EMU Monthly – November 2013

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

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

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

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

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

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

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

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

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

Major criteria[

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

Minor criteria[

Other signs and symptoms

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

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

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

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


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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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


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

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

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

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




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

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

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

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


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


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

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

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

Calvin: I see.

Dad: Nicely put, dear


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

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

Susie Derkins: Imadoofus.

Calvin: Thanks.

(Calvin realizes Susie has tricked him)

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



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


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

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

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


Hi Yosef

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

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

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

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

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

Best wishes, Ken

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

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

EMU LOOKS AT: Looking great and breathing easier

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

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

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

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

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

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

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

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

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

Lung Transplant Emergencies:

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

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

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

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

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

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

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

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

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

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

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

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

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

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