Rural Doctors Net



I am putting this one up more to invite contributions from the community. It’s a case that has been included for our PRCC students – the guys who spend the entire third year of their four year graduate entry medical degree attached to a rural community (the so-called parallel rural community curriculum).

Time will tell whether this initiative translates to a career in rural medicine. However one thing is clear, the PRCC students are far more likely to get hands-on experience, whether it be doing minor gynae procedures, assisting at a LSCS, basics of airway management, assessment of undifferentiated patients in the ED or having own consulting sessions.

This week’s problem-based learning session is on a neonate with breathing and feeding difficulties. As an experiment, I am putting the case up and hoping that #FOAMed enthusiasts will be able to comment – because I’d love to demonstrate the power of #FOAMed to these rural students. So come on, don’t disappoint me…

Here’s the case

Hamish is 6 days old. He was born at 38 weeks as the second child to his 29 yo married mother. Antenatal course was reportedly unremarkable. Birth weight was 3 kg. He was discharged on day two after delivery, formula-fed and with an unremarkable ‘baby check’ by the obstetric RMO.

He presents to the hospital with parental concern that “there’s something wrong with my baby”. Mum reports difficulty in breathing and feeding (60ml of formula 5 x per day).

In terms of other history, birth parents and Hamish’s elder 4 yo brother are well with no medical problems. A paternal uncle died at 2 weeks of age from ‘hole in the heart’

On examination, Hamish looks ‘crook’ – he is pale, peripherally shut down. He is NOT cyanosed and appears afebrile. He is lethargic and sweaty. RR is 100 with intercostal recession HR is 150 with palpable upper limb pulses but the attending doctor reports difficulty with lower limb pulses. BP 63/40 arm, 45/30 leg. Heart sounds are dual with S3 gallop. There’s a ejection systolic murmur at the LSE grade 1-2/6. There is palpable firm hepatomegaly 4cm below costal margin.

I am interested in how the #FOAMed community would

(i) assess this child and come to a differential?

(ii) investigate and manage, from small rural hospital through to specialist centre?

(iii) what resources could be helpful along the way…

Over to you…



  1. rfdsdoc says:

    Reblogged this on PHARM and commented:
    Help out Tim please!

  2. Amanda says:

    Oh dear, am thinking a co-arctation of the aorta, with elements suggesting heart failure and shock which will be progressive. Other differential would include a L to R shunt (accounting for the lack of cyanosis) but would less explain the lack of lower limb pulses.

    I would cease oral feeds for now, reduce cardiac workload as much as feasible and get advice from a neonatal specialist. It may be difficult to get an IV line if the treating doc is inexperienced, or if baby is peripherally shut down, so get an intraosseous line in. REFER with a skilled retrieval team to a tertiary unit. remember to keep checking BSLs and temp. If another differential is sepsis, may need ABs.

    Great experience to be a rural medical student or junior doc, what does not kill us only
    makes us stronger!

  3. rfdsdoc says:

    This baby is sick = evacuate to neonatal centre
    Call early and request specialist neonatal retrieval team
    Get em on phone to describe case. Record video of breathing pattern and general look of baby and message it to on call neonatal consultant heading retrieval team.

    Sick babies < 7 days old = sepsis or weird shit going on
    IV access early..might still be able to use umbilical stump..ask the experts about this!
    IV ABs = ceph du jour and gentamicin and ampicillin for listeriosis

    The clinical picture looks cardiac with systolic murmur and hepatomegaly which is always heart failure in sick kid till proven otherwise ( like +ve malaria smear or leishmaniasis..or TORCH +ve screen..remember for exams folks but forget afteryou qualify 😉

    The upper limb pulses present but absent lower limb pulses = textbook exam case for coarctation of aorta
    All academic because your job as remote doc is keep kid alive till cavalry arrives

    ABCs in a baby
    give oxygen first
    nasal CPAP would be great if possible..if not formally available, place nasal cannula and titrate O2 flow to SaO2. Get kid to suck on dummy and you might even generate some PEEP.

    If you got something fancy like a NeoPuff gas driven resuscitator then some mask CPAP is possible with it..just ensure you got plenty of O2 supply to run it!

    Get advice from Neonatal doc re use of heart failure medications whilst awaiting your CXR to develop.

    Place IDC and NGT( helps decompress stomach full of swallowed air and improve diaphragmatic excursion)
    Prepare for worst case – setup and discuss advanced airway plan ( this maybe just LMA, ETI is best but take what you can get!) . Draw up resus drugs

    VBG might help you track if things are getting worse but might also just make you more anxious!

    RSI in a kid like this is extremely high risk. Know of a similar case remotely years ago and kid died perintubation. Lots of things can go wrong in these intubations! My strategy nowawadays is to place a LMA v quickly and stabilise the situation with PEEP and IPPV. If stable on LMA then leave it in, deflate cuff and tube over it whilst running O2 down via LMA ( CPAP mode of a Neo Puff or just stick an O2 tubing down the LMA and run it at 3-4L/Min carefully
    So wait for backup! But get all setup in case things spiral quickly into crisis!

  4. Ewen McPhee says:

    “What Minh Said”

    I’ve “missed” a couple of these representing a couple of weeks. Signs can be subtle at first until Ductus closes and pressures/resistances change.

    Tacchypnoea and poor feeding are early signs.

    Call PICU, consider Telehealth and get the Paediatric in the room.

  5. Rachrwlnds says:

    Arrange transfer to tertiary centre ASAP
    Commence prostin- baby doesn’t need to be intubated for this.
    Treat for sepsis with antibiotics guided by local policy.
    NBM and ng tube to decompress stomach.
    IO can be used for Ab’s but you will need a cannula for the prostin- scalp veins are often visible even if shut down peripherally.
    As for #FOAMped well most tertiary centres will have local policies on line so know where to find them. is a collection of podcasts on PEM topics and has one on how to approach the collapsed neonate.

  6. gerryconsidine says:

    I’ll write this from my perspective as a GP registrar in the country without anaesthetics training.

    Sick bub, so back to first principles, DRABC.

    D: keep crazy nurses away, might need to consider family, maintain as calm an environment as possible.

    R: eyes following?

    A: keep airway clear, no need for head tilt at this age. Consider nasopharyngeal airway. Not sure if ETT is a good idea, maybe a tiny LMA?

    B: High flow oxygen via mask, attach sats probe, assist breathing with appropriate bag/mask ventilation

    C: Look for IV access, might be able to use umbilical/scalp vein. If slim pickings, go for IO. For kids 20ml/kg and repeat as needed. Care in this bub as he looks to be in cardiac failure. Take some bloods for culture or an iSTAT if you can for electrolytes.

    D: AVPU, lethargic, responsive to voice?

    E: temperature, BGL, examine for rashes or bruises

    Further mx: Empirical antibiotics ceftriaxone 100mg/kg, have defib ready 4J/kg, call other doctors in for help if available. Grab my APLS manual and see if I’m forgetting anything

    Call for help. This baby has outstripped the capabilities of the country ED. MedSTAR Kids are just a phone call away, 13STAR (137827). In some EDs there is the option of video conferencing. They can then help with any procedures you might need to do while the team comes to meet you.

    – Infection, think of TORCH, perhaps too early for meningiococcal?
    – Ductal co-arctation, right timing for closure of ductus arteriosus
    – Other funky things, metabolic problems, congenital lung disease

  7. says:

    Yep, infection, primary lung or cardiac disease & weird metabolic stuff are the forefront for sick neonate.

    What do you think of BP inequality. Should arm = leg?

    Meanwhile will add some more info….

  8. this looks like a tipical aortic coarctation (pulses, murmur, s3) with already clinic of heart failure. Take At and pulses in four limbs, thoraxxr, ekg and consider vasoactive drugs (dopamine 5-10mcgr/kg/min and diuretics. def treatmen is surfical says:

    Nice! Thanks

    • this looks like a tipical aortic coarctation (pulses, murmur, s3) with already clinic of heart failure. Take At and pulses in four limbs, thoraxxr, ekg and consider vasoactive drugs (dopamine 5-10mcgr/kg/min and diuretics. def treatmen is surfical says:

      And of course Use always the pediatric triangle and the Abcde sequence

  9. says:

    OK, managed to get in an IO (failed IV x 2)

    Did think about scalp veins – but which way to insert? Towards vertex of head? Or towards the body?

    CXR is cooking

    Managed to draw an ABG

    pH 7.30
    pO2 107 mmHg
    pCO2 20 mmHg
    BE – 15 mmol/L
    Bicarb 9.6mmol/L

    iStat Na and K – hypo Na at 125, K is 6.5

    Should I be worried?

    Glucose at least is 7.1

    Mum is having conniption fits asking

    “Is he going to die like my little brother did?”

    and dad is getting aggressive

    “why wasn’t this picked up on antenatal scans or in the baby check before discharge?”

    Retrieval will take another 60 mins to arrive…

    • Rachrwlnds says:

      Scalp veins- towards the body but you can block and milk vein to double check.
      Age and presentation typical of a coarctation which often only becomes evident as the duct closes. You need prostin if at all possible. This baby is in failure and too much fluid will make it much worse. Low Na probably due to this. Give Ab’s to cover sepsis. In UK we wouldn’t use ceftriaxone in this age group, and you need to cover for listeria also.
      60 minutes isn’t too bad- baby obviously isn’t in WA!! 🙂

  10. gerryconsidine says:

    Wouldn’t want those electrolytes to get further out of whack. But is it worth doing anything about them? I probably wouldn’t have thought so. Again, I would ask retrieval team for advice about electrolytes. ABG looks reassuring to me, but bub is working really hard to keep it like that.

    Explain to the parents that we need to focus on bub right now to best treat them. Can look at screening etc later. Ask your most calm nurse to get them to a quiet room and have a chat. If the Dad continues to be aggressive, discreet call to the local police.

  11. caseyparker207 says:

    As stated above. All sensible
    My only additions:
    Check pre and post ductal SpO2 and observe if any change with oxygen

    Kid needs septic screen, IV ABs and I think empirical Prostaglandins would be a fair thing to do en route to somewhere better

    Fun n games in neonatology 😦

  12. Some great suggestions all round.

    Although it sounds like a cardiac case must always consider/cover for sepsis at this age. As well as ceftriaxone don’t forget to cover listeria with ampicillin/gent.

    First thing is this sounds like a ductal dependent circulation. They tend to be cynotic (transposition, TOF, pulmonary atresia etc) or CVS collapse with signs of heart failure (coarctation or aortic interruption, aortic/mitral atresia, hypoplastic left heart).

    Given normal antenatal hx and presentation it would seem that coarctation/interruption most likely. Would be interesting to see pre/post ductal SpO2. I suspect PDA ~closed hence deterioration and likely small difference. PGE2 infusion likely to benefit **BUT** you must understand things are likely to get worse before they get better with PGE2!!! They will hypoventilate or become apnoiec so you are pretty much commiting yourself to intubation. Hypotension, twitching and convulsions also reported. But its the apnoea issue you must be prepared for if you weren’t already given how sick they are. In my n=1 experience we had to intubate ~10mins after starting it. Some would suggest prophylactically intubating if PGE2 is to be started.

    Interesting case and something we hope not to see too often as non-neonatologists.


  13. doc shardy says:

    Sounds very scary. Agree with all the above excellent clinical. I might add a useful mneumonic I use for sick babies “THE MISFITS”: different pathologies in the ill neonate (Trauma, Heart disease/Hypovolemia, Electrolyte imbalances, Metabolic disease ex. congenital adrenal hyperplasia, Inborn errors of metabolism, Sepsis, Formula-related, Intestinal, Thyroid, Seizures). Also, would consider a 5 french catheter to cannulate the umbilical stump for a more long term resuscitation line.

  14. Rachrwlnds says:

    Personal experience of PGE2 is that if lower dose (<15) they often don't need intubation. Interesting article here about the risk benefit of tubing prior to transport.
    Essentially if this is a coarctation the PGE2 may be what keeps them alive for the 60 minutes.

  15. inseiffolliet says:

    Most bases covered by excellent commenters. A cxr would help as well for possibility of a diaphragmatic hernia. The severe end of the spectrum clearly just don’t survive but moderate function, shunting and holding on might still make it. Pre and post ducal sats?

    Either way, he’s gonna need help real soon with that resp effort.

  16. says:

    OK, thanks everyone. I may encourage the students to post some questions in a few days over specifics.

    Kids Retrieval service arrived, started prostaglandin E1 to open ductus arteriosus and re-establish systemic circulation. Also received dopamine, diuretics and PEEP via mechanical ventilation.

    Some Qs of my own :

    Does dopamine really help?

    A few people mentioned measuring pre- and post-ductal SpO2. Presume that entails oximetry from upper vs lower extremities? I know we measure newborns SpO2 from R arm….

    Meanwhile, any good FOAMed resources on

    – Normal vs Abnormal neonatal paediatric parameters, how to ‘spot the sick’
    – Cognitive aids like Broeslow, Cookcsley card, online calculators for paeds dosing
    – learning aids / videos on congenital heart disease inc coarctation?

  17. Rachrwlnds says:

    You ask and we shall aim to provide 🙂

    as previous has podcasts on lots of common presentations and is in small bite sized chunks (COI- I may appear on some!)
    In Australia the local tertiary centres all have great websites with local guidelines and how to get advice sections.

    I look forward to the next case.

  18. says:

    Rachel, thanks – and the excellent StEmlyns blog are good to search

    Like this one too from the mob

    In addition to passive reading of blog posts, I love the way comments such as those in this thread and the (not shown here) twitter discussion on the case can enrich understanding and embed knowledge for next time around….

    Viva la FOAMed!

  19. says:

    Thanks Nat for wading in via calls from Twitter….

    Yep, I wondered if anyone would consider beside USS

    McCaskills neonatal nightmares talk at SMACC2013 is good for a broad brush approach to ‘badness’ in these mites…I wonder if any medical students will be encouraged to come along to SMACC GOLD next year for cutting edge FOAMed?

  20. rfdsdoc says:

    Here is my view on dopamine. Get rid of it!
    We had this debate in QLD retrieval and RFDS a couple of years ago and we decided to get rid of dopamine. Some paediatric centres still insisted to have it but its up to them to bring it in their kit rather than us stock it as standard.
    We got advice from some paediatric anaesth/crit care docs and they basically said norad or adrenaline are fine in short term of transport to ICU. Dopamine as far as I can tell is a historical relic and after listening to Prof Myburgh at SMACC 2013, I think he agrees as well!

  21. Rachrwlnds says:

    The problem with inotropes is that this heart is pumping against an obstruction and inotropes won’t fix that. The may just make it pump harder against the restriction. Opening the duct may give some relief. A cardiac surgeon once described the duct in a coarctation to me as a tie tightening round an already narrow aorta. Loosen the tie and flow may improve.
    AFTER this baby is fixed it will need a pile of inotropes and in my experience- unlikely to be dopamine.
    So in reality- don’t waste the one line on dopamine- get in some prostaglandin and try to ‘relax the tie’.

    • Great analogy! I have to agree that prostaglandin would be my priority over inotropes, baby will LLS until cardiac probs fixed so focus on transfer unless peri-arrest (in which case adrenaline will do). Can never remember the PGE1 dose so it’s one of a few important but less common ones (with adenosine, atropine, mannitol & bicarb) I keep in a note on my iPhone for quick reference. Also if you live in the UK the BNFC app is free, great and much quicker than flicking through a paper version…

      • Rachrwlnds says:

        The South Thames Retrieval service app I quoted above includes prostin infusions and lots of handy advice on making up infusions etc. It’s £1.99 well spent!

  22. This is a great post because it is not asking for a solution but an approach.

    I am not going to be able to better my colleagues (and friends!) comments above in terms of clinical practice. As a latecomer to the party I would only add this:

    Can the person (wherever they are) recognise this patient is sick?

    Does the person (wherever they are) understand why the patient might be sick?

    If they can recognise (wherever they are) that sepsis/cardiac are top of the list can they act on:
    i) what they can do practically (access/ABs)
    ii) what they can’t do practically (maybe have any understanding of cardiac physiology)
    iii) what they need to do (get advice / get prostin / get to help)

    I think that the only damage that will come to this child is if you can’t answer the above questions – you don’t need to know the dose of PGE1 or have ever heard of dobutamine to get this child help.

    Looking forward to more of these!

  23. Hi Tim better late than never from NZ here,
    Not much to add medically but few observations from time doing paeds esp NICU.
    When I was doing some NICU in holland they used to had a semi designated parent support. Usually a senior nurse or doctor who was supernumery (not often a situation in KI)
    Its amazing how much this helps both at the time (less yelling agro ect) and later down the line.
    In regards to dad, honesty has always been my policy most people respond well to “We dont exactly know whats wrong yet but are doing everything we can.”
    For the students these are great learning situations, being in the room and observing how its run, who makes what call ect. Good debrief (formal or informal) and discussion is vital to this.

  24. says:

    OK, ran the tute for PRCC students just now – bit difficult doing a tutorial over videolink, more so when can’t file share…

    Reckon we’d be better off doing it as a Google Hangout – but apparently this would cause the University IT Dept to explode.

    Will be interesting to see if any of the keener students pick up on the FOAMed revolution and either post here or take the plunge and use twitter…

    VIDEO OF THE PRESENTATION TO STUDENTS (emailed at the end of the tute) is HERE

    Sad Case of Hamish M from Tim Leeuwenburg on Vimeo.

  25. DrSooze says:

    As a student from said PRCC and a recipient of the excellent tute by Dr Tim, I would just like to thank everyone for their postings.

    Illuminating and exciting to see this kind of response with this kind of immediacy.

    Fascinating to ‘take the pulse’ on everyone’s responses.

    PS Hamish has just survived transfer, been admitted to NICU and undergone surgery….

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I am a Rural Doctor on Kangaroo Island, South Australia with interests in EM, Anaes & Trauma. I am an Ass/Prof in Aeromedical Retrieval with Charles Darwin University and hold senior specialist (retrieval) positions in NT and QLD Avid user & creator of #FOAMed; EMST & ATLS Director, Instruct & Direct on; faculty for Critically Ill Airway course and smaccAIRWAY workshops. Opinions expressed on these sites must not be used to make decisions about individual health related matters or clinical care as medical details vary from one case to another. Reader is responsible for checking information inc drug doses etc.

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