EMU Monthly – October 2016

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

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

TBTR: Metoprolol – is it back for MI?

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

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

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

Deep down, I am pretty superficial –Ava Gardner

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

EMU LOOKS AT: DRUGS

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

TAKING CARE OF PAIN

J Palliative Care 19(2)231

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

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

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

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

SLOWING THAT HEART RATE

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AJM 129:468

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

SMOOTH OUT YOUR BLOOD

J Vasc Surg 63(6)1653

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

EMU Monthly – September 2016

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

when I was born, the doctor slapped my mother

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

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

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

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

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

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

EMU LOOKS AT: Getting Stoned

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

Getting Stoned

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

 

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

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