EMU Monthly – January 2014

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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


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

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


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

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

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

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

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

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


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

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

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

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

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


French Guinea (which is still a colony)


Oh oh !

A casus belli ? ( what does this mean?)

Colony ? thou said colony ?
I suppose you talk about Guyane, or Guiana .
Not a colony.
Ok debatable  ;-)


Thanks for the new issue.

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

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

Officl guidelines say stop !

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

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


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

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

Hi Yosef

Congratulations on 15 years of publication!

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

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


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

Hi Yosef,


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


Go to iclickem.com and search EMU..

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


EMU LOOKS AT:PMS is like pulling teeth

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

Polymyalgia Rheumatica

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

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

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

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

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

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

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

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

9) These patients do well.




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

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

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

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

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

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

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

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

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