EMU Monthly – September 2016

  • Everyone has dreams –am if your dreams are like mine- you dream about (sept-image-1actually that is what Father dreams about)-the rest of us dream about starting Nor on sick morbidly obese patients-so you ask – do you need to give more Nor to these patients? The answer is no.  They raise blood pressure at the same rate as non obese folks (do any of those really exist?) (AJCCM 25(1)27) TBTR: Nor is not prejudiced against fat people.
  • I have issues with this study (besides the issues I have perssept-image-2onally) but I do want to make a point. I don’t care what the ID guys say – if the patient has meningitis or sepsis and is circling the drain – start the antibiotics and let someone sort it out later. How do they sort it out? PCR – and PCR worked fast- faster than blood cultures and actually did better than them. (ibid 25(1)68) You gotta ask – how much did this cost? And since antibiotics were already started – did this make any difference in patient oriented outcomes? But my point remains – just do it in sepsis TBTR: PCR can help- don’t wait for to take cultures- sometimes
  • This idea gets the D’oh award: mechanically ventilated patients can communicate by texting with a smart phone (ibid 25(2) E38) sept-image-3Personally, I prefer telepathy, but a smart phone will do. Hey time for quotes- like take a real old timey guy – Rodney Dangerfield-this is from your parent’s times. His real name was Jacob Cohen and he died a little over ten years ago:I told my psychiatrist that everyone hates me. He said I was being ridiculous, everyone hasn’t met me yet
  • It is a little odd that we cause so many infections with catheters and yet never asked the other side what they think (the other side doesn’t mean the bladder – I meant the patients) This study was definitely skewed – they were all white and only eleven were females. Overwhelmingly they agreed that no one informed them of the dangers of catheters. Actually some even thought it was convenient to have one. (AJ Inf Contr 44(3)304) What can you take from this article? Basically, we are not talking to our patients. TBTR: What do the patients think? Anyone ever thought to ask?

In my life I’ve been through plenty. when I was three years old, my parents got a dog. I was jealous of the dog, so they got rid of me

  • Computer touch screens are full of bacteria – in the hospital it is going to be VRE and Clostridia, but in the super market it is going to be MRSA. And enteric bacteria- that is kinda of sick. What do people do, take a poop, and then say – hey, I’m hungry – wanna go to the grocery for a bite to eat? Oh, and by the way, I forgot to wash my hands. (ibd 44(3)358) TBTR: Computer touch screens- icky.

I live in a tough neighborhood. They got a children’s zoo. Last week, four kids escaped.

  • Anterior coetaneous nerve entrapment syndrome –we’ll call that a
    ACNES for short – is a scourge of kids- it is a common cause of abdominal pain- all investigations show little and the kid is still suffering. So what helps to diagnose this? Well, in this cohort- Carnett’s sign was always positive. Have them tense the abdominal wall (by pulling their legs or head off the bed) and if the pain gets worse or stays the same- it is not intra abdominal. (J Ped Gasto Nutr 62(3)359) Recently, Medscape perspective suggested this for adults, but my surgeons weren’t convinced- hey they gotta have that CT. But like any sign – it may be used to support what you thought anyway. TBTR: ACNES- it ain’t on your face.

I tell ya, my wife’s a lousy cook. After dinner, I don’t brush my teeth. I count them

  • So how do different Europeans deal with renal colic? Honestly, who cares? What interested me is that they are doing a lot more uretoscopy to takeout stones and a lot less lithotripsy. Lithotripsy really hurts, so this is a good development. (Urol Int 96(2)125)

I was an ugly kid. I worked in a pet store. People kept asking how big I get.

  • We haven’t had a good Ken paper in a longtime; so here it is. An attending tells a senior that they should not accept a potential resident because she is pregnant. A medical student is nearby – and was told “pretend you didn’t hear that”. What is he to do? They say – do not confront the attending- as long as there are other options – no need to endanger the medical student’s future. He can turn to the administration or the senior. (JAAD 74(4)766) Whistle blowing is a tough thing –especially when you do not know whose is on whose side. Also, often the protection for these folks is only after the whistle blower is already in hot water. And there are always genteel ways of making folk’s lives miserable. Wish there was a simple answer. TBTR: Whistle blowing in medicine.

When I was born, the doctor said to my father, ” I’m sorry, we did everything we could but he still pulled thru”.

  • Bronchiolitis? There is no such thing! Did I just drop a bomb or what? This article says that has been studied in poor studies and the patients that may actually have this disease are usually excluded sept-image-4from the studies. They claim it is probably early asthma (CMAJ 188(5)351). They also point out that nothing really helps this disease, so if it is early asthma – why don’t steroids and broncho dilators work? TB TR: Bronchiolitis? Banish the thought.

I could tell my parents hated me. My bath toys were a toaster and a radio

  • All my patients think they have thrush – but except in denture wearers and HIV patients- it is kind of rare. Miconazole is more effective than Nystatin, but in denture wearers, microwave therapy is the best (I didn’t know that) (Oral Dis 22(3)185) TBTR: Nystatin – you can do better.

What a dog I got. Last night he went on the paper 4 times – 3 while I was reading it

  • EMU has never gone in to this subject, and it is an uncomfortable one. Human trafficking exists and it doesn’t go away or cease to exist because you close your eyes. There are signs – usually the trafficker accompanies the patient and won’t let them out of their eyes – very similar to domestic violence. You should read this review –this is not just a problem of inner city folks or of runaways. (Ann Emerg Med Apr2016) I was particularly enlightened (and frankly shocked) by hearing the first hand story of such a woman on EM RAP about a year ago. Get this recording if you cna, and remember –there are resources. TBTR: Human trafficking. – identify it. Eradicate it.

One year they asked me to be poster boy – for birth control.

  • There are some phalangeal fractures that do go south. I recently heard Dr. Anan Swaminathan speak about the controversy of whether tuft fractures should b e considered open fractures and given antibiotics or not. He doesn’t give , but I saw two osteo cases lately and it really got me thinking. This article speaks about sequela after phalangeal fractures. Most of these – a small study in any event – were close to or through the joint Only three were in patients with open fractures- I do not know the denominator – so Swami’s question still isn’t answered (Eur J Ped Surg 26(2)164) TBTR: Phalangeal fracture – no big deal?

My uncles dying wish was to have me sit in his lap – he was in the electric chair

  • Skin tears in the elderly? Close them how every you want (I glue them) and then use VAC- that vacuum device the plastics guys love- and you will have great results in no time – viability here was demonstrated in five days (Int Wound J 13(2)283).

On Halloween, the parents sent their kids out looking like me

  • No evidence here – and why should there be- this is a surgical journal- but it seems that acutely – in type B dissections – endovascular therapy acutely may be better than medical therapy. (Eur J Endovasc Surg 51(3)452).  Makes sense to me- endovascular at least fixes the problem.

When my old man wanted to be intimate, my mother would show him a picture of me

  • Oh, how I remember those westerns- remember How Green was my Valley, Gunsmoke, Bonanza, Wagon Train-sept-image-5 (- yes that is the famous baked beans scene in Blazing Saddles) – why am I mentioning this? Because of the phony cheesy line “I got an itchy trigger finger”. Here is a one page summary of all you need to know about trigger finger-patients report locking of fingers on flexion and extension, women and diabetes are at risk – the treatment is easy – cortico steroid injection but often repeated injections are necessary – and in that case – surgery should be considered (CMAJ 188(1)61) TBTR: Trigger finger.

I had a lot of pimples too. One day I fell asleep in the library. I woke up and a blind man was reading my face.

  • Women and heart attacks – this is a patient explanation page but I will just bring two facts from it that I did not know- -only 56% of women think that heart disease is a leading cause of death in women. sept-image-6I did not know (what a moron I am ) that pre eclampsia is a risk for heart disease. Also. Women must know that depression is another risk and is more common in women (I would be depressed if I was married to most men also). I did like that they say the risk increases as we get “less young”. ( Circ 133:e428) TBTR: some info on women and MI. It’s tough to stay married. My wife kisses the dog on the lips, yet she won’t drink from my glass.

It’s tough to stay married. My wife says no because she’s tired then stays up and reads her book

  • Talk about an article I did not understand at all- It started with the classic starling equation (which includes on sigma and two pi (I purposely did not write that in the plural) –it describes swimmer induced pulmonary edema and its relation to HAPE- I couldn’t make sense out of it- but it is here in the data base (Circ 133:951)

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

  • Article of the month. If you don’t read anything I wrote this month- and you shouldn’t- read this. A surgeon you know took out the healthy colon and left the diseased part-what do you do? There are a lot of bombshells in this articles. First of all- it is a panel discussion- the first discussant states the importance that we police our selves- medical science is too complex to be left to non physicians and that we can be trusted to rectify peers (he likes M and M conferences- by surgeons this can be the ultimate in hunting season) – I do not agree- I think inter peer politics still plays a role and as far as the former is concerned – whether we like it or not, non physicians will be involved. He points out that good outcomes often accompany grievous errors and bad outcomes accompany perfect surgery. Who is to blame? Sometimes that can be very nebulous. Report them?  Whistleblowers often suffer consequences and also we often say- someone else will deal with the problem. A second discussant says that we must inform the family and the surgeon who made the error. This discussant is against reporting to the medical board – who often are cretin in their approaches to complaints (just don’t ask Father what he thinks about the New York board of medicine).  A third discussant does feel that we should identify if the error occurred from chance, a momentary error in judgment or egregious incompetence. The last one should be forwarded to the medical board.  This discussant does not get into how we make the determinations in gray cases- since most physicians are not at the ends of the spectrum Get this article (Ped137(3)e20153828) TBTR: when physicians make errors.

I’ll tell ya, my wife and I, we don’t think alike. She donates money to the homeless, and I donate money to the topless

  • Two clinical quizzes that you have no chance at.  A red nipple  that is inflamed in a ten year old boy (in camp we called this a purple nurple)   What could this be ? (JAMA Peds 170(3)289).The second is an 80 year old with abdominal pain after eating and a history of PAF.(JAMA Surg 151(3)287)

I told my dentist my teeth are going yellow. He told me to wear a brown necktie.

My psychiatrist told me I’m going crazy. I told him, “If you don’t mind, I’d like a second opinion.” He said, “All right. You’re ugly too!”

  • How to review a paper- this paper gives the basics (I Liked the way they summarized peer review- Is it new? Is it true? Does anyone give a %$^&?) it is here in the data base – but not much new here (J Electrocard 49:109).

I drink too much. Last time I gave a urine sample there was an olive in it

  • VP shunts are almost always the problem- on boards and in the ED. It is a little silly for me to summarize an article that is already written in an easy to read format. BP shunts are used to drain CSF for a variety of reasons –and you can usually feel the port under the scalp. They generally drain via a long tube into the peritoneum. Shunts – I didn’t know this- fail 40%of the time in the first year and 50% by the second year. Usually this is due to mechanical failure such as obstruction, and fractures of the tubing. Infectious complications can occur, but occur much less in frequency. Obstruction can be subtle – headaches, apathy, sleepiness, even changes in eating behavior in kids. Evaluation of the shunt includes x rays (the shunt series) which show any fractures- (look around the clavicle or the lower ribs). CT or MRI will evaluate problems in the cranial part of the shunt. Problems with the shunt are dealt with by the neurosurgeons but  in an emergency you can try tapping the shunt- make sure you don’t drain too much or leave less than 20 mm Hg. You can do an LP in most patients without a problem of causing herniation – but there is no consensus on when you should enter the port and when you should do an LP. Shunts are rarely tapped even by neurosurgeons even though infection rates are low (Ann Emerg Med 67(3)416) TBTR: What you need to know about VP shunts.  I was so ugly,

when I was born, the doctor slapped my mother

My wife, she’s another one. Last night our house caught fire and I heard tell the kids, “Shhh, be quiet; you’ll wake your father.”

  • This is another article that may be worth your while- maybe. This atlas is for poisonous plants and mushrooms, but of course your flora may be different were you live. Still – cool pictures. (Disease-a-month 62:41)

The shape I’m in, I could donate my body to science fiction

  • So let’s take the geek test- which would you rather have? A good chocolate bar, a good woman, a good wine, or a case report from Circulation? If you answered a good wine – you are either past the age that you can appreciate good women or chocolate or you are Father Greg or you are both. They present this 32 year old athlete who has had chest pain and shortness of breath with radiation to the left arm and a normal EKG. This guy is in good shape, so I don’t think CAD is the answer, but infiltrative cardio myopathy, and myocarditis are defiinetly in the DD. Of course an echo is the first test, but if it is negative, they suggest continuing with a cardiac MRI- something I have never done. A stress test should be done for exercise induced arrhythmias. Naturally, both tests were normal. To make a long story short (whenever anyone says that, you just know it is going to get longer) the guy codes at home, his wife started CPR (why??- must be he had insurance)sept-image-7 and he survived intact- kinda of the way most case reports from Circulation end. What did he have? Coronary artery spasm- he got an ICD although wearable ones are the future. (Circ 133:756) TBTR: The name of this article is “A Shocking Development in a Young Male Athlete” – showing once again that those cardiologists are just one rollicking jolly group sept-image-8

We sleep in separate rooms, we have dinner apart, we take separate vacations – we’re doing everything we can to keep our marriage together.

  • Letters:
  • So the clinical quizzes in 19- the first could have been contact dermatitis, an insect bite, a hemangioma, or a cutaneous lymphoma- but it was Borrelial lymphocytoma- usually found on the outer ear. It is one of the manifestations of Lyme disease. It responded to antibiotics-interestingly enough – this occurred in Belgium- so it can be seen out of the USA. The second was Dunbar syndrome which is compression of the median artuate ligmant from the diaphragm. Yea, I thought this was abdominal angina too.

EMU LOOKS AT: Getting Stoned

As usual this is a pun and the sources for this article are BMJ 352:i52 (2016) and BMJ again352:i124 (2016).

Getting Stoned

  • The first article deals with the workup of renal stones. The name of the article is a misnomer – it really doesn’t have anything to do with the medical management of stones in the ED – but yes in prevention. Here is a statistic – one out of every 11 people will have a kidney stone in their life, and half of them will have a recurrence during their life. In other words- if they know how to make a stone, they probably will do so for life.  Stone disease is also related to many systemic disorders – HTN, obesity, and diabetes.   This is no longer a disease of men predominantly- women are catching up.
  • What are risks for getting stoned?- all that I mentioned before and also hyperparathyroidism, being a carnivore(eating a lot of meat), low fluid intake, eating a lot of salt and avoiding fruits and vegetables.   Family history plays a part as do some medications – especially high doses vitamin C.
  • Blood tests can help a little- raised uric acid – can indicate gout (but low or normal doesn’t rule it out). Low serum potassium and bicarbonate and high chloride imply RTA. High calcium (corrected of course) implies hyperparathyroidism.
  • Check the urine – well, that is a surprise. Urine pH and signs of infection can imply the type of stones. Of course if you know the composition of previous stones that can help you as well. Calcium oxalate stones don’t reveal much – too many disorders cause them , but Calcium phosphate stones can imply RTA, hyperPTH or medullary sponge kidney.
  • Imaging-it is pretty obvious that this can help but not usually in the composition of stones. They do not speak about it, but I am not a fan of scout abdominal films. Even if you see something – is it a fecalith? Phlebolith? a stone? Is it causing trouble?
  • 24 hour urine collection is important- I order this all the time. They like –total pH (not available to me), calcium oxalate, uric acid, citrate, sodium, potassium, and creatinine.
  • So now we get to treatment. They like drinking to a urine volume of sept-image-92 liter a day but not all fluids are created equal. The following will reduce stone formation: coffee, tea, beer, wine and orange juice. (Or in other words, my wife, Homer Simpson, Father Greg, and I are all happy). Sugary drinks and punch cause more stones (because of obesity?). Citrus fruits-no good evidence yet either way.
  • Does eating more calcium make more stones? No, this is multi factorial – yes you will excrete more calcium, but you may not make stones. It seems if you eat your calcium with meals you will excrete most of it with oxalate in the stool, thus reducing stone formation.
  • Probably a good idea to reduce oxalate ingestion- what is that? Dried fruit, pineapple, beans, nuts, grains- oh- just see the list from the hodie toities at Harvard. Oxalate in the urine is also caused by a bacteria O. formigenes and turmeric, cranberry and vitamin C ingestion.
  • Citrate in the urine prevents stone formation- you’ll find this in fruits and vegetables and in OJ. DASH diets also reduce stone formation.
  • Low sodium diets also cause more calcium resorption and less stones. Animal protein: we have mentioned already, but dairy products do not cause more stones.
  • Talk about meds we never use- they have a table of medications to prevent future stone formation. Thiazides prevent calcium stones, but potassium citrate works really well for these and most others (struvite stones are the only exception) Sodium citrate works – but the sodium may offset the positive effects. I used Mag citrate in a patient with hypomagnesemia and stones. Did the trick
  • A longer essay than usual- but still the fact that beer and wine can help you – it is worth getting stoned.

 

And that leads us to our next essay- acute management of decompensated alcoholic liver disease.

  • Cirrhosis causes immune dysfunction with high mortality rates if there is infection present. These folks get UTIs, C Difficile, entercolitis, and cellulitis- and the most feared- SBP. Enterobacter species, an d non entercooccal strep are culprits here.
  • A word on SBP. They can have fever, they can have abdominal pain- most of the time – they have nothing. Tap these folks – if there are more than 250 WBCS- start antibiotics and albumin which has shown some promise in reducing hepato renal syndrome.
  • Alcoholic hepatitis. This presents as rapid onset jaundice, tender RUQ (although most alcoholics have this anyhow) coagulopathy, AST and and ALT being more than two times the normal with AST being two times higher than ALT. Prednisone is used with modest effect; at this point ; NAC, GSF, and early transplantion are experimental.
  • Hepatorenal syndrome- hard call, because these folks have malnutrition and their creatinines may not be that high – sol ook for changes in their normal creatinine, and be aware that this is more common in SBP Give terlipresin and albumin.
  • Ascites- tap it if it is interfering with breathing, but if not make sure they are taking spironolactone and furesomide, and be prepared for all sorts of electrolyte disorders.
  • GI bleeding, encephalopathy- they leave to recent guidelines and do not discuss them. They do not discuss alcoholic ketoacidosis, and alcoholic pancreatitis- both which can be seen the ED and need early ED intervention.
  • Nutrition – careful with refeeding syndrome.
  • They do not tell us how to treat withdrawal – I always used benzos but they say this can cause hepatic encephalopathy. They want you to just be careful.
  • This can occur also by imbibing any wine advertised as the wine of the month on Risk Management Monthly.

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