EMU Monthly – January 2014

1)   Are we there yet? It is 2014. If you are sober now- and you shouldn’t be- let’s get straight to the medical information you will need once you finally wake up and get out of the street. PCA- patient controlled analgesia- which is just a pump that patients can activate but will not get them overdosed-was compared to bolus therapy. PCA won (JEM 43(6)951) It could be that bolus therapy needed a nurse who wasn’t available when needed but that is the usual case in most EDs- so yes, PCA works and is worthwhile – although I do not know of any ED that does this and I imagine few of you have ever seen the machine. This article was done in Malaysia- and was well done I may say- so let’s take the opportunity to say hello to our two Malaysian subscribers. TAKE HOME MESSAGE: PCA is the way to go for pain management in the ED. OK I’ll be serious- here is a real PCA

2)   It is accepted– and proven- that near syncope is just as dangerous as syncope. And there are the Boston Syncope rules which do reduce admission rates for syncope – do they reduce them for near syncope? They do not. Actually they result in more admissions. Here is the Boston rule1) Signs and symptoms of acute coronary syndrome; 2) Signs of conduction disease; 3) Worrisome cardiac history; 4) Valvular heart disease by history or physical examination; 5) Family history of sudden death; 6) Persistent abnormal vital signs in the ED; 7) Volume depletion; 8) Primary central nervous system event. Now if you exclude those with vasovagal causes, or dehydration and the ED workup is normal – then you will reduce the amount of admitted patients (JEM 43(6)958) I am concerned about these diagnoses which can be wrong- how do you quantitate vasovagal syncope – or dehydration for that matter? But the key is that – Treat near syncope just likeyou treat syncope. And secondly – if you do not find anything in the ED, you probably won’t find much in the hospital either. TAKE HOME MESSAGE: Near syncope is like syncope- be careful. Best to Shamai who was the lead author on this article and a long time EMU subscriber (although he forgot to mention that in the article). \

3)   Air embolism- we rarely see this- but we probably do not know how to treat it because really the evidence is weak. They always taught us heparin – but if the clot is in the head at least – they recommend HBO – which probably will help in the lung as well. They also recommend phenobarb and not valium for seizures. Hard to take any of this home but these are your choices. ( ibid p976) TAKE HOME MESSAGE Air embolism – probably HBO is the best treatment. Maybe this is the only case of air embolism I saw- in the Jack Nicholson Movie- One Flew over the Cuckoos’ Nest Yes that is Nurse Wratched who actually works in your ED. Hey it is time for quotes- this month we feature sassy women- that is Roseanne Barr and Joan Rivers. Here is Roseanne Barr #

Women complain about PMS, but I think of it as the only time of the month when I can be myself.

4)   Seems there are a bunch of paramedics in New England who don’t read EMU – and I am not sure why- and thus do not give pain treatment in the pre hospital arena. They identified the following problems. They did not like to give opiods to patients without obvious sources of pain (like a deformity), suspicion of malingering – even in rural EMS (hey guys, yes druggies can be in pain too), ambivalence on how much and to what target (take edge off, complete resolution), fearing of masking symptoms (never should be a consideration) and lastly fear of using therapeutic doses of opiods- like Morphine for example- they rarely used more than 5 mg. Clearly, these guys need a subscription to EMU and need to be Eagles and not Patriot fans (Prehosp Emerg Care 17(1)78) TAKE HOME MESASGE: EMS are reluctant to use effective pain control. You may marry the man of your dreams, ladies, but fourteen years later you’re married to a couch that burps.

5)    They are not dead until they are dead- did they teach you that? Well they are right. There is no clear test that can tell what patients will have no prognosis after CPR especially in the face of sedation, intubation, and cooling the patient (I know, I know, we aren’t doing the Birdseye stuff any more) What can help? Well first of all, no prediction until 72 hours of free of sedatives and cooling. Repeated EEGs, neuro exams, and somatosensory evoked potentials will help. Biomarkers such as NSE and S-100B may help. MRI may help. In short, it is a tough call and short of rigor mortis, you may find yourself doing a full resuscitation on everyone. (Acta Anest Scand 57(1)6) TAKE HOME MESSAGE: Hard if not impossible to predict poor outcomes after cardiac arrest in the ED. My husband said he needed more space. So I locked him outside

6)   This is dangerous, so I want you calm and sitting down. This may sound like a joke in the USA, but this is very serious in other countries- and yes USA- there are other countries other than the USA out there- and many have longer life expectancies than you. In many countries, ICU ambulances have physicians riding on the rig. Since EM is not recognized in many countries or is a new specialty with manpower limitations, these physicians riding on the ambulances have traditionally been anesthesiologists. So it made sense to those guys in the UK to make a subspecialty called EM for folks trained in anesthesia. (Anaesthesia 68(supp1)1) I have just picked up a few more UK readers and would like to hear from you about this – how does this affect those choosing EM as a career and not anesthesia? On the other hand- they do acknowledge that EMS management requires training and they have opened up this fellowship to EPs. And of course – anesthesiologists.(ibid 68(supp1)40). I hate the word housewife; I don’t like the word home-maker either. I want to be called Domestic Goddess.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

7) While we are doing the Hustle with the gas passers, let’s add another point that is in a different journal. If you don’t remember the Hustle- and that means that you were born after 1975– here is a little history on this phenomenon . It was written by Van McCoy. They point out that that ICU guys intubate just as well as anesthesia guys and the complications rates – albeit common- are about the same. Basically ICU guys know these types of patients and are at home in the ICU which makes it easier for them to find things (Chest 142(6)1375) I think the same could be said for the ED- TAKE HOME MESSAGE- Anesthesiologists should not tread in the ED- unless they are here for treatment. #

It’s okay to be fat. So you’re fat. Just be fat and shut up about it.       #

Take this marriage thing seriously – it has to last all the way to the divorce.

 

8) This articled should have caused a storm – did you see it? They said that rhythm control showed less strokes than rate control (Circ 126(23) 2680) However there are problems here. First of all this is from a registry- dead patients and patients with other codes may not have made it in. Furthermore, the INR of people taking warfarin are not reported, nor is the severity of stroke. Aspirin is not equal to clopidogrel or to warfarin, although to their credit- warfarin patients showed the same results as takers of the other medications. What about the pro arrhythmic affect of some anti arrhythmics? And the CHADS2 scores were lower in the rhythm control group meaning they were healthier or younger (or both). We have a lot left to see but this is provocative. TAKE HOME MESSAGE: Rhythm control may result in less strokes than rate control in PAF. #

Birth control that really works – every night before we go to bed we spend an hour with our kids

9)   I like this journal – all they do in this journal is swab things all the time and this time there target were the hospital curtains. A whopping 24% had MRSA and 42% had VRE- and this was on the edge of the curtain where you pull it to close it (Am J Inf Contr 40(1)904 ) However to be fair- the study was done in 2 ICU s and one medical ward – not the ED. On the other hand, this was Iowa City which is not a large metropolis (although bigger than Ypsilanti) and to know there is VRE out there even in smaller communities is bothersome. TAKE HOME MESSAGE: Curtains are yucky-avoid touching them and wash your hands #

A guy is a lump like a doughnut. So, first you gotta get rid of all the stuff his mom did to him. And then you gotta get rid of all that macho crap that they pick up from beer commercials. And then there’s my personal favorite, the male ego.

10)                 When all else fails for seizures- and in their study – all else failed- try Special K. They tried midazolam, they tried propofol, they tried thiopental, they tried anesthesia- nothing worked. In these 9 patients- Ketamine worked in 6, the others went to surgery to resect the focus (Neurology 79(24)2355) This is obviously not great evidence- – it failed in almost half the patients- but it is a very safe drug and could be worth a try. TAKE HOME MESSAGE: Ketamine can be in option in status epilepticus. I had one kid with the birth control pill, I had one with the diaphram and I had one with the I.U.D. I don’t even know what happened with my I.U.D. It never came out. But I have my suspicions because that kid picks up HBO

 

I had left home like all Jewish girls in order to eat pork and take birth control pills. When I first shared an intimate evening with my husband I was swept away by the passion (so dormant inside myself) of a long and tortured existence. The physical cravings I had tried so hard to deny finally and ultimately sated… but enough about the pork

11)                 We wrote an essay back in 2005 on this subject- you do remember don’t you?– but we will use it as a clinical case because it is not in the minds of most people. You know, fever, malaise, weakness, yada yada and in addition some neurology – either signs like meningitis, encephalitis, or flaccid paralysis- and the LP shows no bacteria. Did you ask about a mosquito bite? This patient has never been to a malaria country and lives in Queens New York- 704 Houser street in the Corona section. Any ideas? (Ann Intern Med 157 (11)823) There isn’t any “New Man”. The New Man is the old man, only he whines more.

12)                 We are stuck here on Neurology. There is a bacterial meningitis score and if it is negative they would consider discharging. The score includes 2 points for a positive gram stain, one point for CSF neutrophil count 100, peripheral ANC of 10000 or higher, protein of 80 and seizure activity.(JEM 43(6)1181) This is a tough one- I agree most viral causes will do fine at home (with the exception of herpes of courses); in my country they admit everyone with possible viral meningitis- and the neurologist sitting next to me almost bit me in the MCA for suggesting other wise. But this score is problematic- – gram stain should be worth 1 million points if it is positive. So should CSF neutrophil count. The key is the viral meningitis patient with absolutely nothing else going on may be able to be discharged TAKE HOME MESSAGE: you may be able to discharge patients with viral meningitis if they are absolutely normal. Chili represents your three stages of matter: solid, liquid, and eventually gas.

13)                 This makes sense – no? You got a patient needing antibiotics – so give it continuously and not in bolus form. They tried this in 60 patients in five ICUs in Australia and Hong Kong (odd that in five ICUs – could only find 60 patients). They found that with continuous- MIC was exceeded more often and clinical cure was superior (but in this one – the p value was a measly 0.037)(CID 56(2)236). However the ICU free days by day 28 and survival to hospital discharge were unaffected. While this is probably due to the fact that a lot of these folks probably died or underwent colonoscopy (very similar in the way they feel) but these two measures are the only patient oriented ones and these are the ones that matter to our patients. TAKE HOME MESSAGE: Continuous IV antibiotics may help seriously ill patients #

They’re all mine… Of course, I’d trade any one of them for a dishwasher

14)                 Last month I complained about the JEM article giving some guidelines on end of life care (I was going to mention colonoscopy again but my wife told me I had to be serious this time). (Hi Love- I couldn’t find the bathing suit picture). This article is an ethics article so you can disagree with them – but this is what they think-Firstly they feel that withholding treatment is no less morally repugnant than withdrawing treatment. I remember we used to not intubate patients because then it would be a big problem extubating them if the care was futile. Here they say that is an error. Secondly it is a myth to believe that providing analgesia to dying patients will hasten their death. Here they did bring studies that prove their point, and I think most of us would rather die without pain. And the last one- people may be different in culture, but when they are dying there should be not differences in the way they are treated no matter what culture or country they are in. Nevertheless- depending on the country attitudes can vary greatly. (J Med Ethics 39(6)389) I would love to hear from Knox and Ken on this subject but TAKE HOME MESSAGE: What would you want if you were at the end? That is probably what most folks want too.This month’s peer reviewer’s take home message: Look for advance directive / living will / family members to figure out (and honor where legal) WHAT DID THE PATIENT WANT / DID NOT WANT DONE AT THE END OF HIS/HER LIFE. If such information is not available, think of what would you have wanted…. (GZS         So I’m fat, I thought I’d point that out. Have you ever noticed that fat people don’t think like skinny people… We have our own way of thinking. And have you ever asked a fat person for directions? Cause that is when the difference in thinking really shows y’know. Cause you got up to them on the street and ask them where something is and they tell you this “Well… go down here to Arby’s… And go right past Wendy’s, Mcdonalds, Burger King and it’s that chocolate brown building down there. But it’s good that I’m fat, cause I’m a mom and fat mom’s are better than skinny moms. Cause what do you want when you’re depressed? Some skinny mom “Well why don’t you joke around a while and that’ll release adrenaline in your blood and you’ll better cope with stress”. Or some fat mom “Well lets have pudding, Oreos and marshmallows. When you wake up from that sugar coma, Itll be a brand new week

15)                 Peritonsillar abscess may be due to acute tonsillitis- but a large amount of them are due to infection in the in the Weber glands instead. (Oto Head Neck 145(6)940).This study was done in my shop Soroka. This study was retrospective and based on a lot of assumptions. So I went over to Dr. El Saied who was walking by and he referred me to his own paper on the subject which was at least prospective albeit with only 41 patients. (Oto Head Neck 147(3)472) which showed high amylase in the pus which would maybe point to a salivary source – like the Weber glands. The evidence is not great but I believe it. What this could mean for us as EPs is that peritonsillar abscess doesn’t automatically mean tonsillectomy and furthermore, after tonsillectomy- there may still be a chance of this happening TAKE HOME MESSAGE: Peritonsillar abscess may not be a result of tonsillitis.The fastest way to a man’s heart is through his chest.            Women are cursed, and men are the proof

16)                 It is kinda of naive to assume that ibuprofen cannot cause acute renal failure in kids- this study says it can. (J Ped 162(6)1153) The problem here was the denominator. They claim a 2.7% occurrence rate. But that is 2.7% of all acute kidney injury in kids- that is not the percent of kids who got ibuprofen. Furthermore there is no report of pre existing diseases- those with DM may have higher chances – although younger kids tend to be sicker if they got it. They do mention that 15 of their kids were normally dosed- but I cannot make conclusions about dosing overall. TAKE HOME MESSAGE: Ibuprofen for kids can cause acute kidney injury and it can be serious under age five – but it is probably rare. Honey, I found the other picture of you Mike Summers: Hi, I’m Mike Summers, your state representative. How’ya doin’?
Roseanne: Great.
Mike Summers: Good, I’m going door-to-door, trying to get to know my constituents.
Roseanne: Oh, door-to-door, huh. That takes a lot of time. Why don’tcha just go down to the unemployment office, and see everybody all at once

17)                 We have discussed this before and I think this should be another nail in finally butting this barbaric practice to rest. First time UTI in boys needs a well done ultrasound and you can omit the VCUG (voiding cysto urethra gram). You will not miss much. Actually everyone with an abnormal VCUG had an abnormal US as well or had an abnormal US and a normal VCUG with the exception of six who had a normal US and an abnormal VCUG- only one needed intervention and that was because of febrile UTI. (see J Ped Urology 8 (1) 72, Acta Paed 101(3)e105)) The problem is there were only 77 patients and it was retrospective – so who knows? TAKE HOME MESSAGE: you may be able to omit the VCUG if the US was well done in boys first UTI Here is my wife’s response to the above discussion about herI agree `Honey- here is just that look

18)                 Here is a message for Scott who is the president of the League Against Careless Testing and Thoughtless Exams (L.A.C.T.A.T.E) –Lactate is important and clearing it is important – this went about speaking about kinetics and was basically beyond me- but I took a critical point out of this- 50% of septic patients have normal lactates and these folks do worse. Alactemia is important – but it isn’t everything.(Chest 146(6)1521) I bet Scott has more to say on this article as he is probably the one who can most distill this down to language that I could understand- but in the mean time—high lactate- get it down with fluids; low lactate- they could still be very sick and that is the TAKE HOME MESSAGE . Now let’s go over to another sassy comedienne- Joan Rivers People say that money is not the key to happiness, but I always figured if you have enough money, you can have a key made.   #

Don’t cook. Don’t clean. No man will ever make love to a woman because she waxed the linoleum. “My God, the floor’s immaculate! Let’s go for it”

20) Steve Selbst’s Legal Briefs are a great read and there were two points I wanted to make from them this month. Firstly they taught you all that wheezes is not asthma and they bring a case of a mediastinal tumor that was missed. I am pretty liberal with x raying these cases but I am more afraid of missing a foreign body or a pneumothorax. The other case is a baby death due to an umbilical around the neck- the nurse missed the later decels on monitor. But the case was ultimately won by the physicians when it was established that there was a “conversation” on Facebook between the jurors and the defendants. (PEC 28(12)1402). This was discussed on Risk Management Monthly in the past – beware of all the new technology especially people copying charts or photographing you with smart phones TAKE HOMEMESSAGE- All that wheezes is not asthma and watch what you say on Facebook. I wish I had a twin, so I could know what I’d look like without plastic surgery.   #

I’ve had so much plastic surgery, when I die they will donate my body to Tupperware.

21)            Post herpetic neuralgia is not that hard to diagnose- yea you got to check the patient- but the treatment is a little more refined. Like most things prevention is the best- and a vaccine exists. First line meds are not opiods but rather TCAs, pregablin (Lyrica) and Gabapentin. They also mention the lidocaine 5% patch- we do not have this in Israel so I have no experience with it. However this works the fastest with the least amount of side effects. Capsacin cream and opiods are second line therapies, and indeed the former takes time to work and burns at the beginning. (Drugs Aging 29(11)863) Do your patients a favor- get them vaccinated before age 60. TAKE HOME MESSAGE: Vaccinate for zoster or use the lidocaine patch. When a man has a birthday, he takes a day off. When a woman has a birthday, she takes at least three years off.     I use a smoke alarm as a timer

22)            This article says nothing. Absolutely nothing. No research. No results, no conclusions. But it does give a push that we need to identify which CHF patients can be sent back to the community and which need to be admitted. If you are like me – you are admitting most of those who come through the ED basically because they do so poorly outside- but isn’t that what the IM ward is supposed to prevent on discharge? ( J Card Fail 18(12)900) What is my idea on this? No comment. Absolutely none. TAKE HOME MESSAGE: None. Absolutely none. The fashion magazines are suggesting that women wear clothes that are ‘age appropriate’. For me that would be a shroud      #

I hate housework! You make the beds, you do the dishes and six months later you have to start all over again

23) On the other hand, this article says a lot. The FDA has guidelines regarding the use of long acting betas in asthma. The FDA wants you to use long actings only if used concurrently with inhaled steroids. That is true. Once asthma is controlled, they want you to stop the long actings- the authors don’t like that. Some folks may do better with going down on the inhaled steroids first. Others may need both to stay in control. And of course those who were well controlled on steroids alone probably do not need the longactings at all.(Curr Opin All Clin Immun 13(1)58) Basically they say do not look at long actings as black and white- some may actually need them- what about tachyphylaxis? May be an issue maybe not- I would like Barry Brenner’s opinion on this- he is a big asthma ED guy- Barry are you still reading? TAKE HOME MESSAGE Long acting beta agonists may need to be continued in select patients. #

I was so ugly that they sent my picture to Ripley’s ‘Believe It or Not’ and he sent it back and said, ‘I don’t believe it.     I said to my husband, my boobs have gone, my stomach’s gone, say something nice about my legs. He said, “Blue goes with everything.”

 

24) So I like to get high and if you are good, you can hear my lecture on flight medicine on EM RAP (Hi Rob). But like everything it depends what you mean by high. So let me explain. The altitude that you feel in the cabin when you fly is higher than in the past. It is between 6341+/- 1813 feet (which is 1933 +/- 554 meters) and the higher sides are seen in flights traveling over 750 miles. 10% of flights have cabin pressured to altitude of 8000 feet. (Aviat Space Environ Med 84(1)27). So you can imagine it is a little harder to breathe. Indeed I was taught that the saturation goes down about 3-4% at these heights. For you that may not be a problem but if your pulse ox is 91 and you have COPD- arranging flight oxygen may be worthwhile. And this is a concern if you believe this case report where they did echo on a patient in flight with a hand held echo and discovered pulmonary hypertension even in the face of a normal sat. (ibid p 65) TAKE HOME MESSAGE: Careful with lung disease in commercial air flights- the altitude can be as high as 8000 feet. BTW- before I get a letter from Axel about getting high- I use no drugs, don’t drink alcohol and do not smoke- But I do have that weakness for Fleet’s lite #

My husband killed himself. And it was my fault. We were making love and I took the bag off my head. #

My husband wanted to be cremated. I told him I’d scatter his ashes at Neiman Marcus – that way, I’d visit him every day

 

25) Dr. Kevin who is double boarded in Peds and Peds EM and lives about twenty minutes away from me was interested in Propofol causing green urine and here is another one for him – especially if he is treating pimples in adolescents. Minocyline – in this case used for rheumatoid arthritis – can cause blue/black/green discoloration of the shins, ankles and arms. Looks bad but of no consequence (QJM 106(1)77)TAKE HOME MESSAGE: Minocylcine can cause a blue/black rash on the extremities. When you first get married, they open the car door for you. Eighteen years now… once he opened the car door for me in the last four years – we were on the freeway at the time     #

Grandchildren can be f**king annoying. How many times can you go ‘And the cow goes moo and the pig goes oink’? It’s like talking to a supermodel.

 

26) There have been case reports on the use of propofol for migraine headaches and this Iranian study showed it compared well with dexamethasone. (BMC Neuro 12:114) OK, maybe- dexa is not that solid as a migraine med although I have had success. They do not say how they knew this was a migraine and not some other headache. In addition dexa takes time to work; propofol is very fast acting so it is a hard comparison. (BMC Neuro 12:114) TAKE HOME MESSAGE: Is propofol also a possibility for migraines? Does feeling green get better when you urinate green? #

My body is falling so fast my gynaecologist wears a hard hat.

The one thing women don’t want to find in their stockings on Christmas morning is their husband.

27) About 8 months ago I dedicated a lot of space to Lisfranc’s fractures and you (and everyone else) are still missing them (no, ordering a lactate will not help). The high velocity lisfrancs you aren’t going to miss. But the low velocity–stepping off a curb for example- are harder – especially since the x ray findings can be very subtle. This from Life in the Fast Lane- Thanks Chris. The article actually says to look for a shift of the cuboid bone (the medial bone) away from the first cuneiform. Also the inter cuneiform joint space should line up with the intermetatarsal space (not seen on this radiograph) but yes seen in this one We probably miss this about 40% of the time This could lead to midfoot instability, an early osteo arthritis and the most feared problem- compartment syndrome., Ultrasound may help, CT and MRI will definetly help. In the low velocity cases- no weight bearding and a snug 3 sided splint with attention to compartment syndrome is the treatment. (CFP 58:1199) As scary as this seems, I think it isn’t to hard to miss- true the x rays are subtle, but these folks have swelling in the midfoot and cannot not walk at all- That is when you need to have your antenna up. Also, a fracture of the base of the second metatarsal- not an easy thing to do- helps as it associated with this dislocation. TAKE HOME MESSAGE: Lisfranc’s can be subtle- have it in mind when the midfoot is swollen If by chance you are from the culture capital of Michigan- Ypsilanti- the article is in French as well. I blame my mother for my poor sex life. All she told me was ‘the man goes on top and the woman underneath.’ For three years my husband and I slept in bunk beds.   I had a cold and my doctor recommended coffee enemas. I can never go back to Starbucks…

28) Playing with your circadian clock can increase your cancer risk, but I can’t tell you how. These authors from Finland can, but this was too basic science for a moron like me. It seems that breast, non Hodgkins lymphoma and prostate are of more risk (although that may be due to the fact that prostates are often active in some folks when most other people are sleeping) (Annals of Medicine 44:847)I hate thin people; “Oh, does this tampon make me look fat?”
I was the last girl in Larchmont, NY to get married. My mother had a sign up: ‘Last Girl Before Freeway.’
29) Hi paramedics- we got quite a few, but I do not remember everyone’s name and place of work. You guys are speeding us MIs because time is heart muscle. We can activate the Cath team and be waiting for you at the door. Strokes are doing better because you are getting them to us quickly and allowing us to clear that CT scanner. But there is a disease with more prevalence than MI and stroke and double the mortality- sepsis. And the interventions are easy- get in that IV, get the fluids and antibiotics rolling and give pressors if need be. And get those antibiotics in fast. However, in this study, there were long on scene times, high mortality (although better of course than those not brought in by EMS) and only 37% came in with IV access. What seems to be the problem? They claim that EMS providers have a poor understanding of management of this condition, but I think with proper education that can be easily changed. True we have labs and imaging to help us that they don’t – but a little old lady with marginal blood pressure and fever should not provide a diagnostic dilemma. Over aggressive fluids could be damaging as well and they have no way of measuring- but I counter -keep an eye on the blood pressure- that will help. Is scoop and run the answer? Well it would get the patients to the hospital faster which has its benefits as well. The authors do not mention that this will not allow the drawing of blood cultures, but these patients need fluids and broad spectrum coverage quickly and we can also look for the bug later in PCRs if need be. I am of the opinion that the paramedics I know and I train can make a difference here- let’s give them the education –and most of all- the chance to do what they do best- save lives (AJRCCM 186:1204) TAKE HOME MESSAGE: Has the time arrived to start sepsis treatment in EMS? When I was born, my mother asked the doctor “will she live?” He said: “Only if you take your foot off her throat”.

You want to get Cindy Crawford confused? Ask her to spell ‘mom’ backwards

 

30) I dedicated a whole essay to this two years ago and so I am going to be brief but I gotta mention this because it is from the EM cardiology guru William Brady(as good as Amal Mattu is- Brady is the leader of the pack ). ST elevation can be other things and indeed-60 to 80% of the time it isn’t associated with a STEMI (not quite sure how they know this). I also say – many of these conditions are not going to be diagnosed in hate ED-they will be diagnosed only after the cath was negative. We’ll start out with last month’s essay – myocarditis. Pericarditis is electrically silent but will give ST changes when the myocardium is involved. If the ST elevations are in multiple coronary distributions and the patient isn’t deathly ill- then myocarditis is more likely. ST depression, PR depression with ST elevation and PR elevation in AVR also favors myocarditis. Early repol is a tough call sometimes, T waves here are concordant except in V1 and 2 and the there is an elevation at the J point. – if in doubt- repeat the EKG- the early repol changes should not change. Here is one that has tricked me before- ventricular aneurysm –admittedly much less common these days due to faster cath. Echo will not help here- how do you know if the wall abnormality is new? – a Q wave could be the tip off here along with slightly inverted t waves However, it is hard to tell if the Q is recent or not, so you will probably be stuck with doing serial EKGs and troponins here. Coronary vasospasm (Prinzmetls ) can cause this (don’t forget Kounis syndrome where allergy can cause this spasm) (an if you do forget, Kounis will remind you – he is famous for pouring our like 20- 30 article son his syndrome all saying the same thing). This condition actually doesn’t bother me because if you err because you will probably send him to cath anyhow which is best) However, if there is a rapid response to nitrates- this should make you consider it). Takosubo is also with clear coronaries and often seen in emotional people. This too is indistinguishable so it is OK if cath is done. Brugada- this is ST elevations in V1-V3 but generally syncope and not chest pain is the presentation. Hyperkalemia can cause ST elevations – you better not miss that one- the QRS will be widened and the T waves will start to peak. This next one is important – post cardioversion of defib- there can be transient ST elevation- THIS IS NOT ASSOCIATED WITH MYOCARDIAL INJURY. J point ST elevation can occur with hypothermia- this should not be a diagnostic dilemma (these are called Osborn waves). He does not mention CVA which can also cause ST elevations. Mimics include LBBB (remember – new LBBB is a catastrophic MI- so most patients that look good – their LBBB is not new). Sgarbossa criteria may help- we have discussed this before – but the sensitivity is low. . LVH can also show ST elevations, as can paced beats and RBBB which can be a bad sign in MI and not always that noticeable. In all these cases- I let complaints help me (either the patients about my care or what they are complaining about): If there is chest pain, if there is a change on serial EKGs, if there is a delta troponin- don’t take chances. (Cardiol Clin 30:601) To be honest, this article is too basic to be of use for most cardiologists and is a good start for EPs – it is a shame it didn’t appear in our literature. TAKE HOME MESSAGE: ST elevation is actually more often than not- not a STEMI. While we are on Brady’s work- he did publicize an article on EKG artifacts and lead reversal in a emergency journal. Again- pretty basic. However, some of the changes can be subtle- leg arm reversal on the right can show an isoelectrical tracing in one of the limb leads. Leg reversals do not make much of a change in the EKG, but arm reversal does. – look for AVR to be upright and normal appearing. Limb arm reversal on the left is the hardest to detect. And even after reading the article I am not sure how to detect it. He also speaks about the proper placement of the precordial leads- I bet most of you don’t know the proper positions. (JEM 43(6)1038) TAKE HOME MESSAGE: EKG lead reversals can cause subtle changes- read the text to see what kind Thank you Dr. Brady ץ (If you are too young- this is the Brady Bunch which was a popular show 1969-1974. Check out those hair dos. Boy was it sermonizing- but not a bad as this one – Remember Room 222? Or the Partridge Family? Gosh people were odd then- so Axel – now you know where I got it from? It isn’t just from Fleet’s lites. 70) Camilla Parker-Bowles is so ugly that at airports they make her frisk herself              You know it’s time to start using mouthwash when your dentist leaves the room and sends in a canary
 
 

31) Hey it’s boredom time! (no, smart aleck- it wasn’t boredom time all along) You gotta know how to read an article- and I can’t do it for you all the time. Today- let’s talk about the non inferiority trial. A superiority trial is simple – to show benefit of what you are studying (for example to show that Skippy Peanut Butter is really tastier than the generic brand- Mama’s). However, sometimes people do non inferiority studies to show that the outcomes may not be different (or better for that matter) but the harms or other considerations are less. Using our example – if Skippy is more expensive or only available at the store down town then Mama’s brand may be more worthwhile. Now how do you know the information is valid? So firstly check to see what the thresholds are. If they were lenient – like a difference in 2 cents (or agorot,, or dinars, or pence) so to show that it is this more worthwhile to buy Mama’s- then really you have proven that is that Mama’s is cheaper, but that doesn’t mean much in view of the minimal savings and what you’ll give up by missing the good flavor of Skippy. The other problem is a straw man comparison- using different dosages or known non effective dosages. Our example- one teaspoon of Mama’s is cheaper than a jar of Skippy. Or that patients are enrolled with a low risk or if the treatment is given by a strange manner or if the follow up was short. Examples- Skippy was given IV and Mama’s by mouth. Low risk – well if the groups have folks who like peanut butter so by definition they won’t have peanut allergy so to say Mama’s is as safe as Skippy’ isn’t saying much. Another issue- make sure the trial doesn’t disagree with previous studies- if it does then this may be a red flag (all the studies up to now have shown that Skippy is just as cheap). Intention to treat is also very important- they must analyze all comers- even those who do not like peanut butter and were enrolled in the study, Lastly check to see if these results are generalizable to your patients- re they similar to the study group? (JAMA 308(24)2605) TAKE HOME MESSAGE: Non inferiority trials- I forgot – I was asleepI have no sex appeal. If my husband didn’t toss and turn, we’d never have had the kid.

My face has been tucked in more times than a bedsheet at the Holiday Inn

31)            This just in from the Annals of Internal Medicine- Dec 17 issue so it is still not in Pubmed. Taking vitamin supplements is useless and a waste of money. Vitamin E (cancer) Vitamin A (liver failure) and Beta carotene (increased mortality) are dangerous to take in high amounts. Vitamin D – we still think you should take massive dosages but that is still being studied. Folic Acid- yes in women who could get pregnant. All the others- waste. TAKE HOME MESSAGE: Vitamins- not worthwhile to take unless they are Skippy. And for that final flourish- let’s go back to Roseanne A lot of stuff bugs me about being married and a lot of stuff bugs me about husbands y’know. Like when they all the time wanna talk to ya. I hate that. He comes in and says “Roseanne. Don’t you think we should talk about our sexual problems?” Like I’m gonna turn off Wheel Of Fortune for that. Put it on a gift certificate babe. Then it bugs me that they think you’re gonna clean everything huh. Like he’ll say “Well Roseanne you think maybe you’ll wash a dish this week?” Get real. So I said “Well what’s the matter is Lemon Joy kryptonite to your species?” But I am happy and you know me, I’m not one to whine. But you know what I think, I think husbands are the very best of men. There the Cadillacs of men. Cause at least they can make a commitment and deal with life. Not like these young bucks, they young warrior types. “Well Roseanne, I’m not ready to settle down, I’m living life of the edge of the fast lane.” Sure get in a relationship and face the real danger. Look a mortgage in the face for thirty years. You sky-diving wimps. But this bugs me the worst, it’s when the husband thinks the wife knows where everything is huh. Like they think the uterus is a tracking device. Cause he comes in and goes “Hey Roseanne, do we have any Cheetos left?” Like he can’t go over a lift up that sofa cushion himself

32)            And now letters. Axel is back at it from Paris And here is what he says this month,

 

French Guinea (which is still a colony)

 

Oh oh !

A casus belli ? ( what does this mean?)

Colony ? thou said colony ?
I suppose you talk about Guyane, or Guiana .
Not a colony.
Ok debatable  😉
http://en.wikipedia.org/wiki/French_Guiana

 

Thanks for the new issue.

I stopped at lactation tonight. ( I think you are a little old for that , no?)

I’m having a hard time convince my rads to stop telling breast feeding ladies to stop.

Officl guidelines say stop !

Americans are very politically correct in their 2013 book on contrast.  There is no danger but discuss.

I think this is bad advice. If no danger don’t stop !

 

I’ll tell you what my irradiators reply to my mail tonight on the topic Thanks for writing, Axel- are other folks running into the same problems?

And now from Ken Iserson, who is actually on 2 hours flight time from French Guinea. BTW- anyone know where the only French colony in the Northern Hemisphere is and what its name is?

Hi Yosef

Congratulations on 15 years of publication!

As always, a fine EMU issue.The comment about using isoflurane for severe asthmatics seems to be a bit antiquated—and dangerous. Isoflurane appears to now primarily be a veterinary anesthetic. That may explain, in part, why the series had only about 2 patients per year over 15 years at a major children’s hospital. The problems with this drug is that (1) 77% of their patients required vasopressors; (2) 10% had adverse neurological events; (3) inhalational anesthetics must be provided in specially ventilated areas—usually the OR—and these patients averaged 54 HOURS on isoflurane; and (4) there may be significant adverse neurological effects on any child getting isoflurane.   That said, for pediatric patients, Ketamine works very well in low doses to prevent the need to intubate severe asthmatics. A loading dose of 0.2 mg/kg IV is followed by an infusion of 0.5 mg/kg/hr for 3 hours. This may be continued if necessary. The patient requires close monitoring. (Craven R. Ketamine. Anaesthesia. 2007;62(supp 1):48-53.) Best wishes from Guyana, Ken. Not much to add Ken other than I have no experience in this and that is why I so appreciate your comments. However, while I have you on the line I read your article on preparing medical care in far flung places and saw you did not like dipyrone. This medication never got approved in the USA due to aplastic anemia concerns but actually that isn’t too common and it is OTC in most of Europe and Israel. It is also a great and cheap way of dealing with pain IV. See J Clin Epidem 1998. Unfortunately not a lot of articles because it isn’t available in the USA- but our experience has been good and it seems to casue less problems than NSAIDS. And now from the Father

Greetings from beautiful downtown Ypsilanti, Michigan. Kind sir I most enjoyed the latest edition of the newsletter. We do need to clear up a few points. Mama Cass did die in proximity to a ham sandwich but not BECAUSE of a ham sandwich!! I did not want to give Moshe any more evidence in his fight to get me to  eat vegan Kosher. And thanks to the entire crowd at the Staten Island program for all there kindness during my recent visit.  Next. Don’t pick on David Newman. He does trash most things but then most things need trashing and he does it in such an elegant way. Jerry Hoffman is getting up there and we need someone to take his spot. Lastly, even the locals don’t really know what that rather phallic looking structure is at the entrance to Ypsilanti. It’s not the walls of the Old City but it’s all we got. Give us hicks from the Midwest a little something to be proud of.  Best to everyone during this holiday season. Father Henry

 

I won’t (actually I can’t) comment on father’s ranting other than to say I reserve the right to be tough on any major EM player who is not an EMU subscriber. Amal Mattu got it last month. This month is Dave “the Rave” Newman. On the other hand, let’s hand it to our EMU subscribers- they get free plugs- Like Barry Brenner and his procedures book which is way better and more useful than Robert’s (who is from my old home town of Philly but is not a subscriber) and Ken’s book on Improvisational Medicine . Both great books. And of course Father’s book on on fine Wines- like this 2013 white Chardonnay Blanc with a strong flavor and aroma but with great taste and less filling. This got a 10 from Wines magazine which is extremely uncommon, and they state that it rates up there with the finest Napa wines. It is bottled in Michigan to give our Ypsilanti folks something to be truly proud of. Here is a picture as it comes off the production line. . Carlos from Puerto Rico wrote me and wished me well during this season. Carlos is a nice man and I believe is helping build up the specialty in his community. He was kind enough to send me a picture of his beautiful family. It is always good to hear from you Carlos.   At this point I would like to thank two folks who have taken their time to help EMU –Scott and his resident Christine from NY- Scott and I have never met- we were introduced by a mutual friend Chris from Australia- but I jus wanted to thank you for all the help in getting EMU’s first website up and going- this is exciting for me andI will provide details as they come. Furthermore, Scott has always been there for comments on ICU/EM and has been a true friend. Tim is involved in a massive project but he will be putting EMU on it- see Tim’s letter below

Hi Yosef,

 

We’ve made some great progress on offering your docs on our site.

 

Go to iclickem.com and search EMU..

33)            Number 11 clinical quiz was of course (of course?) West Nile Fever. Not hard but we forget it a lot. And of course, there is no Houser street in Corona Queens, that was Archie Bunker’s address in All in the Familya TV show from the seventies And the French colonies in North America are two small Islands off the coast of Labrador called St Pierre and Miquelon

 

EMU LOOKS AT:PMS is like pulling teeth

After all that Roseanne stuff don’t get your hopes up- we are going to talk about PMR not PMS ( “oh that’s very different- never mind”) And then one of Ken’s articles on dental extractions PMR comes from the Lancet 381.63 and Ken’s article is from Wllderness and Environmental Medicine 24:384.

Polymyalgia Rheumatica

1) Yeah we know this is associated with Temporal Arteritis, but what else do you know about this? Have you ever made the diagnosis?

2) Who gets this? You have to be older than 50 and mean age is 73

3) What causes it? Genetics, environmental factors, or more succinctly- no one knows. What we do know is that is some kind of articular and periarticular inflammation. Yes you heard it right- while this is called myalgia – it is rare that we see muscle inflammation

4) Ok we said it above –this goes together with Temporal Arteritis- well kind of sort of. You will see it overtly in 16-21% of PMR but if you took biopsies from everyone you would see evidence of subclinical arteritis-not that you should be doing biopsies to everyone

5) So what do these folks complain of? Shoulder, hip and neck pains. They have morning stiffness and after resting – it is worse. Low grade fever, anorexia, weight loss. Of course if there is headache, jaw claudication, scalp tenderness in the artery distribution, visual complaints or low grade fever; temporal arteritis has to get on your radar., There can be swelling of feet and hands but this is seen in the major differential diagnoses like spondylarthritis and rheumatoid arthritis. Malignancy can also show these signs but in view of PMR responding so well to prednisone – giving steroids can help make the diagnosis.

6) Other DDX include thyroid and parathyroid disease, endocarditis, Parkinson’s, low Vitamin D and of course myopathy from statins

7) Diagnosis is usually clinical There are at least four study groups with criteria for PMR. CRP is now the only lab test that can help. Of course if you want to rule out things- do a rheumatoid factor, calcium level, CPK, TSH and liver tests. Joint effusions can be seen on ultrasound. Forget CT and MRI and PET scans they are expensive and give limited information

8) NSAIDS are not advised. But steroids at15-30mg of prednisone are very helpful You can also give a shot of IM methyl prednisolone which is slow release and will help over three weeks. Methotrexate and Azathioprine have shown mixed results

9) These patients do well.

 

 

PULLING TEETH.

1)   So Ken was sunning one day in Baffin Bay when a patient with a bad tooth came to him requesting help. Here is the patient he treated: I will add a little of what I know on the subject.

2)   Yanking out a tooth is the death sentence for the tooth- so the dentists try to avoid it when possible. Often- because the mouth bacteria are so sensitive to PCN, antibiotics can cool down a potentially dreadful infection in a tooth. Broken teeth can often be treated with eugenol (which is just clove oil gentlemen, so yes, you can try using a clove) and capped with histoacryl. Most of the time these require root canal , which I am not a big fan of (because you are basically destroying the immune function of the tooth, so for sure at some point it is going to get infected), but sometimes an extraction is impossible to avoid. For example, constant pain, a broken tooth with an exposed pulp or the tooth is loose and painful when moved.

3)   Firstly you want good anesthesia- using a lidocaine – epi mixture will be best to minimize bleeding, – Ken recommends to use 0.1cc of the standard epinephrine (which is 1:1000) in 19.9 cc of lidocaine (gives you a 1:200000 solution . Learn how to do a nerve block, but if you can’t – try blocking the tooth at its base. He had the patient use a chlorhexidine mouthwash to reduce the occurrence of an alveolar osteitis which is also known as dry socket syndrome- Ken – any evidence this really works?

4)   What anchors the tooth in are the periodontal ligaments- they are strong but thin. These are the ones you want to preserve in Hank’s solution, milk or saliva when a tooth has been knocked out in an athletic event (the best idea would be to return it to its place immediately, but that is not always possible) You can tear these by just inserting something that resembles a flat head screwdriver between the tooth and the socket.

5)   Once these are torn- rock the tooth back and forth; that is towards the cheek and towards the tongue. DO NOT YANK- you’ll just break the tooth. Not that that is a big problem, as retained roots, either pop out on their own at some point, or stay there and don’t cause trouble or get abscessed and which can be drained through the buccal surface.

6)   Then control bleeding through local pressure, gel foam or epi/hexacaproic acid on a cotton pad.

7)   Post extraction bleeding is treated the same way. Do you need antibiotics for this? Well- wait until next month when we discuss what Cochrane has to say. Alveolar osteitis is thought to occur when the clot is dislodged – it is painful and called dry socket syndrome. Eugenol or lidocaine paste will help you here.

8)   I guess it would be prudent to recall one of the most chilling dental scenes- from the 1977 movie Marathon Man where Lawrence Olivier play as a Nazi dentists drilling Dustin Hoffman’s teeth without the use of novocaine. .You can see this on youtube. I prefer the dental work of Richard Keil who played Jaws in the Spy who loved me and Moonraker Bond films and for Father, here are the hot babes of the month Roseanne Barr, and Joan Rivers. Thanks Ladies, it was a fun month

EMU Monthly – November 2013

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

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

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

4)   A word – actually too many words- on penicillin allergies. PCN allergies are usually – not allergies but long ago reactions that that were never allergies or were out grown. Most patients who say they have an allergy who undergo skin testing do not have the allergy and if you do this test and it is negative, it is probably safe to give the stuff. Desensitization if it was ever done may not be permanent. Lastly – and you all know this already from past EMUs- you can give cephalosporins in PCN allergies- cross reactivity is low with the newer ones. (Clin Rev All Immun 43(1)84) TAKE HOME MESSAGE: PCN allergies are usually not -and you can do a simple skin test to determine this. This month’s quotes are philosophical as seen by the eyes of a six year- we are speaking about Calvin and Hobbs “Reality continues to ruin my life.” “I’m not dumb. I just have a command of thoroughly useless information.”

5)   I can summarize this fast and you probably wish I would. Today’s wound care is: moist, and do not disturb. Gauze macerates wounds so do not use it- use a petroleum based dressing or one that has a plastic side that doesn’t stick. (J Wound Care 21(8)359)“Calvin : There’s no problem so awful, that you can’t add some guilt to it and make it even worse.”

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

7)   People can have a stroke while taking Coumadin and giving TPA is complicated under such conditions. They gave this fellow with an elevated INR and a sign of a stroke PCC and within 15 minutes the INR was 1/2 of what it was and he got his TPA. (Cerebro Dis 33(6)597). This is pretty quick and I was unaware reversal could be so quick but nevertheless, it is only a case report, and I am surprised they could get the INR (and the type and cross) results back so fast as this is one of the lab tests from the ED that takes a while to do. TAKE HOME MESSAGE: PCC can reverse INR if you need to do so quickly. “I’ve been thinking Hobbes”
“On a weekend?”
“Well, it wasn’t on purpose”

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

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

Major criteria[

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

Minor criteria[

Other signs and symptoms

  • Abdominal pain
  • Nose bleeds
  • Preceding streptococcal infection: recent scarlet fever raised antistreptolysin O or other streptococcal antibody titre, or positive throat culture. Gotta love Dr. Jones first name. What did they call him for short? You are right- they called him Fred (you didn’t really think I would say Ducky would you?) TAKE HOME MESSAGE: RHD is around and can affect adults. Calvin: Moms and reason are like oil and water.   Calvin: That’s one of the remarkable things about life. It’s never so bad that it can’t get worse.

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

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

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

 

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

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

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

 

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

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

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

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

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

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

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

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

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

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

21)   TASER- I haven’t had any experience with this- neither on the treating, receiving or distributing end. This is a device that shoots two sharp electrodes and delivers a high voltage low current shock to a person which temporarily immobilizes them (from what I remember from electricity – current is this the more damaging than voltage). According to Ohm’s law (V=IR) the electricity will travel the path of least resistance and this is along tissue layers, so the risks to hearts is minimal. However muscles can be damaged and expect an increase in CPK- up to 1465. Nerves seem to be preserved. They recommend that only medical personnel remove the darts but that all depends on where they are. (J Forensic Science 57(6)1591) TAKE HOME MESSAGE: TASERS seems to be safe- but you should take the darts out of the patient. Or yourself if you are a klutz. Or even if you are not Calvin: I hate to think that all my current experiences will someday become stories with no point.Calvin: Somewhere in Communist Russia I’ll bet there’s a little boy who has never known anything but censorship and oppression. But maybe he’s heard of America, and he dreams of living in this land of freedom and opportunity! Someday, I’d like to meet that little boy…and tell him the awful TRUTH ABOUT THIS PLACE!!

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

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

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

23)

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

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

 

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

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

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

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

 

 

 

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

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

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

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

 

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

 

24)I guess this is only relevant if you are Israeli, Jordanian or from Utah, but dead sea water intoxication can happen and is dangerous- even a swig of 50 cc can elevate your magnesium and calcium significantly (PEC 28(8)815). My hospital is the nearest to the Dead sea and we see a lot of these; my director Dr. Carmi was kind enough to allow me to interview him on how he treats this. Calcium is generally easily treated with fluids and diuretics. Magnesium responds less well to diuretics. First aid includes fluids but then – if the level is eight or higher – or the patient is comatose you better consider dialysis. I think Father Greg can be the first to tell you – you got to be careful what you drink TAKE HOME MESSAGE: hypermagnesemia can result swallowing small amounts of Dead Sea water. Calvin: One of my baby teeth came out! I have to say, I’m not entirely comfortable holding a piece of my own head.

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

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

Calvin: I see.

Dad: Nicely put, dear

 

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

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

Susie Derkins: Imadoofus.

Calvin: Thanks.

(Calvin realizes Susie has tricked him)

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

 

 

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

 

27)                 Dislocations- there are three in the hand you better know because you may miss them on plain films. This article s on perilunate dislocations. They are high energy outstretched hand things. The can tether the median nerve and cause aseptic necrosis from compromised blood supply so this is a dislocation that you want to deal with immediately. Often there will be associated fractures such as of the scaphoid or the radial styloid. (BMJ 345: e7026) The first picture is a perilunate dislocation. The second is a lunate dislocation. These dislocations are best seen on lateral films. The last dislocation is a scaphoid lunate dislocation which you see best on AP – there is a large hiatus between these two bones- it can be less pronounced than this picture TAKE HOME MESSAGE: Don’t miss dislocations in the hand. After Calvin nails Susie with a snowball he walks up to her and says “I must say, the stinging snow makes your cheeks look positively radiant.”“I have a hammer. I can put things together! I can knock things apart! I can alter my environment at will and make an incredible din all the while! Ah, it’s great to be male!”
– Calvin and Hobbes

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

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

 

Hi Yosef

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

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

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

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

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

Best wishes, Ken

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

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

EMU LOOKS AT: Looking great and breathing easier

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

1) Let’s face it – it isn’t always obvious what that red droopy eyelid is. Let’s leave trauma out of this- that is the easy one

2) Infectious is the one that is most bothersome and the one we most often see. Hordoleums and blepharitis can cause this as can the usual streps and staphs. However, do not miss these: EBV seems to have a predilection to cause edema around the eyelid; Hep B can do this too. Lyme and RMSF can cause this due to a vasculitis. Ova can cause hypersensitivity reactions, so consider trichinellosis (still common in some places in rural USA and in the rest of the world) Chagas, filarialand amoeba. Do not forget infected bites or non infected bites. And of course-Nec Fasc can strike here as well. Sinusitis, especially Pott’s Puffy tumor from the frontal sinus can cause periorbital edema, and orbital cellulitis can start out this way.

3) Non infectious causes- allergy is going to be the leading cause. Facial creams, eye drops and makeup do the most damage, although systemic allergies can cause this as well. Guess what- the thyroid can cause this also, but that doesn’t bother me- the thyroid seems to cause everything. This will cause orbital swelling as well. Do not forget dermatomyositis and lupus. We will mention tumors, but I do not think that will be that hard to diagnose.

4) There is a weird bird called blepharochalsis which is a disease of young adults that comes and goes for an average of two days.

5) The article doesn’t say this, but I use heat as helping me make the diagnosis. Allergy in only one eye is rarer, is usually less hot and less red. It may be itchy.

6) Hey what about meds? Imatinib causes this often but we use that only for CML and most of us will not see that. Biphosphonates can cause this as well as scleritis and uvietis. Hyaluronidase is often a filler in cosmetics and often causes edema. NSAIDS and some antipyshotics do it as well.

7) Post surgical causes can come from the ears as well- cochlear transplants can do this!

8) If you are faced with a case that you are not sure of the cause, so there is an algorithm here with all sorts of blood tests, but this is boring enough.

Lung Transplant Emergencies:

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

2)   Yes, that is U Thant, the former Secretary General of the UN. Not quite sure what people who didn’t know his name said to him (“hey, you””Yes?”)

3)   Well, you guessed it- the lifelong taking of sometimes three or more immunosuprressives causes most of their problems. – Infection, graft rejection, and bone marrow supprsion. But do not stop reading yet.

4)   Rejection often occurs because inadequate immunosuprresion. These symptoms can be very subtle such as malaise, dyspnea and low grade fever. Actually, the only sign may be reduction on spirometry –so ask – most of these patients know how to measure this themselves. However do not go reaching right then and there for the meds- be sure that you are not looking at a respiratory infection first. Problems is that clinical assessment is not enough and chest film may be confusing as bronchietasis and pleural effusion may be present which can be seen in rejection or in……bronchietasis and pleural effusion. CT helps a lot (without IV contrast- they get renal failure too easily), but sometimes bronchoscopy and biopsy may be necessary to rule in or out rejection. For me as an EP, I’ll do a CT and go from there if there is a bona fide infection. High acute fever and a lousy looking patient will help. Cyclopsorine gets the kidneys- so keep an eye on them with Cr and urea checks. Prednisone is often tapered, but just keep in mind that getting this right takes years sometimes and despite all efforts, bronchiolitis obliterans syndrome can occur- you won’t be treating this, but it is just an example about how important good immunosuprresion is here. I do not personally feel comfortable adjusting immunosuppresives on my own.

5)   Clarithyomiycin may cause the level of cyclosporine to go up, so they prefer Azithro, Azole antifungals are another problem, so they use caspofungin. They never use fluconazole. Be careful to use pancreas enzyme replacement for Cystic Fibrosis patients after lung transplant. They have a list of common medications interactions that will cause rejection or toxicity or nephrotoxicity in the article. Be careful with metoclamide (Reglan, Pramin) as this is commonly used and can cause lower levels of cyclosporine.

6)   Like strange names – here is a Secretary General of the UN from before U Thant.  His name was Dag Hammarskjold- good luck trying to pronounce that one (“Hey you” would probably work here too)

7)   Cytopenia is fairly common given the tonnage of meds they take. Do watch the WBC. Antibiotics do this especially TMZ-SMX, and Flagyl. Some anti virals can do it too. You may have to mix and match the meds

8)   So you see this guy with a runny nose. They attack him with nasal viral and bacterial cultures and then start moxifloxicin. If it is the flu season they start Osetamivir. Patients that look worse and older folks get put in the hospital. They do not like macrolides for reasons we stated above and even if all the cultures are negative they still continue moxi for another week. Fungi and atypicals are searched for. The truth be told they actually aggressively work up all changes in the status of the patients.   Who am I to argue? CMV is always tested for- its pneumonia can be treacherous in these patients and it is often reactivated after transplant

9)   GI problems occur alot. Recall that immunosupressives mask normal signs of intra abdominal disasters. Intestinal motility is lessened by the meds so give them laxatives. CF patients especially need this because they develop distal intestinal obstruction syndrome. Vomiting is another disaster- even a little aspiration can lead to infection or rejection and besides it makes it hard for you to know how much med they did manage to get into their blood stream They prefer feeding tubes and not NGT tubes (zonde). Diarrhea occurs but do not forget C Difficile as these folks are constantly getting that Moxi. Laxatives can cause this diarrhea, but as we noted last month- sometimes this is constipation with only liquid stool coming out. When in doubt- x ray. They do not give pro biotics- who knows when these friendly bugs can turn mean. UTIs abound because the signs are often absent.

10)                 Here is another great name Craphonso Thorpe. I am not going to attempt to pronounce that one

11)                 Osteoporosis and osteopenia is very common among these patients and most will be getting calcium, vitamin D and a biphosphonate. Still, fractures are quite common. Also do not forget that since many are taking a respiratory quinolone- Achilles tendon pain or transection may be present. Use lidocaine patches, do not use NSAIDS. They do use antibiotics as prophylaxis quite frequently (like for dental procedures) but agree the literature is sparse.

12)                 HTN is common; they avoid calcium channel blockers because of the edema they can cause. Remember with the suppressant drugs they take, they can have a bad MI or CHF and show few signs. Ditto with pulmonary embolism, so if there is a DVT – check those lungers. Before surgery- speak to these guys- mortality is high

13)                 Yes that is Ha Ha Clinton Dix- a name only rivaled by the New Jersey Town Have a great Thanksgiving and Hanukah!