EMU Monthly – August 2016

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

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

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

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

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





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

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

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

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

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

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

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


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

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

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

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


EMU Monthly – June 2016

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

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

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

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


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

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

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


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

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

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


Flight Attendant: Please fasten your seatbelt

Ali: Superman don’t need no seatbelt

Flight Attendant: Superman doesn’t need a plane either

Ali put on the seatbelt.

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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


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

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

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

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

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

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

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

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


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



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

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

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

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



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

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

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

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

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

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



Skiing combines outdoor fun with knocking down trees with your face

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


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



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



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


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

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


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

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



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

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


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

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

EMU LOOKS AT: Liverimage022

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

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