• clinical assessment
• emergency department

It has been a quiet week in Lakeside Emergency Department. On Monday one of the patient helpers had a fit at the hydrotherapy pool. Luckily she was not in the water. Her lactate was 13 when she was brought to us. She went home later. On Tuesday we admitted a young woman with a reduced level of consciousness, a metabolic acidosis and a raised lactate. A brain scan was unremarkable, and she got better with intravenous fluid. She was diabetic, on metformin, and had had too much to drink the night before. On Wednesday the Medical Reg asked me to see a lady with an infective exacerbation of chronic obstructive pulmonary disease (COPD). He was going to send her home but she had a lactate of 8 mmol/L, so he wanted to admit her. The Acute Medical Unit staff wouldn’t accept her because of the high lactate. She was sitting on the edge of the trolley chatting to her daughter and eating a pear. She went to the ward. On Thursday a man presented with diarrhoea, vomiting and abdominal pain. His early warning score was not elevated, and he felt much better after analgesia and some intravenous fluid. He was referred for admission because his C reactive protein and lactate were high. In the morning he had a cardiac arrest. Postmortem blood cultures grew Neisseria meningitidis. On Saturday a lady in her sixties was brought in vomiting and feeling unwell after going out for dinner. Her initial lactate was 4 mmol/L, and she didn’t look well. After some fluid she felt better but her lactate had increased to 7 mmol/L and she had a coagulopathy. By the time she reached the intensive care unit (ICU), she had painful fingers and toes and widespread purpura. She deteriorated rapidly and died of multiorgan failure. …