EMU Monthly – March 2006

 1) In 2001 ACEP printed guidelines on syncope that were

revolutionary in that they did not require blood tests and they stressed high risk and low risk patients differentiation, much like we do with pulmonary embolism. The American Heart Journal (May 05) recently confirmed these rules and found them to be useful. Now I know the numbers are small, and that the study was retrospective, and one always must be wary of 100% sensitivity, but the fact that cardiologists would admit that the rules work on something in their domain is in itself significant. I have found that not many folks are aware of these guidelines, and that the European Heart Journal also printed similar guidelines at around the same time. It is worth your while to download them. They are in vol 27 number 6, in the Annals of Emergency Medicine


2) We have mentioned this before, but it is possible that you have forgotten or your maxillofacial surgeons (if you have one) forgot. Biphosphonates like Fosalan (Fosamax) can cause osteonecrosis of the jaw in folks who have had recent extractions. Jaw pain may not be benign! ( CMAJ 21 Jun 06) The same issue of the Canadian Medical Association Journal reports that NSAIDs may increase the incidence of Alzheimer’s, although this is a very preliminary study. Obviously occasional use will not be a problem, but keep in eye out, especially in arthritis sufferers


3) Does experience matter is the title of this article from the Journal of General Internal Medicine. And the answer is yes- but only sometimes. This study focused only on costs, and indeed in the ambulatory setting (that is Kupat Holim) attendings do practice a more economical medicine, with less testing and less x rays. In teaching hospitals the costs are high, but the same whether care is delivered by specialists or residents (JGIM Jun 05) I included this paper as a stimulus to the often claimed mantra of American Emergency Physicians that their brand of care is actually cheaper than the HMOs. I think in Israel with emergency physicians in a properly run ED, the results may be similar, but this needs to be studied.


4) Oh how I liked that paper I reported two months ago from Neurology that reported that ultrasound could break up clots in the brain. It sounded neat and so futuristic. Someone finally looked at it seriously and found it causes more bleeding so the trial was stopped prematurely. (Stroke Jul 05) True with fine-tuning it may work out, but if you use it with TPA your bleed rate was 13/14 and 5/12 if you did not get it.


4) A tough study to understand- they claim that Morphine patients do worse in MI s

(American Heart Journal Jun 05). True it was retrospective and true they may not have controlled well enough for sicker patients (they claim they did) but these folks did so much worse than those getting nitroglycerin. I cannot tell you what to do here other than to wait for better studies.


5) We like to give high doses of brochodilators, but in COPD it does not really make a difference (Chest Jul 05) I really believe that in asthma at least if the bronchodilator is going to work, it will show much improvement in the first dose. In COPD, I do not think we are very successful in the ED no matter what we do


6) Satisfied patients want three things. That is, at least in the USA. They want a courteous nurse and physician, a thorough physician or at least one who acts like it, and low perceived waiting time (Annals of Emergency Medicine Jul 05) In Israel, patients always wait forever, so you will be a winner if you say the waiting time will be longer, and in the end it is not ( that is saying the blood tests will take three hours, and then it only takes two. You will have happier patients)


7) Things in reverse. With certain exceptions, LBBB does not portend to more mortality. In the setting of MI LBBB will be associated with more mortality, but outside of that, LBBB has less mortality, due to pre existing angina- a concept mentioned in the article but not defined. (Journal of the American Association of Cardiologists, 5 Jul 05) However, in CAD LAHB does portend to more mortality (same journal, Sept 05)


8) This was a poorly done study- only 37 patients, but with interesting conclusions and perhaps you will be inspired to do the study correctly. Ketorolac eye drops (In Israel we have Voltaren) did not help pain any better than artificial tears. (Eye Jul 05) I am a believer in using pain meds locally so I venture to guess it is not that ketorolac did poorly here but rather artificial tears is not a bad therapy. Perhaps the lubrication soothes.


9) The American Academy of Pediatricians recently evaluated the likelihood of allergy to cephalosporins if one has an allergy to penicillin. While it is rare, it happens more frequently with cephalosporins with a similar side ring as penicillin. So they conclude avoid these three cephalosporins in a penicillin allergy cephaloridine (not available in Israel), cephalothin (Keflin), and cefoxitin (also not available in Israel. Allergies to amoxycillin or ampicillin should beware of using cephalexin ( Ceforal, Keflex and others) cephadrine, cefatrizine, cefadroxil (duracef), cefaclor (ceclor and others), cefprozil. When in doubt, use caution when the allergic reaction was serious and you plan to use first generation cephalosporins.

Second and third generation is generally safe. (Pediatrics Apr 05)

10) Prescribers letter Feb 06 brings a list of medications that can cause taste disturbances. We all know that metronidazole (flagyl) causes a metallic taste. There are others that will change your taste perception- ACE inhibitors, Angiotensin inhibitors, Calcium Channel Blockers, Clarithromycin (Karin, Biaxin), PTU, methotrexate, and of course TCAs, and anticholinergics can cause dry mouth


11) There is usually a sixth month delay in the articles I present, but this weeks NEJM (16 Feb 06) had a very pertinent article to Israeli practice. Older ladies are often prescribed vitamin D and calcium when they truly need a biphosphonate for their osteoporosis. Often we see these women in the emergency setting with compression fractures. In Israel , Fosalan (Fosamex) is very expensive so people who need often do not get it. We can help by prescribing the drug, which forces the Kupah doctor to consider it (In Israel, the Kupa i.e. the HMO, have a prescription plan)


EMU LOOKS AT: Weird Stuff


If you are a long time reader of EMU like I am, you know that the issue before the Jewish holiday of Purim (a holiday dedicated to intense   happiness) comprises the most unusual articles of the year. Indeed, over the years we have compiled quite a collection of very interesting articles. I do not have anything to match last years BMJ article on Dog s having the ability to sniff out bladder cancer, but here we go.



Many folks do there best reading in the Shayrutim (anyone know why a Taxi and a bathroom have the same word in Hebrew) and therefore should not miss the article on Toilet Seat Contact Dermatitis (Pediatric Dermatology 22 (4) 344-45, 2005. I was going to ask how a person would use the bathroom if they are truly allergic to toilet seats but I thought better of it



Tropical Doctor Oct 24 (4) 227-8 reported a new way of dealing with priapism in people who have no access to traditional treatments. The folks in India thing you should consider

Cold Saline Enema In Priapism, A Useful Tool For The Underprivileged“

Seems if you are not underprivileged this will not work, or perhaps it pays to have some cash when you go to the ED in India




Two winning articles here. Allergy 2005 60:1088-1089 reports on anaphylaxis after horse bite. But the Journal of Emergency Medicine 20005 Feb 28(2) 153-4 reports on an allergic reaction after a woman who had an allergy to cephalosporins slept with a man who was taking one. Cannot say if it is better to be bit by a horse or be caught horsing around.



In a New York barbershop, a good joke was so funny that the barber did a syncope (JAMA 293(23) 2863). They do not tell us the joke however. But thank goodness for South Korea where a real bum (actually his name is Bum Su Kim) reports on syncope induced by belching. Again, they do not tell us what he was eating when he syncopised. No reports as of yet of horse bite syncope



The Playboy Rabbit sign on an ultrasound of a thirty five year old woman. The folks at CMAJ would not let me copy this for EMU ( Gosh, talk about no sense of humor) but you can see it for free by going to the Canadian Medical Association Journal, 6 Dec 05 on page 1445





Sarcoidosis in a Gecko (Lancet 2005 365:1876), Second best Hooray for Hypoxia

(PloS Medicine Jun 05). Honorable Mention: Nit Picking (Journal of American Academy of Dermatology 53(1))






In Turkey a gentleman took a bus between cities and developed an acute subdural hemorrhage- therefore traveling by bus can cause a SDH. (Journal of Travel Medicine Jul- Aug 2005). I believe this study- taking an Israeli bus can cause



They got researchers to watch hundreds of episodes of Guiding Light, General Hospital, All My Children, and other Soaps, and discovered that in a ten-year period 65 characters had a coma, and most came out of it. Now were they speaking about the actors or the people watching these programs?



Life is a sexually transmitted disease with one hundred percent mortality

RD Laing

(BRI Book of Quotes)

A happy Purim to all- Yosef

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