EMU Monthly – July 2013

1)   A bit of a groaner, but could be helpful if you practice in some forsaken place like Alice Springs Australia, or Ypsilanti Michigan. Those little bottles of bacteriostatic normal saline have a preservative called benzyl alcohol which has mild anesthetic properties (ethyl alcohol probably has more) If you inject this before the IV, you will get some anesthesia, although less than by lidocaine. It is of course cheaper ( J Perianesth Nurs 27(6)399) Here are my comments. Firstly, kudos to the authors who have shown a good double blinded study done by nurses. Secondly, many nurses are not allowed to inject lidocaine but are allowed to inject this agent. Thirdly, we need to remember that IVs do sting and it is a humane thing to do to take away the pain. On the other side, it would be hard to say that this stuff works as IV are not that painful and it was not that beneficial. In addition lidocaine is pretty cheap. TAKE HOME MESSAGE: In a pinch- you can use bacteriostatic water as a local anesthetic before IV insertion.

2)   Really, I am not just looking for pain and palliative care articles since MD Anderson took us aboard- this is just what happened. In some hospitals you can call for a palliative care consult- this does happen not infrequently in the ED where they do have this service and usually is used for young people who meet with trauma or sudden death. (J Palliatve Care 15(6)633) However- and Knox is free to disagree with me- these consults were for bereavement counseling. True that is uncomfortable for us, but I would like to see more instruction in palliative and comfort care- like making that end stage lung cancer who is gasping for breath (what a night mare) more comfortable with out killing him. I should mention here that palliative care is a recognized subspecialty of EM and is an increasingly popular career track for emergency physicians- https://www.abem.org/public/_Rainbow/Documents/Eligibility%20Criteria%20for%20Web.pdf TAKE HOME MESSAGE: Palliative care consults are appropriate in the ED. On a related subject; here is an article that you should all not only read but tune in to what it means. Patients have fears- what they call “existential suffering.” These are fears that add on the physical suffering of being sick. They include death, anxiety, loss and change in their lives, loss of control of their lives, loss of dignity, fundamental aloneness, altered quality of relationships, the innate search for meaning in our lives, and mystery as to the unknowable. Be sensitive to this and I promise you will be the best physician you could be. (Arch Int Med 172(19)1501) TAKE HOME MESSAGE: Feel for you patients- it isn’t easy being ill.

3)   One size fits all is a dangerous way to ventilate. Obese patients have different mechanics and diminished end expiratory lung volumes. This paper recommends step wise recruitment maneuvers before PEEP applications –which I really do not what that is, and tidal volume titration according to inspiratory capacity (Minerva Anest 78(12) 1136) Basically I think this is another call to not use formulas for tidal volume- go by plateau pressure. Remember the magic number is less than 30. TAKE HOME MESSAGE: Obese patients have different ventilator needs and should be titrated to cause the least lung strain. China had a dilemma. Chinese is a very different language than English, yet the British had a colony called Hong Kong and insisted that all movies that were produced there had to have English subtitles. The Chinese complied and during the era of popularity for Bruce Lee movies and the genre of chop sockey movies – some interesting tough guy translations took place. Let’s get started. * “I threat you! I challenge you meet me on the roof tonight for a duet!” * “I am damn unsatisfied to be killed in this way.”

4)   I was leafing through the swimsuit edition of this journal and discovered a great article in between the pictures. There is something called breakthrough varicella. This is a varicella in a vaccinated patient- and this can happen. This can be tricky- There are fewer or no vessicles, no fever and the rash isn’t in crops like the real thing. Yes it can still look like localized herpes but it can look like an insect bite or poison ivy. You can still test for it- serology, PCR, direct fluorescent antibody- but I guess it is only relevant if you are pregnant or are around pregnant people. Should you want to see the article- or the swimsuits here is their reference (Pub Health Rep 127(6)585) TAKE HOME MESSAGE: Varicella can still infect vaccinated individuals- the symptoms are very subtle however. Here are swim suits to whet (pun intended) your appetite

5)   You knew this and I want you to skip this paragraph. There is no reason to repeat it so please scroll down- NOW. Gosh- hard to get kids to listen these days- Oxygen is not required for MIs, CVAs, ROSC or obstetric emergencies. (BMJ 345: E6856) It just doesn’t help unless of course they are hypoxic. And please give oxygen lightly to
COPDers. TAKE HOME MESSAGE: Oxygen is a drug and it isn’t for everyone- MI and CVAs do not need it. * “Fatty, you with your thick face have hurt my instep.” * “A normal person wouldn’t steal pituitaries.”

6)   Welcome back. This you should also know. Syncope can be caused by PE- but not, in my opinion – without some other sign. In this case series- these syncope patients with PE all had hypoxia. I generally use saturations and pulse to guide me- if they are abnormal. If not, think of other possibilities as causes for syncope (Int Med 51(8)2631) My peer reviewer adds: Here you could mention the PERC score, which does not include syncope as a criterion so that if PERC (-) the patient is very low risk with or without syncope. Of course it is non specific so that most people who are not PERC (-) with syncope still won’t have PE. TAKE HOME MESSAGE: Syncope can be caused by PE- but you need more than just syncope. * “You always use violence. I should’ve ordered glutinous rice chicken.”

7)   Time for some Cochrane- even though they always say more research is needed – sometimes you can read between the lines. Cranberries for UTI prevention- larger studies have shown this doesn’t work. Also, many people can’t stomach drinking that much cranberry juice. The pills may be an improvement- but no evidence exists.(Cochrane 1321). Here is another Cochrane that we discussed not long ago- the use of ultrasound to aid in thromoblysis- albeit it only five studies-but it seems to help- NNT of only four! (ibid 8348) Who said steroids don’t help for sore throats. Well, when used with antibiotics- they actually are pretty impressive- and a NNT of only 4 also. They reduced the time to complete pain relief by 14 hours and started to work by 6 hours. (ibid 8268) TAKE HOME MESSAGE: Don’t drink cranberries do drink steroids and if you get a stroke – poke open the artery with an ultrasound machine. * “Beware! Your bones are going to be disconnected.”

8)   I thought it would be worse. This difficult to quantify article claims that news representation of scientific articles is affected by spin about 50% of the time meaning the public is getting wrong information – usually information that is overly positive (PLoS 9(9)e1001308). There are factors here such as the definition of spin and who reads and authors these news articles – I would think usually laymen- but the average doctor does not know how to read these articles either and therefore abstracting services that do not evaluate articles may lead practitioners down the wrong path. Did I just trash EMU? TAKE HOME MESSAGE: The press often over estimates the result of medical studies due to spin. “Quiet or I’ll blow your throat up.”

* “You daring lousy guy.”

* “Beat him out of recognizable shape!”

9)   Don’t you love to sound so technical when speaking to orthopedists about the shoulder? “Oh, yes, the Jobe test and Hawkins Kennedy test were normal but the Neer test was positive”. (Please, oh please do not use these lines when you are going out for the first time). Could we be looking at a SLAP lesion? Yea you really are cool However none of these tests are that sensitive- only the shrug sign for osteoarthritis inched up above 80%. If you combine tests you do improve somewhat- but only marginally. Take a good history. (BJ Sports Med 46(14)964) Excellent article but not done by orthopedists but by physical therapists, so you still can’t conclude that orthopedists can write a decent article. TAKE HOME MESSAGE Physical exam of the shoulder is woeful.

10)                 There have been some reports of local anesthetics causing damage to chrondrocytes and therefore impairing healing when injected into sore joints. Well, those are case reports and you know what they are worth. There have been some in vitro studies that have shown mixed results. When the day is done though, in most cases in the ED a one time treatment rarely hurts – although you would be right to say: prove it (Knee Surg Sports Traum Arthroscp 20(11)2294) (hope this journal doesn’t make tee shirts- how would you fit that all on your shirt?) TAKE HOME MESSAGE: Lidocaine maybe harmful to cartilage. How can you use my intestines as a gift?”

* “Damn, I’ll burn you into a BBQ chicken!”

11)                 Resuscitation-hey I am all with you, man- they all die, so why bother? Furthermore dead people are just the worst of conversationalists. But what can I do? I am a mere conduit. The folks at Lancet looked at 643339 patients with cardiac arrest and found that half actually did have ROSC and 1 out of six was discharged from the hospital alive- there were significantly more survivors in hospitals where mean resuscitation time was 25 minutes compared with hospitals with shorter average resuscitation times (16 minutes). The big difference was in asystole and PEA- those folks when worked on for that long actually did come back and did get discharged alive. However, most of these patients were severely neurologically impaired (the technical term is “gorked”) (Lancet 380:1451) Now I will leave this for the bio ethicists but it seems you are not dead until you are dead. TAKE HOME MESSAGE: That patient will have a better chance of life if you continue CPR for at least 25 minutes. In a similar vein (or artery) there may be a place for beta blockade in CPR- since alpha agonism so important to increase coronary perfusion pressure. While pure alpha stimulation by phenylnephrine has not improved outcomes but perhaps this + a beta blocker+ a non beta pressor like vasopression would work. It does in animals. This would be a marvel as it would reduce the oxygen demands that adrenalin causes. But then again Grandma is not a horse so we still need to see. (Resusc 83:663) TAKE HOME MESSAGE: Beta blockade may have a place in resuscitations. Here is Grandma playing chess- anyone recognize who the horse really is?

12)                 Technology strikes again. My disk on key died and with it was saved the rest of this month’s EMU- and of course it could not be saved. We will try to reclaim what we can. Did you know that pneumonia can present with EKG changes? Sometimes it can look just like…..PE. If you are using an EKG to diagnose PE you probably need to listen to lectures on how to put on a seatbelt that they give before take off, and you probably need a warning that irons are not to be used in bathtub s. (AJC 27(6)1836) That being said – the changes in pneumonia are simlar to to those seen in right heart strain. “This will be of fine service for you, you bag of the scum. I am sure you will not mind that I remove your manhoods and leave them out on the dessert flour for your aunts to eat.”

“Yah-hah, evil spider woman! I have captured you by the short rabbits and can now deliver you violently to your gynecologist for a thorough extermination.”

13)                 No chance on the clinical quiz this month. If you get it you are a genius and I will reward you with: editorship of the EMU for the next three years, and free trip to North Korea (one way ticket only). You’ll see this disorder in alcoholism. It is rare but they have altered mental status, seizures and multifocal central neuro signs which come from demylination of the corpus callosum. This is of course? (no cheating please AJEM 30(9)E7) Go ahead- give it a try- do feel lucky?

14)                 Try another one. Be a real man. Visual acuity loss with complex hallucinations caused by an occipital lobe lesion. That is ____(ibid E5)Can’t figure it out? Go to the link on real men.

15)                 Zinc- does it work or not? Well first of all, it has only worked in the Third World. In the developed world, we may just have enough zinc to go around. In this study it worked with a NNT of 15 as an adjunct to therapy for serious bacterial infection. Less mortality –which we would all agree is a good thing. (Lancet 379(9831)2072) The methods are hard to follow, but treatment failure was defined as anything from fever returning to death from all causes –so I do not know how they could know if zinc helped. Furthermore, we know that all heavy metals like Bismuth control diarrhea and has some antibiotic effect-and zinc is a heavy metal and most of the serious bacterial infections in this Indian study were diarrhea. Let’s do some summarizing on Zinc from Cochrane. Zinc doesn’t help to prevent ear infections (2012) Zinc doesn’t help as an adjunct to pediatric pneumonia (2013) Zinc can prevent the common cold if taken for five months and can reduce the severity of the cold (2011)(but I have seen many papers that disagreed), it will help in pediatric diarrhea (2013) TAKE HOME MESSAGE: Zinc helps for diarrhea and the common cold. The Jury is out on the rest. Your spear is useless… You better use it for mixing excretory. Now I feel flatulent, and you did it

16)                 Droperidol may be great for migraines, but in many places – like my home country- it is just unavailable. So now they are marketing a combo of naproxen and sumatriptan. This was a group of kids that got frequent migraines- so there is referral bias. And surprisingly- the only conclusions they can make is that it is as safe and effective as that well known migraine- giant- placebo. (Peds 129(6)e1411) Now there is a lot to say here- there were definite statistically significant improvements with the combo but the p values were really unimpressive and this of course does not take into account the clinical differences that were negligible. But here is another flaw in the treatment here. Sumatriptan is an abortive treatment for headaches that must be used with in the first few hours of headache onset- otherwise it is effect is much less. I do recognize that NSAIDS are good for head aches so my ED combo is Haloperidol- the closest cousin I can get to Droperidol (although in Israel now, they have made it illegal to give IV based on those darn Americans), dexamethasone (some good evidence in this preventing recurrence of the headache) and a NSAID. Oh, and I forgot to mention – this study was performed by Dr. Glaxo, Dr Smith, Dr Klein and Dr French- – guess who paid for it? TAKE HOME MESSAGE: Migraine cocktails vary, but sumatriptran/naproxen didn’t work so well I please your uterus. You kiss my toes. It’s fair

17)                 Sippy cups pacifiers and bottles are designed sound- product failure is rare. However injuries are not so rare, mostly being lacerations in the mouth.(ibid p1104) This article was in Pediatrics, not clear if the same findings can be generalizable to adults in Ypsilanti

18)                 Yes we have left Ypsilanti, and now are in Switzerland (Suisse) and in that country most people do have GPs. However, many go to the ED for minor problems. This study looked at this and concluded people go to the ED- not because of convenience, and not because of 24/7 availability but rather because they trusted the doctors in the ED more than their GPs. (Swiss Med Week 142:w13565). I think we see the same phenomena in a lot of countries and this behooves us somehow to make our Family docs as strong as possible. It is true that the academia mostly resides in the hospital, but if you are a FP-consider moonlighting every week in the hospital, or rounding with them and make sure you are as up to date as possible. It isn’t convenient for most busy FPs to get to conferences and workshops, but at least between patients-pick up an article or better yet- get your friends to start reading EMU. TAKE HOME MESSAGE: Most people will bypass their GP to go to the ED even with minor complaints just so they can get what they think is better treatment

19)                 You have a baby and need urine. Why bother with messy collection bags, large bore needles to the bladder, or 26 French catheters? They have this technique were they give the kid a drink, tap on the bladder area, massage the back and viola! Out it comes fresh and steaming hot- just like Mama’s. (Arch DIs Child 98(1)27) Sure is less invasive. See this picture and be convinced! I think in the study they gave them beer to drink but I am not sure TAKE HOME MESSAGE: Tapping on the bladder area and back massage is a technique to get urines from new borns that is non invasive.

20)                 I am sure you have heard a bout Choosing Wisely. Basically they got the specialty societies together and each specialty decided what procedures and tests that they do are inappropriate. Here are some to bark at your fellow doctors about. No urinary catheters to measure fluid output, and leave them in as short of a time as possible. No osteoporosis screening in women less than 65 or men less than 70. No routine yearly EKGs in patients without symptoms (that one is a little tough for me-silent MIs are not that rare). No routine chest films in asthma. No acid suppression in GERD for kids- it doesn’t work. No CT or carotid imaging for syncope alone. No preoperative chest films and no routine ones for admission (interestingly enough the internists omitted the latter but said the former, the radiologists added the latter). No CT for uncomplicated headache.(this assumes you know what an uncomplicated headache is-but see the NICE criteria to aid you with this) No tube feedings for demented adults- use slow assisted feeding- the pneumonia rate is the same. No benzos or antipsychotics for agitated demented adults (as a routine and chronically), and leave people over the age of 65 with HG1AC of 7.5 alone. Here are some more. No need for antibiotics in conjunctivitis- just clean them well, it goes away by itself. No cough and cold meds to kids under age four (my corollary- no cough meds to kids over age four either), no oral antibiotics for otitis externa, no antibiotics for sinusitis nor bronchitis, no NSAIDS in HTN, CHF or CRF, no opioids or barbs in migraine. Want more? See www.chosingwisely.org. TAKE HOME MESSAGE: I won’t let you get away this time- read the whole paragraph!

21)                 I will mention this because it was an Israeli paper, but you really should know this. They had 14 elderly patients with altered mental status. They all ended up having non convulsive status epilepticus. (Eur J IM 23(8)701) This paper really bothered me. It was written by an internists and the diagnosis was only made in the ward. I know this hospital and often the patients are in the ED for a few days before going upstairs. What this means is that the ED missed the diagnosis. And indeed all did response somewhat to anti epileptic medication. Now the ones in the ED that they thought were septic from a UTI – I can accept- and perhaps they really didn’t have status- the EEG was equivocal in some of these patients, but six of the patients had a known seizure disorder and that should have been an alarm going off. Also remember myxedema coma. TAKE HOME MESSAGE: Do not miss non convulsive status epilepticus. Don’t mess this one up- G-d gave you a brain so use it please

22)                 Everything you wanted to know and a lot of what you didn’t about amnesia is found in this article. I leave it here as a reference but these disorders are rare and this was more basic science than clinically relevant (Lancet 380:1429)

23)                 We have lots of letters. I do not know why, but last month’s first paragraph elicited a response- if you recall it was about medical education. I want to thank both Dr. Ls who responded- here is a letter that one wrote. Mazal tov on your son’s engagement

Regarding your first comment – I majored in modern languages and linguistics (I was the first person ever to finish the degree with 1 major and 3 minor languages and also got departmental honors as a junior rather than as a graduating senior) and minored in biochemistry.  My essay for medical school was about the experience of living in Israel during the first war in Lebanon and I convinced a crusty old thoracic surgeon that the best preparation for a career in medicine was a degree in MLL – he said I was the only liberal arts major he ever recommended accepting! I’m not so sure Dr L that languages aren’t good prep for med school. If you speak “drunk” you would be very valuable in many EDs.Last month I commented:

Why they can not invent a physiologic fluid that is osmolar and contains other goodies like potassium and calcium and anything else that is
floating around in most people’s systems? – I do not know.
Scott Weingart was kind to respond:
they have, isolyte, plasmalyte, normosol

good stuff.

Scott I just wanted to point out how important it is that you provide your skills as an ICU /ED guys- because no one else pointed this out. However, I just want to say that these materials are not found in most EDs (cost) so we do need to find a way to get them into and of course show that they are improvement over good old normal saline. Here’s a letter from Brian MacMurray in Tennessee:

I enjoy EMU as ever.  Love the House interludes.

On the azithromycin and QT prolongation issue….is this written by the same sons of Buicks that made it hard for us to get/use droperidol?

Now, here is the thing in the good old USA….if zithromax caused CLINICALLY MEANINGFUL QT prolongation, the death rate in America would have now skyrocketed; torsades de pointes would be the most common arrhythmia in America; and our ER staffing would be decimated especially because we ER doctors and our Nurses and Staff folks take this potent antiviral A LOT.  Just my fervent opinion.  The heck with evidence-based.  Let’s play the reality game. Actually Brian, the evidence is not that good. (of course you meant antibacterial). However, my point was different. Macrolides are not very effective antibiotics and we basically have better antibiotics for everything we use macrolides for. Azithromycin has a long half life and can cause really bad abdominal pain, and if it is true that the mortality is greater – then on both accounts we have a long acting drug that will be around in the system for a long time. And it isn’t cheap.Thanks for writing. Here is a letter from Knox Todd down in Houston. While it is an advertisement, if it could help someone or could help Knox- I am pleased to include it

 

 

Mazel Tov on the engagement!! Thanks to Yosef for his mention in this month’s EMU of the new Department of Emergency Medicine at the University of Texas MD Anderson Cancer Center.  In addition to fellowships in pain and palliative medicine, we are recruiting for the second year of our Fellowship in Oncologic Emergency Medicine and are seeking new faculty for our growing department.  Please contact me if you know of qualified applicants.  Position descriptions appear below.

Director, Emergency Ultrasound

The newly established Department of Emergency Medicine at The University of Texas MD Anderson Cancer Center seeks an Emergency Ultrasound Director to join our growing faculty. Candidates must be board-prepared or board-certified in Emergency Medicine or Pediatric Emergency Medicine and fellowship-trained in emergency ultrasound. Responsibilities include providing patient care to patients with oncologic emergencies in our 45-bed Emergency Center; providing training and oversight to our ultrasound program; educating medical students, residents, and fellows; and engaging in academic pursuits to support the development of oncologic emergency medicine as a distinct specialty.

Assistant or Associate Professor – Emergency Medicine

The newly established Department of Emergency Medicine at The University of Texas MD Anderson Cancer Center seeks emergency physicians to join our growing faculty. Candidates must be board-prepared or board-certified in Emergency Medicine or Pediatric Emergency Medicine. Responsibilities include providing patient care to patients with oncologic emergencies in our 45-bed Emergency Center; educating medical students, residents, and fellows; and engaging in academic pursuits to support the development of oncologic emergency medicine as a distinct specialty.

Oncologic Emergency Medicine Fellowship

The Oncologic Emergency Medicine fellowship provides advanced training in the emergency treatment of cancer patients. Trainees may focus on pain management, palliative care, or operations research. The main goal of the program is to facilitate expertise in the diagnosis and treatment of a wide variety of conditions that are specific to cancer patients presenting to the emergency department as well as to advance scholarship in the growing subdiscipline of oncologic emergency medicine. The duration of the program is 12 months with an optional 12 month research extension.

Interested applicants should send a cover letter, CV and list of three references to:

Knox H. Todd, M.D., MPH
Professor and Chair
Department of Emergency Medicine, Unit 1468
The University of Texas MD Anderson Cancer Center
PO Box 301402, Unit 1468
Houston, TX 77030-1402

or send via email to:

khtodd@mdanderson.org

Also, remember that past issues of EMU are posted at www.empainline.org for your convenience.  Thanks again, Knox. Anyone else with availabilities- no problem with me advertising to the EMU community- at least you know you are getting a physician on the same page as you!

And now from Ken Iserson- you know we he write it is going to be relevant and useful

A few comments on this month’s issue:

NNT for antihypertensives? You quote >100 for effectiveness. But, the following abstract from Tulane (and experience) suggest otherwise:

Ogden LG, He J, Lydick E, Whelton PK:Long-Term Absolute Benefit of Lowering Blood Pressure in Hypertensive Patients According to the JNC VI Risk Stratification. Hypertension.2000;35:539-54

Abstract—Blood pressure (BP) levels alone have been traditionally used to make treatment decisions in patients with hypertension. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) recently recommended that risk strata, in addition to BP levels, be considered in the treatment of hypertension. We estimated the absolute benefit associated with a 12 mm Hg reduction in systolic BP over 10 years according to the risk stratification system of JNC VI using data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. The number-needed-to-treat to prevent a cardiovascular event/death or a death from all causes was reduced with increasing levels of baseline BP in each of the risk strata. In addition, the number-needed-to-treat was much smaller in persons with ≥1 additional major risk factor for cardiovascular disease (risk group B) and in those with a history of cardiovascular disease or target organ damage (risk group C) than in those without additional major risk factors for cardiovascular disease (risk group A). Specifically, the number-needed-to-treat to prevent a death from all causes in patients with a high-normal BP, stage 1 hypertension, or stage 2 or 3 hypertension was, respectively, 81, 60, and 23 for those in risk group A; 19, 16, and 9 for those in risk group B; and 14, 12, and 9 for those in risk group C. Our analysis indicated that the absolute benefits of antihypertensive therapy depended on BP as well as the presence or absence of additional cardiovascular disease risk factors and the presence or absence of preexisting clinical cardiovascular disease or target organ damage.I find this very interesting, Ken. My only comment is that often we can not be sure a patient really has HTN as few measurements are taken before the diagnosis is given. In addition, this is assuming an absolute benefit of 12 mm reduction which may or may not be true. Furthermore, this data is 13 years old- why isn’t it be applied? – and lastly – there may be a closer NNT to NNH with patients without risk. Did I say I only had one comment?

 

I’m pretty sure that I previously sent you something about using intravenous lidocaine for intractable hiccups. I described it in Improvised Medicine and used it successfully in Antarctica.

Tattooing a DNR on the chest? It is a no-go ethically, as I explained in: Iserson KV: The `no code’ tattoo—an ethical dilemma. Western Journal of Medicine 1992;156:3:309-312. The reasons are that, as you noted, it is undecipherable, the person may have changed his/her mind, and the order itself has many permutations. The photo below (from the article) is from an EM colleague who got it on his 65th birthday.

Bravo on both accounts! I recently had an oncologic patient that I used viscous lidociane but it didn’t work- perhaps I had to use IV.

Finally, Dr. House’s misanthropic remark that we became doctors to treat illnesses, not patients, has always bothered me. That’s the surest way to burn out as a clinician. My take has always been to find out something about the patients I treat. Some fascinating folks come through the ED. We only have to discover them to remain interested in medicine and become more interesting people.

Best wishes, Ken

This is sage advice and probably the real reason we are doctors- after all engineers also diagnose – but their patients have no life ( sometimes neither do they- I would know I was an engineer). What is interesting is that when I prepared that EMU, I found myself strangely drawn to this character that I have never seen. To be eccentric, always right and sardonic has an appeal- then I realized that sub consciously that is our revenge- we get abused all day by patients who do not want to be here, while our colleagues have their carpeted offices and never get spit on or threatened. And true, with that comes burn out. But as you pointed out – that is the exactly wrong attitude. Our patients do appreciate us and our efforts; they just often just don’t know how to express themselves. Thanks for writing Ken.

24)                 Yes, in 11 – that was the Mister ED. Clinical Quiz in 13- Machiafava-Bignami disease. And the line about feeling lucky is from Dirty Harry- played by Clint Eastwood. 14 was Charles Bonnet Syndrome. Now as a another little present- Tako Tsubo was not a real person- the syndrome of normal coronaries and MI changes on EKG with billowing and hyperkinesis on echo was named after the Japanese Octopus trap which the echo resembles (AJEM 30(9)E3)

EMU LOOKS AT:Bleeding

I know this has been all over the news lately but it is time for us to give our opinion. The new anticoagulants have been heavily marketed and we will speak about them, based on an article from AJEM 30:2046. I would also like to thank Joe Lex- a real friend of EMU who has dedicated his life to EM education and has graciously agreed to allow me to use some of his lecture notes from a lecture he gave on the subject.

1) As I said the new anticoagulants have been heavily marketed and indeed this optimistic study has some industry involvement. What did we have up to now? Well Warfarin is cheap, and familiar, but does have an initial prothrombotic effect and also there are dosing issues due to genetic differences in people. It does have an antidote but it needs monitoring, and has lots of interactions (this is why the following patient ended up have a CVA The clotting factors have different half lives, and they will be inhibited at different times so warfarin may not achieve anticoagulation for a few days and indeed – you need to add a faster acting agent like the LMWHs or else clots can still occur. Just remember – once you are above 3- every 1 unit increase in INR doubles the bleeding risk. If someone is bleeding; stopping warfarin will result in factor recovery in about 50 hours. Vitamin K can reduce this to 24 hours. IV can cause anaphylaxis but the diluent has been changed and this is very rare now. You can give it by mouth but it takes longer to work (just put the IV liquid in a cup.). SC administration doesn’t work and should be avoided. Vitamin K dosage is one mg for minor bleeding, and 2-5 for major bleeding. FFP is also used but it takes almost an hour to thaw, takes about six hours to give the full dose of 15ml/kg (about four units) and since it’s INR is 1.7- that is as low as you can get with FFP. It can be a lot of fluid- 4 units are about 3 liters. PCC is more concentrated and can be used as an antidote, but you w ill still need vitamin K, and the USA PCC is lacking one of the factors. Skin necrosis rarely happens with Coumadin and there isn’t much you can do to prevent it.

2) Heparin has a very short half life. Protamine is the antidote but is rarely used. Dialysis patients who bleed more than two hours after dialysis- don’t give protamine- the bleeding is not from the heparin. SC heparin is rarely given anymore but it worked well and was much cheaper than LMWH.

3) Enoxaparin and fondaparinux do need monitoring but they have no antitode and they need to be injected.

4) These new anticoagulants work by inhibiting the conversion of fibrinogen to fibrin (dabigitran) and or the conversion of prothrombin to thrombin (rivaroxaban and apixaban).They are derived from leeches They need no monitoring, are given orally, have few interactions and a wide therapeutic window. They have all been approved for use in non valvular PAF and rivar has been approved for DVT prophylaxis. As of this writing, no approval yet for ACS or DVT treatment for any of these agents, but it is on the way. Interestingly enough, the ACCP has approved dabigatran as their first line treatment for CHADS2 score higher than2 2

5) Dabigitran is given as 150 mg twice a day with a reduction to 75 twice a day if the patient has a lower creatinine clearance. It does cause dyspepsia, and interestingly enough, there were higher rates of MI when compared to warfarin- but that is with the higher dose. ICH was lower than warfarin . 150 mg showed the best efficacy over warfarin with similar bleeding rates in the rest of the body. The problem is that this was an open label study.

6) Rivaroxaban also showed less intracranial bleeding than warfarin but more GI bleeding. Apixaban also showed lower bleeding rates than warfarin

7) Really want to know how you are doing with regards to anticoagulation? Then you need an Ecrin clotting time, which I carry around with me in my pocket along with a front loader, an I beam and a copy of Frankie Yankovic’s polka favorite “Who Stole the Kishka?” (Oh please, father Greg, please stop dancing. We are not in Hamtramck). PTT may help for rivaroxaban or apixaban but here to you will be plagued by lack of standardization

8) Bleeding? Well, four factor PCC- which we have in Israel – may help for rivaroxaban but not for dabigatran. If it is minor bleeding, they have relatively short half lives, so you can just stop the medication. Dialysis has been recommend but these drugs are only partly dialysable,

 

9) and now for the other side of the story . Dabigatran doesn’t work well with Protein C or S deficiency. It did beat warfarin in PAF for stroke and embolism prevention but the NNT was 172 for benefit over warfarin. Although to be fair- the NNH for MI (we said above they cause some more MIs) is only 1 in 500. Dabigitran starts to work within an hour and needs no bridging. Its half life is 12-17 hours which beat warfarin. Unlike warfarin, you can’t miss a dose because the factors rebound fast and this has caused it to be black boxed in the USA. Antidote- there is none, and they have tried everything including tranexamic acid, DDAVP, and recombinant factor VIIa.

10) Rivaroxaban and apixaban have shorter half lives-6 to seven hours. However; the NNT over warfarin for PAF is 222. These are protein bound so don’t even think about dialyisis. Factor VIIa and PCC seem to work – at least partially- although they were tested in healthy patients. PT may help as a measure –here your Ecrin bleeding time will not help.

11) Remember none of these new drugs are approved for mechanical valves and they may not work for this entity.

13) Warfarin with INR testing in the USA amounts to 80$ a month while the new boys on the block costs about $250

 

For our second essay, we have a roundtable featuring David Levy from New Zealand, Mike Drescher from UCONN and formerly the head of trauma at Tel Hashomer (although not being a surgeon but an EP) , Yoram Klein who is the head of Surgery at Kaplan Hospital here in Israel and head of the Israeli Trauma Society. And of course yours truly . Here is the first question:

1) Many have said that trauma is no longer a surgical disease since so many previously surgical conditions are treated expectantly- what do you think?

Yoram:

 

Trauma was, is and will always be a surgical condition, regardless of the prevalence of emergency surgical interventions. There are multiple reasons for that. A) Surgeons will always intimately understand the Pathophysiology of trauma for the simple reasons that we creating trauma in our patients on a daily basis. Our understanding of hemorrhagic shock or tissue damage is based on the fact that most our procedures involve inflicting this type of pathology. B) The head of any team should be able to make the most crucial decision regarding the subject that the team treats. No non-surgeon will ever be able to make the decision to take the patient to the OR. Let me remind you that even in places where the ER is running completely surgeon-free, the minute the option of surgical intervention in raised a surgeon is called. Even in non-dramatic cases such as acute appendicitis. C) Who will take care of the severely injured patients if not the surgeons? Let us remember that the time that a trauma patient spend in the ER is just a tiny fraction of his hospitalization.  D) There are numerous surgical conditions that are being treated by surgeons despite the fact that a surgical intervention is rarer than in trauma (i.e acute diverticulitis, acute cholecystitis, acute pancreatitis etc.)

David:As I enter my 25th year of practice I have seen the EPs roles in
managing the trauma patient expand. I recall hearing a lecture in the
1980’s where a renowned trauma surgeon made the following statement
“the only role of ER doc in trauma should be to take the blood
pressure.” We’ve come a long way baby.” I believe emergency medicine
trained doctors are the most qualified to run the initial
resuscitation and stabilization of the trauma patient. We are the
resuscitation specialist and are able to take a holistic view of the
patient. Patients more and more present with underlying complex
co-morbidities that require concomitant medical management. Once the
patient is stabilized, and we can then direct the patient to the
appropriate specialties for assistance in caring for secondary and
tertiary injuries if necessary.

Me: Well, obviously I am a little bias here, but why should trauma be any different than any other emergency- we stabilize the patient- we call for help. IN addition we will never have to get any clearances for the patient- i.e. consultations about the internal medical problems, medication use, cardiac clearance, etc. On the other hand, EPs in my country rarely get involved in traumas- we get frustrated by the leaving us with little to do except “take a blood pressure”(see next question). Lastly, the tendency of many surgeons to just pan scan and not use EBM frustrates us. Wish there was a middle ground

Mike:

2)  Many hospitals have trauma teams that include an ultrasound tech, and anesthesiologist and an EP whose role is ill defined since there are other people handling the airway or doing the ultrasound. Many EPs in Israel just don’t even bother going in to traumas.  What is the role of the PE in a trauma?

 

  1. Yoram: The role of the EP is like pornography – a matter of geography. In other words the EP can be a team member, can be in charge of the airway instead of an anesthesiologist. Remember that theanesthesiologist crisis is not going anywhere. And if Israel will follow the USA I would rather have an experience EP over a nurse anesthasist… in Israel, the current situation is problematic, since most EP are internal medicine attending that continued to EM residency. Their experience in trauma won’t allow them to lead a trauma team. Maybe the direct residency to EM will change the situation.

David:
At Waikato Hospital in Hamilton, New Zealand (a major trauma centre),
the emergency medicine consultants are the team leaders in all trauma
resuscitations. Since we have emergency medicine registrars (aka
residents in US) they are assigned roles as are the surgical and ICU
registrars. Primary responsibility for the airway falls to the
assigned EM registrar, with the ICU registrar serving as a back up.
For major traumas, anaesthesia also is available for back up. We
usually supervise the performance of the FAST exam; frequently
performed by the surgical registrar (we are still early in the
credentialing process for trainees). I feel it would be a major
mistake for EPs to forego their leadership role.

ME: I think we need more dialog on the subject- and we should join together to improve research and practice. Ultrasound should definitely be ours, as should be the airway- how many anesthesiologists have experience with emergency airways? And with the Glidescope, this should be ours alone. CVP? –our ultrasound skills can make the difference. I think the surgeons should be called only when necessary.

Mike:

3) We see so much minor trauma- “fender benders” – what kind of hidden surprises have you found that we miss in minor trauma?

 

Yoram: Basically three types: misleading mechanism (especially with penetrating injury with hidden or innocent looking penetration wounds).  Example: a 17 YO male, collapsed at home after a party. The paramedic found him in cardiac arrest. After a short ACLS round he regained spontaneous circulation. In the ER the EP noticed a pin-point puncture wound next to the left nipple and called the surgeon. In the OR I’ found a pericardial tamponade due to transaction of the LAD from a dagger. The patient had a coronary bypass and recovered.  misleading patient (the mechanism was really mild but the patient medical background is so severe that even this mild injury flipped him over the edge of his physiological envelope). Example: a 62 YO female that arrived to the ER quadriplegic after being involved in a low speed fender accident. Evaluation of her medical record revealed severe chronic ankylosing spondylitis. The third is the misleading disease: the accident was really low energy but the reason for it was a VF.

David:The most frequent ‘surprising injury’ from low speed crashes I have
seen has been C1-C2 injuries in elderly patients. I have also cared
for a patient with abruption of the placenta from an apparently
innocuous motor vehicle collision. Additionally over the years I
uncovered initially unsuspected intracranial injuries, intra-thoracic,
intra-abdominal injuries, and long bone fractures (often in
non-restrained or improperly restrained occupants). My most
embarrassing case was in caring for an autistic child with a presumed
minor mechanism of injury who was apparently tender everywhere, except
the left thigh (and over-imaging him) who eventually was discovered to
harbour a left femur fracture that I did not initially image

 

ME: We just see so many of these cases, just do not let your guard down. A bad mechanism does not automatically portend to hidden badness, but keep you ears perked. Elderly and pregnant patients always need extra attention, as do infants. This being said- do not turf to others- no one is any better than you in determining trauma (an you imagine? I know some hospitals that they call a neurologist for head trauma!!!?!) Be liberal with your ultrasound probe.

Mike:

4) The pan scan is just so convenient – yet so mindless- What are you doing in thing to change this – or is it worthwhile to?

 

Yoram: Guidelines are the key. Every place should develop evidence based guidelines for imaging in trauma.

David:  Boy this is tough one. Despite the increasing role of ultrasound in
the initial management, the patient with major trauma usually
undergoes a pan scan. Whenever we try push back, it seems someone is
always citing a case of a missed injury secondary to lack of imaging.
We usually make these decisions in conjunction with the trauma
consultant. One safe guard we have in NZ is that radiology plays a
more active role in approving studies rather than serving as simple
conduit (this also has negative consequences when one has to battle
for a necessary study!) Bottom line for me is if the trauma surgeon
really wants the study, I put up minimal resistance

 

Me: Yoram- have Evidence Based Guidelines and we’ll be doing a lot less cans. And David- I don’t like non clinicians- radiologists- dictating which scans we can do. Is education the answer?

Mike:

5) ATLS is required for most physicians but those who actually deal with trauma have gotten good training during their residencies and ATLS has often be criticized for being archaic. What do you think?

Yoram: I think that the ATLS is still irreplaceable in creating a mutual basic language for trauma caregivers. I think that today the ATLS should be a precondition to start working in the ER (like the ACLS) and not toward the end of the residency.

David: This is where I feel differently than the party line echoed by many
EPs that ALTS is merely a merit badge. I have been an ATLS/ EMST
instructor for over 20 years, teaching in different countries. ATLS
(or EMST in Australasia) provides a basic framework for all trauma
care providers. It is an opportunity for the multiple disciplines to
learn from a common playbook and interact in simulated scenarios. I
always learn something new from any course I participate in, both from
my fellow instructors from various disciplines (surgery, anaesthesia,
emergency medicine, critical care) and the student participants. I do
not think EPs who regularly manage trauma need to take the course more
than once, but I do think they should stay familiar with the updates
(even if they have a 5 year lag or more from actual practice).

 

Me: I am opposed to badge course- I think that good training and good updating (like EMU) should be enough. Recerting is good thing in general for all specialties but cook book approaches often cause more damage. I like the PALS philosophy the best- use these courses to take a scary situation and be comfortable with them.

 

 

Mike:

Last question: 6) Please some pointers on trauma in the pregnant patient that we may not remember.

 

Yoram: lateral decubitus position to avoid excessive pressure from the vena cava. B) Remember physiological changes of pregnancy (especially fluid overload).   C) the only guaranty to the well being of the fetus is the well being of the mother  D) early fetal monitoring (might be a sign of maternal distress as well) – the nemesis is placental bleeding and separation E) successful  post mortem CS is mostly a myth and can create disastrous consequences. F) Ante-mortem CS should be carefully considered. G) evacuation of the uterus from a dead fetus might improve the condition of the critically injured pregnant patient. The timing should be carefully planned by a team of the trauma attending, ICU and OB-GYN.

David:
The severity of the maternal injury may not correlate well with the
frequency of adverse pregnancy outcome. Even minor trauma can have
very serious consequences for the pregnancy.
Maternal acidosis may correlate with fetal outcome
No real value of Betke Kleihauer test in Rh positive females (really
doesn’t change management)
Ultrasound may miss 50-85% of cases of abruption

 

Me: Couldn’t have said it better- all of these are serious concerns- just also remember seat belt injuries and that the intra abdominal organs are displaced. Be liberal with your ultrasound

Mike:

I really enjoyed this and I am sure we’ll hear form you – a lot of controversial points here. Write me –Now!

 

 

EMU Monthly – June 2013

EMU- at least to me- is like a family. To subscribe to EMU, you must write me personally, and that gives me a little connection with all of you. I shared with my readers the passing of my parents and those who replied gave me strength. Now we share some more rites- my son Avi Dovi has gotten engaged. The wedding is in two months. If you are in the neighborhood- drop by!

1)     Not that clinically relevant (I know what you are thinking-you already skipped to next paragraph) but this opinion piece takes US medical education to task and rightly so. But since this is an international forum let’s compare it to what the rest of the world does. American medical education is a graduate degree- meaning you need an undergraduate degree to get into medical school. Sure there are courses you must take (his point- organic chemistry is one of them- but who ever uses it in their day to day practice?) but you can major in ancient Middle Eastern laundry and still go to medical school. Oh, you do have to take a test called the MCAT, but most candidates take a course on taking this test and can do well. The fellow writing this opinion piece puts down that we should be taking more social sciences – of course, he is a family practice guy- and be less reliance on the MCAT and USMLE. He thinks not everyone should finish in four years- some need more time some less. We shouldn’t allow the choice of career to be wily nily – but he doesn’t say how he proposes to get people into underserved specialties. Also researchers and clinicians should have different tracts. (JFP 61(7)382). I will just point out that in most countries in the world; med school is a six year investment coming right out of high school. True, folks aren’t that mature yet, but longer residencies can make up for this. In residency in most countries – you stay in residency until you can pass your tests and you are found fit by the program director to finish. I must add that on the positive side of the USA- they do recertify – which doesn’t happen in a lot of countries. On the other side, a lot of their CME is a joke- but I think this is changing. It must be, as more and more programs are getting EMU. (Another reminder- if you are finishing up your training- give us a new address to forward your EMU.) TAKE HOME MESSAGE: Medical education reform would be good for our patients- let’s put emphasis on treating patients and not alternating benzene double ring bonds. Or savings bonds. Or Bon Appetit.

2)     Hey not just one but two clinical challenges. 22 year old Chinese lady with discoid eczema presents with a weepy vesicular rash. Fever to 38.5 and vesicles all over her face trunk and limbs. This is? (Annals of Singapore Academy Medi 41(8)366)(you can come out of the closet now- we all know you read this journal- and I heard they have a centerfold) PS this is not chicken pox. Or small pox. Or monkey pox. Or bagels and lox.

3) I know you love those rashes so here is another clinical quiz that you can really learn something from. 21 year old fatso who brushed he leg against steps 2 weeks earlier. He has ulcerative colitis (this is after all the GI literature) and gets azathioprine and balsalazide. He had a relapse recently and is getting high dose prednisolone. It was debrided and just got worse. All sorts of antibiotics did not help, but infliximab did help- somewhat. What in tarnation is this? (Gastro 143:e11)I don’t know who Dr. House is and I have never seen the show, but I heard his lines were pretty pithy, so he is our quote master for the month. Let us get started (this is all from the first two seasons, so that leaves us room to re visit him for more quotes) Dr. Cuddy: Your reputation won’t last if you don’t do your job; the clinic is part of your job. I want you to do your job.

Dr. House: Ah, yes, but as the philosopher Jagger once said, ‘You can’t always get what you want.

4) EMU is the only EM periodical that comes in a brown paper wrapper to your door. And like most people claim, you only read it for the articles. I do not want to embarrass you but you know our secret love for Lactate. (Please don’t tell my wife). But while lactate is good as a measure of what is going on in sepsis, and it may help in a septic joint if you send the fluid for lactate, it is not a great test for mesenteric ischemia. It will go up eventually, but then it will be too late. There is a difference between the isomers of lactate you measure, but we won’t go there right now (Digest Surg29(3)226). Guess you will have to just examine the patient and take a history, huh??? TAKE HOME MESSAGE: Don’t use lactate to help you diagnose mesenteric ischemia. It won’t help. Dr. House: Everybody lies.

Dr. Cameron: Dr. House doesn’t like dealing with patients.

Dr. Foreman: Isn’t treating patients why we became doctors?

Dr. House: No, treating illnesses is why we became doctors. Treating patients is what makes most doctors miserable

5) Somehow, and it is really scary to think about how this could have happened- in San Diego they gave 100 units of IV Insulin Glargine push and the patient did fine and needed no extra glucose. They suggest maybe 6 hours of obs is enough. (JEM 43(3)435)This is a real dilemma, because they want to assert that IV is way less dangerous than SC. That would be good if it is true because there is a case report in the same journal two years ago that a massive SC dose did result in profound hypoglycemia (JEM 41(4)374) and two years before that – same thing (JEM 36(1)26). And just for a change of scenery, the same thing reported even back to 2004(Pharmcotherap 24(10)1412). All of these are case reports, so let’s just say we don’t know and we should just see insulin as what it is and does. If you do not live in San Diego- don’t send these patients home until they have been observed for 24 hours. BTW I did speak to my nurses and they said that at least in Israel this would be a rare event as Insulin is one of the drugs that is double checked by two nurses before it is given to the doctor for administration. TAKE HOME MESSAGE: Lantus does cause hypoglycemia in overdose. IV and SC. Dr. Chase: It doesn’t necessarily have to be that bad. If we exclude the night terrors it could be something systemic: his liver, kidneys, something outside the brain.

Dr. House: Yes, feel free to exclude any symptom if it makes your job easier.

 

6) Headaches- my usual history taking includes whether this is a thunderclap headache, associated symptoms like vomiting and neck stiffness and fever, and whether they have headaches in the past. You should however ask if the headache is positional. No I am not speaking about sinusitis, but there is a headache that worsens when the patient sits up- this is a CSF leak headache. There are many treatments but a blood patch is probably the most relevant treatment. Cause is speculative (JEM 43(3)486) TAKE HOME MESSAGE: a headache that gets worse on sitting upon- think CSF leakDr. House: [talking to Wilson about a patient and quickly changing the subject as he sees Dr. Cuddy coming] —the cutest little tennis outfit! My God, I thought I was going to have a heart attack! Oh my! I didn’t see you there – That is so embarrassing…

Dr. Cuddy: How’s your hooker doing?

Dr. House: Oh, sweet of you to ask, funny story, she was going to be a hospital administrator, but hated having to screw people like that.

7) We used to admit all DVTs – we don’t now. And probably the same could be said by PE- the problem is with all the scores available- none are reliable enough to identify where the subset is located. Troponin, BMP, echo- all can help (Eur Resp J 40(3)742). I really believe this is true, but I have seen many PEs that looked OK and ended up crashing and burning, so we still need more info here- a lot more info. TAKE HOME MESSAGE: PE can be sent home sometimes- we just know when that sometime is.

Dr. Foreman: Occam’s razor. The simplest explanation is always the best.

Dr. House: And you think one is simpler than two?

Dr. Cameron: I’m pretty sure it is, yeah.

Dr. House: Baby shows up. Chase tells you that two people exchange fluids to create this being. I tell you that one stork dropped the little tyke off in a diaper. Are you going to go with the two or the one?

Dr. Foreman: I think your argument is specious.

Dr. House: I think your tie is ugly

 

8)   I am going to say a lot about this subject so if you are bored already (and who wouldn’t be?) just skip this paragraph, and have a drink on me at Archie’s Barf and Grill in Ypsilanti. The old days when you went the ED- you were seen by your doc or by a family practitioner who was moonlighting and then admitted to the hospital if need be to be taken care of by the nurses who contacted the family doc if there were any concerns. This has changed. There are now EPs and hospitalists doing this job and coincidentally; both work shifts and both are responsible for the patient-so why not cooperate? This is especially important in light of ED overcrowding where EPs must now be internists and ICU docs. In some places – patients will be admitted through the ED and actually discharged from there a few days later. So why not establish dialog to see who will be responsible for these patients and make protocol for their treatment. This could also affect the cost of care and increase the use of EBM. As far as I know – this dialog does not exist. And in many ED s I worked in – admitted patients boarding in the ED get no or really poor care. I may be controversial, but I learned how to cast and take care of an acute abdomen. I did not learn how to work up inpatient syncope- just some food for thought. (AJM 125(8)E1) TAKE HOME MESSAGE: Collaboration between wards and the ED on boarded patients is essential. Dr. House: This is our fault. Doctors over-prescribing antibiotics. Got a cold? Take some penicillin. Sniffles? No problem. Have some azithromycin. Is that not working anymore? Well, got your Levaquin. Antibacterial soaps in every bathroom. We’ll be adding vancomycin to the water supply soon. We bred these superbugs. They’re our babies. And they’re all grown up and they’ve got body piercings and a lot of anger

9)   You will thank me one day. What are the causes of a swollen uvula? Well here is the list- hereditary angioedema, drugs causing the same (like ACE, NSAIDS, and cocaine), infection (s pneumo, H flu), traumatic (intubations for example that did not go well), myxedamtous infiltration due to hypothyroidism, granulomatous infiltration due to Sarcoid, and uvular hydrops caused by opiods. Epi and steroids is what most people use for this, although intubation is rarely needed (Clev Cli J Med 79(9)600.). This article came out of my old home town so hey, let’s give a big Hello to my pals out in north Philly at Albert Einstein hospital where Steve Parrillo practices. TAKE HOME MESSAGE: Want to know what causes uvular swelling? See above. Here is a word from our peer reviewer:Well… The most common cause of uvular edema I see (This month’s peer reviewer, Gil Shlamovitz) is idiopatic ie: Qincke’s Disease or ENT’s Saturday Night Palsy (Snoring, ETOH & uvular angioedema), both don’t require epinephrine or steroids and respond well to sucking on ice chips and time… Dr. House: See, this is why I don’t waste money on shrinks, cause you give me all these really great insights for free.

Dr. Cuddy: [smiling] Shrink. If you would consider going to a shrink, I would pay for it myself. The hospital would hold a bake sale, for God’s sake

10)        Those rollicking guys over at Stroke (43(9)2539) (no, I won’t test you on this one- this is the butler “Lurch” from the Adams’ Family) discussed the role of hemostatic therapy in anticoagulation associated intracerebral bleed, and actually came out with a pro and con They basically ask the question whether or not PCC should be added to FFP and Vitamin K or not. PCC is expensive and if anything, I would use it without the other two, but that isn’t my point here- why wasn’t tranxemic acid considered? It is super cheap. Does it work well? Well even in trauma patients in the CRASH -2 study it works a little, but the side effects are minimal TAKE HOME MESSAGE: Tranxemic acid may have some role in the bleeding. Lucas Palmero: This is a good hospital?

Dr. House: Depends what you mean by “good”. [looks around] I like these chairs

 

 

Dr. House: Ah! The husband described her as being unusually irritable recently.

Dr. Cameron: And?

Dr. House: I didn’t know it was possible for a woman to be unusually irritable.

Dr. Cameron: Nice try, but you’re a misanthrope, not a misogynist

 

11) The debate gets exhausting. I’ll just summarize it. Lactated Ringer’s (also called Ringer’s Lactate and Hartmann) is often used for volume expansion, but it does contain lactate which may cause elevated lactates and confuse you in septic patients. Normal saline can cause a hyperchloremic acidosis. However, the amounts of lactate in Ringer’s is minimal, and acidosis in Normal Saline is not usually a problem although a recent study (which we will review in the future said there is more ICU mortality). Now this article reports that LR is hyposmolar which may not be the healthiest thing in brain injury (Curr Opin Anest 25(5)556).Why they can not invent a physiologic fluid that is osmolar and contains other goodies like potassium and calcium and anything else that is floating around in most people’s systems? – I do not know. TAKE HOME MESSAGE: Crystalloid is the way to go- which one? I dunno. Dr. Foreman: The kid was just taking his AP calculus exam when all of a sudden he got nauseous and disoriented.

Dr. House: That’s the way calculus presents.

 

Dr. House: I assume “minimal at best” is your stiff upper lip British way of saying “no chance in hell.”

Dr. Chase: I’m Australian.

Dr. House: You put the Queen on your money; you’re British

 

12) I think we really need to know about this subject- and this paper is not the practical how-to – go to guide, but if you care about your patients you need to care about palliative medicine as well. It was a panel discussion lead by a Dr. Quest (fitting name I think) and the points are: you need to know about this in the ED because these patients will come and competency and understanding are crucial. Now this isn’t just a pitch to get the chaplain and social worker involved, but that you have to be really good in pain management and presenting the possible therapies. (J Palliative Med 15(10)1076) I just want to bring out two points. Firstly they describe an encounter that occurred in a filthy room off to the side. Investment in a calming atmosphere and not using the supply room is humane .Another point, in some countries; hospices are paid by patient turnover – making them dreadful places to be in. Home hospice seems to be a better option if all care needs can be met. TAKE HOME MESAGE: Palliative care must be part of everyone’s practice- and Knox Todd- one of the panelists- was kind enough to add a few words for EMU: Thanks for covering the palliative care article.  I would like to highlight both the palliative care and pain medicine fellowships offered by MD Anderson.  These programs are very interested in emergency physician applicants and all can be found through links on our website (www.mdanderson.org/emergency-medicine).Thank you, Knox. I will just mention that palliative care was just announced as Israel’s newest specialty. Now just to add a practical point- many advanced cancer patients end up with intractable hiccups which are extremely uncomfortable. Lidocaine gel that was swallowed did help here in this case series so anti psychotics such as Thorazine may not be necessary ( Supp Care Cancer 20(11)3009) TAKE HOME MESSAGE: Try lidocaine gel for intractable hiccups. Dr. House: [to Georgia] I’m sorry, but the fact that the sexual pleasure center of your cerebral cortex has been over-stimulated by spirochetes is a poor basis for a relationship. Learned that one the hard way

13) We know that blood pressures rises and falls during the course of a day so why are we so quick to label them with hypertension based on office readings? Really, you should Holter BP all those who you suspect, or do a number of measurements in a claming atmosphere such as at home or a side room where it is quiet (not the supply room). Using automated machines probably scares patients less (J Hyperten 30(10)1894) Blood pressure meds are not always without significant side effects and the NNT is actually over 100. TAKE HOME MESSAGE: HTN is a disease that should be diagnosis by Holter or repeated measurements at home. Dr. Foreman: You assaulted that man.

Dr. House: Fine. I’ll never do it again.

Dr. Foreman: Yes, you will.

Dr. House: All the more reason this debate is pointless.

14) I dabble a lot in flight medicine and this Israeli study showed a drop of about 2% in sats when going up to an elevation of 725 m- which by the way is way less than the cabin’s pressure on a commercial flight (Respir 84(3)207). These however, were healthy volunteers; it would probably be worse in people who were not healthy. You can arrange oxygen for flights – never rely on the oxygen they have on all fights – the canister they have will last only a half hour- so it is always a good idea to prearrange it TAKE HOME MEMSSAGE: Sats drop on even moderate elevations.

 

 

 

Student: You’re reading a comic book.

Dr. House: And you’re calling attention to yourself by wearing a low-cut top.

[the student covers her chest with her clipboard]

Dr. House: Oh, I’m sorry, I thought we were having a state-the-obvious contest. I’m competitive by nature.

15) Stop, family doc- this article is relevant to you too. NICE guidelines: Fever in neutropenic patients is always a challenge-admitting these folks expose them to bad hospital bugs but sending them home could result in sudden death. Usually we define neutropenic fever as less than 1000 ANC. I am just going to review the points that I did not know. These folks should be started on empiric antibiotics – but not aminoglycosides. Also- this is a surprise- no routine chest films either. Is there such a thing as an occult pneumonia? I am beginning to think not. They like CRP and Lactate levels- not really sure why the first. Their empiric antibiotics of choice- Tazobactam/Pipercicillin (Tazocin)._Hooray for my shop – that is what they use too. No GSF is necessary in most cases- and here is the surprise for family docs- you may want to consider an empiric p.o. quinilone during the period of expected neutropenia (BMJ 345:e5368). TAKE HOME MESSAGE: No CXR or GSF in a neutropenic fever as matter of routine. If you know the patient will be neutropenic- give antibiotics as an outpatient. Dr. House: His liver is shutting down.

Father: What? What does that mean?

Dr. House: Means he’s all better, he can go home.

Father: What?

Dr. House: What do you think it means? He can’t live without a liver, he’s dying.

Father: What is your problem?

Dr. House: Bum leg, what’s yours?

16) I mean seriously- when do you see an article like this? Some people- now that tattoos are so popular – are considering a tattoo on their chest that says DNR. Now they say that people doing resuscitation may not know what DNR means (Department of Natural Resources?) but aside from that- which is unlikely- what are the legal implications? Was it a joke? Did you change your mind? Would you have changed your mind under these circumstances where resusc would result in a normal life? (J Gen Int Med 27(10)1238) Perhaps you should have the whole DNR contact printed on your chest with date and notary’s signature? And we as health care providers- what do we do if we see one? Lawyers and ethicists out there (yes, that is you Sandy and Ken) what do you say? TAKE HOME MESSAGE: Tattooing DNR on the chest may not have any meaning. Patient #3: I can’t get my contact lenses out-

Dr. House: Out of what? They’re not in your eyes.

Patient #3: But they’re red.

Dr. House: That’s because you’re trying to remove your corneas.[moves to next patient] What’s wrong with you?

Patient #4: Uh, lately, my wife has noticed that…

Dr. House: Yeah, yeah. Symptoms, [gestures at Cuddy] we’re working on a personal best here.

Patient #4: Numbness in my feet and hands, constipation…

Dr. House: And?

Dr. Cuddy: Maybe he doesn’t feel comfortable talking about his private matters…

Dr. House: Well, neither would I, if I was having trouble controlling my pee pee!

[to patient]

Dr. House: You’re a dentist. Nitrous oxide poisoning, which means you’re either dipping into your own supply, or you’ve got a bad valve in the office. Laughing gas rehab’s probably more expensive than the plumber. Meanwhile, get yourself some B12.

[moves to college student]

Dr. House: Who’s left?

College Student: I can’t see. [House and Cuddy look appalled] Nah, I’m just screwing with you. [House looks at Cuddy, who smiles] It’s a hangover, my English Lit professor told me he’d fail me next time if I didn’t show up with a doctor’s note.

Dr. House: Well, make friends with the dentist. He can give you a note, and maybe a little nitrous to take the edge off.

[he looks at the clock and walks out]

17) I guess the adage is – anything that can be abused will be abused-and now Baclofen joins the growing list. I couldn’t figure out from the article exactly what it does other than give “a buzz” but for you as the health provider- know that Baclofen can give pretty bad seizures- including non convulsive ones (Eur J Peds (171 (10)1541)TAKE HOME MESSAGE: Baclofen is a drug of abuse and can cause seizures(now this is not a seizure but rather the challenge of giving a dog a bath. Come to think of it, you may want to take one too) Dr. Cuddy: You put him on Lupron.

Dr. House: Uh-huh.

Dr. Cuddy: And, you told them it was like milk.

Dr. House: Yes.

Dr. Cuddy: Is there any way in which that is not a lie?

Dr. House: It’s creamy. But, I had three reasons.

Dr. Cuddy: Good ones?

Dr. House: Well, we’ll see in a minute; I’m just making them up now

 

 

Dr. Chase: How would you feel if I interfered in your personal life?

Dr. House: I’d hate it. That’s why I cleverly have no personal life

 

18) I know you all read this journal, so I was hesitant to bring this article- but it is a problem you may face so let’s do it. Missing IUD strings is quite common. The way you found them in the past was using a cervical brush to tease them out of the os or colposcopy. Both methods are pretty poor. This retrospective study- methods are probably not that important as it easy to pick up these cases from the charts) – showed that most of the time they were in position. A few times they were expelled, and rarely; they had perforated. How can you determine this? Simple- do an ultrasound. (Contraception 86(4)354) TAKE HOME MESSAGE: lost IUD strings- don’t waste time with maneuvers- check to see if you see them, and if you don’t do an ultrasound.

Jeffrey Reilich: You’re treating him for both diseases?

Dr. Foreman: Covering all the bases.

Jeffrey Reilich: What, throw everything against the wall and see what sticks?

Dr. Chase: Works for spaghetti.

[Everyone stares at him}

 

Dr. House: But the patient’s getting better.

Dr. Chase: In spite of the Cytoxin.

Dr. House: On the other hand… getting better.

Dr. Chase: Cytoxin makes him more susceptible to infection. The anthrax could relapse and be more resistant.

Dr. House: Better!

Dr. Chase: You want a negative test on every autoimmune disease known to man? Fine!

Dr. House: Be home by midnight or you can’t have the car this weekend

 

 

 

19) I’ll just mention this briefly- don’t you wish I would say that all the time- low tidal volume reduces mortality in ARDS and acute lung injury, but can result in hypoxemia, atelectasis, and hypercarbia which could be bad in head injured patients. So like Prof Hoffman always says- “just do the right things”. What is that? Anyone want to volunteer an answer? (Ann Emerg Med 660(2)215). Now before I get it on the head from Scott- and I know its coming- let me say I do know the answer- work with your plateau pressures and keep them under thirty. However, for some of us- that is hard to measure on some of the machines we have. Is this a plea for a machine that can tell us the plateau pressure at a glance? Well in a word- yes. TAKE HOME MESSAGE: Maybe a TV of 8 ml/kg is a better start. [about Vogler being appointed board chairman of the hospital]

Dr. Cameron: That’s not necessarily bad news.

Dr. Foreman: Do you ever watch “Gilligan’s Island” reruns and really, really think they’re going to get off the island this time?

 

Dr. House: No pneumonia, no bacterinia, no hep B or C or any other letters

Dr. Cuddy: Substance abuse? Any hist…

Dr. House: No alcohol, no drugs

Dr. Cuddy: Any psychological conditions, history of depression?

Dr. House: She’s a little blue…but it turns out she needs a heart transplant

 

20) This has been reviewed on EM RAP but is such an important topic. Also the lead author is an EMU reader and a great guy. We know what causes TTP now- it is a lack of ADAMSTS13 which cleaves the von Willebrand factor in to little pieces. If it is not cleaved they began to clog things up. That results in the classic pentad which is really a triad- hemolytic anemia (that is a low hemoglobin with spherocytes), some kind of neurologic complaint – which may actually clear before they are seen and thrombocytopenia. The fever and renal damage are helpful but not always there. HUS can look similar but it is seen more often in kids and there is diarrhea. Causes include autoimmunity, medication related (think Clopidogrel), cancer, pregnancy and infection. Plasma exchange is the treatment but in the interim you can give FFP or cryoprecipitate and steroids. Rituximab will help as will cyclosporine if nothing else helps or if you have no plasma exchange. But then again- try to get plasma exchange as mortality without it is high. Platelet transfusion is contraindicated- although maybe not- we always thought it was but it seems that some recent studies have questioned this (JEM 43(3)538). TAKE HOME MESSAGE: Low platelets and anemia- you better at least consider TTP.

Dr. Cameron: They just stopped Carly’s heart. And your dumb patient-

Dr. House: They’re all…oh, the guy who can’t talk, right.

Dr. House: Why are you doing this?

Dr. Cameron: I’m not doing anything.

Dr. House: You’re manipulating everyone.

Dr. Cameron: People… dismiss me. Because I’m a woman, because I’m pretty, because I’m not agressive. My opinions shouldn’t be rejected just because people don’t like me.

Dr. House: They like you. Everyone likes you.

[he starts to walk away]

Dr. Cameron: Do you? I have to know.

Dr. House: No.

Dr. Cameron: [smiles quietly] Okay

21) There have been a lot of articles recently that say we shouldn’t teach intubation to pre hospital folks- it is costly, skills need to be maintained and it hasn’t shown survival benefit. And besides – we have lots of supraglottic devices that can hold people over until they get to the ED- like the LMA, the combi tube and the laryngeal tube. This is an editorial on a paper in Resuc 83(9) 1061 which actually showed benefit to intubation in EMS hands. David Cone- the editor in Chief of AEM gives his opinion here and while he doesn’t like the study, the objections are rather skimpy. It is an observational study and there is a lot of missing data. Furthermore there is no record as to whether the patients who got SGA (supraglottic airway) were failed intubation and of course did worse. (Resusc 83(9)1047) I think the issue isn’t so clear but it would make sense to go with scoop and run and not delay with ET tubes in the field especially since the SGA may be enough in many cases – like CHF. TAKE HOME MESSAGE: Intubation in the field may not be advantageous over the LMA- however this study said it was. Bill: His name’s Joey, he’s my only brother.

Dr. House: He’s important to you. Got it. No placebos for him, we’ll use the real medicine

 

Lucille: I’m not pregnant.

Dr. House: Sorry, you don’t get to make that call unless you have a stethoscope. Union rules

 

22) Hey, you are just not hip (the sixties) if you aren’t using awesome (the eighties) amounts of vitamin D for just about everything. It is really beat, (the fifties). You would think that since it h as an immune function that it would help for the common cold. Well, it doesn’t and joins inhaled steroid, echinacea, vitamin C, fluids, anti viral and zinc as things that Cochrane says that don’t work (JAMA 308 (13)1375) I mean totally (eighties) groovy( seventies). TAKE HOME MESSAGE: Vitamin D does not help in the common cold. Psychedelic! (sixties) Vogler: So, there is some hope.

Dr. House: Always. But just in case, I special-ordered a jumbo-sized coffin.

Vogler: Hey …

Dr. House: Don’t thank me. It’s just who I am.

 

Dr. Wilson: You’re not going to be happy with anyone.

Dr. House: So what, your advice is… hire someone I’m not happy with and be happy?

Dr. Wilson: No, my advice is much more subtle. Stop being an ass

 

23)                 What you bring home on your next trip abroad could be a mug or a T shirt but I would advise you to be more exotic- why not bring home an arbovirus? Yes these fun, playful arthropod borne viruses are not available in any store, and come free with that ginseng knife. I thought this article would be an interesting read, but indeed other than letting me know that Dengue is still the most common virus you will get abroad ( and we have discussed dengue in the past) – all the others are pretty uncommon – and most importantly- they have no real treatment options. And of course the most dangerous animal of them all remains the mosquito (J Clincial Virilogy 55:191) TAKE HOMEMESSAGE: Fever, joint pains after a nice trip to the tropics- think arbovirus Dr. House: It is in the nature of medicine that you are gonna screw up. You are gonna kill someone. If you can’t handle that reality, pick another profession. Or finish medical school and teach.

Dr. House: Straight from the bladder, that’s as fresh as it gets

24)                 This is a really important article but because no body is still reading at this point anyway, I decided to sneak it in here. Azithromycin is a risky drug. While it is rare, azithro has shown much more mortality than with amoxy, especially in patients with cardiac disease, QT prolongation, and those using amiodarone or sotalol. Considering that most common uses of this drug are for sinusitis and bronchitis where numerous studies have clearly shown it doesn’t work) and we do know that it is weaker than the penicillins in treating strep (Penn allergic- go to cephalosporins- see April EMU)- maybe you should be like me (a good idea in any case) and never use this drug (NEJM 368(18)1665) TAKE HOME MESSAGE: Azithro joins its brother erythro as being a bad boy- this time with cardiac deaths. Dr. House: [closing the blinds so he can’t see Stacy] What? Mommy and Daddy are having a little fight, it doesn’t mean we’ve stopped loving you. Now, go outside and play. Get Daddy some smokes and an arterial blood gas test

 

 

Dr. Cameron: Black defendants are ten times more likely to get a death sentence than whites.

Dr. Foreman: Doesn’t mean we need to get rid of the death penalty, it just means we need to kill more white people

 

24) PICC Lines are not safer than conventional IVs. Bloodstream infections and thrombosis are not that all uncommon. (AJM 125:733) Dr. Foreman: Her oxygen saturation is normal.

Dr. House: It’s off by one percentage point.

Dr. Foreman: It’s within range. It’s normal.

Dr. House: If her DNA was off by one percentage point, she’d be a dolphin

 

 

Dr. Cuddy: Dr. Sebastian Charles collapsed during a presentation at Stoia Tucker.

Dr. House: Really? Crushed under the weight of his own ego

 

25) Lower GI bleeds- guess what? They have longer hospitalizations, more resource use and higher mortality than Upper GI bleeds. True 85% are self limited but they can be treacherous. Is the upper GI tract still the most common cause of lower GI bleed? Probably not- they still like putting NGTs (zonde) in but it is not associated with any mortality benefit. I would use it in severe bleeds. CTA is the diagnostic tool of choice, colonoscopy is another weapon (that was terrible) at your disposal, but you need a good cleaning which may take a few hours. It can however often stop the bleeding, other times embolization or surgery may be necessary. Video capsule endoscopy has some utility but here is the surprise for me- those red blood cell nuclear scans are useless- that was a holy cow from when I was a med student (back when Father Greg was a young man of 65 (I graduated in 1986). Causes- the classic teaching is still true- painless- think diverticulosis (an arterial bleed which can be massive), hemorrhoids, AVMs (usually less severe, ischemic colitis, all the diarrheas (don’t forget C difficile), neoplasms, and anal disorders which are usually much less bloody and painful. Don’t forget chemo and meds can cause bleeding- if your grandma is on cocaine- that does cause an ischemic colitis. (Drugs Aging 29:707) Here is a picture of some druggies – so be careful Actually that is Irene Ryan – the grandmother from the Beverly Hillbillies. TAKE HOME MESSAGE: LGI bleeding can be serious and embolization is the treatment in most cases if it is serious. Dr. Chase: You were right.

Dr. House: Now there went three wasted words

 

 

Dr. Cameron: It’s kind of a long shot.

Dr. House: Yeah, but it’s been over an hour since we poked the patient with something sharp. Get him a lumbar puncture

 

Dr. House: [after injecting the cyclist] Tensilon erases the symptoms of MG for five or six minutes. [patient falls to the ground] Sometimes less. This is exactly why I created nurses. [yells out the door] Cleanup on aisle three

 

 

 

26)                 Time for letters. Firstly from ICU guru Scott Weingart- I have never met Scott personally (Scott- when you coming to visit Israel?) but he is a great guy and I appreciate his answering my questions and participating in a round table discussion not too long ago. Scott was recently quoted as being a drug pusher. He is in favor of this and actually has done this many times. Oh, I guess I should be more explicit- we are talking about push pressors- those quick solutions to get BP up when you over sedated a patient or until you can get in a CVP. Barry Brenner- another good friend – in the old days just opened the dopamine wide open, and Scott is in favor of phenylephrine and epinephrine – but what about Terlipressin? Or just pushing norepinephrine? Scott answers- that Terlipressin has a rather long half life- about a half hour- so not much room there for overshoot. (phenylephrine lasts about seven minutes). My ICU guys say Teligpressin works fine the first time, but additional pushes give less of a response. Also it really causes a lot of splanchnic ischemia. Pushing nor- he is all in favor- but there are no studies. I also asked him about ET tubes that were put into the esophagus (darn medical student) and my fast thinking of throwing an NGT (zonde) down the ET tube to drain out all the baked flambé this guy has eaten in the last three hours but then getting laughed at by the nursing staff as the ET tube can not clear an NGT. Well the only solution is to use a hook knife or a stitch cutter and cut off the ET tube- I was thinking perhaps cutting off the head of the NGT and using an adapter but I couldn’t find one. In other letters: Alxel Ellrodt from Hopital Americain in Paris immediately identified the bubble gum scene from last month’s movie quiz- but let’s see if he remembers in what picture you will find Rick’s Café Americain? Thanks for writing. Father Greg does write. Father; please be careful what you write- I’m a little sensitive about Billy Carter- he was my Grandmother. Here is part of Greg’s letter-I couldn’t print it in the entirety because Greg is a legal kind of guy and might bust me for the Mann act (transportation of medical information across state lines for immoral purposes) This is Father Henry commenting on the May issue of EMU. First, I got all 3 famous people right off the bat but that’s because I’m DELETED! I probably have shoes and belts DELETED than a lot of your readers with Ken DELETED being the exception. Thank you for your DELETED endorsement of Risk Management Monthly. Next month we are doing a special on DELETED. I must say that Israel seems an odd place to be commenting on US country music. DELETED Just to add to your great country lines there is one that combines hillbilly music with dermatology : “your father can put me in jail for loving you but he can’t stop my face from breaking out.” Keep the faith. Thanks Father for writing,

27) The rash in number 2 was eczema herpeticum which likes the face. The lesions often become pustular. This is caused by our old pal Herpes – using other skin diseases as an excuse to reappear. The Acyclovir family is the treatment and patients do well if they are treated- but not if they do not receive therapy. This is what it looks like later on- this is not impetigo Number 3 is pyoderma gangrenosum. This is made worse by debridement. It is often seen with IBD but you will see it in RA and SLE too. Anti-inflammatory treatment is recommended, steroids usually but not always help. Dr. House: [To a patient who’s been using strawberry jelly as a spermicide, and got an infection from it] You probably shouldn’t have relations for a while.

Patient: For how long?

Dr. House: On an evolutionary basis, I’d recommend… forever.

 

Dr. Cameron: How would you describe my leadership skills?

Dr. House: Nonexistent. Otherwise excellent

 

 

EMU LOOKS AT:Chucks and Up chucks

The source of these two essays are JFP 61(7) 384 and AJEM 31:859. For those trying to figure out what I am talking about, the first essay will make you want to use a chuck (an American word for an absorbent covering of a bed sheet), the latter is a word from the eighties that is a term for regurgitation.

First Essay: Come on, you don’t fool me. And now I am going to get revenge on you- I am going to publicize to all the EMU readers who you have been sleeping with. Here we go – the hootchie’s (gigolo’s) name is Cimex

1)   Yes cimex. Let me show you a picture of this beauty. Yes that is a bedbug. These fellows were pretty rare in the nineties – so much so that they couldn’t even collect specimens for medical purposes. That has changed obviously as insecticides are less effective and this bug is extremely resilient. They can live a year with out feeding (Gosh, can’t they make a teenager like that?) and they are small enough that they can travel with your luggage or through cracks to new destinations. They use the Al Capone method- feed early and feed often. They do this as they can not get to the next stage without doing so. Since they only feed off of humans- they are hard to bait or trap.

2)   Fortunately they do not spread any disease that we know of-but their bites are very pruritic. Scabies can look like this, but they burrow and like skin folds- bedbugs are less fussy. Flea bites, mosquito bites and spider bites can all look the same- a linear three bite pattern may help to suggest these little folks- but it is not specific enough.

3)   Treatment of bites is easy- the usual antipruritics.

4)   They do leave a lot of debris so discovering them as a biting source shouldn’t be too difficult. Have a doubt? There are bug detectors machines and even specially trained sniffing dogs. You can get rid of these pests by desiccant dusts such as silica; heating or freezing for an hour, sealing cracks in the room, and perhaps taking ivermectin which poisons the bug when they use you for dinner. It should be noted that there is little research on the use of ivermectin. You can also trying killing the bacteria that live in the bedbug’s bodies and whom they need for survival.

5)   When you travel, wrap your luggage in plastic. Store it in the bathroom- less chance the bugs will get there. Cover your bed and box springs Buying used furniture? Fumigate it! Have no bedbugs where you live? Don’t say I didn’t warn you, these creatures are nightmares in bed.

Second essay: Two points- this is no joke- there are no good guideline for these patients and their cases are sad- young ladies who sometimes die. I am speaking bout eating disorders. I will also just mention that if you are an EMA listener; Jerry and Billy spoke about this earlier, but they used an article from the Int J of Eating Disorders (45(8)977) and ours is of course newer. But then again- the literature police strike again- our article was written by two of the same authors.

1)   Well the two culprits here are anorexia and bulimia- well know to us but actually they have DSM –V definitions for these and indeed there is overlap between the two syndromes. We all know this is a disease primarily- but not limited to- females, but I didn’t know that after asthma and obesity- it is the most common chronic condition in female teens.

2)   These people have co morbidities- self esteem, high concern parents, perfectionism issues, history of sexual abuse, depression, substance abuse or weight loss for athletic reasons. Anorexia shouldn’t be too hard to identify- these folks are very cachectic. They will also have brittle nails, thinning hair and fine lanugo hair on the arms and face. Blood tests are usually not helpful unless they in a severe stage. Amenorrhea is common.

3)   While anorexia often have some form of bulimia, the opposite is rarely true. Bulimia is-again a disease of females. The same co morbidities are often present

4)   Bulimics may have physical findings- such as hypertrophied parotid glands, poor dentition and erosions on the hands- known as Russell’s sign-are signs of purging. Hypokalemia and metabolic alkalosis may be found on blood tests.

5)   This severe malnutrition results in decreased cardiac mass, contractility and cardiac output. They have bradycardia. And dysrhythmias are common. Purging may cause pneumomediastinum

6)   So be careful- fluid management is critical- too much into these weakened hearts and your patient will slide over to CHF. Refeeding syndrome is also a concern as this will cause a lot of insulin to be released reducing potassium, magnesium and phosphorus stores. Here is an example they give- a female ingesting only 500 calories a day can be overwhelmed by 1000 cc of D5 which contains 200 kcal So they need to be re fed slowly. – And this is not to be done in the ED but on the floor. However, feel free to give vitamin supplementation. I should just mention that this syndrome can be seen also in alcoholics and in hyperemesis gravidarum.

7)   Bulimics can also abuse ipecac leading to a cardiomyopathy as ipecac contains a cardiac toxin. They can have a pseudo Bartter syndrome. These folks also should be given fluids judiciously as aldosterone levels take time to fall and they will go into CHF. Spironolactone is an excellent agent here for mild diuresis and potassium supplementation. As bulimics abuse stimulant laxatives- they may have a rebound constipation- use PEG.

8)   The SCOFF questionnaire will help identify who is an anorexic but these patients are in denial and while suicide is common, there is little the system can do. They cannot in most jurisdictions be admitted against their will unless they are in really bad shape.

9)   Curiously, the article did not mention SKA- a mild acidosis of starving treated by fluids.

Carmen, a patient with schizophrenia is being treated by Dr. Randall Powell

Carmen: There are bugs all over this room!

Powell: Where do you see them?

Carmen points to the wall. There is nothing on the wall

Powell: Point exactly on one on the wall

Carmen points to a spot on the wall. There is nothing there

Powell slams his hand on the wall.

Powell: There, I killed it. You’re cured. Next!

(Yes, this actually happened)