EMU Monthly – December 2016

1) Seems like an important study. A prospective study of 216 cardiogenic shock patients in 9 centers over eight countries. The bottom line? Epi caused higher mortality. Higher bio-markers elevation. Higher renal bio-marker elevation. Greater mental status changes .However, let us dissect this a little. 216 patients is kind of small. And maybe these disease and not patient oriented outcomes (except mortality of course) were all caused by these patients being sicker. They did try to control for this, and I will mention that this finding was confirmed with a multi variable logistic regression and a propensity score matched analysis. Not that I can really tell you what those are, but these statistic gymnastics both found the same thing. Oh and I forgot to tell you that nor had a higher mortality but only when combined with dobutamine or levosimendan. Again, this means to me that these were sicker patients. TBTR: Epi is killing people??

Critical Care 20(1)208

2) Delirium in the ICU isn’t pleasant- actually it isn’t pleasant anywhere, but if haloperidol fails, consider dexmedetomidine. The patients that got this drug needed less morphine, less costs, and less hospital stays. They occasionally needed atropine for sedation. Maybe, but I have a few questions. I have never found a patient that I couldn’t knock down with haloperidal. Even so, there are many other options including other anti psychotics. Dex- I have absolutely no experience with this since we haven’t got it in this country- but I understand that it does take some time to work- time I may not have when the department is being ripped apart by this bull in a china shop.  TBTR: Dexmet may be better than haloperidol for delirium. If you aren’t sure – try them both on yourself and see.

CCM 44(7)1426







3) Ever notice you give opiods and they don’t seem to work on some people? Could be they are slow metabolizers; and in this study could be because back pain is different but the relief was just “mild”. This was even when there was a morphine equivalent of 240 mg- no better than placebo. Pretty impressive, no? I do have some problems though. Morphine equivalents don’t mean very much, and indeed, many of the studies that were used for this meta analysis used tramadol, which is indeed a very week opiod. But with a better study, maybe we would see that these are not very effective. TBTR: Percocet may not be worth writing all those prescriptions you write for the kickbacks.

 (JAMA Int Med 176(7)958).

Let’s get started with some quotes.  Zsa Zsa Gabor died recently – she was the penultimate socialite – married nine times and once for only ten minutes.  While being a Hungarian immigrant with a heavy accent – she still wowed us with her quotes.

Let’s run through some

“I never hated a man enough to give him his diamonds back.”

4) Terson syndrome exists and you should know about it. It basically is acute visual loss when you inject things into the epidural space such as saline, epidural anesthesia and blood patches. They think that this is due to acute blockage of the retinal venous drainage. Good news- it gets better in most. Just be careful how fast you inject things into this space. Relevance to EM?  We have given blood patches in the ED. TBTR: Terson syndrome – know about it.

Reg Anest Pain Med 41(2)127

“I’m a marvelous housekeeper—every time I leave a man, I keep his house.”

5) I think we have mentioned this before but we will again it is a medical myth. Early repolarization is a risk factor for sudden death after controlling for every thing else. Fine, but it is also very common – do we sned all these patients to EPS? Do we put in ICDs to them? Should we be worried when we see this on an EKG in a syncope patient? No answers now. TBTR: early repol could be dangerous.

Circ Arryth Electrop 9(6)3960

“When in trouble, take a bath and wash your hair.

6) In the states they probably know about this already but the ABCDX categories are being retired. Now they will be replaced with detailed data about the risks and benefits complete with a summary and information written for health personnel and for patients. I haven’t seen this yet in practice, but it does seem like it can be confusing – especially if the clinician and the patient interpret the information differently. But it is here – so get used to it.

Clin Derm 34(3)401

Pharmcoth 34(4)389

“My husband said it was him or the cat. I miss him sometimes.

7) If you do not read anything else this month in EMU- and believe me – you shouldn’t – read this article. Double blind cross over study sponsored by the Chocolate industry – chocolate significantly increase acne in teens. They couldn’t tell us why and furthermore, maybe it isn’t all chocolate- they used dark chocolate in this study – but it has nothing to do with glycemic index – rather perhaps with falvinoids. TBTR: Choc late and pimples – be careful.

JAAD 75(1)220

“How many husbands have I had? You mean apart from my own?”

8) Genital ulcers are no fun. Especially when you have chest pain, back pain a sore throat and a fever. And especially when you are a 13 year old girl who is a Virgil


“I think Doctor that is supposed to be a virgin”. You are so right

. In any case vaginal pain with a fever is a UTI so they gave her some antibiotics and some phenazopyridine (Pyridium or Sedural) and – well, it didn’t work. And the Urine culture was negative. So she came back, and with a vag discharge, they called this a Candida infection and she got fluconazole and clotrimazole cream and a repeat urine culture. The culture came back negative and she is getting worse. She now has a foul smelling vaginal discharge and an ulcer on an inflamed labia. HSV, GC, tric, Chlamydia- they were all negative. But one test wasn’t- this is’ of course…..



Fam Prac 65(6)400

Sorry, I know you were expecting Madonna, but she is very old these days- and not a virgin.  And not a blonde either

“My most favorite joke is that to keep a marriage, the husband should have a night out with the boys and the wife should have a night out with the boys, too.”

9 )I do not know why these criteria are recommended – they date back to 1999 and were based on a retrospective case series. Yet they are still in use and you should know them. You know someone once accused me of taking my time to introduce what I am talking about and I wonder if that is really the case. Could be- I gotta give it some thought. Could be my ADHD. Oh yes- we are speaking about knowing the difference between transient synovitis and a septic hip. And the Kocher criteria are a way to help you differentiate include- inability to weight bear (don’t both of them have that?) fever greater than 38.5, ESR>40 and WBC greater than 12000. However, note that while having three gives you a 93% chance of having septic arthritis; if they are the three latter ones- well all kids with fever can have this. Here are the references for these

ACEP Mobile article 


Ped Annals 45(6)E209

EM RAP looked at this many years ago-2010- when they recorded Marty Hellman at the Scientific Assembly. And he brought many studies – even prospective ones- which showed these criteria aren’t that great. Basically, septic arthritis is rare, these patients do look sick, they don’t get better with an NSAID, and their CRP is not so high. However, everyone agrees – do an US and you will have the answer most of the time, and an MRI and you will have it all of the time. TBTR: Can you figure out when it is a septic hip??

“I always said marriage should be a fifty-fifty proposition. He should be at least fifty years old, and have at least fifty-million dollars.”

10) I found this interesting but then again, I am a sick guy.

Traditional autopsy and post mortem CT scans both find stuff the others one doesn’t.  There still is a lot to be done to define what is good for what- as this study is powered enough to tell us. Of course CT isn’t good at vessels as you can’t give contrast to a dead person, but was better at boney stuff. More to come. TBTR: Autopsy – going out?

Surgery 160(1)211




“Diamonds are a girl’s best friend and dogs are a man’s best friend. Now you know which sex has more sense.”


11) This is odd but EMU is ecumenical and non discriminatory (with the exception that we are against the Gay Nazis for Peace) so if you are one of these strange guys who instead of deflating pediatric ET cuffs you just cut off the pilot balloon- just know that 2/3 of the volume is retained. IS this dangerous? Will this happen in bigger sizes of ET tubes? The article doesn’t say but I think the take home for all of us in general is do not overinflate these pilot balloons.BTW I have seen similar results with cutting off the port of a Foley. TBTR: Do not cut off the pilot balloon to deflate the cuff in an ET tube.

Int J Ped Otot Larynx 86:15

“I believe in large families. Every woman should have at least three husbands.”

12) I respect dentists although I do not like them.  Here they write that they feel NSAIDS are very effective and opioids are questionably effective. Then they give a whole bunch of reasons why you should not use opioids. Like all opinion articles and review articles –the medical academic dictum ”garbage in garbage out” may apply to the articles they used for this paper. Readers of EMU know that opioids do have a lot of questions when it comes to effectiveness, but no one doubts that NSAIDS are not really strong pain relievers. I am waiting for a mini lidocaine injector to the site of the extraction- no addiction no pain. Is this Buck Rodgers talk???

JADA 14(7)530.

“A man in love is incomplete until he has married. Then he’s finished.”

13) I am not sure why, but once we realized that anti emetics were safe in children – we went straight to Odansetron. True the Americans love their Comapazine, but it has a lot of side effects and isn’t available in many countries- like mine. What about good ole Pramin? AKA Reglan. AKA metoclopramide. They looked at kids in this study and determined that the side effects- some sedation, EPS and diarrhea – were minor and of no significance. The “problem” with this study was it was a review – and it really depends on what dosage you use.  I think you should feel safe in using it. TBTR: Metoclopramide seems to be safe in kids.

Drug Safety 39(7)675

“I want a man who’s kind and understanding. Is that too much to ask of a millionaire?”

14)  A quick one here- if you have no ring cutter and the ring is stuck – you should try the two rubber band technique. The article has good pictures, and is free access. However, this does require you can advance a hemostat under the ring.

Am Roy Coll Surg Eng 98(5)300

“Personally, I know nothing about intercourse, because I have always been married.”

15) This is a case report of a STEMI equivalent that was missed- specifically the De Winter sign.  For thosetwits who do not remember what the DeWinter sign is (I am one of those twits) here it is from Chris Nickson’s excellent life in the fast lane. However truth be told- you better not miss this – it has enough ST depression – even though it may be reversible – that it should worry you.

JEM 50(6)875

“One of my theories is that men love with their eyes; women love with their ears.”

16) Ever notice that EPi has a very short expiration date? And this is important considering how much folks are paying for auto injectors these days. Well heat will affect epi but only prolonged exposure. Cold seems to preserve epi – refrigeration did help. Freezing? We do not know. Same problem here – this was a review of published studies- seems like an easy enough question to study on its own. TBTR: Put epi in the fridge- maybe.

Ann All Asthma Immuno 117(1)79

“You never really know a man until you have divorced him.”

17) Maybe. This Chinese study only had 152 patients but they reported – double blinded – that Fosfomycin did the trick in ridding males of gonorrhea. But again- the numbers were small. They were Chinese- other people may be different. TBTR: Fosfomycin for GC?

Clin Derm 34(4)482

“I have learned that not diamonds but divorce lawyers are a girl’s best friend.”

18) Yet another study showing that superficial venous thrombosis is not beingn. However , this too was  areview of the literature and because the data was so divergent, they usede a weighted mena prevelance. The problem is that this assigns weights to the events and that can only be an assumption. Really, I mean seriously – can’t we get a good study done?

J Thrombo Haemo 145(5)964

“Getting divorced just because you don’t love a man is almost as silly as getting married just because you do.”

19) Rectal foreign bodies – I know- you were just doing some gardening in the nude and fell on tomato plant- how do you get them out? I have tried obstetrical forceps in the past without success, but this article suggests – use just one and angle it right…. hard to explain without getting the article – but yet again – it is free access and comes with a picture – removing an apple – I guess they did not realize that will keep the doctor a way. TBTR: Rectal foreign bodies- how do deliver them.

Ann Roy Coll Surgeons 97(5)397

Now to finish up – we lost another beloved actress – Mary Tyler Moore. Here are some quotes from her TV series

“I’m an experienced woman; I’ve been around. Well, all right, I might not have been around, but I’ve been … nearby.”

20) Here is something for the trivia department- the amount of sodium in 0.95 Normal saline (anyone out there know why it is called normal?) is equal to a serum sodium of 154.

AJKD 68(1)11

“Take chances, make mistakes. That’s how you grow. Pain nourishes your courage. You have to fail in order to practice being brave

21)  Morphine is the falling star in MI pain but in this DOO (disease oriented outcome paper) it seems to delay the onset of action of Prasugrel. Maybe

Thromb Haem 116(7)96

Lou: Mary, where are the idiot cards?

Ted: Cue cards, Lou! Cue Cards!

Lou: Excuse me, Ted. Mary, could you please give those cue cards to this idiot?

22) As you all know (all three of you readers) that I am a huge fan of Steve Selbst’s Legal Briefs- while they appear in a pediatric journal – they do take a lot of adult cases. If you want the excitement of reading the cases themselves – get the article; but I will just summarize some important points. A lady with a psychiatric breakdown is sent to jail and gets Lamictal (lamotrigine). A few days later she gets a rash. Stevens Johnson-. Just make sure you warn people. Oh dear do not restrain patients physically and defiantly not in the prone position- this can kill people. And of you want more of the gore and stupidity that we physicians are capable of- make sure you tune into Greg Henry and Rick Bukata’s Risk Management Monthly. I am just burying this here to see if they find it. If they did – than I award them with first prize- they will be honored to provide me with a free subscription to RMM. But only if they acknowledge this within 5 days of posting. TBTR: Legal stuff

PEC 32(6)422

Rhoda: There are no men friends when you’re thirty. They’re either fiances or rejects

23) Skin infections- we see a lot of cellulitis here in the warm sweaty climate of the sub tropics. So while I was reading this article on the beach under a palm tree and sipping a pina colada while you freeze your patuchkies off. 

I thought I would update you a little on this subject- indeed broken skin is where this all starts like in fungal infections, leg ulcers from PVD and yes- frostbite. It is not like you are going to know the causative agent – doing cultures of the skin with a needle aspiration is a waste of time and blood cultures is also (even the culture loving IDSA agrees here). It is going to be strep usually in immune competent adults and Staph also – but much less of the time. If the person is healthy and the cellulitis is not complicated (not clear what they mean here) then you needn’t worry about MRSA. Cellulitis is nearly always unilateral (but then again so is DVT) and it has dolor, calor, rubor and tumor – that is swelling, heat, erythema and pain- but then again so can DVT. Lymphatics may be inflamed as well. Lab tests- do not help. Special cases include aquatic cellulitis from bites or punctures (think Vibrio and Aeromon
as), nec fasc and animal bites. Diabetic infections also need consideration.  These need special attention because often the treatment is surgical or special antibiotics are needed.  Abscesses are always treated surgically –antibiotics generally do not help. DDX include a whole bunch of things but the things that will get you mixed up are insect bites, allergic reactions, gout and DVT- although if it is clearly cellulitis- DVT doesn’t generally go together with it.  Often there is enough damage to lymphatics, that recurrent cellulitis is a given and indeed half of the cases will have another flare-up within three years. I use high doses of Cephalexin for this but there are other possible regimens- liked Augmentin for example if you like to see you patient wobbling to the bathroom to deal with diarrhea. Prophylaxis fails in ¼ of the cases but may be worth it in patients with 3-4 episodes a year. PCN 250mg may be enough TBTR: Cellulitis- some warm thoughts.

JAMA 316(3)325

Ted[bragging] I even got cheered for cutting a ribbon at a supermarket!

Murray: That’s because they didn’t think you could do it.

24) Maybe someone out there will make this diagnosis – I won’t – but periodic fever, apthous stomatitis , pharygitis and adenitis  is called PFAPA . Mostly occurs before age five- but adults can get it too.  Prednisone will help, but it will come back real fast once it is stopped. The treatment is surgical – i.e.- ripping out the tonsils which works remarkably well, and some biological

Clin Derm 34:482

Mary: At our age, having your tonsils out can be dangerous.

Rhoda: At our age, having your hair done can be dangerous.

25) Small numbers –but admittedly a hard study to design- colloids –especially heat treated albumin may do better in large burns. The key is ”may”.

PCCM 17(6)578

Ted[badly mispronouncing German] This is Ted Baxter, saying Oof Weederzane.

Lou: Now that he’s demolished English he’s branching out.

26) NSAID bashing again? No I have grown out of that. We do know that NSAIDS are really good for prostaglandin induced pain – like renal stones.  In Suisse (that is how they call themselves- we call it Switzerland) – they hospitalize 10% of folks with stones (wow). They point out that all NSAIDS are good for this indications and compare favorably against opioids, – with the exception of indomethacin which is inferior (don’t laugh – we still have this med in our department). They note –as well should – that chronic use of NSAIDS will results in ulcers in 15- 30% of the patients and that there is a slight increase in relative risk of MI and death with diclofenac, naproxen, rofecoxib and celecoxib. None was seen in ibuprofen. This may be but it is isn’t telling. Both coxibs are known to cause increases of MIs – that is why Vioxx was taken off the market. Diclofenac has a large degree of COX -2 inhibition (but not enough to be called a Cox-2). Naproxen was a surprise. TBTR: NSAIDS back in the EMU news again.

Drugs 76:993 

Phyllis: Believe it or not, I too once had a feeling of inadequacy.

Rhoda: Oh, no. We’re not going to hear about your honeymoon again, are we?

27) Diarrhea. While acute diarrhea is really fun, this article is going to focus on chronic diarrhea. Bacterial causes are rare – they just do not last that long.  However, E coli, Shigella, Salmonella, Campylobacter and some non cholera Vibrios can be causes. C DifFicle of course can hang around in patients who have taken antibiotics. Think also parasites as well as helminthes and norovirus.  Non infectious causes include celiac disease, cancer, mal absorption, lactose or carbohydrate processing disorders. , IBD, IBS and of course idiopathic (ever notice that idiopathic and idiot start out the same way?).  Think also about Sprue and Brainerd diarrhea (if you drink unpasteurized milk). Treatment and diagnosis vary and there are good charts here (no way I can copy all of them – at least not legally) and treatment can include antibiotics, and yes – loperamide if you already started antibiotics in a bacterial cause. Fecal transplants- can also help- I take one of these with breakfast every morning. TBTR: Chronic runs- how to get you patient not to paint the porcelain.

JAMA 315(24)2712

Ted: I saw you do the news, Lou. You were terrible.

Lou: I know, but that’s because I made a mistake.

Ted: What’s that, Lou?

Lou: I started drinking after the show.

28) When to stop NOACS or DOACS before surgery? The guidelines say 4-6 days for dabigitran, 3 days for rivoroxaban and 3-5 days for apixaban. This study seems to think that one day was enough for low risk bleeding, and more than two days for high risk bleeding. Don’t have to stop at all for fecal transplants!

Reg Ana Pain Med 41(2)127

Ted: You like my new jacket, Lou?

Lou: No, I don’t like your new jacket! At this moment, I don’t like your face, your voice, your fingernails, your name! Waddya say to that?

Ted[looks slightly troubled] Would you like it better in green?

29) Prolonged grief disorder is more common in ICU deaths than hospital or home deaths. Other risks include being a female, living alone, close acquaintances that did not have a chance to say good bye, ditto for patients that were incubated and those with poor communication with the medical providers. Please be sensitive to this.

ICM 42:1279

Murray: Ted has been in love ever since he was a baby and saw his reflection in the bathwater.

30) Letters: we got one from Eric Schneider (from where?) who answers our conundrum about  Pseudomonas- what is the pseudo here? Walter Migula coined the term Pseudomonas for a genus he described as, “Cells with polar organs of motility. Formation of spores occurs in some species, but it is rare.” Migula never clarified the etymology of the term. However, the description of Pseudomonas as “false unit” does not make much sense, and an alternative explanation posits that Migula “had not traced directly the Greek ancestry of the name, but had simply created the name Pseudomonas for the resemblance of the cells to those of the nanoflagellate Monas in both size and active motility.” Thank you Eric.. I was frankly surprised that Ken didn’t give this answer, but Ken checked in anyhow to thank me. I always appreciate it, Ken, BTW –where are you now?

31) Yes, in eight it was Mono – EBV can cause this – not clear why. Direct inoculation? EBV has been found on the cervix. Another name for this ulcer is a Lipschutz Ulcer (AJEM 34(7)E1)

EMU LOOKS AT: Pre Eclampsia

The essays this month really have nothing to do with pre eclampsia- rather with subjects related to this malady.  Sources for this essay are Curr Opin Nephro Hypertens 25:301 and Clinics in Derm 34:368


1) OK, so you used up all the magnesium in the hospital for that eclampsia patient- what about Mrs. Smith with the 0.001 magnesium level in the IM ward?  So this is what you gotta know on low mag- no hormones in the body protect your levels, most o f it is in the cells so it won’t be that easily measured and there are only two ways to get it in and out- the GI tract and the kidneys.

2) It s not like this is going to be obvious when folks are low- they have weakness- never saw that one before in an ED patient- ataxia , cramps, and maybe seizures and rhythm disturbances.

3) Let’s talk about causes- but please recognize this is supposed to be useful and not exhaustive – I absolutely refuse to include genetic causes. Dietary decencies can occur and the bone and other extracellular stores hold on to their magnesium tightly – so there will not be much replenishment from the body like there is with calcium. You can also lose mag by vomiting – but much less than  you lose with diarrhea since the  lower GI tract has a higher concentration of mag. Primary Familial hypomagnesemia –I promised and I am not backing off. We will not talk about this.

4) Pancreatitis will cause this due to saponification The use of PPIs together with a diuretic will also cause low mag through blockage of channels. Hypercalcemia will cause this – due to competition of excretion via the kidney

5) Fluids – such as volume expansion and our favorite fluid – alcohol can cause low mag. Uncontrolled DM results in more mag sent out to the urine. Lastly, hungry bone syndrome, chelation therapy and high fat diets can cause this as well.

6) If you are still confused as to if the source is GI or renal – do a 24 hour urine and check FEMg (UmgX Pcr/(0.7XPmg) xUcr  and times it all by 100%. <2% is GI;>2% is renal.

Our second essay concerns skin infections in pregnancy. As you all know pregnancy is a rampant, sexually transmitted condition which is fortunately self limited. The incidence favors females at the present, but this may change.

There may be one person in the world who doesn’t know who this is- so here is a picture of her in the past: 

1)Let’s start out with the real enemy – the Herpes Zoster virus- the cause of chicken pox which as we all know can be reactivated later in life. Zoster- the reactivated form is not dangerous and requires no antivirals or immunoglobulin for treatment. The fetus is protected by maternal antibodies. This rule is to be disregarded if the virus is disseminated, or in the eye.

2) Now if Mom has never had the chicken pox, but had a significant exposure, then there is danger to the fetus. What is an exposure? Either face to face contacts with a patient suffering from this disease for more than five minutes, living in a house with someone with this disease, or staying in the same room for more than 15 minutes with them. Here you would give passive immunization (immunoglobulin) which in the US is given by injection to the muscle and in Europe- IV. Will it prevent disease in Mom? Yes, in most cases. Will it prevent disease in Junior? Maybe. Maybe there will be a milder disease. We just do not know.

3) Moms who actually get the disease have a harder course – especially in the third trimester. That means higher rates of pneumonia, hepatitis and encephalitis. Uncomplicated case of the pox- used Acyclovir five times a day by mouth. Pneumonia requires IV therapy. Danger to Junior? Only 25% of cases pass on to the fetus, and of those, 1-2% result in congenital Varicella syndrome. What is that? Read on.

4) Congenital Varicella Syndrome is limb problems, eye problems, and in one third – microcephaly, Mortality is 30% in the first few months, but if they make it through, prognosis is good, Give infants acyclovir as well.

5) Infants with Varicella do generally well although the infection may have started when they were still inside.

6) So what about the really young ones- under a month. These kids have a stormy course – without therapy they have a 30% mortality, With therapy – that falls to 10%. If Mom has is in labor – they should try to stop the labor and give immunoglobulin if possible. There is no evidence to say we need to give acyclovir to newborns that were exposed but not showing signs of infection.

7) Condylomata have been in the news lately. This is a virus and can cause what folks call genital warts. They are also the cause of cervical cancer.  In pregnancy they can grow massively. Even better they can get transmitted to kiddies’ anus, genitals, eyes and mouth during delivery. These warts can also trap bacteria leading to infection of the amniotic fluid.  C section may be the answer to the first problem – although it has never been proven. Surgical therapy is the best here and that includes laser and cryo therapy. Podophyllum is toxic for mom and teratogenic for baby.

8) Every doctor has seen a pregnant lady with a yeast infection. Indeed – 50% of pregnant ladies have this problem. These are due to the changes in hormones and pH during pregnancy which favors the fungus. You can use the topical antifungal agents (the “azoles”) but response is slower, and recurrence is more common so you may need a one to two week course of therapy. Note candida albicans yeast infections may be resistant and need amphoteracin B vaginal suppositories which we do not have in Israel. They recommend oral therapy only in severe cases- not clear to me why – after all, problems in offspring have only been seen in high doses for long periods of time – the one time dose that is commonly used poses no problems. We are speaking of course about the pill called fluconazole.

9) Lyme disease – we won’t speak about it – since the incidence is lower in pregnancy and it isn’t to common outside of the USA. They can keep their spirochetes to themselves. What is relevant is that the cyclines- like tetra and doxy – are contra indicated in pregnancy despite being wonderful agents for acne and pneumonia – and Lyme disease too.  They can affect Mom- causing fatty necrosis of the liver.

10) Scabies is yucky and can occur in pregnancy. This mite is best treated with Permethrin. Lindane is not given in pregnancy. This and yeast infections do not cause any adverse pregnancy outcomes but are very annoying. Ivermectin works well, and if you haven’t heard of this medication in Israel (still not approved here) it is still very effective against other yucky bug- lice. However at very high doses – it is teratogenic- but we do not use these dosages generally.

11) We did not get into rubella here since most people are screened for that.

EMU Monthly – November 2016

  • Dancing the twist was very popular years ago. Getting your knickers in a twist is a popular British expression. Twist and shout was a Beatles hit. Ain’t anyone singing about the Testicular Twist. How do you approach the angry testicle? Waiting for bell clapper sign is too late. Doing cremaster reflexes – this is one of the most unreliable signs we have. Ultrasound takes time and can still miss up to 25% of the time. So we reported in the past on the urology idea to make incisions and directly check the spermatic cord. Probably works but I would imagine there may be a paucity of volunteers for a good study. So these folks in China came up with an interesting idea- make a smaller incision, and use a paediatric cystoscope to check the cord. OK, this is only fourteen patients but it was fast, and there was less swelling and post op pain then attacking that poor scrotum with a knife. TBTR: Scrotoscope- a new twist for torsion. J Endourol 30(6)704

Ondansetron for pregnancy induced vomiting. This first worked miracles and now it seems to be on the down. So the gyne people looked at this systemically and the methods are actually very good- no case reports here. The results showed either no problem or a very small risk of septal defects. (1) To be honest, causality it really hard to prove considering that the danger only appeared in two studies and the prevalence was very small. You should also see this link which delves deeper into the statistics (2).  And we would be wrong not to bring the NEJM that said the same thing (3).   However, both the Obs people) and the EM guys (4) found that odansterton is really no better than metoclopramide.  However, the same journal – this year sees no problem with giving it (5) TBTR: Odensterton probably is safe in pregnancy but it is not a miracle drug.

Obs/Gyn 127(5)878

Obst Med 9(1)28

NEJM368(9) 814

(Obs/Gyn 123(6)1272

(Ann Emerg Med 64(5)526

bid 127(5)873i

  • Loved this article. Really. Some of us in primary care and some in the ED do take off casts- but complications such as abrasions and emu-1thermal injuries abound.   The article comes with photos. Thicker casts, fibreglass casts, and less padding increase the risk of thermal injury.  Abrasive injuries are more common with dull blades and inadequately hardened casts.  He has a technique for reducing injuries but of course no science here.. TBTR: Cast injuries- how to avoid them.  (J Ped Ortho 36(4 suppl1) S1 Well it is time for the quotes section – let’s face it- Trump is the president and Obama is done- not everyone liked Obama (I wasn’t a big fan) but he was very quotable. Let’s see: On Harvard degrees and Mitt Romney: “I have one, he has two. What a snob.
  • This seemed to me to be a pretty strong study. This well done study done in the Republic of Ikea (Sweden for you males) seems to show that people with higher CHADS-2 scores do worse if not anticoagulated before electric cardioversion even if the PAF is less than 48 hours in duration.  (1). However, there are a few points to be made. 48 hours may not be as safe as we think – some studies are saying it has to be within the first few hours of PAF appearance. Furthermore, when this is elective, we usually give three weeks prior and three weeks after- because of our fear of the stunned myocardium. Could there be a stunned myocardium in ED PAFers too? TBTR: Give a pill of anticoagulation before you do microwave that heart.

Int J Cardio 215:360

“I want to especially thank all the members of congress who took a break from their exhausting schedule of not passing any laws to be here tonight.”

  • Ever get a phone call in the middle of ED work? A lot of icky viruses will be on that cell phone!   (1) Stethoscopes – even after checking one patient- are just as icky (2)

Clin Micro Inf 22(5)E1

Inf Contr Hosp Epid 37(6)673

“The White House Correspondents’ Dinner is known as the prom of Washington D.C. — a term coined by political reporters who clearly never had the chance to go to an actual prom.”

  • The New England Journal reported that we may be overestimating the vitamin D levels that are necessary (375:1817) but this article implies that in critical care – very low levels of vitamin D- that is less than 7- do worse () This doesn’t mean these two studies disagree- and we do know Vitamin D has an effect on the immune system- but it is very hard to prove causality here- especially since low vitamin D may mean the patients were sicker to start with. TBTR: Are we low on Vitamin D or not?

Clin Micro Infec 22(5)E7

This is a tough day for Rahm Emmanuel – he is not used to saying the word day after the word mother (on Mother’s Day)

  • An interesting opinion piece. They want to put forward that in Europe- with the exception of Klebsiella, resistance rates to current antibiotics have remained stable and low. Death rates are similar whether the bug is MDR or not. Their feeling? No need to find new antibiotics.

(ibid 22(5)408

“All this change hasn’t been easy. Change never is. So I’ve cut the tension by bringing a new friend to the White House. He’s warm, he’s cuddly, loyal, enthusiastic. You just have to keep him on a tight leash. Every once in a while he goes charging off in the wrong direction and gets himself into trouble. But enough about Joe Biden.” — 2009 White House Correspondents’ Dinner

  • Wanna feel what your patients feel? Honestly, I never thought about this, but epistaxis must be terrible.  They took a survey in this study and found people found nasal packing to be pure torture-86% of emu-2patients complained about discomfort from this, 26% described it as strong or very strong pain. Cautery was described as strong pain in 8% with about half describing discomfort alone.  Other complications included breathing difficulties – and nasal crusting.) TBTR: epsitaxis treatment- no fun.

“Now I even let down my key core constituency: movie stars. Just the other day, Matt Damon — I love Matt Damon, love the guy — Matt Damon said he was disappointed in my performance. Well Matt, I just saw the ‘Adjustment Bureau’ so right back at you buddy.” — 2011 White House Correspondents’ Dinner

(Auris Nasus Larynx 43(4)412

  • The idea is attractive- just forget about troponin, and admission – just do the CT coronary and you are all set- if they have plaque- admit and catheterize and if not, – ala casa. () I know this has been studied but I can’t remember where I saw it. But this is what I remember-MI can occur even without findings on CT or cath. And calcifications remain a problem in CT.  Let’s not forget the cost.   I think I will classify this as not ready for prime time in the interim.  Could be in the near future, though. TBTR: CT cath- ready for the ED?   That is the original casemu-3t of SNL – that’s right – the original not ready for prime time players From Left to right- Garrett Morris Here he is today: Next to him is Gilda Radner who tragically died from ovarian cancer at a young age. She was married to Gene Wilder emu-4who also recently passed away.





Behind them is Bill Murray emu-5








  • emu-6
  • pictured over here. Larraine Newman is the next woman  emu-7
  • And next to her Is Jane Curtin.
  • emu-8
  • Dan Akroyd is still around but the last one – John Belushi died from a drug overdose.  Yea they all look older than Father, but they started SNL going. And they were funny (Jane, you ignorant slut) But then again – so is Father. (I tried to get a emu-9picture of Father as a young man – but this is all Google gave for Dr. G Henry as a young man:

BJR 89(1061)50954

“Now, I know that he’s taken some flak lately but no one is prouder to put this birth certificate matter to rest than The Donald. And that’s because he can finally get back to focusing on the issues that matter, like, did we fake the moon landing?

  • A confusing opinion piece – but what I understood was that endarterectomy- versus stent versus intensive medical therapy – all have the same very low risk of stroke so why not do the least invasive? (1) In the USA – 90% of patients with an occlusion get a stent or surgery- Denmark-0%.

Int J Stroke 11 (5)50

“Ultimately though, tonight’s not about the disagreements Governor Romney and I may have.

It’s what we have in common, beginning with our unusual names. Actually Mitt is his middle name. I wish I could use my middle name.” –at the 2012 Al Smith Dinner

  • Quick and to the point. I guess with Internet it isn’t hard to find these things- but if you are unsure about the use of a medication in pregnancy – this article ahs some good phone numbers/site/applications that can help (AJOG 214(6)698)

“You notice that people who’ve been in Washington too long, they don’t talk like ordinary folks,. We had this debate in Las Vegas, and somebody asked me, What are your weaknesses?’ So I said, Well, you know, I don’t keep track of paper that well, I’m always losing paper, my desk is a mess.’ And then they asked the next two candidates. And one candidate says, Well, my biggest weakness is I’m just so passionate about helping poor people.’ And then the other one says, I’m just so impatient to help the American people solve their problems.’ So then I realize well, I wish I’d gone last and then I would have known.. I’m stupid that way, I thought that when they asked what your biggest weakness was, they asked what your biggest weakness was. And now I know that my biggest weakness is I like to help old ladies across the street.

Barbs – my heavens – haven’t they gone the way of people who say “my heavens?” Turns out, that many folks are resistant to benzos when withdrawing from the spirits. This literature search believes that barbs are better and may not cause so much respiratory depression. Could be, but I would still feel better with a study – emu-10and in the meantime- would not go any further than pills if benzos didn’t work. Unlike the new generation, I do have experience with barbs and still fear them. And you may not be doing any favors if they are drug addicts as well. So now it is time to remember one of the famous drunks of all time. That is WC Fields- whose best friend was gin which eventually killed him. Although he looks rather benign: He was quite a bigot, so we will feature another famous drunk – who did not die of alcoholism.  emu-11Don’t remember him? Check out his bio. He did die of lung cancer however.  TBTR: Barbs instead of Benzos for alcoholism??-

Psychosomatics 57(4)341

With regards to Barbs in Status Epliticus they are still to be used according to this additional article – but with propofol and ketamine – not sure why

J Clin Neurophys 33(1)22

“But the truth is when you really get to know Rahm, he does have a softer side, Amy will attest to this; very few people know, I think, know prior to this evening that he studied Ballet for a few years. In fact, he was the first to adopt Machiavelli’s the prince for dance. It was an intriguing piece, as you can imagine, there were a lot of kicks below the waist

  • Boxers fracture – or for you purists – a fracture of the distal neck of the fifth metacarpal – are really common. And you know how to treat them – you reduce them by pulling the fifth phalanx and pushing on the fracture and then casting and …… wait a minute- maybe you do not have to do anything. This is what Dr. Dunn says after casing the literature. Could be – but who really knows? After all, these are all orthopedic studies and we know the quality of their studies-I have already received a complaint from Local 402 of the Carpenters union. I still reduce but I spoke to the bone guys where I work

Orthopedics 39(3)188

TBTR: Boxers fractures – don’t just do something- stand there.

“It’s been a great ride. But I know how quickly these fads can pass. You all remember the pet rock, the mood ring, Howard Dean.”

  • I flagged this study as a really helpful study because of the question it chose to answer – which is the best med for preventing recurrence of a fib? What they found was that all of them- were more effective than dronedarone (dofetilide was equal). That is all well and good – but no one I know uses dronedarone. They also controlled for co morbidities – which I do not think you can do as PAF can occur in some pretty sick patients. From dissecting their data it seems that Amiodarone is the best but all were pretty good TBTR: Dronedarone and dofetilide are inferior choices for preventing PAF recurrence.

J Card 67(5-6)395

Well, not everything Obama said was intelligent: 8. “The reforms we seek would bring greater competition, choice, savings and inefficiencies to our health care system.” –in remarks after a health care roundtable with physicians, nurses and health care providers, Washington, D.C., July 20, 2009

  • If you are really geeky – you will be enthralled by this article – I certainly was and I am geeky. emu-12Basically there is a microbiological structure in our bodies that is essential for growth –and in utero- for proper development. There are no sterile areas in the body- and that includes the fetus. So why do we give antibiotics in pregnancy willy nilly? There can be more epilepsy, and obesity and necrotizing enterocolitis but not so clear if this is early child hood exposure or in utero- why it should make a difference isn’t clear to me. However, the author does acknowledge that exposure to antibotics in some disease does improve development of the fetus – so we aren’t there yet. TBTR: Antibiotics in pregnancy? Maybe that is the reason you are what you are today.

BMC Med 14:91

“UPS and FedEx are doing just fine, right? It’s the Post Office that’s always having problems.” –attempting to make the case for government-run healthcare, while simultaneously undercutting his own argument, Portsmouth, N.H., Aug. 11, 2009

  • Can you scuba dive if you have a CSF shunt- they say yes, but no evidence. This is a point that I have made for many years and so has EMA-no evidence for means also no evidence against.

Acta Neurochir 158(7)1269

“Six years into my presidency some people still say I’m arrogant, aloof, condescending. Some people are so dumb.”  — 2015 White House Correspondents’ Dinner

  • I have spoken about this before.  And with respect to Rick Bukata, I will mention it again in his words “for the new subscribers”. However there are no new subscribers to EMU, and actually, I am not sure there arte any subscribers, but I do enjoy listening to myself. HINTS- the head impulse test- is much better than a good history in differentiating peripheral versus central vertigo. I still think it isn’t as easy as Dix Hallpike but there are some good videos on it now. Here is a link for you to see Peter Johns- the guru of this test – in action.


The point of this article was to show we EPs are not using this test- and we aren’t. TBTR: Be good with peripheral vs central vertigo

Can J Neuro Sc 43(3)398)

“I’ve now been in 57 states — I think one left to go  (there are 50 states in the USA).

  • Could there be a decent paper on statistics that even a moron like me can understand? The answer is no. I will just mention this article emu-13which blasts p values and confidence intervals which will not tell us anything about the research since often there are still errors in size, or data violations. I found it entertaining that one journal even bans the use of such values, but when I checked the references I found it that this was that respected journal-Basic Applied Social Psychology. The problem I had with this paper was that while blasting these values (they even call their paper a “caustic primer”) is they do not tell us in normal language what we should do instead. If you are an egghead- get this paper. If you are a moron- skip it. And know you are in good company I am actually proud to be a moron. TBTR: P value smashing

Eur J Epidem31:337

“Even though most people agree… I’m presenting a fair deal, the fact that they don’t take it means that I should somehow do a Jedi mind-meld with these folks and convince them to do what’s right.” –mixing up Star Wars and Star Trek references while discussing working with Republicans in Congress

  • It was Patton that said –”compared to all human pursuits- they all pale when compared to ar. Gosh how I love it”. I feel the same way about diarrhea.  And now those rollicking folks at ACG have come out with a new guideline on this riveting disease. They have a flow chart but there is nothing really new- we still differentiate between dysentery- blood, fever,- and regular diarrhea. Cultures, fecal WBCs and the like usually do not show us the diagnosis. Probiotics are discouraged unless it was antibiotics that caused the diarrhea. Traveler’s diarrhea is the only one that needs antibiotics, otherwise no use for them. Frequent hand washing- of course you say? They say only – maybe. For traveler’s diarrhea- it won’t help. Endoscopy for persistent diarrhea is discouraged too.. They have no problem with Bismuth preparations and loperamide.  They point out however; most of the recommendations are based on poor evidence. TBTR: Diarrhea – Go with the flow.

“The Middle East is obviously an issue that has plagued the region for centuries.

AJG 111(5)602

  • Here is an article you really see- although no good evidence- and the experience of one person only, but I love articles that discuss day to day issues that I have in the ED. On the other hand, I love being a moron too. So you got this cast you need to remove. Why doesn’t it cut up the skin? And what can you do to avoid other injuries – which are usually thermal and abrasive injuries? The answer to the first question is that this is an oscillating saw which can only cut fixed surfaces- the skin is not supposed to be fixed (although with enough pressure you can fix the skin). You got this vacuum cleaner attachment to your saw? That reduces thermal injury. So what causes thermal injury? Worn blades, thicker casts, concavities of the case (because it is thicker there), and less padding cause more thermal injuries. Soft casts are more likely to cause abrasive injuries.  Also ulnar styloids, humeral epicondyles and all areas with little fat or subcutaneous tissues can cause abrasive injuries. Proper technique reduces all injuries- including pushing down and pulling up , or letting the blade cool off (feel the blade).   Make sure the teeth are free of cast material. If it is a Gortex cast, – cut only on the blue line. Liberally use cast spreaders. TBTR: Tips on reducing injures from cast removal.

“There a few things in life harder to find and more important to keep than love. Well, love and a birth certificate.”
2010 White House Correspondents’ Dinner                                                                         J Ped Ortho 36:Supp 1

  • I don’t like to wax sentimentality here, but I got to put in a word for Scott Weingardt- who I have never met, but who nevertheless managed to encourage EMU and instilled affection for ICU-EM.. Yea, they think I’m crazy for introducing delayed sequence intubation and anoxic oxygenation, but it is slowing catching on here in Israel- thanks to you, Scott. So this one is for you – Scott has often recommended the use of US to check fluid status via the IVC- and you should know while this is easy to perform- there are ten situations where it may not work. They include high PEEPs, low TV, COPD, RV dysfunction, and others. I think most of these are self evident for most ICU guys, but I just wanted you to learn how to do these if you do not do them already. CVP measurement is really not the way to go nowadays.  Also be aware that these are theoretical – there is no science here. TBTR:  IVC ultrasound- not that hard but be careful.

The good news is that, according to the Obama administration, the rich will pay for everything. The bad news is that, according to the Obama administration, you’re rich.
– P. J. O’Rourke

 Intensive Care Medicine 42:1164

  • Article written by pharmacists and they usually cut to the chase – so we will too. Hepatic encephalopathy – what works what doesn’t. Branched chain Amino Acids- don’t work, Acetyl L Carnitine has a minimal role. Zinc – minimal effect on psychometric testing, but doesn’t prevent recurrences. Neomycin- too many side effects as does metronidazole. Ditto Vanco. Vegetable and dairy protein seems to be beneficial, Zinc and Probiotics- some modest effects. Lactulose – defiantly works, Rifaxin is add on therapy.. Now here are some possibilities- bromocriptine, flumazenil, LOLA, and sodium benzoate- the last is the safest. TBTR: Some pointers on pharrm therapy for hepatic encephalopathy.

Ann Pharm 50(7)569

For [Supreme Court Justice] David Souter’s replacement, the President chose [Sonya Sotomayor] a Catholic diabetic woman from the South Bronx of Puerto Rican descent. Apparently that search for the albino midget lesbian unwed Bangladeshi mother with a bum leg and lycanthropy fell just a bit short.
– Will Durst

  • Lastly, a look at a disease that we don’t consider much in the ED. Actually, the primary care guys may seed this more than you. OK, let’s make it simple- you have before you a patient that is pishing too much. They may be incontinent, they make have nocturia, they may just have enuresis. Yet the urine solute excretion is normal and there is no glucose in the urine. Diabetes? You are right!. But not the diabetes you were thinking about- rather it’s poor cousin- Diabetes Insipdus. This comes in four flavors. Pituitary DI: This is usually acquired or genetic and is the most common. It it is due to a deficiency of AVP production. You however, will only see a small – if any rise in plasma osmolality and sodium. The test for this is fluid restriction followed by AVP injection. This is done in hospital so it shouldn’t concern us EPs and the results involve plasma sodium and urine osmolality every hour. Treatment is SVP, desmopressin, Chlorpropamide  anyone see that medicine any more (Diabanese for you young whippersnappers) and Tegretol. Primary polydipsia are people who drink too much – reminds of Carlos who on my psych rotation drank out of the toilet. Treatment here is what we gave Carlos- psychotherapy and maybe SSRIs?  There is a Gestational DI: AVP is degraded faster due to placental vasspressinase.  The treatment here will be desmopressin. Naturally, the kidney could be the culprit .Since AVP is normal or elevated in this form of DI, but is low or undetectable in pituitary and primary, you can just test the baseline AVP. emu-14Gosh, that is a enough – if I wanted to be an internist I would have been an egghead.  TBTR: All you really didn’t want to know about Diabetes Insipdus

Best Pract Res Clin Endr 30:205

President Obama delivered an upbeat inaugural address, ushering in a new era of cooperation, civility, and bipartisanship in a galaxy far, far away. Here on Earth everything stayed pretty much the same.
– Dave Barry

Letters? What letters?

Well, there actually was one from Sody Namer who pointed out that Dabigitran is recommended for patients with low GFR above the others.I think we will all be better acquainted with these drugs as time moves on. By the way, I am dying to know what kind of first name Sody is. I do also want to say hello to Alex Wang Dudi Digmi and Ben Sluckis. Alex is now in the USA doing a EM rotation (looking for a emu-15resident? He is good!) Dudi is a PA by day and body builder at night and Ben is a Brit  emu-16Ben just dropped by for a visit in my shop – Good to see you, Ben.

EMU LOOKS AT: Peeing Bullets


  • Well not really. However, while transplant patients should always bother us, kidney transplants patients are the most frequent transplant patient we see. Obviously quality of life is improved with transplantation and they have a lower mortality and less expenditure than long term dialysis. Nevertheless, mortality is not insignificant. 5-10% of the patients find themselves in the ICU at some point; usually because of sepsis or respiratory difficulties. Many of these patients have heart problems even before they were transplanted and even though they have lessened mortality when compared to dialysis patients, 30% of them still die from heart disease .A fib is bad-this means a higher rate of stroke, graft failure and death.   Keep this in mind when these patients come in shock.
  • ARF-well, D’oh, no?  Most of these will find themselves in the ICU for cardiogenic pulmonary edema. 30% of these patients will need intubation. Most do well, but this is an ominous sign for graft function
  • Ah, infections,-w hat would do if we didn’t have those little buggers who stupidly kill hteir host while enjoying one last suicidal meal before going to their demise as well? emu-17
  • Well, this is going to do in kidney transplant patients too. Truth be told, post op- while 59% have complications, most of these are minor like fluid collections and bleeding.  However, mycotic arteriits does occur. Rare, but it can occur.   This is an invasive fungal infection which can lead to aneurysms, leaks, wall rupture, or shock. The payers, are the usual villains- Candida and Aspergillus. Contamination of preservation fluid and gut damage from the surgery can also occur – prognosis is poor in all of these.
  • Pneumonia. Isn’t that sweet?  Foir thos of you who do not remember the original Addams Family that is Gomez and Morticia played emu-18
  •  by John Astin who recently died, and Carolyn Jones.  But pour favorite will always be Lurchemu-19 (“you rang”)                                                         (that’s him next to Uncle Fester) And Cousin Itt who just mumbled. emu-20
  •  Itt was played by Felix Silla, Lurch by 6’9 inch (2.08m) Ted Cassidy, and Fester by Jackie Coogan.  Enough ADHD- here is what you need to know about pneumonia in these patients. It occurs in about half to two thirds of the patients. Aside from the usual bacteria, you should know that mycophenolate mofetil  can cause bronchiectasis (this med is knownin my country as CellCept- I think as well in the USA.). This can lead to colonization or infection by the arch villain Pseudomonas. (pseudo means fake- I always wondered what the fake was? Well, Wikipedia will tell you but I still do not understand).   CMV is much less common these days, but RSV and influenza are the new murderers- both viruses and bacteria approach 35% mortality. Same for PCP now known as PJP (who is this Jiroveccie guy? Back to Wikipedia).  Does Anti lymphocyte IG also cause ARDS? Maybe, but these folks are pretty sick to start with if they are getting ATG.
  • Kidneys get infected as well. Acute graft pylonephritis develops in almost 20% of patients. If this occurs within three months of transplantation, this spells the end of the transplant, and can cause deterioration of graft function even later on.  Most of these patients end up with septic shock, and many get ARDS, If they survive, the graft is often shot
  • Blood stream infections also occur – secondary to the urinary tract, and stents. 25% of the time we don’t know the source. However, Gram negatives and to a lesser extent- Candida are the culprits. emu-21
  •  That’s Dudley Do-Right capturing the arch villain Snidely Whiplash from Rocky and Bullwinkle. Other pathogens that abound are TB (often not in the lungs), C difficile, Nocardia (likes to make pneumonia and brain abscesses) crytopcouccus (pneumonia and meningitis) and Toxo (pneumonia, myocarditis and neuro).
  • Managing these patients is tricky in florid sepsis. Immunosuppression affects the sepsis seems a plausible theory but never proven. But also you have the problem that the pharmokinetics of the drugs are affected by sepsis. And moiré seriously- calcineurin (Tacrolimus- in my country this is Prograf) and mTOR don’t mix with azoles and macrolides.
  • While we are speaking about these drugs, you should know the combo of Prograf and CellCept can cause neutropenia. This may lead opt having to discontinue the drug or the need to start GSF.  However, Sirolimus (Rapamune) can cause lung toxicity- but this is usually mild-like cough and fatigue- but they can have pretty bad looking x rays with infiltrates, and consolidations.  However, it can lead to ARDS and the drug may need to be stopped and steroids given.
  • Also Tacrolimus can cause PRES:posterior reversible encephalopathy syndrome. They will need an MRI to make this diagnosis- they will have to cease taking the drug. TMA can occur too- this is acute kidney injury, HTN, anemia, thrombocytopenia and as a result- organ injury.  This is due to micro aniopathic thrombosis and occurs most frequently from the Tacro and Sirolimus drugs. CMV and malignancy can also occur. This is not rare- can occur in up to 14% of cases usually after transplantation but it can occur years later.
  • Lastly they caution us to avoid nephrotoxic drugs, evaluate kidney graft with US Doppler, and have low threshold to use GSF if there is neutropenia.


  • Gunshot wounds are a daily part of your life if you work in some parts of the USA. Indeed this article starts out with a polemic – I don’t 1005 agree with their politics, but the statistics are pretty frightening. In the great USA- someone is shot every 4 minutes forty four seconds, and someone dies from being shot every 16 minutes. Hospital costs often reach 1 million dollars in a population that is often uninsured.   The USA also leads the world in mass shootings. The USA has 5% of the world population while owning between 35-50% of the guns. They then claim that the lower gunshot wound rate in other countries is due to the strict firearm control. I am dubious- in Israel it isn’t too hard to get a gun but in Israel for example, aside from terror events, murder is extremely rare.
  • I don’t think we have to enter into all the intricacies of ballistics, but obviously damage depends on the characteristics of the bullet (mass and velocity which of course tells us how much energy is imparted) ,orientation and the tissue it penetrates. In this respect- Velocity is the most important determinant of energy imparted. As such rifles can impart much more energy than a handgun.
  • How bullets work and how recoil ain’t what it is in the movies is interesting but not relevant at the moment- see the article if interested.
  • Bullets come with jackets to prevent deformation due to the high temperatures. Fully jacketed bullets impart very little of their energy and are likely to continue on their course after traversing the body. However, if they are partially jacketed they may deform and fragment causing more internal damage. Pointy bullets deform very little as do those with boat tails thus conserving their energy and being very accurate. Hollow head bullets deform on impact and cause much more damage.  Now they have those with heads that explode on contact to the skin – both of these may be illegal in some countries.
  • Caliber is the outer diameter- they are expressed in mm or in hundredths of an inch.  While the police use a 38 caliber, the 357 magnum can cause more damage because of the amount of propellant it has. For the record- Lincoln was assassinated with a 44 caliber, Garfield with a 44 caliber and McKinley with a 32 caliber bullet.- All were from revolvers.  Kennedy was killed with a rifle.
  • Handguns by definition are low velocity. Revolvers arte more popular and can shot six times with only six pulls of the trigger. Semiautomatic pistols are becoming popular. Rifles are also becoming semiautomatic which means that the bullet firing the first round- the second is automatically loaded without cocking.
  • Shotguns shoot pellets; birdshot is the smallest, then come buck shot and slugs.  They go out in a conical fashion which means if you are close by, you will have a big hole in you. Greater than 7 yards may result in much lighter injuries that may not even penetrate the fascia.
  • Tissue damage is all dependant on elasticity. Skin and lung are more elastic than liver and spleen and brain. Fluid filled organs like the heart and bowel can just burst. Bones are not elastic at all- so they can shatter and cause secondary damage from fragments. These principles also apply to the danger of cavitation.
  • They have a myths section but most of this is directed to what we see in Hollywood- and not relevant to the ED. I will just mention if you want to stop a person – shooting rarely is enough to knock a person down. The bullet must hit the brain, high spinal cord or bones of the legs. Even the heart takes some time until cardiac output falls too low to support an upright person.

EMU Monthly – October 2016

  • Been waiting for this one- and I guess it is time to remember Dr. R- she was a foul tempered surgical resident, had been married a few oct-image-1times, chain smoked and who didn’t enjoy trauma. If someone came in after being kissed by a fender or being run over by a steamroller – they got the same work up – total body CT. Then I started working in this huge trauma center, and sure enough – total body CT. Well we can all rest easier now. This four-center international study showed that outcomes were the same in both groups.  (Lancet 388:673) Does sound convincing but the fact is that in the selective group 46% still got a head to pelvis scan – making this a lot less helpful. TBTR: Selective versus total body CT- – outcomes are the same in trauma. (Lancet
  • This is a return call to give metoprolol in a renewed effort to push beta blockers to the forefront again.   Now they point out oct-image-2

that most studies that questioned this practice were done before the age of fibrinolytics. It could be true that these do limit infarct size but we need a good study to prove it- not a post hoc analysis that they bring. Is it better than Effient and Brillinta? When combined with those, is there a synergistic effect? That is the info we really need to know. JACC 67(18)2105

TBTR: Metoprolol – is it back for MI?

  • Do transfusions cause more mortality? Go ahead, I challenge you – prove it. Usually the studies that show increased mortality are in patients that are real sick anyhow – so how can you tell? So this study says that it doesn’t in patients with renal failure who are receiving renal replacement therapy.  But the kicker is that this was shown in patients who were in the ICU – where they got maximal therapy- and only in those who survived five days. TBTR: RBC transfusions – more mortality? Maybe not. CCM 44(5)1014)

Quotes this month come from a site I discovered accidentally. Witty quotes from wise women.

I always wanted to be someone; I should have been more specific. – Lily Tomlin

Deep down, I am pretty superficial –Ava Gardner

  • Our Ministry of Health- which carries a lot of weight here- makes our nurses ask the pain scale – you know- rate your pain on a scale of one to ten. Everyone here always says ten. I think that Joint Commission also requires this. I think we must be sensitive to pain but I also think this scale is asinine. This article – which really should be read by all of you – makes it clear that this is a possible cause of the opioid epidemic, it doesn’t check the patients desire for analgesics, it cannot take into account other factors which make contribute to the pain (i.e. like anxiety) and it makes us look bad (“Your Honor, it is clear that  they did not take the plaintiff’s pain seriously”) (Ann Emerg  Med 67(5)573) This was written by pain gurus Steve Green and Baruch Krauss and I can’t added anything – this is a true bulls eye. TBTR: Pain scales pain me.

I am not offended by all the dumb blond jokes because I know I am not dumb- and I also know I am not blond either. Dolly Parton

I don’t have the time every day to put on makeup- I need that time to clean my rifle.  Henrietta Mantel

I refuse to look at them as chin hairs – I think of them as stray eyebrows Janette Barber

  • Yea I am biased. This is an Israeli study. However, it is on a subject many of us are weak on. Adnexal torsion. They sought to compare the presentation of paediatric, adolescent and reproductive age women aoct-image-3nd found that actually, the presentation was pretty similar. However, the younger women –girls and adolescents – usually waited before presenting for care. Also the causes for the torsion differed although this is less relevant to our practice. All the causes though- can recur. (J Women Health 25(4)391) TBTR: Adnexal torsion. Don’t miss it. Can you imagine a world without men? No crime and lots of  happy fat women   Nicole Hollander.
  • Ever hear “it’s all natural” meaning it has to be safe. Well, there is actually a database for adverse drug reactions called VigiBase and it is run by the WHO and yes; you can access it. Allergies seem to be the most common side effect- something very common for you Aloe Vera aficionados. (Drug Safety 39(5)455)TBTR: Natural medicines- safety??

Who ever dreamt up the word mammogram? Every time I hear that, I think I am supposed to put my blood in an envelope and mail it to someone.  Jan King

  • I usually do not bring Annals articles because many of you read oct-image-4them, but you all know how much I like lactate (oh c’mon, we’re just friends  We know that according to the new sepsis guidelines – which I reviewed last month- above three is serious. What about between 2-3? If the patient looks infected- this could have serious repercussions- begin therapy with antibiotics and fluids. (Ann Emerg Med 67(5)643) TBTR: Lactate. Love it or treat it.

We have women in the military but they don’t put us on the front lines. They don’t know if we can fight; if we can kill.  I think we can. All the general has to do is walk over to the women soldiers and say “you see the enemy over there? They say you look fat in your uniforms”  Elayne Boosler

  • This is a JAMA study – how could I criticize it? I am truly not worthy, but I think the point is important. Giving electrolyte fluid in minor gastroenteritis is barbaric – the stuff tastes so icky. Why not give them what they want to drink? And indeed more children continued with the therapy when this happened. (JAMA 315(18)1966) The problem is – all children had to have diluted apple juice/proffered fluids first if they were in the group that got to drink what they wanted.  Then they got to drink afterwards according to institutional protocol. That really isn’t giving kids what they want to drink That is another problem – most kids with AGE don’t go to the tertiary ED. TBTR: kids – give them what they want to drink.


There are three ways to get something done. Do it yourself, employ someone or forbid your children to do it.  Monta Crane

  • We all know this, but here is an article to wave in front of your kidney docs – which is what I did. Kexylate can cause colonic necrosis – – and it is not that rare (0.4% in their series).It can also cause hypernatremia and hypokalemia, but I can’t really say how often this occurs since they called hypernatremia greater than 145 and hypokalemia less than 3.5- clinically speaking that may not be significant. (Clin Neph 85(1)38).So what should you use? Well, dialysis is a good idea after you have used the initial therapies and I like furosemide. TBTR: Sodium Polystyrene – time for an alternative?

Success didn’t spoil me, I have always been insufferable.  Fran Leibowitz

  • Big time literature search which tries to help us treat cardiovascular toxicity due to cocaine. Benzos- can help but not always. Calcium channel blockers can reduce hypertension and vasospasm, but not necessarily tachycardia. Nitroglycerin can cause sever hypotension and reflex tachycardia . Alpha one blockers – same as calcium channel blockers – but much less evidence. Beta blockers- we were taught these are really bad because of unopposed alpha stimulation –the evidence shows it could be correct – go to labetolol or carvedilol but be aware that the alpha blocking is not as strong as the beta blockade. Antipsychotics- will help with agitation but not consistently with tachycardia or hypertension. EPS can result. Morphine deals with coronary vasospasm, but not tachycardia. Basically, the evidence ain’t great, but there is some guidance. (Clin Tox54(5)345) TBTR: Cocaine chest pain- some guidance.

I am furious at the women’s libbers.  They get on soapboxes proclaiming how women are smarter than men.  That’s true but it should be kept quiet or it will ruin the whole racket.  Anita Loos

  • We really do not give injections IM as much as we did in the past, but I learned from Nurse Mary how to give a painless shot- give the skin a nice pinch and inject- they feel the pinch but not the injection. Here they checked three techniques – all of them reduced pain but I do not buy that internally rotating the foot will help. The Z technique may be worthwhile. Here is a picture of how it works.  (Int J Nurs Pract 22(2)152) TBTR: IM injections- how to, not why.


Dear, never forget one little thing- this I my business; you just work here  Elizabeth Arden to her husband

  • I guess there may be some relevance to this article to EM. They claim that if you take sign-out in written form during change of shift the information on the paper won’t stay current for very long- half of the patients will have inaccurate information within six hours (BMJ Qual Saf 25(5)324). I imagine that in many pales electronic or easier to update smart phones should have replaced written sign out but I guess people may not update those also. TBTR: Sign-out blues.

Women’s rule of thumb- if it has testicles or tires- it is only going to cause trouble – Anon ( I imagine a female said this)

  • Type one and Type two errors- I read a lot of articles on statistics, but I think this is one of the clearer ones. The one thing I liked with this article – other than it was short- is that it didn’t use any examples- the articles that do are so confusing. The article will define these errors to you – which basically is whether the null hypothesis was accepted or rejected in error. In this is the definition of p value – which is the amount of error we find acceptable in making our conclusion (i.e. if we accept the results as true- a p value of 0.05 means we still have a 5 % chance of being wrong.) What you need as a reader of the literature  is to know that type one error is increased if multiple endpoints are  investigated, there is a secondary analysis of the data (what Prof Hoffman – “Jerry” calls data snooping or data torturing), interim analysis of the data and stopping trials early. Type two errors – or beta error is due to an improperly powered study. Power is defined but that part was confusing to me but sample size is a big part of this. It also depends on whether the clinically relevant difference is going to be big or little. TBTR: A little statistics – it won’t hurt. Acta Paed 105:605

If they can put a man on the moon, why can’t they put them all there? Anon

  • Dental avulsions- most commonly affect the incisors, but we have written on this subject in the past. Here are some pointers-(pun intended? What pun?) – but remember these are dentists whose dedication to EBM is not the strongest.(“what they hell do I care what the evidence says? As long as I get to use my drill and it hurts…”). Even if the root remains (I assume they mean one or two of the roots) you can still reimplant. For them, milk is the ideal solution for preserving teeth if you can not reimplant them. In adults, the rate of avulsion is less as they more frequently fracture. By age 10-11; blood flow at least to the incisors is reduced and these teeth often need root canal if re implanted. They like tetracycline for antibiotic coverage (although in the “how to reimplant section they say amoxicillin) but they give no evidence why we need antibiotics in the first place BMJ i1394

TBTR: Teeth that have avulsed are not like pulling teeth.

Men- can’t live with them, can sell them for parts  -Cheers


Yes a golden opportunity to slow that heart rate, take care of your pains, and even smooth out your blood. We are of course speaking about Acetaminoamiodonoac. ?????? The sources for these essays are listed below


J Palliative Care 19(2)231

1) I dunno, they say IV acetaminophen is really expensive, but in Israel – at my shop- it goes for four dollars a treatment which isn’t terrible.

2) This med has higher concentrations in the CSF. It also works faster while having the same duration of action as po. However, how this translate into patient oriented outcomes is questionable- there have been some studies that saw no difference in overall pain control with IV.

3) IV has less chance for liver toxicity but in malnutrition or iatrogenic causes (i.e. – your doctor was an idiot) – it can occur. The Rumack Matthew nomogram does not work for IV.

4) This was not in the article but we have written in the past of the poor absorption by the rectal route of this medication in general.



AJM 129:468

  • Your either hate it or love it. I am speaking about amiodarone. And I hate it.
  • One study showed an almost 20% reduction in mortality in high risk LV dysfunction patients. Another study showed no effect on survival but up to five fold increases in pulmonary and thyroid toxicity.
  • AED are much better for VT but Amiodarone + beta blockade can reduce the frequency of shocks.
  • It is used for A fib, but was actually never FDA approved for this use. The drug has a long half life and a huge volume of distribution and as such can take days to weeks to reach effective levels. IV increases levels rapidly but it can still take a few days to suppress arrhythmias. By mouth it can keep 65% of a fibbers in sinus rhythm over a year. This doesn’t sound great but then again-sotalol and propafenone are only 37% effective. By IV – in one study- only 5.2% converted to sinus.
  • IV is the way ACLS wants you to give this drug but while it does increase survival in shock resistant VT it does not lead to more discharges alive from the hospital.
  • Oh, those side effects. They can occur 15% of the time in the first year, and up to 50% during long term use. Fatigue (hypothyroidism, or bradycardia or even AV block), cough  (pulmonary toxicity), syncope, skin changes (photosensitivity), weight loss (hyperthyroidism), weakness or parasthesia (neuropathy) AEDs may not detect the slow VT that can happen with this drug and it may take more energy to defibrillate.
  • Drug interactions – you name it-dig, qunidine, warfarin,procanamie, dilt and verapamil, beta blockers, flecanide, phenytoin, cyclosporine, statins, and anesthesia.
  • When it does cause trouble – it stays around for a while – with pulmonary toxicity – it will respond to steroids but you need to take them for a long time. Thyroid? You may not see frank thyrotoxicosis since the beta blocking effects of amiodarone block these. But hypothyroidism is more common. You will need prednisone and an anti thyroid drug here. Did hyperthyroidism cause a patient’s a fib? Careful using amiodarone!
  • Liver toxicity occurs and can stay around a while but usually resolves when the drug after the drug is stopped. Poly neuropathy may occur and this may not get better with discontinuation of the drug.


J Vasc Surg 63(6)1653


  • You knew it was coming – you just did- we will speak about NOACS. I hated these also- but I have started to appreciate the beauty of these drugs
  • Let’s get the names straight and what they are approved for as of press time. Pradaxa(Dabigatran)- the oldest one- is approved for Afib stroke prevention, treatment of DVT and PE, and prevention of VTE. No useto in hepatic or renal populations. It cannot be used in nursing or pregnancy. Under 60 kg- it can be used. APTT may be increased by 1.5-1.8. It needs to be taken twice a day generally and has an antidote. It intereacts with rifampicin and ketocaonazole.
  • Xarelto (Rivaroxiban) is approved for all of the above and in CAD as well. Everything we wrote about Pradaxa above applies here other than there is no antidote and that it is given once a day. It interacts with carbamazepine, phenytoin,rifampicin, HIV protease inhibitors, itra and keto conazole. Also clrarithromycin.
  • Elquis is apixaban and is approved like Pradaxa. Also given twice a day. Don’t give in renal impairment or in hepatic impairment or in weights less than 60 kg. Same interactions as Xarelto. Given twice a day. APTT is barely elevated but PT does by two fold.
  • Lixiana is the new kid on the block and is given once a day. It is only approved for stroke prevention in afib and DVT/PE treatment. Can’t be used in hepatic or renal failure or in less than 60 kg unless you reduce the dose. Has all the interactions of the above plus verapamil, and quinidine and dronedarone. APTT barely moves, but PT does.
  • So what do I use? Xarelto is easy ot dose and has about the same interactions as the others. But I change my mind quickly.

EMU Monthly – September 2016

  • Everyone has dreams –am if your dreams are like mine- you dream about (sept-image-1actually that is what Father dreams about)-the rest of us dream about starting Nor on sick morbidly obese patients-so you ask – do you need to give more Nor to these patients? The answer is no.  They raise blood pressure at the same rate as non obese folks (do any of those really exist?) (AJCCM 25(1)27) TBTR: Nor is not prejudiced against fat people.
  • I have issues with this study (besides the issues I have perssept-image-2onally) but I do want to make a point. I don’t care what the ID guys say – if the patient has meningitis or sepsis and is circling the drain – start the antibiotics and let someone sort it out later. How do they sort it out? PCR – and PCR worked fast- faster than blood cultures and actually did better than them. (ibid 25(1)68) You gotta ask – how much did this cost? And since antibiotics were already started – did this make any difference in patient oriented outcomes? But my point remains – just do it in sepsis TBTR: PCR can help- don’t wait for to take cultures- sometimes
  • This idea gets the D’oh award: mechanically ventilated patients can communicate by texting with a smart phone (ibid 25(2) E38) sept-image-3Personally, I prefer telepathy, but a smart phone will do. Hey time for quotes- like take a real old timey guy – Rodney Dangerfield-this is from your parent’s times. His real name was Jacob Cohen and he died a little over ten years ago:I told my psychiatrist that everyone hates me. He said I was being ridiculous, everyone hasn’t met me yet
  • It is a little odd that we cause so many infections with catheters and yet never asked the other side what they think (the other side doesn’t mean the bladder – I meant the patients) This study was definitely skewed – they were all white and only eleven were females. Overwhelmingly they agreed that no one informed them of the dangers of catheters. Actually some even thought it was convenient to have one. (AJ Inf Contr 44(3)304) What can you take from this article? Basically, we are not talking to our patients. TBTR: What do the patients think? Anyone ever thought to ask?

In my life I’ve been through plenty. when I was three years old, my parents got a dog. I was jealous of the dog, so they got rid of me

  • Computer touch screens are full of bacteria – in the hospital it is going to be VRE and Clostridia, but in the super market it is going to be MRSA. And enteric bacteria- that is kinda of sick. What do people do, take a poop, and then say – hey, I’m hungry – wanna go to the grocery for a bite to eat? Oh, and by the way, I forgot to wash my hands. (ibd 44(3)358) TBTR: Computer touch screens- icky.

I live in a tough neighborhood. They got a children’s zoo. Last week, four kids escaped.

  • Anterior coetaneous nerve entrapment syndrome –we’ll call that a
    ACNES for short – is a scourge of kids- it is a common cause of abdominal pain- all investigations show little and the kid is still suffering. So what helps to diagnose this? Well, in this cohort- Carnett’s sign was always positive. Have them tense the abdominal wall (by pulling their legs or head off the bed) and if the pain gets worse or stays the same- it is not intra abdominal. (J Ped Gasto Nutr 62(3)359) Recently, Medscape perspective suggested this for adults, but my surgeons weren’t convinced- hey they gotta have that CT. But like any sign – it may be used to support what you thought anyway. TBTR: ACNES- it ain’t on your face.

I tell ya, my wife’s a lousy cook. After dinner, I don’t brush my teeth. I count them

  • So how do different Europeans deal with renal colic? Honestly, who cares? What interested me is that they are doing a lot more uretoscopy to takeout stones and a lot less lithotripsy. Lithotripsy really hurts, so this is a good development. (Urol Int 96(2)125)

I was an ugly kid. I worked in a pet store. People kept asking how big I get.

  • We haven’t had a good Ken paper in a longtime; so here it is. An attending tells a senior that they should not accept a potential resident because she is pregnant. A medical student is nearby – and was told “pretend you didn’t hear that”. What is he to do? They say – do not confront the attending- as long as there are other options – no need to endanger the medical student’s future. He can turn to the administration or the senior. (JAAD 74(4)766) Whistle blowing is a tough thing –especially when you do not know whose is on whose side. Also, often the protection for these folks is only after the whistle blower is already in hot water. And there are always genteel ways of making folk’s lives miserable. Wish there was a simple answer. TBTR: Whistle blowing in medicine.

When I was born, the doctor said to my father, ” I’m sorry, we did everything we could but he still pulled thru”.

  • Bronchiolitis? There is no such thing! Did I just drop a bomb or what? This article says that has been studied in poor studies and the patients that may actually have this disease are usually excluded sept-image-4from the studies. They claim it is probably early asthma (CMAJ 188(5)351). They also point out that nothing really helps this disease, so if it is early asthma – why don’t steroids and broncho dilators work? TB TR: Bronchiolitis? Banish the thought.

I could tell my parents hated me. My bath toys were a toaster and a radio

  • All my patients think they have thrush – but except in denture wearers and HIV patients- it is kind of rare. Miconazole is more effective than Nystatin, but in denture wearers, microwave therapy is the best (I didn’t know that) (Oral Dis 22(3)185) TBTR: Nystatin – you can do better.

What a dog I got. Last night he went on the paper 4 times – 3 while I was reading it

  • EMU has never gone in to this subject, and it is an uncomfortable one. Human trafficking exists and it doesn’t go away or cease to exist because you close your eyes. There are signs – usually the trafficker accompanies the patient and won’t let them out of their eyes – very similar to domestic violence. You should read this review –this is not just a problem of inner city folks or of runaways. (Ann Emerg Med Apr2016) I was particularly enlightened (and frankly shocked) by hearing the first hand story of such a woman on EM RAP about a year ago. Get this recording if you cna, and remember –there are resources. TBTR: Human trafficking. – identify it. Eradicate it.

One year they asked me to be poster boy – for birth control.

  • There are some phalangeal fractures that do go south. I recently heard Dr. Anan Swaminathan speak about the controversy of whether tuft fractures should b e considered open fractures and given antibiotics or not. He doesn’t give , but I saw two osteo cases lately and it really got me thinking. This article speaks about sequela after phalangeal fractures. Most of these – a small study in any event – were close to or through the joint Only three were in patients with open fractures- I do not know the denominator – so Swami’s question still isn’t answered (Eur J Ped Surg 26(2)164) TBTR: Phalangeal fracture – no big deal?

My uncles dying wish was to have me sit in his lap – he was in the electric chair

  • Skin tears in the elderly? Close them how every you want (I glue them) and then use VAC- that vacuum device the plastics guys love- and you will have great results in no time – viability here was demonstrated in five days (Int Wound J 13(2)283).

On Halloween, the parents sent their kids out looking like me

  • No evidence here – and why should there be- this is a surgical journal- but it seems that acutely – in type B dissections – endovascular therapy acutely may be better than medical therapy. (Eur J Endovasc Surg 51(3)452).  Makes sense to me- endovascular at least fixes the problem.

When my old man wanted to be intimate, my mother would show him a picture of me

  • Oh, how I remember those westerns- remember How Green was my Valley, Gunsmoke, Bonanza, Wagon Train-sept-image-5 (- yes that is the famous baked beans scene in Blazing Saddles) – why am I mentioning this? Because of the phony cheesy line “I got an itchy trigger finger”. Here is a one page summary of all you need to know about trigger finger-patients report locking of fingers on flexion and extension, women and diabetes are at risk – the treatment is easy – cortico steroid injection but often repeated injections are necessary – and in that case – surgery should be considered (CMAJ 188(1)61) TBTR: Trigger finger.

I had a lot of pimples too. One day I fell asleep in the library. I woke up and a blind man was reading my face.

  • Women and heart attacks – this is a patient explanation page but I will just bring two facts from it that I did not know- -only 56% of women think that heart disease is a leading cause of death in women. sept-image-6I did not know (what a moron I am ) that pre eclampsia is a risk for heart disease. Also. Women must know that depression is another risk and is more common in women (I would be depressed if I was married to most men also). I did like that they say the risk increases as we get “less young”. ( Circ 133:e428) TBTR: some info on women and MI. It’s tough to stay married. My wife kisses the dog on the lips, yet she won’t drink from my glass.

It’s tough to stay married. My wife says no because she’s tired then stays up and reads her book

  • Talk about an article I did not understand at all- It started with the classic starling equation (which includes on sigma and two pi (I purposely did not write that in the plural) –it describes swimmer induced pulmonary edema and its relation to HAPE- I couldn’t make sense out of it- but it is here in the data base (Circ 133:951)

I got myself good this morning too. I did my pushups in the nude, I didn’t see the mouse trap

  • Article of the month. If you don’t read anything I wrote this month- and you shouldn’t- read this. A surgeon you know took out the healthy colon and left the diseased part-what do you do? There are a lot of bombshells in this articles. First of all- it is a panel discussion- the first discussant states the importance that we police our selves- medical science is too complex to be left to non physicians and that we can be trusted to rectify peers (he likes M and M conferences- by surgeons this can be the ultimate in hunting season) – I do not agree- I think inter peer politics still plays a role and as far as the former is concerned – whether we like it or not, non physicians will be involved. He points out that good outcomes often accompany grievous errors and bad outcomes accompany perfect surgery. Who is to blame? Sometimes that can be very nebulous. Report them?  Whistleblowers often suffer consequences and also we often say- someone else will deal with the problem. A second discussant says that we must inform the family and the surgeon who made the error. This discussant is against reporting to the medical board – who often are cretin in their approaches to complaints (just don’t ask Father what he thinks about the New York board of medicine).  A third discussant does feel that we should identify if the error occurred from chance, a momentary error in judgment or egregious incompetence. The last one should be forwarded to the medical board.  This discussant does not get into how we make the determinations in gray cases- since most physicians are not at the ends of the spectrum Get this article (Ped137(3)e20153828) TBTR: when physicians make errors.

I’ll tell ya, my wife and I, we don’t think alike. She donates money to the homeless, and I donate money to the topless

  • Two clinical quizzes that you have no chance at.  A red nipple  that is inflamed in a ten year old boy (in camp we called this a purple nurple)   What could this be ? (JAMA Peds 170(3)289).The second is an 80 year old with abdominal pain after eating and a history of PAF.(JAMA Surg 151(3)287)

I told my dentist my teeth are going yellow. He told me to wear a brown necktie.

My psychiatrist told me I’m going crazy. I told him, “If you don’t mind, I’d like a second opinion.” He said, “All right. You’re ugly too!”

  • How to review a paper- this paper gives the basics (I Liked the way they summarized peer review- Is it new? Is it true? Does anyone give a %$^&?) it is here in the data base – but not much new here (J Electrocard 49:109).

I drink too much. Last time I gave a urine sample there was an olive in it

  • VP shunts are almost always the problem- on boards and in the ED. It is a little silly for me to summarize an article that is already written in an easy to read format. BP shunts are used to drain CSF for a variety of reasons –and you can usually feel the port under the scalp. They generally drain via a long tube into the peritoneum. Shunts – I didn’t know this- fail 40%of the time in the first year and 50% by the second year. Usually this is due to mechanical failure such as obstruction, and fractures of the tubing. Infectious complications can occur, but occur much less in frequency. Obstruction can be subtle – headaches, apathy, sleepiness, even changes in eating behavior in kids. Evaluation of the shunt includes x rays (the shunt series) which show any fractures- (look around the clavicle or the lower ribs). CT or MRI will evaluate problems in the cranial part of the shunt. Problems with the shunt are dealt with by the neurosurgeons but  in an emergency you can try tapping the shunt- make sure you don’t drain too much or leave less than 20 mm Hg. You can do an LP in most patients without a problem of causing herniation – but there is no consensus on when you should enter the port and when you should do an LP. Shunts are rarely tapped even by neurosurgeons even though infection rates are low (Ann Emerg Med 67(3)416) TBTR: What you need to know about VP shunts.  I was so ugly,

when I was born, the doctor slapped my mother

My wife, she’s another one. Last night our house caught fire and I heard tell the kids, “Shhh, be quiet; you’ll wake your father.”

  • This is another article that may be worth your while- maybe. This atlas is for poisonous plants and mushrooms, but of course your flora may be different were you live. Still – cool pictures. (Disease-a-month 62:41)

The shape I’m in, I could donate my body to science fiction

  • So let’s take the geek test- which would you rather have? A good chocolate bar, a good woman, a good wine, or a case report from Circulation? If you answered a good wine – you are either past the age that you can appreciate good women or chocolate or you are Father Greg or you are both. They present this 32 year old athlete who has had chest pain and shortness of breath with radiation to the left arm and a normal EKG. This guy is in good shape, so I don’t think CAD is the answer, but infiltrative cardio myopathy, and myocarditis are defiinetly in the DD. Of course an echo is the first test, but if it is negative, they suggest continuing with a cardiac MRI- something I have never done. A stress test should be done for exercise induced arrhythmias. Naturally, both tests were normal. To make a long story short (whenever anyone says that, you just know it is going to get longer) the guy codes at home, his wife started CPR (why??- must be he had insurance)sept-image-7 and he survived intact- kinda of the way most case reports from Circulation end. What did he have? Coronary artery spasm- he got an ICD although wearable ones are the future. (Circ 133:756) TBTR: The name of this article is “A Shocking Development in a Young Male Athlete” – showing once again that those cardiologists are just one rollicking jolly group sept-image-8

We sleep in separate rooms, we have dinner apart, we take separate vacations – we’re doing everything we can to keep our marriage together.

  • Letters:
  • So the clinical quizzes in 19- the first could have been contact dermatitis, an insect bite, a hemangioma, or a cutaneous lymphoma- but it was Borrelial lymphocytoma- usually found on the outer ear. It is one of the manifestations of Lyme disease. It responded to antibiotics-interestingly enough – this occurred in Belgium- so it can be seen out of the USA. The second was Dunbar syndrome which is compression of the median artuate ligmant from the diaphragm. Yea, I thought this was abdominal angina too.

EMU LOOKS AT: Getting Stoned

As usual this is a pun and the sources for this article are BMJ 352:i52 (2016) and BMJ again352:i124 (2016).

Getting Stoned

  • The first article deals with the workup of renal stones. The name of the article is a misnomer – it really doesn’t have anything to do with the medical management of stones in the ED – but yes in prevention. Here is a statistic – one out of every 11 people will have a kidney stone in their life, and half of them will have a recurrence during their life. In other words- if they know how to make a stone, they probably will do so for life.  Stone disease is also related to many systemic disorders – HTN, obesity, and diabetes.   This is no longer a disease of men predominantly- women are catching up.
  • What are risks for getting stoned?- all that I mentioned before and also hyperparathyroidism, being a carnivore(eating a lot of meat), low fluid intake, eating a lot of salt and avoiding fruits and vegetables.   Family history plays a part as do some medications – especially high doses vitamin C.
  • Blood tests can help a little- raised uric acid – can indicate gout (but low or normal doesn’t rule it out). Low serum potassium and bicarbonate and high chloride imply RTA. High calcium (corrected of course) implies hyperparathyroidism.
  • Check the urine – well, that is a surprise. Urine pH and signs of infection can imply the type of stones. Of course if you know the composition of previous stones that can help you as well. Calcium oxalate stones don’t reveal much – too many disorders cause them , but Calcium phosphate stones can imply RTA, hyperPTH or medullary sponge kidney.
  • Imaging-it is pretty obvious that this can help but not usually in the composition of stones. They do not speak about it, but I am not a fan of scout abdominal films. Even if you see something – is it a fecalith? Phlebolith? a stone? Is it causing trouble?
  • 24 hour urine collection is important- I order this all the time. They like –total pH (not available to me), calcium oxalate, uric acid, citrate, sodium, potassium, and creatinine.
  • So now we get to treatment. They like drinking to a urine volume of sept-image-92 liter a day but not all fluids are created equal. The following will reduce stone formation: coffee, tea, beer, wine and orange juice. (Or in other words, my wife, Homer Simpson, Father Greg, and I are all happy). Sugary drinks and punch cause more stones (because of obesity?). Citrus fruits-no good evidence yet either way.
  • Does eating more calcium make more stones? No, this is multi factorial – yes you will excrete more calcium, but you may not make stones. It seems if you eat your calcium with meals you will excrete most of it with oxalate in the stool, thus reducing stone formation.
  • Probably a good idea to reduce oxalate ingestion- what is that? Dried fruit, pineapple, beans, nuts, grains- oh- just see the list from the hodie toities at Harvard. Oxalate in the urine is also caused by a bacteria O. formigenes and turmeric, cranberry and vitamin C ingestion.
  • Citrate in the urine prevents stone formation- you’ll find this in fruits and vegetables and in OJ. DASH diets also reduce stone formation.
  • Low sodium diets also cause more calcium resorption and less stones. Animal protein: we have mentioned already, but dairy products do not cause more stones.
  • Talk about meds we never use- they have a table of medications to prevent future stone formation. Thiazides prevent calcium stones, but potassium citrate works really well for these and most others (struvite stones are the only exception) Sodium citrate works – but the sodium may offset the positive effects. I used Mag citrate in a patient with hypomagnesemia and stones. Did the trick
  • A longer essay than usual- but still the fact that beer and wine can help you – it is worth getting stoned.


And that leads us to our next essay- acute management of decompensated alcoholic liver disease.

  • Cirrhosis causes immune dysfunction with high mortality rates if there is infection present. These folks get UTIs, C Difficile, entercolitis, and cellulitis- and the most feared- SBP. Enterobacter species, an d non entercooccal strep are culprits here.
  • A word on SBP. They can have fever, they can have abdominal pain- most of the time – they have nothing. Tap these folks – if there are more than 250 WBCS- start antibiotics and albumin which has shown some promise in reducing hepato renal syndrome.
  • Alcoholic hepatitis. This presents as rapid onset jaundice, tender RUQ (although most alcoholics have this anyhow) coagulopathy, AST and and ALT being more than two times the normal with AST being two times higher than ALT. Prednisone is used with modest effect; at this point ; NAC, GSF, and early transplantion are experimental.
  • Hepatorenal syndrome- hard call, because these folks have malnutrition and their creatinines may not be that high – sol ook for changes in their normal creatinine, and be aware that this is more common in SBP Give terlipresin and albumin.
  • Ascites- tap it if it is interfering with breathing, but if not make sure they are taking spironolactone and furesomide, and be prepared for all sorts of electrolyte disorders.
  • GI bleeding, encephalopathy- they leave to recent guidelines and do not discuss them. They do not discuss alcoholic ketoacidosis, and alcoholic pancreatitis- both which can be seen the ED and need early ED intervention.
  • Nutrition – careful with refeeding syndrome.
  • They do not tell us how to treat withdrawal – I always used benzos but they say this can cause hepatic encephalopathy. They want you to just be careful.
  • This can occur also by imbibing any wine advertised as the wine of the month on Risk Management Monthly.

EMU Monthly – August 2016

  • Hey it is August guys- the heat, the beach, summer camp with pimply counselors, and arts and crafts (I remember camp well – I was the goalie for Archery practice). Lacerations are a big part of summer and we have championed the intrathecal volar nerve block – but it is in an area full of nerves. So maybe do the dorsal two injection technique – but that has two sticks. This study found they both hurt at the same rate. But I am still in awe of these Aussies- both techniques failed more than 25% of the time. And pain scores of eight were still present five minutes after the injection. What were these guys doing?? Chris? (Emrg Med Austr 28(2)193) The one shot technique is the one I do and it is really easy – shoot in the middle of the base of the finger and when you hit the tendon – you won’t be able to inject- with draw a millimeter and inject. TBTR: Digital nerve blocks for chronic nose pickers.
  • Are you a woman? (we’ll give you a few minutes to figure that one out) Are you older? (we’ll give you a few more minutes to think about that one) Are you in poor general health? If you are given tranexamic acid you have more of a possibility of getting a seizure. For some reason this happens more often in post cardiac surgery patients. This may occur from inhibition of glycine. (Ann Neuro 79(1)18) I have never seen this, but they say it occurs up to 7.3% in post cardiac surgery patients. I would surmise however, that topical use for nose bleeds and the like and low doses in healthy people are fine TBTR: Seizures can come from using Tranexamic acid.
  • Ten myths in UTIs: this was already featured in MEDSCAPE and indeed there is nothing new here for those who read EMU religiously (am I nuts to think anyone does?) but get this article for your FPs (JEM 51(1)25) I just wanted it to be in our data base. And it is time for quotes: We at EMU never want to be accused of being politically correct, so let’s hit you guys with ridiculous Trump and Clinton quotes. First the Trumpster:“An ‘extremely credible source’ has called my office and told me that Barack Obama’s birth certificate is a fraud“Ariana Huffington is unattractive, both inside and out. I fully understand why her former husband left her for a man – he made a good decision.”
  • The moment you have been waiting aug-image-1for. Yes it’s our ketamine moment – a chance to sit back, relax and disassociate. (This is going too far back for most of our readers- but the association was a musical group responsible for the big hit “Windy” –I’m sure you all have heard it- “whose walking down the street of the city..” It was actually written reported to be about a male hippy- but Ruthann Friedman denies that rumor- she wrote the song)  There are some case reports out there thaaug-image-2t you can use this drug for prolonged sedation of children such as those in the ICU, those with opioid withdrawal, those with bronchospasm, or if they are having a prolonged temper tantrum (Ann Pharm 50(3) 234) TBTR:Ketamine IVCD- -silly, ketamine is for kidsaug-image-3

All of the women on The Apprentice flirted with me – consciously or unconsciously. That’s to be expected.”

“One of they key problems today is that politics is such a disgrace. Good people don’t go into government.”

  • We have two natural medicine articles for you this month- there are some places with limited health care resources nevertheless scabies doesn’t discriminate- they are free to for the asking. The common treatments – Ivermectin and Permethrin – are showing some resistance, so maybe try Tea Tree oil – it kills the buggers, and is anti-pruritic, and anti-bacterial as well. (Am J Trop Med Hyg 24(2)258) I am fine with that, but there is still no good evidence. Fu Zi is derived from Aconitum Carmicheaeli and is used as analgesic. It put this patient into VT. The authors of this case report that here was no safety information given to the patient (she took a large dose apparently), no notation on how the active ingredients were extracted (are there adulterants? Were the milligrams of the medicine weighed accurately?) This seems to be a problem with a lot of natural medications, and as I say to the patients –Natural doesn’t mean safe.(Can J Card 32:291) TBTR: Natural medicines – one may work, one may not safe.“It’s freezing and snowing in New York – we need global warming!”“I think the only difference between me and the other candidates is that I’m more honest and my women are more beautiful.”
  • Cyclic vomiting syndrome –with pregnancy – well, doesn’t that sound sweet? What works here? They say amitriptyline did the trick, and indeed I checked and it is category C in pregnancy. (Ob Gyn 125(6)1487) Now this could be because CVS has a brain gut connection, it could also be that this med has anticholinergic effects. However, there may be a psychological cause to CVS and that may be the reason this works. I am not sure how they concluded that this wasn’t Hyperemesis Gravadarum. TBTR: Cyclic vomiting syndrome with pregnancy – what would you to use?”The point is, you can never be too greedy.””My IQ is one of the highest — and you all know it! Please don’t feel so stupid or insecure; it’s not your fault.”
  • This is somewhat maverick  – aug-image-4but we like to be modern here. Appendicitis – maybe the surgery can be done ambulatory? They made a score here to help make this decision (Ann Surg 262(6)1167) but the study is retrospective, and they have a heavy dependence on blood tests. They did – to their credit – do imaging, but perhaps the ones that were eligible for ambulatory surgery didn’t need surgery ion the first place-? Too many questions but perhaps the futureaug-image-5

( this is  going back to the sixties also but click here for info on this film) TBTR: Ambulatory surgery for appendicitis?





“I was down there, and I watched our police and our firemen, down on 7-Eleven, down at the World Trade Center, right after it came down

“Number one, I have great respect for women. I was the one that really broke the glass ceiling on behalf of women, more than anybody in the construction industry.”

  • Fever on and off and ear pain for 10 days in an autistic child. They did a CT and found a Bezold abscess, sinus vein thrombosis, mastoiditis, and an epidural abscess. (JAMA Oto Head Neck Surg 142(1)95) OK, this raises a question – we all know that otitis media is a viral disease, and antibiotics are usually not required – but sometimes they are – and a miss can be serious. There are guidelines out there (these are the AAP but there are Danish, Japanese, Israeli – all recent). But I generally will not give antibiotics in garden variety but fever and a prolonged course or under one year old – I do give. Oh, and you say you do not know what a Bezold abscess is? Nearly got that one by you!! It is an abscess of the sterno cleido mastoid which forms by direct extension from the mastoid. TBTR: Ear infections – rare complications but be aware. You could see there was blood coming out of her eyes”The beauty of me is that I’m very rich.”
  • Boarding – we all hate this – but here is a new wrinkle – are you boarding psych patients? We all know psych beds are at a premium – and boarding takes a lot of manpower – but it still happens. The state of Washington Supreme Court has recently ruled that this practice is illegal. (Psych Serv 66(7)668) TBTR:

Boarding psych patients is against the law. aug-image-6

“If Hilary Clinton can’t satisfy her husband, what makes her think she can satisfy America?”

“Love him or hate him, Donald Trump is a man who is certain about what he wants and sets out to get it, no holds barred. Women find his power almost as much of a turn-on as his money.” (Trump on Trump.)

  • This is an article that is definitely a game changer and I would love to hear from Scott on it. There are new definitions for sepsis. The new definition is a 2 point increase in the SOFA score, hypotension unresponsive to fluids, the need for vasopressors to get SBP to at least 65(these patients are circling the drain in my opinion)  and – this is the curious one- Lactate greater than 2. On the positive side- SIRS is out. ( JAMA  315(8)757) The author of this editorial illustrates that the definition is still too broad – the treatment of an 18 year old and a 90 year old may still differ because sepsis is a spectrum. TBTR: – new definitions for sepsis.  And now some quotes from the Clinster”In my White House, we will know who wears the pantsuits.” –on the role her husband would play in her administration”Well, that hurts my feelings.” -on why voters like Barack Obama better
  • I didn’t want to mention this, but I still see too many folks who are confused – what is the definitive treatment for abscesses-do they need antibiotics or not? The answer is – it depends (isn’taug-image-7 it annoying that that is the answer to all questions in medicine  (- Howard the Duck – how is that for annoying?). Generally – and read the discussion in this article- they don’t. DM may, and MRSA seems to do better with antibiotics if there is a high prevalence in your area. (EJM 374(9)882. I would add also those who live on the street or (in my hospital) in the desert or have poor follow up probably will benefit as well. I routinely give to breast abscesses that I needle aspirate and peritonsillar abscesses. Olecranon abscesses- see last month’s essay. TBTR: Abscesses- should you use antibiotics?”I’m undaunted in my quest to amuse myself by constantly changing my hair.”If I didn’t kick his ass every day, he wouldn’t be worth anything.” –on Bill Clinton
  • Morphine is in trouble again. It is bade enough that it is aaug-image-8 member of the infamous opiate family and constantly chased by the narcs (Narcan) – but now it has run  into a DOO (disease oriented outcome)problem- Ticagrelor seems to work slower and weaker in patients who have gotten morphine for their MI. The authors admit you gotta give something- MIs do hurt- but we don’t know what that should be until further studies are done. I say – let us see some patient oriented outcomes that really matter. They also point out that while Morphine has some anti-sympathetic tone properties, there really is no role for it in acute pulmonary edema. There is some literature that people who received morphine in APE aug-image-9do worse. (Eur Heart J 37:253) I actually have become less of a morphine fan and more of a Fentanyl fan – thus avoiding all the problems of cumulative doses, changing doses in CRF, histamine releases and slow and fast metabolizers (although the problem with Ticagrelor- no info if it would still be a problem with Fentanyl). While we are talking, it is time for an eighties flashback – the author of this study was Atar, and that name is shared by two folks from back them – Crazy Eddie  –(some write it as Antar, but close enough) aug-image-10 those electronics stores whose” prices were insane” – all those stores are closed after the CEO was arrested and Pat Benatar aug-image-11(really she is an Atar – ben is a prefix that means son of) (Pat is really Polish, but Benatar is her ex-husband’s name)You have for sure heard her signature song – “Hit Me with Your Best Shot” TBTR: Morphine in MI – give it some thought before you do it.”I have said that I’m not running and I’m having a great time being pres — being a first-term senator.””We have a lot of kids who don’t know what work means. They think work is a four-letter word.”
  • This is a basic article but I still see a lot of flumazenil given wily nilly. The purpose of this article was to contrast Narcan and flumazenil- the former now given freely for use by non-medical personnel and the latter black boxed in the USA. It is true that Flumazenil is a problem in patients who then subsequently seize but the article points out – these patients usually have other high risk features that would lead you to be cautious. But the truth is, you don’t need to come on to this – benzo over dosages- unlike opioids that cause respiratory depressions centrally – cause respiratory effects by upper airway occlusion (this is based on a article from 2002 – seems hard to believe – but maybe) Therefore, intubation is more popular as treatment for a Benzo OD.  Flumazenil can have some use- it is the drug to use if you over sedated a patient; it also causes patients to awake if they have had sevoflurane, or propofol ( interesting – I was taught that if you gave Flumazenil and they start to seize –give them propofol- will it still work? You always have ketamine.) . It can reverse depression of diaphragm function in patients that were intubated, and it can treat paradoxical agitation that can occur with midazolam. Naloxone can be given IM, IV, nebulization or in the nose, but orally or by ET  aug-image-12tube are discouraged (I was always taught that ET  route can be used.) The dose has gone down lately – they say 40 micrograms is enough in most patients, but remember that both drugs wear off rather quickly.(BJCP 81(3)428) TBTR: Narcan and Flumazenil- the nitty gritty.”He ran a gas station down in St. Louis… No, Mahatma Gandhi was a great leader of the 20th century.”
  • We have been proponents of apneic oxygenation of patients pre intubation – this is: have a nasal cannula pumping in oxygen they whole time. However, they found no difference in disease oriented outcomes in patients who did not get this nor did they find any advantage over pre oxygenation (AJRCCM 193(3)230) Maybe, but you need a lot more than 15 liters per minute of oxygen to flow into the lungs (i.e. positive pressure) in in this study they only used 15. Furthermore, they ignore, that this allows us more time to intubate. TBTR: is apneic oxygenation out??  Now the other half of the Clinton team –Bill.”Being president is like running a cemetery: you’ve got a lot of people under you and nobody’s listening.””You know, if I were a single man, I might ask that mummy out. That’s a good-looking mummy.” (on seeing an Incan mummy)
  • Just a couple of dental articles- not because I have any love for Dr. Yankems- who does?- but if you are going to cause so much pain and suffering – you better have some literature to back yourself up. If there is no fever you do not need antibiotics for endodontic infections or pain – although they admit their EBM search showed only fair studies. I dunno; it always helped me. What about antibiotics after extractions? |(JADA 147(3)186) Here we have a Cochrane, but again the evidence isn’t great and most of it is on impacted wisdom teeth – which may be different than other extractions. In these extractions, their NNT is 12 for infection prevention and 38 to prevent dry socket. They also may reduce pain – but there is no NNT here. What about more infected extractions and folks with other illnesses? What seems to be clear is that you do not need them routinely, although a NNT of 12 is pretty impressive. (Cochrane CD00381) TBTR: Tooth fairy concerns.”What’s a man got to do to get in the top fifty?” –Bill Clinton, reacting to a survey of journalists that ranked the Monica Lewinsky scandal as the 53rd most significant story of the century”Sometimes I feel like the fire hydrant looking at a pack of dogs. For six years I had declined to tell those kinds of jokes, because I have been told it is not presidential. But I feel kind of outdoorsy today.” –Bill Clinton, at a party honoring the 150th anniversary of the Interior Department


Hey we all remember Oscar Madison from the Odd Couple aug-image-13His initials are OM so let’s get started with OME-Otitis Media with Effusion. The source for this essay is Oto Head Neck 154(2)201.

  • Not really an emergency problem but definitely an incidental-oma that we see a lot of. Just know that this is extremely common – 90% of kids under school age will have OME and they will develop 4 episodes of it per year. This can result from an URI, poor Eustachian tube function or as an inflammatory response to OM. Kids with Down syndrome and cleft palate have this problem even more so.
  • Why does this bother us? Because these kids may have hearing problems (my kids are big and have hearing problems also – or maybe it is just listening problems), balance problems poor school performance and recurrent OM.
  • Learn how to do pneumatic otoscopy- this is cheap and easy to do- but most docs do not know how to do it. Fear not, the article does have a nice table on how to do this properly and how to interpret it.
  • Tympanometry helps decide on whether this is really an effusion and what your chances of for spontaneous resolution. IT is more accurate and can also tell if there is a perforation. The article doesn’t tell you how to do this because you aren’t going to do it- you send them to a tech to do this study.
  • If you find OME and there are no school problems or hearing problems – just keep an eye on it.
  • No Steroids. Period. No antibiotics. Period. No antihistamines. No decongestants. Double period. aug-image-14
  • Smoking around the kid – if you are really that stupid -makes things worse. Have kids swallow when planes land to reduce pain – they can fly with an effusion.
  • Yes to hearing tests if they have an effusion that doesn’t go away.
  • If there is a persistent effusion and there are learning or hearing problems – under four have them get tubes, over four they recommend tubes and adenoidectomy. Tubes can have otitis problems- they should be treated with drops. They can go swimming with tubes (as long as the water is clean) and the tubes usually fall out in 12- 18 months. No mention about adults with OME – I spoke to my ENT and they suggest endoscopy toconfirm that there is no tumor. I know diuretics also do not work

Madison is also Addison with an M attached – so we now delve into that subject. Source here is the AJM 129(3) 339.

  • Well, Addison’s is the realm of the internists and as such there are – as usual going to be primary, secondary and glucocorticoid induced causes of adrenal crisis (yes, I know, glucocorticoid is a secondary cause, but go tell that to an internist). Primary causes include autoimmune, infections (TB, AIDS, and fungi), congenital, bilateral hemorrhage, or adrenalectomy (what a surprise). Secondary include any tumors or surgery affecting the pituitary, head trauma, Sheehan’s syndrome, and empty sella. Curiously, mets to the adrenals do occur, but insufficiency is rare unless the mets are bilateral and extensive Primary is the most serious and one most likely to lead to crisis but glucocorticoid suppression is the most common cause,
  • Here is the problem – crisis can be the first presentation in up to 50*of patients with Addison’s. Most of the time, the diagnosis is delayed since the progression may be slow and the symptoms nonspecific-fatigue, nausea, fever, lethargy etc. When crisis occurs, they have hypotensive shock and, altered sensorium and may have vomiting or diarrhea or abdominal pain which may lead to a mistaken diagnosis.
  • Hypotension: It may be due to hypovolemia or secondary to lack of catecholamine. The former may be treated with fluids, but the later may be refractory to fluids.
  • Hyponatremia occurs, and is due to either failures to suppress vasopressin leading to impaired free water excretion (this is in secondary adrenal crisis) or aldosterone deficiency in primary. If it is the latter you will see also hyperkalemia and volume depletion. Hypoglycemia and hypocalcemia may also occur in crisis.
  • Most of the time there is a precipitating event usually GI illness (due to impaired absorption of oral steroid treatment?). However, be aware that emotional stresses can also cause this problem -the literature includes such precipitants such as flight delays, wasp bites and reading EMU.
  • Do not forget occult sources of steroids that may cause adrenal suppression- inhaled, intra articular, Megesterol, Medroxyprogesterone, and use of anti fungals or ritonavir which inhibit the CYP3A metabolism network. P450 enzyme inhibitors can causethis too. DI, DM, and hypogonadism (oh boy, are you in trouble) can cause precipitate crises but the reason is unknown.
  • DO NOT BE AN INTERNIST when these patients come in – if they are unstable – treat them – if you have time you can take a serum cortisol and an ACTH and DHEA and renin and aldosterone, but do not waste precious time if they are in crisis. Fluids- here you do want normal saline – are given first and dextrose if they are in hypoglycemia. Careful with cortisol – it will correct the sodium – but you need to do this slowly so they do not develop osmotic demyelination syndrome. So do not correct the sodium more than 9 meq in the first twenty four hours- giving 100mg of Solucortef will usually be enough in the ED.
  • Prevention is debated hotly, because we are not really sure how much steroid people need daily and with stress. Since GI problems are the most common precipitating cause – they recommend early parenteral treatment. They recommend that a family member be trained to give the first steroid dose at home and not the patient – since patients are often altered. For other cases – major surgery, birth, and dental surgery – see the chart in the paper on how much steroid to supplement to prevent crisis.
  • I will give some steroid in shock that is not responding to fluids and pressors, because you never know.


EMU Monthly – June 2016

  • How old are you? I just had a birthday –and it brings back warm memories of birthday parties with barbeques, iced birthday cakes, party favors and esophageal food impactions. Life was simpler in those days, we just treated these things with Adolf’s Meat Tenderizer. image001That’s papain for you young’uns, and then all of the sudden we were told – don’t do that, you’ll liable to tenderize the esophagus and heavens to Mergatroid, they will perforate. These guys from Harvard did treat meat impactions with this stuff, and by golly no one had a perforation and all were soon playing the piano again. (JEM 50(1)183) Sounds great, and we all love nostalgia but please, there were only 69 patients and some also received SL NTG or glucagon – so the meat tenderizer may not have done the trick nor stayed in the esophagus too long. This also was done by the department of thoracic surgery so I am not sure of what kind of patients these were. I guess if you have no choice- like you are at a birthday party – but I see little possibilities for this in the ED. Perhaps for chicken because as many of you may remember – it takes a tough man to make a tender chicken image002
    TBTR: Papain may be on the comeback for meat impactions.
  • I think most of you probably saw this but the NEJM had a 41 center trial looking at irrigation for open fractures- and pressures didn’t matter- contrary to what we have always been taught in EM. (NEJM 373(27)2629) I am not worthy, but I think there were some problems here. 41 centers only came up with 2447 patients. Also the endpoint was fishy- failure was reoperation for infection or inadequate bone healing within 12 months- that may or may not be related to infection. As usual- we have got to see, but in practice- irrigation under a faucet or with a 10 cc syringe and an 18 gauge IV does fine for me TBTR: irrigation – pressure doesn’t matter.
  • This is a plug for someone I don’t even know. This article shows a new running butterfly suture technique- the pictures aren’t’ the greatest but I figured them out – I did not see much advantage to running subcuticular sutures. (JAAD 74(1)e19)This gives me an opportunity to introduce a great website called lacerationrepair.com. This is a great place for residents, students and even old fogies like me TBTR: suture like a pro. Mohammed Ali just died and while we hated him-that was his allure – he was pompous, arrogant, and we ate it up. Let’s dedicate some quotes to him this month. image004Ain’t no reason for me to kill nobody in the ring, unless they deserve it.
    • Comment after the match with Jimmy Ellis was stopped by the referee in the twelfth round (July 1971)

Last night I had a dream, When I got to Africa,
I had one hell of a rumble.
I had to beat Tarzan’s behind first,
For claiming to be King of the Jungle.
For this fight, I’ve wrestled with alligators,
I’ve tussled with a whale.
I done handcuffed lightning
And throw thunder in jail.
You know I’m bad.
just last week, I murdered a rock,
Injured a stone, Hospitalized a brick.
I’m so mean, I make medicine sick.
I’m so fast, man,
I can run through a hurricane and don’t get wet.
When George Foreman meets me,
He’ll pay his debt.
I can drown the drink of water, and kill a dead tree.
Wait till you see Muhammad Ali

  • It just is amazing how you can go from one extreme to the other with poor evidence. We said here in EMU that appendicitis is just like diverticulitis- why do you need surgery? Antibiotics should be enough for both. This was based on the axiom that uncomplicated diverticulitis does well with antibiotics. Then came two poor studies out of Scandinavia that say, well, diverticulitis is an inflammatory disorder and not a bacterial one and giving IV fluids will accomplish the same thing as giving antibiotics. So what comes out of this? Now many European Societies of GI are saying – do not give routing antibiotics and even the Americans are now saying – “not so fast” on antibiotics for diverticulitis (Gastro 149(7)1650). I wouldn’t jump on the bandwagon yet, but I will say if you do not use them – there is some backing. TBTR: Antibiotics for diverticulitis- maybe you should just stay away from seeds???

If you were surprised when Nixon resigned, just watch what happens when I whup Foreman’s behind!


I hated every minute of training. But I said to myself, ‘Suffer now, and live the rest of your life as a champion’.

  • Medicare is now rating hospitals on patient satisfaction. This is a tough pill to swallow. For all the reasons the article mentions. The questionnaires are only filled out by angry patients and rarely ask the truly important questions. They are likely to trash the doctor even though he was fine but the nurse or staff wasn’t. The surveys do not pay attention to the hard work and lifesaving we do. They will lead to doctors doing dumb things to get their scores up like prescribing antibiotics when they are not needed or even prescribing opioids. Also, we have so much more to fix in medicine – why not put precious resources into that? Lastly we are not bank tellers- we are advisors and not service personnel. How are they able to judge what is we do? The author of this article goes on to refute all these claims although you gotta agree from the start – these reasons seem valid to me. So he we go. He says if you ask the right questions you will get the answers –and you need to speak to patients to tailor your care. We are no talking if we did the LP correctly; we are asking if it was explained sufficiently beforehand. However, he throws in that the questions were asked to random patients- I believe it really is true that if left up to patient’s devices alone they will only respond if they are disgruntled. He refutes the score complaint by saying – professionalism is paramount- we still need to listen – even if there are some docs that will do stupid things to get their scores up. He then argues that nothing is prefect but we still need to extract what we can from these surveys. (Ann Int Med 163(10)792) This does go against everything I learned from Dr. House,image005 but I include it here to remind us – we are dealing with humans like ourselves, and unlike some professions we will be on the receiving end at some point – maybe image006TBTR: Why your patient’s opinion matters.

I’m retiring because there are more pleasant things to do than beat up people.


Frazier is so ugly that he should donate his face to the US Bureau of Wildlife

  • The good news is that I was right – NSAIDS do cause more heart failure- as a matter of fact – 40% more in patients with heart failure – with rofecoxib being the biggest offender. The bad news is this was a meta-analysis of only six papers on the subject and you can bet your sweet bippy  that they were of varying quality so I may not be right. But EMU wishes to go on record to say I am right- – and that is that. (Eur J Int Med 26(9)685) TBTR: NSAIDS will get your heart failure patient doing the SOB thing.

It’s just a job. Grass grows, birds fly, waves pound the sand. I beat people up


Flight Attendant: Please fasten your seatbelt

Ali: Superman don’t need no seatbelt

Flight Attendant: Superman doesn’t need a plane either

Ali put on the seatbelt.

  • The new Beers criteria are out and you should defiantly have one image007while you are reading this Here are the changes from 2012 that you should be aware of :
  1. Nitrofuratoin is safe in the elderly providing you do not use it in folks with creatinine clearance of less than 30. Long term use is probably never a good idea in anyone.
  2. Rhythm control is now back – these folks can have results better than rate control. Amiodarone, dronedarone ,disopyramide and digoxin are all to be avoided as first line meds and never give dig at daily doses greater than 0.125
  3. The non benzo hypnotics (zolipidem, eszopiclone and zalpalone) work minimally and the risk are not worth it
  4. Avoid sliding scale insulin (this is not new)
  5. PPIs should not be continued beyond 8 weeks if possible – something we have been voicing at EMU for years
  6. Desmopressin for nocturia – out – causes too much hyponatremia
  7. Other drugs on the list to avoid in common use (although no change from 2012 ) include first generation antihistamines , antispasmodics. Alpha 1 inhibitors for hypertension, TCAs ( except doxepin less than 6 mg a day – this drug, BTW it is a good sleeping aid). All antipsychotics (higher risk of CVA) Benzos), NSAIDS (did I need to tell you that?) (Cytotec helps but does not eliminate risk) and Dalbigitran (JAGS 63(11)2227) TBTR: Beers criteria – summarized for you- Bottoms up! OK we have used all the Ali quotes we can find. Now to  a humorist never featured before on EMU – nothing to do with Ali- Dave Barry:

But I do think we need to explore the commitment problem, which has caused many women to mistakenly conclude that men, as a group, have the emotional maturity of hamsters. This is not the case. A hamster is MUCH more capable of making a lasting commitment to a woman, especially if she gives it those little food pellets. Whereas a guy, in a relationship, will consume the pellets of companionship, and he will run on the exercise wheel of lust; but as soon as he senses that the door of commitment is about to close and trap him in the wire cage of true intimacy, he’ll squirm out, scamper across the kitchen floor of uncertainty and hide under the refrigerator of Non-Readiness

  • You know that look- that bookish, pony tailed cutie colleague that seems to finally be the intelligent girl you would be interested in pursuing. You sidle over and open the conversation. “Hi, Doctor, – wanna talk some literature?” I gotta admit – that is a great pick up line- you quickly pick up your I phone and press on EMU. But she beats you to the punch- with a little bat of her long lashes she says” Sure, I just read this great article on complications after circumcision” (J Paed Child Health 51(12)1158). The conversation quickly turns to syncope after she sees your reaction. We will keep this clean –most of these were kids 3 years old – which lends me to believe that they were not ritual circumcisions- the reasons for coming to the ED included redness, swelling, bleeding, urinary problems, and pus. While the readmit rates were fairly high, most of these presentations could have been avoided by more carefully explaining the normal progression and recover to the parents. They saw more problems in community circumcisions. I have seen some of these in the ED- mostly in Israel all have been minor (gel foam or a suture is often all that is needed). There I kept it clean. Wasn’t easy. Just remember to give who ever does the circumcision a tip. TBTR: Circumcision woes- mostly aren’t

What, exactly, is the Internet? Basically it is a global network exchanging digitized data in such a way that any computer, anywhere, that is equipped with a device called a “modem” can make a noise like a duck choking on a kazoo

  • While we are in the neighborhood- (J Ped Urol 11(6)321)these urologists did a literature search and worked hard to eliminate publication bias (they did funnel plots!! image008) and found that giving kids medical expulsive therapy helped significantly . I would be convinced but look it- these were in kids up to 18 and an eighteen year old is an adult for me. Furthermore, they found nifedipine was helpful but we know it isn’t from that Lancet article we quoted not long ago. And what are the right dosages? We can’t know. But I think you gotta realize the key point here- kids can get urinary stones. TBTR: Read the last line.

Of course it’s possible that there really ISN’T any shadow government. The whole thing could be a phony story that was fed to The Washington Post to mislead our enemies. As you recall, Secretary of Defense Donald Rumsfeld recently admitted that the Pentagon had set up an office-officially named “The Office of Disinformation”-that was supposed to put out false statements to the media, thus throwing our enemies off the track. For example, if we were getting ready to attack Iraq, officials of the Office of Disinformation would hold a press conference and state: “Well, we’re certainly not going to attack Iraq!” The news media would report this, and Iraq would relax. France, meanwhile, would surrender.

  • This is an exhaustive article on pediatric ankle fractures and to tell you the truth, if you are an EP you should know these; if you feel uncomfortable with these than by all means pull the article. But I do want you to remember to serious fractures- the Tillaux fractureimage009 and the triplane fracture:image010 Not That I really believe you will miss these, but they do need surgical intervention, so know how to speak the ortho lingo. (Foot Ankle Clinic 20(4)705) TBTR: Pediatric ankle fractures.

But this should serve as a reminder to brides of the importance of discouraging reception guests from discharging their firearms unless they have a good reason, such as the band vocalist attempting to perform “I Will Always Love You” in the official Whitney Houston Diarrhea of the Vowels version (“And IIIIIIeeeeeIIIIIIIII, will alwaaaaays love yoooooeeeeeeeooooooouuuuueeeeeeeeeoooooo” BANG)

  • We have mentioned this before – but it has been many years (use our search function) –This Korean study – a small compared one – compared patient’s getting thromoblysis with surgical embolectomy – and the latter group did better. Less cardiac risk. (Int J Card 203:579) This study of course could not be controlled, but they were sick – almost one quarter were on ECMO already when they received the treatment. We mentioned before that surgical embolectomy results in less pulmonary hypertension in the future, but the main problem is that few chest surgeons have experience with it. But I think they should. TBTR: PE should be a surgical disease. After all, they often cause it. The first major president to be elected after the War of 1812 was President Monroe Doctrine, who became famous by developing the policy for which he is named. This policy, which is still in effect today, states that:
    1. Other nations are not allowed to mess around with the internal affairs of nations in this hemisphere.
    2. But we are.
    3. Ha-ha-ha
  • People get depressed. If you have suffered agony, or a loss or you live in Cleveland-and giving Escitopralam can help – but like many antidepressants this takes time to work. So there is a drug you can give that helps make this drug and maybe all SSRIs ) work quicker- what could that be? Yes, faster than a locomotive – we are speaking about image011Ketamine. Give a low (0.5mg/kg) dose slow IV over forty minutes, and they will be singing “happy days are here again”image012in no time.(Psych Med 46(3)623) This study was a small study with patients with severe depression, so you may need to wait for a decent trial before trying this. TBTR: Ketamine strikes again.

Without question, the greatest invention in the history of mankind is beer. Oh, I grant you that the wheel was also a fine invention, but the wheel does not go nearly as well with pizza

  • We have discussed this before – once – and I cannot say there is great evidence yet. But there may be a group of women that can have a UTI and do not need antibiotics They gave these patients ibuprofen and many did fine – however many also had severe pylo . (BMJ 351:H6544) This was a symptom based study – there was no mention if these folks really had a UTI (i.e. culture proven). The big question is who are these women? They admit they cannot tell either, but they use this study for some shared decision making (Father is not a big fan of shared decision making – he believes decisions are made with a Luger) TBTR: UTIs without antibiotics- are you nuts?

We travel because, no matter how comfortable we are at home, there’s a part of us that wants – that needs – to see new vistas, take new tours, obtain new traveler’s checks, buy new souvenirs, order new entrees, introduce new bacteria into our intestinal tracts, learn new words for “transfusion,” and have all the other travel adventures that make us want to french-kiss our doormats when we finally get home

  • There really isn’t anything interesting in this article and I won’t talk about it either.(EMJ 32(12)926) So why are you even reading this paragraph?
  • Here is a little clinical quiz with a good lesson. This is not the EKG from the article but it looks similar: image014This patient was in terrible pain and Morphine and Nitro didn’t touch him; BP was 98/60. Pulse- well you can see it on the EKG; 96% saturation. Straight to the cath lab- they did a cath and found- nothing. The patient was given the diagnosis of Takostubo’s Cardiomyopathy and observed. But what did he really have? (EMJ 33(1)71).


Ha ha! We are just poking a little friendly fun at Germany, which is famous for enjoying a good joke, or as the Germans say, “Sprechnehaltenzoltenfussenmachschnitzerkalbenrollen.” Here is just one hilarious example of what we are talking about.

  • Ok, OK, I give in – what was I speaking about in 14? It is an article about REBOA – a new device the balloons the aorta in saves you from having to do a thoracotomy. I don’t have one at my place- do you? What is your experience with it? Afterwards, one my FACS guys looked over my shoulder and actually read a few lines of EMU (what a miracle- they read!) and said the vascular guys do have one but the trauma guys weren’t that impressed.

Buying the right computer and getting it to work properly is no more complicated than building a nuclear reactor from wristwatch parts in a darkened room using only your teeth


As you get older; you’ve probably noticed that you tend to forget things. You’ll be talking

with somebody at a party, and you’ll know that you know this person, but no matter how

hard you try, you can’t remember his or her name. This can be very embarrassing, especially if he or she turns out to be your spouse

  • Serotonin syndrome is nothing new and there ain’t much you can do about it (yea, go ahead – find me some cyproheptadine your ED)image015 but there are some meds you may not have thought of that can cause this syndrome Here are a few I had forgotten about: metoclopramide, ginseng, nutmeg, cocaine, lithium, Tegretol and linezolid) (JEM 50(1)89) TBTR: Meds that can cause Serotonin syndrome – did you know these?

When I purchase a food item at the supermarket, I can be confident that the label will state how much riboflavin is in it. The United States government requires this, and for a good reason, which is: I have no idea. I don’t even know what riboflavin is. I do know I eat a lot of it. For example, I often start the day with a hearty Kellogg’s strawberry Pop-Tart, which has, according to the label, a riboflavin rating of 10 percent. I assume this means that 10 percent of the Pop-Tart is riboflavin. Maybe it’s the red stuff in the middle. Anyway, I’m hoping riboflavin is a good thing; if it turns out that it’s a bad thing, like “riboflavin” is the Latin word for “cockroach pus,” then I am definitely in trouble

  • Know what this is? image016This is a nodule growing in the umbilicus (JEM 50(1)123)

Thus the metric system did not really catch on in the States, unless you count the increasing popularity of the nine-millimeter bullet

  • I’ll be honest- I really didn’t understand this article from Denmark. But what I could take out of it is that – as we have said in past issues- Fusobacterium is common in symptomatic tonsillitis and treating it with PCN or FLagyl – might prevent Lemeire’s syndrome. (Clinc Micro Inf 21(3)266) In my country RHD is rampant – but in countries where it is less so- LeMierre’s may be more dangerous so why are we not doing cultures for it? Then again – no one has proven to me that treating it will prevent LeMierre’s syndrome. Also- strep is also treatable with PCN so maybe just treating makes sense. Actually maybe none of this makes sense because the article didn’t. But think about it TBTR: More – maybe – on fusobacterium.
What Women Want: To be loved, to be listened to, to be desired, to be respected, to be needed, to be trusted, and sometimes, just to be held. What Men Want: Tickets for the world series.


What Women Want: To be loved, to be listened to, to be desired, to be respected, to be needed, to be trusted, and sometimes, just to be held. What Men Want: Tickets for the world series.



  • Gosh itching has been around for so long you’d think we’d have good evidence on how to treat it. So they did look at this with EBM and found – as usual – not very good evidence. With the best evidence available here is what could work – naltrexone for cholestatic itch and eczema; nalfurafine and gabapentin for uremic itch and ursodeoxycholic acid for intrahepatic cholestasis of pregnancy. All others studied show no effects or evidence lack. (Eur J Pain 20(1)24) This is not acute itch so remember that. TBTR: Itching – what works – what doesn’t.

I never could get into traditional hobbies, like religion or stamp collecting. I mean, the way you collect stamps is: Every week or so the Postal Service dreams up a new stamp to mark National Peat Bog Awareness Month, or whatever, and you rush down and clog the Post Office lines to buy a batch of these stamps, but instead of putting them to a useful purpose such as mailing toxic spiders to the Publisher’s Clearing House, you take them home and just sort of have them. Am I right? And then the biggest thrill, as I understand it, the real payoff, comes when you get lucky and collect a stamp on which the Postal Service has made a mistake, such as instead of “Peat Bog” it prints “Beat Pog,” which causes stamp collectors to just about wet their polyester pants

  • I agree with the premise- opioids are not always the answer. They present a case of a lady getting 200 mg of morphine equivalency a day who was getting opioid hyperanalgesia – meaning they were now more sensitive to pain (Pain Phys 18(6)e1119) I am not sure there is a one size fits all, but flooding with opioids can make things worse.

Like many members of the uncultured, Cheez-It consuming public, I am not good at grasping modern art.



How do these celebrities stay so impossibly thin? Simple: They have full-time personal

trainers, who advise them on nutrition, give them pep talks, and shoot them with tranquilizer darts whenever they try to crawl, on hunger-weakened limbs, toward the packet of rice cakes that constitutes the entire food supply in their 37,000-square-foot mansions. For most celebrities, the biggest meal of the day is toothpaste (they use reduced-fat Crest).

  • Blood alcohol greater than 400? Sure you just had a beer on the way home from work. But you are more likely to survive that crash and have minor injuries-I would love to know why- but you also have a much greater chance of visiting my trauma center again soon. (Injury 47(1)83) TBTR: Drinking a lot is protective.

If a woman has to choose between catching a fly ball and saving an infant’s life, she will choose to save the infant’s life without even considering if there is a man on base

  • Kids in pain? This is not like pain from kids. image018However as much as you are all experts on pain from reading EMU – there are some added points from pain guru and EMU reader Baruch Krauss. Baruch praises the intranasal route- I must admit I have had less success with this route – the kids end up swallowing it all and complain over the lousy taste. Paracetomol can – and should be given at higher doses as long as the daily limit is not surpassed. (I use 20 -25mg/kg, he uses – less than 60 kg10-15 mg/kg  max 100 mg/kg per day; greater than 60 kg(that is some kid) up to 1000 mg  four times a day).NSAIDS do not seem to cause the same rate of GI and renal problems as in adults. Sucrose does not work over age one but I have found chocolate good for all ages. Codeine is no longer recommended – it can cause respiratory depression in ultra-rapid metabolizers and low to no efficacy ii slow metabolizers.  They recommend patient controlled analgesia in SCA and recommend Synera (lidocaine and tetracaine) or Tetracaine gel alone for IV sticks because both work much faster-30 minutes) than EMLA (BMJ 387:33) TBTR: Kids pain- how to treat.

My therapist told me the way to achieve true inner peace is to finish what I start. So far I’ve finished two bags of M&Ms and a chocolate cake. I feel better already



Skiing combines outdoor fun with knocking down trees with your face

  • I expected a lot from this article- in essence it was a basic review on imaging for foreign bodies that you should all know –if you don’t – then pull the article – and here it is (Ann Emrg Med 66(6)570).


To judge from the covers of countless women’s magazines, the two topics most interesting to women are 1 – why men are all disgusting pigs and 2 – how to attract men



Men: You know how, when your wife can’t open a pickle jar, she gives it to you, and you’re supposed to smile in a manly patronizing way as you effortlessly twist it open? That’s not what happens in our house. What happens is, after a grim struggle lasting several minutes, I wind up lying on the kitchen floor, exhausted and whimpering, while the pickle jar, unopened, laughs and flirts boldly with my wife. Sometimes it gives me a wedgie



Never be afraid to try something new. Remember that a lone amateur built the Ark. A large group of professionals built the Titanic


  • Flight Medicine – I worked in this field and while I appeared on EM RAP once on this subject – I won’t give you the reference – I didn’t think it turned out too well. I can talk and talk about his subject – but let just give you a few pointers from this article – which spoke about para professionals rendering medical help in the air- para professionals meaning medical students, nurse and the like. Some of this we have mentioned in the past. Firstly, most airlines have access to ground medical control – usually a university medical center. Recall that a diversion may cost the airline up to % 500000 (just to give you an idea of what hat kind of money is- it is half the salary per game of Sam Bradford –the Eagle’s quarterback – and he has never won anything). On the other hand, The captain makes the decision and he does have the power to ignore the medical practitioner on board although he usually will be very conservative –especially in view of the famous 2011 case where the captain refused to divert a plane right after takeoff  and took a heart attack patient from Singapore to London. As we have pointed out in the past the USA, England and Canada do not legally require physicians to render help on a flight.  Australia and much off Europe do require it. In the USA you are protected by Good Samaritans laws, on international flights that carrier has limited liability. There has been one case in the literature where a surgical resident who rendered help was sued. His program decided to cover his costs, but by the Montreal convention, a plaintiff can sue at any of these venues- the principal place of business of the carrier, the final destination, the place where the ticket was purchases, or the patient’s home country. Furthermore individuals can be sued also in the place of the plane’s origination and even the country the plane is flying over at his moment. (JEM 50(1)74-7) This is all well and good , but it seems to me that there may be jurisdiction problems if someone is sued in Croatia and they live in Cleveland. Father? TBTR: Some flight medicine tidbits.

Your hand and your mouth agreed many years ago that, as far as chocolate is concerned there is no need to involve your brain


It is a well-documented fact that guys will not ask for directions. This is a biological thing.

This is why it takes several million sperm cells… to locate a female egg, despite the fact that the egg is, relative to them, the size of Wisconsin



  • A word on ankle injuries. Surprisingly – these are injuries of females more than males. We usually use two classifications for these injuries. Grade I is a small tear in the ligaments, Grade II a more substantial tear, and grade III a complete tear. If they cannot bear weight, this is usually Grade III. These last ones benefit from casting or splinting. Weber classification is also useful – A – need only casting (some do not even need this) , C need surgery and B is controversialimage019. Fifth metatarsal fractures often accompany these – although alone they do not need any special care unless they have gotten to the diaphysis where there is less vascularity and need casting.   High ankle fractures- so popular in the NFL – are actually tears of the syndemosis and can lead to joint instability. Consider Masioneuve’s fractures here too.  You check sprains with a talar tilt (inversion of the joint), anterior drawer- (pushing the heel forward) (these check for ankle stability (the former the CFL ligament, the latter the ATFL ligament) and you check the syndemosis with a Hopkin’s test (squeezing the mid-calf over the tib and fib and if there is pain over the syndemosis – it is positive) and the external rotation test which also elicits pain when externally rotating the foot.  They like Aircasts as treatment for sprains and indeed – the key to sprain healing is to encourage weight bearing and ROM exercises ASAP. Even if that is not possible – have them stretch the Achilles at least. Surgery is indicated for instability in the ankle – but never acutely. And of course physiotherapy. (BMJ 351:h6698) TBTR: Ankle fractures- what you need to know. And probably some stuff you don’t.

A woman knows everything about her children. She knows about dental appointments and football games and best friends and favorite foods and romances and secret fears and hopes and dreams. A man is vaguely aware of some short people living in the house


Organizational structures can be found throughout nature. Monkeys form troops, birds form flocks, fish form schools, intestinal parasites form law firms.

  • Letters- we got some- actually one- from Axel – whom we haven’t heard from in a long time- I think I will give it a try, Axel: Here speaketh my mind.
    Hi Yosef, there is a much better risk calculator for A-fib than MDcalc.
    Which tells you the risks (absolute risks by the way) of treatment vs no treatment and according to which treatment is chosen (if we accept results at face value) and the bleeding risks.
    All figures in the same page : very easy to understand and help reaching a shared decision.
    Check your boxes and play. Much more informative than looking up one of the CHADs ant then HAS-BLED
  • Number 15- remember? I look at two diseases the same way – renal colic and ACS- if you cannot get relief with simple medications, you better consider other things- renal artery or vein thrombosis in the former and aneurysm in the latter. And it was an aneurysm. Number eighteen was of course a Sister Mary Joseph nodule which is a grim sign of an abdominal or pelvic malignancy. She was an actual nun who was born with the name Julia Dempsey in the eighteen hundreds and was William Mayo’s assistant who actually published the article describing this. My ADHD made me remind you of these two relics from long ago: image020– yes that is Sally Field- who would later get an Oscar for her role in Places in the Heart – in an earlier TV role as The Flying Nun a weird sitcom from the Sixties. And Zach Mayo – the character played by Richard Gere in the film from the eighties “An Officer and a Gentlemanimage021 Lou Gosset Junior was great in that film – as was Debora Winger-see it sometime.

EMU LOOKS AT: Liverimage022

There is only one essay this month- and it is about the liver—specifically liver infections- more specifically infectious complications of liver transplant. Maybe you don’t see many of these but the principles are relevant to other transplants as well. (With the exception of brain transplants) This source for this article is The Cleveland Clinic Journal of Medicine 82(11)773)

  • Who gets these after transplant? Those with pre transplant ascites, post-transplant dialysis,wound infections, reoperation, hepatic artery thrombosis and Roux-en-Y) Since they are immunosuppressed, they may not manifest fever or pain in the same way or at all. The bacterial infections are often polymicrobial and resistant to multiple drugs.  Do not forget C. Difficile.
  • Do not forget viruses – We will begin with CMV. The major risk is something you will see throughout- higher levels of immunosuppression – more infections- lower the immunosuppression – less infections.  Probably the best prophylaxis is close monitoring of serial testing for the virus, but there are some who put post-transplant people on prophylactic Gangcyclovir- but this can cause neutropenia and is expensive. In addition is the problem of resistance – and then you gotta do genotype testing to decide what to do next if the patient actually gets CMV. Foscarnet and immunoglobulin has been used. Cidofovir can be used if there is a genotype that is susceptible.
  • EBV can cause lymphoproliferative disease after transplant. Fever weight loss, cell line cytopenias all should tip you off. Serology is the way to diagnose this. The treatment is reducing the immunosuppression; anti virals may or may not work. Monoclonal antibodies, surgery, radiation and chemo may all be tried with varying success.
  • Fungi like liver transplant folks. Candida by far was the most common but Aspergillus is roaring up in the polls. Blasto, Histo, Coccidio and Crypto also can be encountered. These are hard to call because by the time they appear clinically, they are well established. Screening tests therefore may be helpful.
  • Candida is usually nosocomial, and risks include long OR time during transplantation, renal failure, copious transfusion requirements during surgery. Most of these will be Candida Albicans, but other non Albicans species can occur and there are many that are resistant to fluconazole. Candida can cause a UTI, abdominal or blood stream infections – so you have think about culturing for it. Candida can be disseminated meaning it can “metastasize” even getting into the eyes, or causing skin nodules, or hepatosplenic abscesses.   The treatment is azoles and amphotericin (ampho- terrible) to cover resistance. There have been many proponents for anti fungal prophylaxis.
  • Aspergillus – the most common species is A. Fumigatus (great name for your daughter if you need one). These happen usally during the first year after transplant with intense immunosuppression, renal failure and fulminant hepatic failure being the risks. Diagnosis is difficult – blood cultures do not help. There is some serology that may help; CT often is suggestive. Voriconazole seems to be the most effective treatment. This is often a lethal fungus in transplant people although prophylaxis still has not been recommended in guidelines.
  • Here is an old timey enemy- Pneumocystits Jirovecii. Here prophylaxis has helped reduce this significantly -that is a tab of TMZ SMX once a day. Pentamidine is already not used anymore for prophylaxis and is definitely a second line treatment. Fever, cough, hypoxemia and an abnormal CXR can give us an idea. Bronchoscopy specimens are sent for antibody staining or PCR. Treatment again is TMZ SMX, consider also clinda+ primaquine if there are side effects to TMZ SMX or Pentamidine – but the latter can cause renal dysfunction, glucose management problems ( hypo or hyper) , pancreatitis, and cell line suppression.  Some folks do use steroids if PO2 falls below 70.
  • TB- the bad guy who just won’t die. This is usually reactivation of latent disease, so pre transplant – check these patients for TB with a PPD and CXR. This requires 4 drug therapy but often these cause interactions with the immunosuppression or cause hepatotoxicity. They need treatment for 4-6 months.
  • Let us jump back to a few of our virus pals. Hep B is often a cause for transplant and if it appears; these patients seem to do well. They are given antivirals and immunoglobulins. Resistance may mandate the need for entecavir or tenofovir which have little resistance. Hep C: This is a major cause of loss of the transplant. Prophylaxis doesn’t work; although making sure there is no viremia before transplant will reduce incidence. PEG interferon and ribavirin seem to cause more rejection. Newer agents are still being studied.
  • Vaccination is possible and recommended but zoster varicella and papilloma virus vaccination should be given before transplant.

EMU Monthly – May 2016

  • Tako Tsubo Cardiomyopathy is generally benign but it can turn rotten and can kill image001(this is Johnny Rotten from the British Group “The Sex Pistols”). Those with co morbidities are at the highest risk. In their cohort of only 2477 patients- 19% had adverse outcomes, and unlike other studies – these patients really were sick (hypotension requiring pressors, CHF, cardiac arrest). (AJC 116(5)765)- seems kinda of high to me, and again this is a difficult diagnosis to make from the ED – since you need to know they have clear coronaries. My point is just be aware that this is not always a “well, you had cath two months ago which was clear so all is well” TBTR: Tako Tsubo can be bad- really bad.
  • Vertebral osteomyelitis-well, epidural abscesses, and osteo are definitely the rising stars of the malpractice image002show and OK – you know – or you should know that back pain and fever are not just some pylo. Think of this also with back pain and elevated CRP or ESR, or new neuro symptoms with fever even without back pain. You will need blood cultures, keeping in the back of your mind TB, Brucella, and fungi – culturing these as necessary from the blood stream as well. MRI will be necessary as well. Antibiotics need not be given immediately if the patient is stable – you can await sensitivities (I’m not sure I agree with the artyicle onthat one). Surgery is indicated if antibiotics fail. Antibiotics are continued for six weeks (CID 61(6)859). This is an executive summary of IDSA guidelines, Orthos may have other ideas. By the way – TB osteo of the spine is called? TBTR: guidelines on osteo of the spine.
  • Neck pain and stiffness? Could be dystonia- from that fluoxetine or escitalopram that you are giving the patient. This can also cause rabbit syndrome –(Psychosomatics 56(5)572) I didn’t know what that is – but I do now-go on this hyperlink and stay away from the carrots- and female rabbits image004TBTR: Cervical dystonia can be seen with some SSRIs. Here are our quotes for the month- let’s start from our favorite geeks- the Big Bang Theory

Leonard Hofstadter: We have to do this.
Sheldon Cooper: No, we have to take in nourishment, expel waste and keep our cells from dying. Everything else is purely optional


Leonard Hofstadter: [about his date with Penny] Where could I have possibly gone wrong?
Howard Wolowitz: The littlest things can set women off – like, “Hey, the waitress is hot! I bet we could get her to come home with us.” Or, “How much does your mom weigh? I want to know what I’m getting into.”


  • Odds ratios generally do not change the quality of the data – i.e. making results more or less significant – but if they are looked at as relative risks than the results will be misinterpreted – usually to the side of exaggeration. (Postgrad Med J 127(4)359) What in tarnation am I talking about and why will it interest anyone? Is anyone still reading? Well, I got another article this month which will explain these concepts and maybe it will interest you – although I doubt it will. See # 13 below. Let’s try it- and remember you must be sober to try. Raj: I don’t like bugs, okay. They freak me out.
    Sheldon: Interesting. You’re afraid of insects and women. Ladybugs must render you catatonic
  • This is not new. Nor is it a genius thing. But if you are not doing it, than be glad that you read EMU and that you have some semblance of a brain (orthopedists need not read further). They did this study with nursery songs to ease kids into the CT scanner. After all sedation can be dangerous or unpredictable depending on what you use. (AJEM 33(10)1477) It seemed to work, but they did this article on VAS scores and sedation scores and the scores were similar.  Could be that some kids may have been prepared for a CT scan or may just be naturally sedate.  I would have liked to hear parent’s opinions as well. Nevertheless, we have graduated today to iPhone and smartphones showing cartoons and soothing music (what I wouldn’t’ do to hear a little Air Supply image005or Barry Mannilowimage006( for G-d’s sake, this guy is 73 years old !!! )  before getting a head CT) but they did not study MRI where this may not be enough. They also did not head to head it with sedation but rather with nothing where of course it did better (Still, I like the idea and do use it. TBTR: Crank up those Smurfsimage007 before doing painful procedures. For adults consider thisimage008

Howard: Sheldon, don’t take this the wrong way, but, you’re insane.
Leonard: That may well be, but the fact is it wouldn’t kill us to meet some new people.
Sheldon: For the record, it could kill us to meet new people. They could be murderers or the carriers of unusual pathogens. And I’m not insane, my mother had me tested


Sheldon: Then it’s settled. Amy’s birthday present will be my genitals

  • Pancreatitis- this is one for you wine of the month guys. Is there anything new here? Actually there is- Ranson’s criteria have been updated. But here have been other new developments- some for EMU readers, some you should have known already. Pain control is important. So you were taught you should use penthidine (meperidine) since it causes less spasm of the sphincter of Oddi- but in clinical terms this effect is insignificant –in other words – this fact doesn’t lead to too much improvement in pain scores. Now the new kid on the block is epidurals for pain control – while they improve microcirculation and oxygenation – they can cause derangement of inflammation and coagulation parameters. These are a lot of disease oriented outcomes that may not be relevant- I would consider using it. Feed these people. While that will put a strain on the pancreas; not feeding these patients causes atrophy of the intestines and bacterial overgrowth. Putting feeding tubes in the jejunum has not shown that much promise. These folks need a lot of fluids but almost a quarter will develop abdominal compartment syndrome – be on the lookout. (Intens Care Med 41(11)1957)  Since this article was done by folks in Rennes France and Hamburg Germany – kind of reminded me of Mili Vanilli- remember them? They were a German and a Frenchman image009who faked their songs. Here they are if you don’t remember them.image011 TBTR: some new tidbits on pancreatitis.

Leonard: I did a bad thing.
Sheldon: Does it affect me?
Leonard: No.
Sheldon: Then suffer in silence.


  • Terrible evidence but the articles – with the few patients that they had- seem to show that lidocaine can help against seizures in 70% of the time. As Rob Orman once said – This is DD evidence- it needs a lot of support. (Seizure 31:41)

Leonard: You’ll never guess what just happened.
Sheldon: You went out in the hallway, stumbled into an inter-dimensional portal, which brought you 5,000 years into the future, where you took advantage of the advanced technology to build a time machine, and now you’re back, to bring us all with you to the year 7010, where we are transported to work at the think-a-torium by telepathically controlled flying dolphins?
Leonard: Penny kissed me.
Sheldon: Who would ever guess that?


  • And another shortee but goodee. Spiral tibia fractures are not uncommon – but can be associated with significant additional injuries .CHECK THE ANKLE! We all should be familiar with Masioneueve’s fracture, but there were also posterior malleolar fractures, anterior inferior tibiofibular ligament avulsion fractures, lateral malleolar fractures and combinations thereof. (Foot Ankle Intl 36(10)1209) They CT ed everyone, but I believe a good physical exam suffices. I thought it was kinda cool that this Korean study included a mechanical engineer in their authors- being that I was an old mech eng before I went to med school (yes ,Virginia, there were dinosaurs in those days- but then again there still are- they are called hospital administratorsimage012 TBTR: check the ankle in tibial spiral fractures.

Leonard: Our babies will be smart and beautiful.
Sheldon: Not to mention imaginary.



Sheldon: I’m exceedingly smart. I graduated college at fourteen. While my brother was getting an STD, I was getting a Ph.D. Penicillin can’t take this away

  • It is really hard for me to avoid mother in law jokes here but this article reminds of the mother in law that never leave- when we will finally stop this pendulum and come to a final decision? Patients with CAP (Community Acquired Pneumonia) who get steroids do have less need for intubation and less ARDS if they do get intubated. But it is clear that not everyone needs them, since only 1/3 of hospitalized patients get intubated (only? That seems like a lot!). So who should get them? They say check the CRP which made me sick- I for one do not believe a CRP can tell me how sick a person is- lactate yes – but CRP?? (Ann Int Med 163(7)560) I would also like to know what the ideal dose is – we can’t tell from this study. This could be a standard in the near future but the struggle continues. OK, I couldn’t contain myself. Allow me one mother in law joke. So there is this small town where there are two eligible bachelorettes with no male suitors. So a train arrives with a male (no doubt from the male order catalogue) and two women immediately pull at them, claiming that they ordered him for their unmarried daughters. Fortunately there is a wise king in this town and he hears the case and recommends they bring a large sword and he will cut the potential groom in half and give a half to each daughter. One of the mothers says- “good idea” The wise king says – stop – that is the real mother in law” image013TBTR: Steroids are back – maybe- for CAP

Penny: Oh, big deal. Not knowing is part of the fun.
Sheldon: “Not knowing is part of the fun.” Was that the motto of your community college?




Sheldon: There’s no denying that I have feelings for you that can’t be explained in any other way. I briefly considered that I had a brain parasite, but that seems even more far-fetched. The only conclusion was lov3

  • Left sided hemiparesis and a CT like this – what is your call?image014  (BMJ351:H5013)

Howard: I thought you didn’t like Facebook any more.

Sheldon: Don’t be silly, I’m a fan of anything that tries to replace actual human contact

  • OK AEM is a hoity toity journal and like all journal with the exception of EMU they reject a lot of manuscripts- what becomes of them? (on the other hand there is the Journal of Universal Rejection –look this one up). AEM in these two years of study rejected 68% of the articles of which about 2/3 were resubmitted elsewhere and accepted. It took about 16.7 months till they were accepted elsewhere. (AEM 22(10)1213) This confirms what Prof Steiner – once told me – “every paper does have its address” just most of my papers were suitable for the Mongolian Journal of Parrot Cloaca Hygiene- which basically means lining the bird cage. TBTR: Don’t be discouraged – you paper will be used – somewhere.

Howard: You gotta like this: the girlfriend, the ex-girlfriend, bonding over your rooty-tooty stinky booty? (All but Leonard laugh)
Leonard: Kill me.
Sheldon: It wouldn’t help. The human body is capable of being flatulent for hours after death


Rajesh: Why so glum, chum?
Sheldon: Apparently you can’t hack into a government supercomputer and then try to buy uranium without the Department of Homeland Security tattling to your mother.


  • I do not believe this article and when something flies in the face of accepted practice, physiology and past articles it is called a face validity problem. Here these authors- based on a meta analysis recommend liberal transfusion strategies in patients that were not critically ill in the peri operative period. (BJA 115(4)511) The key here is this was a meta analysis and therefore you can’t control for the heterogeneity of patients- maybe those lived longer because they were healthier-not because they got blood. They claimed to use the Cochrane Q and I2 tests to control for heterogeneity but I am not convinced that that is enough to make this reliable TBTR: Can giving blood help save lives in people who are well? Did I just write that??

Sheldon: A neutron walks into a bar and asks how much for a drink. The bartender replies “for you, no charge”.




Penny: Mrs. Cooper? Hey, it’s Penny. I think I broke your son. Hold on. Talk to your mother.
Sheldon: (Crying) Mommy, I love you. Don’t let Spock take me to the future


  • How many times have I written about odds ratios and relative risk and confused the hell out of you and me too? Well this guy must have heard me because he wrote an article explaining these in plain language. I am going to try and imitate him. Let’s say you have a 8.33% chance of being hit by a car crossing interstate 95 and if you are dressed like a clown – that goes up to 20%. The relative risk of being hit by a car when dressed like a clown (which includes any polyester at all) is 20 divided by 8.33 or 2.40 times more likely when you are dressed like a clown. RR is significant if less than .5 or greater than 2 (the risk is halved or doubled) but can be significant even if between those two if there is a serious side effect or a large sample size. Odds ratio is a measure of likelihood of occurrence versus nonoccurrence. In our case – there were 36 folks running across I95 and 40 dressed up as a clown. Of the first group 33 made it safely across and of the second group 32 made it across safely. So the odds ratio dressed as a clown are 8/32 divided by 3/33. – comes out to be 2.75 As I have pounded into your brains in the past – ORs are not as good as RRs. ORs can over or underestimate occurrence if the event is common.  And it ain’t easy to convert between ORs and RRs. If it includes 1 in the confidence interval the OR is meaningless (RR is as well). OR is much harder to express in plain English. RR tells you how much of a risk of the event happening. But OR is harder to express- basically if the OR is 2.75 it means that there will be 2.75 people  who get hit by a car dressed as a clown for everyone who is dressed normally (I think- this is getting confusing). This example did not take into account crossing I95 when not dressed – your odds of getting hit are probably much less. (J Clin Psych 76(7)e857) I just wanted to point out that these concepts are common but not related to hazard ratios or the star- likelihood ratios. TBTR: A little statistics came your way.image015

Sheldon: I’m sorry, coffee’s out of the question. When I moved to California I promised my mother that I wouldn’t start doing drugs.



Sheldon: Well, well, well, if it isn’t Wil Wheaton. The Green Goblin to my Spider-Man, the Pope Paul V to my Galileo, the Internet Explorer to my Firefox!


  • Here is another clinical quiz – this is for our peds guys – please do not miss this What is this?? image016–( it is a lump on the inside lip) (J Peds 167:204)

Sheldon: Good Morning your honor, Dr. Sheldon Cooper appearing in pro se – that is to say representing himself.
Judge: I know what it means, I went to law school.
Sheldon: Yet you wound up in traffic court

  • This is an odd article and its for you deviants out there who need to get a life. Legally speaking – what happens when damage occurs due to sleep walking, sexosmia(you know what is-guess what happens due to a person who is asleep) and sleep terror. These are rare although many drugs can cause this as well as stress and sleep deprivation. A big problem is that alcohol can cause sleep walking events – but alcohol alone can cause a state that looks like sleep walking – and in many places the former is not culpable whereas the latter is. Truth be told I don’t want to get any deeper into this article – I would much prefer to talk about you running across I95 unclothed –especially if you are Father Henry. (Med Sci Law 55(3)176) TBTR: Sleep walking and doing illegal things….

Amy: Acquiring a joint pet is a big step for us.
Sheldon: It’s true. It means we care so much about each other, there’s enough left over for an eight-ounce reptile


Leonard: I’m just saying, you catch more flies with honey than with vinegar.
Sheldon: You catch even more with manure, what’s your point?



Sheldon: I think that you have as much of a chance of having a sexual relationship with Penny as the Hubble telescope does of discovering at the center of every black hole is a little man with a flashlight searching for a circuit breaker

  • Shoulder dislocations – we have always featured these in EMU and if you are a long term reader (or deviant as EMU readers are called) you know we like scapular manipulation although we reported on the Spaso technique when it first came out and here is the Aufmesser technique. I will agree with them that it looks easy, the pictures look good and it seems you do not need to be image017 to do it. Naturally they report they can do this without sedation or pain control and it worked almost all the time, but all bone guys say this. What I liked about this is that it seems to work by pulling the humeral head out from under the glenoid as opposed to bringing the glenoid down or the humeral head up. ( Arch Ortho Traum Surg 135:1379) But of course I gotta try it to see. Here is a shout out to Cole- who is a tight end on my son’s team in the IFL – his team won the championship – who dislocated his shoulder in the game. I responded – did a little Hennepin, and a little Milch and that baby popped back in. I got to see the rest of the game from the sideline. TBTR: More techniques on reducing shoulders.

Sheldon: For the record, I do have genitals. They’re functional and aesthetically pleasing





Sheldon: I believe I would like to alter the paradigm of our relationship.
Amy: I’m listening.
Sheldon: With the understanding that nothing changes what so ever – physical or otherwise, I would not object to us no longer characterizing you as not my girlfriend.
Amy: Interesting, now try it without the quadruple negative


  • Two articles for Ken’s corner- For those of you who do not know Ken – Ken is former faculty at U of Arizona, and was the bio ethics guy for EM for years. He also has an MBA and has written on almost everything. He has a great book on improvised medicine and is one of EMU’s best friends (also one of EMU’s editor’s best friend) He is spending his retirement years traveling to underserved areas and has written me from assignments in a variety of countries (whose capitals I knew without even looking them up) – he is now in his second visit as the doc in Antarctica at one of the USA bases (no capital city on this continent). Curiously – and he won’t tell me why- he did not take malaria prophylaxis before he went there. I am going to present these articles but I – without a doubt – am sure he has written on these subjects as well. The first is a case report from JAMA Int Med (175(10)1606) about a med stdent who came back from Brazil where she ate a lot of a fruit that can be infested with Reduviid bug droppings. She thought she had lost some weight and had perhaps a little lymph adenopathy – so she did a test for Chagas disease which came out positive. But this parasite can lay dormant for many years if not treated within six months and can cause megacolon, and CHF. She actually took a year off and somehow got to the CDC who did a newer more reliable test which was – negative. Take home lessons here abound (TBTR) –don’t take a test that you are not prepared to know what to do with the result. Also, do not test indiscriminately. Lastly a big malpractice mistake is that people do favors and take unnecessary tests from the ED (like a PSA) and no one follows up with the result (so let’s use this a s a plug for Risk Management Monthly where you can learn how to get yourself out of a suit and get some good wine too). Also – for goodness sake – don’t be your own doctor- it was actually Osler I think who said – whoever is his own physician has a fool for a doctor. Another article deals with how to confront patients- you sometimes have to if they are in deep denial or hiding dangerous facts- there is a good way, and a bad way. There can be a good response (they acknowledge) and bad response (the silent treatment) and the ugly (I’ll sue you, bastard). Their recommendations are basically the usual- communicate clearly and sincerely, acknowledge the patient’s point of view, keep calm, eye contact – all these things that never worked for me ( I guess screaming “you Jerk” works only with Dr. House) (Psychosomat 56:556) TBTR: Confronting patients- how to do it.

Sheldon: Let’s see. What do I know about Amy? She loves medieval literature. Chaucer’s her favorite. And her eyes sparkle when she watches old French movies. And I enjoy how harp music causes her fingers to dance as if she’s playing along.
Bernadette: Wow, you really do love her.
Sheldon: I do. Now, let’s find the kind of gift that makes her feel small and worthless



Sheldon: Interesting. Sex works even better than chocolate to modify behavior. I wonder if anyone else has stumbled onto that.


  • This article speaks about q waves in LBBB –inferior wall q’s should raise suspicion of an MI. ( AJC 116:822) I think you always have to have your antennae up – but I would still advise the modified Sgarbossa criteria.

Store Clerk: Excuse me, Sir, you don’t work here.
Sheldon: Yes, well apparently neither does anyone else.



Penny: Well, she did soften your life, didn’t she?
Sheldon: Yes! She’s like the dryer sheets of my heart

  • This is not a real ED topic unless you board these types of cases in the ED, but you all know my love for ICU medicine so here it is but I won’t bore you with it too much. So you got this guy who is intubated and you want to extubate him. How do you avoid post extubation laryngeal edema and stridor? Well, first, and this is important to all ED guys – you may be very macho image018by intubating anything that will allow you to (including the pizza delivery man, the cleaning lady, and even insects) but this is a very damaging exercise. Not only does it cause edema, but it can cause ulcer to the vocal cords, not to mention all the ventilator problems such as VAP. That is the reason there is a growing body of literature pushing for the use of LMA s in pre hospital and EDs when feasible. How many have you put in? I have put in a lot – but all were on dolls. EM RAP (why do I give plugs for Risk Managements and not EM RAP? Rob Orman did use to read EMU so it is a good question) recently had some airway people pushing for this in the April EM RAP. This article can’t tell you much about incidence of edema – there are just too many bad studies. Risk factors also aren’t reliable enough-although they have traditionally been long duration of intubations, difficult intubations, female gender, higher balloon pressures and large size tubes. There are a few tests you can use to determine that the patient is ready for extubation. The easiest is the cuff leak test- I actually found it a little complicated to describe – it is the kind of thing you need to do at the bedside with the instructions before you to learn well. Ultrasound can also help by measuring air column width-that is the width of the acoustic shadow at the level of the cords. How can you prevent edema post extubation? Despite their saying that risk factors don’t predict well, they still push for modifying them- – use smaller tubes (which by the way still increases the work of breathing) and cut duration of intubation to a minimum. Killing the patient is not considered an acceptable way of achieving this goal. Cuff pressures should be kept below 25 H2O – that is not evidence based, but higher pressures will cause more ulceration. Steroids didn’t help in the past – but that is because they weren’t used correctly – recent studies do show that if started several hours before extubation – they work (Dex 5, or Methylpred 20 -40 mg). They also think nebulized steroids after intubation may work as well. NIV will not work well if you extubated the patient and they have stridor although it is another strategy to prevent intubation if used beforehand. If you do need to reintubate, consider the Ventrain– a transtracheal insufflation device – I think you should try a bougie which may work just as well and is cheaper.  Heliox and nebulized epi are great ideas with little evidence. (Critical Care 19:295) TBTR: How to prevent post extubation respiratory failure.

Penny: OK Sheldon, what can I get ya?
Sheldon: Alcohol.
Penny: Could you be a little more specific?
Sheldon: Ethyl alcohol, 40 millilitres


This next quote is for my wife

Sheldon: Under normal circumstances I’d say I told you so. But, as I have told you so with such vehemence and frequency already the phrase has lost all meaning. Therefore, I will be replacing it with the phrase, I have informed you thusly

  • This actually happened to me- let’s paint the picture here- it was a dark and stormy night image019and a lady came in obtunded. Not only that; she didn’t respond also. The paramedics found empty bottles of medications at her bedside with Chinese characters written on them, with the only English being “made in Australia”.  She was receiving medication by a practitioner of Chinese medicine for chronic pain. Now what do I do? Can’t call poison control, do know the name of the prescribing physician, the glucose is normal and Narcan didn’t’ work. What now? Well, of course you go up on to EMU, scroll down to the April/May issue and scroll down to number 21. It won’t help you too much but at least you will have a good read. And this article actually did come from Australia. Chinese medicine begins with a balanced and symbiotic function of body mind and spirit via energy that gets distributed to the destinations via meridians – if there is balance that is called Qi. If not, usually due to some blocked meridian –you have to help unblock them. What causes blockage of qui- imbalanced diet, imbalanced lifestyle, stress, excessive or repressed emotions, and lack of exercise. Kind of interesting that the Chinese knew these dangers long before western medicine did. How do you improve Qi? Easy- Tuina, Qigong and tai chi. The former is acupuncture and acupressure, the second is for balancing the state of mind- and includes medications and the latter is for exercising the body and is quite popular today. Does it work? Considering how few people who practice western medicine and do research understand Chinese medicine it is no wonder that most of it has never been studied. But Chinese medical practitioners are not witch doctors- they must have formal university education and pass a national exam to get a lisence. Their medications are under national scrutiny as well. That isn’t to say that adulterated medicines are not available – they are and are like any other medicine available on the internet- you don’t know what you are getting. That is also not to say that some medications have poisonous components- but only certain practitioners are allowed to use them and they are in doses below that which will cause untoward side effects. Now you have been waiting for what is in these medications – I could tell you, but this is where pharmacology comes in and it isn’t easy. The general headings are alkaloids, flavonoids, pyrones, and terpenes. Ones used with caution include aconitines, strychinine, pyrrolizine alkaloids, and aritstolochic acid. What these are used for is in the article and has varying levels of safety. (BJCP 80(4)834) My take on all this is that is probably merit to this form of medicine but I would not recommend it for you to try on your own- leave it to people who know what they are doing. Just like western medicine. While my med student Alex Wang has seen this article – and agrees with the content- but I will just mention our discussion of politics. It seems apparent that many people are disenchanted by the choices this time around and while I would welcome Bernie Sanders marrying Sara Palin,  image021 image020there is one thought that this is not likely to happen. So I want to tell you what you should do which would be the best for America- vote for Father- he stands for motherhood, apple pie and Gallo Chablis. He also stands for fatherhood, pierogis and Ripple. He has promised me he will bring the Edsel back providing more jobs for Detroit. And he will fix Flint’s water problems by connecting them to Finlandia. We were unable to provide a campaign picture for Father, but we did get one of his vice presidential hopefulimage008. A vote for Father is a vote for what is good in America. TBTR: Chinese medicine and voting in the upcoming election- both good reads.


Penny: Yes, I know men can’t fly.
Sheldon: No, no let’s assume that they can. Lois Lane is falling, accelerating at an initial rate of 32ft per second, per second. Superman swoops down to save her by reaching out two arms of steel. Ms. Lane, who is now traveling at approximately 120 miles per hour, hits them, and is immediately sliced into three equal pieces


Sheldon: I present to you the Relationship Agreement. A binding covenant that in its 31 pages enumerates, illuminates and codifies the responsibilities of Sheldon Lee Cooper – hereinafter referred to as the “Boyfriend” – and Amy Farrah Fowler – hereinafter referred to as the “Girlfriend.
Amy: That’s so romantic!
Sheldon: Mutual indemnification always is

  • This is a big problem – opioid constipation. Unfortunately the opposite isn’t true because if it was- getting old would be a lot more fun. (we will just mention in passing (pun intended) two other drug related bowel problems- narcotic bowel syndrome – pain due to opioid use – usually managed by more opioids which just makes things worse, and cannaboid hyperemesis syndrome- see an excellent review of the subject by an moron named Leibman) A person can develop a tolerance to opioids. He can develop an tolerance to the nausea from these meds. Ditto for sedation. But no for constipation. Often these patients have other good reasons for constipation as well (Ken what is the difference between constipation and obstipation? What about between urination and micturition? Why do we need two medical words for the same thing??) such as reduced mobility, advanced age, hypercalcemia, fissures and altered nutritional intake. The problem is that there are mu receptors in the bowel- which leads to decreased water and electrolyte movements and decreased peristalsis. This is how loperamide (Immodium) works, and as such is now being abused in the States. Increasing fiber and fruit should theoretically work but it doesn’t free up the mu receptors. Laxatives have their own problems including kidney stone development and electrolyte imbalances. For example bulking agents which can lead to bulky stool that just doesn’t move. Fiber can cause the same problem especially if not enough fluid is drunk. Stool softeners do not work. Osmotic laxatives have high salt content causing electrolyte imbalances. So do stimulant laxatives. Nalaxone is often used (Targin) but these do cross the blood brain barrier and reduce the effectiveness of the opioids. PAMORAs do exit – they are peripheral acting mu receptor antagonists. These include alvimopan, mathylnaltrexone, naloxegol, none of which I have seen used in practice. Tapentadol does have nor ep uptake inhibition which increases opioid agonist activity leading to less constipation as lower doses can be used.  And now they have oxycodone/naloxone 2:1 with better results. Other strategies include using osmotic as an adjunct (I like PEG products and pico sulfates) or opioid rotations which may lead to less constipation with other agents. (Scand J of Gastro 50(11)1331) TBTR: Some ideas on how to prevent opioid induced constipation.

Sheldon: I can’t seem to get in touch with Amy. I tried e-mail, video chat, tweeting her, posting on her Facebook wall,texting her, nothing.
Leonard: Did you try calling her on the telephone?
Sheldon: The telephone. You know, Leonard, in your own simple way, you may be the wisest of us all


Sheldon: Ah, memory impairment; the free prize at the bottom of every vodka bottle

  • Letters: Kevin – the a double boarded peds and peds EM guy and the world commander of the militant Federation Against Adult Practitioners (FAAP) actually agreed with my assertions concerning Ritalin use in adults:
    Tzion also got in touch with me- I remember him as a med student 10 years ago – he still reads EMU and has a thriving FP practice. Thanks for being in touch.
  • Number 2- TB of the spine is called Pott’s disease. There is a Pott’s Fracture and Puff’s Puffy tumor-so Pott was a pretty all around guy. And his first name was Percival – a great name for a disease naming doctor. Number 2- did you catch the dense MCA? It is an early warning sign for stroke. Here it is if you didn’t catch it. image022 Number 14 was Riga-Fede disease. This is when little kiddies lower incisors erupt and traumatize the lingual mucosa- totally benign – needs no treatment other than perhaps filling those choppers down a little.


Leonard: Have you considered telling her how you feel?
Sheldon: Leonard, I’m a physicist, not a hippie


Leonard: What makes you think she wouldn’t sleep with me? I’m a male and she’s a female.
Sheldon: Yes, but not of the same species


We will look at some antibiotics news, and some news on hamstrings (the mechanical means of killing bugs mentioned above image023) The sources for these articles are Intes Care Med 41:1950 and BJSM 49:1241

Here are ten antibiotics that will never disappear.

  • Really? Don’t the authors remember that they predicted in the sixties that with aminoglycodsides gram negative sepsis will disappear forever?
  • Polymyxin:

Myth: Why these will kill your kidneys, your nervous system and you!

Reality: Recent evidence seems to say this is less likely than once thought. These drugs work well against powerhouses such as Pseudomonas, Acinetobacter and Klebsiella (I bet they can deal with Duke, Villanova and UNC image024as well Colistin is a combo of Polymyxin A and B – so you may be familiar with this drug already.

  • Fosfomycin

Myth: Everyone knows that this is a weak antibiotic that induces resistance fairly quickly.

Reality: When given IV this med goes into a nearby phone booth and begins the fight for truth, justice and the American way. It can knock out such villains as ESBL, MDR enterobacter and in combo with other anti Klebisiella drugs- can wipe out this truant as well.

  • Aminoglycosides –well you knew I would speak about them.

Myth: Oh you are just so sixties sometimes. Genta isn’t mod anymore and really, Amikacin isn’t groovy either. There are really more psychedelic meds – so be a flower child and use what the beatniks use- – stuff that works.image025

Reality: Genta and Ami are both parts of a powerful combo to knock the stuffing out of monster Klebsiella infections. And you can give these guys once a day- an option for ESBL as an outpatient. Give them one shot of 180 a day and you will kill the ESBL without sacrificing the kidneys or their hearing. Right on, brother!

  • Vanco- native Americans are offended by the Washington Redskins football team name, but most people do not know that they were named for Vanco induced red man syndrome and not a s a derogatory reference to native Americans

Myth: Just not that effective anymore. MRSA and enterococci have figured this one out

Reality: Still the most effective treatment for C Difficile. In the field though, most MRSA strains are still susceptible.

  • Rifampin

Myth: Have you ever used this dinosaur? Once it worked for TB but this thing is so resistance inducing that the bacteria laugh every time they see itimage026

Reality: This guy has a talent for biofilm bacteria hunting. Give it with Vanco and you will knock out staph and enterococci. Give it with sulbactam and carbapenems and you will give the eight count for extreme drug resistant gram negatives. Biofilms on prosthetic valves- use this guy.  And it still works well for Leprosy.

  • Oxacillin

Myth: This baby was gorilla –cillin for a while but MSSA is really not in style anymore

Reality: But MSSA is still with us – not everything is MRSA and while Vanco is good for MRSA it is weaker against MSSA than ox. True there are meds you can use to cover both, but let’s try to be streamlined here, OK?

  • Penicillin-

Myth: Are you kidding? This stuff belongs on cheese and that’s it. What is still sensitive to it?

Reality: Strep is especially when you give this IV. And Syphillis is still scared stiff – resistance is low and you only need 0.1 mcg/ml to immobilize these worms.


Myth: The Bactrim Septra wars ended- this drug is just not the man it used to be.  Testosterone patches and Viagra aside, the drug is just not potent any more.

Reality: Well, you knew this was coming- it does kill MRSA. And it seems to work against Stenotrophomonas and Listeria too. It is and always was effective against Pneumocystis and Nocardia.

  • So where are the ten? These are only eight! Well they counted Amikacin and Genta as two and Cefazolin and Ox as two


  • We spoke about these last month, so I will only go over new things- the article does begin with a disclaimer that we still do not have a good understanding of this injury, and they recur a lot. Here is what we do know.
  • Lengthening of the muscle can lead to tears – but this is slower onset than the faster sprint type injury in runners. Nevertheless the lengthening injuries – such as in high kicking and tackling – actually take more time to rehabilitate. Anatomy of the individual may play a role as well.
  • MRI now shows hamstring mimics coming from the gluteal trigger points or the spine.
  • Return to play – they bring a number of confusing articles that US, MRI or clinical parameters do not help. When the athlete feels he can – he probably can.
  • Recurrence remains a problem probably due to – well they posit many possibilities. But those who get them usually have multiple hamstring injuries, localized discomfort and knee extension or isometric force flexion deficits.
  • As a result ,the recommend post injury PT to prevent recurrence –Nordic Hamstring Exercise, Romanian Dead Lift and Askling’s extender, diver and glider exercises- I checked all of these on you tube and they not only are easy to do, they are really cool.
  • Platelet rich plasma was being used for tendon problems but the evidence is weak and it appears that it has no role in hamstrings.
  • You can prevent hamstring injuries through the yo yo curl and NHE programs (Nordic Hamstring Exercise)
  • Why is this even called a hamstring? Well here you go – fresh from Wikipedia.- Ken did you know this? The word “ham” is derived from the Old English ham or hom meaning the hollow or bend of the knee, from a Germanic base where it meant “crooked”. It gained the meaning of the leg of an animal around the 15th century.[7] String refers to tendons, and thus, the hamstrings are the string-like tendons felt on either side of the back of the knee

EMU Monthly – March/April 2016

All the EMU goodness for March/April 2016

  • I got a Lucas in my ED or something like it- do you? Lucas is a CPR machine that looks like this:image001 It simply does the compressions for you. These machines will not result in any more sternal fractures, or internal organ damage than regular CPR. However they do cause on average 6.6 rib fractures (In J Legal Med 129(5)1035) Now they think this is because the Lucas is generally on the patient for more time than regular CPR and that may be true, but this needs to be studied too – maybe all the fractures were at the beginning when the device was attached or maybe they needed to be calibrated or maybe there is a difference between CPR on a 100 kg male and a little old lady from the nursing home image004. For you young folks that is Irene Ryan –who played the grandmother on the Beverly Hillbillies a TV serial from the sixties. I assume that Father did not have a crush on her. Here is Bridgette Bardot again for him: image005We’ll have to take a short break right now while we treat Father’s chest pains. TBTR: Lucas devices cause a lot of rib fractures.
  • The idea is interesting- the article couldn’t give an answer- maybe while we are screening people by asking them to check their doo doo –we can also screen them for stroke prevention. This wild idea is based on a simple premise- we have NOACS they are easy to give sand we are real good at screening for A fib – so why not screen everyone for this? (Circ 131(25)2167) TBTR: Stroke screening- coming to Rite Aid near you (or a Coffix if you live in Israel)
  • Let’s talk about poisons- not toxicology – but rather drinking sugar sweetened drinks- this can cause worldwide – 184000 additional deaths, from cancers, DM and CAD. This would be worse in Mexico and less so in Japan. (ibid  132(8)639).  True this is a computer analysis and a mish mash of assumptions –but the important point here is that these beverages are dangerous (we spoke about this last month) Here in my country – and I assume in a lot of other countries that EMU goes to- consumer activism is absent and therefore beverage companies (in Israel that would be Spring, Pepsi, Coke, Jump) are making a lot of money on these poisons. Can EMU start a revolution? Probably not, but we can be revolting. TBTR: Sugar drinks – making our job harder.  Time for quotes, guys. I think it is time to knock on the respected legal profession:

Some men are heterosexual and some men are bisexual and some men don’t think about sex at all … you know, they become lawyers. Woody Allen

  • This really has nothing to do with EM, so if your ADHD is as bad as mine you can go to the next article, but I am really against using meds for ADHD in adults (actually in kids too, but I am afraid of Kevin’s assassins). But if you do go the med route, you should know that Ritalin in adults has caused sudden death, addiction and unmasking of psychotic behavior. There are other options. Medscape brings information about Bupropion at 1150 mg a day, and this article brings some low level evidence for the use of TCAs for ADHD- nortriptyline and desipramine. In short term they do work (that is 2- 6 weeks), in longer term no information (AFP 9(5)352). This could be but the side effect profile for TCAs is not the greatest- especially the anticholinergic side effects. Ketamine anyone? TBTR: TCAS for ADHD? Maybe. Maybe not. Let’s go out and play catch.

This is what has to be remembered about the law; beneath that cold, harsh, impersonal exterior beats a cold, harsh, impersonal heart. David Frost

  • I really am not a kid person and I am convinced I have scared most pediatricians away but this was a well done study– so I had to include it. It was six centers in the UK but only included 158 infants. They discovered- the opposite of what Cochrane did – that hypertonic saline inhalations do not reduce length of stay in the hospital in bronchiolitis. (Health Tech Assess 19(66)1) There was no control for heterogeneity in this study (and why should there be? All babies do look the same), and they discharged patients with sats above 92% – a little gutsy for my tastes and I am not sure what it was doing in this journal- but at the end of the day – the treatment of bronchiolitis remains what it always was – supportive. TBTR: read the last line

There is a general prejudice to the effect that lawyers are more honourable then politicians but less honourable than prostitutes. That is an exaggeration. Alexander King

  • Metronidazole can cause cerebellar toxicity but it is rare and reversible – you need to take 1517 mg for 60 days on average to develop this (Neuro Sci 36(9)1737).

Lawyers should never marry other lawyers. This is called “inbreeding,” from which comes idiot children and more lawyers. Kip Lurie: Adam’s Rib (1949)

  • Food delays absorption of pain meds. If the patient gets early pain relief, they are more likely to have longer lasting pain relief and less rededication. So take Aspirin, NSAIDS and paracetomol without food ( BJ CLin Pharm 80(3)381) So they say – but they are pharmacists- what about GI bleeds- does food help prevent this? That what they taught us. Is it true? TBTR: more effective pain relief by taking on an empty stomach.

I never met a litigator who did not think that he was winning the case right up to the moment when the guillotine came down. William Baxter

  • Gosh, what could I tell you about afib that you don’t know? This article was about misconceptions, but you are a bright guy, read EMU all the time and knew everything in this paper. Except for one point. As can be expected in any scoring system, the CHADS 2Vasc score is not all that it is built up to be. (I will take this opportunity to send you to a great web site called MD CALC where you can find this and many other important medical calculations (see the above hyperlink). Let us just start with what constitutes a positive score, i.e. – when you need to start anticoagulation. The Europeans say a score of one, the Americans a score of two. But female sex is already a point. Furthermore, even a one score can still have a 2% stroke rate. Also the most important risk factors according to studies remain age and prior stroke but they are scored equally with the other risks in the score even though the others contribute a lot less to the to the total risk. CHF is also a risk, but studies show that is only when the LV function is severely decreased. Stoke risk overlaps with bleeding risk (advanced age is a risk for both) so this confuses things even more. Lastly they say C statistics prove their points; and if you know what a C statistic is than you are way too intellectual to read EMU. Actually, if you know what color a fire truck is you also are too intellectual to tread EMU. They say – just give the anticoagulation if the patient isn’t that old – the bleeding risk will always be less than the stroke risk (AJM 128(9)938)  TBTR: CHADS 2- may be better not to use.

I think we may class the lawyer in the natural history of monsters.
John Keats

  • Short and to the point – cause we have discussed this before. Nor ep IV – if it extravasates – give phentolamine in the same IV and NTG paste. But this is a rare event in their single center ICU. (J Hosp Med 10(9)581) No one seems to mention though- what happens when you dump their blood pressure with phentolamine and NTG while you look for a new IV site. I think just do IO or CVP from the start and avoid these problems. Not good at CVP insertion – so get good at it. But see our cogent discussion on this in the essay below. TBTR: Nor EP – extravastation – rare event.

Necessity knows no law; I know some attorneys of the same
Benjamin Franklin

  • Hi family docs. Hope you are not giving Nor EP in your clinics and you probably shouldn’t be giving a lot calcium supplements also. Calcium does decrease bone resorption and increases bone density- but only in the short term. It has no long term effects on osteoporosis and what probably is most important to our patients- it has no proven effect on fracture prevention. What it can do is cause diarrhea, MI and of course renal stones. (ibid 278(4)354) TBTR: maybe want to tail back on those calcium supplements. Give them the nor ep instead.

It was so cold last winter that I saw a lawyer walking down the street with his hands in his own pockets


  • I think you need to be careful about this study; it was tiny when compared with NEXUS – but when they applied the NEXUS rules in the elderly (that is defined greater than 65) missed 4.1% of clinically significant fractures- I went over the list and while not all needed surgery – all would’ve concerned me. (JEM 49(3)294).But on closer look it only missed two (only one was serious) and it isn’t clear that the rules were applied correctly – especially since the injury that was missed were pretty severe. Also, many of these fractures had NEXUS positive only because of the distracting injury or clouded sensorium- which may lower your guard.  I think we should say here what we do about all rules. Nothing is 100%. TBTR: NEXUS works- most of the time.

99% of lawyers give the rest a bad name


  • Droperidol is very effective for migraines and vomiting. But since its black boxed it is getting hard to find. So why not haloperidol its cousin? True it recently has been black boxed also but it works better than metoclopramide for migraines and we reported in the past that it works well for vomiting.( ibid p326). I have tried this with very good results. TBTR: Haloperidol pinch hitting for droperidol.

A good lawyer knows the law. A better lawyer knows the judge. But the best lawyer knows the judge’s mistress

  • These tests are good – not great – but are fun to do if you are concerned about a supraspinatus tendon tear (that is part of the rotator cuff). Hey while I am writing this, Villanova from my home town Philly won the NCAA national championshipimage006 Considering the Sixers this year won 24 games less than Villanova – that isn’t bad. Anyway, these test are the Yocum test, the Jobe test, the Patte test, Nerve Impingement Sign and the Hawkins Kennedy Test- all are positive if there is pain or weakness. Instead of describing them ,you can either get the article or look these on you tube. ( J Hand Surg 28(3)247) The first two are pretty easy to do. TBTR: Rotator cuff tests

How can you tell when a lawyer is lying?
His lips move.


  • We all know that fever is dangerous- and you just gotta get that kid’s fever down fast with ibuprofen and paracetomol ASAP. This is definitely what parents think. But the literature – while agreeing that 41.5 is damaging – the body will make sure you don’t get there (unless of course she enters the pictureimage005. Does high fever mean more serious infections? – maybe a trend but not a predictive value. Dropping fever does make kids feel better but doesn’t prevent convulsions. I was taught that fever was a beneficial mechanism and therefore it allowed better functioning of antibacterial mechanisms and killing of those buggers.  Fever can also cause more mortality(causality?) but these studies are pretty low quality – so you really can’t say either of these statements. Colling with fans or cool water makes kids uncomfortable. Ibuprofen lasts slightly longer and is slightly more effective than paracetomol but the combo of both only reduces fever about 0.27 degrees C.  Alternating them however may show some benefit.(Arch Dic Child 100(9)818) TBTR: Fever- it ain’t so scary.

What’s the difference between a lawyer and a trampoline?

You take off your shoes to jump on a trampoline!

  • Can I reminiscence with you? His name was Steve. And he was a surgeon. And he was my preceptor as a student. And he suffered from a personality disturbance not uncommon among surgeons-Jarisch Ebstein Rendu Krukenberg syndrome or in abbreviations – he was a JERK.image007 . Did I learn better because of this guy? I didn’t think so. And while this study was very contrived the results showed diagnostic and procedural accuracy suffered in those who were exposed to a rude instructor. (Peds 136(3)487) Now kids and kid doctors maybe a little more sensitive than battle hardened surgeons like Steve’s students image008– but I think the conclusion is correct. (The picture by the way is George Patton– the WW II general. TBTR: Want your residents to know something? Be a mensch.

What’s the difference between an attorney and a pit bull?

  • Coffee – ah- let’s just quote Emo Phillips take on coffee which we quoted years ago “that first piping hot cup of coffee in the morning; there is nothing like it- oh, I have tried other enemas…” This article sings the benefits of the cup of Joe. Caffeine does speed up the heart and keep you awake – and if you are a slow caffeine metabolizer – then there is a slight increase in MIs. But in moderation, there is no increase in MIs or exacerbations of CHF, indeed it might improve CHF. All-cause mortality is less in moderate coffee drinkers and stroke risk is lowered. Arrhythmias and hypertension are not affected by moderate intake. DM risk is less in coffee drinkers. Decaf does not provide any advantage over regular (Curr Vasc Pharm 13(5)637) I never having a cup of coffee in my life  so I believe that there might be some bias here from this confirmed coffee drinker image009TBTR: Coffee – great for the heart- and a good enema too.


A new client had just come in to see a famous lawyer.
“Can you tell me how much you charge?”, said the client.
“Of course”, the lawyer replied, “I charge $200 to answer three questions!”
“Well that’s a bit steep, isn’t it?”
“Yes it is”, said the lawyer, “And what’s your third question?”


  • I love my ADHD – We get along famously. Fame-wasn’t that a 80s hit film with the title song sang by Irene Cara?image011. It was also the name of a string of delis in NY –known for its corned beef-Father loves corned beef- anyone know why it’s called corned beef? Yes from the corns of salt used to cure it. Does that bore you? Or are you just sleeping because you have had propofol. Or maybe since you have ADHD you need more sedation for procedures – well this study says not. (Ped Aneast 25(10)1026) This was a great idea for a study but it was for an MRI and all got midazolam first before getting propofol- why is beyond me. TBTR: ADHD need sedation at same doses as non ADHD.image012


  • Perianal abscess and fistulas are interesting. (Actually they aren’t) But you gotta know – if you can do a rectal exam – and there isn’t any bogginess or severe pain once you are inside- you can open the abscess- if not – CT or OR. Please make sure you remove your finger before doing any more testing. ( Ann EMerg Med 66(3)240)

A man is innocent until proven broke. – Anonymous


  • A couple of EBMs- flail chest – there are some small studies suggesting that surgical treatment results in less pneumonia and shorter ICU stays (Cochrane 7:9919) Fluid overload CHF- giving continuous drips doesn’t help. The best loop diuretic seems to be Torsemide (Mayo 90(9)1247) TBTR: Flail chest and CHF – how to tie these two together- not sure.

A man and a woman were conversing at a party. The woman said: “Lawyers are jerks.” The man responded: “I take offense to that remark.” “Why,” said the woman. “Are you a lawyer?” “No,” he responded: “I’m a jerk.”

  • This article was a tough read- I am an EP and supposed pathophysiology bores me. And the subject matter as well is boring.- orthostatic hypotension. So let’s cut to the chase image013(That’s from the French Connection – the best car chase in film history and it was done without permits- most of it was real!- check it out on youtube. ) you can send these folks to a tilt test if you got a question and the treatments are – controversial. Midodrine –an alpha agonist – probably helps – but there is some literature out there that says that it doesn’t help. Droxidopa is a nor ep agonist – used off label for years- probably does help but there isn’t a lot of literature. Pyridostigmine – efficacy questioned. Fludrocortisone – a mineral corticoid – worsens supine HTN and causes hypokalemia. Pseudoephedrine – efficacy controversial. Desmopressin- efficacy uncertain. Salt tablets- careful in HTN and CHF. Direct stockings- they work and are safe. (JACC 66(7) 848) If you get this article and read it in its entirety I will ask the judge to take off two years from your sentence. TBTR: Orthostatic hypotension- all you really didn’t want to know.
  1. What do lawyers use for birth control?
  2. Their personalities


  • Is it time for a clinical quiz? Well guess what- I did this one before. Too bad you missed it last time – get it right this time, ok? 60 year old lady breast cancer, fever and panful nodules on the legs They are non-blanching and have hemorrhagic centers


    This is, of course – …..

  • Like I said in number 20 this is another paper that is impossible to read on acute porphyrias.(Clinics Res Hep Gastro 39:412) Fortunately, I found another clearer paper in – where else- the emergency literature. (JEM 49(3)305) –This would be a good topic for an essay – but those with good memories

will remember we spoke about this once before. So let’s run thorough it. First of all why should you care? The answer – most of the time you shouldn’t since most patients are asymptomatic for their entire lives. However, exacerbations can even cause death – so you should know about it.  The whole spectrum of porphyria is caused by a deficiency of a specific enzyme in heme synthesis. It is usually not 100% which is the reason why most of these folks get attacks intermittently or not at all.  But there are triggers- prolonged fasting (I couldn’t find if there are more exacerbations in Ramadan), dieting, alcohol, meds (barbs, dantoin, rifampin, steroids and hormones- especially progesterone) and other illnesses or stress. They may be linked to menstrual cycles but typically do not happen during pregnancy.  There are four types; we will focus on the most common which is AIP. They have intermittent abdominal pain which is colicky, and starts gradually. It is unrelenting, but usually no localizable and abdominal findings are usually absent.  The main problem is neurological – they get pains and aches in extremities and the back – but also paresis that may progress to respiratory failure.  They can also get convulsions and here it is important to avoid barbs and dantoin- use gabapentin. If they have red or brownish urine – the makes the diagnosis much easier- these are heme pigments. The diagnosis is easy – use the random urinary BPG test and you’ll have an answer within 10 minutes- however- this test is not widely available -which is nice medical-ese to say – you don’t have in your ED and probably not in the entire county. If you can measure BPG in the blood – it is always increased in AIP attacks – but this is probably not available in your ED either. Treatment of an acute attack includes pain meds, a high carb intake (I can go for that – cookies!) and phenothiazines. Pan hematin should be given ASAP at a dose of 3mg/kg/day via a CVP.  If they get worse – ICU. TBTR: All you didn’t want to know about porphyria.

A truck driver used to amuse himself by running over lawyers he would  see walking on the side of the road.  Every time he would see a lawyer walking along the street, he would swerve to hit him.  After hearing a loud  “THUD,” he would swerve back on the road.

One day, as the truck driver was driving along he saw a priest hitchhiking.  He stopped and asked the priest, “Where are you going, Father?”  “I’m going to the church 5 miles down this road,” replied the priest.  “No problem, Father. I’ll give you a lift.  Climb in the truck.”

The happy priest climbed into the passenger seat and the truck driver  continued driving.  Suddenly the truck driver saw a lawyer walking down the road and instinctively he swerved to hit him.  But then he remembered there was a priest in the truck with him, so at the last minute he swerved and missed the lawyer.  However, he still heard a loud “THUD.”  Not understanding where the noise came from he glanced in his mirrors and, when he didn’t see anything, he turned to the priest and said, “I’m sorry, Father.  I guess that I must have hit that lawyer.”

“You missed him,” replied the priest. “But that’s OK. I got him with the door.”



  • While we are in the boring zoneimage015let’s speak about another topic that rivals PE in the general interest level of most physicians- yes that is dizziness. Instead of going into this topic- let us just go into the errors that are often made. We were all taught in quack school image016that you should ask them what they mean by dizzy- and then classify it into vertigoimage017 , pre syncope, disequilibrium and ill defined. The problem is that patients are unreliable when reporting dizziness and these categories are not valid. On the other side, patients reports of triggers and timing are reliable, and this will help you – just don’t leave it at – “does it get better when you lie still” – all dizziness does- ask them if it goes away when they lie still – this is a major piece of information. Another error is not to check eye findings- nystagmus – when it is there – can lead you to BPPV (upbeat– seen during the Hallpike maneuver – and lasts less than 30 sec) Vertical or torsional that is spontaneous nystagmus and no fatiguing in Hallpike is a central cause. Curiously – they do not mention the HINTS test (my neuro guys think it is overrated). Another error is relying too much on age and neuro exam and vascular risks – these will miss many young people with stroke. True if there are neuro signs that will point you to a stroke but many times dizziness is all that is seen. Their last point is one we all know – do an MRI – CT misses too much. (Neuro Clin 33:565)  TBTR: Dizziness- but actually an important read.

What do you call a lawyer with an I. Q. of 50?

Your honor

What do you call a lawyer with an IQ of 25?



  • Let us return to the interesting- nothing beats a ruptured AAA for drama. This is definitely a place you do not want to get to. So let’s prevent them from coming to the ED in the first place- and that’s why we need you friendly FPs. Screening is the way but when to screen is a different story. Here is a summary of guidelines for who gets screening.
  1. SAAVE law (Medicare) Men: 65-70 who smoked. Women-only if have a family history
  2. Society of Vascular Surgery Men: >54 with FH, all men >64 Women >64 who smoked or have a FH
  3. ACC/AHA Men>64 smokers >60 in FH All others- no screening
  4. ACPM Men 65-70 smokers. All others-none
  5. Canadian Soc Vasc Surg Men>64 who are willing to undergo surgery
  6. European Soc Vasc Surg Men – 65- , younger if FH, smokers
  7. USPTF >65 if smoked- yes, non smoker- maybe; women who smoked- indeterminate, women who didn’t smoke- no

The way of screening is of course US – and you only have to check it once. Now what if it is positive? 5.5 cm and above- they go to surgery. 4.5-5.4 – six month interval check. 12 month intervals for 3.5- 4.4 cm. 3.0-3.4 every three years. 2.6- 2.9 every five years. (J Vasc Surg 62(3)774) As far as I know this is not included in Israel’s quality measures for preventive medicine and I do not remember seeing much about in the USA. But screening does reduce mortality by 40%.  TBTR: AAA screening can save lives.

Why won’t sharks attack lawyers?

Professional courtesy


25) Letters: We do have some letters, but first I will apologize to Sandy – a class person who is one my lawyer readers for the quotes in this issue – I was only joking, Sandy – please don’t send that registered letter!  Also a shout out to Alex Wong who finally did show up in our ED to say hi. Really, Alex, I always was a Ursinus College football fan! I even know their quarterback – here is a picture:image005 Ken wrote us and so did John Hipskind. Here is what they had to say. Ken gives us some more on the Dutch question: Hi Yosef


As usual, an excellent issue. Here is a more complete answer to your question than you could possibly want:


“Netherlands” refers to the country as a whole, while “Holland” comprises just the two provinces of North and South Holland, the country’s two most densely populated provinces with most of the country’s major cities . The term Dutch is a relic from a time before the Germans, Dutch and other Northern Europeans split into different tribes. At firstthe word Dutch simply meant “popular”, as in “of the people”, as opposed to the learned elite, which used Latin instead of the Germanic vernacular. In the 15th and 16 centuries, the word “Dutch” simultaneously meant both German and Dutch, or “Low German”.


As to your comment about nitrous oxide not having analgesic effect, I was puzzled. The reason for using it was just that, a safe analgesic effect. Here’s the abstract of an EM review that supports using only a 50% concentration.

A systematic review of the safety of analgesia with 50% nitrous oxide: can lay responders use analgesic gases in the prehospital setting?

  1. S C Faddy1,
  2. S R Garlick2
  • Emerg Med J2005;22:901-908
  • Accepted14 December 2004


A safe and effective form of pain relief would be an advantage in the prehospital treatment of patients experiencing extreme pain. Although used by many emergency medical services, 50% nitrous oxide (an inhaled analgesic known to have good pain relief properties) is not widely used by volunteer and semiprofessional organisations. This review aimed to determine whether 50% nitrous oxide is safe for use by first responders who are not trained as emergency medical technicians. A thorough search of the literature identified 12 randomised controlled trials investigating the use of 50% nitrous oxide (as compared with placebo or conventional analgesic regimens) in a range of conditions. The outcomes analysed for this review were: adverse events, recovery time, and need for additional medication. None of the studies compared the treatments in the prehospital setting; children were well represented. Adverse effects were rare and significant adverse outcomes such as hypotension and oxygen desaturation could not be attributed to nitrous oxide. Compared with patients receiving conventional analgesia, those receiving 50% nitrous oxide did not require additional medication any more frequently and had a faster recovery from sedative effects. The low incidence of significant adverse events from 50% nitrous oxide suggests that this agent could be used safely by lay responders.


Yes Ken, I muffed on the Nitrous- there is some analgesia- but not much. John writes: Another winner (unlike the Republican presidential candidates)!  Thanks again for the fascinating and occasionally scary (Bridgette, did you really have to, really?) collection of medical information.  Your reference to assorted trivia and 1960’s TV shows reflects a similar skewed upbringing as mine.  Keep up the great work!   I am not going to get into politics John but I suggest y ou take my Father’s advice – he has written in Richard Nixon for every election since 1980 since “he was the last good president we had”.  By the way Alex claims someone at Geisinger called me a legend- could this be true? A legend? Like Richard Nixon?

  • Remember the clinical quiz in number 21? It was Sweet’s syndrome and it comes from three causes. Idiopathic (sometimes after a virus, or IBD or during pregnancy but for unknown reasons), drug induced (usually but not always after use of GSF) and malignancy induced. The last one is important because if you can’t find another cause – look for malignancy, They treat this with steroids, potassium iodide or colchicine (JEM 49(3)e95)



This month we will take another look (again we reviewed this before but this is a different perspective) into leg ulcers and also into crashing Pulm HTN patients. The sources for this essay are  BJD 173:379 and Emrg Med Clinc NA 33:623.

  • There are four types of chronic ulcers: venous leg ulcers, diabetic foot ulcers, pressure ulcers and arterial disease trauma- let’s look at all of them a little more in depth.
  • What are the risks for venous ulcers? Age greater than 55(uh oh), males (uh oh), history of reflux of the deep veins, history of DVT and PE; previous ulcers, family history of ulcers, multiple parity, BMI image019and physical inactivity.
  • These are usually over the malleolus and usually have a exudate. They rarely get to the muscle or tendon level. They get stellate while scarring. Osteomyelitis risk is low. Treatment is leg elevation and in more advanced cases – compression therapy.
  • Diabetic foot ulcers- we all know about these. They present the Wagner diabetic ulcer classification and also the University of Texas classsificaiton but I do not really think they add much. Check the sensation and if you can- probe to the bone. Look also for undermining- the ulcer continues under the skin. Treatment is OFFLOADING!!!! Get the pressure off!. Debridement helps. Antibiotics for osteo.
  • Pressure ulcers can actually start within two hours of pressure – careful in the elderly of course- loss of elastin and fluid exposure (guess from where) create these. Here too there are classifications but they are not great because many ulcers skip the first steps. Try the National pressure ulcer advisory panel classification. The treatment is the same as diabetic ulcers.
  • Arterial ulcers are usually from atherosclerosis These tend to be dry, on the foot and with eschar. First test is a Doppler or an Ankle Brachial index (less than 0.9 is positive for vascular disease) but MRI is the gold standard, especially because the first two tests can be falsely elevated in the elderly.
  • Atypical ulcers can be from connective tissue disorders. Vasculitis, pyoderma, sickle cell, nec fasc – nice chart in the article
  • Very little on moist dressing and vacuum treatment-we covered this in the past.


The next subject is a subject I didn’t know about – I admit it- and it is one of those things which isn’t rare and the treatment is not like other crashing patients. Read this carefully. The crashing pulmonary HTN patient.

  • These folks crash fast because the RV is much less suited to accommodate high pressures and failure occurs quickly. Causes of pulm HTN include idiopathic, hereditary, medication associated, connective tissue disorders, HIV, portal HTN, schistomasisis (the most common cause worldwide), LV dysfunction, valvular disease, COPD, MDS, CRF, hemolytic anemia, sarcoid, and thyroid disease. – and other rare causes. The meds that definitely can cause this are SSRIS and maybe cocaine, phenylpropanolamine, amphetamines, and St John’s Wort.
  • Let’s meet our bashful RV- The RV only needs to generate 25% of the pressure of the LV since the resistance of the pulmonary vasculature is so low. As a result it is much thinner. As such it cannot tolerate sudden changes in afterload. If the changes are chronic- the RV will do the same adaptations as the LV does under higher afterloads- –so then it begins to affect the LV filling. This will also affect RCA filling and this leads to more ischemia and the final result- RV failure.
  • This process takes a while – so most Pulm HTN patients are not diagnosed for two years into the disease since the presentation is so nonspecific. –Dyspnea, edema, syncope, chest pain – this doesn’t help us much. Risks may help you – females, HIV, pregnancy, HTN, thyroid disease. If you are good at murmurs – JVP increase, left parasternal lift, and midsystolic click. P2 is almost always present.
  • Lab testing: BNP and troponin – especially if they are elevated from previous values that were measured
  • EKG: This is pretty obvious- RAD, signs of RV hypertrophy (incomplete RBBB, tall R wave in V1. Prominent p waves in the inferior leads can be a sign of RA strain. A fib is malignant in these patients and mortality exceeds 80% since there is less of an atrial kick that they so need image020for cardiac output.
  • Chest film – venous congestion, RAE. Vascular pruning – early tapering of the pulmonary artery shadow – is pretty common image021This is large pulmonary trunk with smaller peripheral vessels- best seen on the right side.
  • CT should be done early – why? CV compromise can be due to PE.
  • Echo – of course is very useful.
  • The moment you have been waiting for- management in the ED. Just go by the guidelines. However, that comes with one small caveat- there are no guidelines. Knowing preload and volume status is also tough, as RV dysfunction makes traditional tests (CVP, etc.) unreliable. They do not mention checking the Vena cava on ultrasound- maybe my CCU gurus – or ultrasound folks – can help here. You can give fluids but be careful – not too much – filling pressures are already high.  If you can ascertain that indeed they are fluid overloaded, you can use diuretics judiciously. But if the patient is hypotensive, give the 50 cc fluid bolus, but repeated boluses are less likely to help than inotropes or vasopressors
  • So you are going to want to use inotropes? Go for dobutamine- it is even more effective than nor ep – and we all know that nor ep cures everythingimage023. Just titrate up to 10 mcg/kg/min – but no higher and be careful – dobutamine can cause hypotension due to beta2 effects and then you gotta hit them with the nor ep. Milrinone can also help.  They recommend this for multifactorial pulm HTN, LV failure or cardiac transplantation. Dosages are at 0.375 mcg/kg/min up to a max of 0.75. But honestly – the dosages are harder to work with, and I haven’t found where they are hiding this med in my ED image024They also do not say if you can combine these two as they work through different mechanisms.
  • Vasopressors should be started fast if the patient is hypotensive. Nor ep seems the best but high doses may cause pulmonary vasoconstriction which would be a disaster for these patients. Vasopressin does not cause this and as such is preferred (the article won’t say as the first line- but definitely as a second line. Phenylephrine does increase pulmonary vasculature resistance and as such should be avoided. While I like phenylephrine, I will point out that Scott is not a great fan of it (it can cause bradycardia) and besides, Scott is a big fan of giving push doses of pressors (even nor ep). I will also point out that Jerry (that is Hoffman) doesn’t see almost any need for a CVP in the ED, so I am assuming he agrees with Scott on push dose. I do use phenylephrine because my wards cannot use nor ep – so this keeps the BP up until they get to the ward where I can let the internists finish killing him off. Truthfully I could just push nor ep. As far as Jerry is concerned I am a little perplexed – in EDs where patients wait in the ED for an ICU bed – it is so much easier to give nor ep by CVP and avoid having to run every five minutes to push nor ep.
  • You want to decrease afterload by all means- Oxygenation can help this but avoid intubation and positive pressure ventilation. Permissive hypercapnia also increases pulmonary resistance. Nitric oxide (Laughing gas) that is nitrous oxide –not nitric) will work in the short term. Pulmonary vasodilators that have been stopped abruptly should be restarted but I am not familiar with these drugs. They include epoprostenol, treprostinil, iloprost and our personal favorite sildenafil –which basically reduces PVR but it could be even if doesn’t work, the patient won’t care much (unless she is a woman) Of course there are other effects of this drug.
  • A few last pointers-atrial arrhythmias – do convert them quickly and don’t use beta blockade and don’t use calcium channel blockers- the reduce contractility. Etomidate is preferred for sedation. Anemia should be avoided but no one agrees where you should be – above 7 for sure though. Those receiving protacycline therapy – need anticoagulation .ECMO can buy you a lot of time and is an exciting therapy, but we ain’t got it in my ED.


EMU Monthly – February/March 2016

All the EMU goodness for Feb/March 2016

  • Drug induced Status Epilepticus is pretty rare. But it does occur and you should know about it. OK, we know about drugs doing this, and obviously intracthecal agents. Don’t forget older anti epileptics and even a new one – tiagabine can cause non convulsive SE. Antibiotics and INH can also casued this (Epil Behav 49:76) In the ED – control the seizures and then you can sort out the source later – and STOP THE MED! I think there is a more important point here: don’t forget non convulsive status can be a cause for coma. And especially remember that if you treated the seizure – especially with paralytics- and the patient stops seizing but doesn’t wake up – this is non-convulsive status. This author must change his name – in the name of decency I will not tell you his name. TBTR: Non convulsive – do not forget it.
  • This was a terrible study. I mean rotten to the coreimage001, image002ugly), yucky image003. They surveyed pain doctors about pain scales; and there was only a 3.8% response rate. But it was clear that no one uses them. And they ask – why should we?  I am still waiting for some one to say – yea- my pain –it’s a 3.1415. (Pain Med 16(7)1247). TBTR: Pain scales – no one is using them.
  • Maybe, just maybe you are bored with my fascination (fetish?) with sedation, but we rarely speak about Nitrous (laughing gas) It works fast, no need for IV, and there are very few contraindications (pneumothorax is the key one) They say it has not been proven to cause any teratogenic effects which I didn’t know. The fact that this was written by anesthesiologists and they are allowing us to use sedation in itself is a miracle. (Eur J Anaesth 32(8)517) I do have experience with this- they say vomiting is uncommon, I saw it a lot. It does not give a deep sedation and does nothing for pain, but is perfect for inserting an IV or nursemaid’s elbow or any similar short painful procedure. I use the 70% NO 30% O2 mix. While we are speaking about sedation, let’s milk sedation for another article. They have a really agitated person that EMS failed to intubate. But they still felt that he could benefit from BiPAP. Gave him ketamine, and viola (picture) the patient allowed the BiPAP and improved. So did his priapism (see last month) (AJEM 33(11)1720) It has been reported that ketamine an also clean windows, lubricates sparkplugs and is just super in salad with escarole.   TBTR: NO is back – use it. And ketamine –able to leap tall buildings in a single bound. Quote time! Let’s look into the wisdom of Divas

“I love to see a young girl go out and grab the world by the lapels. Life’s a bitch. You’ve got to go out and kick ass.”
 image004Maya Angelou

  • Really, I know you are intelligent. I know you know this too. But just in case there are some people from New Jersey reading this, I will just repeat the obvious. Anaphylaxis – give the frigging epi. Forget the H1 blockers, the steroids – they take too much time to work. Just give the shot IM or IV if you got one and then you give whatever you want (Curr Opin All Clin Immuno 15(4)323) why this paper got published is beyond me- this is not exactly new information. But I will say – if you are in doubt – give them the epi even if they are a heart patient. Do H1 work in the acute setting? The evidence does not seem to support this. TBTR: Just give the epi! “Big girls need big diamonds.” image005
    Elizabeth Taylor
  • Dysuria, fever, frequency – hey slam dunk image006– UTI! Well, in this population – most of the time it wasn’t. They did a culture on everyone even those discharged by the doc with no need for a culture and found that only 48% had UTIs on culture, and 23% had undiagnosed STD. (J Clin Micro 53(8)2686) I think that often we do jump on UTIs when indeed often they are really STDs. Also consider other diagnoses: candidiasis (vaginal), interstitial cystitis, allergy. At the moment – you only need to treat asymptomatic bacteria in pregnancy, and do not culture catheters unless there is an unexplained fever. TBTR: See the last line. And the line before. And one more before that. “Sometimes I wonder if men and women really suit each other. Perhaps they should live next door and just visit now and then.”
    Katharine Hepburnimage007
  • Taking your boards? They will for sure make you remember the derm signs of endocarditis-Osler’s nodes,image010 Janeway lesions,image008 and splinter hemorrhagesimage011Well Oslers are rare in this day and age of antibiotics, but they are painful. The other two are not. (JGIM 30(8)1229) Truth be told, you can always just look these up, but since you read EMU ( hear about the EMU reader who was so lazy…How lazy was he?…He went to San Francisco with his girlfriend and waited for an earthquake.) we’ll show you them Janeway lesions

Osler’s nodes and splinter hemorrhages. TBTR: Derm signs of Endocarditis- that you will see as often as a Westermark Sign,  Charcot’s triad, and a Unicorn  “I believe that it’s better to be looked over than it is to be overlooked.”
Mae West   image012


  • My impression of the literature – and this is just me-the triptans are effective abortive for migraines if taken within the first few hours after migraine onset. They did a meta-analysis here to study triptans and while these appear to be effective medicines; the numbers were all over the joint. For example, standard dose triptans relieved headaches within two hours in 42% (in other words more than half the patients) – 76% of patients (3/4 of the patients). The number spread continued for completely aborting the headache. When compared to NSAIDS, ASA, and paracetomol they did do better- (again the numbers are not convincing (or expressed in odds ratios either) but they didn’t do well against combination therapies. (Headache 55(4)221) So yes, you can try these but be prepared to use others meds if they fail. TBTR: Are triptans the way to treat headaches? Maybe. Maybe not.  “I never worry about diets. The only carrots that interest me are the number you get in a diamond.” 
    Mae West
  • OK, let’s speak about HEART score. This is an attempt to allow us to use an easy score (TIMI is not an easy one) to discharge low risk chest pain patients. Amal Mattu is a big fan of this, but Amal doesn’t read EMU, so no free plugs here. But Anand Swaminathan up at Bellevue is also a fan of this and he is a reader of EMU – or so I have heard – so if you do read this, Swami- just know I like your delivery and your knowledge base and that you live in New Jersey, and are a proud new parent and that your middle name is Kumar. If you are not a reader, well, just know that I will not like New Jersey ever again, and will never go to Bellevue. The HEART score is basically like this:image014 Why is this important? Because previous scores were tough to use (especially TIMI) and this gives you good backing if you discharge a patient with a 0-1 score. I also liked that it takes into account your clinical gestalt. The likelihood ratios in the study I am about to mention were great – if the score is less than 3- the neg LR is 0.15 whereas the positive is 5. Their point though was that clinical gestalt did just as well. Well, maybe, but it is hard to compare clinical gestalt with a test that incorporates clinical gestalt. You may say well, that means the rest is superfluous, but gestalt is not the same in everyone, and it could be that is in this study it was very good. Still, I use only three scores- the Blatchford scale for UGI bleeds, The PERC score for PE, and this one. (EMJ 32(8)595)  Also remember that with only a positive troponin you can have a score of 1 but I wouldn’t let them go home- just use the scores with your brain. TBTR: Start using the HEART score for low risk patients.  “I’ll try anything once, twice if I like it, three times to make sure.”
    Mae West
  • There is no evidence of a link between stethoscope bugs and infections in people- yet- but there is a definitely a transfer of really bad bugs from stethoscope to skin. Do any of us clean our stethoscopes? I just did (J  Hosp Inf 91(1)1) TBTR: Clean your stethoscope image015 “You only live once, but if you do it right, once is enough.”
    Mae West
  • Infections from coughing patients in airplanes- may be spread to the immediate fellow passengers, but GI infections definitely are – so says this article. (AJM 128(8)799) They base the question about respiratory infections because of recirculate air in air planes- but I thought air was actually brought in from the outside and warmed up. Anyone know more? TBTR: GI infections do spread in airplanes. Congrats to Charles Shumer, R- NY who wishes tointroduce legislation to stop packing people into economy class like sardines. “People say I’m extravagant because I want to be surrounded by beauty. But tell me, who wants to be surrounded by garbage?”
    Imelda Marcosimage016
  • They claim listening to heart sounds through a gown means you can’t hear them well, but most docs do it anyhow (Post Grad Med 91(1077)379) I do this- because for what I am listening for – I do not need to hear an S3. Also, recall Bill Frishmans article last month- use ultrasound. TBTR: Listening to heart sounds in a dressed patient won’t give you much. I firmly believe that with the right footwear one can rule the world. —Bette Midlerimage017
  • There are a few of us who are interested in nutritionimage018 so here are some notes on the subject.  Olive oil
    image019 has been shown to improve
    cardiac risk factors. Does it help for prevention of Diabetes? Well if you use margarine butter and mayonnaise – you have a 5- 8% higher risk of type two diabetes than if you use olive oil. (AJ Clin Nutr 102(2)2309). That is pretty modest, but this is hard to study – most people are not so extremist- except perhaps me, who has never eaten mayonnaise in my life – or butter since childhood.  On a related subject-eggs- those female empowerment instruments that get estrogen surreptiously into our virile bodies- this article was oft quoted- seems that dietary intake of cholesterol does not affect your CV profile.  (ibid p235) I am not sure what is new here. Cholesterol – like diabetes- is an enzyme disorder- and under usual conditions the body creates the cholesterol it needs from fatty acids. Dietary cholesterol is harder to find in nature and as such the body doesn’t depend on it and most of it goes straight out in the feces. That is what I learned from my nutrition elective with Dr. Darwin Dean 30 years ago. One last and critical note- sugar drinks are real bad boys in the USA but not in Israel and I am not sure why. This study does link them to DM type II even while controlling for adiposity. They also note that artificially sweetened drinks and fruit juices also can cause this but they claim this is bias. They recommend against them too, but I am a little perplexed. Not only because sugar drinks abound still but also what does this article expect us to drink after rigorous physical activity? Wine? (Father is in seventh heaven!!) I think fruit juices are not those bad- if the pulp is present. Water is hypo osmotic. This is just my opinion (BMJ H3576) TBTR: Some dietary notes – won’t make a difference in the ED, but in your life- maybe. “A woman’s dress should be a like a barbed-wire fence: serving its purpose without obstructing the view.” —Sophia Lorenimage020
  • Really I like the Dutch – they are neat people – they have a country that is called the Netherlands or Holland – but they themselves call themselves Dutch (10 points for anyone who can tell me why), and they practically live under water. They have an impossible language to speak and names like the author of this paper van Winjgaarden (ooo, that double aa is so sexy) that are also impossible to pronounce. But they have two medical things that are unquestionably Dutch – no, not wooden shoes, but they don’t give antibiotics or Otitis media, and they are into assisted death. Here they took a survey – granted only 25 people were interviewed and classified why older people want to die. They came up with five reasons. They arte- loneliness, the pain of not really mattering, multidimensional tiredness (I am not sure what that is), inability to express oneself, and fear of being defendant. (Soc Sc Med 138:257) I would really be supervised if Ken hadn’t written a similar article at some point. TBTR: The reason for wanting to die if someone is old – see above. “I can’t concentrate in flats!” —Victoria Beckhamimage021 Oh yes, to answer our question- the country is called the Netherlands-meaning flat lands. Holland means wood lands and is the most important province Dutch simply means the people and really only English speakers call them that. Do I owe you ten points?
  • This little paper from a great journal shows that worldwide- doctors who are male are 2.5 times more likely to be sued for malpractice than females. (BMC 351:172) This is probably true- again, I can’t believe Ken hasn’t written on this, and while we are name dropping, I am sure father has seen this – but this was a massive meta-analysis and that means a lot of heterogeneity. TBTR: Males- you’re more likely “to read the nurses notes” in court than females. “A woman who doesn’t wear perfume has no future.” —Coco Chanelimage022

“People will stare. Make it worth their while.” —Harry Winston

  • I am not sure who this practice pointer is for but they look at the painful un inflamed eye- if there is decreased vision – call an eye doctor. If not – and it is not red – it is usually benign but considered optic neuritis, temporal arteritis, aneurysm and glaucoma. (BMJ H4141) I don’t know- corneal FB and abrasions are painful, but we can handle them without an eye doctor. Metal against metal with a piece flying into the eye may cause pain without affecting vision and we do need an eye doctor for that. Temporal arteritis- well, that can be without vision loss, but you should be taking a good history and optic neuritis the same. Glaucoma? Most I have seen look like – glaucoma. Steamy eyes, visual loss, decreased EOMI- but pull the article if you want a primer. TBTR: painful un inflamed eyes- see inside. “And now, I’m just trying to change the world, one sequin at a time.” —Lady Gagaimage023

“Men tell me that I’ve saved their marriages. It costs them a fortune in shoes, but it’s cheaper than a divorce. So I’m still useful, you see” —Manolo Blahnik


  • Ketamine- aah a breath of fresh air – just like talking about DVT ! Yes, here in a few seconds is the ketamine article fo the month. With all the accolades I give this drug; it does have its drawbacks if abused. And it is being abused even by those without priapism they have more delusions but these are generally sub clinical. Memory gets affected, but this can improve if ketamine is stopped. It affects the bladder causing pain and hematuria which can lead to cystectomy although it isn’t clear how this happens. Mostly but not always there is some improvement after ceasing use of ketamine. It can also increase LFTs and cause biliary tract dilation. (J Pain Symp Man 50(2)268) TBTR: Ketamine abuse – what you will see- you’ll have trouble peering but you won’t remember it. “Attitude is everything.” —Diane von Furstenberg  image024 We don’t wake up for less than $10,000 a day.” —Linda Evangelistaimage025
  • Does our patient have PTSD? Do you have PTSD from your patient? Do you have PTSD from reading EMU? Do I have PTSD thinking about you reading EMU?  There is a simple scale called the primary care PTSD screen – one positive answer and you should consider PTSD.  Actually the LR were pretty good – the positive likelihood ratio was  9 and the negative was 0.3  (JAMA 314(5)501) The scale is as follows:

Have had nightmares about it or thought about it when you did not want to?

Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

Were constantly on guard, watchful, or easily startled?

Felt numb or detached from others, activities, or your surroundings?

Whoever said that money can’t buy happiness, simply didn’t know where to go shopping.” —Bo Derekimage026

  1. “Shoes transform your body language and attitude. They lift you physically and emotionally.” — Christian Louboutin

18) After years of listening to Rick Bukata –I know a lot about him- a true pioneer in EM education (you better be a subscriber to Emergency Medical abstracts and risk Management Monthly if you want to continue reading EMU) and aside from his son Ricky babaloo- his favorite  thing in the world is Magnesium. Magnesium does relieve constipation but never made it as the laxative of the month (take, that Father Greg). This article reminds us that hypermagnesemia can cause paralysis, constipation, urinary retention – and this can be seen in Dead Sea drowning which does occur in my area and presumably across the border in Jordan as well. Low magnesium is hard to check because most Mg is intracellular, but is usually goes along with drops in potassium, phosphate, sodium and calcium. So check all of those ions. (Mayo 90(8)1104) TBTR: Magnesium- too bad Rick Bukata doesn’t read this. “People say, ‘What do you mean you want to help the world, but you’re so concerned about fashion?’ It’s illegal to be naked. It is something that is extremely important.” — Kanye West

“I don’t want a politician who’s thinking about fashion for even one millisecond. It’s the same as medical professionals. The idea of a person in a Comme des Garcons humpback dress giving me a colonoscopy is just not groovy.” — Simon Doonan


18) Hgb-a1-c has supplanted fasting glucose and GTT for the diagnosis for diabetes (and why Ob people are still doing GTTs is a mystery to me) but just know that hemotogical disease (like hemolytic anemia) , CRF and alcoholism can all give false values (MJA 203(2)89) See also Postgrad 86(1021)656 where they worry more about missing some patients with this test with the controversy of pre diabetes and what  criteria to use but this worries me less. TBTR: HG1-ac –still a good screen but not for everyone. On a similar subject – I like the idea of metformin for gestation DM – and this study reviews the current literature- it does seem that it causes less fatal hypoglycemia than insulinimage027  and less maternal weight gain. Still needs more studies but it is so much easier for women to take. (Aust NZ J ob /gyn 55(4)303)  TBTR: metformin for GDM – go for it.  

  1. “I’ll stop wearing black when they make a darker color.” -Wednesday Addamsimage028
  • Glucosamine and chondroitin – do they work? This study says they do- but there was a 44.8% drop out rate, and one has to ask himself- – was the study powered to answer the question from the start? I think not. (Clin Rheum 34(8)1473) However, Cochrane does think there is some merit here.  Do ozone injections work?
  1. “I feel that flip-flops are the downfall of many relationships. It’s, like, first it’s the flip-flops, and then it’s the sweatpants…it’s the gateway drug to no sex.” –Lady Gaga

. “I really would not call myself a fashion icon. I would call myself somebody who gets dressed by professionals…I would call me more of a monkey.” -Jennifer Lawrenceimage029


  • I love guidelines! The only things I like less than guidelines are nerve gas, ricin intoxication, and exploding hemorrhoids. This is a guideline based on guidelines – oh what a thrill – for kidney stones. But lucky you – I summarize them for you! And you get a running commentary! Initial evaluation: They say – all patients should have a urine dipstick – well, OK – you can mix up renal colic with a UTI and in additional infection in renal colic is pretty bad thing – but the patient will look pretty bad too. Serum chemistry – why – the other kidney usually compensates so bumps in keratinize are not that meaningful. CBC+ CRP – why do I need those? Also- if there is to be a procedure – they want INR – again – why? Most people know if they have a bleeding disorder. They do urge caution on imaging- they like a low dose (less than 4 mSV) CT but they admit it won’t work if the patient’s BMI is more than 30 They do give an option of checking the scout film – if it is alright – do a KUB – if you see a stone on either – you may be done- my comment? Bravo. However, they do mention that bedside US is coming into vogue – and we reviewed this before in EMU- that is what I do- no hydornephrosis – then I do not care much.  Treatment: NSAIDS- I agree. Opioids as an add-on – OK with that too. Fluids – there is some evidence that this makes things worse – more spasm. I don’t give if the patient is not volume depleted. Less than 10 mm- observation – 6 mm is my criteria- the chances they will fall when more than 6 mm is less than 10%Massive stones s- bigger than 10 mm do better with uretoscopy, less than 10 – they recommend lithotripsy. I didn’t see much on medical expulsive therapy, but we know I am not a big fan of this. Evaluation in the community- they like PTH checking and 24 hour urine collection for volume, pH, calcium, oxalate, uric acid, sodium, potassium, and creatinine, They do comment that the ACP doesn’t recommend these as they haven’t show efficacy in stone prevention. Here they do recommend fluids, restricting sodium intake (calcium stones), more fruits and vegetables if the citrate is low and it is ac calcium stone, and less animal protein in uric acid stones. Thiazide diuretics seem to help in calcium stones, and citrate will help too.  Interestingly, allopurinol is not recommended – here the problem is a low pH and not a metabolic defect. Just get the pH up – with citrate. They like repeat 24 hour urines to see progress- but I would buy a separate refrigerator for them to keep checking this. (BJUI 116(2)184) TBTR: Guidelines on kidneys tones for EPs and FPs.

“Crying is for plain women. Pretty women go shopping.” -Oscar Wilde

“I like Cinderella – she has a good work ethic and she likes shoes.” -Amy Adams


  • You know that when people have vasovagal events they can seize. How do you know when it is a seizure and when it is just syncope? Well, I loss the article that refers to this scale but I still have the scale- Tongue lacerations are two points. Déjà vu or jamais vu before the spell ; emotional stress before the event, people seeing head turning during the event, or jerking movements or unresponsiveness; no memory of events; witnesses that you are confused after an event. – all these are worth one point, If the person reports lighthead ness before spells, or sweating or if the events are associated with prolonged sitting or standing – take off two points for each – total score greater than one it is a seizure. Less than one – it is syncope. They claim accuracy of 94% but I am dubious especially with the emotional stress –isn’t that also associated with syncope? ( JACC 40:142) I also don’t know how they proved that it was a seizure or syncope. TBTR: Is it syncope or seizure- only your hairdresser knows for sure. Valentino Garavani
    “An evening dress that reveals a woman’s ankles while walking is the most disgusting thing I have ever seen.”
  • Hi, dopes-I’m speaking to the dopes who wrote this article– how can you answer the question your article asks “who should manage patients with chest pain in the ED” if the authors are not EPs? One is a CHF cardiologist who is hospital based and the other is a community physician who is his brother. We EPs cannot be trusted –we mistakenly send home 2% of MIs and 2% of patients with ACS. So I ask – do cardiologists do any better? No reason to think they would. Then they say –well, let’s just bypass the ED and go straight to the Cards department. Any proof that saves lives? Often the patients just wait there in the hallway until someone can clear the cath lab or they wait for the cath team to come in. We in the ED could give care in the meantime. EKG- they recommend that a cardiologist read the EKG via tele transmission- we of course do not know how to read EKGS. All these patients need chest films – are they nuts??? Very low risk patients can be discharged- what are very low risk patients? No mention of the HEART score (see above) (EHJ 36:1634) This is all crap and the authors are Israelis and if any of my readers know these guys ( thye are from SZ) – let them pleas know that we are now in the 21 century and EPs have long ceased to be the little boys in the emergency room. TBTR: read this paper in the rest room – then dispose of it properly in the receptacle that you are presently using.

“The most beautiful makeup of a woman is passion. But cosmetics are easier to buy.”Yves Sainte Laurant

Donatella Versace image030
“What is natural? What is that? I do not believe in totally natural for women. For me, natural has something to do with vegetables. I don’t even know what my natural hair colour is.”



  • Maybe I am just writing this because I just suffered from a two month bout with a pulled (torn?) hamstring. Risk factors are age (guilty as charged), poor warm up (, guilty as charged) previous injury, fitness level, and flexibility of the hamstrings. The way it occurs is rapid hip flexion with the ipsilateral knee in extension. US and MRI and the best way of diagnosis although I think clinical signs are often enough. These can feel like sciatica too. Running takes the longest to return and a few select pulls become chronic. No steroids, no immobilization – stretching will help (Knee Surg Sports Traum Arthro 23:2449) TBTR: All you knee to know about hamstring injuries.
  • Remember RSD? Just the word remembers is going to get me started. This month let’s remember that cop show with the catchy tune- Hawaii Five O– and the famous – book em, Dano. Here were the stars from the show – led by Jack Lord who was Garret and Danny Williams “Dano” played by James Mac Arthur. Chin Ho Kelly was another police officer played by Kam Fong image032. RSD in any case is now CRPS –complex regional pain syndrome (sounds too close to CRAPS for my liking image033 but this is defined as hyperalgesia and allodynia (even using a feather can cause them to feel pain), usually color changes of the skin, hair changes on the skin in that area and sweating. It is often after some kind of trauma like a fracture.  Carpal tunnel surgery is another often found cause. This is a disease more commonly found in middle aged women. It also slows on onset – more likely to appear three months after cast removal than immediately after cast removal. While it is uncommon, acute CRPS can also resolve on its own. That is called acute CRPS and is usually with a warmer extremity, colder limbs are usually chronic CRPS. Diagnosis – is basically clinical grounds. Treatment- I know you are all waiting for this, especially in view that there is a large psychological aspect to this malady. The evidence is low quality, but consider bisphosphonates, ketamine, calcitonin, and mirror therapy. I cannot explain how these work. Vitamin C probably doesn’t work, but avoiding tourniquets is probably a good idea. They suggest lidocaine patches, anti-depressants and anti convulsants but there is no good evidence- yet.  (BMJ h2730) TBTR: All you wanted to know about CRAPS.

I don’t understand how a woman can leave the house without fixing herself up a little- if only out of politeness. And then, you never know, maybe that’s the day she has a date with destiny. And it’s best to be as pretty as possible for destiny. – Coco Chanel 

  • I always found myocarditis an interesting and challenging disease, and would have made this an essay this month if not for the tradition of this being the Purim issue. Myocarditis can kill. If can also cause a lot of morbidity as it is the cause of 1/3 of the cases of dilated cardiomyopathy. Viruses cause a lot the cases, and those who aren’t caused by viruses are usually auto immune – Churg Strauss, Wegners, SLE and the like. Other causes include Lyme, vaccines, many meds including lidocaine, thyrotoxicosis.  It can accompany peripartum CM and Takotsubo CM.  The signs can be subtle, but do think about this in a patient with fever or a recent viral infection who know presents with effort to intolerance, CHF or chest pain – especially in younger people. Troponin may be normal as can be CRP and ESR.  EKG may show ST – more concave than usually. Echo may show DCM signs ; and apical aneurysm points to Chagas disease. There are some good charts taken from the European society of Cardiology task force (34:2636) but the article is for free so instead of copying the charts- go into the article.  The articles does discuss RHD – which is still a problem in Israel despite being an industrialized country. These folks can have mild CHF  or tachycardia – be on the lookout –also first degree hear block – or any heart block with fever is a sign of myocarditis – especially RHD) PET CT may help – do you have that in your ED? (Heart 101:1332) TBTR: Myocarditis review.

The most beautiful makeup for a woman is passion. But cosmetics are easier to buy. – Yves Saint Laurent

  • This is the last article this month. This is a great article and deserves more attention, but this is the last article of the month and it is already Mid-March so I am taking the easy way out. Basically they took the guidelines for how to insert a chest tube from ATLS, BTS, European Trauma Course and found that the criteria are risky – counting ribs, go by the nipple ( how do you do this in women?) looking for the safe triangle- all put a significant risk to insertion in the abdomen. The ETC guideline on average went into the seventh intercostal interspace. (they use the one hand’s width method below the anterior axillary line)  I will give them this – all of them avoided critical nerves – the long  thoracic never and the lateral cutaneous branches for the intercostal nerves with the exception of the ETC guidelines at its extremes (EMJ 32(8):620) My main problem with this paper- and they acknowledge this – is that it was done on cadavers which may not be too realistic. Nevertheless, this is another EMJ article that tackles interesting subjects and I am happy to be a peer reviewer for them. TBTR: Major society guidelines on how to insert chest tubes may result in major damages.
It’s simple, if it jiggles, it’s fat.
Arnold Schwarzenegger
All my life, I always wanted to be somebody. Now I see that I should have been more specific.
Jane Wagner


27) Letters: We had a letter from a reader about the format we are using- not that I understand anything about computers, but my new partner does and I will be introducing him soon – Look forward to podcasts, and thrills in many languages soon to come. Here is what Ken has to say from the Down Down Under (Antarctica):    You and I have the same sensibilities about what is useful and interesting to clinicians. You mentioned ___ items in the recent EMU that I covered in the 2nd edition of Improvised Medicine: Honey for wounds, not using ophthalmic medications past their expiration dates, and the use if IV lidocaine as an analgesic. The piece about lidocaine is:


Lidocaine Infusions. These are often successful, especially in treating peripheral nerve pain. The safest, especially in patients with a history of arrhythmias or seizures, is a 4-hour infusion of 2 mg/kg IV. Dilute the lidocaine in 240 mL of normal (0.9%) saline (NS) and run it at 1 mL/min. Monitor pain scores every 15 minutes. If available, use cardiac monitoring and oximetry. If the patient has a positive response (less pain) with the lidocaine infusion, additional periodic lidocaine infusions will probably be an effective analgesic. Positive response to lidocaine indicates that mexiletine (an oral medication in the same class) may be effective.” (From: Iserson KV. Improvised Medicine: Providing Care in Extreme Environments, 2nd ed. NY: McGraw-Hill, 2016, p. 204

Sounds good to me- I get a lot of fibromyalgia patients so this may be worth a try. He also found an error on a hyperlink of mind on aerosolized antibiotics: Hi Yosef. I located the articles. The journal name was a bit off. The correct citation is: Restrepo MI, Keyt H, Reyes LF. Aerosolized Antibiotics. Respiratory care. 2015 Jun 1;60(6):762-73. The following article is on surfactants, as you noted

A shout out to Ramez Sulaiman MD who loves EMU – glad to hear from you. He has a 718 area code, so maybe he can find out for me if Anand Swaminathan from Bellevue is a reader ( see above) Alex Wang promised to visit me in the ED in Israel – would love to meet you – he is a medical student and John has written concerning my safety – I really so appreciate your letters.

EMU LOOKS AT: The Purim Issue

This is everyone’s favorite issue (Everyone? all three readers) when we take our yearly dive into the literature’s strangest articles.

  • Let us start with great author names. This gastroenterologist at Queen Elizabeth Hospital in London wrote a nice article on coffee ground emesis but I think he chose the wrong specialty. I am of course referring to Dr. L. Pee.
  • This guy may not be the most popular lecturer. I liked his article in Pharmacotherapy  on asymptomatic bacteriuria but I wouldn’t want to hear him- Prof RB Dull.
  • Speaking about articles that will absolutely change your life. Can you go deep sea diving if you are pregnant? They do not investigate why you would want to. Like everything in pregnancy the answer is – we don’t know (or for you older folks- category c) but I liked that they did do this study on pregnant sheep- did they really put on flippers and a wet suit image034 (Ob Gyn Surv 69(9)551)
  • If we haven’t changed your life yet, this will do it. Survival after avalanche induced cardiac arrest doesn’t result in good outcomes. (Resusc 85(9)1182) image035There are other situations that can result in similar results.image036
  • This is not indexed but a good article for you to read. It is in the journal Judgment and Decision Making 10(6)549. People tend to be more receptive of vague syntactic structures (which they call pseudo profound bullsh*t-talk about professional terms) their example is “Wholeness quiets infinite phenomena” They conclude and I quote “that some people are receptive to this type of bullsh*t”. I can believe that – some people read EMU too.
  • It is the time for the culture section of EMU –image037. CPR as portrayed on TV (and yes, they actually watched 91 episodes of gray’s anatomy and House) and found that ROSC was 70% and survival to discharge was 50 %-(Rescus 96:148). I would seriously consider instructing your ambulance team in the event you need CPR to transport you to southern California. Live in Australia? Doesn’t matter. take a water taxiimage039
  • Pelvic and lower extremities are important and can be life threatening. That is why it is critical to know about these injuries that are mentioned in Homer’s Iliad.image040 This may be a little bit beyond the locals in Ypsilanti, but then again, they may know more about these injuries than we do. Here is view of downtown Ypsilanti image042(J Trauma 78(1)204)
  • What about resuscitation in the 24th century? Well, these folks watched a lot of Star Trek. The exclusion criteria where great- if they were annihilated by energy weapons (being vaporized is not a good prognostic indicator) and patients that were unable to get treatment except by the assassin who rubbed them out. image044
    Seems patients didn’t do too well, but then again, Southern California may not exist in the 24th You may just have to go to Pluto General(Resuc 85(12)1790) And no – beam me up Scotty is not a treatment for ED.
  • OK in the 24th century they were using phasers, but we have smart phones and it pays to be careful. While we have yet to see anyone who phasered themselves by mistake, this genius image045played Match 3 puzzle video game all day for eight hours and blew out his extensor policus longus tendon.(JAMA Intern 175(6) 1048) My reaction – some us work for living – get a job , guy! Speaking of getting a job- some very bored EPs found time to publish this important piece of information – they poured blood on different surfaces and measured the side of the puddle. PVC and concrete have the largest puddle sizes. (EJEM 21(5)360) This isn’t “get a job” this is “get a life”image046.
  • I understand these, guys – I mean this could be catastrophic- there is some bead they sell as a children’s toy called Orbeez image047Now they are concerned about kids swallowing these things and then get bowel obstruction from the expansion of these water absorbing beads. These beads actually grew the biggest when exposed to vodka- (Ped Emrg Care 31(6)416) image048(Yea well, I gotta really be concerned that some kid is going to do a water bead Stolichnaya cocktail. Maybe he has a bigger problem than these beads.
  • Friends it is time to be a little – shall we say – a little more delicate? These articles deal with a blue subject – the issue of human reproduction which seems to be practiced by a number of people. Thanks to the Turks, I now know that this exercise can be effective for passage of distal ureteral stones that are less than 6 mm. Their RCT required doing this activity 3- 4 times a week and required in their terms – a sexual partner.image049(Urology 86(1)19) Think of it fellows – you’ll never hear again “not tonight, dear, I have a kidney stone”image050 It took two weeks to complete the therapy and they report that patients were generally happy with the treatment despite not drinking Stolichnaya. Similarly, if you have long QT syndrome or catecholaminergic polymorphic VT – you could be in for a profoundly shocking experience if you attempt the aforementioned exercise program. – but it is actually rare- unless your partner is image051
    (J Cardiovasc Electro  26(3)300) While we are on the subject- men have a terrible tendency to not urinate due to a prostate that wants attention after being kept in the dark and as close to the rectum as possible all these years. Women fortunately retain the ability to urinate on demand any time the want to for all their lives. And they tend to do that, too. image052 So if you missed this Iranian study published inhte International Brazilian Journal of Urology- let me present it now Adding sildenafil does not help tamsulosin get your bladder emptied. It may assist in other issues. (40(3)373)  Thanks to the Teheran University of Medical Sciences (TUMS).
  • It is a weird, weird world out there. This 18 year old female was intent on not getting a NG tube (zonde). So she inserted superglue in both nares. (J Laryn Oto 129(1)98) Kinda of gives one pause – I think the take home message is to be very careful picking your nose – you never know what you’ll find.
  • Did you know that you could get hypercalcemia from hot tub lung? (Chest 146(6)e186) Try it some time.
  • Did you know that you could get your SVT straightened out by doing handstands? (Arch Dis Child 100(1)54) Try it sometime. No, not in the hot tub. If this is the cause of your SVT then handstands may not help.   We’ll let the cat out of the bag- the blonde we are showing was a beauty from the sixties- Bridgette Bardot. Here is how she looks today:  image053
  • This brings us to our next subject – Exploding Head Syndrome – this is actually a benign syndrome. It is just is the perception of a sudden loud noise like a bomb exploding in your head. (Cephalagia 34(10)823) No, it has nothing to do with therapy for kidney stones.
  • Lastly it is time for the Honorary Rick Bukata School of Title Writing. Rick doesn’t really read EMU any more (he prefers the Wall Street Journal. I prefer Mad Magazine. Father prefers. Ken prefersimage054
  1. The first two are – don’t ask any questions – I don’t want to know how this happed Pneumoscrotum (Ind Ped 51911)942)
  2. Dentures in the Cecum (AJ Gastro 110(3)378)
  3. Death before Disco (JEM  48(1)43)
  4. Panic Attack Symptoms Differentiate Patients with epilepsy from those with Psychogenic Non Epileptic Spells (Epilepsy Behav 37:210) Unfortunately, the neurologists have called the latter malady by its initials and no, you aren’t going to get me to write it
  5. Wheel chair cleaning and disinfection in Canadian health care facilities –That’s wheelie gross”( Am J Inf Contr 42(11)1173)
  6. Trust me – This is the Worst Acne of your life (Ann Emerg Med 65(1)147)
  7. Suicide : An existential reconceptualization ( J Psych Ment Heal Nurs 21(10)873) This paper was based on Camus Sounds like it should have been based on Pseudo Profound Bullsh*t- see number 5 above
  8. Afraid of Being Witchy with a B” (Acad Med 89(9)1276). This article looked at females as code leaders in cardiac arrest. Because I do want to alienate the last two women that read EMU (and one is my wife) I will not go deeper into this study but I will mention that some females apologized for their strong behavior as code leader- which seems odd to me when scratching out their mate’s eyeballs for buying an anniversary gift  of a vacuum cleaner seems normal
  9. How Deep is Your Love: Choosing the Most Appropriate Depth for Pediatric Chest Compression (Resuscitation 85(9)1125) (here are the Bee Gees for those of you who don’t remember their hit song of the same name Only Barry –image055 the middle one is still alive.
  10. Sex, death and the diagnosis gap (Circ 130(9)74)

Well the issue would not be complete with out Father’s iinput –a Tradition here at EMU: Yosef, Yosef, Greetings and salutations. The Purim issue needs some historical background. For our readers who are non -Jewish and for the 95% of Jews who don’t care

or who flunked Hebrew school. Allow your resident cleric to help everyone out. I consulted my rabbi on this one. Yes, the secret is now out. Even I have a rabbi. How else would I know where to buy wholesale? Purim is the feast of Esther. This is the only book in the Talmud that never even mentions God. Not once. It’s about sex, money, violence and political intrigue all of which make it always relevant. This sounds like a script for a Donald Trump speech. Again, for those who don’t remember, Esther was the hidden Queen of Persia. Now I have certainly known some hidden Jewish queens in my time but this was different and it didn’t take place in the East Village. How she tricked the Persian king is not very clear. She changed her name(Hadasa) to Esther which is Persian for star. But things get even stranger when you find the Hebrew for this name is “ astir” which means “ I hide”. This is why people( kids mostly) get to run around in costumes which brings us back to the drag queens referred to earlier.  Now we have a basis for doing and saying strange things on Purim. As an aside, we get great names from the Book of Esther like Mordechai and Haman which will appear in Clint Eastwood movies( reference High Plains Drifter).  Now back to the Purim issue. The article on deep diving on pregnant sheep was Baaad! How did they pull the wool over their eyes with diving masks on? Sheer garbage! Next. The fact you proclaim there is a “cultural” section is the second clue this is the Purim issue. By the way, this article on TV-CPR was done over 20 years ago(please check with Rick Bukata) with the same results except that the reference shows were Chicago Hope and ER. I think at that time the save rate in even traumatic CPR was 85%No wonder the public doesn’t understand. God help us all on this one! By the way, the photo you used for Ypsilanti, Michigan was just plain wrong. The scene is way too clean, it is way too modern, and there is not near enough firepower. This must be Switzerland. The casual reference to Bridgette Bardot and the treatment of kidney stones both broke my heart and put me into hypovolemic shock as I do not have enough blood to run multiple organs. Her t-shirt sans bra in God’s Little Acre changed my life at 15. So no rude comments about my Bridgette, please. My mother had enough horrible things to say about my sneaking into her movies. Lastly, The Brothers Gibb’s How Deep Is Your Love seems more of a commercial for Viagra than a cardiology reference. I believe Staying Alive is the new mantra for CPR. God bless you all. Father Henry

Have a great Purim

















EMU Monthly – January 2016

All the EMU goodness for Jan 2015 – In order to catch up- this issue was not peer reviewed

  • It is just a push of a button – no different than ordering dinner at the Golden Arches.image001You know what I mean- they wheel in the patient from a trauma – backboard and neck collar- complaining of a broken fingernail and viola –you get the pan scan. I am from the old schoolimage003I think – Egad! image004that you should check the patient first – and selectively do CTs- and then do repeated exams as necessary. But alas- there are detractors. This article only cuts down the methodology of the four studies that even look at this and we will have to wait for the REACT trial for the real answer (J Trauma 78(6)1236) This editorial was based on a silly article touting whole body CT in all cases.  Their article had ISS scores higher in the whole body CT group and also looked at ages 1 to 44 years old – I would agree too that a physical exam on a one year old after trauma is not easy( ibid 77 (4) 534). OK, we’ll wait for the answer. TBTR: The pan scan – should we scan or pan?
  • I do not like to repeat myself, but when are you going to learn? I know – you paramedics will claim it is still in your protocols, and you nurses- well it is all we can do until the MD comes, and you MDs – well I really can’t explain why you do this – but quit using the 100% oxygen therapy if the patient is not hypoxic. It doesn’t help and yes, it can hurt. Here are some bennies you get with oxygen- pulmonary inflammation, recurrent MI and arrhythmias in patients with MI, and increased mortality in brain injury, stroke and intracranial bleeding. It decreases cardiac output,  however it may reduce heart rate, and prevent surgical site infections through antibiotic properties – I don’t really buy that – peroxide isn’t a great antibiotic if that is the way it works. (Intens Care Med 41(6)1118). TBTR: Back off image006 the oxygen.
  • This article speaks about the clinical diagnosis of influenza in the ED (which just so happens to be the title of the article also) I know what you are thinking who cares? – Please be patient!!. CDC criteria are fever, cough and sore throat- but this has a sensitivity of 55-69%. Clinical diagnosis doesn’t help much either- 36% sensitivity. But what got my goatimage007 is that they lab confirmed influenza and only 36% got antivirals (which is good in my eyes – doesn’t work anyway) and 52% got antibiotics (that sucks). (AJEM 33(6)770) Still H1 N1 is important – you really need to know about it in hypoxic people. TBTR: Influenza – back off image008the meds for this. Let’s start with quotes- this month we feature Bart Simpson’s blackboard.
  • I will not aim for the head.
  • I will not barf unless I’m sick
  • I will not expose the ignorance of the faculty
  • Recurrent abdominal pain – oh what a drag image010(Yes that is a man-> it is Dustin Hoffman in his role as a woman in the film Tootsie from 1982).  This could be porphyria, it could be IBS- but is could also be abdominal migraine.  It is a diagnosis of exclusion (AJEM 33(6)E1)- it responds to NSAID – will triptan help? Doubt it.  Gosh abdominal migraines- are brain rectal bleeds next? TBTR: Recurrent abdominal pain – could be a migraine- or a headache for you. Here is the real Dustin Hoffman:image011 .
  • I saw nothing unusual in the teacher’s lounge.
  • I will not conduct my own fire drills
  • I will not prescribe medication
  • I have a soft spot for creative ideas and this study states that intravenous lidocaine worked well for ischemic limbs – and even better than morphine. (EMJ 32(7)516) This would be great for us as we cruise towards opiate free EDs if possible. The down side here is that this study did not evaluate safety. Also a third of the patients were excluded- and I cannot tell if it was double blinded. TBTR: IV Lidocaine may be worthwhile for pain control
  • I will not teach others to fly.
  • I will not bring sheep to class.
  • A burp is not an answer.
  • Why I am including this study? Honest- I have no idea- it was just so neat- and so useless. These Germans feel that you can start a good resuscitation at sea. They came in by helicopter (they point out this was a pilot study- funny, huh?)  and they used a LMA, a heliboat platform to stabilize the patient, and then IO, and also a LUCAS resuc device and viola the mannequin lived. Crazy, no? (EMJ 32(7)533) TBTR: don’t even bother.
  • Coffee is not for kids.
  • I will not eat things for money.
  • I will not yell “She’s Dead” at roll call.
  • Kids- 11 and above can do CPR even if they had no training beforehand- of course when instructed by a dispatcher. They can only do the hands part – which is fine as far as I am concerned (Rescu 90:138) Of course why not just train everyone? Money?
  • The principal’s toupee is not a Frisbee. “.
  • Goldfish don’t bounce.
  • Mud is not one of the 4 food groups
  • We have pointed out in the past that if you are doing CPR and they shock the patient and you get shocked too – it is unpleasant –but not dangerous. If you are looking for that not dangerous and not unpleasant shocking experience (keep this clean, guys) then try insulating electrical gloves (like the ones electricians use) and you can continue the compressions even while shock is going on ( ibid 90:163) Does this create a survival advantage? Who knows but the Danes like itimage012 TBTR: Electrical gloves for CPR and you’ll be shocked how you can continue CPR.
  • No one is interested in my underpants. .
  • I will return the seeing-eye dog.
  • I will not charge admission to the bathroom
  • This article was dedicated to updates in mechanical ventilation and sedation and general ICU stuff. Much of the articles quoted show all sorts of surrogate marker improvements but some things are practical. ECMO is the rage and seems to be here to stay. I have no experience with this to be truthful.  Periodic sedation for intubated patients seems to be a better way to go than continuous sedation-but let me remind you that Scott Weingart holds – keep them somewhat awake- a least communicative- and treat them with pain killers. Early mobilization and delirium control are imperative. (AJ REspm CM 191(12)1367)  TRBR: ICU updates.
  • OK, first clinical quiz- this fellow has chest pain and neuro findings after strenuous exercise- on chest film – pneumomediastinum. But what about the neuro findings? CT gave the answer image013 (Thorax 70(7)707)
  • The cafeteria deep fryer is not a toy.
  • I am not authorized to fire substitute teachers.

Organ transplants are best left to professionals

  • Haven’t I yet tired of killing sacred cows? I guess now. The Allen’s test- you know that test to see patency of the collaterals in the hand- is important before you decide to invade the radial artery. But the sensitivity -–which is what really interests us- is low. (J Inves Card 27(5) E70)
  • I did not see Elvis.
  • I will not call my teacher “Hot Cakes”.
  • Garlic gum is not funny
  • Let’s play some American football with this study- many infractions here. They want to show us that procalcitonin is a good test for bacteremia- since most studies only looked at sepsis and not infectionsimage014 Illegal assumption. If it doesn’t work to detect sepsis why would it detect infection? They looked at SRUC but that is a set of points and is unable to give a yes or no answer (illegal procedureimage015 ). Then they pooled sensitivities from a number of studies (but this needs a regression analysis to see how well the points agree – were they scattered?) and how they extracted the data is not clear. image016They did a subgroup analysis – which may be the only way to create a meta-analysis but since they do not share the same primary outcome it is statistically a foulimage017. But in the end it was pretty poor with a sensitivity of only 76%- meaning – that 25% of the time it called it no infection when it really was. (Clin Micro Infect 21(5)474) TBTR: Procalcitonin is not ready for prime time.
  • I will not encourage others to fly. .
  • Tar is not a plaything.
  • I will not Xerox my butt
  • We have mentioned this before. Honey is a good dressing – but not all honey. Honey is acidic which inactivates proteases and the high osmolality causes the wound to stay moist. Most honey has antibiotic properties based on the hydrogen peroxide content which is easily inactivated but Manuka honey has antibiotics properties based on a different substances which is not inactivated. It may also promote autolytic debridement and stimulate immune response (Wounds 27(6)141) It also makes exudates a lot tastier. But all seriousness aside- it is now available in medical grade in my country and is worth a try. TBTR: Honey – sweet in wounds.
  • I am not a 32 year old woman.
  • I will not drive the principal’s car.
  • I will not belch the National Anthem
  • Tranexamic acid in trauma-if you go like CRASH2. The dose is 1 gram loading dose over ten minutes and then1 gram over one hour. J Thromb Hemo 13:s195
  • I will not grease the monkey bars. .
  • I will not sleep through my education.
  • I am not a dentist
  • This is really esoteric- or maybe not. Lionfish, scorpion fish and stonefish are able to give quite painful stings. Now while this may not interest you because they are usually found in the Indian and Pacific ocean- in tropical areas – but lionfish have now been introduced to the eastern Atlantic and Gulf of Mexico so it isn’t just hurricanes you have to deal with on the coast. There is an antivenom but standard treatment – like hot compresses which work for most marine envenomations- are the best. (J Trav Med 22(4)251) TBTR: Lion fish are coming to a beach near you. Here are these critters if you would like to meet them. Scorpion fishimage019  Lionfish: image020 and Stonefish image022TBTR: The above fish are probably knocking at your door right now. And they are not selling magazine subscriptions.
  • Spitwads are not free speech.
  • Nobody likes sunburn slappers.
  • High explosives and school don’t mix.
  • We will be speaking a little about paracetomol today – here is an article describing a new trans buccal formulation. Now I cannot take much from this paper- it is a non-inferiority paper- which you would expect from the company wishing to show that the product works somewhat. However they compared it with the IV prep which is very expensive and I don’t think anyone uses it. Is it as effective as p.o? They say it is better but the research hasn’t convinced me yet. Just know it exists. (Pain Psych 18(3)249) TBTR: Trans buccal paracetamol- coming to you soon. Then the BMJ took on this medication and reminds us that it is not so benign- it too has COX-2 activity – but as of now has not shown an increase in heart attacks. What interested me was that this medication is not good for all pain. It does work for dental pain. For headaches- it is marginally better than placebo. Back pain – it is equal to placebo and the same for knee and hip pain. (BMJ 351: H3727). The next guy has a real bone to pick-image023with good ole Tylenol. He claims that that taking it in pregnancy can cause ADHD in offspring; it hinders psychosocial development and can inhibit male fertility in offspring. What I did find interesting is that paracetomol can close a patent PDA. (Eur J Pain 19(7)953) Truth be told, I wasn’t convinced by the study on ADHD, and indeed, millions of women have taken this drug with no ill side effects to offspring. This next article feels that the ADHD study was very flawed and the neurological development side effects have as yet only been seen in animal studies (Dev Med Child Neuro 57(8)718) My take is to be aware of these facts but I wouldn’t change anything yet. But it should spur us to think about doing better studies even on ancient meds. This month also gave us a review of the use of the IV prep of this medication – it is an “all you wanted to know but were afraid ask” type article but I did notice that the efficacy of this drug was always compared to placebo- what about compared to other pain meds? Also look at the prices in the USA. Wholesale prices of the med po 2.5 cents for a 500 mg pill, $1.57 for the suspension to 35.40 for the IV- seems a little extreme, no? (PEC  31(6)444) TBTR: All you needed to know about paracetomol.
  • Hamsters cannot fly. . .
  • I will finish what I sta
  • “Bart Bucks” are not legal tender.
  • Underwear should be worn on the inside.
  • Dementia is no fun (although it can be) and you may have to determine if your patient (or girlfriend) is demented, or in coma for a different reason (non convulsive status, severe hypothyroidism, drugs). Many of us use the mini mental status examimage025(but that didn’t do that well in this study – four other scales were much better. They recommend the Montreal
    Cognitive Assessment Exam – however this also requires some modification to make it more sensitive. (Clin Rehab 29(7)694). The real MOCA is a 30 point exam that takes 30 minutes – way more than we have time for in the ED. There is a mini MOCA but it is even worse. And furthermore, the folks in Montreal want us to even undergo training before using their exam. My point here is that the MMSE doesn’t work so well. I personally just do clock drawing and a short memory exam – and leave MOCA (mochaimage026) for drinking. TBTR: MMSE – not enough for dementia image028 Yes for you youngins- that is Demento. Dr Demento was famous for his songs that no one else would play like “it’s a gas” by Alfred E Neuman (it was farting to music) and My Baby Fell out of the Window by Spike Jones (“he fell in a barrel of sh….aving cream”) he also may famous the Utah Phillips classic “Moose Turd Pie” which I do not remember.
  • I will not send lard through the mail.
  • I will not use abbrev.
  • Indian burns are not our cultural heritage.
  • I will not dissect things unless instructed.
  • Here’s one for you kiddie docs (Kevin and Elisheva and Menucha – I want you guys to ace this). Infants can have episodes of torticollis, ataxia, autonomic syndrome, apathy and drowsiness. What is this? ( J Paed Child Health 51(7)674)?
  • No one wants to hear my armpits.
  • I will not mock Mrs. Dumbface.
  • I will stop talking about the twelve inch pianist.
  • Next time it could be me on the scaffolding.
  • Here is another hooray for the home team. (But it is more Peds so skip it if it bores you – I promise I won’t say any good jokes in this paragraph). This was done at Dana kid’s hospital in Tel Aviv, but there is really nothing new here. They say that extreme leukocytosis- defined at 25,000 with a fever should make you do a chest film and urine in kids in the post pneumoccal era. (PEC 31(6)391). Truth be told, they only found pneumonias and UTIs in35% of these patients. Would you have gotten there without the CBC? I think so TBTR: Pneumonia and UTIS in kids in the post PNuemococcal era- do a CBC?
  • Wedgies are unhealthy for children and other living things.
  • I do not have power of attorney over first graders..
  • I am not certified to remove asbestos
  • Tramadol – a terrible medication p.o. but seems OK IV – can cause seizures and respiratory depression in OD. However, while this med can cause serotonin syndrome when used with SSRIs- they didn’t see one case of serotonin syndrome in this case series of tramadol OD. (CLin Tox 53(6)545) This basically means in mild overdoses – you can just watch them, in combination ODs – be more careful. TBTR: See the last line
  • The boys room is not a water park.
  • Beans are neither fruit nor musical.
  • Nerve gas is not a toy.
  • Cooling of burns- it is correct that skin temperature returns to normal within a few seconds of cooling. However, there are benefits beyond that- including reduced progression of burns and shorter healing time. (Burns 41(5)882).The problem is many if not all of these studies were done in animals. They agree they do not have any idea how this works. TBTR: Continued cooling of burns?? Let’s continue with other Simpsons’ quotes.

Lisa: Dad, just for once don’t you want to try something new?

Homer: Oh Lisa, trying is just the first step toward failure.

Marge: Sitting that close to the TV is bad for your health.

Homer: Talking to me while I’m watching TV is bad for your health

  • Interesting concept-aerosolized antibiotics for pneumonias. This would be useful especially for ventilator associated pneumonias. So far this has only worked for CF patients but the potential does exist. Unfortunately, the literature doesn’t exist. (Resp Med 60(6)762) Surfactant, anti inflammatory and analgesics may also be tried this route (ibid p 774) I cannot tell you much more because – in a rare case- I cannot get this article. May be one of you guys can send me it?? TBTR: Inhaled route- doesn’t work yet, but maybe.

Homer: Kids, just because I don’t care doesn’t mean I’m not listening

Chief Wiggum: [shopping for his wife at a women’s clothing store] My wife’s looking for something that doesn’t make her look like a horse, so, I’m gonna be here for a while

  • MERS (Middle Eastern Respiratory Virus)- I do not know if you are ever going to see this, and I hope not, but another corona virus is scourging around and indeed it is similar to the SARS virus. It got to humans from camels and is basically seen in anyone who lives in the Arabian Peninsula or traveled there recently. Nowadays it is mainly spread in hospitals – community transmission is rare. The big problem is a fatality rate of nearly 40% (although death is more likely in older (they define that as older than 50 – hey wait a minute! image029or those with chronic illness. 66% develop pneumonia. Treatment is supportive (CMAJ 187(9)679) TBTR: MERS is here. We will speak about Zika virus in the near future.

Mr. Burns: [Giving a talk to inspire the school] Okay, I’m going to keep this short. Friends, family, religion. These are the demons you must slay if you wish to succeed in business. Any questions?


Homer: Oh no, Aliens! Well, I suppose you want to probe me, might as well get it over with.

Kang: Stop!

[Tentacles quiver]

Kang: We’ve reached the limits of what rectal probing can teach us…


  • Now the feds have made substance abuse even easier. Powdered alcohol has been approved by the USA FDA. This powder is easy to hide and can be smuggled by teenagers almost anywhere. True when reconstituted as should be, it will result in 10% alcohol content, but you can get that up to 50% with improper reconstitution. Many states are already going against the feds and are banning this (JAMA 314 (2)119). Father has word for beverages with 50% alcohol content- he calls that water. Liquid nicotine has been around for a long time for electronic cigarettes. (PEC 31(7)517)These work by battery powdered gizmos that vaporize liquid nicotine. All sorts of vicious fumes come out of these but here seems to be some evidence that they do indeed help in smoking cessation, although I personally do not buy it. The problem is that they are unregulated by the FDA, and minors are using them – even as early as sixth grade. 90% off them are bought on line and they can easily be sneaked into places where smoking is illegal. Yes they can be toxic, and yes they can result in death And yes they can be abused by “Dripping” by just inhaling the valor of drops put directly on the heating element usually in combo with other substances or adjusting the nicotine concentration. The treatment is supportive the exception of when it causes SLUDGE syndrome (salivation, lacrimation, urination, defecation, gastric emesis) where Atropine will help. TBTR: Liquid nicotine and powdered alcohol. The world is getting more complicatedimage030

Therapist: You hate your father, don’t you?

Homer: The guy I really hate right now is your father!

Therapist: I’m sorry, I was just venting…


Marge: [Bart is in an asylum after faking sociopathy to get back at his parents for testing him for it] How could he go so wrong!

Homer: We did everything we could for him during the commercials

  • Priapism- this case report in a psychiatric non cooperative patient with priapism – who need to be sedated for treatment and got ketamine and voila, the priapism disappeared with the injection of ketamine (no, it wasn’t injected there but rather in the arm. (ibid 508) More on priapism? See our essay this month!

Well, he’s kind of had it in for me ever since I accidentally ran over his dog. Actually, replace ‘accidentally’ with ‘repeatedly’ and replace ‘dog’ with ‘son.’ – Lionel Hutz

English, who needs that? I’m never going to England – Homer Simpson

  • Another clinical challenge: Fever, rash, disoriented, and tick bite seen in an ED in Tennessee. No not Lyme. Not babeosis Not RMSF. Yes- it is……( (ibid p533)

How come things that happen to stupid people keep happening to me? – Homer Simpson

  • If you listen to EM RAP (Dec 2015) or your name is Rob Orman (who used to read EMU) they brought an opinion of an addictions specialist that Gabpentin is equal to lorazepam for managing alcohol withdrawal. This article feels it is only effective in mild withdrawal (AnnPharmaco 49(8)897) Since it is non sedating, improves mood and is non-addictive – there may be some future of this med in alcohol withdrawal – perhaps at different dosages then in this article?. TBTR: Gabapentin for alcohol withdrawal? Maybe better just to eat the alcohol powder we just spoke about.

I’m normally not a praying man, but if you’re up there, please save me Superman. – Homer Simpson

If you don’t like your job you don’t strike, you just go in every day and do it really half assed, that’s the American way- Homer Simpson

  • Diagnosis by computer- 50000000 people worldwide do the computerized self-triage game- that is they plug their symptoms into a Google and viola- they get treated for whatever the kid in number 26 above had. Is this a bad thing? Maybe not. On a plane, in a strange country, out in a rural area, – working in the Artic- this could be a boon. Now I know what you are thinking. Many of these sites are not reliable, and in this study they found an accuracy of 58%- that seems optimistic to me. Many sites are risk aversive and one site concludes each search with –”consult a doctor”. Often patients will ignore good advice from the site and do what they want – whereas a face to face with a physician gives good rapport and a voice to disagree. Professionals may recognize subtle danger signs as well. But on the other side, people will be more honest to a computer than to a doctor concerning – for example alcohol use. Shut ins and mothers with small children could use this service. (BMJ 351:H3727)I think largely that telemedicine will supplant this and indeed many rural states in the USA have banded together to license such doctors in multiple states. TBTR: Patients using computers to self-diagnose- may not be so bad.

I’m trying to be a sensitive father, you unwanted moron! – Homer Simpson

What’s a wedding? Webster’s dictionary describes it as the act of removing weeds from one’s garden. – Homer Simpson


  • I don’t like statistics any more than you do – but I will let you in on what his article discussed in little bites that even I could understand. RR- that is relative risk is the number or bad outcomes in a group divided by the whole group. Example: The number of lung cancers (numerator) in smokers divided by the number of smokers (the denominator). A RR less than one implies that the first group – if there was an intervention will do worse and greater than one favors the other group. For example, intubation in pulmonary fibrosis did worse than no intubation in pulmonary fibrosis if the R is less than one.  RR does poorly when there is a need for controlling variables and also doesn’t work in case control studies where the amount of cases is by design. The odds ratio is simply the amount of people who get the vent divided by those who did not – that is the amount of people who get lung cancer divided by those who don’t.  Odds ratio doesn’t include those with the disease, while RR does; although they can be very similar when the disease is rare. They then speak about logistic regression for binary (yes/no) variables but I lost them when they started with logarithms. (J Paed Child Health 51:670) TBTR: RR, OR, and forget the rest.

This is indeed a disturbing universe – Maggie

Alright, Brain. I don’t like you and you don’t like me. But let’s just do this and I can get back to killing you with beer. – Homer Simpson

  • Do you feel lucky punk? Well do you?image031. Can you use optho drops after the expiration dates? I am not talking about grody open bottles with scale on them but bottles that were just lying around. Well, we always thought that the expiration date was just an approximation and that is true. But there could be sterility questions, evaporation issues (will affect concentration) stability issues, acid bases issues (i.e. buffering) and if the bottle was improperly stored- the drug may be not effective even within the expiration date. What I found uprising is that manufacturers do not want a short expiration time; because the pharmacies will return expired meds to the wholesalers who return it to the drug company who just eat the loss. (Ocul Surf 13(2)169) TBTR: eye drops at least should not be used after the expiration date.image032

In this house, we obey the laws of thermodynamics! – Homer Simpson 

Homer and Bart: You don’t win friends with salad

  • Bill Frishman was one of my instructors and is a pretty famous cardiologist until he turned coat and jumped to NY Med from Einstein. He is claiming something we already knew- toss out your stethoscope. US is the way the go now. He does say you will still need it for the lung exam (although US can detect effusions better) and for abdomens to hear bruits (just US the aorta) and bowel sounds (useless in my opinion.) (AJM 128 (7)668). TBTR: US learn how to use it and you will forget gallops and rubs forever.

Bart: Hi Homer, wanna eat my shorts?

Oh boy, buffalo testicles! – Homer Simpson

Some pneumothorax news. There probably is no such thing as a primary pneumothorax –as we improve our imaging we are seeing more identifiable causes – such as bleb. But still smoking, especially cannabis (gotta stop that, fellows image033cause bleb formation and significant lung destruction (especially cannabis). Of course male sex and tall folks are still a big risk factor as are Marfan’s syndrome and Birt-Hogg-Dube syndrome (yea,right). The rest of the article discusses stuff we have been pushing for years- aspiration instead of putting in a tube,  smaller bore tubes when you got to put one in, use of Heimlich valves so patients can go home, and even blood patches (Lancet  Resp 3(7)578) TBTR: Pneumothorax – new approaches.

“There’s an angry mob here to see you, sir.”

“So I said to myself: what would God do in this situation?”

  • Here is an article that was a pain in the assimage035 This article discussed oral ulcerations. Local trauma is going to be the most common cause – think from braces, fractured teeth, dentures,- these just need a little readjusting by the dentist. But do not forget meds- labetolol, alendronate, captopril, NSAIDS, methotrexate, protease inhibitors, and tacrolimus. This is independent of Stevens Johnson – which basically can cause sever ulcerations of all the mucosa from any medication. Aphtous ulcers – you should know about these. Lidocaine derivatives are the main stay, but topical steroids are often needed. Recalcitrant cases may need colchicine, or other immunosuppressants (thalidomide, azathioprine, etc). Malignant ulcers- most commonly SCC, but breast, lung and prostate also metastases to the oral cavity. Risks for SCC include smoking, betel use (quit using that stuff, will you!) and excessive alcohol use. Nothing about Birt Hogg Dube syndrome. Infectious causes, include herpes –which we are all familiar with-(not that herpes- please guys!) but cold sores and the like.  Coxsackie virus can cause herpangina and hand foot mouth disease.  Both of these are usually supportive treatment. HIV and TB can give ulcers too. All three stages of syphilis can give ulcerations.  Fungal infections are uncommon in immune competent patients. Heme disorders include leukemia, lymphoma and neutropenia. Iron deficiency and vitamin B12 or folate deficiencies are also causes.  Pemphigus is not a hard call. Celiac, and IBD round out the list but do not forget Behcet and what they do not mention – Kawasaki.  (BJHM 76(6)337). This was pretty confusing and not that helpful, and the pictures weren’t very helpful either but if you see oral ulcerations in the ED, rule out Behcet, Kawasaki, and Steven’s Johnson. If it doesn’t go away – think malignancy. TBTR: see last sentence.
  1. “Well, we hit a slight snag when the universe collapsed in on itself.”

“Yes! In your face, space coyote!” “…

  • There are many reasons to write about articles in EMU – but I liked the journal name (Maturitas 81:343) and the name of the first author – Dudley Robinson. The article discusses the management for UTIs in octogenarian women – that is a very big word but it just means women in their eighties. Which gives me a chance for one of other favorite games- here is another installment of what sirens look like todayimage036 know who this was? Here she is today: image037That was Charo – a Latin siren from the past. Well known for her signature line Cuchi Cuchi) If you are a woman (I’ll give you a minute to check) – then you have a risk of an UTI over your lifetime of 20%. Add to that that vaginal epithelium that is not under estrogen stimulation becomes colonized with gram negative bacilli and you got a perfect set up for an UTI. Truth be told there is no real good test to prove a UTI short of culture. But they did not consider symptoms (dysuria, frequency etc.) combined with other tests (leuk esterase, etch) which I believe should clinch the diagnosis.  Now I am not going to teach you much about UTIs that you didn’t know but here is some useful information with regards to those hard to manage recurrent infections. Check the urine out for fastidious organisms (mycoplasma hominis, ureaslyticum, and chlamydia). Do urinary tract imaging to rule out stones and check to see if there is a significant post void residual. Transvaginal ultrasound will rule out pelvic masses and prolapse. Uro dynamics are important (although I cannot usually find anyone to do them) and then consider cystoscopy. Management is antibiotic’s – they like nitrofuratoin as a first choice) potassium citrate and/ or post coital prophylaxis (coitus at age 80???) as preventative measures.  Vaginal estrogens should also help TBTR: UTIs at age 80 – some helpful pointers.

Man: Sir you can’t operate a boat under the influence of alcohol.

Homer: Oh, that sounds like a wager to me


Ron Howard: [pitching a movie] And it builds to a powerful emotional climax, where the father has to decide which of his children will live….and which one…will die.

Executive: Pass. What else have you got?

Ron Howard: Well, there’s one about a killer robot driving instructor, who travels back in time for some reason.

Executive: I’m listening.

Ron Howard: And this robot- He’s got a challenging decision to make about whether his best friend lives….or dies.

Executive: Ehh.

Ron Howard: His best friend’s a talking pie.

Executive: Sold! Howard, you’ve done it again!



  • I get as tired about writing about these as you get reading them, but the management of SVT (superficial venous thrombosis) has been changing. Most of these are the great saphenous vein (I don’t know why it is so great) and is often felt like a red and painful cord. But SVT is definitely a risk for DVT in the future, and often can easily extend to the deeper veins (BTW the superficial femoral vein is considered a deep vein). Often there is a DVT in a non-contiguous area from the SVT. This of course still leaves us with many unanswered questions such as anticoagulation for how long, with what (NSAID +enoxaparin? Fondaparinux?) How long? Does it make a difference which superficial vein? Are there some veins that do not need it? (J Thromb Haemo 139(supp1) S320)TBTR: More on SVT

Marge, don’t discourage the boy! Weaseling out of things is important to learn. It’s what separates us from the animals! Except the weasel

Dear Mr. President: there are too many states nowadays. Please eliminate three. Ps, I am not a crackpot


  • ARDS – this is not as nebulous as it used to be; all have some clinical risk factor. But there are ten diseases that can look like this. CHF is the obvious one. Diffuse alveolar hemorrhage is seen with cytotoxic drugs, bone marrow transplantation, and has cough and hemoptysis. Goodpasture’s looks the same. Acute hyper sensitivity pneumonitis can give a similar x ray, but they will report they have been exposed to an antigen if asked. Acute eosinophillic pneumonitis – has eosinophils on lavage – not a diagnosis you will make in the ED. And the rest? They are so subacute that they will not make it to the ED. If it truly is ARDS – do lung protective techniques on the ventilator settings and just know that optimal PEEP and the use of steroids is still controversial (Intensive Care Medicine 41:1099). TBTR: ARDS can confuse you. If you are an ICU guy, you may want to read this article on burn care in the ICU, but if you are not – just remember that shortness of breath can be from cyanide poisoning from burning plastics. (ibid 41:1107)

Lisa: Dad all the bees are dying.

Homer: Oohh no more bees! Now who’ll sting me and walk over my sandwiches?

Lisa: But without bees there would be no flowers.

Homer: (scoffs) Flowers: The painted whores of the plant world.


Moe: You gotta make me shorter doc.

Dr. Hibbert: (laughs) What do you mean?

Moe:I mean take out bones, guts, whatever you gotta do to make me a micro Moe.

Dr. Hibbert: What you’re asking is completely unethical. No licensed physician would preform that operation.

[Cuts to Dr. Nick.]

Dr. Nick: Now close your eyes and when you wake up you will be a woman.

Moe: No, no, no, no, no! I-I wanna be shorter, for a woman.

Dr. Nick: Uh oh. I mixed you up with the last guy



  • Letters : would you believe that Ken is now on his second trip as a medical officer in Antartica? Here is what he has to say inbetween surfing and drinking Mai Tais. His comments are on the Nov issue:

Hi Yosef

Okay, since I’m writing from McMurdo Station, Antarctica, I’m now the most remote EMU reader, I think. To answer your questions:

  1. I know some of the authors, but they’re all trauma surgeons—so that explains any inconsistancies.
  2. As for the pronunciation of Tucson, English is a strange language. (But aren’t all languages peculiar in their own way?) “Tucson” derives from an Indian word, “chuk son,” or “dark spring at the foot of the mountain” or “(at the) base of the black [volcanic hill.” This probably referred to what we now call the popular hiking area around Sabino Creek and the adjacent Catalina Mountains. The Spanish seem to have adopted this name as Tucson [tukˈson], Of course, American settlers couldn’t leave well enough alone, so they Anglicized it to be pronounced as “Toosan.”

BTW, the second edition of “Improvised Medicine: Providing Care in Extreme Environments” (McGraw-Hill) came out in early January!


Best wishes from the Ice, Ken

Do appreciate your comments always, Ken. Father Bulldog also wrote and here are his comments on the Dec issue :

Yosef,Yosef,Yosef. We need to clear up some points from the December EMU. It must be the US Mail’s fault that it only arrived on my e-mail today. First, Rick Bukata has always looked this way. You posted his 6th grade First Confirmation photo. But that was the After picture. If nothing else he is consistent. Second, he did not release me, I escaped!! Third, Rita and I are STILL an item but, of course, she is dead so I can now keep up with her sexually. Next, I loved you dog photo in this issue. Doggie shots should become a regular feature, since you have given up comedy,  so I have enclosed pictures of my second wife which you are at liberty to use. Your babblative attack on the low sales of sun screen products in Sault Ste. Marie, Michigan although correct was still hurtful. In fact the entire winter population of that town, all 7 of them, would take you outside and thrash you if they could go outside! Summer will be July 12th this year so I wouldn’t be in town that day if I were you.  And lastly, as this EMU issue illustrates, you have given up writing comedy, I would be slow to confront Billy Mallon to a comedy slap-down. If it does happen we would need to have categories like best expatriate American in a second banana role. All my best to my Middle Eastern friends and may God(pick one) bless  Father Greg   I gotta answer some of this. I have not kept up with all of Greg’s wives but I do know that Father has applied for residency in Utrah. As far as the Sault is concerned  I will let Ken answer that one. As far as humor is concerned – let’s look at your best lines, Father- those which I hear over and over again  “If you don’t want to read the nurses notes in the department, just be prepared to read them on the stand in court” Well I did read the the nurses notes- they said – four heads of broccoli, two bottles of milk. 3 boxes of eggs” They took me out of court in a strait jacket. “That kind of behavior went out with red meat” the Master quoter brings Tommy Smothers” red meat is not bad for you,  blue green meat is”. And lastly “being dead is not a good prognostic indicator” For Rita it was. Besides didn’t you always teach me that being drunk is? C’mon – bring on Billy and let me wipe the floorr with him!

  • Number 10 was pneumorrhachis- air in the epidural space. If there are no neuro findings- you leave these alone and the air resorbs alone. Number 18 is Benign Toriticollis of childhood. This is- as it says- benign – but there is some risk for migraines when they grow up. It subsides by itself – but most of the physicians they studies were unaware of this condition. Number 26 was erlichosis


The sources for these articles are Blood 125(23)3551 and AJEM 33:815

Going to sleep

  • Really nothing readers of EMU didn’t know already but we have a treat for you this month. This article is from Israel and we interviewed the authors on some questions that you may have had for your ED as well.
  • Background: Ketafol – the combo of propofol and ketamine was used in their peds ED. The theory is that propofol can reduce the vomiting that is sometimes seen with ketamine, and ketamine can reduce the pain which propfol can’t . Ketamine also reduces the pain of propofol infusion. They report 52 cases of serious adverse events but none of them were really serious and all resolved with at most oxygen.
  • Here are my questions to the authors:
  • 4) Itai Shavit who runs all the pediatric sedation courses in Israel was kind enough to have the lead author Eric Sheier respond (Itai is also an author on the paper):

Hi Itai
Your article will be featured in the Jan EMU. Congratulations- it was a good article.
Can I get your answers to these questions relating to the paper.?
1) You wrote that theoretically the propofol will take care  of vomiting  and the ketamine: the low BP. Both of these are rarely problems –  Many use pain relieving doses of ketamine- ie non-sedating and less propfol  for their ketofol- what do you think?
2) Were discharge times longer with ketofol than propfol alone?
3) ketamine is so safe -can it be used in the outpatient setting if one is trained in its use?
4) Why are so many ED s( at least in Israel) still resistant to pediatric sedation in the ED (My hospital does not allow the pediatric ED to use sedation(they can give oxycod_)).They send them to us.
Thanks itai

YB Leibman MD Specialist in EM


: Eric Scheier >>
תאריך: 19 בינואר 2016 בשעה 18:33:26 GMT+2
אל: Itay Shavit <
נושא: בעניין: Your article AJEM 33(6)815

נא לאשר:

Hi Yosef
Thank you for featuring our article. Our answers to your questions are as follows:
1) You’re right that hypotension and vomiting are both rare events. The hypotension from propofol is almost never clinically relevant in healthy kids and the vomiting from ketamine is almost always in higher doses, and is never more than a nuisance that prolongs ED stay. I think that the bottom line in all sedations is to titrate the drug to get the level and length of sedation you need. That’s why we preferred to dose ketamine and propofol separately and not as “ketofol”, the single syringe combination of ketamine and propofol. What I liked about the sequence was that the ketamine both induced sedation and provided analgesia, while propofol allowed us to work with better conditions. To me it’s important, when i have a scalpel in hand or when I’m suturing, that the child be as still as possible. Straight ketamine can cause children to tremor or otherwise move suddenly, and that can make the procedure more difficult for us to do. I’ve done many sedations with a fentanyl and propofol combination as well, and while fentanyl is another option for analgesia, many more of these kids will become hypoxic on that mixture. So more than treating hypotension, the ketamine seems to be a better analgesic than narcotics when it comes to treating respiratory depression. And the nausea and vomiting following straight ketamine can be bothersome to parents and patients, and can be almost entirely eliminated by propofol. As for the ketamine dose, I think that a nonsedating dose of ketamine followed by propofol and with local analgesia or a regional block is a fine idea, and would eliminate the horizontal nystagmus that can scare parents. And the minimum dose of propofol is always the dose you’ve titrated to achieve the targeted length and depth of sedation.
2) We only had 35 sedations that used propofol, so I’d be unable to come to any conclusions about length of stay.
3) This is a tough question to answer, because the line between inpatient and outpatient is blurrier than it used to be. A trained pediatric emergency physician does not need anesthesia or critical care back-up in order to perform deep sedations. Free-standing emergency rooms (i.e. not connected to a hospital) will sedate in the United States. In 2014, the good folks at Emory (my alma mater) wrote about 654 pediatric deep sedations that their sedation service (including emergency physicians) did and found a very low complication rate (Emrath ET, Stockwell JA, McCracken CE, Simon HK, Kamat PP. Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging  center. Pediatr Radiol. 2014 Aug;44(8):1020-5). So I think it’s less a question of where and more a question of how. The physician needs to be a trained emergency or critical care physician, the nursing staff need to be well trained and credentialed in deep sedation, and the equipment needs to be appropriate for the management of a rare complication. So I wouldn’t approve of its use by a general pediatrician in the outpatient clinic, but I do think that pediatric sedation can be done by trained staff in an outpatient procedure suite.
4) Resistance to sedation in the pediatric emergency department stems from a combination of ignorance and fear. Pure and simple. This is not a criticism of your hospital per se. Unfortunately, this is the case in many pediatric facilities. We should never restrain children, We should make every effort to minimize pain. We have the tools in the emergency room to do procedures quietly and comfortably, and we should be using them on a routine basis.

All the best,
Eric and Itai

Thanks guys


The second essay deals with the management of priapism.

  • For all those who were wondering, priapism comes from the Greek mythology Priapus – the one for fertility who had a big phallus.image038
  • How do erections occur? And what is the pathophysiology of priapism? This is very involved with nitric oxides and frankly pretty boring. So let’s cut to the chase recognize there are three types of priapism.
  • Ischemic priapism is the one that most interests this journal called Blood. And despite all the treatments for ED- it is still the most common cause in the USA. This is due to low flow or vaso occlusive reasons – mainly sickle cell disease (hereditary spherocytosis and G6PD can also cause this) It is like a compartment syndrome and IT HURTS! Within 24 hours there will be necrosis.
  • Recurrent Ischemic priapism (they call this RIP- love the nickname) often occurs during sleep and lasts for less than three hours before resolving on its own. Doesn’t sound too bad but in fact one third of the cases progress to ischemic priapism and even those who do not; between a third and a half will lead to ED and we do not mean emergency department.
  • Non ischemic priapism – this is the one I have seen. It can be from an injury which leads to fistulas although there may be a hematologic component to it. In these cases, the corpora are usually not hard, and it is not painful.
  • There are a lot of other causes; I will just mention the ones I would not have thought of. Obviously injectable ED agents but also alpha blockers (doesn’t’ seem fair that they can help shrink that prostate to allow someone to urinate than give him priapism to make it harder to urinate). Anticoagulants, antidepressants including SSRIs, and phenothiazines. Alcohol, cocaine and grass can cause it too. Malaria, rabies, scorpion and spider bites (they don’t mention if the sting has to be in “that” area).Neurogenic- I knew that- but think also of general anesthesia or even regional too.
  • Diagnosis may seem easy, but we want to differentiate between ischemic and non-ischemic- as we mentioned before ischemic is painful. Lab tests?? Are they serious? Yes, they are- blood gases will show acidosis if it is ischemic. US will show no or little blood flow in ischemic. Non ischemic will show normal to high blood flow.
  • You would think that ejaculation would help this, but no guys, it won’t. Exercise and warm or cold compresses do not work very well either. Actually using low dose Viagra may reduce episodes of at least RIP by modulating the NO balance. Hormonal therapies have lots of side effects, and testosterone is still being studied- no good studies for that yet.
  • RIP can be self treated by teaching men to self inject phenylnephrine. The prevalence of side effects is surprisingly low- even in heart patients.
  • The best treatment is to just aspirate and irrigate with saline. A penile block is helpful and a lateral approach is the way you aspirate. Surprisingly, most men I have done this to do not object to a large needle stabbing their “you know what”. You may have to aspirate a lot of blood to succeed.
  • Surgical management is not usually for acute cases and has a lot of problems involved with it.
  • Gosh, got through that without any puns or shady jokes. It was pretty hard.