RE: EMS Challenge (2) Hint #1

June 13, 2010

Alyssa watch the TV show Mystery Diagnosis which my CIV no medical training

GF watches. Drives me nuts as I think most of the stuff is over dramatized

as most situations are non life threats but then again I've had my share

of drama in my personal medical life

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

In a message dated 6/13/2010 8:42:49 P.M. Central Daylight Time,

amwoods8644@... writes:

They still did it faster than the doctors in the ER! It took a total

of nearly five months for her to be properly diagnosed. Ironically,

her saving grace was her inability to control her alcoholism.

Alyssa Woods, FF/NREMT-B

> How far was the ED?

>

> With the time you guys spent on this Val DeFrance in Alaska would have

> been back in service for an hour by now

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/EMSI

> Freelance Consultant/Trainer/Author/Journalist/Fire Protection

> Consultant

>

> LNMolino@...

>

> (Cell Phone)

>

> " A Texan with a Jersey Attitude "

>

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 -

> 1962)

>

> In a message dated 6/13/2010 8:03:41 P.M. Central Daylight Time,

> amwoods8644@... writes:

>

> And it goes to Wes!

>

> Congratulations!

>

> Alyssa Woods, FF/NREMT-B

>

> > Delerium tremens?

> >

> > Wes

> >

> > Sent from my iPad

> >

> > > nope...the problem is something more common than lithium toxicity.

> > >

> > > ck

> > >

> > > In a message dated 6/13/2010 19:48:42 Central Daylight Time,

> > > ExLngHrn@... writes:

> > >

> > > If it's an actual lithium OD, I have. My patient was in cardiac

> > arrest,

> > > though. Sodium bicarb brought back ROSC, probably because of the

> > chemistry of

> > > it binding at the electron level with the positive lithium ions.

> > >

> > > Wes Ogilvie

> > >

> > > Sent from my iPad

> > >

> > > On Jun 13, 2010, at 19:38, _krin135@..._

> > (mailto:krin135@...)

> > > wrote:

> > >

> > > > yes, Wesley, I am jerking your chain again....I'm sure that you

> > have

> > > seen

> > > > this condition before.

> > > >

> > > > ck

> > > >

> > > > In a message dated 6/13/2010 19:35:48 Central Daylight Time,

> > > > _krin135@..._ (mailto:krin135@...) writes:

> > > >

> > > > I'm waiting for Wes to chime back in. I jerked his chain pretty

> > hard

> > > > earlier, so I'm betting that he's been doing some research. I'd

> > wait at

> > > > least

> > > > another half hour.

> > > >

> > > > I'm also waiting for someone to ask the obvious question, about

> > how

> > > > closely

> > > > you and I are working together...some of them know how devious I

> > can

> > > be...

> > > >

> > > > ck

> > > >

> > > > In a message dated 6/13/2010 19:33:09 Central Daylight Time,

> > > > __amwoods8644@..._ (mailto:_amwoods8644@...) _

> > > (mailto:_amwoods8644@..._ (mailto:amwoods8644@...) )

> > writes:

> > > >

> > > > Think it's time for another hint?

> > > >

> > > > Alyssa Woods, FF/NREMT-B

> > > >

> > > > On Jun 13, 2010, at 6:57 PM, __krin135@..._

> (mailto:_krin135@...

> > )

> > > _ (mailto:_krin135@..._ (mailto:krin135@...) )

> > > > wrote:

> > > >

> > > > > chuckle...then you are missing something.

> > > > >

> > > > > Even without inside knowledge, I can reasonably predict that

> > while the

> > > > > lithium levels may be elevated to a toxic (a common side

> > effect of the

> > > > > medication and dehydration), the Tums didn't cause her acute

> > problem.

> > > > >

> > > > > and if you were to persist in treating the patient *just* for

> > lithium

> > > > > toxicity, you will miss a life threatening complication that

> is

> > > > > staring you in

> > > > > the face.

> > > > >

> > > > > ck

> > > > >

> > > > > In a message dated 6/13/2010 18:50:08 Central Daylight Time,

> > > > > __rob.davis@..._

> (mailto:_rob.davis@...

> > )

> > > _ (mailto:_rob.davis@..._

> > > (mailto:rob.davis@...) )

> > > > writes:

> > > > >

> > > > > On Sunday, June 13, 2010 18:18, ___krin135@..._

> > > (mailto:__krin135@...) _

> > > > (mailto:__krin135@..._ (mailto:_krin135@...) ) _

> > > > (mailto:__krin135@..._ (mailto:_krin135@...) _

> > > (mailto:_krin135@..._ (mailto:krin135@...) )

> > > > > )

> > > > > said:

> > > > >

> > > > > > OH? and what was your diagnosis?

> > > > >

> > > > > Too early to spoil the whole shebang yet. But someone should

> > have

> > > > > told her

> > > > > to lay off the Tums while taking Li.

> > > > >

> > > > > Rob

> > > > >

June 13, 2010

yep.

paraldehyde can also be used for detox, but because of problems with

plastics, is rarely available these days. I remember the little blue bottles on

the med carts when I first started back in the 1970s.

and the sedative detox problem?

ck

In a message dated 6/13/2010 21:22:08 Central Daylight Time,

amwoods8644@... writes:

Propofol?

Alyssa Woods, FF/NREMT-B

> if benzos are contra indicated for some reason, what other two drugs

> are

> still available for assistance in detoxing the DTs?

>

> and why is the detox of sedative drugs used long term (including,

> but not

> limited to alcohol and benzos) so much more dangerous than the detox

> of

> folks who have been on cocaine or methamphetamine?

>

> ck

>

> In a message dated 6/13/2010 20:39:18 Central Daylight Time,

> ExLngHrn@... writes:

>

> Typically with benzodiazepines or in extreme cases, low doses of

> antipsychotics.

>

> -Wes Ogilvie

>

> In a message dated 6/13/2010 8:37:02 P.M. Central Daylight Time,

> _amwoods8644@..._ (mailto:amwoods8644@...) writes:

>

> It has been brought to my attention that the treatment was not noted.

> Wes, I'm sure you know this, so, take it away...

>

> Alyssa Woods, FF/NREMT-B

>

> On Jun 13, 2010, at 8:33 PM, _lnmolino@..._ (mailto:lnmolino@...

> )

> wrote:

>

> > How far was the ED?

> >

> > With the time you guys spent on this Val DeFrance in Alaska would

> have

> > been back in service for an hour by now

> >

> > Louis N. Molino, Sr., CET

> > FF/NREMT-B/FSI/EMSI

> > Freelance Consultant/Trainer/Author/Journalist/Fire Protection

> > Consultant

> >

> > _LNMolino@..._ (mailto:LNMolino@...)

> >

> > (Cell Phone)

> >

> > " A Texan with a Jersey Attitude "

> >

> > " Great minds discuss ideas; Average minds discuss events; Small

> minds

> > discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 -

> > 1962)

> >

> > In a message dated 6/13/2010 8:03:41 P.M. Central Daylight Time,

> > _amwoods8644@..._ (mailto:amwoods8644@...) writes:

> >

> > And it goes to Wes!

> >

> > Congratulations!

> >

> > Alyssa Woods, FF/NREMT-B

> >

> > > Delerium tremens?

> > >

> > > Wes

> > >

> > > Sent from my iPad

> > >

> > > On Jun 13, 2010, at 19:49, _krin135@..._ (mailto:krin135@...

> )

> wrote:

> > >

> > > > nope...the problem is something more common than lithium

> toxicity.

> > > >

> > > > ck

> > > >

> > > > In a message dated 6/13/2010 19:48:42 Central Daylight Time,

> > > > _ExLngHrn@..._ (mailto:ExLngHrn@...) writes:

> > > >

> > > > If it's an actual lithium OD, I have. My patient was in cardiac

> > > arrest,

> > > > though. Sodium bicarb brought back ROSC, probably because of the

> > > chemistry of

> > > > it binding at the electron level with the positive lithium ions.

> > > >

> > > > Wes Ogilvie

> > > >

> > > > Sent from my iPad

> > > >

> > > > On Jun 13, 2010, at 19:38, __krin135@..._

> (mailto:_krin135@...) _

> > > (mailto:_krin135@..._ (mailto:krin135@...) )

> > > > wrote:

> > > >

> > > > > yes, Wesley, I am jerking your chain again....I'm sure that

> you

> > > have

> > > > seen

> > > > > this condition before.

> > > > >

> > > > > ck

> > > > >

> > > > > In a message dated 6/13/2010 19:35:48 Central Daylight Time,

> > > > > __krin135@..._ (mailto:_krin135@...) _

> (mailto:_krin135@..._ (mailto:krin135@...) ) writes:

> > > > >

> > > > > I'm waiting for Wes to chime back in. I jerked his chain

> pretty

> > > hard

> > > > > earlier, so I'm betting that he's been doing some research.

> I'd

> > > wait at

> > > > > least

> > > > > another half hour.

> > > > >

> > > > > I'm also waiting for someone to ask the obvious question,

> about

> > > how

> > > > > closely

> > > > > you and I are working together...some of them know how

> devious I

> > > can

> > > > be...

> > > > >

> > > > > ck

> > > > >

> > > > > In a message dated 6/13/2010 19:33:09 Central Daylight Time,

> > > > > ___amwoods8644@..._ (mailto:__amwoods8644@...) _

> (mailto:__amwoods8644@..._ (mailto:_amwoods8644@...) ) _

> > > > (mailto:__amwoods8644@..._

> (mailto:_amwoods8644@...) _

> (mailto:_amwoods8644@..._ (mailto:amwoods8644@...) ) )

> > > writes:

> > > > >

> > > > > Think it's time for another hint?

> > > > >

> > > > > Alyssa Woods, FF/NREMT-B

> > > > >

> > > > > On Jun 13, 2010, at 6:57 PM, ___krin135@..._

> (mailto:__krin135@...) _

> > (mailto:__krin135@..._ (mailto:_krin135@...)

> > > )

> > > > _ (mailto:__krin135@..._ (mailto:_krin135@...) _

> (mailto:_krin135@..._ (mailto:krin135@...) ) )

> > > > > wrote:

> > > > >

> > > > > > chuckle...then you are missing something.

> > > > > >

> > > > > > Even without inside knowledge, I can reasonably predict that

> > > while the

> > > > > > lithium levels may be elevated to a toxic (a common side

> > > effect of the

> > > > > > medication and dehydration), the Tums didn't cause her acute

> > > problem.

> > > > > >

> > > > > > and if you were to persist in treating the patient *just*

> for

> > > lithium

> > > > > > toxicity, you will miss a life threatening complication that

> > is

> > > > > > staring you in

> > > > > > the face.

> > > > > >

> > > > > > ck

> > > > > >

> > > > > > In a message dated 6/13/2010 18:50:08 Central Daylight Time,

> > > > > > ___rob.davis@..._

> (mailto:__rob.davis@...) _

> > (mailto:__rob.davis@..._

> (mailto:_rob.davis@...)

> > > )

> > > > _ (mailto:__rob.davis@..._

> (mailto:_rob.davis@...) _

> > > > (mailto:_rob.davis@..._

> (mailto:rob.davis@...) ) )

> > > > > writes:

> > > > > >

> > > > > > On Sunday, June 13, 2010 18:18, ____krin135@..._

> (mailto:___krin135@...) _

> > > > (mailto:___krin135@..._ (mailto:__krin135@...) ) _

> > > > > (mailto:___krin135@..._ (mailto:__krin135@...) _

> (mailto:__krin135@..._ (mailto:_krin135@...) ) ) _

> > > > > (mailto:___krin135@..._ (mailto:__krin135@...) _

> (mailto:__krin135@..._ (mailto:_krin135@...) ) _

> > > > (mailto:__krin135@..._ (mailto:_krin135@...) _

> (mailto:_krin135@..._ (mailto:krin135@...) ) )

> > > > > > )

> > > > > > said:

> > > > > >

> > > > > > > OH? and what was your diagnosis?

> > > > > >

> > > > > > Too early to spoil the whole shebang yet. But someone should

> > > have

> > > > > > told her

> > > > > > to lay off the Tums while taking Li.

> > > > > >

> > > > > > Rob

> > > > > >

> > > > > > [Non-text portions of this message have been removed]

> > > > > >

> > > > >

> > > > > [Non-text portions of this message have been removed]

> > > > >

> > > > > ------------------------------------

> > > > >

June 13, 2010

Wow, you guys have gotten farther than I thought you would!

However, I see a herd of zebras. And a bunch of people looking at the

trees before trying to name what forest they're in.

So, as requested, your first clue:

Your patient was taken to the ER, where she was diagnosed with heat

exhaustion, and given fluids. A couple of hours later, her symptoms

went away. The docs, snickering at your over-thinking, sent her home

two hours later. She was discharged with instructions to take more

frequent breaks.

About three or four weeks later, you are dispatched for a 58 y/o

female, possible stroke. En route, your dispatch is changed to AMS.

Upon arrival, you find the patient and a 17 y/o female just outside of

a restaurant. The 17 y/o girl is holding the woman's hand, but looking

away from the pt. The girl states: " She's having some sort of

neurological event. She hasn't been acting quite right, and then all

of a sudden, she started saying that everything is melting, and she's

got some sort of aphasia. Her pupils are good, though. " She seems

nervous. Upon questioning, she reluctantly admits to being the

patient's daughter. The patient herself cannot form responses. She'll

say things such as, " That sign is really bright! " With much alarm,

looking away, when there is nothing in front of her. She'll also mix

up items, such as calling an oxygen cylinder a purse, and your

ambulance a space ship. She seems quite alarmed and distressed.

So, what would you ask? What would you do? What do you want to know?

And, of course, what's happening to your patient, and why?

> nope. I double checked the history with AW, who had access to an

> excellent

> historian for the case.

>

> the skin is described as hot and dry, and there is no evidence of

> active

> salivation, lacrimation, urinary or fecal incontinence or emesis.

>

> Oh, and where would the Acetylcystine come in?

>

> ck

>

> In a message dated 6/13/2010 16:41:54 Central Daylight Time,

> lnmolino@... writes:

>

> SLUDGEM actually Doc.

> Emesis and Miosis with some modern (post 9/11) literature adding a P

> for Physcological as well.

>

> A typo I bet on hour part with your " history " .

>

> Louis N. Molino, Sr. CET

> FF/NREMT/FSI/EMSI

> Typed by my fingers on my iPhone.

> Please excuse any typos.

> (Cell)

> _LNMolino@..._ (mailto:LNMolino@...)

>

> On Jun 13, 2010, at 14:55, _krin135@..._ (mailto:krin135@...)

> wrote:

>

> > Asked and answered, counselor. no contact with toxic substances at

> > work per

> > AW.

> >

> > What are the s/s of organophosphate poisoning? (again a hint from

> > me: SLUD)

> >

> > ck

> >

> > In a message dated 6/13/2010 14:52:16 Central Daylight Time,

> > _summedic@..._ (mailto:summedic@...) writes:

> >

> > I agree with atropine. Can you tell us what the patient has recently

> > ingested? Is this possibly a nicotinic reaction to some sort of

> > organophosphate?

> >

> > Sent from my iPhone,

> > McGee, EMT-P, EMT-T

> >

> > On Jun 13, 2010, at 2:46 PM, __rick.moore@..._

> (mailto:_rick.moore@...) _

> > (mailto:_rick.moore@..._

> (mailto:rick.moore@...) ) >

> wrote:

> >

> > Atropine?

> > Rick

> > Sent via Blackberry

> >

> > ________________________________

> > From: __texasems-l _ (mailto:_texasems-l

> )

> _ (mailto:_texasems-l _ (mailto:texasems-l

> ) )

> > __texasems-l _ (mailto:_texasems-

> l ) _

> (mailto:_texasems-l _ (mailto:texasems-l

> ) ) >

> > To: __texasems-l _ (mailto:_texasems-l

> ) _

> (mailto:_texasems-l _ (mailto:texasems-l

> ) )

> > __texasems-l _ (mailto:_texasems-

> l ) _

> (mailto:_texasems-l _ (mailto:texasems-l

> ) ) >

> > Sent: Sun Jun 13 14:42:40 2010

> > Subject: Re: EMS Challenge (2)

> >

> > BZZZT!

> >

> > Look up the medications in G&G (or even a nursing text) and try

> again.

> >

> > Your medication order would make this patient worse- somnolent,

> > markedly

> > tachycardic, and cause a very dry mouth.

> >

> > Choose another selection

> >

> > In a message dated 6/13/2010 14:35:27 Central Daylight Time,

> > __ExLngHrn@..._ (mailto:_ExLngHrn@...) _

> (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) )

>

> %40aol.com>

> > writes:

> >

> > Extrapyramidal reaction to her schizophrenia meds? 50 mg of

> > Benadryl, IV

> > push?

> >

> > -Wes Ogilvie

> >

> > In a message dated 6/13/2010 2:30:35 P.M. Central Daylight Time,

> > ___krin135@..._ (mailto:__krin135@...) _

> (mailto:__krin135@..._ (mailto:_krin135@...) )

> > _

> > (mailto:__krin135@..._ (mailto:_krin135@...) _

> (mailto:_krin135@..._ (mailto:krin135@...) )

> > ) writes:

> >

> > ok, I'm going to jump in here a bit. Alyssa does NOT have to

> consider

> > these

> >

> > official hints.

> >

> > 1: based on her medication list, what common psychiatric diagnosis

> > does

> > the

> > patient suffer?

> >

> > 2: Why would this make her reluctant to describe her visual problems

> > in

> > front of her co workers?

> >

> > 3: What kind of dietary indiscretions would make this diagnosis

> worse?

> >

> > 4: Knowing that there is a field treatment for the patient's acute

> > process,

> > what common ALS medication would be indicated?

> >

> > ck

> >

> > In a message dated 6/13/2010 14:00:30 Central Daylight Time,

> > ____ExLngHrn@..._ (mailto:___ExLngHrn@...) _

> (mailto:___ExLngHrn@..._ (mailto:__ExLngHrn@...) )

> > _ (mailto:___ExLngHrn@..._

> (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._

(mailto:_ExLngHrn@...

> )

> > )

> > ) _ (mailto:___ExLngHrn@..._

> (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._

(mailto:_ExLngHrn@...

> )

> > )

> > _

> > (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) _

> (mailto:_ExLngHrn@..._ (mailto:ExLngHrn@...) )

> > ) ) writes:

> >

> > Can I have one of the four promised hints now?

> >

> > -Wes

> >

> > In a message dated 6/13/2010 1:58:47 P.M. Central Daylight Time,

> > _____amwoods8644@..._ (mailto:____amwoods8644@...) _

> (mailto:____amwoods8644@..._ (mailto:___amwoods8644@...) )

> > _

> (mailto:____amwoods8644@..._

> (mailto:___amwoods8644@...) _

> > (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) )

> ) _

> > (mailto:____amwoods8644@..._

> (mailto:___amwoods8644@...) _

> (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) )

> > _

> (mailto:___amwoods8644@..._

> (mailto:__amwoods8644@...) _

> > (mailto:__amwoods8644@..._ (mailto:_amwoods8644@...) )

> ) ) _

> > (mailto:____amwoods8644@..._

> (mailto:___amwoods8644@...) _

> (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) )

> > _

> (mailto:___amwoods8644@..._

> (mailto:__amwoods8644@...) _

> > (mailto:__amwoods8644@..._ (mailto:_amwoods8644@...) )

> ) _

> > (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) _

> (mailto:__amwoods8644@..._ (mailto:_amwoods8644@...) )

> > _ (mailto:__amwoods8644@..._

> (mailto:_amwoods8644@...) _

> > (mailto:amwoo

> > _ds8644@..._ (mailto:ds8644@...) )

> ) ) ) writes:

> >

> > Believe it or not, you can treat this disease in the field.

> >

> > Alyssa Woods, FF/NREMT-B

> >

> > Sent from the itty bitty keyboard on my iPhone

> >

> > On Jun 13, 2010, at 1:45 PM, ______ExLngHrn@..._

> (mailto:_____ExLngHrn@...) _

> > (mailto:_____ExLngHrn@..._ (mailto:____ExLngHrn@...) )

> _

> > (mailto:_____ExLngHrn@..._ (mailto:____ExLngHrn@...) _

> (mailto:____ExLngHrn@..._ (mailto:___ExLngHrn@...) )

> > ) _

> > (mailto:_____ExLngHrn@..._ (mailto:____ExLngHrn@...) _

> (mailto:____ExLngHrn@..._ (mailto:___ExLngHrn@...) )

> > _ (mailto:____ExLngHrn@..._

> (mailto:___ExLngHrn@...) _ (mailto:___ExLngHrn@..._

> (mailto:__ExLngHrn@...)

> > )

> > ) ) _

> > (mailto:_____ExLngHrn@..._ (mailto:____ExLngHrn@...) _

> (mailto:____ExLngHrn@..._ (mailto:___ExLngHrn@...) )

> > _ (mailto:____ExLngHrn@..._

> (mailto:___ExLngHrn@...) _ (mailto:___ExLngHrn@..._

> (mailto:__ExLngHrn@...)

> > )

> > ) _ (mailto:____ExLngHrn@..._

> (mailto:___ExLngHrn@...) _

> > (mailto:___ExLngHrn@..._ (mailto:__ExLngHrn@...) )

> _

> > (mailto:___ExLngHrn@..._ (mailto:__ExLngHrn@...) _

> (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) )

> > ) ) )

> > _ (mailto:_____ExLngHrn@..._ (mailto:____ExLngHrn@...) _

> (mailto:____ExLngHrn@..._ (mailto:___ExLngHrn@...) )

> > _ (mailto:____ExLngHrn@..._

> (mailto:___ExLngHrn@...) _ (mailto:___ExLngHrn@..._

> (mailto:__ExLngHrn@...)

> > )

> > ) _

> > (mailto:____ExLngHrn@..._ (mailto:___ExLngHrn@...) _

> (mailto:___ExLngHrn@..._ (mailto:__ExLngHrn@...) )

> > _ (mailto:___ExLngHrn@..._

> (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._

(mailto:_ExLngHrn@...

> )

> > )

> > ) ) _

> > (mailto:____ExLngHrn@..._ (mailto:___ExLngHrn@...) _

> (mailto:___ExLngHrn@..._ (mailto:__ExLngHrn@...) )

> > _ (mailto:___ExLngHrn@..._

> (mailto:__ExLngHrn@...) _ (mailto:__ExLngHrn@..._

(mailto:_ExLngHrn@...

> )

> > )

> > ) _

> > (mailto:___ExLngHrn@..._ (mailto:__ExLngHrn@...) _

> (mailto:__ExLngHrn@..._ (mailto:_ExLngHrn@...) )

> > _ (mailto:__ExLngHrn@..._

> (mailto:_ExLngHrn@...) _ (mailto:_ExLngHrn@..._

(mailto:ExLngHrn@...

> )

> > )

> > ) ) ) )

> > wrote:

> >

> > > From a treatment standpoint, I'm not seeing anything that I can

> > > provide

> > > actual treatment for, so I'm going to go with the standard oxygen,

> > > IV access,

> > > and cardiac monitoring. Based on some of the neurological aspects,

> > > I'll be

> > > heading towards someplace with neuro capabilities.

> > >

> > > -Wes Ogilvie

> > >

> > > In a message dated 6/13/2010 1:42:01 P.M. Central Daylight Time,

> > > ______amwoods8644@..._ (mailto:_____amwoods8644@...) _

> (mailto:_____amwoods8644@..._

> (mailto:____amwoods8644@...) )

> > _

> (mailto:_____amwoods8644@..._ (mailto:____amwoods8644@...)

> > _

> > (mailto:____amwoods8644@..._

> (mailto:___amwoods8644@...) )

> > ) _

> > (mailto:_____amwoods8644@..._ (mailto:____amwoods8644@...

> ) _

> (mailto:____amwoods8644@..._ (mailto:___amwoods8644@...) )

> > _

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> > (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) )

> > ) ) _

> > (mailto:_____amwoods8644@..._ (mailto:____amwoods8644@...

> ) _

> (mailto:____amwoods8644@..._ (mailto:___amwoods8644@...) )

> > _

> (mailto:____amwoods8644@..._

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> > (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) )

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> > (mailto:____amwoods8644@..._

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> > _

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> (mailto:__amwoods8644@...) _

> > (mailto:__amwoods8644@..._ (mailto:_amwoods8644@...) )

> > ) ) ) _

> > (mailto:_____amwoods8644@..._ (mailto:____amwoods8644@...

> ) _

> (mailto:____amwoods8644@..._ (mailto:___amwoods8644@...) )

> > _

> (mailto:____amwoods8644@..._

> (mailto:___amwoods8644@...) _

> > (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) )

> ) _

> > (mailto:____amwoods8644@..._

> (mailto:___amwoods8644@...) _

> (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) )

> > _

> (mailto:___amwoods8644@..._

> (mailto:__amwoods8644@...) _

> > (mailto:__amwoods8644@..._ (mailto:_amwoods8644@...) )

> ) ) _

> > (mailto:____amwoods8644@..._

> (mailto:___amwoods8644@...) _

> (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) )

> > _

> (mailto:___amwoods8644@..._

> (mailto:__amwoods8644@...) _

> > (mailto:__amwoods8644@..._ (mailto:_amwoods8644@...) )

> ) _

> > (mailto:___amwoods8644@..._ (mailto:__amwoods8644@...) _

> (mailto:__amwoods8644@..._ (mailto:_amwoods8644@...) )

> > _ (mailto:__amwoods8644@..._

> (mailto:_amwoods8644@...) _

> > (mailto:_amwoods8644@..._ (mailto:amwoods8644@...) )

> > ) ) ) ) writes:

> > >

> > > Her temperature was taken rectally.

> > >

> > > Sent from the itty bitty keyboard on my iPhone

> > >

> > > On Jun 13, 2010, at 12:14 PM,

> " _______rob.davis@..._

> (mailto:______rob.davis@...) _

> > (mailto:______rob.davis@..._

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> > _

> > (mailto:______rob.davis@..._

> (mailto:_____rob.davis@...) _ (mailto:____rob.davis@ar

> > mynursecorps.com) ) _

> > (mailto:______rob.davis@..._

> (mailto:_____rob.davis@...) _

> > (mailto:_____rob.davis@..._

> (mailto:____rob.davis@...) )

> %40armynursecorps.com>_

> > (mailto:_____rob.davis@..._

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> > (mailto:____rob.davis@..._

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> > (mailto:______rob.davis@..._

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> > (mailto:_____rob.davis@..._

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> > (mailto:_____rob.davis@..._

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> > (mailto:____rob.davis@..._

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> > (mailto:____rob.davis@..._

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> > (mailto:___rob.davis@..._

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> > (mailto:______rob.davis@..._

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> > (m

> >

>

June 13, 2010