EMU Monthly – September 2013

1)   Adenxal torsion- well, here is a score to help you- abdominal pain, ovarian pain, “unbearable” pain”, vomiting and absence of menorraghia were all assigned points and these help make a diagnosis.(Hum Reprod 27(8)2359). I think this is silly. They only saw 31 patients with this out of 431 patients with pelvic pain and to tell you the truth- like testicular torsion- there does not seem to be subtle cases- if they have they will look sick. I mean like- D’oh TAKE HOME MESSAGE: Adnexal torsion patients look sick. This is not a diagnosis you should miss.

2)   Rare that I bring a NEJM article but this one is so EM (and written by an EP) and yet had important points. Yeh, you know the opiod syndrome- respiratory depression, miosis (absent in cocaine, and pethadine (which in the states is meperidine) and in poly ingestion, stupor, hepatic injury, myoglobinuria, rhabdo ,and hypothermia. But there were some points that would be a shame to forget. Do not forget Fentanyl patches that can be on the body that can be in places that you may miss, and also kids can chew on these and get the opiod toxidrome. Remember paracetomol (acetaminophen) levels as Perccoet and the like have this ingredient. Studies show that urine tox screens rarely help. Narcan (nalaxone) can help but the half life is too short for most ingestions. No IV? You can give this by intranasal or inhalation routes, but not orally (although there have been studies in the past that trans buccal works). (NEJM 367(2)146) I would exercise extra caution with methadone as the bio absorption is erratic and these patients can crash and burn many hours later. TAKE HOME MESSAGE: No tox screens. Narcan may have to been given by continuous effusions. Do not forget fentanyl patches as a source of opioid OD. We look into the media this month- Tabloid headlines- Let’s get started

3)   If you are a long time reader of EMU, you know I love the work of Paul Marik, and ICU guy that was at Allegheny General and now is at East Virginia. He did a metaanalysis and found that new evidence seems to confirm that if your patient is not obese – the infection rates of femoral versus IJ versus SC CVPs are about the same. (CCM 40(8)2528) This is contrary to guidleines, and it is a meta analysis- which may not be worth much, but I think it a least opens the door. TAKE HOME MESSAGE Femoral CVPS may not be more infection causing.

4)   EMU goes to 27 countries and it is possible that you have camels roaming around your country or something similar that drinks a lot before going to work. Yes, you USA guys- there are camels in Arizona from a failed military experiment form long ago. Camels are not pleasant animals. They bite, they spit and they can pick you up and throw you. Injuries are usually severe, and these animals are particularly disagreeable (and dangerous) during mating season. (Injury 43(9)1617). Worth noting that all injured patients were males and that they only saw 33 patients in six years, but that could be referral bias. Another interesting point – and this isn’t meant as an insult- (camel jockey is consider derogatory) but 12 percent were actually camel jockeys and all of these children – and this may explain the severity of injuries TAKE HOME MESAGE: Don’t marry a camel- you are asking for trouble

5)   TRALI- some review and new things. What is TRALI you ask? It is transfusion related acute lung injury. There are risk factors for this- liver transplant patients, alcohol abuse, shock, hyperkalemia, patients getting whole blood and multiple transfusions, and those with anti HLA and anti HNA type blood( not sure if your patient has this? Ask your resident vampire – he is sure to know) Speaking of vampires- here is a picture of Grand pa- who played him and on what series?Interestingly enough – female blood also seems to cause more TRALI so be careful about giving girl blood to these other patients with risks (why is this? Previous auotantibodies?) What are the sympthoms? dyspnea, tachycardia hypoxemia, fever-+/- and most importantly – pulmonary infiltrates that are not CHF. Treatment is supportive and ECMO. (Crit Care Clinics 28(3)363). TAKE HOME MESSAGE: TRALI has risk factors so please be careful when you give blood and look for shortness of breath

6)   Important point here. I worked in a place where you could not take blood cultures if the patient was being discharged. I worked in places where you took blood cultures on all patients- -however I never worked at a place where you took them on selected patients even if they had fever. Our pals in IM like them on all fevers- but indeed- if you do not have rigor or SIRS criteria- they may not be too helpful. Cellulitis and pneumonia lead the way in being futile to take blood cultures, where as septic shock is more useful – obviously. This soon turns out to be a political struggle between us and IM but I always tell my residents- – if you are going to take a blood culture on penumonia then x ray his shoulder too- because you never if it is not broken. How do I know it isn’t? Because it isn’t. Period” ( JAMA 308(5)502) TAKE HOME MESSAGE: Cellulitis, young UTIs pneumonia- do not bother with blood cultures

7)   Clinical pearls in dermatology- are they kidding? Who the heck understands derm? Just give it some Latin name, give a steroid cream and send them for a biopsy. No, really, here are their pearls- good luck! Recurrent erythema multiforme- should make you think of a HSV infection – give them acylcovir. Strep throat can cause a rash that looks like red drops. This is not a drug reaction but rather guttate psoriasis which the strep causes to exacerbate. Phototherapy may be enough. Hard skin in the neck area- if the patient has DM, paraprotinemia and strep infections- think scleroderma. Now here is the part of this paragraph to ignore. Really I mean it. You can also see scleroderma in multiple myeloma, hyperparathyroidism, Sjorgen’s , insulinoma, rheumatoid, and HIV. Other diabetes skin disorders: candida, diabetic dermopathy (brown spots), diabetic bullae, necrobiosis lipoidica, acanthosis nigra, insulin dystrophy and xanthoma. Good grief- who cares? (Mayo Clinic Proc 87(7) 695) TAK EHOME MESSAGE: You aren’t going to catch these rashes, but keep in mind the things that go with them

8)   You thought you should skip the last paragraph- boy – this is really going to put you sleep. P values really are not that good. They can be influenced by many things. First of all – what is a p value? This is measure of how much the data obtained does not match with the null hypothesis. Usually less than 0.05 is considered being no correlation with the null hypothesis. However, multiple hypotheses, data dredging (going back to the data and trying too extract conclusions from the data when the experiment wasn’t designed for this purpose) small and large sample sizes can exaggerate the results. If the null hypothesis is erroneous or ridiculous, the p value loses its value. You know what is much better? Confidence intervals- is the 95% chance the true data point occurs in between these two values –is the best correlation. (Osteoarth Cart 20(8) 805) This is a chart from the article that will help you understand the confidence interval TAKE HOME MESSAGE: Confidence intervals are more reliable than p values. Oh YAWN

9)   Oh, I do not know- why are you even asking me? I do like bashing PPIs and we do know they cause calcium to be poorly absorbed resulting in more fractures. I guess the same could be said for magnesium and indeed this study says that. ( Aliment Pharm THer 36(5)405). However, it could take anywhere between 14 days and 13 years of therapy to occur and resolves fast upon discontinuation of the therapy. In addition this is a meta analysis of small studies and as always the question is – are these studies comparable and where they controlled. As most of these were case reports I do not know if you can conclude much, but what I would say is- use PPIs for short term and give those H2 blockers another chance. TAKE HOME MESSAGE: PPIs may cause hypomagnesiumia

10)                 Just a bone for our naturalists out there. Colds in kids- we know that OTC and prescription cold medicines do not work and/or have serious side effects. Echinacea and inhaled steroids also do not work. Vapor rubs, zinc (maybe- we discussed this in the past), buckwheat honey and germanium extract seem to help symptoms. Prevention – you can use probiotics, zinc, saline washes and the herbal prep Chizukit (contains Echinacea, propilis and vitamin C). In adults none of these really are that effective although garlic may reduce the incidence of colds (maybe because everyone who is sick will stay away from you) Hand washing will reduce the spread of germs (Am Fam Phy 86′(2)153) If you ask me- none of this is too impressive except hand washing. TAKE HOME MESSAGE: Wash your hands to be URI cold free. On a related subject- the mean cough duration in a URI is 18 days – long after the patient feels better already. – Please do not treat these folks with antibiotics. (Ann Fam Med 11(1)5) Another bone for my tree bark eating doctors- they did a multi centered, randomized blinded study of acupuncture in low back pain and it was no better than placebo (Pain 153(9)1883). Could it work for something else? Not sure as low back painers are tough cases in any cases TAKE HOME MESSAGE : Acupuncture doesn’t work for LBP

11)                 You can reduce post LP headache- but like good psychiatrist- you have to want to. In this questionnaire (I know, I know – only 51% responded) most did not use atruamatic needles and most used bigger needles. Many- 44% still recommend bedrest for a prescribed period of time and others used analgesics, fluid and caffeine none of which has been shown to really help. Yes caffeine does help a little, but the blood patch is the real treatment. (Dan Med Bull 59(76)A4483) TAKE HOME MESSAGE: We can do more to reduce post LP headache and give reasonable treatments for it. We just must get everyone to read –either the Danish Medical Bulletin or EMU. In my opinion- you are better off with the former. Especially if you like blondes.

12)                 And now let’s travel a little north to view some more blondes in this Swedish study. They took all these women with pylo and gave them either two weeks or one week of Cipro. Guess what? Seven days worked just as well as 14 (Lancet 380(9840)464). Couldn’t find much wrong with this study, and we do know that long durations of antibiotics just increase resistance- This kind of reminds me of BLS- hit them hard and fast. My question is – do these folks – if they do not look terrible- really need to be admitted since treatment was oral? Seems for the literature that the answer is- no. Of course- perhaps seven days may be too much as well. TAKE HOME MESSAGE: You can give oral treatment for pylo for seven days and that is enough. Speaking of blondes and Swedes- do you recognize this signing group who cranked out Dancing Queen, I do I do I do, Fernando, and SOS.

13)                 I certainly use dexamethasone for migraines that come to me- but they only work in 10% of patients – perhaps some more in higher doses. It is however, well tolerated (Post Grad Med 124(3)110) However, I do not believe this works on the short term, and this all depends how long the patients were followed. However, a similar metaanalysis AEM did back in 2008 (15(12)1553) was more optimistic. A randomized although small trial in 2011 found though that it did not work (JEM 40(4) 463) but again there may have not been enough follow up. TAKE HOME MEMSAGE: Dexamethasone is not that great for migraines, but it is well tolerated. My experience is that it does work, and the studies are not great.

14)                 Yes, a definite maybe- after all, these are orthopedists writing these articles. In clavicle fractures; kids always remodeled well, adults a lot less- in any case there is a big movement now to surgically fix displaced fractures especially in adolescents ( J Am Acad Ortho Surg 20(8)498) Are these just surgery happy orthos? Hard to say. Malunion is for real but is it a functional problem? How much displacement? My advice- consult. TAKE HOME MESSAGE: Clavicle fracture which are displaced may benefit from surgical repair- who gets an operation isn’t clear.

15)                 In my shop we are expected to start ticagelor – this stuff is supposed to reduce cardiac death and MI. There were significant questions about the efficacy and the safety of this drug (it is black boxed in the USA) (especially the PALTO trial) and as such the statistical reviewer and the cross discipline leader of the review team recommended against FDA approval. (Cardiology 122(3)144) Why it got approved is a good question and may be an ethical one as well (industry pressure?) but why should we EPs give such a drug with a block box for bleeding when it just may not be better than clopidgrel? TAKE HOMEMESSGE: Brillinta- when compared to Plavix- doesn’t shine

16)                 You should have known this. Benzos really have few indications other than for seizures. Mood disorders and anxiety – maybe, but SSRIs are better in the long term and in the short term clotiapine works well. Benzos are also not the best bet for sedation (I like propofol) and also not for intubated patients. Valium seems to be immunosuppressive, and has a relatively long half life (don’t let them fool you- so does midazolam – due to fat redistribution). Oversedation and undersedation are common and benzos cause a lot of delirium. They weaken respiratory muscles and increase ICU time. Alternatives? Remifentanil, dexedotmidine and propofol do not cause delirium and have shorter half lifes ( Chest 142(2)281). TAKE HOME MESSAGE: Benzos are not really the best bet for a lot of things we used them for in the past

17)                 Will mention this one last time – another randomized study that shows that antibiotics are the way to go for appendicitis. Sure 1/4 of the patients in this study ended up go to the OR and another 11% had a recurrence within one year, but giving antibiotics is much safer than operations. They did admit them for IV antibiotics with Tazobactam and PCN and it hey did well- discharge with Cipro and Metronidazole. (WJS 36(9) 2028) Only problem here is that it was not randomized. Patients choose what they wanted. Further more- did they really need Tazo? TAKE HOME MESSAGE: Antibiotics should be first line in appendicitis- perhaps

18)                 Do not really know the answer to this, but it will piss some folks off. California passed a law regulating how many patients can be treated by one nurse. As such, more nurses are now working in hospitals and the ratio of patients to nurses has come down. However on the quality indicators of post operative sepsis and respiratory failure there has been no measurable difference before the new law and after (Health Serv Res 48(2)435) What the article did not mention is that respiratory failure does poorly no matter what, and post operative sepsis may be a poor indicator- that could be due to surgical technique, OR sepsis or surgeries with high rates of sepsis no matter what. Greg Henry has gone on record on EM RAP saying that in the ED we do not need nurses- the work can be mostly taken care of by techs just like physicians assistants can do the work of an MD- AND THEY ARE CHEAPER! What do you think? TAKE HOME MESSAGE: More nurses with less patients duties did not result in improved quality

19)                 You really do not have to read EMU – just sum it up as – “everything you were taught was wrong”. And I’ll prove it. Use of FFP has not therapeutic benefit in 80 + trials of its use. Now they agree the quality of trials has not been the greatest- but when are we going to do good work and get the answers? (Transfusion 52(8)1673) Yes let me repeat it- it doesn’t work for coumadin reversal. OK, let me put my two cents in – it does get the INR down to 1.5 but that in many cases will not stop the bleeding. Interestingly enough- many of these studies were not done for INR excess but rather as treatment for snake bites, Myastenia and dengue. BTW, EM RAP also tried to slay another sacred cow by dissing Kexylate as been never proven to work and being dangerous- hey EMU reported on this way back in 2005. I like furosemide as a good treatment if the patient can urinate. Dialysis is always the best bet for CRF. TAKE HOME MESSAGE: FFP may not work – use PCC instead.

20)                 This was not a very interesting article- but then again, is anything in EMU? – but just to remind you- if you are going to inject a joint- remember that Depo Medrol has a half life of 1.8-2.2 days, Kenalog 3.2-6.4 days and Celestone 6.3 days. ( J Hand Surg Am 37(8)1718)

21)                 Let’s talk kids for the next two paragraphs- firstly we’ll give you some ideas for infantile colic. Let’s face it- we do not know what the cause of it is and the kids aren’t talking. First of all the red flags. Apneic episodes, cyanosis, vomiting, respiratory distress, and bloody stools. Even if you are an internists (which you probably aren’t because they would not have read this far into this) you would pick this up. Just remember intussusception and pyloric stenosis as causes. Also, large heads, hypotonia, petechia or low weight or any signs of sepsis (keep in mind maternal fever from group B strep in the Mom can cause neonatal fever). Second important point – – you generally do not need blood tests or x rays if the history is unrevealing. Here is their list: UTI, meningitis, otitis, constipation, cow’s milk allergy, GERD, hernia anal fissue, inborn errors of metabolism (oh, I hate those) hypoglycemia, hydrocephalus, trauma, abuse. Here is my list: consider also corneal abrasion (this happens a lot), constipation and the ever popular- diaper rash. Treatment. Well, the obvious is obvious, but if we are speaking of cow’s milk- use a formula that is completely hydrolysed. Replacing it with soy is not done anymore – it is allergenic. A hypoallergenic diet (no peanuts, fish etc) in moms who breast feed may help – just make sure the kiddies get enough calcium and vitamn D. Lactase supplementation may not help. Simthecone doesn’t help- or hurt either. Diclycimine and Cimetropium do help and do hurt as well- the side effects limit their use. They speak about all sorts of complementary therapy including chiropractic (chiropractic???) only pro biotics have shown any promise. If you are a European- you may know what gripe water is- it doesn’t work either. (BMJ 347.14012) TAKE HOME MESSAGE: Infantile colic- see list above. Do not do tests or films unless really indicated. Gripe water- give it to those who gripe. Not kids.

22)                 Really nothing new here, but we have new subscribers all the time – this is an executive summary of pain control in kids and I liked that the divvied it up into types of pain and quality of evidence. Here are the keys that you all knew already or should know- or at least will know- or maybe not care about. Breastfeeding during the procedure- lowers pain (in infants, silly). Sucrose helps as well. Use EMLA when you can. Do not take blood through heal sticks- use a vein if at all possible. Vapocooling may help (like Ethyl Chloride). Even if you anesthetize the skin, a suprapubic aspiration hurts more than a catheterization. Use nitrous oxide for LPs in kids able to handle it. Buffer your lidocaine- which we all know but never do, probably because it comes in big bottles and you waste most of the bottle. Consider closing head lacerations by the HAT technique which is simply tying two pieces of hair together on each side of the laceration and pulling taut. After tonsillectomy be liberal with lidocaine spray. Use bupivicaine when possible, use nerve blocks when possible. That is all. (Ped Anesthesia 22:1-79s) TAKE HOME MESSAGE: Kids do need adequate pain control and here are some tips- read the rest of the paragraph, big guy and be a better man for it.

23)                 I am not a woman, and like most guys, we do not really understand them that well. Actually, at all. We do however, want to help them when they come as our patients, but their genitalia are mostly internal and because of our lack of understanding, we end up doing painful, uncomfortable and futile pelvic exams. So how do we get better at this? Well, I was always embarrassed to say I learned on women who where under anesthesia for an operation – as was told to do so by my attending. Well, apparently I wasn’t alone. Many physicians learn this way. And there is a word for it – A crime (or in legal language- battery.) Ask your patients- only 19% have any thought that they would be examined in the OR by a medical student. Most of the time there is no consent and in awake patients: no introduction to the patients that the one examining them is a medical student. I am still embarrassed by this way of learning and believe strongly that is wrong. (CMAJ 184(10)1159) The solution is so easy- just get the darn consent. Learning is important. But respecting a person as a person and understand the license to help them that you have been granted is even more important. TAKE HOME MESSAGE: I have said enough. What do you think?

24)                 I really think that the FP’s literature should be up to the standards of all specialties but the authors of this how to paper on treating kidney stones obviously doesn’t read EMU. Listen guys- we do not do an abdominal film to look for stones, we do not give antispasmodics; and alpha blockers have been disappointing. Fluids may actually increase the pain through spasm. Now it pays to remember the causes of stones – including IBD, gout, bowel surgery, obesity DM hyperparathyroidism –see #1 above- D’oh and CRF. Most stones are calcium oxalate and are favored by an acid urine. Check the urine for a 24 hour phosphorus, magnesium, calcium, uric acid and citrate (which is an inhibitor of stone formation). Catching the stone? Really rarely happens. However a good point is increased fructose consumption predisposes to more stones- in the USA they use that a lot for sweetener. (AFP 84(11)1234) TAKE HOME MESSAGE: Good chart here for workup in preventing stones but the treatment is still the same.

25)                 This is one of those everything you wanted to know but were sorry you asked . There are four types of nonconvulsive status eplipticus. Absence, simple partial (patient awake, but somatosenosory symptoms or even hallucinations) complex partial (most common-they have altered mental status) and subtle (the most malignant). The latter is common in the ICU – perhaps in as high as 48% of the patients. Diagnosis is often tough- of course (see D’oh above) but if the patient doesn’t wake up an hour after a regular seizure- he might still be seizing- a little tough for me to swallow that- an hour of frying the brain doesn’t seem healthy. The treatment is the same as for regular status, but consider continuous propofol or ketamine for those tough to stop cases. Really stuck? Consider deep brain stimulation or hypothermia (Curr Treat Op Neuro (14:307) TAKE HOME MESSAGE: no new treatment options, but do not forget non convulsive status for comatose patients.

26)                 Here is the mail for this month. Firstly from Dr. Axel who commented on Farrah Fawcet Majors She is not a blonde. She is not a beauty. As far as pretty is concerned, Axel, if I am correct- you are from France and one cannot compare a country that gave us a fashion standard in Coco Channel to the USA whose fashion statement is most probably Lady Gaga. As far as a real blonde is concerned, I didn’t know that she was a fake (gosh, I am crushed) but let me in on an unpublished study below. BTW, I have no blonde fixations (although Randall Powell might) but I do not control the mail I receive, and I know we discussed blondes above in 11 and 12.

Test Hypotheses is: There are blondes in the world

Design: A convenience sample of 500 blondes was studied visually using the validated brown roots test. 85% were females, 15% were males. Consent was not deemed necessary

Results: There were no incidences of blondes who passed the test

Conclusion: The concept of natural yellow colored hair in humans is an illusion.  (This study was supported by a grant from Clairol) Next we hear from Ken Iserson who hails from Arizona and probably knew about the Camel Corps.        Great EMU issue, as usual, for August.


Good jokes (thanks to your wife), but you need to get the references correct. Someone voted “Miss Phonograph Record of 1966” would have had measurements including 33 1/3 (not 33 ½).


As for measuring physicians with standardized tests, it is becoming increasingly bogus. Now that everyone carries extensive portable brains in their cell phones, it is the aspects of practice not measured by these tests that is vital. Those include not only procedures and interactions with patients, family and other clinical staff, but also how to look up the information you need in a timely manner!


As for epinephrine and fingers, there’s lots of literature saying that even when people inject relatively large doses from Epi-pens into the pads of their own fingers (usually the thumb), there are rarely any adverse sequelae. (I embarrassed to say that I was once the recipient of such a dose into my thumb while trying to treat a patient; 12 hours later it was completely normal.) As usual, comments that are helpful and useful. I could not have said it better. The comment on standardized tests real demands we make a major change in our education system. What do you think?

27)                 Answer to number five- that was AL Lewis in the comedy series- the Munsters. And number twelve was the Swedish singing group ABBA They stop recording together in 1982- but they still get together every once in a while

EMU LOOKS AT: Iron and Sirens (in the head)

This month we look at two interesting (come on – after 37 pages what could be possibly interesting?) (Will you be quiet already so we can get this over with?) (Well, I am just telling the truth) (But no one asked you) subjects. Let’s get straight to them (good, you wasted enough time already) (again you making peole nuts?) (No, you are- who cares about what you write here?)(Well Chris Nickson does) (He is down in Australia, come on – they don’t even play real football) (No one in the world does except for USA and Canada) (You gonna mess with these guys?) ) The sources for thieve articles are PEC 27(10)978) and Clin Ob Gyn 55(3)810).


1)   Officially this article is about kids, but the principles are the same ( and that which I held back and didn’t day that kids are just little a…) (There you said it anyhow you pompous internist) (I am not an internist) (you act like one). Just remember, that the key in iron poisoning is knowing how much elemental iron was ingested not the amount of iron compound, For example, Ferrous sulfate only contains 60 mg of elemental iron despite having a dosage of 325mg. Ferrous fumarate has 10 mg. Ferrous gluconate has 36mg. Carbonyl iron has 45. Children’s multivitamins have up to 20 mg and adult’s up to 50. Prenatal have the most-up to 100mg. Important to note that there are no reports in the literature of fatalities from children’s multi vitamins. I will point out that this means no fatalities- but injury or poisoning can occur. Prenatal and adult MVIs are more dangerous to kids. The existing guidelines allow for home observation of children’s multivitamin ingestions that are asymptomatic.

2)   Severe toxicity is seen at 60mg/kg of elemental iron. 10 mg/kg can cause symptoms of toxicity. Less than this is usually safe.

3)   And now the moment you have been waiting for- the classic four phases of iron poisoning. Phase one is the acute injury. These symptoms can be non specific but are usually GI- nausea, vomiting and GI bleeding that can be upper or lower. However, even safer dosages such as 5 mg/kg can cause some diarrhea. If the patient does not display any signs of poisoning during this six hour period, the likelihood of serious ingestion is extremely low.

4)   Phase two is the latent period- and is from 6- 24 hours after ingestion. Here there is continuing cellular toxicity and organ damage, but some of the GI symptoms might improve. But then again they may not. And even if they do improve- it is never completely. Metabolic acidosis may develop here.

5)   Phase three. This can start anytime and can be earlier with higher dosages. Here there are signs of shock and – coagulopathy, acidosis, negative inotropy but no affect on vascular resistance. Coagulopathy occurs even if the liver is not affected.

6)   Phase four is within two days and here the liver is the target,. This usually requires an iron level of greater than 1000. Actually, it doesn’t happen that often.

7)   Phase five is the recovery. There can be fistula, strictures and internal scarring. Gastric outlet syndrome is common because of the damage done at the pylorus due to the tablets that congregate there. All in all – a pretty lousy way to go.

8)   Testing: here you need to go with the iron level. Concerning should be levels above 300 mcgs. But – do this measurement after four hours. WBC, glucose – not relevant. And yes- neither is TIBC-many reasons for this but let’s not get to involved. Abdominal films can show the pills to help guide WBI, but a negative film doesn’t help you at all.

9)   Here are your choices for treatment- pay close attention. Cathartics- don’t work. Calcium Disodium EDTA- used for lead poisonng- doesn’t work. Bicarb – no help here unless there is a bad metabolic acidosis. (I don’t believe it helps there either). Oral Phosphates- no help here either. Magnesium didn’t help but Kexylate did seem to help but it was a poor study. Lavage – well, no one is supposed to do this anymore. It can get out a lot of the pills, but it can push them further down the tract. WBI – whole bowel irrigation- is recommended- it is probably the best idea in an acute ingestion – but surprisingly – has only been shown to work in case studies. Give a nine month old- to six years- 500 cc, 6-12 1000 per hour and 13 – adult- 2000 ml/hr until clear effluent. Charcoal will not help.

10)                 Deforaxamine is the treatment. This chelates free iron and sends it out the door in the urine – imparting a pleasant vin rose color to the urine. Please do not mix this up with real wine; we do not want it to get to the Wine of the Month series. It will not help for iron bound to hemoglobin, hemosiderin, transferrin or ferriten. You can give this stuff IV or IM, and the dosages are as follows. IM it is 50mg/kg every six hours up to a dosage of 6 gm a day. IV is 15mg/kg for an hour, than 125 mg/hr. However IV is way more effective. In an emergency, giving 50 mg/kg per hour is probably safe. You give it until the urine turns clear again. Following serum levels of iron is not dependable for treatment purposes. This drug is not without dangers. Giving it too fast can cause hypotension, renal failure can happen, although most recover. ARDS can also happen but this is thought to be from infusions that were for long periods of time. Try to limit treatment to 24 hours. Yersinia likes iron to help it grow and there can be Yersinia sepsis when this med is given. Are you pregnant, mate? Well you can have this med – it doesn’t cross the placenta. This stuff works also for aluminum toxicity. It may chelate the stuff you use to turn your hair blonde

11)                 Oral chelation doesn’t work- yet- there are some things on the horizon. Iron is not dialyzable, but the iron –desforoxamine complex is. Plasmophoresis should theoretically work and in one case-was wonderful. Intralipid works for a lot of things- not sure if for this. And lastly an animal study showed that valium reduced morality without chelation. They do not know the mechanism but I am sure it has to do with them being happier


Neuro in Pregnancy

This is a rare review article on the subject and you should realize pregnancy can complicate things considerably. Let’s start with the most common

1)   Headache. This is present in 35% of pregnancies. Well let’s make this into a quiz. Give the most common headache that fits each below.

a) Most common headache


b) Mnemonic POUND

(Pulsatile, one day duration, unilateral, Nausea, Disabling)


c) Comes from use of pain relievers


d) Can have photophobia but no neural or autonomic symptoms


e) Increase in muscular tension


f) Associated with autonomic symptoms such as lacrimation and rhinorrhea


g) Occurs after consumption of >200mg of caffeine steadily for no less than a month,


h) Caused by vessel dilation under the dura mater

Depletion of serotonin along neural pathways and hormonal fluctuations


i) Greater chance of low birth weight and preeclampsia


A)   Migraine

B)   Tension Headache

C)  Withdrawal headache/rebound headache

D)  Cluster headache

E)   None of the above

2)   Are you crazy? I ‘m not giving you the answers!

3)   This is all fine if your pregnant patient comes in with a headache history but often it is the first time and you must rule out bleed, pregnancy induced hypertension and pre eclampsia. These probably make up 33% of all new headaches in pregnancy. Secondary headaches in pregnancy occur frequently with fasting or starvation being common causes (Hyperemesis). Other causes in the pregnancy period include stroke, sinus vein thrombosis, pseudotumor, and pituitary apoplexy. Let’s look into the dangerous headaches of pregnancy a little deeper

4)   Pre eclampsia- really can’t tell you anything new here that you do not know. Protein in the urine, relative hypertension (140/80) and of course bad headaches. SAH is not clearly increased in pregnancy, but is in the puerperium. Cortical vein thrombosis is a form of stoke which is specific to pregnancy. They can have HTN and neuro deficits of course, but also nausea, papilledema and altered mental status. Keep this in mind as they often are mistakenly diagnosed as pre eclampsia. Pseudo tumor does not occur more in pregnancy but it gets worse. It is a daily pulsating headache worse upon position change.

5)   Diagnosis- also nothing new here. CT is CT with all the radiation risks (about 5- 10 mSV) but one CT will not cause fetal loss, fetal abnormalities or more leukemia. Shielding probably makes it even less likely. Iodianted contrast doesn’t get into breast milk in sufficient quantities to affect neonates. So if you have to-just do it.

6)   MRI is fine as is the use of gandolinium.

7)   Treatment- tell them to get some sleep – even though they have another human kicking them in the ribs all the time. Exercise helps as well. NSAIDS are OK up too 30 weeks. Aspirin seems to be good all the time- never have seen any negative effects on the PDA with Aspirin. Paracetomol is of course OK, Optalgin- nothing to report here, but you can give phenothiazines and ondansetron. Steroids were thought to cause cleft palate- but if it does happen it is rare. Triptans seem to be OK; but only sumatriptan has earned a C category. As usual avoid opiods and erogtamines as well. Anticonvulsants are teratogenic.

8)   On to other neuro problems in pregnancy. Firstly CP. These folks often have epilepsy, bladder dysfunction, HTN GERD and osteopenia. There fore they have multiple issues- the mutagenic effects of the anti convulsants, worsening GERD and constipation, more pylo and spasticity. Similarly, women can have spinal cord injury and still get pregnant. Just remember that if the lesion is above T6 they can have ADR- autonomic dysreflexia – noxious stimuli from under the spinal lesion can lead to headache, nausea, sweating and runaway blood pressure. Noxious stimuli include IUDs, distended bladders, vaginal exams, PID and UTI, and labor and even breast feeding. ADR can lead to maternal intracranial bleeds and fetal distress. Also, spinal cord inuries and CP may not feel the contractions of labor. A third similar problem is MS, and 1/3 of women will have a flare during pregnancy.

9)   So what can you do? Vaccinate, work with the PT services, and give folic acid to those taking anti convulsants. Spasticity will worsen in pregnancy. Use glycopyrolate for anticholenergic effects. Patients’ need to know how to indentify pre term labor. ADR versus preeclampsia-ADR shows elevated blood pressure in a pattern mimicking contractions where as in pre eclampsia; symptoms are irrespective of contraction patterns. Not really sure what that means

10)                 Bell’s palsy – mostly occurs in the third trimester. Just remember Ramsey Hunt, Lyme, stroke, cholesteatoma, mumps and Myasetenia Gravis. Steroids are the generally way to go

11)                 Well, maybe I will give you the answers anyway to the head ache questions, but I think you all knew them. The answers to headaches- a-B, b-A, c-C, d-B, e-E,f-D,g-C,h-A,i-A

Hey a great New Year for all our Jewish readers! May we see peace worldwide!



EMU Monthly – August 2013

1)   So you have a patient who is overweight And you go to intubate him. This article looked at the Glidescope versus the Fastrach. Just to refresh your memory here is a Glidescope And here is a Fastrach And here is a dinosaurIn this study- both did well (ACTA Anaest Scand 56(6)755) While it is true there was no significant difference between the two, but the Glidescope did perform better than the Fastrach. And of course this study was done by airway experts; if you aren’t so good, your results may be worse, but most big people in the field believe that the these newer devices are superior than the dinosaur I showed above. We have a Glidescope in my shop- I love the visualization but the insertion technique is different and takes some getting used to. TAKE HOME MESSAGE: Glidescope and Fastrach are good ways of intubating the morbidly obese.

2)   A little early for the clinical quiz but that is just the way the reading went. And it is by one of my favorite authors- who I have never met- but I love his articles- Burke Cunha from Winthrop on Long Island. Here we have a 45 year old man with watery diarrhea, a maculopapular rash and fever. The rash started on his face and soon covered his whole body other than his soles and palms. Of note, the liver functions tests were slightly elevated. He had gotten all the childhood vaccinations. He had not been out of the USA recently. While this looked to the authors to be either C difficle or a drug eruption- investigations revealed none of this. This is not a weird syndrome like last month. The rash looks like this: Want to take a guess? (J Clin Micro 50(6)1835)

3)   Oh, otitis externa isn’t interesting at all. Well, you bet you’re sweet bippy it is (OK, old guys- who said that?) Otitis externa has a few dangers to think about. Remember that painless ear discharge can be a cholesteloma which can be dangerous if not taken care of. Another look alike with hearing loss, cranial nerve palsy, and fever- can all be signs of necrotizing OE- which is actually an osteomyelitis. Be careful especially in diabetics- this is the one case where you need real antibiotics and not just the drops. Do not forget foreign bodies as causes of OE. If there is pain behind the ear- consider mastoiditis. None of the above? just give them the drops. (BMJ 344:E3623) TAKE HOME MESSAGE: Otitis externa can be dangerous in rare cases- watch it in diabetics. Consider all foreign body and cholesteoma. Our quotes of the month- you think you got a tough life? Listen to these sad folks- you ain’t got it as half as bad as Rodney Dangerfield and Phyliis Diller. Rodney first: “My wife and I were happy for twenty years. Then we met”   I had plenty of pimples as a kid. One day I fell asleep in the library. When I woke up, a blind man was reading my face.

4)   Low voltage on EKGs—can be the machine and can be a pericardial effusion- but you are not going to miss those things. Think about some others, however. Here is the list- ischemic cardiomyopathy, amyloid, scleroderma, hemachromatosis, mxyedema, neonatal hyperbilirubinemia, hypothermia, obesity, COPD, pneumothorax, pleural effusion, anasarca, and massive MI with poor LV function. Got it? Well, will use this opportunity to give a shout to Dr. Goh- our only subscriber from this country- and yes please invite me for a guest lecture- I will cover three dollars of the ticket!( Singapore Med J 53(5)299) TAKE HOME MESSAGE: Lots of stuff can cause low EKG voltage- see the list. “What a kid I got, I told him about the birds and the bees and he told me about the butcher and my wife.”“I told my wife the truth. I told her I was seeing a psychiatrist. Then she told me the truth: that she was seeing a psychiatrist, two plumbers, and a bartender.”

5)   Bob Centor weighs in on his Centor criteria- which, as we reported in the past- have been under a little fire recently. Recall his four point scoring system consisted of – fever, no other reason for a sore throat (sneezing, coughing etc) exudates on the tonsils and anterior lymphadenopathy. He points out that his works well for pre adolescents- those whom RHD is most commonly seen. However as kids become young adults the beast- that is group A strep seems to change – or maybe it is the host. Firstly, older kids and adults respond well to PCN- with a two day reduction of symptoms- this reduction is not seen in kids. Non group A occurs more often in older people- and antibiotics reduce the symptoms about one day. Thirdly everyone can get EBV but only young adults get the full blown mono syndrome. Fusobacterium infection – the cause of Lemiere’s syndrome- an internal jugular thrombophlebitis- is more of a disease of young adults than kids. Now in the original scoring – we treated four points empirically and tested three and two but often we just treated three and two as well. What about with older kids and adults with two and three points? Well, if you just throw on the antibiotics it will reduce the symptoms (my comment- a day is not worth the dangers), although this may not be true with Fusobacterium infections where symptoms may persist. Treatment will reduce the spread of the disease to others (my comment: the IDSA guidelines we quoted last month disputed this) it will reduce the suppurative complications (my comment: RHD is much less likely in adults and nothing prevents glomerulonephritis). He claims that the failure of his score when it occurs is due to non group B and fusobacterium which is nearly impossible to test for- so he says –with a three of a four- just throw on the antibiotics. I am just an ant compared to Dr. Centor, but I do not agree with the use of antibiotics with out good reason. However, this should give you the tools to discuss this with your patients and do shared decision making ( Arch Intern Med 172(11)852) TAKE HOMEMESSAGE: Should you treat sore throats that have Centor scores three in older kids and young adults? Yes. Or no. Or maybe. “A girl phoned me the other day and said, ‘Come on over. There’s nobody home.’ I went over. Nobody was home.”   “When I was born I was so ugly the doctor slapped my mother.”

6)   This meta analysis found that old blood results in more mortality. What is old blood? Well, all blood is thrown out after 42 days. Here they arbitrarily decided on 21 days as being old and there was an increase in mortality in using blood older than 21 days. (Transfusion 52(6) 1184) This is all cause mortality, but it is unclear if the two arms- those receiving old blood and those getting newer blood – were equal. Furthermore old blood being more than 21 days old needs to be refined- perhaps the mortality will get to zero if the blood is 5 days. Or 10 days. They also did not take into account multiple transfusions to the same patient. But in any case – if you can control it- try getting the freshest blood you can- or auto transfuse. TAKE HOME MESSAGE: Old blood- greater than 21 days – may increase mortality. “Look out for number one and try not to step in number two.”One year they asked me to be poster boy – for birth control.

7)   Not many articles on the subject- but this just shows how little we know. These olecranon bursitis patients did well if they had aspirations (sometimes repeated) and antibiotics. Of course sicker ones needed surgical procedures and IV antibiotics (J Hand Surg AM 37a(6) 1252) The real question is if they needed the antibiotics. These are orthopedists so we may never know. TAKE HOME MESSAGE: Olecranon bursitits- does well with aspiration. Ab?  We sleep in separate rooms, we have dinner apart, we take separate vacations – we’re doing everything we can to keep our marriage together.   I went to see my doctor. “Doctor, every morning when I get up and I look in the mirror, I feel like throwing up; What’s wrong with me?”
He said, “I don’t know but your eyesight is perfect.

8)   This is a shut case. When you inject fingers with epinephrine. They fall off. All of them. And they get icky and necrotic and then just fall on the floor. Truth be told – all of these fingers falling off occurred before 1950. Since then – in at least this series- they have done over a thousand with no problem (ibid p1254) TAKE HOME MESSAGE: Inject those fingers with epi – and enjoy a bloodless field and longer anesthesia- the finger will not fall off.



Its been a rough day. I got up this morning, put a shirt on and a button fell off. I picked up my briefcase, and the handle came off. I’m afraid to go to the bathroom.


   My wife is such a bad cook, if we leave dental floss in the kitchen the roaches hang themselves.
9)   OK time to be a real man The patient: an anticoagulated PAF patient with minor head trauma. The CT- normal. What do you do next? Well, these kinds of bleeds are slow, and 1 in 25 patients taking anticoagulants will have serious delayed bleeds. So if you are an European, your guidelines say do another CT in 24 hours. . But not everyone can do that outside. So admit them and do it through admission. But this is expensive and we all know that neuro checks in the hospital are worthless. So what should you do? Just call your patient or invite them back to see how they are. (Ann Emerg Med 59(6)457). TAKE HOME MESSAGE: Minor head injury in the anitcoagulated patient- is a slow bleed- be careful OK, so time now to be a real woman

10)                 Are you a sputum lover? You can confide in me- I’ll never squeal Does the color of sputum really make a difference? Well, at least in COPD patients – the sensitivity of green or yellow sputum was actually pretty good but specificity was terrible – that means you can not consider yellow or green sputum as being bacterial. (Eur Resp J 39(6)1354) What to do with this information is another matter- in COPDers who are constantly colonized- there is much you can say by this. TAKE HOME MESSAGE: Sputum color is a useless parameter. And please don’t consume that stuff. One day as I came home early from work, I saw a guy jogging naked. I said to the guy, “Hey buddy, why are you doing that?” He said, “Because you came home early.”

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

11)                 This has nothing- absolutely nothing to do with EM- but I do want you to be healthy. This meta analysis from China says the more fish you eat- the less chance of colon cancer. (AJM 125(6)551) Now this is all fish- I am sure there are fish that are better for you and some that aren’t which is probably why the reduction was only 12%. In addition – the decrease was significant for rectal cancer but much less for colonic cancer. And besides you end up smelling like fish. TAKE HOME MESSAGE: Fish reduces rectal cancer rates and to a certain respect –also colon cancer. Sputum does not have the same effect. This blond beauty was once married to Lee Majors and was one of the original Charlie’s Angels. She died of rectal cancer in 2009. Who was she?My psychiatrist told me I was crazy and I said I want a second opinion. He said okay, you’re ugly tooI’m taking Viagra and drinking prune juice – I don’t know if I’m coming or going.

12)                 Lidocaine works well for local pain. Inhalations may help asthma and hiccups- the evidence isn’t that convincing. It is used to attenuate ICP elevations in intubation. And it is a wonderful anti arrhythmic. But giving it IV to deal with procedure pain or burn pain- didn’t help. OK, it was only one study…but (Cochrane 6:5622 2012) Lidocaine works well for local pain. Inhalations may help asthma and hiccups- the evidence isn’t that convincing. It is used to attenuate ICP elevations in intubation. And it is a wonderful anti arrhythmic. But giving it IV to deal with procedure pain or burn pain- didn’t help. OK, it was only one study…but (Cochrane 6:5622 2012) This morning when I put on my underwear I could hear the fruit-of-the-loom guys laughing at me actually- that isn’t only Rodney that has this problem- My Playtex Living Bra died of starvation – Phyllis Diller

13)                 I am going to be honest- I would have blown this. Lady who takes Topiramate comes in with a worse than usual migraine headache complaining of blurry vision. What do you do now? CT? It was normal. Swing and a miss. LP? It was also normal- another strike.   Neuro consult? Strike three you’re out. How about acute angle closure glaucoma secondary to Topiramate? (AJEM 30(5) e3) Blurry vision in headache is just so common and we usually dismiss it. TAKE HOME MESSAGE: Blurry vision and headache can be glaucoma and can be from meds. “What a dog I got. When he realized we looked alike- he killed himself.” “I went to this great massage parlor- it was self service.

14)                 We have spoken about this before but it is good to review – the PERC rule consists of eight criteria- age below 50, pulse below 100, oxygen sat above 94% , no unilateral leg swelling, no hemoptysis no surgery or trauma in the last four weeks, no oral hormone use, no DVT/PE history. This rule is good to rule out PE, but being positive on any one or more criteria tells you- nothing. However, with a normal PERC score you do not need a D Dimer (Ann Emerg Med 59(6)517) Of course if you ask me, you never need a D dimer. TAKE HOME MESSAGE: Use PERC for PE ruling out instead of a D dimer. I also use Wells with it. “My wife- she is just so fat. I once hit her with a car and she asked why I didn’t go around her. I answered “I was afraid I didn’t have enough gas.”

15)                 We think we know that not everyone with PAF needs anticoagulation. And there are definitely dangers with it. They developed the CHADS-2 instrument to help with this but now this has been supplanted with the CHA2DS2-VASc score. CHADS2 is one point for CHF, hypertension, age greater than 75 and stroke, with greater than 2 warranting consideration for anticoagulation. The latter includes 1 point for CHF, HTN, DM vascular diseases, age above 65, and being female. Two points are given for age above 75 or a history of stroke. Here too – greater than two points warrants giving anticoagulation. (Indeed the second score will result in more people in the high risk group-see the last abstract #29) (AJM 125(6)603) but it seems to me that if they keep changing this, than it may not be that good of a tool after all. I am sorry, I still remember a young person that I did not give Coumadin to who stroked out. I may not give it to older folks who don’t qualify, but I do to the younger folks. TAKE HOME MESSAGE: CHAsDs2-Vasc is somewhat more inclusive, whether it is better is questionable. “My wife has a face like a saint- a Saint Bernard.” “Some kid I got. He scotch tapes the worms to the sidewalk and watches the birds get a hernia”

16)                 Kiddies with chest pain are just like little adults – stress testing is very low yield. However, so were the echos. EKG is the big test – but even here, picking up long QT and WPW in their series was rare. However, pulmonary function testing was much higher yield – a lot of these folks just had reactive airway disease. Now there was referral bias here and it was retrospective. Nevertheless, I think an EKG will suffice in most cases. Syncope is more worrisome, especially after exercise. (Clin Ped 51(7)659) TAKE HOME MESSAGE: Echo and stress tests are low yields in kids. Some kid I got. He put Krazy Glue in my Preparation H.” “My wife just had her driving test. She got 8 out of 10. The other two jumped clear.

17)                 This was good shtick, but I do not know how useful it was- maybe my trauma pals from last month can tell me. This is a case report of a stable abdominal stab wound patient who had is wound irrigated with povidone iodine and some air mixed in. He then worsened and in the CT scanner- the air and iodine form the irrigation outlined the injury. (AJEM 30(5)835) . TAKE HOME MESSAGE: Is there one? Time for Phyllis Diller’s brand of depression.(BTW Burt Reynolds was a hunk from the eighties)Burt Reynolds once asked me out. I was in his room.

18)                 Let me make something clear – there is a fine line between heretic and lunatic. I think with regards to the house of medicine – I have been both. This opinion piece challenges the fluid bolus we give people in shock. He points out- rightly so- that we spend more time studying which fluids (crystalloid versus colloid versus sputum) and what the physiologic effects are then whether it improves patient outcomes. Maybe, just maybe hypotension in shock is good for you. Maybe, just maybe, pouring lots of cytokine rich poisonous blood around the body is not a healthy thing. Folks who get fluid loaded get more ARDS. He then presents an article of 3000 kids who had greater mortality if they got saline or albumin. However, many of the kids were questionably shocky. There are studies now in progress, but until then, give fluids judiciously and consider pressors earlier. (although I haven’t seen any survival benefit to pressors either) (Crit Care 16:302) Now this may not be true for all types of shock ,although we now know that in trauma it is best to leave them someone hypotensive. TAKE HOME MESSAGE: Fluid bolus therapy in shock may not be a good idea

19)                 Ischemic colitis is common in the elderly and shouldn’t bother you. It should bother you if the patient is young and a cocaine user. They have abdominal pain and bleeding – make sure you image them. This has a high mortality (GI Endoscopy 75(6)1226) TAKE HOME MESSGE: Careful with ischemic colitis symptoms in the young adult. It could be Cocaine Ischemic Colitis“My husband can’t stand to see trash and garbage lying around the house. He can’t stand the competition” “I should have suspected my husband was lazy. On our wedding day, his mother told me: “I’m not losing a son; I’m gaining a couch.”

20)                 This subject is hot – I mean really hot. If you are not an American- you have to know what is going on. In the USA- they have a rule that if there is an iatrogenic infection such as from a catheter- the hospital eats the charges- the insurance doesn’t have to pay. This article carries this a little further. In South Africa- and this could be in other places as well- – a hospital can be labile for damages if they fail to implement infection control policies or even if the staff fails to comply with them (So Afr Med J 102:353). This last premise seems a little sticky – what can a hospital do if the staff does not comply? What you must take home here is that hospitals are and you are going to are going to be eating a lot of money for your infections. I have I think one So Afr subscriber- what can you say on this? TAKE HOME MESSAGE: Infections are becoming unforgiving and will affect (and infect) your wallet. It would seem that something which means poverty, disorder and violence every single day should be avoided entirely, but the desire to beget children is a natural urge.

21)                 I am looking for solutions for longer term pain control that lidocaine can not give. I used to use bupicvicaine but I have been disappointed- it lasts about four hours. However, if you liposomal it- that is liposomal bupivicaine- you get great pain control. This stuff lasts 96 hours and can be instilled during the painful procedure directly into the affected area. (Pharmcother 32(9 suppl) 19s). While our procedures do not tend to be that painful or extended- it is an option for those post op pains (extractions, buionectomies etc) that we see in the ED. TAKE HOME MESSAGE: Liposomal bupivicaine gives an option for long term pain control.“It’s a good thing that beauty is only skin deep, or I’d be rotten to the core“My photographs don’t do me justice – they just look like me.” “You know you’re old when your blood type has been discontinued“.

22)                 Another non clinical article, but I doubt that anyone other than Ken Iserson is still reading at this point, and he likes this stuff. Although this is an older article – I missed it last time around. Standardized tests are great- they are reliable, they are fair and they are objective. But they are probably not a good idea for medicine where we should be emphasizing more important capabilities such as creativity, thinking process, critical thinking, fund of knowledge and collaboration (J Am Coll Rad 8(4)271). I think that the department chairman or clinical instructor is the best way to decide who should go further in their, as well as clinical presentations/oral exams. Anyone can be good at taking standardized test (remember, never give three “all of the above answers in a row”) TAKE HOME MESSAGE: Standardized tests may not be the best way to rate a physician.Women want men, careers, money, children, friends, luxury, comfort, independence, freedom, respect, love, and a three-dollar pantyhose that won’t run.

23)                 You give Ketamine- you will see vomiting. Doesn’t bother us much but it does bother patients and their parents. Older kids seem more likely to vomit (actually, though, I never see it in adults) and they postulate that higher BMI kids do as well. (PEC 28(11)1203) I wish I could believe this, but this was a retrospective study with no reasons given for giving odensetron- could be it was prophylactic. Furthermore, no physiology is presented to explain this TAKE HOME MESSAGE: Ketamine causes more post sedation vomiting in older kids and possibly fat ones. “You know you’re getting old when your back starts going out more than you do”. If you are old enough, you’ll getthis one: “They just elected me Miss Phonograph Record of 1966. They discovered my measurements were 33 1/2, 45, 78!”

24)                 This so doesn’t interest me, but they do this at my shop. NAC to prevent contrast injury has never been proven to work. You want to see both sides of the issue- the article. I’ll just go back to sleep (Cleve Clinic 79(11)746) “The reason women don’t play football is because eleven of them would never wear the same outfit in public

25)                 I have gone over this over and over again, but here is the list so you can remember it. Troponin concentrations can be elevated in sepsis, amyloidosis, intracranial hemorrhage, hemo dialysis; chemotherapy induced left ventricular dysfunction, fragility, hip fracture, CHF, COPD, and defibrillator discharge. Normal troponin is a bad sign in CHF with myocarditis. (AJM 125(6)527 ). Troponin can also be elevated in aortic dissection. TAKE HOME MESSAGE: Troponins are specific for the heart- NOT!!!!“I hate smart sales clerks. I said to one, “What do you have in lingerie?” She says, “More than you’ll ever have!”

26)                 If you are an Israeli- I would appreciate you reading this article. If you are a lawyer (yes they read EMU) – please read this. Guidelines- are not law. They are not rules. They aren’t even good suggestions. Doctors often roll their eyes oabout guidelines when they know they are harmful but even so they abide by the same ones they see as harmful. They are based on expert opinion in most cases of whom 71% have significant industry ties. (BMJ 346: f3830 ). I have other problems with guidelines. They can be old. It takes a long time to produce them and the information could have been changed. They are not usually based on enough evidence and the guideline is not constructed to take this into account. They are used by lawyers as law and not suggestion. They are often written by doctors with no ties to EM or who do not understand what goes on in smaller hospitals or hospitals with different patient populations. And they blunt the creative diagnostic process we all need as physicians. TAKE HOME MESSAGE: Guidelines are to guide – they by definition cannot account for all issues- and they are so biased. “It’s hard to find a negligee in my size. I wear a Junior Mister”

“I’m the only woman who can walk in Central Park at night… And reduce the crime rate



28) Well, I guess some one had to write this article – it is all you need to know about feeding tubes. This is a really dry subject (well, actually, not really – it is quite fluid) but if you work in a nursing home or if you live in one you gotta know a few things. First of all feeding tubes do not improve outcomes of pneumonia, pressure ulcers, or nutritional status – nor do they lessen mortality in dementia. They calm that decreased oriel intake does not cause hunger or discomfort in the terminally ill- I find hay hard to believe, epically as I write this during the period that for Jews is Tisha Bav- a fast day and Muslims is Ramadan – a month of fasting. In any case, in most instances the feeding tube will be in the stomach; indications for small bowel placement include severe pancreatitis, GERD, gastric outlet obstruction or altered gastric anatomy- like perhaps – the sleeve operation. Small bowel feedings may cause less reflux, aspiration pneumonia and ventilator associated pneumonia, but the studies are equivocal. Leakage is common, irritation of skin wall as well, but frank infection is unusual. The rest of the article describes troubleshooting, but this depends on the type of tube they put in and its makeup. (Nutr Clic Practice 2012 27:238) All I can tell you – is do not force things. A tube that is in the duodenum is smaller in diameter than gastric feeding tubes and forcing them in can cause tears. TAKE HOME MESSAGE: Feeding tubes- all you ever wanted to know- And yes, father Greg- you can give a 2008 Chardonnay Bleu form Ernest Gallo and sons via the feeding tube.Most people get an appointment at a beauty parlor… I was committed!

I’m eighteen years behind in my ironing. There’s no use doing it now, it doesn’t fit anybody I know.

29)                 This is real important; I have no idea why I hid it in the back. People do have real angina and do make real MIs and do have real ACS and still have normal coronaries. How does this happen? Actually before I answer you the numbers are pretty impressive. In a study by Patel et al, where they did angiograms on chest pain patients- 400000 of them- only 37.6% had 70% occlusions of major vessels or 50% of the LAD which by all measures is borderline. All the rest had minimal occlusions. 105 of patients with troponin elevation have a normal PTCA. And here is the kicker- they have a worse prognosis. So what are the causes? One is hypertension – it causes microvascular dysfunction and reduced coronary vessel reserve. You can best diagnosis this problem with a stress echo. Go for ACE or Calcium channel blockers as treatment. Microvascular disease is another problem but you aren’t going to find it without really hard tests to get (what? you don’t have a pocket PET scanner in your lab coat? It is usually found next to the Gallo Bros Chardonnay) Just know this could be the cause in people with traditional risk factors and normal coronaries- reduction of risk factors may help control the disease. Cardiomyopathies and those with coronary artery disease can also have this. Nitrates do not wok well here; calcium channel blockers may. Syndrome X- they have ST depressions, angina symptoms, and – no risk factors. This is also a form of microvascular disease; they treat with ranolazine. Lastly there is Prinzmetals; these people can even have ST elevation- this is “tonus” at the site of a plaque. They should get calcium channel blockers, nitrates, and statins even if their cholesterol is fine. And do not forget one other cause- myocarditis. (Heart 98:1020) Notice something? Beta blockers were not mentioned as being of any benefit here. That is a surprise? No. TAKE HOME MESSAGE: Normal coronaries do not mean a normal heart. “I’ve been asked to say a couple of words about my husband, Fang. How about short and cheap

30)                 Let me tell you something about your self- you have an undiagnosed psychiatric disorder that causes you to dream about baobab trees and have a cancer that will kill you when you reach age 152. Your answer will be-who cares? And you are right –so why- as technology improves-are we chasing and screening and incidental- omas that have no relevance? In addition by changing definitions we have suddenly made more people sick- like everyone has ADHD now Many cases of osteoporosis and cholesterol – up to 80% according to them now have these diseases and has no relevance. And of course, we won’t mention those ubiquitous and annoying subsegmental PEs. What is the solution? They are having conferences about this but you can learn more by going up on www.preventingoverdiagnosis.net (BMJ 344.e3502) TAKE HOME MESSAGE: We over diagnose. Period. Let’s leave healthy people alone. “Never go to bed mad. Stay up and fight.”

31)                 Hey the mail bag has been active. Here is first of all a correction. I know Brian Mac Murray well and he is a very intelligent doctor-so I should have realized that when he wrote about Azithromycin being a great antiviral – he didn’t make a mistake, rather he meant: it is being used as an antiviral – that is for bronchitis and sinusitis which are viral diseases- we treating with azithro. OK, Brian- got it- and I apologize. Ken Iserson checked in and so did Knox Todd- here is what they had to say: Ken: Good issue, as usual (July).


Once again, you cited (and praised) some folks for doing the same work I had already cited in Improvised Medicine (I wish they’d simply read the book!) about using bacteriostatic saline as a good local anesthetic. I also discuss using injected sterile water (“aquapuncture”), antihistamines, antidepressants, narcotics, and using various cold and pressure techniques. Here’s the section on bacteriostatic saline from page 179 of Improvised Medicine:


Bacteriostatic Normal Saline

Benzyl alcohol, the preservative in bacteriostatic NS, is an ideal alternative local anesthetic. Inexpensive and readily available, bacteriostatic NS is frequently used to flush IV catheters and to dilute or reconstitute medications for parenteral use.

Benzyl alcohol (0.9%) can be mixed to a solution with 1:100,000 epinephrine. This formulation is less painful, but slightly less effective, than 0.9% buffered lidocaine. In children, the pain on injection is about the same as that with lidocaine.(24) Without epinephrine, the anesthetic effect of benzyl alcohol lasts only a few minutes.(25) With epinephrine, the anesthetic effect begins to diminish about 20 minutes after injection. Prepare a benzyl alcohol-epinephrine solution by adding 0.2 mL epinephrine 1:1000 to a 20-mL vial of multi-dose NS solution containing benzyl alcohol 0.9%.(12)” And here is Knox: Regarding EM/palliative care, our good friend Gil Shlamovitz recently authored a case study bringing two of my favorite topics – ketamine and palliative care – together (see attached).

For emergency physicians looking for more, the IPAL-EM website has a number of tools to offer. Check them out at  http://www.capc.org/ipal/ipal-em

True Knox, but take some credit too- you were an author of this paper too- It was in JEM in 2012 and was very interesting. I BTW have had a lot of success with ketamine in RSD and fibromyalgia Thanks to both of you for writing

32)                 The answer in number two above was Measles. I could give you a quick review of this, but you should know about it- it is spread by the airborne route and antibody titers after vaccination may not be enough to imply protection. Diarrhea is rare. Coryza and the rash were typical. Koplik’s spots are of course very helpful. Want to know more- press on the link ( J Clin Micro 50(6)2184) And in number three- Dick Martin would say that to Dan Rowan (these two folks on the TV show called Laugh In back in the late 1960s . This show launched the careers of Lily Tomlin, Goldie Hawn, Richard Dawson, and Ruth Buzzi. And in 11- that was Farrah Fawcett. She was only 60 when she died.


Correct. We are going to discuss two disease complexes that involve the joints. I don’t know about you, but I am really weak in rheumatology. Now two of these articles have to do with pediatric rheum- BUT DO NOT SKIP THEM- alot of the entities in pediatric rheum are similar to adult ones. The sources for the peds rheum are Ped Clin Am 59(2)407, and ibid 59:285,, the second essay is from Int Med J 42:1445


1)   Almost all of these start out the same way-that is – non specific. Fever, malaise, and elevated acute phase reactants such as CRP or ESR. Yeh, rashes and glomerulonephritis help, but that is much later on. Other general principles are – take blood pressure even though it is a child. Takayasu characteristically causes differential HTN so check in all four extremities. Bruits are often common. Livideo Reticularis is also common. And do a good neuro exam- you’ll see more on this later.

2)   Most common rheum disease in kiddies is one we all have seen and in adults too. Henoch Sholein Prupura or HSP is fairly common and it is a vasculitis of the small vessels. Your typical patient is white, male and between the ages of 4 and six. Viruses, bacteria and FMF (Familial Mediterranean Fever) may all be risk factors. These present with lower extremity purpura, abdominal pain and renal disease. The rash can become bullae or even necrotic.

3)   It can affect the joints especially the knees and ankles but it is non destructive and self limited. GI manifestations include bleeding and pain; this can lead to intusseception. Renal disease is usually microscopic hematuria. Renal failure is rare.

4)   HSP can look like TTP, hemorrhagic edema of infancy, ITP, DIC, HUS post strep GN and hypersensitivity. Treatment for HSP is supportive: fluids and NSAIDS. Steroids seem to help for GI complications in severe cases, mild cases- controversial. It probably doesn’t help in preventing nephritis. Severe cases may need cyclophosphamide or plasmaphroresis.

5)   Kawasaki disease- we discussed this only a half a year ago. Conjunctivitis is the most common finding as is prolonged fever; the cervical adenopathy is the least often seen. What is interesting is that there are some symptoms that are not part of the diagnostic criteria including diarrhea, vomiting, and abdominal pain. Also scrotal pain and swelling (found usually in males only) dysuria. Knees ankles and hips can have arthritic symptoms. KD can look like viral exanthams, JIA (formerly JRA) polyarteritis nodosa, and Stevens Johnson. The treamtnet is aspirin, IVIG – steroids are questionable.

6)   Polyarteritis nodosa: This is also associated with FMF. In adults it is associated with Hep B. In general, adults do worse with this disease than kids. This disease can affect the vascular supply to any organ- especially the skin, kidneys and GI tract. Lung involvement is rare. The presentation- not surprisingly is fever, malaise, weight loss, myalgias and arthalgia. Here are some signs that must make you think of this disease in anyone but especially kids: HTN, IHD, testicular pain( also found more often in males) abdominal pain, hematuria, proteinuria, mononeuritis multiplex., Here you may also see digital gangrene and levedio retiuclaris and purpura. Treatment includes steroids, stronger immunosuprression and biologicals

7)   Takayasu’s is a vasculitis that likes big arteries- it goes after the aorta, renal,subclavian and carotid arteries. In the initial presentation-as usual- not much that is specific- headache, dizziness, visual loss, claudication, fever and abdominal pain. HTN is present in almost every kid. Because if involvment of the aortic arch there can be CNS manifestations and cardiac manifestations including seizures and stroke. The best way to diagnose this is with CT or MRI. The treatment is the same as the others, but less successful, for example, steroids help only in 60% of cases.

8)   OK, adult docs- you can skip this one- you will not see this in your practice. PACNS is childhood primary central nervous system vasculitis. These are kids who – fairly suddenly –develop terrible neuro and psych changes. It comes in two flavors- big vessel and small vessel. There can be focal signs but the CSF and inflammatory markers are negative. This can be devastating but if caught early it can be reversible. Treatment is steroids and immunosuprresive agents, and anticoagulation., Sometimes, only a brain biopsy can confirm the diagnosis

9)   Almost done the vascultides- ANCA vasculitis. Not familiar to you? Well it is now considered a group of vasulitides that you may recognize-Wegener’s Granulomatosis, Microscopic Polyangitis (MPA) and Churg Strauss syndrome. These entities may cause rapidly progressive glomerulonephritis, pulmonary hemorrhage, and respiratory and renal failure. The mortality is 100%- that is if you do not treat it. Relapses are common. As usual, this starts as fever and malaise. Weight loss as well. 80% then develop pulmonary manifestations which can include respiratory failure. Renal failure and bleeding in the upper respiratory tract occur in about 3/4 of the cases. Cyclophosphamide is tried but infections commonly occur as do relapses. Biologicals and plasmapharesis seem to work better. Mild cases can respond to steroids.

10)                 The rest of rheumatologic emergencies are kind of rare and come from the second article. To make your life easier, if you are an adult doctor, what is in italics are things you will need to know. The rest will be for Peds guys and EPs.

11)                 OK so you have a neonate with CHB. You know this because you were monitoring the birth and you saw bradycardia. They may also be in CHF and have a pericardial effusion. Do some blood tests and you may find elevated liver enzymes and low platelets. And you will occasionally find a rash. Yes even at this age you can see immune mediated damage to the AV node and this is probably neonatal SLE. Females present with this more, and they may have oral lesions (usually a hard palate ulceration – this is not an apthous ulcer) and generalized lymphadenopathy. In older folks- kids and adults- you can see arthritis and edema, with vasculitis changes, pericarditis, pleural effusions, chorea, psychosis and headache. Urinalysis shows protein and blood. Hemolytic anemia, low platelets and WBC will also be present. Look also for hepatosplenomagaly. Mom should be given florinated steroids if the this is diagnosed in utero, and beta sympathomimetic agents can be given to the neonate as a temporizing measure, These little ones may need a pacer

12)                 Febrile kid with pancytopenia can be macrpophage activation syndrome. Yes, of course you also need to think about leukemia, but do not forget this. It can be triggered by SLE, Kawasaki and JIA all of which can be seen in adolescents and adults so keep this in mind in unexplained fever and neutropenia. Look also for splenomegly Ferriten may be very high; there may high triglycerides, hepatic enzyme elevation and coagulopathy. SLE can also cause fever and cytopenia- but not this bad. JIA has an especially high ferriten and salmon colored plaques. Give these people antibiotics and high dose steroids. There may be a need for immunosuppressive therapy

13)                 Respiratory distress and renal failure: think SLE here too, but also consider Goodpasture syndrome and ANCA vasculitis. We discussed SLE and ANCA already. Good pasture is primarily a glormulonephritis, and the presentation with a falling blood count, full alveoli on chest film and protein in the urine are quite impressive., The diagnosis is by anti GBM antibodies in the blood and IGG deposition in the glomeruli with crestent changes on biopsy. Treatrnent is again steroids, but palasmapharesis works well for ANCA and Good pasture.

14)                 I guess you could see this in adults, I have never heard about it, multiple organ dysfunction, (Hell, that can be due to anything). But if you can find thrombosis and systemic inflammatory response- think CAPS-Catastrophic APLA syndrome. Infection is a trigger as is malignancy and SLE. Since this is primarily small vessel occlusions, they go into ARDS, have PEs, CVAs. seizures, and encephalopathy. Cerebral venous thombosis may occur. Renal failure, abdominal pain- then progression to DIC. You need to recognize this fast, but don’t look at me – I will for sure blow this one. Dialyze, ventilate, treat infections, and give steroids. IVIG, plasmaphoresis anticoagulate. Got it? Forget it chief- if I see this, I give up and will go to be a plumber.

15)                 Lastly pericardial tamponade in kids- think again SLE and JIA although viral infection should be high on the list as well




Our Second essay has got to be one our favorites- an old disease that almost disappeared but now it’s back and it is pissed. If you have had this disease, please share your experiences with us- but not your diseases.

1)   What else could we be talking about? Syphilis of course. Interestingly enough- the old tests are the still the best ones. The VDRL test and the RPR give you info about the stage of infection and treatment response- but they are less sensitive for screening. If the patient is asymptomatic- and one of these tests is positive- do a second as false positives are common. FTA tests and TPPA will be positive in all cases where there is some history of the disease. PCR is great. Dark ground microscopy: no one knows how to do this anymore.

2)   Well, we all know there are three stages of this wonderful disease. It begins with a painless chancre at the inoculation point. If it is on the penis (most often in men) it is easy, but go find one on a cervix. There may be lymphadenopathy nearby- which helps but this is painless and likely to be missed as well.

3)   Secondary syphilis is more systemic. Headache, sore throat, malaise, fever, and a scaly rash, Condylomata lata; patchy alopecia, oral erosisons, and hepatosplenomegaly occur next. Lata are papules that develop in moist areas. Here is a latte Here is a Lata. I would rather have the former. Neurological symptoms at this point can include lymphocytic meningitis and a transient eight nerve deficit. There may be CSF abnormalities but only in one quarter of the patients. Here RPR and VDRL are always positive- if they are negative- it ain’t syphilis.

4)   Now to the most fun you can possibly have – latent syphilis. This is probably not infectious but can cause some bad stuff- specifically neuro syphilis and cardiovascular syphilis. Up opt 12 years after the initial exposure – you can see seizures, and a stroke like syndrome due to endarteritis of the cerebral vessels. Syphilis that involves the parenchyma can cause all the good stuff- depression, confusion, paranoia, and delusions of grandeur. Physical signs include facial tremor, expressionless facies, hyperrelfexia. They progress fairly rapidly to dementia and death over a few months to years. Here is one for memory lane that I am sure Father Greg remembers- Tabes
Dorsalis. This can be 20 years after the initial infection. The syndrome includes DTRs that are reduced, abnormalities of proprioception and parasteias, Charcot’s joints and Argyll Robertson pupils. There is bladder and bowel dysfunction. Diagnosis in neuro syphilis is aided by CSF with elevated lymphocytes and CSF VRDL that is positive. Most people with tertiary syphilis become successful politicians

5)   Here are some more blasts from the past. CV syphilis. Which is mainly a proximal aortic aneurysm and AR. This can be even after 15-30 after exposure. These aneurysms do not generally dissect.

6)   Here is another of our favorites: Gummas. These are graulomas. But need not be cutaneous. They can ulcerate. Usually they take five years to develop.

7)   Ah yes, may yes, what should we treat this disease with? PCN was always a great treatment, and Doxy works well. Azithro worked well, but resistance is growing. Cefrtiaxone probably works well too; there is less data on its success. Following titers is important up to 12 months later. One last remembrance for the sentimental among us- Jarish Herxheimer Reaction- this is basically – you kill these worms- you are going to pay. It is a cytokine mediated reaction to lysis of these buggers and resolves within 24 hours with NSAIDS,

8)   HIV casues all sorts of problems and often these go together. They can have more usual presentations, such as multiple chancres (yum!) Seroconversion may be erratic and syphilis may cause the CD 4 count to fall and viral load to rise. So here is a real Blast from the past –the Partridge family – sit com from the seventies about a musical family that was “groovy”. The redhead boy- Danny Bonaduce was busted for drugs many times and fell out of the public light. Shirley Jones – the mother- died. Susan Dey had a long career including starring in the show “LA law” she still appears in some shows. She is the brunette at the back. David Cassidy was the heartthrob singer- but did little after leaving the show. Love the style

9)   Here is Susan Dey today But then again – here is a picture of Greg Henry- at least that is what Google says: Ah Father Greg- You handsome beast!