EMU Monthly – February/March 2016

All the EMU goodness for Feb/March 2016

  • Drug induced Status Epilepticus is pretty rare. But it does occur and you should know about it. OK, we know about drugs doing this, and obviously intracthecal agents. Don’t forget older anti epileptics and even a new one – tiagabine can cause non convulsive SE. Antibiotics and INH can also casued this (Epil Behav 49:76) In the ED – control the seizures and then you can sort out the source later – and STOP THE MED! I think there is a more important point here: don’t forget non convulsive status can be a cause for coma. And especially remember that if you treated the seizure – especially with paralytics- and the patient stops seizing but doesn’t wake up – this is non-convulsive status. This author must change his name – in the name of decency I will not tell you his name. TBTR: Non convulsive – do not forget it.
  • This was a terrible study. I mean rotten to the coreimage001, image002ugly), yucky image003. They surveyed pain doctors about pain scales; and there was only a 3.8% response rate. But it was clear that no one uses them. And they ask – why should we?  I am still waiting for some one to say – yea- my pain –it’s a 3.1415. (Pain Med 16(7)1247). TBTR: Pain scales – no one is using them.
  • Maybe, just maybe you are bored with my fascination (fetish?) with sedation, but we rarely speak about Nitrous (laughing gas) It works fast, no need for IV, and there are very few contraindications (pneumothorax is the key one) They say it has not been proven to cause any teratogenic effects which I didn’t know. The fact that this was written by anesthesiologists and they are allowing us to use sedation in itself is a miracle. (Eur J Anaesth 32(8)517) I do have experience with this- they say vomiting is uncommon, I saw it a lot. It does not give a deep sedation and does nothing for pain, but is perfect for inserting an IV or nursemaid’s elbow or any similar short painful procedure. I use the 70% NO 30% O2 mix. While we are speaking about sedation, let’s milk sedation for another article. They have a really agitated person that EMS failed to intubate. But they still felt that he could benefit from BiPAP. Gave him ketamine, and viola (picture) the patient allowed the BiPAP and improved. So did his priapism (see last month) (AJEM 33(11)1720) It has been reported that ketamine an also clean windows, lubricates sparkplugs and is just super in salad with escarole.   TBTR: NO is back – use it. And ketamine –able to leap tall buildings in a single bound. Quote time! Let’s look into the wisdom of Divas

“I love to see a young girl go out and grab the world by the lapels. Life’s a bitch. You’ve got to go out and kick ass.”
 image004Maya Angelou

  • Really, I know you are intelligent. I know you know this too. But just in case there are some people from New Jersey reading this, I will just repeat the obvious. Anaphylaxis – give the frigging epi. Forget the H1 blockers, the steroids – they take too much time to work. Just give the shot IM or IV if you got one and then you give whatever you want (Curr Opin All Clin Immuno 15(4)323) why this paper got published is beyond me- this is not exactly new information. But I will say – if you are in doubt – give them the epi even if they are a heart patient. Do H1 work in the acute setting? The evidence does not seem to support this. TBTR: Just give the epi! “Big girls need big diamonds.” image005
    Elizabeth Taylor
  • Dysuria, fever, frequency – hey slam dunk image006– UTI! Well, in this population – most of the time it wasn’t. They did a culture on everyone even those discharged by the doc with no need for a culture and found that only 48% had UTIs on culture, and 23% had undiagnosed STD. (J Clin Micro 53(8)2686) I think that often we do jump on UTIs when indeed often they are really STDs. Also consider other diagnoses: candidiasis (vaginal), interstitial cystitis, allergy. At the moment – you only need to treat asymptomatic bacteria in pregnancy, and do not culture catheters unless there is an unexplained fever. TBTR: See the last line. And the line before. And one more before that. “Sometimes I wonder if men and women really suit each other. Perhaps they should live next door and just visit now and then.”
    Katharine Hepburnimage007
  • Taking your boards? They will for sure make you remember the derm signs of endocarditis-Osler’s nodes,image010 Janeway lesions,image008 and splinter hemorrhagesimage011Well Oslers are rare in this day and age of antibiotics, but they are painful. The other two are not. (JGIM 30(8)1229) Truth be told, you can always just look these up, but since you read EMU ( hear about the EMU reader who was so lazy…How lazy was he?…He went to San Francisco with his girlfriend and waited for an earthquake.) we’ll show you them Janeway lesions

Osler’s nodes and splinter hemorrhages. TBTR: Derm signs of Endocarditis- that you will see as often as a Westermark Sign,  Charcot’s triad, and a Unicorn  “I believe that it’s better to be looked over than it is to be overlooked.”
Mae West   image012


  • My impression of the literature – and this is just me-the triptans are effective abortive for migraines if taken within the first few hours after migraine onset. They did a meta-analysis here to study triptans and while these appear to be effective medicines; the numbers were all over the joint. For example, standard dose triptans relieved headaches within two hours in 42% (in other words more than half the patients) – 76% of patients (3/4 of the patients). The number spread continued for completely aborting the headache. When compared to NSAIDS, ASA, and paracetomol they did do better- (again the numbers are not convincing (or expressed in odds ratios either) but they didn’t do well against combination therapies. (Headache 55(4)221) So yes, you can try these but be prepared to use others meds if they fail. TBTR: Are triptans the way to treat headaches? Maybe. Maybe not.  “I never worry about diets. The only carrots that interest me are the number you get in a diamond.” 
    Mae West
  • OK, let’s speak about HEART score. This is an attempt to allow us to use an easy score (TIMI is not an easy one) to discharge low risk chest pain patients. Amal Mattu is a big fan of this, but Amal doesn’t read EMU, so no free plugs here. But Anand Swaminathan up at Bellevue is also a fan of this and he is a reader of EMU – or so I have heard – so if you do read this, Swami- just know I like your delivery and your knowledge base and that you live in New Jersey, and are a proud new parent and that your middle name is Kumar. If you are not a reader, well, just know that I will not like New Jersey ever again, and will never go to Bellevue. The HEART score is basically like this:image014 Why is this important? Because previous scores were tough to use (especially TIMI) and this gives you good backing if you discharge a patient with a 0-1 score. I also liked that it takes into account your clinical gestalt. The likelihood ratios in the study I am about to mention were great – if the score is less than 3- the neg LR is 0.15 whereas the positive is 5. Their point though was that clinical gestalt did just as well. Well, maybe, but it is hard to compare clinical gestalt with a test that incorporates clinical gestalt. You may say well, that means the rest is superfluous, but gestalt is not the same in everyone, and it could be that is in this study it was very good. Still, I use only three scores- the Blatchford scale for UGI bleeds, The PERC score for PE, and this one. (EMJ 32(8)595)  Also remember that with only a positive troponin you can have a score of 1 but I wouldn’t let them go home- just use the scores with your brain. TBTR: Start using the HEART score for low risk patients.  “I’ll try anything once, twice if I like it, three times to make sure.”
    Mae West
  • There is no evidence of a link between stethoscope bugs and infections in people- yet- but there is a definitely a transfer of really bad bugs from stethoscope to skin. Do any of us clean our stethoscopes? I just did (J  Hosp Inf 91(1)1) TBTR: Clean your stethoscope image015 “You only live once, but if you do it right, once is enough.”
    Mae West
  • Infections from coughing patients in airplanes- may be spread to the immediate fellow passengers, but GI infections definitely are – so says this article. (AJM 128(8)799) They base the question about respiratory infections because of recirculate air in air planes- but I thought air was actually brought in from the outside and warmed up. Anyone know more? TBTR: GI infections do spread in airplanes. Congrats to Charles Shumer, R- NY who wishes tointroduce legislation to stop packing people into economy class like sardines. “People say I’m extravagant because I want to be surrounded by beauty. But tell me, who wants to be surrounded by garbage?”
    Imelda Marcosimage016
  • They claim listening to heart sounds through a gown means you can’t hear them well, but most docs do it anyhow (Post Grad Med 91(1077)379) I do this- because for what I am listening for – I do not need to hear an S3. Also, recall Bill Frishmans article last month- use ultrasound. TBTR: Listening to heart sounds in a dressed patient won’t give you much. I firmly believe that with the right footwear one can rule the world. —Bette Midlerimage017
  • There are a few of us who are interested in nutritionimage018 so here are some notes on the subject.  Olive oil
    image019 has been shown to improve
    cardiac risk factors. Does it help for prevention of Diabetes? Well if you use margarine butter and mayonnaise – you have a 5- 8% higher risk of type two diabetes than if you use olive oil. (AJ Clin Nutr 102(2)2309). That is pretty modest, but this is hard to study – most people are not so extremist- except perhaps me, who has never eaten mayonnaise in my life – or butter since childhood.  On a related subject-eggs- those female empowerment instruments that get estrogen surreptiously into our virile bodies- this article was oft quoted- seems that dietary intake of cholesterol does not affect your CV profile.  (ibid p235) I am not sure what is new here. Cholesterol – like diabetes- is an enzyme disorder- and under usual conditions the body creates the cholesterol it needs from fatty acids. Dietary cholesterol is harder to find in nature and as such the body doesn’t depend on it and most of it goes straight out in the feces. That is what I learned from my nutrition elective with Dr. Darwin Dean 30 years ago. One last and critical note- sugar drinks are real bad boys in the USA but not in Israel and I am not sure why. This study does link them to DM type II even while controlling for adiposity. They also note that artificially sweetened drinks and fruit juices also can cause this but they claim this is bias. They recommend against them too, but I am a little perplexed. Not only because sugar drinks abound still but also what does this article expect us to drink after rigorous physical activity? Wine? (Father is in seventh heaven!!) I think fruit juices are not those bad- if the pulp is present. Water is hypo osmotic. This is just my opinion (BMJ H3576) TBTR: Some dietary notes – won’t make a difference in the ED, but in your life- maybe. “A woman’s dress should be a like a barbed-wire fence: serving its purpose without obstructing the view.” —Sophia Lorenimage020
  • Really I like the Dutch – they are neat people – they have a country that is called the Netherlands or Holland – but they themselves call themselves Dutch (10 points for anyone who can tell me why), and they practically live under water. They have an impossible language to speak and names like the author of this paper van Winjgaarden (ooo, that double aa is so sexy) that are also impossible to pronounce. But they have two medical things that are unquestionably Dutch – no, not wooden shoes, but they don’t give antibiotics or Otitis media, and they are into assisted death. Here they took a survey – granted only 25 people were interviewed and classified why older people want to die. They came up with five reasons. They arte- loneliness, the pain of not really mattering, multidimensional tiredness (I am not sure what that is), inability to express oneself, and fear of being defendant. (Soc Sc Med 138:257) I would really be supervised if Ken hadn’t written a similar article at some point. TBTR: The reason for wanting to die if someone is old – see above. “I can’t concentrate in flats!” —Victoria Beckhamimage021 Oh yes, to answer our question- the country is called the Netherlands-meaning flat lands. Holland means wood lands and is the most important province Dutch simply means the people and really only English speakers call them that. Do I owe you ten points?
  • This little paper from a great journal shows that worldwide- doctors who are male are 2.5 times more likely to be sued for malpractice than females. (BMC 351:172) This is probably true- again, I can’t believe Ken hasn’t written on this, and while we are name dropping, I am sure father has seen this – but this was a massive meta-analysis and that means a lot of heterogeneity. TBTR: Males- you’re more likely “to read the nurses notes” in court than females. “A woman who doesn’t wear perfume has no future.” —Coco Chanelimage022

“People will stare. Make it worth their while.” —Harry Winston

  • I am not sure who this practice pointer is for but they look at the painful un inflamed eye- if there is decreased vision – call an eye doctor. If not – and it is not red – it is usually benign but considered optic neuritis, temporal arteritis, aneurysm and glaucoma. (BMJ H4141) I don’t know- corneal FB and abrasions are painful, but we can handle them without an eye doctor. Metal against metal with a piece flying into the eye may cause pain without affecting vision and we do need an eye doctor for that. Temporal arteritis- well, that can be without vision loss, but you should be taking a good history and optic neuritis the same. Glaucoma? Most I have seen look like – glaucoma. Steamy eyes, visual loss, decreased EOMI- but pull the article if you want a primer. TBTR: painful un inflamed eyes- see inside. “And now, I’m just trying to change the world, one sequin at a time.” —Lady Gagaimage023

“Men tell me that I’ve saved their marriages. It costs them a fortune in shoes, but it’s cheaper than a divorce. So I’m still useful, you see” —Manolo Blahnik


  • Ketamine- aah a breath of fresh air – just like talking about DVT ! Yes, here in a few seconds is the ketamine article fo the month. With all the accolades I give this drug; it does have its drawbacks if abused. And it is being abused even by those without priapism they have more delusions but these are generally sub clinical. Memory gets affected, but this can improve if ketamine is stopped. It affects the bladder causing pain and hematuria which can lead to cystectomy although it isn’t clear how this happens. Mostly but not always there is some improvement after ceasing use of ketamine. It can also increase LFTs and cause biliary tract dilation. (J Pain Symp Man 50(2)268) TBTR: Ketamine abuse – what you will see- you’ll have trouble peering but you won’t remember it. “Attitude is everything.” —Diane von Furstenberg  image024 We don’t wake up for less than $10,000 a day.” —Linda Evangelistaimage025
  • Does our patient have PTSD? Do you have PTSD from your patient? Do you have PTSD from reading EMU? Do I have PTSD thinking about you reading EMU?  There is a simple scale called the primary care PTSD screen – one positive answer and you should consider PTSD.  Actually the LR were pretty good – the positive likelihood ratio was  9 and the negative was 0.3  (JAMA 314(5)501) The scale is as follows:

Have had nightmares about it or thought about it when you did not want to?

Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

Were constantly on guard, watchful, or easily startled?

Felt numb or detached from others, activities, or your surroundings?

Whoever said that money can’t buy happiness, simply didn’t know where to go shopping.” —Bo Derekimage026

  1. “Shoes transform your body language and attitude. They lift you physically and emotionally.” — Christian Louboutin

18) After years of listening to Rick Bukata –I know a lot about him- a true pioneer in EM education (you better be a subscriber to Emergency Medical abstracts and risk Management Monthly if you want to continue reading EMU) and aside from his son Ricky babaloo- his favorite  thing in the world is Magnesium. Magnesium does relieve constipation but never made it as the laxative of the month (take, that Father Greg). This article reminds us that hypermagnesemia can cause paralysis, constipation, urinary retention – and this can be seen in Dead Sea drowning which does occur in my area and presumably across the border in Jordan as well. Low magnesium is hard to check because most Mg is intracellular, but is usually goes along with drops in potassium, phosphate, sodium and calcium. So check all of those ions. (Mayo 90(8)1104) TBTR: Magnesium- too bad Rick Bukata doesn’t read this. “People say, ‘What do you mean you want to help the world, but you’re so concerned about fashion?’ It’s illegal to be naked. It is something that is extremely important.” — Kanye West

“I don’t want a politician who’s thinking about fashion for even one millisecond. It’s the same as medical professionals. The idea of a person in a Comme des Garcons humpback dress giving me a colonoscopy is just not groovy.” — Simon Doonan


18) Hgb-a1-c has supplanted fasting glucose and GTT for the diagnosis for diabetes (and why Ob people are still doing GTTs is a mystery to me) but just know that hemotogical disease (like hemolytic anemia) , CRF and alcoholism can all give false values (MJA 203(2)89) See also Postgrad 86(1021)656 where they worry more about missing some patients with this test with the controversy of pre diabetes and what  criteria to use but this worries me less. TBTR: HG1-ac –still a good screen but not for everyone. On a similar subject – I like the idea of metformin for gestation DM – and this study reviews the current literature- it does seem that it causes less fatal hypoglycemia than insulinimage027  and less maternal weight gain. Still needs more studies but it is so much easier for women to take. (Aust NZ J ob /gyn 55(4)303)  TBTR: metformin for GDM – go for it.  

  1. “I’ll stop wearing black when they make a darker color.” -Wednesday Addamsimage028
  • Glucosamine and chondroitin – do they work? This study says they do- but there was a 44.8% drop out rate, and one has to ask himself- – was the study powered to answer the question from the start? I think not. (Clin Rheum 34(8)1473) However, Cochrane does think there is some merit here.  Do ozone injections work?
  1. “I feel that flip-flops are the downfall of many relationships. It’s, like, first it’s the flip-flops, and then it’s the sweatpants…it’s the gateway drug to no sex.” –Lady Gaga

. “I really would not call myself a fashion icon. I would call myself somebody who gets dressed by professionals…I would call me more of a monkey.” -Jennifer Lawrenceimage029


  • I love guidelines! The only things I like less than guidelines are nerve gas, ricin intoxication, and exploding hemorrhoids. This is a guideline based on guidelines – oh what a thrill – for kidney stones. But lucky you – I summarize them for you! And you get a running commentary! Initial evaluation: They say – all patients should have a urine dipstick – well, OK – you can mix up renal colic with a UTI and in additional infection in renal colic is pretty bad thing – but the patient will look pretty bad too. Serum chemistry – why – the other kidney usually compensates so bumps in keratinize are not that meaningful. CBC+ CRP – why do I need those? Also- if there is to be a procedure – they want INR – again – why? Most people know if they have a bleeding disorder. They do urge caution on imaging- they like a low dose (less than 4 mSV) CT but they admit it won’t work if the patient’s BMI is more than 30 They do give an option of checking the scout film – if it is alright – do a KUB – if you see a stone on either – you may be done- my comment? Bravo. However, they do mention that bedside US is coming into vogue – and we reviewed this before in EMU- that is what I do- no hydornephrosis – then I do not care much.  Treatment: NSAIDS- I agree. Opioids as an add-on – OK with that too. Fluids – there is some evidence that this makes things worse – more spasm. I don’t give if the patient is not volume depleted. Less than 10 mm- observation – 6 mm is my criteria- the chances they will fall when more than 6 mm is less than 10%Massive stones s- bigger than 10 mm do better with uretoscopy, less than 10 – they recommend lithotripsy. I didn’t see much on medical expulsive therapy, but we know I am not a big fan of this. Evaluation in the community- they like PTH checking and 24 hour urine collection for volume, pH, calcium, oxalate, uric acid, sodium, potassium, and creatinine, They do comment that the ACP doesn’t recommend these as they haven’t show efficacy in stone prevention. Here they do recommend fluids, restricting sodium intake (calcium stones), more fruits and vegetables if the citrate is low and it is ac calcium stone, and less animal protein in uric acid stones. Thiazide diuretics seem to help in calcium stones, and citrate will help too.  Interestingly, allopurinol is not recommended – here the problem is a low pH and not a metabolic defect. Just get the pH up – with citrate. They like repeat 24 hour urines to see progress- but I would buy a separate refrigerator for them to keep checking this. (BJUI 116(2)184) TBTR: Guidelines on kidneys tones for EPs and FPs.

“Crying is for plain women. Pretty women go shopping.” -Oscar Wilde

“I like Cinderella – she has a good work ethic and she likes shoes.” -Amy Adams


  • You know that when people have vasovagal events they can seize. How do you know when it is a seizure and when it is just syncope? Well, I loss the article that refers to this scale but I still have the scale- Tongue lacerations are two points. Déjà vu or jamais vu before the spell ; emotional stress before the event, people seeing head turning during the event, or jerking movements or unresponsiveness; no memory of events; witnesses that you are confused after an event. – all these are worth one point, If the person reports lighthead ness before spells, or sweating or if the events are associated with prolonged sitting or standing – take off two points for each – total score greater than one it is a seizure. Less than one – it is syncope. They claim accuracy of 94% but I am dubious especially with the emotional stress –isn’t that also associated with syncope? ( JACC 40:142) I also don’t know how they proved that it was a seizure or syncope. TBTR: Is it syncope or seizure- only your hairdresser knows for sure. Valentino Garavani
    “An evening dress that reveals a woman’s ankles while walking is the most disgusting thing I have ever seen.”
  • Hi, dopes-I’m speaking to the dopes who wrote this article– how can you answer the question your article asks “who should manage patients with chest pain in the ED” if the authors are not EPs? One is a CHF cardiologist who is hospital based and the other is a community physician who is his brother. We EPs cannot be trusted –we mistakenly send home 2% of MIs and 2% of patients with ACS. So I ask – do cardiologists do any better? No reason to think they would. Then they say –well, let’s just bypass the ED and go straight to the Cards department. Any proof that saves lives? Often the patients just wait there in the hallway until someone can clear the cath lab or they wait for the cath team to come in. We in the ED could give care in the meantime. EKG- they recommend that a cardiologist read the EKG via tele transmission- we of course do not know how to read EKGS. All these patients need chest films – are they nuts??? Very low risk patients can be discharged- what are very low risk patients? No mention of the HEART score (see above) (EHJ 36:1634) This is all crap and the authors are Israelis and if any of my readers know these guys ( thye are from SZ) – let them pleas know that we are now in the 21 century and EPs have long ceased to be the little boys in the emergency room. TBTR: read this paper in the rest room – then dispose of it properly in the receptacle that you are presently using.

“The most beautiful makeup of a woman is passion. But cosmetics are easier to buy.”Yves Sainte Laurant

Donatella Versace image030
“What is natural? What is that? I do not believe in totally natural for women. For me, natural has something to do with vegetables. I don’t even know what my natural hair colour is.”



  • Maybe I am just writing this because I just suffered from a two month bout with a pulled (torn?) hamstring. Risk factors are age (guilty as charged), poor warm up (, guilty as charged) previous injury, fitness level, and flexibility of the hamstrings. The way it occurs is rapid hip flexion with the ipsilateral knee in extension. US and MRI and the best way of diagnosis although I think clinical signs are often enough. These can feel like sciatica too. Running takes the longest to return and a few select pulls become chronic. No steroids, no immobilization – stretching will help (Knee Surg Sports Traum Arthro 23:2449) TBTR: All you knee to know about hamstring injuries.
  • Remember RSD? Just the word remembers is going to get me started. This month let’s remember that cop show with the catchy tune- Hawaii Five O– and the famous – book em, Dano. Here were the stars from the show – led by Jack Lord who was Garret and Danny Williams “Dano” played by James Mac Arthur. Chin Ho Kelly was another police officer played by Kam Fong image032. RSD in any case is now CRPS –complex regional pain syndrome (sounds too close to CRAPS for my liking image033 but this is defined as hyperalgesia and allodynia (even using a feather can cause them to feel pain), usually color changes of the skin, hair changes on the skin in that area and sweating. It is often after some kind of trauma like a fracture.  Carpal tunnel surgery is another often found cause. This is a disease more commonly found in middle aged women. It also slows on onset – more likely to appear three months after cast removal than immediately after cast removal. While it is uncommon, acute CRPS can also resolve on its own. That is called acute CRPS and is usually with a warmer extremity, colder limbs are usually chronic CRPS. Diagnosis – is basically clinical grounds. Treatment- I know you are all waiting for this, especially in view that there is a large psychological aspect to this malady. The evidence is low quality, but consider bisphosphonates, ketamine, calcitonin, and mirror therapy. I cannot explain how these work. Vitamin C probably doesn’t work, but avoiding tourniquets is probably a good idea. They suggest lidocaine patches, anti-depressants and anti convulsants but there is no good evidence- yet.  (BMJ h2730) TBTR: All you wanted to know about CRAPS.

I don’t understand how a woman can leave the house without fixing herself up a little- if only out of politeness. And then, you never know, maybe that’s the day she has a date with destiny. And it’s best to be as pretty as possible for destiny. – Coco Chanel 

  • I always found myocarditis an interesting and challenging disease, and would have made this an essay this month if not for the tradition of this being the Purim issue. Myocarditis can kill. If can also cause a lot of morbidity as it is the cause of 1/3 of the cases of dilated cardiomyopathy. Viruses cause a lot the cases, and those who aren’t caused by viruses are usually auto immune – Churg Strauss, Wegners, SLE and the like. Other causes include Lyme, vaccines, many meds including lidocaine, thyrotoxicosis.  It can accompany peripartum CM and Takotsubo CM.  The signs can be subtle, but do think about this in a patient with fever or a recent viral infection who know presents with effort to intolerance, CHF or chest pain – especially in younger people. Troponin may be normal as can be CRP and ESR.  EKG may show ST – more concave than usually. Echo may show DCM signs ; and apical aneurysm points to Chagas disease. There are some good charts taken from the European society of Cardiology task force (34:2636) but the article is for free so instead of copying the charts- go into the article.  The articles does discuss RHD – which is still a problem in Israel despite being an industrialized country. These folks can have mild CHF  or tachycardia – be on the lookout –also first degree hear block – or any heart block with fever is a sign of myocarditis – especially RHD) PET CT may help – do you have that in your ED? (Heart 101:1332) TBTR: Myocarditis review.

The most beautiful makeup for a woman is passion. But cosmetics are easier to buy. – Yves Saint Laurent

  • This is the last article this month. This is a great article and deserves more attention, but this is the last article of the month and it is already Mid-March so I am taking the easy way out. Basically they took the guidelines for how to insert a chest tube from ATLS, BTS, European Trauma Course and found that the criteria are risky – counting ribs, go by the nipple ( how do you do this in women?) looking for the safe triangle- all put a significant risk to insertion in the abdomen. The ETC guideline on average went into the seventh intercostal interspace. (they use the one hand’s width method below the anterior axillary line)  I will give them this – all of them avoided critical nerves – the long  thoracic never and the lateral cutaneous branches for the intercostal nerves with the exception of the ETC guidelines at its extremes (EMJ 32(8):620) My main problem with this paper- and they acknowledge this – is that it was done on cadavers which may not be too realistic. Nevertheless, this is another EMJ article that tackles interesting subjects and I am happy to be a peer reviewer for them. TBTR: Major society guidelines on how to insert chest tubes may result in major damages.
It’s simple, if it jiggles, it’s fat.
Arnold Schwarzenegger
All my life, I always wanted to be somebody. Now I see that I should have been more specific.
Jane Wagner


27) Letters: We had a letter from a reader about the format we are using- not that I understand anything about computers, but my new partner does and I will be introducing him soon – Look forward to podcasts, and thrills in many languages soon to come. Here is what Ken has to say from the Down Down Under (Antarctica):    You and I have the same sensibilities about what is useful and interesting to clinicians. You mentioned ___ items in the recent EMU that I covered in the 2nd edition of Improvised Medicine: Honey for wounds, not using ophthalmic medications past their expiration dates, and the use if IV lidocaine as an analgesic. The piece about lidocaine is:


Lidocaine Infusions. These are often successful, especially in treating peripheral nerve pain. The safest, especially in patients with a history of arrhythmias or seizures, is a 4-hour infusion of 2 mg/kg IV. Dilute the lidocaine in 240 mL of normal (0.9%) saline (NS) and run it at 1 mL/min. Monitor pain scores every 15 minutes. If available, use cardiac monitoring and oximetry. If the patient has a positive response (less pain) with the lidocaine infusion, additional periodic lidocaine infusions will probably be an effective analgesic. Positive response to lidocaine indicates that mexiletine (an oral medication in the same class) may be effective.” (From: Iserson KV. Improvised Medicine: Providing Care in Extreme Environments, 2nd ed. NY: McGraw-Hill, 2016, p. 204

Sounds good to me- I get a lot of fibromyalgia patients so this may be worth a try. He also found an error on a hyperlink of mind on aerosolized antibiotics: Hi Yosef. I located the articles. The journal name was a bit off. The correct citation is: Restrepo MI, Keyt H, Reyes LF. Aerosolized Antibiotics. Respiratory care. 2015 Jun 1;60(6):762-73. The following article is on surfactants, as you noted

A shout out to Ramez Sulaiman MD who loves EMU – glad to hear from you. He has a 718 area code, so maybe he can find out for me if Anand Swaminathan from Bellevue is a reader ( see above) Alex Wang promised to visit me in the ED in Israel – would love to meet you – he is a medical student and John has written concerning my safety – I really so appreciate your letters.

EMU LOOKS AT: The Purim Issue

This is everyone’s favorite issue (Everyone? all three readers) when we take our yearly dive into the literature’s strangest articles.

  • Let us start with great author names. This gastroenterologist at Queen Elizabeth Hospital in London wrote a nice article on coffee ground emesis but I think he chose the wrong specialty. I am of course referring to Dr. L. Pee.
  • This guy may not be the most popular lecturer. I liked his article in Pharmacotherapy  on asymptomatic bacteriuria but I wouldn’t want to hear him- Prof RB Dull.
  • Speaking about articles that will absolutely change your life. Can you go deep sea diving if you are pregnant? They do not investigate why you would want to. Like everything in pregnancy the answer is – we don’t know (or for you older folks- category c) but I liked that they did do this study on pregnant sheep- did they really put on flippers and a wet suit image034 (Ob Gyn Surv 69(9)551)
  • If we haven’t changed your life yet, this will do it. Survival after avalanche induced cardiac arrest doesn’t result in good outcomes. (Resusc 85(9)1182) image035There are other situations that can result in similar results.image036
  • This is not indexed but a good article for you to read. It is in the journal Judgment and Decision Making 10(6)549. People tend to be more receptive of vague syntactic structures (which they call pseudo profound bullsh*t-talk about professional terms) their example is “Wholeness quiets infinite phenomena” They conclude and I quote “that some people are receptive to this type of bullsh*t”. I can believe that – some people read EMU too.
  • It is the time for the culture section of EMU –image037. CPR as portrayed on TV (and yes, they actually watched 91 episodes of gray’s anatomy and House) and found that ROSC was 70% and survival to discharge was 50 %-(Rescus 96:148). I would seriously consider instructing your ambulance team in the event you need CPR to transport you to southern California. Live in Australia? Doesn’t matter. take a water taxiimage039
  • Pelvic and lower extremities are important and can be life threatening. That is why it is critical to know about these injuries that are mentioned in Homer’s Iliad.image040 This may be a little bit beyond the locals in Ypsilanti, but then again, they may know more about these injuries than we do. Here is view of downtown Ypsilanti image042(J Trauma 78(1)204)
  • What about resuscitation in the 24th century? Well, these folks watched a lot of Star Trek. The exclusion criteria where great- if they were annihilated by energy weapons (being vaporized is not a good prognostic indicator) and patients that were unable to get treatment except by the assassin who rubbed them out. image044
    Seems patients didn’t do too well, but then again, Southern California may not exist in the 24th You may just have to go to Pluto General(Resuc 85(12)1790) And no – beam me up Scotty is not a treatment for ED.
  • OK in the 24th century they were using phasers, but we have smart phones and it pays to be careful. While we have yet to see anyone who phasered themselves by mistake, this genius image045played Match 3 puzzle video game all day for eight hours and blew out his extensor policus longus tendon.(JAMA Intern 175(6) 1048) My reaction – some us work for living – get a job , guy! Speaking of getting a job- some very bored EPs found time to publish this important piece of information – they poured blood on different surfaces and measured the side of the puddle. PVC and concrete have the largest puddle sizes. (EJEM 21(5)360) This isn’t “get a job” this is “get a life”image046.
  • I understand these, guys – I mean this could be catastrophic- there is some bead they sell as a children’s toy called Orbeez image047Now they are concerned about kids swallowing these things and then get bowel obstruction from the expansion of these water absorbing beads. These beads actually grew the biggest when exposed to vodka- (Ped Emrg Care 31(6)416) image048(Yea well, I gotta really be concerned that some kid is going to do a water bead Stolichnaya cocktail. Maybe he has a bigger problem than these beads.
  • Friends it is time to be a little – shall we say – a little more delicate? These articles deal with a blue subject – the issue of human reproduction which seems to be practiced by a number of people. Thanks to the Turks, I now know that this exercise can be effective for passage of distal ureteral stones that are less than 6 mm. Their RCT required doing this activity 3- 4 times a week and required in their terms – a sexual partner.image049(Urology 86(1)19) Think of it fellows – you’ll never hear again “not tonight, dear, I have a kidney stone”image050 It took two weeks to complete the therapy and they report that patients were generally happy with the treatment despite not drinking Stolichnaya. Similarly, if you have long QT syndrome or catecholaminergic polymorphic VT – you could be in for a profoundly shocking experience if you attempt the aforementioned exercise program. – but it is actually rare- unless your partner is image051
    (J Cardiovasc Electro  26(3)300) While we are on the subject- men have a terrible tendency to not urinate due to a prostate that wants attention after being kept in the dark and as close to the rectum as possible all these years. Women fortunately retain the ability to urinate on demand any time the want to for all their lives. And they tend to do that, too. image052 So if you missed this Iranian study published inhte International Brazilian Journal of Urology- let me present it now Adding sildenafil does not help tamsulosin get your bladder emptied. It may assist in other issues. (40(3)373)  Thanks to the Teheran University of Medical Sciences (TUMS).
  • It is a weird, weird world out there. This 18 year old female was intent on not getting a NG tube (zonde). So she inserted superglue in both nares. (J Laryn Oto 129(1)98) Kinda of gives one pause – I think the take home message is to be very careful picking your nose – you never know what you’ll find.
  • Did you know that you could get hypercalcemia from hot tub lung? (Chest 146(6)e186) Try it some time.
  • Did you know that you could get your SVT straightened out by doing handstands? (Arch Dis Child 100(1)54) Try it sometime. No, not in the hot tub. If this is the cause of your SVT then handstands may not help.   We’ll let the cat out of the bag- the blonde we are showing was a beauty from the sixties- Bridgette Bardot. Here is how she looks today:  image053
  • This brings us to our next subject – Exploding Head Syndrome – this is actually a benign syndrome. It is just is the perception of a sudden loud noise like a bomb exploding in your head. (Cephalagia 34(10)823) No, it has nothing to do with therapy for kidney stones.
  • Lastly it is time for the Honorary Rick Bukata School of Title Writing. Rick doesn’t really read EMU any more (he prefers the Wall Street Journal. I prefer Mad Magazine. Father prefers. Ken prefersimage054
  1. The first two are – don’t ask any questions – I don’t want to know how this happed Pneumoscrotum (Ind Ped 51911)942)
  2. Dentures in the Cecum (AJ Gastro 110(3)378)
  3. Death before Disco (JEM  48(1)43)
  4. Panic Attack Symptoms Differentiate Patients with epilepsy from those with Psychogenic Non Epileptic Spells (Epilepsy Behav 37:210) Unfortunately, the neurologists have called the latter malady by its initials and no, you aren’t going to get me to write it
  5. Wheel chair cleaning and disinfection in Canadian health care facilities –That’s wheelie gross”( Am J Inf Contr 42(11)1173)
  6. Trust me – This is the Worst Acne of your life (Ann Emerg Med 65(1)147)
  7. Suicide : An existential reconceptualization ( J Psych Ment Heal Nurs 21(10)873) This paper was based on Camus Sounds like it should have been based on Pseudo Profound Bullsh*t- see number 5 above
  8. Afraid of Being Witchy with a B” (Acad Med 89(9)1276). This article looked at females as code leaders in cardiac arrest. Because I do want to alienate the last two women that read EMU (and one is my wife) I will not go deeper into this study but I will mention that some females apologized for their strong behavior as code leader- which seems odd to me when scratching out their mate’s eyeballs for buying an anniversary gift  of a vacuum cleaner seems normal
  9. How Deep is Your Love: Choosing the Most Appropriate Depth for Pediatric Chest Compression (Resuscitation 85(9)1125) (here are the Bee Gees for those of you who don’t remember their hit song of the same name Only Barry –image055 the middle one is still alive.
  10. Sex, death and the diagnosis gap (Circ 130(9)74)

Well the issue would not be complete with out Father’s iinput –a Tradition here at EMU: Yosef, Yosef, Greetings and salutations. The Purim issue needs some historical background. For our readers who are non -Jewish and for the 95% of Jews who don’t care

or who flunked Hebrew school. Allow your resident cleric to help everyone out. I consulted my rabbi on this one. Yes, the secret is now out. Even I have a rabbi. How else would I know where to buy wholesale? Purim is the feast of Esther. This is the only book in the Talmud that never even mentions God. Not once. It’s about sex, money, violence and political intrigue all of which make it always relevant. This sounds like a script for a Donald Trump speech. Again, for those who don’t remember, Esther was the hidden Queen of Persia. Now I have certainly known some hidden Jewish queens in my time but this was different and it didn’t take place in the East Village. How she tricked the Persian king is not very clear. She changed her name(Hadasa) to Esther which is Persian for star. But things get even stranger when you find the Hebrew for this name is “ astir” which means “ I hide”. This is why people( kids mostly) get to run around in costumes which brings us back to the drag queens referred to earlier.  Now we have a basis for doing and saying strange things on Purim. As an aside, we get great names from the Book of Esther like Mordechai and Haman which will appear in Clint Eastwood movies( reference High Plains Drifter).  Now back to the Purim issue. The article on deep diving on pregnant sheep was Baaad! How did they pull the wool over their eyes with diving masks on? Sheer garbage! Next. The fact you proclaim there is a “cultural” section is the second clue this is the Purim issue. By the way, this article on TV-CPR was done over 20 years ago(please check with Rick Bukata) with the same results except that the reference shows were Chicago Hope and ER. I think at that time the save rate in even traumatic CPR was 85%No wonder the public doesn’t understand. God help us all on this one! By the way, the photo you used for Ypsilanti, Michigan was just plain wrong. The scene is way too clean, it is way too modern, and there is not near enough firepower. This must be Switzerland. The casual reference to Bridgette Bardot and the treatment of kidney stones both broke my heart and put me into hypovolemic shock as I do not have enough blood to run multiple organs. Her t-shirt sans bra in God’s Little Acre changed my life at 15. So no rude comments about my Bridgette, please. My mother had enough horrible things to say about my sneaking into her movies. Lastly, The Brothers Gibb’s How Deep Is Your Love seems more of a commercial for Viagra than a cardiology reference. I believe Staying Alive is the new mantra for CPR. God bless you all. Father Henry

Have a great Purim

















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