EMU Monthly – April 2015

All the EMU Goodness for April 2015

Ah, it’s April. What can one say about April? Let us quote Edna Saint Vincent Millay:

image001Life in itself
Is nothing,
An empty cup, a flight of uncarpeted stairs.
It is not enough that yearly, down this hill,

April
Comes like an idiot, babbling and strewing flowers.
Life in itself
Is nothing,
An empty cup, a flight of uncarpeted stairs.
It is not enough that yearly, down this hill,

April
Comes like an idiot, babbling and strewing flowers
Life in itself
Is nothing,
An empty cup, a flight of uncarpeted stairs.
It is not enough that yearly, down this hill,
April

Hyperoxia Post-Arrest

Comes like an idiot, babbling and strewing flowers . (That’s Edna enjoying April) And April of course, is not only showers, and flowers, but also National Hyperoxia Month. And this is what you generally do when you resuscitate patients. And you should probably stop. There is more mortality with hyperoxia in ROSC patients, although neuro outcome was similar (probably because it is poor in any case) ( Resusc 85(9)1123) However, this was a meta analysis of 14 studies and even the authors accept the fact that results were all over the place and that patients were dissimilar- it is hard to generalize- what if some were COPDers? Elderly versus younger? However, I do believe too much of anything is not a good idea.

TBTR: Easy on the oxygen in cardiac arrest. Life in itself

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Weird Flora and Lacerations Sustained in the Water

It wasn’t too long ago that we discussed aquatic infections (use the handy dandy search option on the website) but here is another article on the same subject. Is nothing, They just add here some bugs I wasn’t aware of: Erysipelothrix rhusiopathiae, and Mycobacterium marinum. Now I knew Chris Nickson knew this and probably has neighbors with those names, but my point here is that if you see an infected hand – ask about water activities and remember these are generally weird bugs- and don’t forget Vibrios, Aeromonas, and Strep pyogenes. Some actually may need HBO( J Hand Surg AM 39(8|)1623)

TBTR: Think of weird flora when you are dealing with water injuries.

Collapse During Marathons

Are you a marathon man?

image004These people do die while competing- the question is why. Well, it is true that this is rare (0.0054%) but while the earlier papers seemed to point to HOCM and hyponatremia as cause; this paper says heat stroke is much more common ( JACC 64(5)470) However, this paper was done in Tel Aviv and of course, accounts for just summer marathons in temperate climates- but that is when most marathons are held.

TBTR: Collapse during marathon running is often due to heat stroke.

Steroid Allergies?

Writing EMU all these years has made me somewhat more intelligent –IQ now moron instead of idiot (although the job opportunities for a village idiot were better than being a village moron) but I honestly don’t know what to do in this case. People can have allergic reactions to steroids. It is rare but occurs. Say they have anaphylaxis- OK, I give my epi. Antihistamines don’t do much, but OK. But what about something instead of those potent steroids. There is a possibility this is from one kind of steroids and another may not cause this reaction, but this article doesn’t think so. ( Clin Rev All Immun 27(1) 26) So what is the next step?

TBTR: Steroid allergy exists. Probably not a good idea to treat with Solucortef.

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Dolly Parton is a country music legend ( that’s Dolly, not Edna). But some of her quotes indicate she is a pretty smart cookie. Let’s take a look:

I tried every diet in the book. I tried some that weren’t in the book. I tried eating the book. It tasted better than most of the diets

Impetigo

Nice review of impetigo. It comes in two flavors- the honey colored crusts we all are familiar with and the bullous type. The former is caused by Strep Pyogenes and the latter – exclusively Staph. Fusidic acid and mupirocin are effective and they say much more so than disinfectives (I think they mean antiseptics). That seems strange to me. Oral antibiotics also work, but be careful with all this: MRSA and mupirocin resistant strains exist. For my Israeli readers- they love Bactorban in this country and use it for every scratch. So we have reported in the past that resistance develops quickly- so please don’t use this routinely. They mention some natural treatments, as usual – no evidence to say one way or the other (they include: tea tree oil; olive, garlic, and coconut oils; and Manuka honey) (Am Fam Phys 90(4)229).

TBTR: All you needed to know about Impetigo but where afraid to ask. “I’m not offended by all the dumb blonde jokes because I know I’m not dumb – and I’m not blonde either.”

Sepsis & Fluids

Sepsis- fluids, get that lactate down, yadda yadda blah blah blah. This fellow has the audacity to say that maybe fluids are not to be given in sepsis. He bases this on the FEAST trial which compared albumin with saline with – surprise- nothing at all did the best- much less mortality. Now even the author admits that this was done in Africa in resource poor places in kids and many had malaria – but at least the idea is on the table. (BMJ 349 G4611). Now those of you who like ICU – I am one of them – should look up Scott’s ICU podcasts and the IC network and I believe I saw whispers about this idea on this site, but hopefully, Scott is reading this rag (EMU) and can tell us more. I believe that sepsis is probably a heterogeneous disease and it maybe hard to generalize. Here is what our peer reviewer says: We have to be careful before we throw out fluid resuscitation. Even if one study was not able to show benefit, countless studies have shown that the  best intervention to decrease mortality in severe sepsis/septic shock is early aggressive fluid resuscitation. Maybe we need more studies. PS: I still use fluids. These results may be connected to what type of fluid used, for how long, what co morbidity there is etc.

TBTR: Are fluids still the treatment for sepsis? Scott?

My weaknesses have always been food and men – in that order.

Clinical case

No way will you get this, but I liked the DDX. This is a 75 year old lady will falls and a vertebral fracture treated with steroids. She rapidly progressed to coma. No fever. They did a CT and LP – the latter showed a slightly elevated WBC and high protein, the former multiple enhancing nodular lesions in the chest abdomen and brain. She received steroids and antibiotics, but decided to die three days later. Mets is in the first place, infections – like TB – also. Sarcoid, Wegner’s granulamtosis, Churg Strauss, heavy metals, chronic alcoholic disease, drug abuse (yea, she was 75 and shooting up at the nursing home???) but all of these were not the answer- one positive blood culture gave us the diagnosis.. What was it?

People always ask me how long it takes to do my hair. I don’t know, I’m never there.

Ticagrelor and Clopidogrel Allergy

Ok I agree- no evidence here, but it is from the pharm lit and they are supposed to know how meds work. If someone has an allergy to clopidgrel, the believe – and they tried it with two patients – that they can get ticagrelor (Brillinta) (Pharmcother 34(8)E 152). I spoke to my cardiologists and they agreed.

TBTR: You may be able to give Brillinta to Plavix allergic patients.

I was the first woman to burn my bra – it took the fire department four days to put it out.

Ketonuria in Hyperemesis Gravidarum

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Ever get that feeling that you do not what to do? Ketonuria is not a marker for severity of Hyperemesis Gravidarum. Is nothing scared? H Pylrori maybe a marker. (AJOG 211(2) E1) What do I do? Give them fluids – including sugar (we saw this a few months ago in EMU) and see if they can eat and drink.

TBTR: No need to check urine for ketones in H gravidrum.

If I see something saggin’, baggin’, or draggin’, I’m gone have it nipped, tucked, or sucked!

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Gout

Nice review of gout treatments. NSAIDS = colchicine = steroids IM or po but they do want you to know that low dose colchicine – that is starting with 1.2 mg and continuing with 0.5 in an hour is as effective as higher doses with less side effects( Sem Arth Rheum 44(1)31)Truth be told – this is a Cochrane 2014 I like intra joint steroids with bupiviciane but they didn’t mention intralesional steroids.

TBTR: Use low doses of colchicine for gout.

It takes a lot of time and money to look this cheap, honey

Antibiotics and Sinusitis

They call this a teachable moment – I call it one of two things- either this is a doctor who doesn’t read EMU or he is an idiot. (Although to make things clear- you can still be an idiot and read EMU. Or even better- you can be an idiot and write EMU) He gave this patient with sinusitis antibiotics – OK , maybe because he was taking infliximab- but the guidelines are clear – most sinusitis is viral and only if the area is red and tender and the symptoms lasts for ten days with purulent discharge wit fever, or gets better then worse do we start antibiotics ( to see the article guidelines see this link)(JAMA 174(8)1221) I am not a big believer in purulent discharges telling us anything, but I do think we gotta stop this antibiotic madness . Also, be careful with frontal sinusitis which can turn into Pott’s Puffy Tumor. Oh by the way, this fellow kicked the bucket from C difiicile sepsis.

TBTR: Don’t give antibiotics for ED sinusitis unless they are very sick looking.

They got me busier than a one-legged man in a butt-kicking contest.

LPs and Time of Day

A mishmash of an article but they reviewed LPs- and found that post spinal tap headache was more common in younger healthy patients, with low opening pressures and get this – in LPs- done during the day as opposed to night. (Acta Neuo Scand 130(3) 204) Do we have an explanation for this??

TBTR: Do your LPs at night – less headaches.

I have little feet because nothing grows in the shade

IV Albuterol

Giving IV albuterol (salbutamol) in kids is not evidence based–actually it has never been shown to help. They are worried about increasing the heart rate- -I am less so- but I would only increase heart rate if I knew I was going to get something positive for it. (Arch Dis Child 99(9)873) Hey let’s face the facts- it never has been proven to help in adults either (Cochrtane CD010179).However, I believe that the evidence is better for epi.

TBTR: IV salbutamol- it hasn’t been shown to work.

There are plenty of charities for the homeless. Isn’t it time somebody helped the homely?

Equipment on Planes

We know about my interest in on board emergencies –some of you may have even heard my truncated lecture on EMRAP on the same subject. Well they checked medical equipment on German airlines and for the 13 airlines they studied only four had an AED and four didn’t even have a BVM (or Ambu- bag in Europe) (J Travel Med 21(5)318) I will say there are guidelines for this but there is no enforcement and while charters are cheap, the amount of medical equipment available on such flights may include only a mustard plaster and some gin and tonic.

TBTR: Many airlines – as least in Germany- have limited medical equipment on board.

(on the topic of her bust size) People always ask me if they’re mine. Yes, they are… all bought and paid for.

Clinical Case

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Nothing to do with EM, but this is a gift for our Kiddie doctors. Let’s make it easy – A kid with severe acne, pustloisis and osteisitis- yea that is an easy one- it is …

On plastic surgery: I’m a proud person. I’m not vain. I look at it like it is. If you’ve got the money and you’re going to be out there, you owe it to people not to look like a dog if you can help it.

Vitamin D in the ICU

This is a definite “yea, maybe”. Vitamin D improved immune function in the ICU ( AMJCCM 190(5)483) Well, it is obvious these folks are going to get vitamin D deficient– they get no sunlight (why can’t we just do they ICU thing outside??) However, these were all surrogate markers and indeed, no useful clinical improvements were noted. But of course – it can’t hurt (although a recent Danish study challenged that). Neither can a well placed soapsuds enema

TBTR: Vitamin D – should it be in the ICU?

If I have one more face-lift I’ll have a beard

Tami and Flu

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SE Asia can be a drag to live in – they get a lot of strange influenzas- and some of these can be serious. So they studied giving double dose ostelmavir to their flu suffers- (in their study they were all kids) and it didn’t help much ( BMJ 346:F3449) Indeed it showed no improvement over the use of single dose in any outcome. But I think they asked the wrong question- this drug really doesn’t help anyone- it is expensive and it may reduce less than a day from the illness. Real impressive that they had 148 collaborators on this paper for 326 patients- heck every two patient had some egg head breathing down their necks Maybe it just was some many collaborators since they got infected from the virus they studied and needed to be replaced.

TBTR: Ostelomavir in double doses doesn’t help. Neither does single dose.

There’s a heart beneath the boobs and a brain beneath the wig.

After Momma gave birth to twelve of us kids, we put her up on a pedestal. It was mostly to keep Daddy away from her

Antibiotics for Foleys

This was a meta-analysis of catheters and one we have looked into before (actually it was pretty dark looking inside a catheter) Does giving antibiotics prevent UTI when you take out the catheter? Well it seems it does but this study says it works only for short term cathertetization. Very short duration – straight cath –probably doesn’t need Ab, and long term – you probably have colonization- but short term –like a week – can reduce UTIs by 5.8% with a NNT of 17. May be worth it. Then again – maybe worth it not to put it in in the first place. (BMJ 346:G3147)

TBTR: Give ABX if you insert a catheter for more than few days.

(alluding to her famous bust) If I build another park, it will probably be in Silicon Valley. ( she built Dolly wood park in Tennessee)

If you want to see the rainbow you gotta put up with the rain.

???

We have mentioned Mr. Sokol before who writes for the BMJ and while he is a lawyer he is also an ethicist (talk about an oxymoron). He speaks about people who present for medical care that are not likable but I wanted to mention his story about a drunken smelly combative patient who was asked by the kindly surgeon to be still so he could sew up a forehead laceration of his. The patient answered “you be f**** still” So the gentle surgeon proceeded to suture the patient’s ears to the stretcher and then blithely commented-“now you be f**** still” (BMJ 346:f3956)

TBTR: no comment.

image014That’s enough for Dolly quotes- let’s now celebrate the 35th anniversary of Airplane! – a 1980s flick which parodied the disaster movies that were popular in those days. This movie has been judged to have more laughs per minute than any other film in history – 3.1 per minute. If you remember the movie this will be fun – if you don’t than you won’t be any more bored than you were previously- just be careful you don’t fall off the toilet..

Rumack: You’d better tell the Captain we’ve got to land as soon as we can. This woman has to be gotten to a hospital.

Elaine Dickinson: A hospital? What is it?

Rumack: It’s a big building with patients, but that’s not important right now

Pregnancy Med Classifications Stink

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Unless you are pregnant with Rosemary’s baby you may want to be careful with the meds you take. (If you are a woman and read EMU then it is OK, you can continue your haloperidol) but the ABCDX system leaves a lot to be desired (this is the scale of teretogencity of meds) Let’s face it- almost nothing is an A, B –w ell that seems safe, but this can include meds that the animal studies showed no risk but there are not enough people studies or it can be that animal studies showed risk and people studies showed no risk. And then there is C.65-70% of all meds are indeed category C where we just do not know. Fortunately X is not too common XXX (Cleve CLin J Med 81(6)367)

image015

TBTR: ABCD is for grades in school and not for pregnancy and meds.

Young Boy with Coffee: Excuse me, I happened to be passing, and I thought you might like some coffee.

Little Girl: Oh, that’s very nice of you, thank you.

[takes coffee]

Little Girl: Oh, won’t you sit down?

Young Boy with Coffee: Cream?

Little Girl: No, thank you, I take it black, like my men

 

Rex Kramer: Get that finger out of your ear! You don’t know where that finger’s been

Quit Smoking even though you will be a Fatty

I think you would want to tell this to your patients. 80% of smokers end up eating – and eating and eating.

image019

This is from Life of Brian – the Monty Python movie- this guy eats so much he explodes.) Usually they gain four to five kilo (that is 8.8 – to 11 pounds for you American cretins) but the health benefits on cardiovascular disease are still present despite the negative effects of obesity- In other words- you gain more benefit by stopping smoking than you lose by becoming chubby. JAMA 309(10)1032)

TBTR: Still worth quitting smoking even if you pig out.

Rumack: Can you fly this plane, and land it?

Ted Striker: Surely you can’t be serious.

Rumack: I am serious… and don’t call me Shirley

 

Ted Striker: [plane loses an engine] The oil pressure. I forgot to check the oil pressure! When Kramer hears about this, the shit’s going to hit the fan!

[in the office, shit hits a fan and splatters all over the room]

Shoulder Ultrasound

These articles still come out but I am not sure why. Rotator cuff injuries are very common in people older than fifty. The treatment is barbaric- arthroscopy – painful- not negligible chances for frozen shoulder- then immobilization for two months and then physiotherapy for two months. We will review two articles on the subject- the first checks physical exam maneuvers where they conclude that internal rotation and lateral rotation tests are useless. (Am J Sports Med 42(8)1911) But indeed none of the tests work that great and now we have ultrasound which sees the muscles of the rotator cuff quite well. Why are we doing these tests anymore? This other article tried to make a score with age, trauma (what is this?) and critical shoulder angle – maybe worked but the same question remains- just do the ultrasound( Orth Traum Surg Res 100(5)489)

TBTR: thinking rotator cuff injury? Just do the ultrasound.

Steve McCroskey: Looks like I picked the wrong week to quit sniffing glue.

Operator: [Captain Oveur is on the phone with the Mayo Clinic] Excuse me, Captain Oveur, but I have an emergency call on line five from a Mr. Hamm.

Captain Oveur: Alright, give me a Hamm on five, hold the Mayo

Ultrasound and Appendicitis

We in the underdeveloped world (which to the Americans means anything west of the G Washington Bridge and east of Queens) do do ultrasounds as a first test to rule out appendicitis. It doesn’t always work. If the patient is fat or not in so much pain –US may miss. (Ultrasound Med Biol 40(7)1483) If US doesn’t reveal the cause; then short interval CT is not likely to show more ( J Ultrasound Med 33(9) 1589)

TBTR: US should be your first test for ruling in appendicitis – but it can miss or not reveal the organ of interest ( the appendix you pervert). BTW- I do not know any EPS doing this US – anyone doing it? Got an answer already – my peer reviewer’s place.They hope to publish the data soon

Steve McCroskey: Looks like I picked the wrong week to quit amphetamines

 

Roger Murdock: Flight 2-0-9’er, you are cleared for take-off.

Captain Oveur: Roger!

Roger Murdock: Huh?

Tower voice: L.A. departure frequency, 123 point 9’er.

Captain Oveur: Roger!

Roger Murdock: Huh?

Victor Basta: Request vector, over.

Captain Oveur: What?

Tower voice: Flight 2-0-9’er cleared for vector 324.

Roger Murdock: We have clearance, Clarence.

Captain Oveur: Roger, Roger. What’s our vector, Victor?

Tower voice: Tower’s radio clearance, over!

Captain Oveur: That’s Clarence Oveur. Over.

Tower voice: Over.

Captain Oveur: Roger.

Roger Murdock: Huh?

Tower voice: Roger, over!

Roger Murdock: What?

Captain Oveur: Huh?

Victor Basta: Who?

 TBI

What is new in the management of traumatic brain injury? (Curr Opin Anest 27(5) 459) Not much. Fluid removal in CHF – should it be diuretics or devices? ( Curr Opin Crit Care 20(5)478) Neither worked that well. So why do I bring these two useless articles? The first article was written by Wijayatilake (12 letters) and the second Krishnamoorthy (14 letters). Otherwise the articles don’t change anything in the world order.

TBTR: nothing to learn here.

Elaine Dickinson: Would you like something to read?

Hanging Lady: Do you have anything light?

Elaine Dickinson: How about this leaflet, “Famous Jewish Sports Legends?”

Status Epilepticus

On the other hand there is some new stuff on Status Epilepticus – and this doesn’t come from a journal that is called current opinion…Are you old enough to remember that paraldehyde was in the protocol for refractory SE? It could only be given in glass and had that wonderful mothball smell. Well that is long out and so is general anesthesia. Barbs as well. Who are the new kids on the block? Well, IV valproate is pushing the phenytoins and fopsphenytoins out. Keppra also making a stand. Propofol works great. And the newest kid on the block is ketamine – at 0.4 mg/kg/ hr. The best thing here is that propofol and ketamine may not need intubation while anesthesia and barbs always do. (Int Care Med 40(9)1359)

TBTR: the approach to epilepsy has changed.

Captain Oveur: You ever been in a cockpit before?

Joey: No sir, I’ve never been up in a plane before.

Captain Oveur: You ever seen a grown man naked?

Careful with the EMLA

EMLA is not that safe? It can cause met hemoglobinemia, it can cause CNS tox as well as CV tox. (J Drugs Derm 13(9)1118) I am definitely against the routine use of this agent for depilatory treatments and laser hair removal – they sure do smear a lot of this stuff on for leg treatments. But still – there have had only been 9 cases in kids and 3 in adults of toxicity since the agent was introduced- which means that it doesn’t occur often.

TBTR: EMLA – is not Noxema.

Steve McCroskey: Looks like I picked the wrong week to quit smoking

Randy: Can I get you something?

Second Jive Dude: ‘S’mofo butter layin’ me to da’ BONE! Jackin’ me up… tight me!

Randy: I’m sorry, I don’t understand.

First Jive Dude: Cutty say ‘e can’t HANG!

Jive Lady an 85 year old lady): Oh, stewardess! I speak jive.

Randy: Oh, good.

Jive Lady: He said that he’s in great pain and he wants to know if you can help him.

Randy: All right. Would you tell him to just relax and I’ll be back as soon as I can with some medicine?

Jive Lady: [to the Second Jive Dude] Jus’ hang loose, blood. She gonna catch ya up on da rebound on da med side.

Second Jive Dude: What it is, big mama? My mama no raise no dummies. I dug her rap!

Jive Lady: Cut me some slack, Jack! Chump don’ want no help, chump don’t GET da help!

First Jive Dude: Say ‘e can’t hang, say seven up!

Jive Lady: Jive-ass dude don’t got no brains anyhow! Shiiiiit.

Radiographs and Gastroscopy

There was nothing in this paper but it did remind me to speak to you about bariatric surgery. The sleeve is very popular these days and indeed most complications are likely during the admission- you aren’t likely to see these in the ED or clinic but this operation is not reversible and that tends to bother me. The older operation was the gastric band and they are still around, but now the put the port on the sternum and not in the abdomen. You should feel comfortable putting water in these – about 0.5 cc at a time. Because the backing of the port is very thick so you just puncture the front part of the port and inject- you can’t go through the back end. Two complications may occur with the band that you need to know. Erosion is when the patient stops losing weight and the band has eroded into the stomach wall – this is sent to Gastroscopy to make the diagnosis. It is usually a subacute problem. But the dangerous problem is slippage – when ischemia can occur. Too much stomach comes through the band and gets stuck. No pain and vomiting under control? Can watch and wait. Either of those two- admission to surgery. Severe pain – operation after putting in the NG tube (zonde). In all cases – take the water out of the port- it may just be as simple obstruction. In addition do an x ray – preferably with swallowed contrast. You will see a difference in the lie of the band in the abdomen. This is what you see on X ray – the band should be seen on an angle and here it isn’t

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EBM

Wanna really get people pissed off? Of course you do! Use the EBM mantra- “There is no evidence to suggest”. This article also says facetiously that there is no evidence that ambulance transfers to the hospital in patients with a GI bleed reduce pre hospital deaths when compared to taking the bus. And there isn’t. So try to avoid that stupid egghead phrase! (JAMA 310(20)2149) And try something more intelligent like “Bayesian analysis of the data while performing a regression analysis demonstrates that stegosauruses did eat rhubarb.

TBTR: Avoid EBM mantras. Or EBM altogether. Or EMU altogether.

Ted Striker: Mayday! Mayday!

Steve McCroskey: What the heck is that?

Johnny: Why, that’s the Russian New Year. We can have a parade and serve hot hors d’oeuvres…

 

Johnny: [plugging back in the runway lights] Just kidding.

Pain Control

This article was painful to read. Pain relief with all our best efforts rarely helps more than 50% of patients and misses 82% of the time in back pain patients.   Seems only the NSAIDs and pacetamol help more than 70% of the time. And as expected, fibromyalgia did really poorly – only 8% of the time were patients adequately treated for pain (BMJ 346:f2690) I am not sure what to do here- but I will point out that for most of the conditions in the chart- they studied NSAIDS and Lyrica which may not be the strongest options- but we have the most information on them, so they made it into the chart.

TBTR: Pain control is not very successful.

Steve McCroskey: Looks like I picked the wrong week to quit drinking

 

Jack Kirkpatrick: Shanna, they bought their airline tickets, they knew what they were getting into. I say, let ’em crash

Difficult Patients

I included this “Ken” article even though it is from the derm literature – it is an attempt to teach us how to deal with unhappy and anxious patients.

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True these patients aren’t ED patients, but they can get just as pissed since many skin diseases have no cures. They even point out that reimbursement rates are now going to be based on quality of care and that includes patient satisfaction – I think I had one satisfied patient in the ED about 13 years ago. While their approaches to deal with this problem are tenuous, I liked the classification scheme. The first-the laundry list patient- this is called in my country the Kulabuja syndrome – which is Arabic for everything hurts. Their suggestion is to get the patient to prioritize their concerns- but that isn’t always that easy. The immediate gratification patient. Good luck. They say to tell them that their demands are incompatible with their own safety. The pessimistic patient- they say remind them that this is a new start and try to figure out the cause of their misconceptions. The delusional patient- these are psych patients – suggest they try an antipsychotic (?) Good luck. Poorly compliant patients- not great suggestions for that one either. I think the best point I got out of this paper is that patients see us as the captain of the ship and will hold us responsible for even poor lighting over the bed- don’t take it personally and don’t give a McCoy line like “I’m a doctor and not an electrician”(Clinc Derm 32:697) Some neat names for the authors here- Dr. Koo and Ms Malakouti wrote this article and Dr. Argentina Leon is also an author.

TBTR: Dealing with difficult patients- here is some advice.

Elaine Dickinson: Ladies and gentlemen, this is your stewardess speaking… We’re regret any inconvenience the sudden cabin movement might have caused, this is due to periodic air pockets we encountered, there’s no reason to become alarmed, and we hope you enjoy the rest of your flight… By the way, is there anyone on board who knows how to fly a plane?

[cabin’s hell breaks loose]

PreDiabetes

This is another opinion piece and is important for all of us- not just primary care guys. The article starts with a great quote from Aldous Huxley (if you are untutored – he wrote the epic futuristic novel Brave New World) “Medical science has made such tremendous progress that there is hardly a healthy human left”. The question is – what is pre diabetes or glucose intolerance? According to the newest ADA guidelines – a study of the Chinese shows that 493 million Chinese would be classified as pre diabetic. Are we inventing a new disease? True higher levels of glucose give a higher risk of developing diabetes within 10 years but that is at best – and I mean at best – a 60% higher risk and one meta-analysis even said the opposite – 2/3 will not have diabetes after 10 years. . Now I am going to diverge now – they mention the Glucose tolerance test- this test is unwieldy, painful and not very reproducible. Many obstetricians are still using this test instead of Hg-b-1-ac- anyone know why? Back to our subject- the ADA has lowered the Hgb 1-ac line to 5.7 for pre diabetes- a decision not shared but any other coalition. They point out instead of making more people sick (EMU does that too) let’s focus our attentions on making people healthier- although they do admit that lifestyle changes only delay diabetes but do not prevent it and the delay is only for 2- 4 years. (BMJ 349:g4485)

TBTR: Prediabetes may not be a disease.

Ted Striker: I flew single engine fighters in the Air Force, but this plane has four engines. It’s an entirely different kind of flying, altogether.

RumackRandy: [together] It’s an entirely different kind of flying. ( this one was subtle – read it again)

Subtle EKG in MI

We went over this a few years back (I think it was three) (interlude for a quote:)

Right now I’m having short term memory loss and déjà vu at the same time – I think I’ve forgotten this before.”

but there are some difficult EKG patterns that are easy to miss- and they do warn not to depend on the computerized readings from the machine. Here are some of their examples: hyperacute T waves- the best idea here is to do another EKG because if this is ischemia – it will turn into a STEMI pretty quickly. Of course check the potassium as well. De Winter complex- I could describe this – I guess I will – it is a 1-3 mm up sloping depression at the J point in the precordial leads that continues image026into tall positive T waves with 1-2 mm elevation of ST in AVR. Good Luck – while this could be an LAD occlusion, most of us would miss this, and fortunately it is a temporary finding-again – do multiple EKGs. (hey did 18 EKGs in one patient.) Wellen’s syndrome- biphasic or inverted T in V2-3 is highly specific for LAD occlusion but again –do multiple EKGS and this will turn into a STEMI. My peer reviewer disagrees: Although Wellen’s sign does indicate a high risk for anterior wall MI, many patients with a Wellen’s sign will not convert to ST elevations in the short term. In the original Wellen’s article, he described the risk of anterior wall MI as being in the next few weeks. In his paper, the patients typically got cathed within the week (not acutely) LBBB- actually is pretty uncommon as initial presentation of STEMI. Posterior MI is also a easy miss – this is V1-3 ST depression (they call that STD in the article apparently not realizing what else STD can mean) I was taught to look for prominent R waves in V1-2 and the example they bring has that also. A posterior lead EKG may reveal this as well. In order to really put the fear of G-d into us –they report a miss rate of STEMI of 40% (J Electroca   47:448)

TBTR: Careful – you could miss some significant MIs.

Ted Striker: It was at that moment that I first realized Elaine had doubts about our relationship. And that, as much as anything else, led to my drinking problem.

[pours Gatorade into glass and then pours onto left side of his own face]

 

[looking at the controls of the airplane as he begins to try to fly it]

Ted Striker: Let’s see… altitude: 21,000 feet. Speed: 520 knots. Level flight. Course: zero-niner-zero. Trim and mixture: wash, soak, rinse, spin

Tumor Lysis Syndrome Review

image027I was thinking about using this for the essay but there really isn’t much to this. And they only talk about it in kids although it is the same in adults, I surmise. Tumor Lysis Syndrome can present even before chemo is initiated. And while more common in hematologic malignancies such as leukemia and lymphoma it can happen in solid tumors as well. It is caused by rapid tumor cell breakdown. This leads to hyper uricemia, hyper phosphatemia, hypocalcemia, and hyperkalemia. Truth be told, tumor cells have more phosphate in them and this causes the calcium to fall. We aren’t sure what gets TLS going when there is not chemo involved, but inflammation may be related to this- infection seems to precipitate this. Treatment is fluids, the usual treatment for hyper phosphatemia, don’t give calcium – will just complex more with the phosphate,- only give if they are really symptomatic, and consider rasburicase for the uric acid problem. Dialysis may be needed if there is fluid overload or the uric acid kills the kidneys. (PEC 30(8)571)

TBTR: All you wanted to know about tumor lysis syndrome.

Rex Kramer: Steve, I want every light you can get poured onto that field.

Steve McCroskey: I’ll get that done right now.

[On the runway, a truck dumps a full load of lamps onto the ground]

 

Rumack: I won’t deceive you, Mr. Striker. We’re running out of time.

Ted Striker: Surely there must be something you can do.

Rumack: I’m doing everything I can… and stop calling me Shirley!

Letters

Hey it is time for letters. Before we start- I want to say I miss Axel – where have you gone Frere Axel? And maybe a greeting to rising star Anand Swaminathan (who lifted my myth buster moniker) who I heard nasty rumors that he reads this stuff. If he doesn’t I don’t blame him. But if he does – let me know. We got a letter from a surgeon who disputes our claim that no surgeons read. I’m sorry, let me correct that. No surgeons read EMU. He requested for the sake of his reputation that I do not to use his name, but I can’t do that so I will give you his name Wheel of Fortune style

(_ _ _ _ _ _ _ _ _ _ _ _ _ .

Too hard? I’ll give you a hint- he did my hernia years ago. Go ahead – take vowel for 300.

Ken “Where’s Waldo” checks in – he is now in the USA although I am not sure where.

Hi Yosef

As usually, some comments about the recent EMU. Since I’m back in the U.S. at the moment, I had time to read it completely.

As to oral ketamine, I’ve described its use as an analgesic (short and long-term), antidepressant, and sedative in “Improvised Medicine: Providing Care in Extreme Environments”. It works well, but must be mixed with fruit juice to hide its bad taste. As you pointed out, there is no need for concurrent midazolam. Using two drugs when one is sufficient only muddies the clinical picture and, if there is any adverse reaction, you don’t know which drug caused it.

About honey for wounds: Again, from “Improvised Medicine,” “Theoretically, honey works by depriving microbes of water and by frequently releasing low levels of hydrogen peroxide into wounds. While natural honey may have batch-to-batch variability in its bactericidal activity, the main difference between natural and medical-grade honey is the cost. In austere situations, use whatever honey is available. It works. If using honey on wounds or burns, first clean the site. Apply 15 to 30 mL pure, unprocessed, undiluted honey and bandage the area. One drawback is that honey attracts insects. Bandaging helps reduce this problem. Change the dressing daily.”

My note: we have this in Israel

The paper from Liang and Mirelman is interesting, contains statistical analyses far beyond my abilities, but comes up with results that are intuitively correct and which correspond to my experiences in global medicine. They are:

  1. With more bribe (or “PAC” in the U.S.) money available for the medical-industrial complex to pay out in the richest countries, the government is persuaded to spend more money on health care.
  2. Foreign aid for medical care given to governments results in the recipient countries spending correspondingly less for health care.
  3. Foreign aid for medical care given to non-governmental agencies (NGOs) results in no change in the recipient country’s spending for health care.

Boyd’s article on “Clinical judgement (sic) and the emotions” is a dense, convoluted paper that just proves that writing like you are smart doesn’t mean that you know anything.

Best wishes and looking forward to the next issue. Ken

Ken also points out he has published an article in the WJEM on Jaguar attacks ant a review of the literature – unfortunately my cat ate my copy of this paper. Ken also sent me an on scene report from his activities as a physician helping in the Pacific nation of Vanuatu which was hit by a monsoon Global health has always been Ken’s adjenda- this was how we met actually- and I know he is making a difference.

And of course Father checked in as well. He did not take offense to our court room quotes nor did he mention the plug I gave for Risk. Rather the wine review got him this time

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All right! That’s it! You can review articles, That’s Ricky Bukata’s thing but when you get into cheap wine reviews well, you have gone one screw top too far. First Yosef I hope you still have your US citizenship because we Americans hate people trashing our premium junk wines who are not God fearing, red, white, and blue Gringos. Knowing your background from Philly I can’t believe you did not comment on the correct cheap wine to go with cheese-steak dinners. The failure to even mention Annie Green Springs or Boone’s Farm Apple speaks to an incompleteness in this study. Also, as an old inner city ER doc and not giving at least a tip of the bottle to Wild Irish Rose fortified wine shows that you have grown too fancy to remember your old friends in the US ER pits. I have been offered swigs out of all these bottles over the years by grateful patients. There never was a truer sign of affection! We should move on from wine of the month to whine of the month like “I want to go to Miami”. All my best to your wine or whine of the month department. Next time mention some cheap Israel wines and I don’t mean Mogan David! Stay thirsty my friend. God Bless  Father Henry Careful Father- transubstantiating Mogen David has been linked to circumcision.

Nocardia

 

Number six was Nocardia- which usually responds well to third generation cephaolosporins. It usually occurs in immune compromised individuals, but one third of the time it is in immune compromised individuals. Mortality is high. (JAMA Neuro 71(8)1043) Number 14 was SAPHO syndrome (not named for the Greek Female Poet) but rather for the initials: Synovitis, Acne, Pustilosis, Hyperostosis and Osteitis. Treatment includes isotrentoin, NSAIDS, clinda, and methotrexate. (J Adol Health 55(2)304) Male announcer: The white zone is for immediate loading and unloading of passengers only. There is no stopping in the red zone.

Female announcer: The white zone is for immediate loading and unloading of passengers only. There is no stopping in the red zone.

Male announcer: [later] The red zone is for immediate loading and unloading of passengers only. There is no stopping in the white zone.

Female announcer: No, the white zone is for loading of passengers and there is no stopping in a RED zone.

Male announcer: The red zone has always been for loading and unloading of passengers. There’s never stopping in a white zone.

Female announcer: Don’t you tell me which zone is for loading, and which zone is for stopping!

Male announcer: Listen Betty, don’t start up with your white zone shit again.

[Later]

Male announcer: There’s just no stopping in a white zone.

Female announcer: Oh really, Vernon? Why pretend, we both know perfectly well what this is about. You want me to have an abortion.

 EMU LOOKS AT CORONARY AND CORES

The articles for the essays are Canadian Journal of Cardiology 30:1046 and J Trauma Acute Care Surg 77(3) 495.

Endocarditis

  • Yea endocarditis is pretty straight forward, but it is often forgotten as a cause of prolonged fever, and with RHD common in a lot of the countries EMU goes to I thought it would be a good idea to look into this
  • This disease is getting angrier. We have a lot of patients with various hardwares in the heart and blood vessels, and people getting dialysis and as such staph, enterococci and other bad boys are becoming more predominant.
  • They start out speaking about prophylaxis, and indeed bacteremia varies considerably from 5% in colonoscopy to 88% for periodontal surgery. However, on the other side, antibiotic prophylaxis hasn’t been shown to prevent endocarditis. To cut to the chase, the current recommendations of the AHA are to give antibiotics for dental procedures in patients with proven endocarditis, prosthetic valves. unrepaired congenital cyanotic heart disease or repaired with hardware or with residual defects, and cardiac transplant patients with valvulopathy.
  • Diagnosis is the Duke criteria – this is from Wikipedia: Diagnosis of infective endocarditis is possible if one of the following combinations of clinical criteria are met:
  • 1 major and 1 minor criteria
  • 3 minor criteria are fulfilled

Major criteria

  1. Positive blood culture with typical IE microorganism, defined as one of the following:[17]
    • Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
    • Microorganisms consistent with IE from persistently positive blood cultures defined as:
      • Two positive cultures of blood samples drawn >12 hours apart, or
      • All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
      • Coxiella burnetii detected by at least one positive blood culture or IgG antibody titer for Q fever phase 1 antigen >1:800. This was previously a minor criteria
  2. Evidence of endocardial involvement with positive echocardiogram defined as
    • Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or
    • Abscess, or
    • New partial dehiscence of prosthetic valve or new valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

Minor criteria

  1. Predisposing factor: known cardiac lesion, recreational drug injection
  2. Fever >38°C
  3. Embolism evidence: arterial emboli, pulmonary infarcts, Janeway lesions, conjunctival hemorrhage
  4. Immunological problems: glomerulonephritis, Osler’s nodes, Roth’s spots, Rheumatoid factor
  5. Microbiologic evidence: Positive blood culture (that doesn’t meet a major criterion) or serologic evidence of infection with organism consistent with IE but not satisfying major criterion
  6. Positive echocardiogram (that doesn’t meet a major criterion) (this criterion has been removed from the modified Duke criteria

but these can miss early on. Echo blood cultures and PCR are the keys to diagnosis. Don’t forget to test for coxiella, legionella, bartonella, brucella, mycoplasma, aspergillus. TTE is inferior to TEE, but can be the first test.

  • Clinical picture is fever, but I was surprised that this is present only in 50% of the cases. Look for new murmurs, embolic phenomena, new CHF, new focal neuro signs or abscesses without an identifiable cause. And of course if you meet up with Janeway lesions, Osler nodes, Roth spots or splinter hemorrhages.
  • Antibiotics are the first treatment and should be started quickly. Surgery seems to save lives, but there are varying results.

 

Radiation

  • Hey I promised I would thank Dr. Or Dekel who downloaded this article for me. Thanks Or! Just think about it- now they know you in Indonesia!
  • Yea, so you’re never going to see this. When not until a tsunami hits your power plant, or the folks at your local nuke plant decide to do another Chernobyl test or your find some “dirty” medical waste that some nut left in your mall. Let’s start out with saying we are speaking about ionizing radiation which can break DNA bonds. Non ionizing are usually safe like microwave, and radio waves but these can cause damage with prolonged exposure- usually by heat transfer – like UV light to the skin (or like inserting yourselves into a microwave).
  • Ionizing radiation comes in four flavors (ask Ben and Jerry’s). Gamma rays are photons (little packages of energy). These act like waves, and indeed many physicists think that they are just waves and they pass through the body – but can wreak havoc on the way. Alpha particles are large helium nuclei with a positive charge that and they are so heavy that they can barely penetrate the skin. This is usually of no consequence so you can safely sit on a toilet made of alpha particles. However, getting them into your body is a different story- they can cause cancer.
  • Beta particles are just electrons- they have a negative charge. Also ingestion here is dangerous, but these can penetrate the skin to make burns- do not place these in your pocket or sir on a toilet made of beta particles.
  • Neutrons are inert – no charge at all – but they can bounce off nuclei to cause release of other particles mentioned above. They also get your atom bomb detonated.
  • What material throws off what particles depends on the isotope you are now eating.
  • How do you quantitate radiation? Well there is SI and the old fashioned way. They used to use Curies (Madame Curie actually died from radium exposure) for radioactivity, RADs for dose and REMS for dose in man. The SI units- designed just to make Americans crazy and that is Ok by me- are Becquerel, Gray and Sieverts- we in EMU use Sieverts because it is the most clinically descriptive. Let us just say -according to the article a chest x ray is equivalent to an airport scanner and to a flight from NY to LA – meaning it ain’t much
  • Radiation exposure affects four systems. Usually the body can deal with a little chemical bond breakage but in radiation sickness it is overwhelmed. Just let us make it clear that when symptoms are immediate that means there was a greater exposure with more lethality. Usually there is a latent period. ( the calm before the storm)
  • The four systems-the first we will discuss is neuro- ataxia, disorientation, seizures, confusion – all what you usually see- – in your reviewers of good street wines (see last month’s EMU). These occur with higher doses of radiation which is usually fatal.
  • GI: nausea and vomiting are the most common. Higher exposures may result in bleeding and diarrhea.
  • Heme system: 2-3 grey exposure will cause pan cytopenia and these folks can get infected pretty darn fast- especially if this comes from trauma like your friendly neighbor atom bomb detonator.
  • Skin: these may take even years to develop – they can be burns, bullae or ulceration.
  • Triage is important – you will need a Geiger counter. External decontamination is usually with fluids and the waste must be preserved including clothes. There are protocols for this and your hospital should have a plan – the Israelis for example make this a course much like ATLS.
  • Treatment is usually supportive. The isotopes are very unusual (and heavy) but there are chelators such as KI for radioactive iodine exposure (actually this is a competitor until the shorter half-life raidioactive iodine becomes inert) diehtylene tramine penta acetic acid for plutonium (good thing – that stuff acts like calcium and can stay in bones for 24000 years if you plan to live that long. However, it will allow you to detonate yourself). Prussian Blue works for rubidium, cesium (common isotope in medical radiotherapy) and thallium. Here is another entry from the handbook of Physics that describes another potentially dangerous element:                     Element name: WOMANSymbol: WOAtomic weight: (don’t even go there)

    Physical properties: Generally round in form. Boils at nothing and may freeze at any time. Melts whenever treated properly. Very bitter if mishandled. Ranges from virgin material to common ore.

    Chemical properties: Very active. Highly unstable. Possesses strong affinity with gold, silver, platinum, and precious stones. Volatile when left alone. Able to absorb great amounts of exotic food. Turns green when placed next to a superior specimen.

    Usage: Highly ornamental. An extremely good catalyst for dispersion of wealth. Probably the most powerful income reducing agent known.

    Caution: Highly explosive in inexperienced hands

  • Other possible treatments include Amifostine for free radical scavenging – it may help for prophylaxis after exposure and of course heavy antibiotics for heme patients. Otherwise supportive therapy. I know from experience with a family member who had breast cancer that radiotherapy to the skin can have long lasting effect- the skin broke and never healed her entire life.

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While attending a Marriage Seminar dealing with communication,
Tom and his wife Grace listened to the instructor ’It is essential that husbands and wives know each other’s likes and dislikes.’
He addressed the man ’Can you name your wife’s favorite flower?’
Tom leaned over, touched his wife’s arm gently and whispered ‘It’s Pillsbury, isn’t it?

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