mailto:__lrichardson@...) _ > (mailto:__lrichardson@..._ (mailto:_lrichardson@...) ) _ >> (mailto:__lrichardson@..._ (mailto:_lrichardson@...) _ > (mailto:_lrichardson@..._ (mailto:lrichardson@...) ) ) >> %40ci.duncanville.tx.us> >>>> >>>> %40ci.duncanville.tx.us> writes: >>>>> >>>>> Ok Professor Wes! >>>>> >>>>> Some clues please! scene findings? other VS's? Blood Sugar? >> Stroke >>>>> Scale? Pupils? Obvious trauma? medical alert tags? meds on >> scene? >>>>> ________________________________ >>>>> From: ___texasems-l _ (mailto:__texasems-l ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ >> (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) >> ) > ) >>> >>> texasems-l >>>>> %40yahoogroups.com> >>> [___texasems-l _ (mailto:__texasems-l ) _ (mailto:_texasems- >>> _l _ (mailto:l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> >>>> >>>> %40yahoogroups.com>] On Behalf Of >>>>> ___ExLngHrn@..._ (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) ) _ > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) ) >>> > %2540aol.com>> >>>> >>>>> [___ExLngHrn@..._ (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) ) _ > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) ) ) >>> > %2540aol.com>>] >>>> >>>>> Sent: Thursday, June 10, 2010 6:14 PM >>>>> To: ___Paramedicine _ (mailto:__Paramedicine ) _ > (mailto:__Paramedicine _ (mailto:_Paramedicine ) ) _ >> (mailto:__Paramedicine _ (mailto:_Paramedicine ) _ (mailto:Paramedici > _ne _ (mailto:ne ) ) ) >>>> >>>> %40yahoogroups.com>; >>> ___texasems-l _ (mailto:__texasems-l ) _ (mailto:__texasems-l _ (mailto:_texasems-l ) ) _ > (mailto:__texasems-l _ (mailto:_texasems-l ) _ (mailto:_texasems-l _ (mailto:texasems-l ) > ) ) >> >>>> >>>> %40yahoogroups.com> >>>>> Subject: EMS challenge >>>>> >>>>> Since it's been a while since Professor Gandy offered a >> challenge >>>>> (and the >>>>> prize-winner's trip to Ladonia), I present the following brain- >>>>> teaser for >>>>> all of y'all. Alas, there are no prizes since the half-star >> hotel >>>>> resort >>>>> in Ladonia is closed for fumigation. >>>>> >>>>> On to the challenge...... you are dispatched to an altered >> mental >>>>> status >>>>> call. Upon arrival, you find a middle-aged female laying on the >>>>> floor of an >>>>> office. She is semi-coherent and semi-combative, with slurred >>>>> speech. Her >>>>> co-workers know that she has an extensive medical history, but >>> they >>>>> can't >>>>> remember what it is. >>>>> >>>>> Oddly, while the patient is breathing and speaking (although >>>>> abnormally), >>>>> you cannot obtain a radial pulse or a blood pressure. You do >>> find a >>>>> palpable carotid pulse at 72 bpm. >>>>> >>>>> What is happening to the patient and what is the underlying >>> etiology? >>>>> >>>>> -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. >>>>> -Attorney at Law/Licensed Paramedic >>>>> -Austin, Texas >>>>> >>>>> [Non-text portions of this message have been removed] >>>>> >>>>> ------------------------------------ >>>>> >>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 Then answer the ? And stop clogging up the site. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 21:59:05 2010 Subject: Re: EMS challenge Senor Cardenas: What game? a good paramedic is offering a case scenario (and doing a decent job of it), practicing his teaching skills while trying to get other folks to think outside the paramedic cook book. This is the sort of thing that we need more of on the various paramedic groups. I can assure you that there are similar cases being presented on the 'real' medical groups all the time, albeit frequently being posed in search of other treatment options for really screwy (read zebra or even unicorn) cases. ck In a message dated 6/11/2010 21:55:09 Central Daylight Time, luis.cardenas@... writes: Can you play this game somewhere else. ________________________________ From: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > To: _texasems-l _ (mailto:texasems-l ) _texasems-l _ (mailto:texasems-l ) > Sent: Fri Jun 11 21:41:09 2010 Subject: Re: EMS challenge Yeah, I was working toward lymphoma Wes, but we're trying to differential diagnose here. Her possible demyialation (sp?) might be causing stroke-like symptoms, but it's also possible that engorged lymph nodes are blocking peripheral circulation and causing increased vascular pressure system-wide, leading to a brain bleed. .. Is that getting close? -Brad Sent via BlackBerry, the office that follows you. EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 Mr Cardenas, You must be kidding. As one of the moderators of this list I commend Wes for starting such a productive discussion. I think Dr Krin said it best that this is a teaching discussion. If you don't like the thread then hit delete. Bernie Stafford EMTP EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 That's the problem. Hitting delete too muCh too often. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 22:26:09 2010 Subject: RE: EMS challenge Mr Cardenas, You must be kidding. As one of the moderators of this list I commend Wes for starting such a productive discussion. I think Dr Krin said it best that this is a teaching discussion. If you don't like the thread then hit delete. Bernie Stafford EMTP EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 That's the problem. Hitting delete too muCh too often. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 22:26:09 2010 Subject: RE: EMS challenge Mr Cardenas, You must be kidding. As one of the moderators of this list I commend Wes for starting such a productive discussion. I think Dr Krin said it best that this is a teaching discussion. If you don't like the thread then hit delete. Bernie Stafford EMTP EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 That's the problem. Hitting delete too muCh too often. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 22:26:09 2010 Subject: RE: EMS challenge Mr Cardenas, You must be kidding. As one of the moderators of this list I commend Wes for starting such a productive discussion. I think Dr Krin said it best that this is a teaching discussion. If you don't like the thread then hit delete. Bernie Stafford EMTP EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 , If you're so smart, why don't YOU answer the question? Gene Gandy EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 , If you're so smart, why don't YOU answer the question? Gene Gandy EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 , If you're so smart, why don't YOU answer the question? Gene Gandy EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 This question comes to mind. Wes said the key is the inability to get a BP in either arm. Question: Can you get a BP in the leg or legs? Second question: Does physical exam reveal any past surgical scars? GG EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > [Non-text portions of this message have been removed] > > > > ------------------------------------ > > > > Yahoo! Groups Links > > > > [Non-text portions of this message have been removed] > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 This question comes to mind. Wes said the key is the inability to get a BP in either arm. Question: Can you get a BP in the leg or legs? Second question: Does physical exam reveal any past surgical scars? GG EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > [Non-text portions of this message have been removed] > > > > ------------------------------------ > > > > Yahoo! Groups Links > > > > [Non-text portions of this message have been removed] > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 This question comes to mind. Wes said the key is the inability to get a BP in either arm. Question: Can you get a BP in the leg or legs? Second question: Does physical exam reveal any past surgical scars? GG EMS challenge > > > > Since it's been a while since Professor Gandy offered a challenge > > (and the > > prize-winner's trip to Ladonia), I present the following brain- > > teaser for > > all of y'all. Alas, there are no prizes since the half-star hotel > > resort > > in Ladonia is closed for fumigation. > > > > On to the challenge...... you are dispatched to an altered mental > > status > > call. Upon arrival, you find a middle-aged female laying on the > > floor of an > > office. She is semi-coherent and semi-combative, with slurred > > speech. Her > > co-workers know that she has an extensive medical history, but they > > can't > > remember what it is. > > > > Oddly, while the patient is breathing and speaking (although > > abnormally), > > you cannot obtain a radial pulse or a blood pressure. You do find a > > palpable carotid pulse at 72 bpm. > > > > What is happening to the patient and what is the underlying etiology? > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > -Attorney at Law/Licensed Paramedic > > -Austin, Texas > > > > [Non-text portions of this message have been removed] > > > > ------------------------------------ > > > > Yahoo! Groups Links > > > > [Non-text portions of this message have been removed] > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 Alas, no. Wes Sent from my iPhone > Yeah, I was working toward lymphoma Wes, but we're trying to > differential diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but it's also possible that engorged lymph nodes are > blocking peripheral circulation and causing increased vascular > pressure system-wide, leading to a brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 AlASS. I think so. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 22:42:08 2010 Subject: Re: EMS challenge Alas, no. Wes Sent from my iPhone On Jun 11, 2010, at 21:41, " Brad Sattler " bradsattler@... > wrote: > Yeah, I was working toward lymphoma Wes, but we're trying to > differential diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but it's also possible that engorged lymph nodes are > blocking peripheral circulation and causing increased vascular > pressure system-wide, leading to a brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 AlASS. I think so. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 22:42:08 2010 Subject: Re: EMS challenge Alas, no. Wes Sent from my iPhone On Jun 11, 2010, at 21:41, " Brad Sattler " bradsattler@... > wrote: > Yeah, I was working toward lymphoma Wes, but we're trying to > differential diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but it's also possible that engorged lymph nodes are > blocking peripheral circulation and causing increased vascular > pressure system-wide, leading to a brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 AlASS. I think so. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 22:42:08 2010 Subject: Re: EMS challenge Alas, no. Wes Sent from my iPhone On Jun 11, 2010, at 21:41, " Brad Sattler " bradsattler@... > wrote: > Yeah, I was working toward lymphoma Wes, but we're trying to > differential diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but it's also possible that engorged lymph nodes are > blocking peripheral circulation and causing increased vascular > pressure system-wide, leading to a brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 Makes me wonder where this person is a medic and what their certification level is. Further affiant sayeth not. Wes Sent from my iPhone On Jun 11, 2010, at 22:17, " Cardenas, " luis.cardenas@... > wrote: > Then answer the ? And stop clogging up the site. > > ________________________________ > > From: texasems-l texasems-l > > To: texasems-l texasems-l > > Sent: Fri Jun 11 21:59:05 2010 > Subject: Re: EMS challenge > > > > > Senor Cardenas: > > What game? > > a good paramedic is offering a case scenario (and doing a decent job > of > it), practicing his teaching skills while trying to get other folks > to think > outside the paramedic cook book. This is the sort of thing that we > need more > of on the various paramedic groups. I can assure you that there are > similar cases being presented on the 'real' medical groups all the > time, albeit > frequently being posed in search of other treatment options for really > screwy (read zebra or even unicorn) cases. > > ck > > > In a message dated 6/11/2010 21:55:09 Central Daylight Time, > luis.cardenas@... %40dallascityhall.com> writes: > > Can you play this game somewhere else. > > ________________________________ > > From: _texasems-l %40yahoogroups.com> _ (mailto:texasems-l > ) > _texasems-l > _ (mailto:texasems-l %40yahoogroups.com> ) > > To: _texasems-l %40yahoogroups.com> _ (mailto:texasems-l > ) > _texasems-l > _ (mailto:texasems-l %40yahoogroups.com> ) > > Sent: Fri Jun 11 21:41:09 2010 > Subject: Re: EMS challenge > > Yeah, I was working toward lymphoma Wes, but we're trying to > differential > diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but > it's also possible that engorged lymph nodes are blocking peripheral > circulation and causing increased vascular pressure system-wide, > leading to a > brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 LP. Big urban FD Captain Who has better things to do than hit " delete " every 2 minutes so you can annoy every other user of this site. Have fun boys. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 22:44:36 2010 Subject: Re: EMS challenge Makes me wonder where this person is a medic and what their certification level is. Further affiant sayeth not. Wes Sent from my iPhone On Jun 11, 2010, at 22:17, " Cardenas, " luis.cardenas@... > wrote: > Then answer the ? And stop clogging up the site. > > ________________________________ > > From: texasems-l texasems-l > > To: texasems-l texasems-l > > Sent: Fri Jun 11 21:59:05 2010 > Subject: Re: EMS challenge > > > > > Senor Cardenas: > > What game? > > a good paramedic is offering a case scenario (and doing a decent job > of > it), practicing his teaching skills while trying to get other folks > to think > outside the paramedic cook book. This is the sort of thing that we > need more > of on the various paramedic groups. I can assure you that there are > similar cases being presented on the 'real' medical groups all the > time, albeit > frequently being posed in search of other treatment options for really > screwy (read zebra or even unicorn) cases. > > ck > > > In a message dated 6/11/2010 21:55:09 Central Daylight Time, > luis.cardenas@... %40dallascityhall.com> writes: > > Can you play this game somewhere else. > > ________________________________ > > From: _texasems-l %40yahoogroups.com> _ (mailto:texasems-l > ) > _texasems-l > _ (mailto:texasems-l %40yahoogroups.com> ) > > To: _texasems-l %40yahoogroups.com> _ (mailto:texasems-l > ) > _texasems-l > _ (mailto:texasems-l %40yahoogroups.com> ) > > Sent: Fri Jun 11 21:41:09 2010 > Subject: Re: EMS challenge > > Yeah, I was working toward lymphoma Wes, but we're trying to > differential > diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but > it's also possible that engorged lymph nodes are blocking peripheral > circulation and causing increased vascular pressure system-wide, > leading to a > brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 LP. Big urban FD Captain Who has better things to do than hit " delete " every 2 minutes so you can annoy every other user of this site. Have fun boys. ________________________________ From: texasems-l texasems-l > To: texasems-l texasems-l > Sent: Fri Jun 11 22:44:36 2010 Subject: Re: EMS challenge Makes me wonder where this person is a medic and what their certification level is. Further affiant sayeth not. Wes Sent from my iPhone On Jun 11, 2010, at 22:17, " Cardenas, " luis.cardenas@... > wrote: > Then answer the ? And stop clogging up the site. > > ________________________________ > > From: texasems-l texasems-l > > To: texasems-l texasems-l > > Sent: Fri Jun 11 21:59:05 2010 > Subject: Re: EMS challenge > > > > > Senor Cardenas: > > What game? > > a good paramedic is offering a case scenario (and doing a decent job > of > it), practicing his teaching skills while trying to get other folks > to think > outside the paramedic cook book. This is the sort of thing that we > need more > of on the various paramedic groups. I can assure you that there are > similar cases being presented on the 'real' medical groups all the > time, albeit > frequently being posed in search of other treatment options for really > screwy (read zebra or even unicorn) cases. > > ck > > > In a message dated 6/11/2010 21:55:09 Central Daylight Time, > luis.cardenas@... %40dallascityhall.com> writes: > > Can you play this game somewhere else. > > ________________________________ > > From: _texasems-l %40yahoogroups.com> _ (mailto:texasems-l > ) > _texasems-l > _ (mailto:texasems-l %40yahoogroups.com> ) > > To: _texasems-l %40yahoogroups.com> _ (mailto:texasems-l > ) > _texasems-l > _ (mailto:texasems-l %40yahoogroups.com> ) > > Sent: Fri Jun 11 21:41:09 2010 > Subject: Re: EMS challenge > > Yeah, I was working toward lymphoma Wes, but we're trying to > differential > diagnose here. > > Her possible demyialation (sp?) might be causing stroke-like > symptoms, but > it's also possible that engorged lymph nodes are blocking peripheral > circulation and causing increased vascular pressure system-wide, > leading to a > brain bleed. > . > Is that getting close? > > -Brad > > Sent via BlackBerry, the office that follows you. > > EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 Well, no matter what one's certification level is, there is something to be learned from scenarios. For example, if one is a Basic EMT, it would seem to be of great interest that a patient had no obtainable blood pressures in either arm but a heart rate of only 72. If I were an EMT-B, I would be asking, WHY and trying to learn something. As a paramedic I'm reviewing all the causes I can think of right now and attempting to eliminate all except the right one. A low or unobtainable BP " should " trigger an increase in heart rate through catecholamine release (WHAT? Basics don't know that? They should). So why is that not happening here? Also, a Basic EMT ought to be able to spot signs of a CVA or TIA when they're as plain as in the scenario. There's a great deal for Basic EMTs to learn from this scenario. If you can't get a BP in either arm, then where else can you try? What conditions can lead to absent palpable blood pressures or different BPs in the arms? This scenario happens to be a real puzzler, which should at least tempt one to do some Googling, unless one is perfectly satisfied with one's current level of knowledge. If the Doc doesn't have it yet, it's probably a pretty good learning scenario. Just sayin. With malice to none. Gene G. EMS challenge > > > > > > Since it's been a while since Professor Gandy offered a challenge > > > (and the > > > prize-winner's trip to Ladonia), I present the following brain- > > > teaser for > > > all of y'all. Alas, there are no prizes since the half-star hotel > > > resort > > > in Ladonia is closed for fumigation. > > > > > > On to the challenge...... you are dispatched to an altered mental > > > status > > > call. Upon arrival, you find a middle-aged female laying on the > > > floor of an > > > office. She is semi-coherent and semi-combative, with slurred > > > speech. Her > > > co-workers know that she has an extensive medical history, but > they > > > can't > > > remember what it is. > > > > > > Oddly, while the patient is breathing and speaking (although > > > abnormally), > > > you cannot obtain a radial pulse or a blood pressure. You do > find a > > > palpable carotid pulse at 72 bpm. > > > > > > What is happening to the patient and what is the underlying > etiology? > > > > > > -Wes Ogilvie, MPA, JD, NREMT-P/Lic.P. > > > -Attorney at Law/Licensed Paramedic > > > -Austin, Texas > > > > > > Quote Link to comment Share on other sites More sharing options...
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