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 

And

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

Hypomagnesemia

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.

Link

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

Peeing

  • 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.

Bullets

  • 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.