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Hello everyone and welcome to 
the Quorum podcast. 

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This is where academic medicine 
meets remote, austere and 

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resource limited areas. 
So welcome to the Quorum 

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conversations and we are going 
to hear from Zach Andrews, a 

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soft medic about one of his 
patients He he had and this is 

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an open conversation. 
So do please raise your hand and

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ask any questions within the 
messaging and I'll keep an eye 

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on it. 
But Zach, looking forward to 

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this brother. 
All right. 

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Thanks a brick. 
Thanks everyone for logging on 

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today. 
So this is a clinical case that 

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had a profound effect on me and 
really shaping me as a younger 

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and trying to figure out kind of
who I was and who I wanted to be

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in the the world of medicine at 
this point. 

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And so this really isn't a 
textbook scenario. 

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This this patient actually 
presents quite a typical. 

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Then essentially what happened 
is a a man walked into a tent 

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under his own power in 
physiologic he shouldn't have 

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been able to. 
And that's one of the things 

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that had a significant shaping 
on me. 

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And the rest is how deep just in
how rapid critical care medicine

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can revolve around a patient. 
But the fact that he was walking

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in is one of the most important 
teaching points that we have 

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through this entire session. 
It can be deceptive how severe 

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illnesses can be. 
And we can kind of be loped into

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a false sense of security and 
and think that someone appears 

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relatively well. 
And this isn't just within 

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remotes. 
And this is what then, you know,

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you could be at the emergency 
part or, or working EMS and you 

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know, doing calls. 
And so it's, it's a great lesson

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to learn across. 
But most typically remote 

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medicine usually don't have the 
the time or the backup. 

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So remote medicine, you're, 
you're mine should be focused 

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more on what is hiding and what 
am I not seeing versus kind of 

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getting in that sense of 
security. 

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And we're going to walk through 
the clinical decision making 

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process for this patient, the 
drugs, the equipment where I was

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in a general aspect. 
And we're going to get we're 

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going to go through settings. 
We're going to do a lot on here.

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And I'd like this to be a 
conversation, not, not so much a

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lecture. 
I don't have any trick 

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questions. 
I, you know, I really ask that 

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everything here has it like a 
clinical grounded evidence that 

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I, that I present then. 
And if you, if you have a 

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comment, you know, please jump 
in and defend your reasoning. 

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So what I will say is Abra, can 
there's a Word document that we 

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can we can post Maybe if we put 
this on YouTube, maybe there's a

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way to post it in the 
description about to further 

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list learning out of this, 
whether you're a BSc or MSC 

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student, there's a Word document
with questions that I have per 

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slide on here. 
And it's really just to help you

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drill down and get some clinical
reasoning going on. 

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If you're a BSc student, I just 
worry about the BSc side. 

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If you're MSC student, obviously
it's going to take you that 

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further step, but maybe look at 
the BSc questions too and make 

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sure that you don't have any 
gaps that you need to work 

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through. 
So before we get into this, let 

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me just kind of frame what we're
trying to achieve today. 

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The objectives are not just 
boxes to to check off. 

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Each of them represent a 
clinical skill that could save a

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life. 
And by the time we finish, I 

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want you to be able to look at a
patient in a remote environment 

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with limited resources and make 
sound defensible evidence based 

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decisions under pressure. 
And that's the standard that 

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we're going to work work for. 
For the BSc students, we're 

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focusing on recognition, 
location, a framework and 

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understanding a rationale behind
clinical decisions for our 

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entity students, I want you to 
operate at a higher level. 

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I want you to critically 
evaluate evidence question 

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guidelines that maybe I used or 
maybe what you would use in 

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thinking about the and human 
factors that shape the clinical 

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outcomes. 
Both levels of thinking are 

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valuable and will the Word 
document directs questions in 

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that that area towards towards 
both. 

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OK so the scene let me let me 
paint this picture for you. 

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So we're in remote Africa, I 
mean room Africa. 

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There's not a hospital that is 
close by. 

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There's not a clinic, there's 
not a resuscitation bed. 

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There's not a crash trolley that
is in the infrastructure of this

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place. 
What you see atop is actually 

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out of it's you can tell it's 
the walls if you see the curve 

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there. 
It is a tent and the floor is 

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the covering on it, but it's 
just a plywood floor that's 

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under there. 
And over time we managed to get 

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a significant amount of 
equipment in there for a true 

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ICU. 
But there's no CT labs are very 

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lifted through, but there's, we 
did have X-ray in the the bottom

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right is what a minutes or 
X-ray, but we had no X-ray. 

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So as a medic, I learned how to 
do labs. 

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I learned how to shoot X-rays. 
You really become a Jack of all,

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all trades at that point. 
Now for this patient, the first 

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thing I will kind of put in 
front of you, this patient had 

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been unwell for three weeks in, 
in the last week of that, nobody

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had actually really encountered 
him. 

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They, this is really kind of 
poor judgement in multiple 

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aspects of the company he worked
for kind of just thought he was 

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on a Bender or needed a break. 
Unfortunately, that's that's 

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where they kind of work with 
them. 

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But really what was going on? 
Is he he, he actually had a 

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infectious disease and for three
weeks without treatment when we 

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get to here, I won't break out 
to exactly what he had. 

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Hopefully I didn't put it on the
slides already. 

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Once we built the differential, 
I'll kind of go into what he 

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actually had. 
But with this infection, every 

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day that passed, he was getting 
much worse. 

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And So what really caught the 
attention, he was on the 

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outstation that was actually 
little bit further away. 

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It was a good day's drive 
through the Bush. 

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I mean, it was a hard day's 
drive through the Bush to get 

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there, ideally moving by some, 
you know, rotor wing or fixed 

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wing aircraft to, to be able to 
move in between places. 

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But he ended up walking into the
dining tent and as the dining 

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tent looked much like the 
resuscitation tent that you see 

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there, and he actually lost 
incontinence in front of his 

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colleagues there. 
And then they started 

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questioning him. 
Of course, you know of what's 

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what's going on. 
And he's like, I just, I just 

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don't feel well. 
And they determined, yeah, 

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something's off here. 
And so there was a medic who was

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out there, had a much smaller 
aid station, much less 

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equipment. 
But he wasn't a joke of a, of a 

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medic. 
Actually he was experienced RN 

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who worked in a emergency 
department and the learning 

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points here is he was actually 
hesitant to send the patient to 

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me even though my clinic had 
much more capability and was 

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actually closer in the links to 
definitive care. 

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I was really the last stop 
before we get you to some really

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nice high quality care. 
And you know with that with that

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hesitation that that medic had 
it has clinical consequences 

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with it and as capable as he was
in kind of the first question 

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that I have to put in front of 
US students. 

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If if you were the medic at that
out station and he yeah though 

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lost incontinence was still a no
times for GCS of 15 was able to 

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communicate freely with you move
under his own control. 

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What would you have done? 
You know, and and you have to be

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honest there. 
What are you actually assuming 

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by keeping them and what's your 
red flag that you're going to 

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send him out or what are you 
kind of explaining away in your 

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mind to hold on or would you 
have sent him? 

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And so essentially he stayed 
there about 24 hours before I 

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was able to convince that medic 
that you need to get them over 

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here. 
And we were able to spin up an 

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asset to be able to get them to 
me. 

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But that was a whole 24 hours 
that had elapsed and it was a 

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delay in in care for that 
patient. 

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So the patient arrives at my 
location. 

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What I see is again, 24 hours 
later, it's a man who's he's 

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alert and oriented to in place 
time event GCS of 15. 

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He's talking by the most bait 
neurological assessment we have.

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He appears intact, but if you 
look a little bit more 

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carefully, he's pale, he's 
retic, you know, just sweaty. 

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He's shaking a bit and this 
isn't kind of a subtle tremor. 

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What I noticed is he had this 
large cup and we get from from 

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gas stations, you know, as we 
call them the US or you know, I 

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guess pet stations probably 
elsewhere are the same. 

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But they had this big goal. 
It's made to just put a 

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egregious amount of soda to 
cause diabetes in it over your 

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lifetime. 
And he had it full of ice. 

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And as he was walking in, I just
distinctly remembered the ice 

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rattling inside of it. 
And I can actually, I can still 

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hear it to this day. 
And so that's just one of those 

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subtle signs. 
The body is working 

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extraordinarily hard just to 
maintain its basic function. 

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Now let's look at those vital 
signs. 

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And this is really where it 
started clicking with me that 

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something is wrong. 
A blood pressure of before over 

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50 how he walked in with that 
I'm impressed A heart rate in 

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the waist temperature was 
approximately 100 and 

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Fahrenheit. 
Sorry, I didn't do the oh, I did

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do it. 
It's 39.4°C two of 97%. 

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You know some of those are 
concerning, but overall some of 

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those that are not too bad. 97% 
body is trying to maintain its 

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cardiac by increasing that heart
because of the stroke volume on 

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this patient is failing and we 
know it's failing because look 

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at that blood pressure that's 
not a good blood pressure. 

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That temperature tells us 
there's a significant infectious

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process driving a systemic 
inflammatory response during 

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We'll kind of come back to that 
because when we see some some 

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blood gas results that I had, 
that number will take on a very 

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different set that in mind. 
SPU 2 and 90s. 

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So what would you say is this is
this patient in shock? 

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So what type of shock? 
He walked in under his own 

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power. 
GCS of 15. 

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It's deceptive, but yeah, the 
patients in shock, patients in 

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distributive, a septic shock. 
I didn't tell you what I already

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knew at this point because I 
don't want to break down your 

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differential and kind of lead 
you with that. 

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Patients in septic shock here. 
So if this patient walked into 

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your austere clinic or your 
emergency department or wherever

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it is that you work with these 
vital signs, what would your 

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first three actions be? 
You know, let that kind of 

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process in your mind? 
What would those first three 

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actions be? 
What would you do immediately to

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make this patient better or what
processes would you put in 

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motion to get this patient to a 
better situation? 

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So now let This is why I love 
remote medicine because now we 

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have a problem within a problem.
Now you're in a tent in Africa. 

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What changes the way you 
approach this patient or the 

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problems that you have? 
We have comments of do a news 

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score, do a fluids, do a malaria
test, take three, give three. 

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I'm not sure what that is. 
So here those are the comments 

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coming in so far. 
Great, great comments. 

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I like where you went news 
score. 

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Unfortunately, at this time, I 
actually wasn't familiar with 

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the news score, but that's 
great. 

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That's a great score to be to be
grabbing the malaria test. 

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Hey, everything's malaria in 
Africa, so it's proven 

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otherwise. 
So good on you for that one. 

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The take three goes three. 
I'm not sure what that is, but. 

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Dimitro raised his hand. 
What do you got? 

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Thank you for this opportunity. 
I would say this patient is very

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lucky cause having malaria for 
three weeks with the fever most 

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likely the parasitemia was very 
high. 

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So if this guy would be present 
in my clinic, I would try to 

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stabilise his blood pressure as 
soon as possible and find the 

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reason for this kind of symptoms
of fever. 

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Do the malaria test definitely 
and urinalysis. 

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This and depends what kind of 
laboratory capabilities you had 

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there. 
Investigate deeper for the 

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septic shock. 
Yeah, great, great. 

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So what to drill down further on
that? 

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So I had microscopy, I could do 
staining and then I had some RDS

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with that. 
What? 

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Where do you think you'd go with
that? 

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RDS being a rapid detection 
test? 

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What do you mean about RDTS? 
Yeah, we'll get into it. 

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00:13:28,560 --> 00:13:33,040
So for RDTS, is the the rapid 
blood test similar to like a 

228
00:13:33,040 --> 00:13:39,960
rapid like influenza or you 
know, rapid strep test, the 

229
00:13:39,960 --> 00:13:43,080
things along that line, but they
have some for malaria 

230
00:13:43,080 --> 00:13:49,000
specifically and we had some for
various different diseases that 

231
00:13:49,000 --> 00:13:51,760
were tropical in nature. 
We have a question for Dimitro 

232
00:13:51,760 --> 00:13:52,800
Petra. 
Hi guys. 

233
00:13:52,880 --> 00:13:57,000
It wasn't the question is I 
wrote the take 3 and give 3. 

234
00:13:57,240 --> 00:14:01,280
So you really with the news 
score you take 3 diagnostics and

235
00:14:01,280 --> 00:14:05,360
give 3 treatments. 
But again I wasn't, I was just 

236
00:14:05,360 --> 00:14:08,680
thinking about the septic shock,
not the malaria issue. 

237
00:14:08,680 --> 00:14:13,360
So that that's why I said the 
septic shock in my opinion that 

238
00:14:13,360 --> 00:14:16,120
should be treated first. 
So the take 3 is like for 

239
00:14:16,120 --> 00:14:19,400
example, like blood cultures, 
blood tests and I don't know, 

240
00:14:19,400 --> 00:14:22,440
urine output, for example. 
And then give three oxygen in 

241
00:14:22,440 --> 00:14:28,360
case, in case his sats were not 
good, but he had 97 IV fluids 

242
00:14:28,360 --> 00:14:30,840
and IV antibiotics. 
That would be my first course of

243
00:14:30,840 --> 00:14:32,960
action. 
But then again, we are talking 

244
00:14:32,960 --> 00:14:35,680
about Africa. 
So I would go with the malaria 

245
00:14:35,680 --> 00:14:37,400
test as well. 
Yeah, very good. 

246
00:14:37,760 --> 00:14:39,240
I like it. 
I like where you're thinking 

247
00:14:39,240 --> 00:14:40,880
with that. 
I like to take three, give 

248
00:14:40,880 --> 00:14:42,120
three. 
I'm going to have to remember 

249
00:14:42,120 --> 00:14:44,240
that one. 
So what's what's the difference?

250
00:14:44,280 --> 00:14:48,240
We talked about area, so let's 
just put that up the top of the 

251
00:14:48,240 --> 00:14:50,120
differential. 
What else? 

252
00:14:50,120 --> 00:14:53,880
You're in Central Africa, this 
patient immediately what's what 

253
00:14:53,880 --> 00:14:57,680
else is hitting your mind? 
Yellow fever, Typhoid, Cholera. 

254
00:14:57,760 --> 00:15:00,920
Yeah, yeah. 
If I can throw in though, the 

255
00:15:00,920 --> 00:15:05,880
remote, you know, there is 
travel between, you know, urban 

256
00:15:05,880 --> 00:15:08,320
and rural places. 
So I'd be thinking of things 

257
00:15:08,320 --> 00:15:12,400
like dengue fever. 
Thinking of gastrointestinal was

258
00:15:12,520 --> 00:15:17,320
common for us at this point. 
We got wrecked by poor food 

259
00:15:17,320 --> 00:15:19,120
choices multiple times. 
Yeah. 

260
00:15:19,120 --> 00:15:22,320
So there's a few other we can 
add in there, but areas. 

261
00:15:22,320 --> 00:15:26,160
Comment on dysentery Dysentery 
as a different diagnosis. 

262
00:15:26,160 --> 00:15:28,600
Yeah, yeah. 
So it and that's great because 

263
00:15:28,600 --> 00:15:32,080
we actually did have a couple 
bouts of dysentery. 

264
00:15:32,080 --> 00:15:36,040
I was those that fell casualty 
to dysentery while we were out 

265
00:15:36,040 --> 00:15:38,680
there. 
So we'll talk about the, the 

266
00:15:38,680 --> 00:15:41,640
diagnosis here after this 
patient got to me. 

267
00:15:41,640 --> 00:15:44,760
It was, it was suscept infected 
malaria. 

268
00:15:44,760 --> 00:15:49,760
And so I, I used what's a brand 
called Bionex Bionex now. 

269
00:15:49,760 --> 00:15:52,440
And the only reason I use that 
brand is because that's what was

270
00:15:52,440 --> 00:15:56,200
FDA approved and you know, from 
the, the US, that's, that's what

271
00:15:56,200 --> 00:15:57,680
I had. 
It's not the only one. 

272
00:15:57,680 --> 00:16:01,840
There's actually a better and 
cheaper fantastic tests that are

273
00:16:01,840 --> 00:16:05,160
that are out there too. 
But I had that and I ran it in 

274
00:16:05,160 --> 00:16:09,640
the results and I have a picture
that shows it a bit next and we 

275
00:16:09,640 --> 00:16:14,160
can talk about it was so 
immediate and unambiguous, so 

276
00:16:14,160 --> 00:16:18,480
strongly positive for Plasmodium
falciparum that actually had to 

277
00:16:18,480 --> 00:16:21,880
do another test because I 
thought well, maybe something is

278
00:16:21,880 --> 00:16:24,760
wrong with this. 
So usually that has to develop 

279
00:16:24,760 --> 00:16:27,400
over 10 to 15 minutes to show a 
pop. 

280
00:16:27,640 --> 00:16:34,080
And as you could see the sample 
moving towards the line, it was 

281
00:16:34,080 --> 00:16:37,200
positive immediately. 
And so I went and actually got 

282
00:16:37,200 --> 00:16:43,120
our newest batch just to make 
sure the the latest to expire 

283
00:16:43,200 --> 00:16:46,920
and grabbed it open. 
It ran it an exact same thing. 

284
00:16:46,960 --> 00:16:50,480
And so I think that's something 
to, you know, bit I ran a second

285
00:16:50,480 --> 00:16:52,640
test. 
I didn't just grab it and move 

286
00:16:52,640 --> 00:16:53,720
on. 
And why? 

287
00:16:53,720 --> 00:16:57,240
Because it wasn't typical in the
way that presented as a 

288
00:16:57,240 --> 00:16:59,960
positive. 
And I wanted to be sure. 

289
00:17:00,200 --> 00:17:03,400
And in the resource limited 
environment, you can't afford to

290
00:17:03,400 --> 00:17:07,280
be wrong very long, OK, because 
you're going to paint yourself 

291
00:17:07,280 --> 00:17:11,319
into a corner and then to be 
able to get out of that be 

292
00:17:11,319 --> 00:17:16,839
impossible. 
If if it was a fault positive, 

293
00:17:16,839 --> 00:17:19,599
would I have been treating this 
patient for something they 

294
00:17:19,599 --> 00:17:22,760
didn't have? 
It was a false negative, which 

295
00:17:22,760 --> 00:17:28,240
is less likely, but you know it 
it could be mean missing the 

296
00:17:28,240 --> 00:17:31,560
diagnosis entirely. 
So I ran a second test, you 

297
00:17:31,560 --> 00:17:34,000
know, from a different batch and
it just eliminates the 

298
00:17:34,000 --> 00:17:37,960
possibility of a specific 
manufacturing error. 

299
00:17:39,240 --> 00:17:42,520
That is it, it sound clinical 
government, you know, you do 

300
00:17:42,520 --> 00:17:45,200
have to worry about your 
resources, but I was fine with 

301
00:17:45,200 --> 00:17:47,600
that. 
And this is a kind of thinking 

302
00:17:47,600 --> 00:17:51,000
that that you should put on a 
bit in these situations. 

303
00:17:51,000 --> 00:17:56,680
Now if we applied the sepsis 
framework for this patient which

304
00:17:57,360 --> 00:18:00,720
I applied the sepsis framework 
back then I didn't do the new 

305
00:18:00,720 --> 00:18:04,040
score, which is a great one too.
This is patient meet the 

306
00:18:04,040 --> 00:18:08,160
criteria for sepsis septic 
shock, suspected infection. 

307
00:18:08,480 --> 00:18:14,720
Yes, we we have that organ 
dysfunction with a sofa score of

308
00:18:14,720 --> 00:18:16,840
two or more. 
I will actually we'll see some 

309
00:18:16,840 --> 00:18:21,200
evidence in the labs for the and
then for this patient they're 

310
00:18:21,200 --> 00:18:25,160
going to end up needing 
vasopressant or vasopressor 

311
00:18:25,720 --> 00:18:28,360
actually ended up needing 
norepinephrine. 

312
00:18:28,360 --> 00:18:33,000
So this page falls in there and 
is lactate was enormous. 

313
00:18:33,000 --> 00:18:36,320
You'll see it here or it's 
actually here in the second to 

314
00:18:36,320 --> 00:18:42,840
last one, lactate a 14.36. 
He he wasn't just sick. 

315
00:18:42,960 --> 00:18:46,840
He exceeds all those criteria by
a significant margin. 

316
00:18:47,080 --> 00:18:52,640
So if you're unfamiliar with the
rapid diagnostic test, we can, 

317
00:18:52,640 --> 00:18:58,800
we'll chat about that here. 
Again, you know, I have no stock

318
00:18:58,800 --> 00:19:03,960
in Bionax malaria and actually I
took a charcoal medicine course 

319
00:19:03,960 --> 00:19:08,640
years ago in the Gates 
Foundation deputy director of 

320
00:19:08,640 --> 00:19:12,280
malaria was giving the 
presentation on malaria. 

321
00:19:12,400 --> 00:19:15,280
According to him, he actually 
said the tests that you get in 

322
00:19:15,280 --> 00:19:19,800
Africa are are better than the 
vionax test. 

323
00:19:19,800 --> 00:19:23,360
So I, I don't, I don't stay this
is what you need use this is 

324
00:19:23,360 --> 00:19:27,040
what I had and what I was 
allowed to use and very easy 

325
00:19:27,040 --> 00:19:30,400
simple test if not good at 
microscopy, it's quicker it 

326
00:19:30,400 --> 00:19:32,160
gives buys you a little bit of 
time. 

327
00:19:32,160 --> 00:19:37,320
You can get a a blood simple 
sample on a capillary tube or 

328
00:19:37,440 --> 00:19:40,560
for for you over in the UKA 
capillary tube. 

329
00:19:40,560 --> 00:19:44,280
As I've been corrected. 
It's just that a card in a 

330
00:19:44,280 --> 00:19:47,840
reagent in the reagent is a 
little bottle with the A on 

331
00:19:47,840 --> 00:19:52,160
there and you end up 
transferring blood to the card 

332
00:19:52,160 --> 00:19:56,240
with the capillary tube. 
And then you put the prescribed 

333
00:19:56,240 --> 00:19:59,880
amount of drop and it's all 
labelled within the card when 

334
00:19:59,880 --> 00:20:03,400
you open it step by step. 
How to do it and you should have

335
00:20:03,400 --> 00:20:05,320
a result within 10 to 15 
minutes. 

336
00:20:05,920 --> 00:20:09,480
And really phenomenal. 
They take up very little space. 

337
00:20:09,600 --> 00:20:13,200
I mean, even if you're working 
out of an aid bag, you could 

338
00:20:13,200 --> 00:20:17,440
carry a couple of these and you 
probably wouldn't notice that 

339
00:20:17,440 --> 00:20:19,680
you had it. 
The little, the developer, the 

340
00:20:19,680 --> 00:20:21,800
little dropper, it's the size of
an eye drop. 

341
00:20:22,000 --> 00:20:25,680
And so that's what I used two of
them and immediate results as 

342
00:20:25,680 --> 00:20:29,920
soon as that sample hit that 
test line that was positive. 

343
00:20:29,920 --> 00:20:33,400
So what I will show you here, I 
went too far there. 

344
00:20:33,520 --> 00:20:39,080
So actually the blood gas on the
left is is actually from my 

345
00:20:39,480 --> 00:20:41,960
patient now on the right is this
is an I stat. 

346
00:20:41,960 --> 00:20:43,960
I didn't have a picture of the I
stat I used. 

347
00:20:43,960 --> 00:20:46,720
That's not my patient. 
Please don't confuse the two. 

348
00:20:46,960 --> 00:20:48,800
But that's what I stat looks 
like. 

349
00:20:49,000 --> 00:20:53,600
So I end up getting a blood gas 
on this patient to treat them. 

350
00:20:53,600 --> 00:20:58,320
I did before I got here, I did 
get IVX. 

351
00:20:58,520 --> 00:21:01,400
It was pretty painful to be able
to get IV access on this 

352
00:21:01,400 --> 00:21:05,080
patient. 
But after that I was able to 

353
00:21:05,240 --> 00:21:09,600
start a fluid resuscitation of 
30 MLS per kilogramme and which 

354
00:21:09,600 --> 00:21:12,400
he was a rather large guy. 
So it was a kind of fluid. 

355
00:21:12,400 --> 00:21:15,800
And while that was going, I 
grabbed this, this VBG. 

356
00:21:15,800 --> 00:21:18,120
And I want to start with 
something critically kind of 

357
00:21:18,120 --> 00:21:20,800
important here too, before we 
look at single number. 

358
00:21:21,440 --> 00:21:25,280
So this is a VBG, it's not 
arterial, it's it is Venus. 

359
00:21:25,280 --> 00:21:29,640
So if you're going to do this, 
understand that your baseline is

360
00:21:29,640 --> 00:21:35,680
going to be different for what a
normal value and that can be a 

361
00:21:35,680 --> 00:21:38,160
common source of error in 
practise. 

362
00:21:38,160 --> 00:21:42,080
So make sure that you label it 
as a VBG too, if you ended up 

363
00:21:42,080 --> 00:21:46,280
and out to somebody to read. 
And so we're sampling the blood.

364
00:21:46,280 --> 00:21:49,160
The important thing with the 
VBG, it's already delivered its 

365
00:21:49,160 --> 00:21:52,880
oxygen to the tissue and it's 
returning to the heart. 

366
00:21:53,000 --> 00:21:57,120
So the values we see reflect 
what the tissue has already done

367
00:21:57,120 --> 00:22:00,720
with that, that blood with that 
oxygen, right, Not what the 

368
00:22:00,720 --> 00:22:05,280
lungs have really put into it. 
So the venous pH is typically 

369
00:22:05,280 --> 00:22:10,760
about 0 point 03 to 0.05 to 
lower than the arterial in the, 

370
00:22:10,760 --> 00:22:15,600
the Venus PCO 2 is typically 4 
to 5 millimetres higher of 

371
00:22:15,600 --> 00:22:20,240
Mercury than arterial. 
And the Venus PO2 is essentially

372
00:22:22,080 --> 00:22:25,480
it's, it's not really useful for
assessing oxygenation. 

373
00:22:25,480 --> 00:22:29,280
We, we can't use it to tell how 
how well the lungs are really 

374
00:22:29,280 --> 00:22:31,080
working. 
But with that in mind, let's 

375
00:22:31,080 --> 00:22:34,040
look at these numbers. 
The pH is 7.0. 

376
00:22:34,360 --> 00:22:37,960
Even accounting for the venous 
correction of on the high side 

377
00:22:37,960 --> 00:22:43,840
of .04, the estimated arterial 
pH is approximately 7.06. 

378
00:22:44,480 --> 00:22:48,880
This is catastrophic acidemia. 
If you're not aware, anytime you

379
00:22:48,880 --> 00:22:53,840
get below 7.2, you don't work 
the same way that you were. 

380
00:22:53,840 --> 00:22:57,760
Especially the cardiac tissue 
doesn't work the same way. 

381
00:22:58,000 --> 00:23:01,680
And that's probably a great 
indication of why he was not 

382
00:23:01,680 --> 00:23:06,520
able to maintain a blood 
pressure and was decompensating.

383
00:23:06,520 --> 00:23:08,400
So now let's look at the PCO 
2:00. 

384
00:23:08,920 --> 00:23:13,000
It's at 30.4 millimetres in a 
venous sample. 

385
00:23:13,000 --> 00:23:17,880
The normal range is 41 to 51 and
so this is quite a bit lower 

386
00:23:17,880 --> 00:23:20,200
than the normal range and that's
extraordinary. 

387
00:23:20,200 --> 00:23:25,400
It means that his arterial PCO 2
is approximately 25 to 26 

388
00:23:25,400 --> 00:23:30,000
millimetres of mercury. 
His body is hyperventilating so 

389
00:23:30,000 --> 00:23:33,800
aggressively right now trying to
blow off CO2 and compensate for 

390
00:23:33,800 --> 00:23:40,040
that veer metabolic acidosis 
that his venous PCO 2 was 

391
00:23:40,680 --> 00:23:43,440
paradoxically low. 
And yet, as we'll look in a 

392
00:23:43,440 --> 00:23:46,760
moment, even the extreme 
hyperventilation was not enough 

393
00:23:46,760 --> 00:23:49,400
to fully compensate. 
The lactate as we talked about 

394
00:23:49,400 --> 00:23:52,880
earlier was 14.36 millimols per 
litre. 

395
00:23:53,480 --> 00:23:58,760
Normal is is less than two. 
A lactate above 10 is associated

396
00:23:58,760 --> 00:24:03,840
with extremely high mortality 
and in most published series 

397
00:24:03,840 --> 00:24:08,680
that past 10 is is really kind 
of unseen to live through in 

398
00:24:09,080 --> 00:24:13,000
with his we're we're in a 
territory that's you know, it's 

399
00:24:13,000 --> 00:24:18,760
it's really it's it's 
incompatible with this is not a 

400
00:24:18,800 --> 00:24:20,720
number that tells you the 
patient sick. 

401
00:24:20,840 --> 00:24:23,560
This is a number that tell you 
that tells you the patient's 

402
00:24:23,560 --> 00:24:26,360
tissues are done. 
Now if we look at the venous Sao

403
00:24:26,400 --> 00:24:32,800
2, it's 20%. 
Normal venous Sao 2 is 70 to 

404
00:24:32,800 --> 00:24:36,800
75%. 
So the tissues normally extract 

405
00:24:36,800 --> 00:24:39,920
about 25% of the oxygen 
delivered to them. 

406
00:24:40,560 --> 00:24:46,320
She's we're extracting about 8%.
So the body's an extremis here, 

407
00:24:46,360 --> 00:24:50,720
stripping every every bit of 
oxygen that it can from the 

408
00:24:50,720 --> 00:24:54,560
blood because delivery has 
collapsed so catastrophically. 

409
00:24:54,560 --> 00:25:02,120
So remember back to the Spo 2 of
97 and now the venous Sao 2 on 

410
00:25:02,120 --> 00:25:05,480
the blood gas was 20%. 
How do you reconcile those two 

411
00:25:05,480 --> 00:25:07,840
numbers? 
What what we just talked about 

412
00:25:07,840 --> 00:25:10,320
it, but think in your mind, what
does each of those tell you what

413
00:25:10,320 --> 00:25:12,760
is truly happening to this 
patient? 

414
00:25:12,760 --> 00:25:16,480
Here I said it earlier, I want 
you to really understand of what

415
00:25:16,480 --> 00:25:21,720
has happened and you need to 
understand what is not spoken in

416
00:25:21,720 --> 00:25:24,360
those numbers. 
So here's chemistry panels and 

417
00:25:24,360 --> 00:25:27,880
these are all on the ISTAT and 
these are my actual patients 

418
00:25:28,120 --> 00:25:30,640
panels. 
And this is where this full 

419
00:25:31,440 --> 00:25:35,280
picture of multi organ 
dysfunction becomes undeniable. 

420
00:25:35,920 --> 00:25:40,040
The sodium is 122 millimoles per
litre, which normal if you're 

421
00:25:40,040 --> 00:25:45,440
not tracking is 135 to 140. 
Best way I remember the last two

422
00:25:45,440 --> 00:25:49,800
numbers of each of those is 
because your pH is normally 7.35

423
00:25:49,800 --> 00:25:52,280
to 7.4. 
That makes that a little easier 

424
00:25:52,280 --> 00:25:56,400
to remember. 
So severe hyponatremia at this 

425
00:25:56,400 --> 00:26:00,520
level and the sodium effects the
patient's neurological function,

426
00:26:00,520 --> 00:26:04,840
cerebral edoema, confusion and 
in severe cases, seizures in a 

427
00:26:04,840 --> 00:26:07,080
coma. 
And yet this man still within 

428
00:26:07,080 --> 00:26:10,720
these numbers, he still walked 
in with Agcs of 15. 

429
00:26:10,960 --> 00:26:15,440
Again, going back to patient 
didn't present how we would have

430
00:26:15,440 --> 00:26:18,480
expected this patient to. 
His brain was functioning 

431
00:26:18,520 --> 00:26:20,720
outside of having a sodium 
below. 

432
00:26:20,720 --> 00:26:24,520
And it really tells you about 
the remarkable resilience of the

433
00:26:24,520 --> 00:26:28,160
human body and also how close to
the AT she was. 

434
00:26:28,800 --> 00:26:34,440
Now the blood urea nitrogen or 
the BUN was at 96 and the 

435
00:26:34,440 --> 00:26:37,200
creatine at 5. 
Those two numbers paint a 

436
00:26:37,520 --> 00:26:39,680
picture of severe acute kidney 
injury. 

437
00:26:40,360 --> 00:26:43,200
The kidneys were not being 
perfused and therefore they 

438
00:26:43,200 --> 00:26:45,440
weren't filtering. 
They were weren't really 

439
00:26:45,440 --> 00:26:48,000
producing much urine at this 
point either. 

440
00:26:48,000 --> 00:26:50,920
We, I did get a Foley on them at
some point to be able to check 

441
00:26:50,920 --> 00:26:52,800
urine output. 
Very minimal. 

442
00:26:52,800 --> 00:26:55,680
But that's where the waste 
products should be cleared and 

443
00:26:55,680 --> 00:26:57,120
they're accumulating in the 
blood. 

444
00:26:57,120 --> 00:27:01,160
This is acute tubular necrosis 
driven by prolonged 

445
00:27:01,160 --> 00:27:06,480
hypoperfusion. 
The CKNB is at 39.8 nanograms 

446
00:27:06,480 --> 00:27:10,320
per millilitre against the 
normal which is less than 5. 

447
00:27:10,320 --> 00:27:14,640
Tells us that his heart is under
significant stress in the septic

448
00:27:14,640 --> 00:27:21,720
shock. 
This is cardiomyopathy radiators

449
00:27:21,720 --> 00:27:25,640
released during sepsis directly 
impair myocardial contraction 

450
00:27:25,640 --> 00:27:28,560
cardiac event. 
This is the heart being damaged 

451
00:27:28,720 --> 00:27:32,360
as a bystander. 
It's it's a secondary effect on 

452
00:27:32,360 --> 00:27:35,080
this patient. 
So the eye or the international 

453
00:27:35,080 --> 00:27:40,880
normalisation ratio is 1.8 and 
the prothrombin time is point 

454
00:27:40,880 --> 00:27:44,720
1.3 second. 
So even the clotting system of 

455
00:27:44,720 --> 00:27:47,360
this patient is beginning to 
fail. 

456
00:27:47,480 --> 00:27:53,400
This is the early picture DIC or
disseminated intravascular 

457
00:27:53,400 --> 00:27:58,080
coagulation, an inflammatory 
cascade that is destroying the 

458
00:27:58,080 --> 00:28:01,200
kidneys in the lungs and is 
consuming clotting factors. 

459
00:28:01,200 --> 00:28:04,520
If this patient has survived 
longer without treatment, we 

460
00:28:04,520 --> 00:28:09,080
would expect to actually see 
frank bleeding from multiple 

461
00:28:09,080 --> 00:28:14,680
mucosa sites on this patient. 
In the anion gap on here, is 28 

462
00:28:14,680 --> 00:28:18,840
millimoliter normal? 
It is 8 to 12. 

463
00:28:18,920 --> 00:28:22,600
That gap is almost entirely 
explained by that lactate of 

464
00:28:22,600 --> 00:28:26,480
14.36. 
And the body is producing acid 

465
00:28:26,480 --> 00:28:29,920
faster than it can clear it and 
that acid is accumulating and 

466
00:28:29,920 --> 00:28:33,360
it's in the paste blood. 
So we just talked about it. 

467
00:28:33,400 --> 00:28:37,400
But looking at this chemistry 
panel as a whole, how many organ

468
00:28:37,400 --> 00:28:40,320
systems are failing? 
In any that I missed in here 

469
00:28:40,320 --> 00:28:43,200
that you think are failing, 
which one do you think is most 

470
00:28:43,200 --> 00:28:46,920
life threatening? 
Multiple liver is a answer from 

471
00:28:46,920 --> 00:28:49,600
Alfredo. 
Yeah, I multiple, multiple are 

472
00:28:49,600 --> 00:28:53,520
going, this patient is in mods, 
right, Organ dysfunction 

473
00:28:53,520 --> 00:28:57,120
syndrome didn't have liver 
panels on here, but I would 

474
00:28:57,120 --> 00:28:59,880
assume that the liver is failing
also. 

475
00:29:00,160 --> 00:29:03,840
Well, but we did have the 
prothrombin time and INR. 

476
00:29:03,840 --> 00:29:06,920
So I back up like, yeah, we, we 
are assuming that the liver is 

477
00:29:06,920 --> 00:29:10,320
failing because it's, it's not 
keeping up the kidneys and the 

478
00:29:10,320 --> 00:29:14,120
heart and in the heart being the
most vulnerable here, it's 

479
00:29:14,120 --> 00:29:17,640
additive process of months and 
struggle. 

480
00:29:18,560 --> 00:29:21,280
So this, this patient's not in a
good situation right now. 

481
00:29:21,280 --> 00:29:24,440
And if you do get in your Word 
document, I do have a question 

482
00:29:24,440 --> 00:29:29,520
that it walks you through the 
chelation of anion gap in the 

483
00:29:29,520 --> 00:29:34,400
BSc level questions. 
I recommend a little bit proud 

484
00:29:34,400 --> 00:29:36,800
of myself, but I think I give 
you good questions. 

485
00:29:36,800 --> 00:29:42,960
If you're not familiar, reading 
some chemistry panels that will 

486
00:29:42,960 --> 00:29:44,920
help lead you into some 
conclusion. 

487
00:29:45,400 --> 00:29:49,560
So put the link to that document
in the messages guys so you can 

488
00:29:49,560 --> 00:29:51,360
download it from the quorum 
Google. 

489
00:29:51,400 --> 00:29:52,480
Perfect. 
Thanks, Sabre. 

490
00:29:54,040 --> 00:29:55,800
Let's talk about the vascular 
access. 

491
00:29:55,800 --> 00:29:59,120
So I did give a hint and you, 
you were all right on the money 

492
00:29:59,120 --> 00:30:02,560
that we had this patient and we 
needed to recipitate this 

493
00:30:02,560 --> 00:30:04,800
patient. 
The vascular access in this 

494
00:30:04,800 --> 00:30:07,600
patient needs to be talked about
because it was not straight. 

495
00:30:09,840 --> 00:30:12,840
When a patient is in septic 
shock, the the peripheral veins,

496
00:30:12,840 --> 00:30:16,400
they have no pressure. 
I mean, they just collapse. 

497
00:30:16,560 --> 00:30:22,160
You try to you put on a band and
it's just nearly impossible to 

498
00:30:22,160 --> 00:30:25,720
get anything on this patient. 
But he is shunting blood away 

499
00:30:26,040 --> 00:30:28,640
the best it can and truly it's 
distributed. 

500
00:30:28,640 --> 00:30:31,280
So it really can't in this one 
that well. 

501
00:30:31,320 --> 00:30:34,640
And the ones that you'd normally
cannulate easily, they're flat, 

502
00:30:34,640 --> 00:30:36,960
they're fragile, they're 
difficult to find. 

503
00:30:36,960 --> 00:30:41,120
And this does a frustrating time
critical challenge in managing a

504
00:30:41,120 --> 00:30:45,160
shock patient in here. 
So eventually did achieve 

505
00:30:45,160 --> 00:30:49,440
peripheral access and 
immediately commenced 

506
00:30:49,440 --> 00:30:53,000
crystalloid resuscitation. 
And after that ID stick is when 

507
00:30:53,000 --> 00:30:55,680
we got labs. 
So you know, that's excellent 

508
00:30:55,680 --> 00:31:00,480
practise. 
That's how you don't need to 

509
00:31:00,480 --> 00:31:03,280
wait on lab before you 
necessarily start treating your 

510
00:31:03,280 --> 00:31:05,560
patient, especially the 
hypoperfuge. 

511
00:31:05,720 --> 00:31:09,080
Every minute of delay without 
fluid resuscitation is 

512
00:31:09,080 --> 00:31:12,600
associated with work worse 
outcomes and peripheral access 

513
00:31:12,600 --> 00:31:17,440
of one line really isn't enough.
If you've ever managed a true 

514
00:31:17,560 --> 00:31:21,800
ICU worthy patient, you know 
that you need multiple lines and

515
00:31:21,800 --> 00:31:25,880
drips see them in the hospitals 
and there's pumps things on 

516
00:31:25,880 --> 00:31:29,800
these patients and so not 
confident to be able to get 

517
00:31:29,880 --> 00:31:33,240
another line. 
What was actually inserted is a 

518
00:31:33,400 --> 00:31:37,360
gay under ultrasound. 
If you've not used ultrasound to

519
00:31:37,680 --> 00:31:41,120
place IV catheters, I highly 
recommend it. 

520
00:31:41,120 --> 00:31:43,920
It gets you out of a pickle. 
It gets you out of the way of 

521
00:31:43,920 --> 00:31:48,440
having to default to an I/O I I 
much rather prefer getting 

522
00:31:48,600 --> 00:31:51,320
ultrasound guided IV if I can 
over IO. 

523
00:31:51,520 --> 00:31:56,760
Now the the IG is not a routine 
app does require a bit of skill 

524
00:31:56,760 --> 00:32:01,080
and confidence, but overall if 
you can do Ivs under ultrasound,

525
00:32:01,480 --> 00:32:04,640
you could, you could do this 
patient, but it was the the 

526
00:32:04,640 --> 00:32:07,680
right call. 
It gave a reliable large or 

527
00:32:07,680 --> 00:32:11,840
central access for the vase 
suppressor which was was going 

528
00:32:11,840 --> 00:32:17,880
to be placed in this patient. 
It was needed after 30 MLS per 

529
00:32:17,880 --> 00:32:23,120
kilogramme of crystalloid was 
the surviving sepsis campaign 

530
00:32:23,120 --> 00:32:25,520
recommendation. 
The blood pressure had only 

531
00:32:25,520 --> 00:32:28,480
slightly improved. 
Patient's vasculature was so 

532
00:32:28,480 --> 00:32:32,760
profoundly dilated that the 
fluid alone could not restore 

533
00:32:32,760 --> 00:32:36,080
perfusion pressure. 
And so norepinephrine was was 

534
00:32:36,080 --> 00:32:39,440
convinced and it did bring the 
map up to some degree. 

535
00:32:40,120 --> 00:32:44,720
But overall the urine output 
still remained relatively low, 

536
00:32:44,960 --> 00:32:48,160
telling us despite the improved 
blood pressure, the kidneys are 

537
00:32:48,160 --> 00:32:50,440
still not being adequately 
perfused. 

538
00:32:50,600 --> 00:32:54,880
And the the organ damage at this
point was already likely to 

539
00:32:54,880 --> 00:32:57,760
advance upping at 30 miles per 
kilogramme. 

540
00:32:57,760 --> 00:33:00,880
When I think it's, it's 
important for you to recognise 

541
00:33:00,880 --> 00:33:04,480
that the nature of the shock 
when they get to here, but also 

542
00:33:04,480 --> 00:33:08,240
to understand the risk of more 
fluid. 

543
00:33:09,680 --> 00:33:14,080
So I'm taught by one of the best
physicians, very unlikely 

544
00:33:14,080 --> 00:33:17,440
physician to be working with me 
at the time told me the first 

545
00:33:17,440 --> 00:33:20,960
press or in septic shock is 
fluids, the second is fluids and

546
00:33:20,960 --> 00:33:23,840
the third is fluids. 
Your backstop at a minimum 

547
00:33:23,920 --> 00:33:27,840
IS30ML per kilogramme or really 
at the maximum IS30ML per 

548
00:33:27,840 --> 00:33:28,920
kilogramme. 
Apologise. 

549
00:33:29,040 --> 00:33:30,440
Why is that? 
What are we? 

550
00:33:30,440 --> 00:33:33,040
What are we risking here if we 
continue to do more? 

551
00:33:33,080 --> 00:33:37,800
Alfredo mentioned artisanate for
the malaria as well as your your

552
00:33:37,800 --> 00:33:41,320
fluids. 
Yeah, Artisanate is the answer. 

553
00:33:41,320 --> 00:33:43,920
Actually. 
I did not have artisan and I'll 

554
00:33:43,920 --> 00:33:46,800
get to it in a little bit of 
what I actually had was IV 

555
00:33:46,800 --> 00:33:50,600
quinidine and that's all I had. 
But what you have is better than

556
00:33:50,600 --> 00:33:54,160
what you don't have at the time.
So pushing the patient past 30 

557
00:33:54,160 --> 00:33:58,040
miles per kilogramme of 
crystalloid fluid really start 

558
00:33:58,040 --> 00:34:01,920
to risk fluid overload for this 
patient, which could stress the 

559
00:34:01,920 --> 00:34:05,760
heart further and also most 
importantly the pulmonary 

560
00:34:05,760 --> 00:34:10,520
system. 
We could have a shift pulmonary.

561
00:34:11,880 --> 00:34:16,120
In fact, many remote 
practitioners starting to be on 

562
00:34:16,120 --> 00:34:20,320
the Shire side of crystalloid 
fluid resuscitation in starting 

563
00:34:20,320 --> 00:34:25,080
to to re evaluate the patient at
about 20 MLS per kilogramme. 

564
00:34:26,280 --> 00:34:30,000
There's multiple studies you can
look at, but the one I recall 

565
00:34:30,000 --> 00:34:33,440
was done in Vietnam and they 
actually stopped a bit earlier 

566
00:34:33,719 --> 00:34:38,400
because in their IC US they did 
not have the same capability 

567
00:34:38,400 --> 00:34:41,840
that many other IC US had that 
were successful with 30 mills 

568
00:34:41,840 --> 00:34:44,760
per kilogramme. 
Typically they write ventilator 

569
00:34:45,000 --> 00:34:51,120
to patient ratio and things like
ECMO and respiratory therapist 

570
00:34:51,120 --> 00:34:53,920
and touch in their clinics. 
And so they actually had a 

571
00:34:53,920 --> 00:34:59,000
better outcome of patients in 
the long run to limiting fluids 

572
00:34:59,000 --> 00:35:02,440
a bit more. 
I believe Kenya did a similar 

573
00:35:02,440 --> 00:35:05,480
study on that. 
It's something some I should 

574
00:35:05,480 --> 00:35:08,560
have put that in my notes here 
to tell you so I apologise to 

575
00:35:08,560 --> 00:35:12,800
that one pressed into Tory body 
had been working so hard to to 

576
00:35:12,800 --> 00:35:15,280
compensate for metabolic 
acidosis. 

577
00:35:15,480 --> 00:35:18,640
Breathing fast and deep trying 
to blow off that seat that 

578
00:35:18,640 --> 00:35:23,840
eventually with that PA with 
everything going on with just 

579
00:35:23,840 --> 00:35:27,480
the the sheer fatigue, the 
muscles could not sustain the 

580
00:35:27,480 --> 00:35:29,880
effort. 
So when venol failure occurs in 

581
00:35:29,880 --> 00:35:34,920
a patient with a degree of 
metabolic acidosis, it's a pre 

582
00:35:34,920 --> 00:35:38,760
terminal event and that's 
something that was recognised. 

583
00:35:38,760 --> 00:35:43,960
But RSI in a shock patient is is
a high risk procedure in 

584
00:35:43,960 --> 00:35:47,200
emergency medicine. 
The drugs used to facilitate 

585
00:35:47,200 --> 00:35:50,480
innovation can cause 
cardiovascular collapse in a 

586
00:35:50,480 --> 00:35:54,440
patient who's already 
hemodynamically compromised in 

587
00:35:54,440 --> 00:35:57,560
the act of innovation itself 
that learns about the positive 

588
00:35:57,560 --> 00:36:01,360
pressure ventilation can cause a
precipitous drop in blood 

589
00:36:01,360 --> 00:36:03,640
pressure. 
And if we take over the 

590
00:36:03,640 --> 00:36:07,800
patient's ventilation without 
matching the rate and depth that

591
00:36:07,800 --> 00:36:10,640
they were achieving 
spontaneously, we can actually 

592
00:36:10,640 --> 00:36:13,640
cause a catastrophic worsening 
of the acidosis. 

593
00:36:13,680 --> 00:36:19,640
This is not a procedure to rush 
into it out preparation and to 

594
00:36:19,960 --> 00:36:22,800
prepare for RSI, you can use the
SOAP mnemonic. 

595
00:36:22,800 --> 00:36:26,440
There's also the MIS made 
mnemonic which is similar to 

596
00:36:26,440 --> 00:36:31,200
whatever you remember. 
Everything was was checked and 

597
00:36:31,200 --> 00:36:33,840
confirmed before a single drug 
was given, right? 

598
00:36:33,840 --> 00:36:35,720
And that's the standard that you
should be doing. 

599
00:36:36,000 --> 00:36:39,760
And ideally you recognise as we 
did, this patient was going to 

600
00:36:39,760 --> 00:36:42,640
go into respiratory failure 
before we get there. 

601
00:36:43,800 --> 00:36:45,800
So for induction, ketamine was 
chosen. 

602
00:36:46,520 --> 00:36:50,840
Ketamine is the choice for sign 
hemodynamically compromised 

603
00:36:50,840 --> 00:36:53,960
patient. 
Another common one use is 

604
00:36:53,960 --> 00:36:59,360
atomidate and unlike propofol or
midaz which causes that case of 

605
00:36:59,360 --> 00:37:02,400
dilation and myocardial 
depression, ketamine actually 

606
00:37:02,400 --> 00:37:07,560
stimulates the sympathetic gosh 
sympathetic nervous system. 

607
00:37:07,920 --> 00:37:11,320
It maintains a heart rate and 
blood pressure and it's also a 

608
00:37:11,320 --> 00:37:15,480
bit of a bronchodilator which is
useful in that pulmonary edoema 

609
00:37:15,480 --> 00:37:18,840
and critically in this 
environment, it is it's 

610
00:37:18,840 --> 00:37:22,080
temperature stable too, very 
important for us. 

611
00:37:22,560 --> 00:37:26,680
Not needing refrigeration in a 
tent in Africa matters for the 

612
00:37:26,680 --> 00:37:30,560
paralytic Vecaronium was chosen 
over sexsenocholine and 

613
00:37:30,560 --> 00:37:34,560
sexsenocholine can cause a 
transient rise in serum 

614
00:37:34,560 --> 00:37:39,280
potassium, typically about .5 to
.1 millimoles per litre. 

615
00:37:39,680 --> 00:37:42,640
And in a healthy patient, that 
is inconsequential. 

616
00:37:42,960 --> 00:37:47,520
In a patient with severe AKI, 
though a kidney injury, a 

617
00:37:47,520 --> 00:37:50,920
potassium that may already be 
higher than the measured 4 point

618
00:37:51,080 --> 00:37:55,880
because of a pair's potassium 
excretion, the measured value 

619
00:37:55,880 --> 00:37:59,320
may not reflect that true 
intracellular burden. 

620
00:37:59,480 --> 00:38:01,880
And that rise could trigger a 
fatal arrhythmia. 

621
00:38:02,200 --> 00:38:06,680
So vecuronium was safer choice. 
And it also like ketamine is 

622
00:38:06,680 --> 00:38:09,240
temperature stable, which again,
it it matters. 

623
00:38:09,360 --> 00:38:11,520
So here's my question to you for
this slide. 

624
00:38:11,680 --> 00:38:16,080
You're about to intubate a 
patient with APH of 7.02 who is 

625
00:38:16,080 --> 00:38:18,560
breathing at 30 breath per 
minutes. 

626
00:38:18,560 --> 00:38:23,240
To compensate, you intubate and 
you set the say you end up 

627
00:38:23,240 --> 00:38:25,440
setting the ventilator to 12 
breaths per minute. 

628
00:38:25,640 --> 00:38:27,360
What'd you just do to that 
patient? 

629
00:38:27,360 --> 00:38:32,560
So what you did to that patient 
is you forced them to to stop 

630
00:38:32,560 --> 00:38:35,480
compensating. 
The one thing that was though 

631
00:38:35,480 --> 00:38:38,360
they were way outside of 
tolerance, The one thing that 

632
00:38:38,360 --> 00:38:42,280
was really stopping them from 
just going off the Cliff, you 

633
00:38:42,280 --> 00:38:45,720
turned it off. 
So now we could expect that pH 

634
00:38:45,960 --> 00:38:49,600
to decrease even more and really
put the patient in a dangerous 

635
00:38:49,600 --> 00:38:51,400
situation. 
So once the patient was 

636
00:38:51,400 --> 00:38:55,560
inhibited and the tube was 
confirmed and positioned by by 

637
00:38:55,560 --> 00:39:00,120
of course, a good direct 
visualisation, we also had in 

638
00:39:00,120 --> 00:39:04,520
title and a chest X-ray. 
So the ventilator that I had is 

639
00:39:04,520 --> 00:39:08,760
the the Zol EMV plus. 
It's a transport ventilator and 

640
00:39:08,760 --> 00:39:11,200
we used a lung protective 
strategy. 

641
00:39:11,720 --> 00:39:14,400
Now here where the ventilator 
management of this patient 

642
00:39:14,400 --> 00:39:17,200
becomes genuinely complex. 
And I want you to think 

643
00:39:17,440 --> 00:39:21,400
carefully about this standard's 
approach to birds patient. 

644
00:39:22,240 --> 00:39:25,440
Birds patient is the ARDS net 
protocol something to become 

645
00:39:25,440 --> 00:39:32,200
very familiar with if you if 
you're not, they recommend 4 to 

646
00:39:32,200 --> 00:39:35,160
8 millilitres per kilogramme, 
but really starting in the 

647
00:39:35,160 --> 00:39:38,760
middle at six millilitres per 
kilogramme of ideal body weight.

648
00:39:39,080 --> 00:39:41,320
If you're not familiar with 
that, please go look that up 

649
00:39:41,320 --> 00:39:45,600
because it's not just based on 
height or based on their actual 

650
00:39:45,600 --> 00:39:48,760
weight. 
So it's it gives a low tidal 

651
00:39:48,760 --> 00:39:55,600
volumes and it can allow a 
little bit of permissive hyper 

652
00:39:55,600 --> 00:40:01,720
cadmium, but you accept that is 
maybe slightly higher CO2 in 

653
00:40:01,720 --> 00:40:05,440
exchange for protection of the 
lungs from barrel trauma. 

654
00:40:05,600 --> 00:40:07,800
And that's a standard in these 
patients. 

655
00:40:07,800 --> 00:40:12,440
But in this patient permissive 
hypercapnia was was not so much 

656
00:40:12,440 --> 00:40:16,400
as of an option. 
And we place this patient on a 

657
00:40:16,400 --> 00:40:20,160
very high respiratory rate to 
try to maintain that 

658
00:40:20,160 --> 00:40:23,200
complication. 
And again, we talked about this 

659
00:40:23,200 --> 00:40:25,800
because the patient's pH just 
pointed. 

660
00:40:26,840 --> 00:40:30,000
I didn't talk about his 
bicarbonate earlier, meant to I 

661
00:40:30,000 --> 00:40:35,120
apologise, but his bicarbonate 
was at 7.9, which a normal is is

662
00:40:35,400 --> 00:40:39,520
bicarbonate 22 to 26. 
His entire acid base system was 

663
00:40:39,520 --> 00:40:41,720
on the edge of collapse. 
The only keeping him from 

664
00:40:42,280 --> 00:40:45,680
failing further was his 
respiratory compensation. 

665
00:40:46,280 --> 00:40:50,640
That hyperventilation is just 
off that CO2 as quickly as it 

666
00:40:50,640 --> 00:40:54,200
possibly could let them fall 
anymore, really risking cardiac 

667
00:40:54,200 --> 00:40:56,040
compromise. 
We we already talked about the 

668
00:40:56,040 --> 00:41:01,880
cardiac effect of 7.2 of APH. 
7.2 is where that starts to 

669
00:41:01,880 --> 00:41:04,200
disrupt it. 
The further you go the worse 

670
00:41:04,200 --> 00:41:08,400
that gets away from there. 
Ventilator rate as I said was 20

671
00:41:08,400 --> 00:41:12,200
to 24 breaths per minute and it 
is higher than standard. 

672
00:41:12,200 --> 00:41:16,080
A lot of people using lung 
protective strategy shoots for 

673
00:41:16,080 --> 00:41:22,440
about 15 at a volume 6 somewhere
between 8:00 to 12:00 to recruit

674
00:41:22,440 --> 00:41:25,240
some collapsed alveoli and 
improve oxygenation. 

675
00:41:25,520 --> 00:41:29,880
And the F IO 2 was was at 100% 
starting for this patient and it

676
00:41:29,880 --> 00:41:32,840
was going to be titrated down 
based on AB GS. 

677
00:41:32,920 --> 00:41:38,000
The chest X-ray confirmed 
correct entitled or ET2 

678
00:41:38,000 --> 00:41:41,760
placement and it did show a 
little bit of pulmonary edoema 

679
00:41:41,760 --> 00:41:45,760
consistent with developing ARD. 
And actually lung ultrasound 

680
00:41:45,760 --> 00:41:48,840
confirmed that there was no 
pneumothorax in this patient, 

681
00:41:48,840 --> 00:41:52,240
which is a critical check after 
an inhibation in case you got 

682
00:41:52,240 --> 00:41:56,880
too vigorous with their. 
We all saw the curly B lines 

683
00:41:56,880 --> 00:42:01,280
within that also. 
So that also confirmed pulmonary

684
00:42:01,280 --> 00:42:02,360
edoema. 
All right. 

685
00:42:02,400 --> 00:42:07,080
And I will move to my anti 
malarial treatment of this 

686
00:42:07,080 --> 00:42:09,920
patient. 
Now I guess before I move, since

687
00:42:09,920 --> 00:42:14,320
we hit on the lung protective 
strategy, there is a obstructive

688
00:42:14,320 --> 00:42:19,360
pathology strategy of your 
patients and that is used for 

689
00:42:19,360 --> 00:42:23,480
COPD and asthma and patients of 
the like there. 

690
00:42:23,480 --> 00:42:26,680
But if it's usually not those, 
we're usually going to move to a

691
00:42:26,800 --> 00:42:31,240
lung protective strip. 
So my anti malarial treat. 

692
00:42:31,400 --> 00:42:36,000
So alongside the resuscitation, 
as I talked about earlier, I 

693
00:42:36,000 --> 00:42:42,960
administered IV quinidine. 
It was the drug I had and the 

694
00:42:42,960 --> 00:42:45,280
best drug you can treat it with 
is the one you have. 

695
00:42:46,040 --> 00:42:49,280
Quinidine was historically the 
drug of choice in the US for 

696
00:42:49,280 --> 00:42:51,960
intravenous treatment for severe
fuss. 

697
00:42:53,640 --> 00:42:57,160
It works by actually disrupting 
the parasite's ability to 

698
00:42:58,000 --> 00:43:02,840
detoxify the heme byproduct of 
the haemoglobin digestion and 

699
00:43:02,840 --> 00:43:07,040
it's toxic to the parasite if it
accumulates and blocking this 

700
00:43:07,040 --> 00:43:11,080
process, phenidine kills the 
parasite inside the red blood 

701
00:43:11,080 --> 00:43:15,480
cell. 
However, that globe has already 

702
00:43:16,680 --> 00:43:18,640
shifted. 
The World Health Organisation 

703
00:43:18,640 --> 00:43:22,240
recommends Nate as the first 
line treatment of severe 

704
00:43:22,240 --> 00:43:24,880
falciparum now. 
It was based on the Aquamat 

705
00:43:24,880 --> 00:43:30,920
trial, which superior surviving 
outcome compared to 9 and and 

706
00:43:31,000 --> 00:43:35,440
African children and the the 
sequel map trial and adults in 

707
00:43:35,440 --> 00:43:39,080
Southeast Asia. 
So I will say Artestinate is 

708
00:43:39,080 --> 00:43:42,600
faster acting and it has a 
better safety profile and is 

709
00:43:42,600 --> 00:43:46,680
more effective in in reducing 
parasite clearance time in 

710
00:43:46,680 --> 00:43:50,240
remote field environment. 
You know, Dean may will have 

711
00:43:50,240 --> 00:43:56,400
been what was it or what the 
imperfect beats the perfect when

712
00:43:56,400 --> 00:43:58,040
you don't have perfect every 
time. 

713
00:43:59,760 --> 00:44:02,080
We'll see. 
Quinidine carries a significant 

714
00:44:02,080 --> 00:44:05,960
risk that requires monitoring. 
Does anyone remember the effect 

715
00:44:05,960 --> 00:44:09,000
that quinidine may have on the 
patient? 

716
00:44:09,000 --> 00:44:10,560
And actually I'll give you a 
hint. 

717
00:44:10,560 --> 00:44:13,560
You need to use AECG to find 
this. 

718
00:44:13,560 --> 00:44:17,160
It's OK. 
If not, it prolongs the QT 

719
00:44:17,160 --> 00:44:21,680
interval which can precipitate 
the life threatening arrhythmia 

720
00:44:21,880 --> 00:44:29,520
of torsods or so it it also 
stimulates insulin secretion. 

721
00:44:29,520 --> 00:44:33,240
It's another thing to look for 
and that can cause hypoglycemia 

722
00:44:33,280 --> 00:44:36,200
further hypertension. 
So all all these risks are 

723
00:44:36,200 --> 00:44:40,600
compound in a patient who is all
hemodynamically they're unstable

724
00:44:40,640 --> 00:44:44,960
in mods, they're acidotic and 
they have a vasopressor infusion

725
00:44:44,960 --> 00:44:47,680
going on. 
Now one thing we are expecting 

726
00:44:47,680 --> 00:44:51,760
cerebral malaria with this 
patient and actually an autopsy 

727
00:44:51,760 --> 00:44:57,160
did have and steroids not 
indicated in cerebral malaria 

728
00:44:57,160 --> 00:45:00,440
and actually they show I didn't 
have the study off top of my 

729
00:45:00,440 --> 00:45:04,000
head, but the steroids worse 
enough comes in in cerebral 

730
00:45:04,000 --> 00:45:06,960
malaria. 
So question why IV treatment 

731
00:45:06,960 --> 00:45:12,200
versus oral or antimalarials. 
Maybe if he walked in and write 

732
00:45:12,320 --> 00:45:17,720
he actually wasn't intubated the
four clinidine today we gave him

733
00:45:17,720 --> 00:45:21,000
a oral anti malaria. 
What would be the risk with this

734
00:45:21,000 --> 00:45:22,800
patient? 
Dimitro, you have your hand up, 

735
00:45:22,800 --> 00:45:25,760
bro. 
Yeah, because this is the severe

736
00:45:25,760 --> 00:45:29,960
malaria, you can treat it only 
these the four medications or I 

737
00:45:29,960 --> 00:45:34,240
am medications like you 
mentioned quinidine or artisanet

738
00:45:34,240 --> 00:45:37,120
Artematar. 
So oral medications are not 

739
00:45:37,120 --> 00:45:40,520
useful for severe malaria type 
and because of the low 

740
00:45:40,520 --> 00:45:44,200
absorption level and most likely
most of these patients, they're 

741
00:45:44,200 --> 00:45:49,000
not able to swallow medications.
This one was, but I would also 

742
00:45:49,000 --> 00:45:51,280
move to IV medications in this 
case. 

743
00:45:51,360 --> 00:45:53,160
Yeah, Yeah, very good. 
Yeah. 

744
00:45:53,160 --> 00:45:59,160
And giving, giving a oral 
medication to a patient who is 

745
00:45:59,840 --> 00:46:04,560
in multi organ dysfunction, the 
likelihood of that absorbing as 

746
00:46:04,560 --> 00:46:09,880
you pointed out is is very low. 
It's not going to you need to 

747
00:46:09,880 --> 00:46:12,360
move to IV medications on this 
patient. 

748
00:46:12,360 --> 00:46:15,960
So we'll talk a little bit about
point of care ultrasound in the 

749
00:46:15,960 --> 00:46:20,560
field. 1 of abrix favourite 
topics here, but it was used 

750
00:46:20,560 --> 00:46:25,520
significantly and 1 and 
critically in in this patient a 

751
00:46:25,520 --> 00:46:28,560
few times. 
It's an indispensable tool in 

752
00:46:28,560 --> 00:46:30,360
pre hospital and austerity 
medicine. 

753
00:46:30,640 --> 00:46:34,200
Oram has a great course with it.
I recommend that you you get 

754
00:46:34,200 --> 00:46:36,000
your hands on it. 
It's becoming more and more 

755
00:46:36,000 --> 00:46:38,720
affordable. 
Yeah, at this point the size 

756
00:46:38,720 --> 00:46:40,960
wise you can fit it almost 
anywhere. 

757
00:46:41,000 --> 00:46:44,480
So first it was used to guide 
the the internal jugular 

758
00:46:44,480 --> 00:46:48,880
cannulation and without 
ultrasound, central venous 

759
00:46:48,880 --> 00:46:52,840
access in a in a shocked 
patient, it's a blind procedure 

760
00:46:52,840 --> 00:46:56,200
and there's significant 
complications. 

761
00:46:56,200 --> 00:47:00,080
You can only imagine, you know, 
arterial Sure you can. 

762
00:47:00,080 --> 00:47:02,680
Actually, if it's a long enough 
needle, you can actually cause a

763
00:47:02,720 --> 00:47:10,320
hematorax hematoma occur and you
can actually disrupt blood 

764
00:47:10,320 --> 00:47:16,360
perfusion or or increase ICP by 
inhibiting venous return 

765
00:47:16,680 --> 00:47:18,760
ultrasound. 
You can see the vein, confirm 

766
00:47:18,760 --> 00:47:21,160
its patency. 
You can watch the needle enter 

767
00:47:21,160 --> 00:47:24,120
the vein in real time and 
dramatically reduce the 

768
00:47:24,120 --> 00:47:28,840
complication in a tent in Africa
with no backup that that's 

769
00:47:28,840 --> 00:47:31,160
enormous. 
Second, it was used to confirm 

770
00:47:31,560 --> 00:47:35,200
lung sliding after innovation, 
which confirms that both lungs 

771
00:47:35,200 --> 00:47:37,880
were being ventilated and that 
no pneumothorax had been 

772
00:47:37,880 --> 00:47:40,280
created. 
And this is a critical safety 

773
00:47:40,280 --> 00:47:45,000
check and is particularly 
important after the IG. 

774
00:47:45,800 --> 00:47:49,960
On that same side, as I talked 
about earlier, a lung ultrasound

775
00:47:49,960 --> 00:47:54,280
also identified the curly B 
lines, the sound signature for 

776
00:47:54,280 --> 00:47:57,840
pulmonary edoema, which is 
consistent with that developing 

777
00:47:57,840 --> 00:48:00,000
ARDS. 
And yeah, we did get a chest 

778
00:48:00,000 --> 00:48:01,520
X-ray. 
So someone may say, well, why 

779
00:48:01,520 --> 00:48:04,280
don't you just get the chest 
X-ray earlier when you're alone 

780
00:48:04,280 --> 00:48:07,760
and doing, you're getting the 
cassette behind the patient, you

781
00:48:07,760 --> 00:48:11,440
have all this. 
It's much quicker to get the 

782
00:48:11,760 --> 00:48:16,040
view of what's going on with the
patient with ultrasound actually

783
00:48:16,040 --> 00:48:20,040
moving to X-ray but not going to
be sweating in the back of your 

784
00:48:20,040 --> 00:48:22,560
mind. 
Wonder if you actually have good

785
00:48:22,560 --> 00:48:25,080
on this patient. 
So other things, if I was more 

786
00:48:25,080 --> 00:48:29,160
developed at the point, I could 
have had a good cardiac view of 

787
00:48:29,160 --> 00:48:31,560
the patient. 
I could have looked at the left 

788
00:48:31,560 --> 00:48:35,560
and right ventricular function. 
Is the really telling me is the 

789
00:48:35,560 --> 00:48:39,760
heart failing as a pump or is it
being overwhelmed by fluid? 

790
00:48:39,800 --> 00:48:44,760
I could look at the IVC 
collapsibility, it give a real 

791
00:48:44,760 --> 00:48:47,000
dynamic assessment of fluid 
status. 

792
00:48:47,000 --> 00:48:50,440
There's really quite a bit that 
can can be done here with the 

793
00:48:50,440 --> 00:48:54,240
the low fluid urinary output. 
I could have done a bladder scan

794
00:48:54,240 --> 00:48:57,920
to see if maybe there was 
something more distal in line 

795
00:48:57,920 --> 00:49:01,640
with this patient to make sure 
that they were able to pass 

796
00:49:01,640 --> 00:49:03,520
urine. 
So it doesn't replace clinic 

797
00:49:03,720 --> 00:49:09,680
judgement, but ends your your 
reach significantly. 

798
00:49:10,920 --> 00:49:13,600
Yeah, I'll move on to, to the 
next piece of here. 

799
00:49:13,800 --> 00:49:17,080
I have some good questions that 
ask about POCUS if you're if 

800
00:49:17,080 --> 00:49:19,320
you're wanting to look at that a
bit further. 

801
00:49:19,440 --> 00:49:23,240
So this patient was evacuated in
with the critical care team 

802
00:49:23,560 --> 00:49:29,160
unabated ventilated 
norepinephrine infusion and as 

803
00:49:29,160 --> 00:49:33,480
stable as you could have hoped 
to have made them, though truly 

804
00:49:33,480 --> 00:49:36,200
they still weren't stable, but 
they were just a little bit 

805
00:49:36,200 --> 00:49:42,120
better than prior in the 
handover was comprehensive, but 

806
00:49:42,120 --> 00:49:45,200
even in the arms of the 
receiving team, the patient 

807
00:49:45,800 --> 00:49:51,320
passed the patient died just 
patient was not compatible with 

808
00:49:51,640 --> 00:49:54,120
surviving. 
So and I want that to sit with 

809
00:49:54,120 --> 00:49:57,680
you for a minute too. 
This was a hard thing to to 

810
00:49:57,680 --> 00:50:01,840
think about as the young medic 
and someone dies very much will 

811
00:50:01,840 --> 00:50:05,440
blame yourself may have done 
everything right and and as I 

812
00:50:05,440 --> 00:50:09,920
believe a good job was done on 
this patient and they were the 

813
00:50:09,920 --> 00:50:14,040
patient was diagnosed rapidly. 
The guidelines were followed 

814
00:50:14,040 --> 00:50:17,840
pretty comprehensive care, more 
comprehensive care than probably

815
00:50:17,840 --> 00:50:21,280
was within hundreds of 
kilometres from this patient. 

816
00:50:21,320 --> 00:50:26,440
The anti malarial treatment was 
given, patient still died and 

817
00:50:26,440 --> 00:50:29,320
this is a reality of medicine in
austerity environments. 

818
00:50:29,880 --> 00:50:32,760
Sometimes the disease has 
progressed too far beyond what 

819
00:50:33,480 --> 00:50:35,680
you or the patient or anyone 
else can see. 

820
00:50:35,800 --> 00:50:39,720
Three weeks of untreated 
Plasmodium farciferum malaria in

821
00:50:39,720 --> 00:50:45,000
a man in his mid 50s or early 
50s had caused irreversible 

822
00:50:45,000 --> 00:50:46,560
damage. 
This point. 

823
00:50:46,560 --> 00:50:49,760
The truth is is there was likely
nothing I could do to fully 

824
00:50:49,760 --> 00:50:53,360
reverse this patient. 
The likelihood of the patient 

825
00:50:53,400 --> 00:50:59,560
actually oxygenating enough with
the parasitic load was was very 

826
00:50:59,560 --> 00:51:04,280
low and the what was done gave 
the patient the best chance. 

827
00:51:04,280 --> 00:51:07,800
Still was was going to die 
unfortunately. 

828
00:51:07,840 --> 00:51:11,360
And that's something you know, 
as as a question to you is does 

829
00:51:11,360 --> 00:51:15,240
this patient die? 
Does that mean the clinical care

830
00:51:15,240 --> 00:51:17,480
had failed? 
You know, how do you separate 

831
00:51:17,480 --> 00:51:21,600
the quality of the clinical 
decision making from the 

832
00:51:21,600 --> 00:51:24,360
outcome? 
And what does that distinction 

833
00:51:24,360 --> 00:51:29,160
mean for how we evaluate 
performance in austere medicine?

834
00:51:29,280 --> 00:51:32,640
You know, something to something
to give yourself as a as a 

835
00:51:32,640 --> 00:51:36,640
question and to kind of hold in 
the back of your mind that way 

836
00:51:36,800 --> 00:51:40,880
you don't have a moral injury, 
you know, especially one that 

837
00:51:41,000 --> 00:51:44,440
wasn't earned on a patient like 
this when doing the correct 

838
00:51:44,440 --> 00:51:46,520
thing. 
One thing I didn't talk about 

839
00:51:46,520 --> 00:51:51,040
was nursing care interventions 
for this patient, but what were,

840
00:51:51,040 --> 00:51:54,200
what would some of the top 
nursing care interventions that 

841
00:51:54,200 --> 00:51:56,520
you would see need to be 
employed on this patient? 

842
00:51:56,520 --> 00:52:00,760
So if you're not familiar with 
nursing care interventions, I 

843
00:52:00,760 --> 00:52:03,160
truly I don't like calling it 
nursing care. 

844
00:52:03,160 --> 00:52:05,520
It's not my favourite term for 
it. 

845
00:52:05,520 --> 00:52:10,040
I think it kind of cheapens the 
role of what a nurse does. 

846
00:52:10,120 --> 00:52:13,280
It's care that can be performed 
by anyone and everyone. 

847
00:52:13,280 --> 00:52:20,400
It is predominantly performed by
nurses, but some people feel 

848
00:52:20,400 --> 00:52:23,640
it's below them. 
Oh, it's nursing care and I they

849
00:52:23,640 --> 00:52:26,040
may be a mid level practitioner 
or physician. 

850
00:52:26,040 --> 00:52:28,720
If you're all that's there and 
still your your care to do 

851
00:52:28,720 --> 00:52:32,600
specifically patients like this 
is you have to worry about the 

852
00:52:32,720 --> 00:52:36,960
oral care of these patients 
worry about suctioning. 

853
00:52:37,280 --> 00:52:42,400
You have to one thing to really 
pay careful attention to the 

854
00:52:42,400 --> 00:52:46,560
pressure within the ET tube of 
this patient. 

855
00:52:46,840 --> 00:52:50,200
If you just fill it up to 10 ML 
because that's what you were 

856
00:52:50,200 --> 00:52:54,640
taught in paramedic school or as
you innovate, you're likely to 

857
00:52:54,640 --> 00:52:57,160
cause tracheal escape on these 
patients. 

858
00:52:57,160 --> 00:53:00,480
And that's a whole nother 
problem since you're, you're 

859
00:53:00,480 --> 00:53:05,400
creating an internal tourniquet 
in that trachea and the 

860
00:53:05,400 --> 00:53:09,280
pressures that can be 
administered through the ET tube

861
00:53:10,080 --> 00:53:13,360
are four or five times the 
appropriate amount on their 

862
00:53:13,360 --> 00:53:15,880
nifty resource. 
They do have some really cool 

863
00:53:15,880 --> 00:53:20,480
syringes that have actual a 
manometer in them and you can 

864
00:53:20,480 --> 00:53:24,960
measure what it's at, but and it
is the size of the ML syringe. 

865
00:53:26,360 --> 00:53:31,400
But to likely have that, I 
rarely see one and usually I 

866
00:53:31,960 --> 00:53:35,400
it's somebody brings one with 
them and there's usually only 

867
00:53:35,400 --> 00:53:37,720
one. 
Another way that you could do 

868
00:53:37,720 --> 00:53:42,640
this is actually after you 
confirm placement on this 

869
00:53:42,640 --> 00:53:46,080
patient and you come back, 
secure the tube, everything's in

870
00:53:46,080 --> 00:53:51,240
place, deflate the cuff and 
reflate it with 10 MLS and then 

871
00:53:51,240 --> 00:53:56,760
hold the, the syringe onto the 
bulb and let it equalise in 

872
00:53:56,760 --> 00:53:59,480
pressure. 
And there is a CRNA programme in

873
00:53:59,480 --> 00:54:03,000
the United States military out 
of a military hospital called 

874
00:54:03,000 --> 00:54:08,080
Womack and they showed that that
is very closely getting on 

875
00:54:08,080 --> 00:54:11,080
target for what the right cuff 
pressure is supposed to. 

876
00:54:12,080 --> 00:54:15,120
And you just let that equalise. 
Once it equalisers, you 

877
00:54:15,120 --> 00:54:18,960
disconnect it from there and do 
continue to watch your patient. 

878
00:54:19,160 --> 00:54:21,840
But that's the recommendation 
they have. 

879
00:54:22,040 --> 00:54:24,320
So key learning points. 
Let me do this together. 

880
00:54:24,360 --> 00:54:26,720
Lots of learning points from one
case. 

881
00:54:26,840 --> 00:54:31,120
The 1st and most important thing
is disease is deceptive. 3 weeks

882
00:54:31,120 --> 00:54:36,880
of flu like symptoms, talking 
under your your own power, DCS 

883
00:54:36,880 --> 00:54:42,800
of 50 and outrageous lack. 
Don't let that over assure you 

884
00:54:42,800 --> 00:54:46,240
that the patient isn't 
critically I'll just by initial 

885
00:54:46,360 --> 00:54:49,480
patient presentation look at 
that whole picture. 

886
00:54:49,680 --> 00:54:53,720
Second, your blood gas know that
the difference between VB GS and

887
00:54:53,720 --> 00:54:57,840
AB GS drug selection matters. 
It did not only in the austere 

888
00:54:57,840 --> 00:55:05,000
set the clinical course of our 
patient and what's going on them

889
00:55:05,000 --> 00:55:11,840
and again back to the vectorium 
versus and also the ketamine 

890
00:55:11,840 --> 00:55:15,640
versus a drug like propofol in 
the patient in that ventilatory 

891
00:55:15,640 --> 00:55:17,680
management is not just about the
lung. 

892
00:55:17,760 --> 00:55:21,080
So in a patient with severe 
metabolic acidosis that the 

893
00:55:21,080 --> 00:55:25,640
ventilator is also part of the 
acid base management and also we

894
00:55:25,640 --> 00:55:30,280
didn't get too much to it, but 
venous return as the way we 

895
00:55:30,280 --> 00:55:34,360
normally breathe for negative 
pressure that help augment his 

896
00:55:34,360 --> 00:55:39,000
return in a hemodynamically 
unstable patient as we now put 

897
00:55:39,000 --> 00:55:44,720
positive pressure clear Tampa 
nodding venous return and and 

898
00:55:44,720 --> 00:55:48,920
actually impacting that a bit. 
Again, a patient that's 

899
00:55:48,920 --> 00:56:00,200
hemodynamically unstable, the 
one thing to augment cardiac 

900
00:56:00,200 --> 00:56:04,240
output is and that's exactly 
what we're disrupting. 

901
00:56:04,360 --> 00:56:07,600
All right. 
In most powerful intervention in

902
00:56:07,600 --> 00:56:10,880
this case was not the 
innovation, it was not the vase 

903
00:56:10,880 --> 00:56:15,120
suppressor or the antimalarial. 
Most powerful intervention was 

904
00:56:15,120 --> 00:56:19,560
really the recognition that the 
moment that it the take this 

905
00:56:19,560 --> 00:56:23,200
patient and go all this patient 
is sick and not only sick but in

906
00:56:23,200 --> 00:56:29,960
sepsis and they are on a razor 
thin edge here that recognition 

907
00:56:29,960 --> 00:56:33,240
is is everything it stops 
delayed treat. 

908
00:56:34,880 --> 00:56:38,320
It allows you to start 
culminating the resources you 

909
00:56:38,320 --> 00:56:43,280
need to getting things in motion
and especially in the steer 

910
00:56:43,280 --> 00:56:47,480
environment to get a critical 
care team to me at that point in

911
00:56:47,480 --> 00:56:52,680
the best of situation is minimum
6 hour and much likely many 

912
00:56:52,680 --> 00:56:55,480
times in that situation was 
actually 24 hours. 

913
00:56:55,600 --> 00:57:00,400
So even delaying the recognition
by three to 4 hours can greatly 

914
00:57:00,400 --> 00:57:03,520
affect my on there. 
All right, I have some 

915
00:57:03,520 --> 00:57:07,040
references if you want to see 
some of where the, you know, 

916
00:57:07,840 --> 00:57:10,200
kind of read in on some of these
things. 

917
00:57:10,320 --> 00:57:14,720
Ards net on here. 
There's kind of multiple other 

918
00:57:14,720 --> 00:57:18,400
publications that you can hunt 
down and read and I believe most

919
00:57:18,400 --> 00:57:20,240
of them are open source at this 
point. 

920
00:57:20,240 --> 00:57:25,080
You can find them somewhere, but
do give those a read and at that

921
00:57:25,080 --> 00:57:30,560
point, I'm going to turn this 
back over to a brick and answer 

922
00:57:30,560 --> 00:57:33,240
any questions that you may have.
Fantastic. 

923
00:57:33,320 --> 00:57:36,720
And that's one of the most 
difficult cases of malaria I've 

924
00:57:36,720 --> 00:57:39,720
ever heard someone present. 
So that's we have some time. 

925
00:57:39,800 --> 00:57:43,480
Who's got some questions. 
This has been a presentation 

926
00:57:43,600 --> 00:57:45,960
from the College of Remote and 
Offshore Medicine. 

927
00:57:46,480 --> 00:57:50,360
If you would like to earn CPD 
credits for this podcast, you 

928
00:57:50,360 --> 00:57:54,000
can join the council of members.
Being a member of the College 

929
00:57:54,000 --> 00:57:57,880
gives you free CPD credit, free 
access for our Virtual field 

930
00:57:57,880 --> 00:58:00,720
guide, and discounts on our 
e-learning courses. 

931
00:58:01,120 --> 00:58:06,080
You can join the team on our 
College website at quorum.edu 

932
00:58:06,280 --> 00:58:07,040
dot Mt.