EMU Monthly – December 2013

Welcome to the EMU for December 2013

Bath Salts

 You’ve never heard of bath salts? I guess it could be that you live in a hole

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(yes, Father, I have repented – I will leave Flint alone- I just chose it because it makes beautiful downtown Ypsilanti look so pretty)

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I don’t know what this thing is Father, but I think you may need to call a urologist.

Bath Salts are now making the rounds in the druggie world. Here are a few things you may not have known about them. No, these are not real bath salts and will not do anything to make your skin softer; they are cathirone type substances that will give you are sympathomimetic syndrome (remember that one? That is the same as the anticholinergic toxidrome – hot as a hare, dry as a bone, red as a beet, mad as a hatter, blind as bat but here you are wet not dry). Drug screens will not detect this. Treatment is supportive.  It can cause dependence and withdrawal symptoms (CMAJ 184(15)1713). I am sure many forms of this drug will be seen on the streets and that is why it is important to stay abreast of designer drugs For example Krokdyll has hit the USA and will seen be seen in other countries (this is desomorphine)

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TAKE HOME MESSAGE: Bath salts are here- know about them.

Clostridium difficile Infection

Just a word on C difficile which is now in the community and it is angry. We have discussed this scourge before and the new treatments- most are still experimental or not that effective and we have discussed fecal transplants in the past – fidaxomycin is now the next antibiotic to treat this. It is not absorbed at all. Monoclonal antibodies are also useful ($$$$$$). Actually a vaccine is in phase 2 trials (Mayo Clinc Prc 87(11)1108). This is not just seen in patients with antibiotic exposure.

TAKE HOME MESSAGE:  A diarrhea with fever, an exceptionally high WBC and bad looking patient- do test for C Diff.

Augmentin and Hepatotoxicity

After bashing NSAIDs my next favorite sport is blasting Augmentin. This is the drug that will give you the diarrhea that you dreamed about. While it is rare, Augmentin can also cause hepatotoxicity.  They only saw 11 cases in three years but we do not know the denominator. They estimate there is one case for every 78,000 exposures in kids from 1- 11 y/o ( J Ped Gastro Nurti 55(6)2012). Of course, you can always say that a one year old is not equal to an eleven year old and maybe the kinetics are different in older kids

TAKE HOME MESSAGE: Augmentin can cause liver damage – but it is rare.

Our quotes this month are from critics. Let’s start with Simon Cowell.

“If you imagine Madonna, Bobby Brown, and Dracula had a child it would be you. But in a weird way I quite liked you.”

Inhaled Anesthesia in Pediatric Status Asthmaticus

Kids with bad asthma – we do not like intubating them but why not do it with isoflurane? It seems to work and if you do not have it in your ED- your friendly neighborhood anesthesiologists will be glad to give you some (Resp Care Nov 2012). I am not sure why this should relax more than propofol but no studies to say either way. Ketamine is the traditional agent of choice since it is a brochodilator but I find it hard to intubate with ketamine unless you paralyze too.

TAKE HOME MESSAGE: Inhaled anesthesia is an option for status asthmaticus.

“If they ever remake the film, you could replace the ice berg. Just sing the song and down it goes.” (To Changyi Li after she sang “My Heart Will Go On” from Titanic, Episode 5)

Clinical Quiz 1

Clinical quiz time: yea so there was this guy with a DVT and bilateral pulmonary embolisms- his condition deteriorated and he developed fever, hypotension and ARF. Echo showed no vegetations, there is no UTI and no pneumonia.  A WBC scan was done. Pretty obvious, no?? (Vas Med 17(6)429)

Burns in Patients on Home Oxygen Therapy

A thought provoking study. Lots of folks have home oxygen- and many continue to smoke (a great idea

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if you ask me ). They then get burned and this burn center decided not all needed intubation – they preferred a wait and see with bronchoscopy when possible. (J Burn Care Res 33(6)e280). It is hard to say- they do not report the usual criteria and I think ENT may be more available and better equipped to tell us about upper airway injury. Then again, you may become comfortable with this too. But an automatic intubation may be a problem as most of these folks are COPDers and will be on the machine a long time- as the study showed this.

TAKE HOME MESSAGE: Home oxygen and smoking does happen, but not all need to be intubated.

While we are speaking about burns, this is an article that recommends we reintroduce colloids for burns. This will not reduce  burn edema, but will reduce edema in non burnt tissues and reduce fluid needs for resuscitation – sounds great no? But they do note that it increases extra vascular lung fluid accumulation which means to me- ARDS. (ibid p702)

TAKE HOME MESSAGE: Albumin- still looking for a good use.

“Years ago I sat on two cats and that’s what it sounded like. It was painful.”

“My advice would be if you want to pursue a career in the music business, don’t.”

“That was terrible, I mean just awful”

Triptans and Migraine Headaches

I guess you already knew this, but let’s state it anyhow. Triptans do cause vasoconstriction so you may want to be careful in heart patients. They can also cause serotonin syndrome when given with SSRIs but it isn’t too common (CNS Drugs 26(11)949). I would point out that they do give triptans to kids. Also that these medications are not great once the migraine is well established – they should be used within the first few hours of a migraine.  Also they can help the pain of a SAH so be careful that you know what kind of headache you are dealing with.

TAKE HOME MESSAGE: Triptans can cause serotonin syndrome and do cause vasoconstriction. If this doesn’t give you a headache –

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Auricular Acupuncture

Auricular acupuncture helped relieve anxiety in patients undergoing dental procedures (Clin Oral Invest 16(6)1517) The p value was just barely significant and the sham group did not do too poorly-although both were much better than no treatment which means the placebo effect was pretty important here. Furthermore, this is all based on anxiety scores that needed to be corrected for baseline anxiety before they made comparisons – is this score useful at all?

TAKE HOME MESSAGE: Acupuncture in the ear probably doesn’t help much to relieve dental anxiety, but honestly – what would?

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“You sounded like Dolly Parton on helium.”

“I don’t know what cats being squashed sound like in Lithuania, but I now have a pretty good idea.”

Intravenous Contrast Studies in Breastfeeding Patients

Iodinated contrast and gadolinium are passed on to baby through Mom’s milk. But it is minimal amounts of the minimal amounts that are given and even Mom clears it quickly. Do not stop breastfeeding if you need to undergo a contrast study (CMAJ 184(14)e775)

TAKE HOME MESSAGE: Do not stop breastfeeding for contrast studies.

“You have the personality of a handle.”

“I’m tempted to ask if you sang that the night before your wife left you.”

Patients with Tracheostomy Tubes

It was at Meir Hospital – in came a blue patient

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and he had a trach – everyone froze when suction didn’t help – would you know what to do? Well, if you listened to EMRAP two months ago- then you know. I am not being a copy cat but this article just showed up this month and you will see more here anyhow (take that, Mel!). Firstly your mouth and nose humidify oxygen but a tube in the throat can not- so make sure you give these folks humidified oxygen. Bleeding soon after a new tracheostomy placement is usually from the procedure- never take out the tube- – a little adrenaline soaked gauze should help. Later bleeding – after the tract is mature is from granulation tissue, malignancy, tracheobronchitis – or a sentinel leak from a trachio-inominate fistula.  If the trach pulsates – you better be careful- call your ENT folks and have them look at this on the inside. I would probably do this even if it doesn’t pulsate. Subcutaneous emphysema can occur after tracheostomy from sutures that are to tight around the tube- – you just need to remove the skin sutures. Pneumothorax can also follow from new placement from air dissection.  Tube obstruction can be from secretions, or from impingement on the posterior wall or a tracheal flap. If the tract is mature- more than 7 days-take it out now- you can always replace it (this is what I did for my patient) or even stick in a regular ET tube. (BJHM 73(10)c152).

TAKE HOME MESSAGE: Know tracheostomies- even if you are a clinic doctor-give them humidified air, look out for bleeding and take them out if they are obstructed.

“Last year I described someone as being the worst singer in America. I think you’re possibly the worst singer in the world.”

“Do you have a singing teacher? Get a lawyer and sue her.”

Clinical Quiz 2

A scarier clinical quiz – 51 year old lady with flank pain.  187/71 BP and normal blood tests including creatinine. No pyuria or hematuria. No abdominal pulstatile masses. They did a CT with contrast. What are your thoughts??

Clinical Guidelines

OK Critical Care guys- this one is not for you. The article is written by a CCM physician- I’ll give you that. And I actually kinda of know him- he works in Hadassah hospital in Jerusalem- where David Linton heads the other ICU (Dave is an EMU subscriber- I’ll give a wave). He was supposed to speak about the use of low dose steroids in septic shock.  But indeed, he then makes a great point which is relevant to all of us. An outcome effect – even from the best trials – applies to the average patient- but patients are individuals and you must guide your therapy to each case separately. As such – guidelines which are influenced by opinions, politics, bias, industry, and just who is sitting on the panel- should not guide treatment (ICM 38:1911) So here we have to quote Father Greg (who, to his credit- has never done

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a Father Guido imitation ) who brought the case of Jilek vs Stockson where the lower court established that guidelines do not constitute standard of care, rather expert opinion should. This was overturned by appellate court, but the Michigan Supreme court than agreed with the lower court- guidelines are not standard of care. Yes Father, there is intelligent life in Michigan

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TAKE HOME MESSAGE: Guidelines are not standard of care.

You know it is interesting, because another journal made this point regarding blood transfusions- when do you have to transfuse? We said 10 and 30 in the old days, and then we said that aggressive transfusion can result in increased mortality- now there studies have come out showing decreased mortality with transfusions. (CCM 40(12)3308)  So there is no threshold- even for the heart patient with 9.8 and we need to individualize so –

TAKE HOME MESSAGE: The hell with guidelines.

“Not in a billion years. There’s only so many words I can drag out of my vocabulary to say how awful that was.”

Ketamine Cystitis

I do not know what you are snorting (although I do know what Father is drinking – listen to Risk Management Monthly and you will know too – (that s another free plug Rick and Greg), but if you are using ketamine know that ketamine cystitis is a “potentially explosive problem.” (They actually wrote this with a straight face.).  They mention in passing that ketamine is good for neuropathic pain an indeed I have used it with success in RSD (RPS) and fibromyalgia.  Anyhow, returning to our bladders these folks have dysuria, intense urgency, extreme frequency, and post urination pain. It is in heavy ketamine abusers but it can happen anywhere between after only a few days or after many years.  CT is the way to image it, but the usual stuff like oxybutynin doesn’t work. Hyaluronic acid worked in a case report, but really, you got to stop using the stuff and it will probably get better. (BJHM 73(10)576)

TAKE HOME MESSAGE: Ketamine can cause cystitis.

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Now for another critic- Roger Ebert.

“I had a colonoscopy once, and they let me watch it on TV. It was more entertaining than The Brown Bunny.” 

(Review of an early version of The Brown Bunny, when it was shown at the 2003 Cannes Film Festival (4 June 2003) ) . After director Vincent Gallo responded to the above criticism by mocking Ebert’s obesity, Ebert responded:

“It is true that I am fat, but one day I will be thin, and he will still be the director of The Brown Bunny.[1] (4 June 2003)

Medical Errors

Whenever I read these types of articles I think of Ken and I really shouldn’t -I really think these types of articles are to be of interest to all of us.  So you made a medical error. Congratulations – you really are human. You choices: you can get PTSD, you can grieve and recover, or just move on and you can grow. This article looks at the latter.

The five steps are – firstly acceptance – it isn’t someone else’s fault – you take responsibility. Then there is stepping in, go in there and make things better – be human being and talk to the patient and if they sue it you ( and the likelihood is less if you communicate with the patient), well, you know you at least did the right and moral thing. This may include an apology and may include reaching out to the family.  Then comes integration. Forgive yourself, deal with your imperfections and G-ds sake, find meaning in what you did and go to the next level –  new narrative: make ways to change yourself and be willing to listen.  Lastly comes wisdom- strength, humility, compassion, tolerating ambiguity, and seeing the deeper meaning – make yourself a better person. (Pat Ed Counsel 91:236). Yea, I know this is all heady stuff, but the key point always is to take a step back. You’re human and sometimes you just need to be reminded of it.

TAKE HOME MESSAGE: Learn – always – all the time – from all experiences. 

Another non medical article which has much less reverberations is a rant saying we should not be called providers and patients are not consumers. We are not a business.  And besides, customer in old English – see Othello – means prostitute. (Int J Card 165(3)395) .

The movie created a spot of controversy… Rob Schneider took offense when Patrick Goldstein of the Los Angeles Times listed 2004’s Best Picture nominees and wrote that they were:

“ignored, unloved, and turned down flat by most of the same studios that … bankroll hundreds of sequels, including a follow-up to Deuce Bigalow: Male Gigolo, a film that was sadly overlooked at Oscar time because apparently nobody had the foresight to invent a category for Best Running Gonad Joke Delivered by a Third-Rate Comic.”

Schneider retaliated by attacking Goldstein in full-page ads in Daily Variety and the Hollywood Reporter. In an open letter to Goldstein, Schneider wrote:

“Well, Mr. Goldstein, I decided to do some research to find out what awards you have won. I went online and found that you have won nothing. Absolutely nothing. No journalistic awards of any kind. … Maybe you didn’t win a Pulitzer Prize because they haven’t invented a category for Best Third-Rate, Unfunny Pompous Reporter Who’s Never Been Acknowledged by His Peers…”

“As chance would have it, I (Roger Ebert) have won the Pulitzer Prize, and so I am qualified. Speaking in my official capacity as a Pulitzer Prize winner, Mr. Schneider, your movie sucks.”

Steroid Injections

Steroid injections are pretty routine and they do work – but in this study of tennis elbow – it helped but one year later – it was worse. (JAMA 309(5)461) Look, the numbers were tiny and it is possible there is steroid rebound once it wears off or the patient may feel so much better they overdo. I have found it helped my biciptal tendonitis, but of course nothing helps these jokes of mine.

TAKE HOME MESSAGE: Steroid injections- do they make things worse in the long run? In the short term, they do well.

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Use of Procalcitonin Levels to Detect Sepsis in Cancer Patients

Procalcitonin – oh my – this can tell you when cancer patients have sepsis even when they are not neutropenic. (Cancer 118 (23)5823) I’ll admit it – I will use CRP occasionally to maybe help me, but not procalcitonin – the p values here are not great (I’m sorry but a p of 0.048 is barely statistically significant), and you have to understand that there are many reasons for fever in cancer patients – like tumor fever and mets, and here the procalcitonin values were less convincing.

TAKE HOME MESSAGE: Procalcition may help to detect sepsis in cancer patients – but then again….

“This movie doesn’t scrape the bottom of the barrel. This movie isn’t the bottom of the barrel. This movie isn’t below the bottom of the barrel. This movie doesn’t deserve to be mentioned in the same sentence with barrels… The day may come when “Freddy Got Fingered” is seen as a milestone of neo-surrealism. The day may never come when it is seen as funny”

Pharmacologic Sedation for the Agitated Patient

I do not know why – but the woman above reminded me of this woman:

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While she was connected with a politician, she was not preyed on by Bill Clinton (yes, even he has standards).  That is Martha Mitchell whose husband was indicted in the Watergate scandal and commented that going to jail was better than spending any more time with Martha. In any case, if you are still reading, Rob Orman, this one is for you (not Martha, the article). Rob did a worldwide survey of the knockdown of agitated patients for EMRAP (yes, I was part of it , and gave a plug for clotiapine). These two – yes you read correctly- these two studies looked at the combo of a benzo with olanzipine versus haloperidol with the benzo versus olanzipine alone. All were fine with regards to lowering blood pressure – they didn’t. However, in drunk patients – and only in drunk patients (or those who drank the wine of the month) – olanzipine plus benzo caused more oxygen desaturation. (JEM 43(5)790, ibid 889) Yea, well I am not sure why you would need olanzipine more than haloperidol – haloperidol is tried and true and dirt cheap even though the side effect profile may be somewhat worse.

My peer reviewer adds: See also – now published:  Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The Psychopharmacology of Agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West JEM. In press.  This study is important if you do not have an IV in agitated patient and use the olanzipine/benzo dart – you may find yourself having to do an intubation with out an IV.  Also – old reports say haloperidol makes seizures more frequent in ETOH patients — I am not sure if that is correct – I certainly haven’t seen it –

TAKE HOME MESSAGE: Haloperidol and benzos are fine for the agitated patient who drank – be careful with olanzipine and benzos.

“This is a plot, if ever there was one, to illustrate King Lear’s complaint, “As flies to wanton boys, are we to the gods; They kill us for their sport.”

I am aware this is the second time in two weeks I have been compelled to quote Lear, but there are times when Eminem simply will not do.

Palliative Care in the ED

This is for Adam and Knox for my friends down at MD Anderson –this article is a how-to on palliative care in the ED – most of this you should know – like making folks comfortable and POA, and truth be told I would have liked more pointers than the basics, but it is a start (ibid p803).

Little Indian, Big City is one of the worst movies ever made. I detested every moronic minute of it…if you, under any circumstances, see Little Indian,  Big City,  I will never let you read one of my reviews again.”

Weight Based Dosing of Antibiotics

The issue of adjusting dosages of antibiotics for obese people has been discussed before in these hallowed pages. Aminoglycosides – uses ideal body weight – do not go over 640mg. Vanco – total body weight – 15-20. Teicoplanin- not known. Penicillin: if the MIC is high – consider higher dosages of the PCNs or continuous infusion. Cephalosporins – they use 2 gm for obese patients of cefazolin and cefepime. Quinolones- they use 800 IV every twelve hours in the really really obese.  Most other drugs are unknown. (Curr  Opin Inf Dis 25(6)634)

TAKE HOME MESSAGE: If they really need antibiotics, give higher dosages in general to the obese.

I know you really want a picture of an obese person here, but I will not do it. Alright, maybe someone famous:

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Mama Cass Elliot from the Mamas and the Papas. Great voice – died while – eating. 

Mad Dog Time is the first movie I have seen that does not improve on the sight of a blank screen viewed for the same length of time. Oh, I’ve seen bad movies before. But they usually made me care about how bad they were. Watching Mad Dog Time is like waiting for the bus in a city where you’re not sure they have a bus line…Mad Dog Time should be cut into free ukulele picks for the poor.”

Use of Alpha-Blockers for Renal Colic

The urologists in my factory love alpha blockers for renal colic (they also like Ypsilanti), I have reported in the past that the evidence is poor- these folks (BMJ 345:e5499) claim the NNT is 4 – who is right? You expect me to know? I still think the evidence is thin. My peer reviewer says: I think the evidence is pretty good, but size matters.  Stones > 4mm good literature shows alpha blockers help, 4mm or less, they pass so often on their own that one can’t improve passage with meds. However, Dave Newman on EM RAP disagreed – but then again – while he is brilliant- he trashes everything. Is the evidence thin?  Twiggy was and she was the rage in the sixties. Her real name was Leslie Hornsby – she is still around, still thin, and still not the sharpest knife in the drawer.

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“If [Chicago] believes Mandingo should be shown to children, then there are no possible standards left and the only thing to do is transfer the censors to the parks department, where they can supervise paper plate ‑ throwing contests.”

Inpatient Care of ESRD Patients

OK ICU guys- this one is for you. You got an end stage renal disease patient that needs ICU care- not a patient you can just flood with fluids. This is actually quite common being that 0.2% of the population in the USA has ESRD. I am not going to go over the effects of renal disease- they have impaired immune response, electrolyte issues, and they have more c morbid issues than other patients- especially heart disease (didn’t I just say I wasn’t going over these?).  Just be careful with putting in PICC lines- a shame to ruin your landmarks when you can give dialysis via IJ access.  Try not to put A lines in the fistula arm. And please do not use the fistula/graft for blood draws or for continuous renal replacement therapy. Giving contrast and then doing dialysis does not prevent acute kidney injury – actually it may worsen it. All iodinated contrasts can cause significant fluid overload.  The real interesting thing is that these patients do better overall than those with ARF in the ICU and ICU patients overall Curr Opinion Crit Care 18:599

TAKE HOME MESSAGE: Kidney patients need specialized ICU care but do well. You can use contrast if they are already receiving dialysis.

“Parents: If you encounter teenagers who say they liked this movie, do not let them date your children.  There is a scene in this film where a character is defecated on by several people at the same time, and I dunno…I didn’t enjoy it.” (Review of Tim and Eric’s Billion Dollar Movie (29 February 2012)

Rheumatological Causes of Fever

Gosh, this could have been the star paper – to me was convoluted but in any case, the subject is important. You got a patient with a fever and musculoskeltal complaints- you gotta know the rheumatology causes of fever. Bacterial arthritis, joint infection from prosthesis, septic bursitis, and osteo – you better know about these and how to work them up.  A form of chronic osteo is called SAPHO syndrome and it has pustles on the hands, feet on the face and back, peripheral synovitis, and joint/bone swelling in the thorax. They discuss lepto, HIV, and rheumatic fever (which we discussed last month). Autoimmune diseases: lupus, myositis, and vascualitis, Still’s disease, Behcets, Familial Periodic Fever syndromes, Felty’s syndrome – these all can cause a relapsing fever – as can sarcoid, but I am not going to make these diagnosis in the ED. (Curr Rheum 31:1649). I think that if you have a fever that comes and goes in a patient who hasn’t traveled recently – just admit them and let the eggheads figure it out. But it does point out that you do not need to give antibiotics for prolonged fevers – you do need to think.

TAKE HOME MESSAGE: Prolonged fever – think rheumatology

Rod Slater: My God, you’re beautiful.
Terry Steyner (Sussanah York): Kiss me you fool.
Farrel (John Gielgud): Rod Slater, Do you know what your getting yourself into?
Rod Slater: No, No I don’t

(the movie “Gold” in 1974)

Clinical Quiz Answers

So the answer to clinical quiz 1 was indeed obvious – it was a septic thrombophlebitis and with withdrawal of the thrombus the patient improved.  Keep this in mind especially in females after giving birth with unexplained fever. Number 2 is a little stickier – this was a spontaneous renal artery dissection. We would have done a non contrast CT and could have missed this. This patient did well with conservative treatment – but not all do. The severity of pain with a normal study should raise your antenna

Letters

Hey it is time for letters. The postman was busy – and let me remind you that I enjoy your letters – don’t be bashful! Mike Herra asked my opinion about the NEJM article trashing cooling after cardiac arrest. Chris Nickson has dealt with this on his ICU network so I am not going to add much other than the study was well done and I have to say – EMU in the far past was not so impressed with the original study. But it did make good movie material for you Woody Allen fans, Sleeper was based on a patient waking up many years later

Sleeper (1973)

Thanks for writing Mike. Ken is off globetrotting again- he is now in Guyana- which for you folks who are South American Fans – is one of three former colonies on the north coast – Dutch Guinea, – now Surinam, British Guinea – now Guyana and French Guinea (which is still a colony), Guyana was in the news back in 1978 for the famous Jonestown massacre, but things have been quiet there, and they still speak English. And no, Ken, I didn’t look any of this up. Here is what Ken has to say:

Hi Yosef

            Happy Thanksgiving, although I’m not sure anyone but Americans know about it in Israel. (you are right- we do not  eat our turkeys- we let them govern)

            I’ve attached two recent articles about remote medicine I published in the Journal of Wilderness and Environmental Medicine, along with links to their abstracts (below):

http://www.wemjournal.org/article/S1080-6032(13)00149-X/abstract

http://www.wemjournal.org/article/S1080-6032(13)00163-4/abstract

I thought you’d find them interesting

Thanks for sending them Ken. I will be using at least one of them for an essay (with your permission),  if you do not have access to this journal – please be in touch and I will send you the pdf.  Hey thanks to Stan Mayer and Brian MacMurray for wishing me a happy Hanukah. Ken also commented on our ethical dilemma last month concerning power of attorney. I am indebted for this – Knox are you reading? Comment re: Baumrucker SJ, et al. Surrogates with conflicting interests: who makes the decision? Am J Hospice Palliative Med 2012;29(6):497-500.

:There were three actors in this scenario

  • Patient—unknown wishes/permanently comatose

  • POA (designated surrogate)—desires feeding tube and “aggressive treatment” [The patient’s son questions the POA’s financial motives in making that request.]

  • Physicians—believe that they should only institute comfort care, since this is a “futile” case

            The ethics committee’s role in such situations is to gather the facts, evaluate them, and make a recommendation to the parties involved. If, by gathering the parties together they can get them to agree on a course of action, they have resolved the dilemma. However, in the case presented, both vocal parties (the patient is permanently unconscious) seem to have laid out and informed the other of their diametrically opposing position.

            In these cases, hospitals can apply for a court-appointed surrogate to make the patient’s healthcare decisions. Since the son raised the question of the POA’s motives, a court would probably appoint a neutral third party, such as a public fiduciary.

            As for your suggesting that they ask for the clergy’s view in this case, clergy might help resolve the issues if they visit with the POA and the physicians. The clergy’s training (hopefully, as a chaplain) and the parties’ religious backgrounds, motivations, and flexibility play a large part in the success of such interventions. Clergy, of course, often play an important role on ethics committees.

            Hope that helps.

Ken

.Nothing to add Ken – this was an excellent analysis

Well, here is Dr Axel from France. Kinda of makes me wonder about those French – maybe he has been eating too much English food – that would make anyone ill.

Hi Yosef

So when I visit the Dead Sea some day I’ll try and remember 1- to not gulp a sip (or sip a gulp) of it, 2- pay you a visit (hey this is just an idiom) since you work close by.

But is the guy who wrote ” Avoid Abbreviations !”  also the one who earlier wrote ” yes you heard me right- avoid benzos – and anticholinergics, and give PT” and ” POA is the caregiver” ?

I was thinking of “person of … of what? Mental attempted Gallicism.  Indeed we have “personne de confiance” for such situations. I figured it out.

But PT?  (c’est une physiotherapie, mon ami)

Well I dont look given horses into ze mouth so …(when I was a horse dentist, I did)

THANKS !

Er… by the way , what do you smoke before you write EMUs ? (Fleet’s Lite)

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Thanks for writing, Axel.

Scott and Chris checked in and are working – voluntarily- on getting EMU up on the web and improving its format. I did learn computers as a college guy – but that was Fortran and APL and kinda of got lost on the technology of today- so it is with real appreciation that I thank both Scott and Chris – folks who I have never met – but nevertheless believed in EMU and me.

EMU LOOKS AT: AROMAS THAT WILL WARM YOUR HEART

This month we look at cardiac emergencies – specifically endo, myo, and pericarditis, and it is from Med Clin N AM 96:1149, and CO poisoning update from AJ Respir CCM 186(11)1095)

Cardiac Stuff:

1)   I liked the way the article started

“out of all the medical specialties, cardiology has the most emergent situations”

     What is EM- chopped liver?

Endocarditis

2)   Endocarditis – is really infection of the endocardial surface of the heart – we are used to that being the valves., but it can be VSDs and ASDs, and even the walls of the heart.

3)   Firstly, there has been a major shift in this disease – indolent, subacute disease is becoming rarer, and mostly there are acute presentations without the classic signs they taught you. Mortality, however, has not changed- it is still as high as 40% within one year.

4)   OK, so here is the scoop for the 2000s- it often follows an acute illness (usually within a month) and Staph is now the star (especially in those with hemodialysis access, DM, and those with cardiac implantable devices). However, some studies still show Strep leading the way. Mitral and aortic valves are still the most commonly affected.  Risks remain IV drug abusers, valve disease, and indwelling venous catheters.  The most common complications are heart failure, embolization, stroke, and – 14% of the time – intracardiac abscess which I have never seen but I imagine it is not a good thing.

5)   Just a word on our buddies who are drug abusers – they still get this on the tricuspid valve, they still get fungi (especially common with brown heroin dissolved in lemon juice) and mouth flora from cleaning needles with saliva.   Non druggies can get this too from cardiac surgery or prosthetic valves. Or eating English food.

6)   Vegatations- they tend to be more friable and suppurative in acute disease, and as such can cause corrosion of heart structures and abscesses, They also can travel to other places in the body

7)   OK enough of the small talk – let’s get to what you will see in the typical endocarditis patient – malaise, weakness, low grade fever, and joint pains. That was helpful, no?  Of course if the patient has chest pain or CHF – it is easier to make this diagnosis.  AMI and fever also make this climb the charts.  Splenic infarct also means you better think of this. But on the other side – fever may be absent in the elderly or in immunosupressed patients, so look for chills and joint pains- these happen frequently  and of course – check for a new murmur. You can use the duke criteria, but you need to think of this disease to use the duke criteria.

8)   Basically you need to take blood culture – alot of them – they like three sets with 10 cc of blood in each bottle. Of course, an echo will help.

9)   Treatment is coverage for gram positives- although they like daptomycin for MRSA more than they like vanco. They give recommendations for pseudomonas and Candida but prayer may work better. Surgery does actually give good results if used for the right indications- bad heart failure due to a destroyed valve, valvular abscess, persistent bacteremia, large vegitation (bigger than 10 mm) and bad organisms.

10)   Of note is they do not mention SBE.

Pericarditis

11)    Pericarditis is a little more optimistic. Viruses are the most common causes – 90% of the cases. Note they are talk about infectious causes – not uremic, cancer or Dressler’s Syndrome. While bacteria can cause pericarditis and can commonly cause effusions, S pneumo is much less common than in the past – even while still being the most common bacterial cause.  Just remember than TB pericarditis does occur in the immunocompromised.

12)    Pleuritic chest pain is the key here – sitting makes this better.  Fever helps.  I am not a big user of pulsus pardoxicus.  Nor do I think rubs are that common.

13)     EKG is helpful –with the classic signs that you should all be familiar with- the concave ST elevation seen best in II III and V5-6.  Echo can clinch the diagnosis and an elevated ESR or CRP can help also.

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14)      Viral pericarditis does well with NSAIDS or colchicine- they do not mention aspirin, and I am not sure why. Recurrence occurs in a quarter of the cases, but usually within two weeks and is usually less severe.

Myocarditis

15)       Having fun yet?  Let’s go on to myocarditis. Myocarditis mimics a heart attack. The real diagnosis is done by biopsy and stain, but no one really does this any more.  Either they try MRI or if it is a young patient who they suspect it and they take them to cath and find nothing – they usually give this diagnosis.

16)       Well, almost anything can cause this: drugs, toxins, sarcoid- but viruses are the most common cause and you should ask about a recent cold- within the last four weeks. –These also do the best. Interestingly enough this can occur after immunization.

17)        All the usual – malaise, fever; but the chest pain should be there.  These can be sour immediately with arrhythmia, CHF, and even sudden death. 14% of pericarditis involves the myocardium as well.

18)        These don’t work: steroids and immungolbulins.  Antivirals and interferon do not seem to work.  Cyclosporin didn’t do much. Ganciclovir may help in CMV.

CO POISONING

1)   This is an update and if you say – well, I’ll just skip this part – it is just oxygen and that is it – you are mostly right, but I will forge on because maybe someone is high enough that he may keep reading ( I like Fleet’s Lite – great tasting and less filling).  Just hope what he snorted wasn’t carbon monoxide.

2)   OK, this is due to inhalation of this colorless and odorless gas which shifts the oxyhemooglobin curve to the left. However, effects are not entirely due to carboxyhemoglobin, and indeed levels of carboxyhemobloin do not correlate with the clinical severity.  That is the main point with regards to levels of CO HB. As far as I am concerned, the mechanisms they bring are egghead-y and you are probably bored enough.

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3)   Symptoms will not help you too much – fatigue, confusion, shortness of breath. Cherry red skin is rare, and needs a lethal level of carboxy hgb.  Carboxy hemoglobin levels greater than 3-4% in non smokers, and 10% in smokers is considered suspect for CO poisoning. You can take it arterially or venously. If your blood gas machine is old and doesn’t have a CO oximeter – the saturation will be normal.  This is the case with most pulse oximeters. However, that is of little consequence since CO is reversibly attached to hgb and as such all these patients should get oxygen.

4)   Is 100% oxygen better than air?  Actually there are no such studies proving this. Whatever. Once the patients carboxyhemoglobin is normal or they are symptom free – you can let them go home.

5)   Hyperbaric oxygen does hasten resolution of symptoms but studies comparing it to normobaric oxygen have been poorly constructed. It may lessen long term effects. It is still recommended for those at risk. Who are at risk? Older than age 36 (isn’t everyone older than 36?), LOC, Carboxy hgb of 25% or more, or exposure for more than 24 hours. The problem is that this is really extreme, and lesser parameters has still given cognitive defects later on even if early effects are not seen. Pregnant women get hyperbaric oxygen – seems it doesn’t hurt the fetus – but again we do not know. Kids get it too.

6)   Proper dose of hyperbaric oxygen and how many treatments-  no one knows.

7)   Motor dysfunction and anxiety, depression, memory disturbance, and inability to calculate can occur even after correct treatment.

Hey that is all for this month – 2013 was a great year, and we hope you enjoyed EMU. Actually we hope that you even read EMU.  Or that your canary did.

Peer Reviewers

As is our custom – we use this issue to thank our dedicated peer reviewers. These guys have given their all for EMU. Thanks guys – I appreciate it more than you will ever know.

Mike Drescher

Attending Physician and Associate Professor
Department of Emergency Medicine
Hartford Hospital/University of Connecticut

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Tom Ashar MD FACEP

ED Director
Community ED Group in Alabama
Pegasus Emergency Group

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Moshe Weizberg MD FACEP

Residency Director

Staten Island University Hospital

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Chris Nickson

Emegency Phsycians and CCU specialist

Alice Springs Australia

I do not have a picture of Chris but this is what you find on google if you put in Chris Nickson and Life in the Fast Lane.

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Gil Shlamovitz, MD, FACEP

Assistant Medical Director of Clinical Information Systems

Harris Health System

Director of Medical Informatics, Section of Emergency Medicine

Assistant Professor, Department of Medicine

Baylor College of Medicine, Houston, TX

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Adam Miller MD MSMM MSCS FACEP 

Associate Professor, Department of Emergency Medicine, Division of Internal Medicine

The University of Texas MD Anderson Cancer Center, Houston, TX

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And to our reviewer in a pinch:

Yechiel Reit MD FACEP  (Can’t copy what comes up on google pictures for your name)

And new volunteers are always welcome! (Like the above, they must have been featured in the New England Journal of Great Looking Guys)

And our yearly review of policies:

EMU Policies:

  1. EMU is distributed free of charge.
  2. All parties with the exception of for profit organizations can reproduce it.  It can not be reprinted for profitable purposes.
  3. EMU is peer reviewed.
  4. EMU does not accept advertising.
  5. EMU does not usually quote articles from Annals of Emergency Medicine and the New England journal because most of EMU’s readership already receives these journals.  EMU also does not generally use articles reviewed in Emergency Medicine Abstracts as many EMU readers are subscribers as well, and I do not wish to take away from that excellent publication.
  6. I have no connections to any drug or medical appliance company, and thus the information in EMU is objective.
  7. EMU is dedicated to the development of Israeli and International emergency medicine.  Therefore, new subscribers worldwide are welcomed, and we appreciate your referrals.

That is it, friends- 15 years publishing monthly. I hope you have enjoyed it as much as I have.

–Yosef

EMU – November 2013

New Magnets

Magnets are stronger than ever as they now contain neodymium. And they are around- magnetic earrings are simulations for those who have not yet pierced their ears who do not want to. Swallowing magnets can be devastating- they can cause perforation and ulceration if another magnet or another metallic object is concurrently ingested. Abdominal x ray is still used for diagnosis. (Ped Gastro Nutr55(3)239). Don’t wait for the TSA guys to make this diagnosis!

TAKE HOME MESSAGE: Magnet ingestion can be dangerous.

Gabapentin and Post Dural Headaches

A definite maybe. This tiny study said that Gabapentin did help with post dural induced headaches. (Anest Inten Care 40(4)714) These headaches were tough ones as some failed blood patch. It worked in 50% of patients which actually is not that great. Being that Gabapentin is a known pain reliever; I do not know if using a cheaper one may work just as well.

TAKE HOME MESSAGE: Gabapentin is another option in pain relief

Balloon Occlusion of ETTs

ICU stuff- I really did not know this (c’mon Scott- tell me you did). They present a case where they could not ventilate a patient who they intubated. They did all the DOPE stuff (Dislodgement,* O*bstruction, Pneumothorax, Equipment failure) and nothing helped. They took them off the vent and bagged – but no luck. Even the suction catheter did not advance. Then they got a revelation. I was crushed. So was the ET tube. Seems that if you blow up the balloon more than 10 cc you can occlude the tube. Now they went back to the lab and tried this in vitro and discovered this can only happen in tubes smaller than a 7 but in any case, be careful – too much air is bad – for ET tube balloons and politicians. (Resp Care 57(8)1342). I do not intubate many kids, but occasionally I do use a 6.5 on petit adults, so this is good info.

TAKE HOME MESSAGE: Do not overinflate those ET balloons.

Penicillin Allergy

A word – actually too many words- on penicillin allergies. PCN allergies are usually – not allergies but long ago reactions that that were never allergies or were out grown. Most patients who say they have an allergy who undergo skin testing do not have the allergy and if you do this test and it is negative, it is probably safe to give the stuff. Desensitization if it was ever done may not be permanent. Lastly – and you all know this already from past EMUs- you can give cephalosporins in PCN allergies- cross reactivity is low with the newer ones. (Clin Rev All Immun 43(1)84) TAKE HOME MESSAGE: PCN allergies are usually not -and you can do a simple skin test to determine this.

This month’s quotes are philosophical as seen by the eyes of a six year- we are speaking about Calvin and Hobbs

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Calvin-“Reality continues to ruin my life.” “I’m not dumb. I just have a command of thoroughly useless information.”

Wound Dressings

I can summarize this fast and you probably wish I would. Today’s wound care is: moist, and do not disturb. Gauze macerates wounds so do not use it- use a petroleum based dressing or one that has a plastic side that doesn’t stick. (J Wound Care 21(8)359)

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“Calvin : There’s no problem so awful, that you can’t add some guilt to it and make it even worse.”

Green Urine

Here is a clinical quiz. The case is a man with Sarcoid who presents with respiratory failure. He is tubed, put on a propofol drip and started on Rocephin and Azithromycin. He takes amlodipine and prednisone. He is bucking the vent so the propofol is increased and fentanyl is added.48 hours later- his urine is green. He did not receive arsenic nor has the urine bag been filled with spinach (yuk). So what happened? PS urine porphyrins were negative (Neth J Med 70(6)282). The two authors were from NY – one from SUNY Upstate and one form SUNY downstate (do they neutralize each other?) – Why they stretched to the Neth J of Med is unknown but this is not the first report of this case. What is going on?

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This statue is in Prague. Gives new meaning to a pissing contest, right Father Greg?

PCCs for Warfarin

People can have a stroke while taking Coumadin and giving TPA is complicated under such conditions. They gave this fellow with an elevated INR and a sign of a stroke PCC and within 15 minutes the INR was 1/2 of what it was and he got his TPA. (Cerebro Dis 33(6)597). This is pretty quick and I was unaware reversal could be so quick but nevertheless, it is only a case report, and I am surprised they could get the INR (and the type and cross) results back so fast as this is one of the lab tests from the ED that takes a while to do. TAKE HOME MESSAGE: PCC can reverse INR if you need to do so quickly.

“I’ve been thinking Hobbes”
“On a weekend?”
“Well, it wasn’t on purpose”

“I have all these great genes, but they’re recessive. That’s the problem here

Rheumatic Heart Disease

RHD-that is- Rheumatic Heart Disease- can occur in adults and be on the lookout, according to the Japanese. (Int Med 51(19)2805) Look I know you Americans are all laughing at me be being concerned about this and since sanitation is great in your country (I know, you already bought the sewage management plant for the city of Detroit- and the police station as well) but this disease exists in the developed world as well and I think it is only a matter of time until it hits your shores. So let me remind you of the Jones criteria. Here it is copied from Wikipedia: Modified Jones criteria were first published in 1944 by T. Duckett Jones, MD.[3] They have been periodically revised by the American Heart Association in collaboration with other groups.[4] According to revised Jones criteria, the diagnosis of rheumatic fever can be made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of streptococcal infection: elevated or rising antistreptolysin O titre or DNAase.[1] Exceptions are chorea and indolent carditis, each of which by itself can indicate rheumatic fever.[5][6][7]

Major criteria

  • Polyarthritis: A temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards.
  • Carditis: Inflammation of the heart muscle (myocarditis) which can manifest as congestive heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur.
  • Subcutaneous nodules: Painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees.
  • Erythema marginatum: A long-lasting reddish rash that begins on the trunk or arms as macules, which spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance. This rash typically spares the face and is made worse with heat.
  • Sydenham’s chorea (St. Vitus’ dance): A characteristic series of rapid movements without purpose of the face and arms. This can occur very late in the disease for at least three months from onset of infection.

Minor criteria

Other signs and symptoms

  • Abdominal pain
  • Nose bleeds
  • Preceding streptococcal infection: recent scarlet fever raised antistreptolysin O or other streptococcal antibody titre, or positive throat culture. Gotta love Dr. Jones first name. What did they call him for short?

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You are right- they called him Fred (you didn’t really think I would say Ducky would you?)

TAKE HOME MESSAGE: RHD is around and can affect adults.

Calvin: Moms and reason are like oil and water. Calvin: That’s one of the remarkable things about life. It’s never so bad that it can’t get worse.

Leukotriene Receptor Antagonists

Leukotriene receptor antagonists do not reduce asthma admissions and there is not enough evidence to provide any benefit in lung function This is an EBM review ( Paed Resp Rev 13(4)226) Nice combination of both a patient and disease oriented outcome. Are they steroid sparing? I really do not care as steroids are really not that dangerous that I would want to spend money on this med TAKE HOME MESSAGE: Leukotriene inhibitors really do not work well. And may be dangerous- this is a series of aggressiveness that started with the medication being used and ceased when it was stopped. All occurred between the ages 9-14/ Incidence cannot be known as the article did not provide the denominator, but suicide does occur at 1 in 24000 exposures (J Invest All Clin Immun 22(6)452)

Calvin: I don’t need parents. All I need is a recording that says, “Go play outside!”

Calvin: Every time I’ve built character, I’ve regretted it.

Electrical injury

Electrical injury (that is low voltage) can cause chronic weakness parathesia and memory problems. This is because the nerves are such good conductors. (J Neuro Neuro Psych 83(9) 933). This reminds me of WC Fields, “My Father had a chair in applied electricity at the State Penitentiary”

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Calvin: As far as I’m concerned, if something is so complicated that you can’t explain it in 10 seconds, then it’s probably not worth knowing anyway

MRI

I mention these two articles because of the USA’s great love affair with MRI (while at the same time complaining about health care costs). In these patients with chest pain, elevated troponin and normal coronaries on PTCA- they then underwent MRI as outpatients – much later- and 10% were found with evidence of myocarditis and 10% were found with an MI. (BJR 85(1016)E461). The key point here is that MI is still possible even with clean coronaries- probably from spasm- an issue we have discussed before. However, we also see the MRI was not that useful most of the time. Now also there are cases of nursemaid’s elbow that do not reduce and an MRI can tell you the reason- in this case report for example- full entrapment of the annular ligament. (J Ped Ortho 32(5)E20) Could CT or ultrasound have shown the same?

TAKE HOME MESSAGE: MRI can be used for nursemaids elbow and elevated troponin in the face of a PTCA that is negative , but the question is if it is cost effective.

Psych Emergencies in the ICU

Back to you ICU guys- what can I do – I am a frustrated ICU guy-they have soooo much fun. Well there are four psych emergencies in the ICU that you need to know how to handle. Delirium-lower the noise level, make sure sleep/awake cycles are preserved, avoid benzos – yes you heard me right- avoid benzos- and anticholinergics, and give PT. If there is agitation, use antipsychotics and dexmedetomidine- see last month’s EMU. NMS- here you want to stop the medications causing it. What to give is a question, dantrolene, dompamine agonsists. benzos or even ECT. Serotonin syndrome- again discontinue meds and consider benzos. And of course- be careful with overdosing psych meds in patients with hypotension or failing kidneys which are all so common in the ICU palace. (CCM 40(9)2662)

TAKE HOME MESSAGE: Psych emergencies in the ICU- delirium, serotonin and NMS syndromes and psych iatrogenic overdoses- here are the ways to deal with them.

 

**Calvin: Everybody I know needs a complete personality overhaul

Calvin: Give me the strength to change what I can, the inability to accept what I can’t, and the incapacity to tell the difference

CTs in First Time Seizures

We CT everyone with a first time seizure but if they return to them selves it really isn’t necessary in the ED. In this Fam Pract article- they here recommend it only in focal seizures or those with developmental delay. However they then say that those with no structural brain disease do not need anti seizure meds- well how do you know with out the CT? Naturally, if bleeding is suspected then CT should be performed. (AFP 86(4)334) I think the important point here is not doing the CT from the ED and truth be told, I never found any surprises on CT after a first time seizure in the ED.

TAKE HOME MESSAGE: CT after a first time seizure- in the ED is not necessary if it wasn’t focal and the patient is normal now. In the clinic- probably still need one.

Breast Masses

image_5Delicate subject- men refer to these  differently than women however, things do go wrong with the mammary glands and you should know about them.  Masses, pain and discharge are the problems. Masses- mammography is the standard but ultrasound is more sensitive in the under thirty group (since ultrasound has no radiation, I am not sure why they don’t just ultrasound everyone). Pain is usually not due to a malignancy and medications can be common causes which include hormones, OCs, psych meds and some CV meds. Discharge is more complicated. If it is one sided, associated with a mass or is spontaneous- that is suspicious. If it is bilateral, check out TSH and prolactin (ibid p343) Note that they do not discuss trauma where fat necrosis can occur. By the way, the birds above are a tufted titmouse, and a blue footed booby bird. There, we got that past the censors. The last bird is a Stunning Finch it has nothing to do with our discussion and even I do not know what it is doing here.

TAKE HOME MESSAGE: Breast disorders require workups if they are masses or discharges.

Calvin: Leave it to a girl to take all the fun out of sex discrimination.

Susie: I was going to ask you to play House, but I think you’d be a weird example for our children.

Rash?

Another case for you ( ibid p361) A rash- we all love these – that is very itchy and spreading. Steroids creams did not help. He has no allergies and no sensitivities. The rash has coalesced over the shins. The rash is scaly. Yes it could be tinea versicolor, but that has smaller and circular lesions. It could be pityriasis rosea but this is usually asymptomatic. Excreta and tinea corporis are also good thoughts, but look different- eczema has a cracked appearance and tinea tends to be more papular. It will help if I say this came after a strep throat. Oh, you want to see the rash??

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T-Wave Inversions may not be MI

image_9If you read EMU in the bathroom – and you should be- then you may fall asleep as this isn’t terribly useful. Let me make it quick so other people can use the lavatory- t wave inversions in the anterior and inferior leads can be a sign of PE. It occurs about 11% of the time which is more than S1QIIITIII but was less likely to be picked up. (JEM 43(2)226) They then do Kappa to see how people agreed on this finding, but this muddies the study by trying to do two things in one study. Also, Kappa is a hard thing to use- if the prevalence is low, the kappa- a measure of agreement- looks better. I however included this study also because I like Amal Mattu who is a brilliant man and a great lecturer although he refused my offer (through his resident) for a free EMU subscription. My offer is still open Amal- think of all the good jokes you are missing!

TAKE HOME MESSAGE: T wave inversions in the anterior and inferior leads can mean a PE.

 

Calvin: If you do the job badly enough, sometimes you don’t get asked to do it again.

Calvin: Girls are like slugs – they probably serve some purpose, but it’s hard to imagine what

Clinical Quiz

One last clinical quiz. So there was this young guy who had a fever and wasn’t breathing too well. His WBC was only 8.8 but his BP was 100/70 and his creatinine went up to 5.8. Platelets were only 24. If it helps, I first heard about this diagnosis when reading a National Geographic in a barber shop on Blakely Street in Dunmore right outside of Scranton PA. What was it?

Yea I know I didn’t give you much to go on. Well, the author’s name was Hong and he was from Korea. Why would that be important?

Oh the reference is important also- J Clin Vir 55(1)1. I have for sure made this too easy at this point

Shouldn’t Theophylline be dead by now?

Theophylline- didn’t we put this med to sleep already? Well if you are a believer in meta analysis- and you shouldn’t be- than this is the best thing since sliced bread to prevent contrast induced kidney injury (AJKD 60(3)360). Well, do not start giving this dreadful drug yet- this helped only with creatinine elevations which is not a patient oriented outcome- most patients with bumps in creatinine do well with tincture of time. Also it didn’t help with patients who started with a creatinine of 1.5 – which is the population that most worries us. No long term benefits either. So you can return this medication to the shelf- hopefully at some point we will find a use for it. Same goes for me as well

TAKE HOME MESSAGE: Theophylline was thought to help prevent contrast induced kidney failure, but it did not.

TASERs

I haven’t had any experience with this- neither on the treating, receiving or distributing end. This is a device that shoots two sharp electrodes and delivers a high voltage low current shock to a person which temporarily immobilizes them (from what I remember from electricity – current is this the more damaging than voltage). According to Ohm’s law (V=IR) the electricity will travel the path of least resistance and this is along tissue layers, so the risks to hearts is minimal. However muscles can be damaged and expect an increase in CPK- up to 1465. Nerves seem to be preserved. They recommend that only medical personnel remove the darts but that all depends on where they are. (J Forensic Science 57(6)1591)

TAKE HOME MESSAGE: TASERS seems to be safe- but you should take the darts out of the patient. Or yourself if you are a klutz. Or even if you are not

Calvin: I hate to think that all my current experiences will someday become stories with no point.

Calvin: Somewhere in Communist Russia I’ll bet there’s a little boy who has never known anything but censorship and oppression. But maybe he’s heard of America, and he dreams of living in this land of freedom and opportunity! Someday, I’d like to meet that little boy…and tell him the awful TRUTH ABOUT THIS PLACE!!

Calvin’s Dad: Calvin, be quiet and eat the stupid lima beans.

Calvin: Why waste time learning, when ignorance is instantaneous?

Futile and Palliative Care in the face of Opposition

Hi Ken and Knox- are you guys still reading at this point? – so you got this case of a 93 year old man with a massive cerebral bleed EEG was unremarkable, but this guy is a vegetable and is going to stay this way. POA is the caregiver who was appointed as such after the son- the previous POA- was ousted over his alledged trying to admit the father to a nursing home. The POA wants aggressive treatment and the son does not. The POA says the son is only concerned about the inheritance, the son claims that the POA will get paid for as long as the patient lives and so he is acting out of self interest. It is clear to the son the Father would never have wanted his life prolonged like this. They asked for the perspectives of many people. The lawyer says – the law is clear-the POA is considered the voice of the patient and the family is powerless. However the physicians caring for the patient do not have a legal obligation to provide futile care. The lawyer and the ethicists recommended sending this to the ethics committee of the hospital and trying to get them to resolve the bad blood between son and POA. After this they get the social workers, nursing and physician’s perspective that raise further issues. (AJ Hospice and Palliative Care 29(6)497) I just have two comments here- I think a clergy perspective is critical here, but the authors of the article apparently did not agree. Furthermore, the question is pretty clear according to the law. What if there is no POA designated and the family members do not agree?

TAKE HOME MESSAGE: You must follow PAO but you do not have to provide futile care.

Calvin: People think it must be fun to be a super genius, but they don’t realize how hard it is to put up with all the idiots in the world.

Hobbes: Isn’t your pants zipper supposed to be in the front?

Susie: I see you’re bringing a glove today. Did you sign up for recess baseball?

Calvin: Yeah, don’t remind me. You’re lucky that girls don’t have to put with this nonsense. If a girl doesn’t want to play sports, that’s fine! But if a guy doesn’t spend his afternoon chasing some stupid ball, he’s called a wimp! You girls have it easy!

Susie: On the other hand, boys aren’t expected to live their lives twenty pounds underweight.

Calvin: And if you don’t play sports, you don’t get to make beer commercials!

Blood Guidelines

The AABB provided new practice guidelines for blood transfusions which is based on a restrictive rather than a liberal transfusion policy. There is no hemoglobin level which is for sure an indication for transfusion (although I assume that a level of 0.01 gram/dl may trigger a transfusion) and this means that people with a 7 or 8 who are just fine thank you can stay that way. Even more so, they admit that there is little evidence for that well accepted nut that all heart patients need to be over 10mg/dl. (Ann Int Med 157(1)49). However, read the editorial. In many cases the dangers anemia may be worse than transfusions but sometimes the case may be vice versa. Especially since the safety of blood transfusions has improved significantly- both from leuko reduction and from better storage which calls in question the higher mortality seen in liberally transfused patients – and that study was done long ago, and was stopped because of the slow recruitment of patients. Fatigue and tachycardia may be drivers for giving blood but there are many drivers that physicians use. In short, the editorial is against a one size fits all. Individualization is important (ibid p71) I would like to point out- one transfusion reaction especially TRALI will make you think twice about randomly giving blood.

TAKE HOME MESSAGE: Give blood to those who need it.

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Yes guys, that is Bella Lugosi in his role as Dracula.

Calvin: In my opinion, we don’t devote nearly enough scientific research to finding a cure for jerks.

Calvin: Miss Wormwood, I protest this “C” grade! That’s saying I only did an “average” job! I got 75% of the answers correct, and in today’s society, doing something 75% right is outstanding! If government and industry were 75% competent, we’d be ecstatic! I won’t stand for this artificial standard of performance! I demand an “A” for this kind of work!

(next panel)I think it’s really gross how she drinks Maalox straight from the bottle.

Calvin: I understand my tests are popular reading in the teachers’ lounge

The Perils of Drinking from the Dead Sea

I guess this is only relevant if you are Israeli, Jordanian or from Utah, but dead sea water intoxication can happen and is dangerous- even a swig of 50 cc can elevate your magnesium and calcium significantly (PEC 28(8)815). My hospital is the nearest to the Dead sea and we see a lot of these; my director Dr. Carmi was kind enough to allow me to interview him on how he treats this. Calcium is generally easily treated with fluids and diuretics. Magnesium responds less well to diuretics. First aid includes fluids but then – if the level is eight or higher – or the patient is comatose you better consider dialysis. I think Father Greg can be the first to tell you – you got to be careful what you drink

TAKE HOME MESSAGE: hypermagnesemia can result swallowing small amounts of Dead Sea water.

Calvin: One of my baby teeth came out! I have to say, I’m not entirely comfortable holding a piece of my own head.

Calvin: Cigars are all the rage, Dad. You should smoke cigars!

Calvin’s Mom: Flatulence could be all the rage, but it would still be disgusting.

Calvin: I see.

Dad: Nicely put, dear

Upper Extremity DVT

Yes, so it was back in 1993- I was in Grand Rapids and a young man had arm pain after lifting weights. Yea, you know, arm pain, lifting weights- well, it’s a sprain and give it some ice and NSAIDS and life will be rosy. A week later I get called in by the boss- he got a dirty letter that we missed an upper extremity DVT. Well, Boss, I said, I accept what you say, but don’t you remember that you saw him too and missed it a few days later? Then there was a strange quiet- but it is a good point- this is a commonly missed diagnosis. And it is occurring more often. The reason is because of more use of indwelling central lines. However, the case I mentioned is called Paget Schroetter disease (Gosh, that Paget guy got around) and is found in young men who do vigorous exercise usually as a result of an undiagnosed underlying venous thoracic outlet syndrome. PE is less likely than lower extremity DVTs and a distal DVT in the arm causing a PE is very rare. The data is not clear as to the occurrence rates for post thrombotic syndrome. They continue anti coagulation for three months but the evidence ain’t great for how long you really need to anticoagulate. Obviously if this was due to a catheter you remove the catheter, and if it is Paget syndrome- they may need surgical correction for the outlet syndrome ( Circ 126:768)

TAKE HOME MESSAGE: Upper extremity DVT is safer but is often missed.

Calvin: Hey Susie, what’s the answer to Question 7?

Susie Derkins: Imadoofus.

Calvin: Thanks.

(Calvin realizes Susie has tricked him)

Calvin: The Tooth Fairy’s gonna make you rich tonight, Susie

“Mom will you drive me into town?” Reply “Why should I drive you, Calvin? It’s a perfect day outside! What do you think people have feet for?” “To work the gas pedal.”
– Calvin and Hobbes

Hand Dislocations

There are three in the hand you better know because you may miss them on plain films. This article s on perilunate dislocations. They are high energy outstretched hand things. The can tether the median nerve and cause aseptic necrosis from compromised blood supply so this is a dislocation that you want to deal with immediately. Often there will be associated fractures such as of the scaphoid or the radial styloid. (BMJ 345: e7026)

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The first picture is a perilunate dislocation. The second is a lunate dislocation. These dislocations are best seen on lateral films. The last dislocation is a scaphoid lunate dislocation which you see best on AP – there is a large hiatus between these two bones- it can be less pronounced than this picture

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TAKE HOME MESSAGE: Don’t miss dislocations in the hand.

After Calvin nails Susie with a snowball he walks up to her and says “I must say, the stinging snow makes your cheeks look positively radiant.” “I have a hammer. I can put things together! I can knock things apart! I can alter my environment at will and make an incredible din all the while! Ah, it’s great to be male!”
– Calvin and Hobbes

Avoid Abbreviations

One last fun article which laments the preponderance of frankly dumb abbreviations in medical articles. (Radiolgy 266(2)383). He brings a funny NEJM letter from 1989 320(17)1152 (would you believe those rats from NEJM want me to pay for the article? Must be friends of Bill Belicheck) But seriously speaking- many abbreviations have you leafing back through the paper to see what they are talking about or can be confused with other things- like MR can be Magnetic Resonance or Mitral Regurg or Mental Retardation ( I know that is not politically correct but it is still in use in many countries)

TAKE HOME MESSAGE: (THM) Avoid Abbreviations (AA)

Letters

Those who do not read the EMU for the centerfold often read the letters only. Even though EMU went out late last month, Axel was kind enough to forgive me for it, although Father Greg requested a number of Hail Mary. I thank you for your forgiveness and forgive the French for Les Charlots. Speaking of Father Greg, he did check in with us last month, which will get him less home attendant hours from his social worker. Yosef, Another brilliant work of medical insights and comments on the passing seen. You can pretend that Israel can avoid work redesign but it is coming. The best way to predict the future is to make it. We need to get on top of this situation and run it top to bottom before nit-wits shove it down our throats. By the way the death of the male Black Widow Spider which you so graphically described would not be so bad depending on which head the female bites off. Just ask Bill Clinton. By the way, my sandwich of the month is the Super Ruben at Zingerman’s Deli in Ann Arbor, MI. I t’s a meal to die for, or to die from, I’m not sure which. I know you East Coasters are now howling I would mention the Midwest and great deli in the same sentence but trust me it can hold its own in the deli wars. Father Henry Actually, Father, while the medical system in Israel is depressing, it is the way you guys are going. But I did like the line about making the future. I am no longer an East Coaster, but I drifted a little further East. Thanks for the cogent comments- I will definitely think of you next time I have a sandwich or get my head chewed off. Hey, what is a month without a letter from Ken?

Hi Yosef

Again, great November issue of EMU. Keep up the fine work!

Since you wrote that you were expecting me to write about scorpions, I won’t disappoint. In my experience, the diagnosis is usually made in children due to the acute onset of bizarre symptoms. They thrash around, have roving eye movements, unusual head and neck movement, mild cholinergic symptoms and, if they are verbal, pain at the sting site. Adults primarily have severe pain (sometimes requiring IV narcotics) that may last for months.

As for antivenom, Dr. Leslie Boyer (pediatrician/toxicologist) at our University of Arizona went through the multi-year process of getting the Mexican-produced antivenom approved in the United States. She won the Hero of Medicine award for that. But, we need to remember that the Mexicans developed the vaccine and have it in use.

Regarding the item on physical, especially the chest exam, I assume that was a joke. As emergency physicians we routinely get unconscious patients without a history and, at least where I often practice internationally, I can’t get a radiograph—quickly or at all. So, the physical is our “go-to” evidence to direct our treatment. In the developed world, I use it to confirm what I have diagnosed via history and observation or, if I have no idea what’s going on, to look for clues. So, at last for me, the physical exam remains a vital part of my armamentarium. I assume it does for you and most EMU readers, also.

By the way, my newest book, “The Global Healthcare Volunteer’s Handbook: What You Need to Know Before You Go” (www.galenpress.com) went to the formatter today. It then goes to the printer and should be out in January! Yeah!

Best wishes, Ken

That book sounds very interesting. I will give it a plug and vouch for all of Ken’s work, while not be able to accept a free copy, since I can not accept any gifts. However, if it was given to me…. By the way, that guy was serious about the chest exam-I stand in the middle- I am not going to diagnose any TR murmurs but it does help for wheezing and the like. Thanks for writing- interested in knowing where you can get a good sandwich in Michigan? Try Flint.

Number six was a patient with respiratory alkalosis which causes propofol to be metabolized to pretty green urine. Here is the DD for green urine form the article just in case you wondered why you have a subscription to EMU: Cimetidine, Promethazine, Indomethacin, Metoclopramide, Flutamide, Methylene blue, Asparagus, Clorets (chlorophyll), Wilisan pills (Chinese herbal medication), Hartnup disease, Indicanuria, Pseudomonas urinary tract infection, Bile via vesicoenteral fistula, Green beer (Father?), some green dyes. Number 14 was guttate psoriasis which will respond to higher potency steroids and UVB treatments. I would have thought this was a fixed drug reaction but there was no exposure to any meds. I included it because if you aren’t a genius- and I am not – at least you will think of this when standard anti allergy treatments do not work. Oh and of course- treat his strep throat please. Lastly number 18, 19 and 20 was of course a Hantavirus infection which comes from aerosolized dry feces of a mouse. It can turn bad, but treatment is supportive. Named Hanta because of its discovery in Korea. And it is a virus. I made that one too easy.

EMU LOOKS AT: Looking great and breathing easier

This month we look at two subjects that we know little about (at least I do) Periorbital cellulitis (Curr Opin Optho 23:405) & Lung transplant emergencies (Respiration 84:163)

Periorbital Cellulitis

  1. Let’s face it – it isn’t always obvious what that red droopy eyelid is. Let’s leave trauma out of this- that is the easy one
  2. Infectious is the one that is most bothersome and the one we most often see. Hordoleums and blepharitis can cause this as can the usual streps and staphs. However, do not miss these: EBV seems to have a predilection to cause edema around the eyelid; Hep B can do this too. Lyme and RMSF can cause this due to a vasculitis. Ova can cause hypersensitivity reactions, so consider trichinellosis (still common in some places in rural USA and in the rest of the world) Chagas, filarialand amoeba. Do not forget infected bites or non infected bites. And of course-Nec Fasc can strike here as well. Sinusitis, especially Pott’s Puffy tumor from the frontal sinus can cause periorbital edema, and orbital cellulitis can start out this way.
  3. Non infectious causes- allergy is going to be the leading cause. Facial creams, eye drops and makeup do the most damage, although systemic allergies can cause this as well.image_13
  4. Guess what- the thyroid can cause this also, but that doesn’t bother me- the thyroid seems to cause everything. This will cause orbital swelling as well. Do not forget dermatomyositis and lupus. We will mention tumors, but I do not think that will be that hard to diagnose.
  5. There is a weird bird called blepharochalsis which is a disease of young adults that comes and goes for an average of two days.
  6. The article doesn’t say this, but I use heat as helping me make the diagnosis. Allergy in only one eye is rarer, is usually less hot and less red. It may be itchy.
  7. Hey what about meds? Imatinib causes this often but we use that only for CML and most of us will not see that. Biphosphonates can cause this as well as scleritis and uvietis. Hyaluronidase is often a filler in cosmetics and often causes edema. NSAIDS and some antipyshotics do it as well.
  8. Post surgical causes can come from the ears as well- cochlear transplants can do this!
  9. If you are faced with a case that you are not sure of the cause, so there is an algorithm here with all sorts of blood tests, but this is boring enough.

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Lung Transplant Emergencies:

These Swiss docs are honest from the outset- they say this is what they do. You aren’t going to see much science here, but it at least makes some sense. Keep in mind this article is not for post op complications bur rather for the lung transplant patient that comes to your ED or clinic from the community. But one thing I liked about this article was the first author’s name had two U in it (Schuurmans). Kind of reminds me of this fellow- do you remember him?

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  1. Yes, that is U Thant, the former Secretary General of the UN. Not quite sure what people who didn’t know his name said to him (“hey, you””Yes?”)
  2. Well, you guessed it- the lifelong taking of sometimes three or more immunosuppressives causes most of their problems. – Infection, graft rejection, and bone marrow suppression. But do not stop reading yet.
  3. Rejection often occurs because inadequate immunosuppression. These symptoms can be very subtle such as malaise, dyspnea and low grade fever. Actually, the only sign may be reduction on spirometry –so ask – most of these patients know how to measure this themselves. However do not go reaching right then and there for the meds- be sure that you are not looking at a respiratory infection first. Problems is that clinical assessment is not enough and chest film may be confusing as bronchiectasis and pleural effusion may be present which can be seen in rejection or in……bronchiectasis and pleural effusion. CT helps a lot (without IV contrast- they get renal failure too easily), but sometimes bronchoscopy and biopsy may be necessary to rule in or out rejection. For me as an EP, I’ll do a CT and go from there if there is a bona fide infection. High acute fever and a lousy looking patient will help. Cyclopsorine gets the kidneys- so keep an eye on them with Cr and urea checks. Prednisone is often tapered, but just keep in mind that getting this right takes years sometimes and despite all efforts, bronchiolitis obliterans syndrome can occur- you won’t be treating this, but it is just an example about how important good immuno-suppression is here. I do not personally feel comfortable adjusting immuno-suppressives on my own.
  4. Clarithyomiycin may cause the level of cyclosporine to go up, so they prefer Azithro, Azole antifungals are another problem, so they use caspofungin. They never use fluconazole. Be careful to use pancreas enzyme replacement for Cystic Fibrosis patients after lung transplant. They have a list of common medications interactions that will cause rejection or toxicity or nephrotoxicity in the article. Be careful with metoclamide (Reglan, Pramin) as this is commonly used and can cause lower levels of cyclosporine.
  5. image_16Like strange names – here is a Secretary General of the UN from before U Thant. His name was Dag Hammarskjold- good luck trying to pronounce that one (“Hey you” would probably work here too)
  6. Cytopenia is fairly common given the tonnage of meds they take. Do watch the WBC. Antibiotics do this especially TMZ-SMX, and Flagyl. Some anti virals can do it too. You may have to mix and match the meds
  7. So you see this guy with a runny nose. They attack him with nasal viral and bacterial cultures and then start moxifloxicin. If it is the flu season they start Osetamivir. Patients that look worse and older folks get put in the hospital. They do not like macrolides for reasons we stated above and even if all the cultures are negative they still continue moxi for another week. Fungi and atypicals are searched for. The truth be told they actually aggressively work up all changes in the status of the patients. Who am I to argue? CMV is always tested for- its pneumonia can be treacherous in these patients and it is often reactivated after transplant
  8. GI problems occur alot. Recall that immunosupressives mask normal signs of intra abdominal disasters. Intestinal motility is lessened by the meds so give them laxatives. CF patients especially need this because they develop distal intestinal obstruction syndrome. Vomiting is another disaster- even a little aspiration can lead to infection or rejection and besides it makes it hard for you to know how much med they did manage to get into their blood stream They prefer feeding tubes and not NGT tubes (zonde). Diarrhea occurs but do not forget C Difficile as these folks are constantly getting that Moxi. Laxatives can cause this diarrhea, but as we noted last month- sometimes this is constipation with only liquid stool coming out. When in doubt- x ray. They do not give pro biotics- who knows when these friendly bugs can turn mean. UTIs abound because the signs are often absent.
  9. image_17Here is another great name  Craphonso Thorpe. I am not going to attempt to pronounce that one
  10. Osteoporosis and osteopenia is very common among these patients and most will be getting calcium, vitamin D and a biphosphonate. Still, fractures are quite common. Also do not forget that since many are taking a respiratory quinolone- Achilles tendon pain or transection may be present. Use lidocaine patches, do not use NSAIDS. They do use antibiotics as prophylaxis quite frequently (like for dental procedures) but agree the literature is sparse.
  11. HTN is common; they avoid calcium channel blockers because of the edema they can cause. Remember with the suppressant drugs they take, they can have a bad MI or CHF and show few signs. Ditto with pulmonary embolism, so if there is a DVT – check those lungers. Before surgery- speak to these guys- mortality is high

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Yes that is Ha Ha Clinton Dix- a name only rivaled by the New Jersey Town

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Have a great Thanksgiving and Hanukah!

–Yosef