EMU Monthly – January 2016

All the EMU goodness for Jan 2015 – In order to catch up- this issue was not peer reviewed

  • It is just a push of a button – no different than ordering dinner at the Golden Arches.image001You know what I mean- they wheel in the patient from a trauma – backboard and neck collar- complaining of a broken fingernail and viola –you get the pan scan. I am from the old schoolimage003I think – Egad! image004that you should check the patient first – and selectively do CTs- and then do repeated exams as necessary. But alas- there are detractors. This article only cuts down the methodology of the four studies that even look at this and we will have to wait for the REACT trial for the real answer (J Trauma 78(6)1236) This editorial was based on a silly article touting whole body CT in all cases.  Their article had ISS scores higher in the whole body CT group and also looked at ages 1 to 44 years old – I would agree too that a physical exam on a one year old after trauma is not easy( ibid 77 (4) 534). OK, we’ll wait for the answer. TBTR: The pan scan – should we scan or pan?
  • I do not like to repeat myself, but when are you going to learn? I know – you paramedics will claim it is still in your protocols, and you nurses- well it is all we can do until the MD comes, and you MDs – well I really can’t explain why you do this – but quit using the 100% oxygen therapy if the patient is not hypoxic. It doesn’t help and yes, it can hurt. Here are some bennies you get with oxygen- pulmonary inflammation, recurrent MI and arrhythmias in patients with MI, and increased mortality in brain injury, stroke and intracranial bleeding. It decreases cardiac output,  however it may reduce heart rate, and prevent surgical site infections through antibiotic properties – I don’t really buy that – peroxide isn’t a great antibiotic if that is the way it works. (Intens Care Med 41(6)1118). TBTR: Back off image006 the oxygen.
  • This article speaks about the clinical diagnosis of influenza in the ED (which just so happens to be the title of the article also) I know what you are thinking who cares? – Please be patient!!. CDC criteria are fever, cough and sore throat- but this has a sensitivity of 55-69%. Clinical diagnosis doesn’t help much either- 36% sensitivity. But what got my goatimage007 is that they lab confirmed influenza and only 36% got antivirals (which is good in my eyes – doesn’t work anyway) and 52% got antibiotics (that sucks). (AJEM 33(6)770) Still H1 N1 is important – you really need to know about it in hypoxic people. TBTR: Influenza – back off image008the meds for this. Let’s start with quotes- this month we feature Bart Simpson’s blackboard.
  • I will not aim for the head.
  • I will not barf unless I’m sick
  • I will not expose the ignorance of the faculty
  • Recurrent abdominal pain – oh what a drag image010(Yes that is a man-> it is Dustin Hoffman in his role as a woman in the film Tootsie from 1982).  This could be porphyria, it could be IBS- but is could also be abdominal migraine.  It is a diagnosis of exclusion (AJEM 33(6)E1)- it responds to NSAID – will triptan help? Doubt it.  Gosh abdominal migraines- are brain rectal bleeds next? TBTR: Recurrent abdominal pain – could be a migraine- or a headache for you. Here is the real Dustin Hoffman:image011 .
  • I saw nothing unusual in the teacher’s lounge.
  • I will not conduct my own fire drills
  • I will not prescribe medication
  • I have a soft spot for creative ideas and this study states that intravenous lidocaine worked well for ischemic limbs – and even better than morphine. (EMJ 32(7)516) This would be great for us as we cruise towards opiate free EDs if possible. The down side here is that this study did not evaluate safety. Also a third of the patients were excluded- and I cannot tell if it was double blinded. TBTR: IV Lidocaine may be worthwhile for pain control
  • I will not teach others to fly.
  • I will not bring sheep to class.
  • A burp is not an answer.
  • Why I am including this study? Honest- I have no idea- it was just so neat- and so useless. These Germans feel that you can start a good resuscitation at sea. They came in by helicopter (they point out this was a pilot study- funny, huh?)  and they used a LMA, a heliboat platform to stabilize the patient, and then IO, and also a LUCAS resuc device and viola the mannequin lived. Crazy, no? (EMJ 32(7)533) TBTR: don’t even bother.
  • Coffee is not for kids.
  • I will not eat things for money.
  • I will not yell “She’s Dead” at roll call.
  • Kids- 11 and above can do CPR even if they had no training beforehand- of course when instructed by a dispatcher. They can only do the hands part – which is fine as far as I am concerned (Rescu 90:138) Of course why not just train everyone? Money?
  • The principal’s toupee is not a Frisbee. “.
  • Goldfish don’t bounce.
  • Mud is not one of the 4 food groups
  • We have pointed out in the past that if you are doing CPR and they shock the patient and you get shocked too – it is unpleasant –but not dangerous. If you are looking for that not dangerous and not unpleasant shocking experience (keep this clean, guys) then try insulating electrical gloves (like the ones electricians use) and you can continue the compressions even while shock is going on ( ibid 90:163) Does this create a survival advantage? Who knows but the Danes like itimage012 TBTR: Electrical gloves for CPR and you’ll be shocked how you can continue CPR.
  • No one is interested in my underpants. .
  • I will return the seeing-eye dog.
  • I will not charge admission to the bathroom
  • This article was dedicated to updates in mechanical ventilation and sedation and general ICU stuff. Much of the articles quoted show all sorts of surrogate marker improvements but some things are practical. ECMO is the rage and seems to be here to stay. I have no experience with this to be truthful.  Periodic sedation for intubated patients seems to be a better way to go than continuous sedation-but let me remind you that Scott Weingart holds – keep them somewhat awake- a least communicative- and treat them with pain killers. Early mobilization and delirium control are imperative. (AJ REspm CM 191(12)1367)  TRBR: ICU updates.
  • OK, first clinical quiz- this fellow has chest pain and neuro findings after strenuous exercise- on chest film – pneumomediastinum. But what about the neuro findings? CT gave the answer image013 (Thorax 70(7)707)
  • The cafeteria deep fryer is not a toy.
  • I am not authorized to fire substitute teachers.

Organ transplants are best left to professionals

  • Haven’t I yet tired of killing sacred cows? I guess now. The Allen’s test- you know that test to see patency of the collaterals in the hand- is important before you decide to invade the radial artery. But the sensitivity -–which is what really interests us- is low. (J Inves Card 27(5) E70)
  • I did not see Elvis.
  • I will not call my teacher “Hot Cakes”.
  • Garlic gum is not funny
  • Let’s play some American football with this study- many infractions here. They want to show us that procalcitonin is a good test for bacteremia- since most studies only looked at sepsis and not infectionsimage014 Illegal assumption. If it doesn’t work to detect sepsis why would it detect infection? They looked at SRUC but that is a set of points and is unable to give a yes or no answer (illegal procedureimage015 ). Then they pooled sensitivities from a number of studies (but this needs a regression analysis to see how well the points agree – were they scattered?) and how they extracted the data is not clear. image016They did a subgroup analysis – which may be the only way to create a meta-analysis but since they do not share the same primary outcome it is statistically a foulimage017. But in the end it was pretty poor with a sensitivity of only 76%- meaning – that 25% of the time it called it no infection when it really was. (Clin Micro Infect 21(5)474) TBTR: Procalcitonin is not ready for prime time.
  • I will not encourage others to fly. .
  • Tar is not a plaything.
  • I will not Xerox my butt
  • We have mentioned this before. Honey is a good dressing – but not all honey. Honey is acidic which inactivates proteases and the high osmolality causes the wound to stay moist. Most honey has antibiotic properties based on the hydrogen peroxide content which is easily inactivated but Manuka honey has antibiotics properties based on a different substances which is not inactivated. It may also promote autolytic debridement and stimulate immune response (Wounds 27(6)141) It also makes exudates a lot tastier. But all seriousness aside- it is now available in medical grade in my country and is worth a try. TBTR: Honey – sweet in wounds.
  • I am not a 32 year old woman.
  • I will not drive the principal’s car.
  • I will not belch the National Anthem
  • Tranexamic acid in trauma-if you go like CRASH2. The dose is 1 gram loading dose over ten minutes and then1 gram over one hour. J Thromb Hemo 13:s195
  • I will not grease the monkey bars. .
  • I will not sleep through my education.
  • I am not a dentist
  • This is really esoteric- or maybe not. Lionfish, scorpion fish and stonefish are able to give quite painful stings. Now while this may not interest you because they are usually found in the Indian and Pacific ocean- in tropical areas – but lionfish have now been introduced to the eastern Atlantic and Gulf of Mexico so it isn’t just hurricanes you have to deal with on the coast. There is an antivenom but standard treatment – like hot compresses which work for most marine envenomations- are the best. (J Trav Med 22(4)251) TBTR: Lion fish are coming to a beach near you. Here are these critters if you would like to meet them. Scorpion fishimage019  Lionfish: image020 and Stonefish image022TBTR: The above fish are probably knocking at your door right now. And they are not selling magazine subscriptions.
  • Spitwads are not free speech.
  • Nobody likes sunburn slappers.
  • High explosives and school don’t mix.
  • We will be speaking a little about paracetomol today – here is an article describing a new trans buccal formulation. Now I cannot take much from this paper- it is a non-inferiority paper- which you would expect from the company wishing to show that the product works somewhat. However they compared it with the IV prep which is very expensive and I don’t think anyone uses it. Is it as effective as p.o? They say it is better but the research hasn’t convinced me yet. Just know it exists. (Pain Psych 18(3)249) TBTR: Trans buccal paracetamol- coming to you soon. Then the BMJ took on this medication and reminds us that it is not so benign- it too has COX-2 activity – but as of now has not shown an increase in heart attacks. What interested me was that this medication is not good for all pain. It does work for dental pain. For headaches- it is marginally better than placebo. Back pain – it is equal to placebo and the same for knee and hip pain. (BMJ 351: H3727). The next guy has a real bone to pick-image023with good ole Tylenol. He claims that that taking it in pregnancy can cause ADHD in offspring; it hinders psychosocial development and can inhibit male fertility in offspring. What I did find interesting is that paracetomol can close a patent PDA. (Eur J Pain 19(7)953) Truth be told, I wasn’t convinced by the study on ADHD, and indeed, millions of women have taken this drug with no ill side effects to offspring. This next article feels that the ADHD study was very flawed and the neurological development side effects have as yet only been seen in animal studies (Dev Med Child Neuro 57(8)718) My take is to be aware of these facts but I wouldn’t change anything yet. But it should spur us to think about doing better studies even on ancient meds. This month also gave us a review of the use of the IV prep of this medication – it is an “all you wanted to know but were afraid ask” type article but I did notice that the efficacy of this drug was always compared to placebo- what about compared to other pain meds? Also look at the prices in the USA. Wholesale prices of the med po 2.5 cents for a 500 mg pill, $1.57 for the suspension to 35.40 for the IV- seems a little extreme, no? (PEC  31(6)444) TBTR: All you needed to know about paracetomol.
  • Hamsters cannot fly. . .
  • I will finish what I sta
  • “Bart Bucks” are not legal tender.
  • Underwear should be worn on the inside.
  • Dementia is no fun (although it can be) and you may have to determine if your patient (or girlfriend) is demented, or in coma for a different reason (non convulsive status, severe hypothyroidism, drugs). Many of us use the mini mental status examimage025(but that didn’t do that well in this study – four other scales were much better. They recommend the Montreal
    Cognitive Assessment Exam – however this also requires some modification to make it more sensitive. (Clin Rehab 29(7)694). The real MOCA is a 30 point exam that takes 30 minutes – way more than we have time for in the ED. There is a mini MOCA but it is even worse. And furthermore, the folks in Montreal want us to even undergo training before using their exam. My point here is that the MMSE doesn’t work so well. I personally just do clock drawing and a short memory exam – and leave MOCA (mochaimage026) for drinking. TBTR: MMSE – not enough for dementia image028 Yes for you youngins- that is Demento. Dr Demento was famous for his songs that no one else would play like “it’s a gas” by Alfred E Neuman (it was farting to music) and My Baby Fell out of the Window by Spike Jones (“he fell in a barrel of sh….aving cream”) he also may famous the Utah Phillips classic “Moose Turd Pie” which I do not remember.
  • I will not send lard through the mail.
  • I will not use abbrev.
  • Indian burns are not our cultural heritage.
  • I will not dissect things unless instructed.
  • Here’s one for you kiddie docs (Kevin and Elisheva and Menucha – I want you guys to ace this). Infants can have episodes of torticollis, ataxia, autonomic syndrome, apathy and drowsiness. What is this? ( J Paed Child Health 51(7)674)?
  • No one wants to hear my armpits.
  • I will not mock Mrs. Dumbface.
  • I will stop talking about the twelve inch pianist.
  • Next time it could be me on the scaffolding.
  • Here is another hooray for the home team. (But it is more Peds so skip it if it bores you – I promise I won’t say any good jokes in this paragraph). This was done at Dana kid’s hospital in Tel Aviv, but there is really nothing new here. They say that extreme leukocytosis- defined at 25,000 with a fever should make you do a chest film and urine in kids in the post pneumoccal era. (PEC 31(6)391). Truth be told, they only found pneumonias and UTIs in35% of these patients. Would you have gotten there without the CBC? I think so TBTR: Pneumonia and UTIS in kids in the post PNuemococcal era- do a CBC?
  • Wedgies are unhealthy for children and other living things.
  • I do not have power of attorney over first graders..
  • I am not certified to remove asbestos
  • Tramadol – a terrible medication p.o. but seems OK IV – can cause seizures and respiratory depression in OD. However, while this med can cause serotonin syndrome when used with SSRIs- they didn’t see one case of serotonin syndrome in this case series of tramadol OD. (CLin Tox 53(6)545) This basically means in mild overdoses – you can just watch them, in combination ODs – be more careful. TBTR: See the last line
  • The boys room is not a water park.
  • Beans are neither fruit nor musical.
  • Nerve gas is not a toy.
  • Cooling of burns- it is correct that skin temperature returns to normal within a few seconds of cooling. However, there are benefits beyond that- including reduced progression of burns and shorter healing time. (Burns 41(5)882).The problem is many if not all of these studies were done in animals. They agree they do not have any idea how this works. TBTR: Continued cooling of burns?? Let’s continue with other Simpsons’ quotes.

Lisa: Dad, just for once don’t you want to try something new?

Homer: Oh Lisa, trying is just the first step toward failure.

Marge: Sitting that close to the TV is bad for your health.

Homer: Talking to me while I’m watching TV is bad for your health

  • Interesting concept-aerosolized antibiotics for pneumonias. This would be useful especially for ventilator associated pneumonias. So far this has only worked for CF patients but the potential does exist. Unfortunately, the literature doesn’t exist. (Resp Med 60(6)762) Surfactant, anti inflammatory and analgesics may also be tried this route (ibid p 774) I cannot tell you much more because – in a rare case- I cannot get this article. May be one of you guys can send me it?? TBTR: Inhaled route- doesn’t work yet, but maybe.

Homer: Kids, just because I don’t care doesn’t mean I’m not listening

Chief Wiggum: [shopping for his wife at a women’s clothing store] My wife’s looking for something that doesn’t make her look like a horse, so, I’m gonna be here for a while

  • MERS (Middle Eastern Respiratory Virus)- I do not know if you are ever going to see this, and I hope not, but another corona virus is scourging around and indeed it is similar to the SARS virus. It got to humans from camels and is basically seen in anyone who lives in the Arabian Peninsula or traveled there recently. Nowadays it is mainly spread in hospitals – community transmission is rare. The big problem is a fatality rate of nearly 40% (although death is more likely in older (they define that as older than 50 – hey wait a minute! image029or those with chronic illness. 66% develop pneumonia. Treatment is supportive (CMAJ 187(9)679) TBTR: MERS is here. We will speak about Zika virus in the near future.

Mr. Burns: [Giving a talk to inspire the school] Okay, I’m going to keep this short. Friends, family, religion. These are the demons you must slay if you wish to succeed in business. Any questions?


Homer: Oh no, Aliens! Well, I suppose you want to probe me, might as well get it over with.

Kang: Stop!

[Tentacles quiver]

Kang: We’ve reached the limits of what rectal probing can teach us…


  • Now the feds have made substance abuse even easier. Powdered alcohol has been approved by the USA FDA. This powder is easy to hide and can be smuggled by teenagers almost anywhere. True when reconstituted as should be, it will result in 10% alcohol content, but you can get that up to 50% with improper reconstitution. Many states are already going against the feds and are banning this (JAMA 314 (2)119). Father has word for beverages with 50% alcohol content- he calls that water. Liquid nicotine has been around for a long time for electronic cigarettes. (PEC 31(7)517)These work by battery powdered gizmos that vaporize liquid nicotine. All sorts of vicious fumes come out of these but here seems to be some evidence that they do indeed help in smoking cessation, although I personally do not buy it. The problem is that they are unregulated by the FDA, and minors are using them – even as early as sixth grade. 90% off them are bought on line and they can easily be sneaked into places where smoking is illegal. Yes they can be toxic, and yes they can result in death And yes they can be abused by “Dripping” by just inhaling the valor of drops put directly on the heating element usually in combo with other substances or adjusting the nicotine concentration. The treatment is supportive the exception of when it causes SLUDGE syndrome (salivation, lacrimation, urination, defecation, gastric emesis) where Atropine will help. TBTR: Liquid nicotine and powdered alcohol. The world is getting more complicatedimage030

Therapist: You hate your father, don’t you?

Homer: The guy I really hate right now is your father!

Therapist: I’m sorry, I was just venting…


Marge: [Bart is in an asylum after faking sociopathy to get back at his parents for testing him for it] How could he go so wrong!

Homer: We did everything we could for him during the commercials

  • Priapism- this case report in a psychiatric non cooperative patient with priapism – who need to be sedated for treatment and got ketamine and voila, the priapism disappeared with the injection of ketamine (no, it wasn’t injected there but rather in the arm. (ibid 508) More on priapism? See our essay this month!

Well, he’s kind of had it in for me ever since I accidentally ran over his dog. Actually, replace ‘accidentally’ with ‘repeatedly’ and replace ‘dog’ with ‘son.’ – Lionel Hutz

English, who needs that? I’m never going to England – Homer Simpson

  • Another clinical challenge: Fever, rash, disoriented, and tick bite seen in an ED in Tennessee. No not Lyme. Not babeosis Not RMSF. Yes- it is……( (ibid p533)

How come things that happen to stupid people keep happening to me? – Homer Simpson

  • If you listen to EM RAP (Dec 2015) or your name is Rob Orman (who used to read EMU) they brought an opinion of an addictions specialist that Gabpentin is equal to lorazepam for managing alcohol withdrawal. This article feels it is only effective in mild withdrawal (AnnPharmaco 49(8)897) Since it is non sedating, improves mood and is non-addictive – there may be some future of this med in alcohol withdrawal – perhaps at different dosages then in this article?. TBTR: Gabapentin for alcohol withdrawal? Maybe better just to eat the alcohol powder we just spoke about.

I’m normally not a praying man, but if you’re up there, please save me Superman. – Homer Simpson

If you don’t like your job you don’t strike, you just go in every day and do it really half assed, that’s the American way- Homer Simpson

  • Diagnosis by computer- 50000000 people worldwide do the computerized self-triage game- that is they plug their symptoms into a Google and viola- they get treated for whatever the kid in number 26 above had. Is this a bad thing? Maybe not. On a plane, in a strange country, out in a rural area, – working in the Artic- this could be a boon. Now I know what you are thinking. Many of these sites are not reliable, and in this study they found an accuracy of 58%- that seems optimistic to me. Many sites are risk aversive and one site concludes each search with –”consult a doctor”. Often patients will ignore good advice from the site and do what they want – whereas a face to face with a physician gives good rapport and a voice to disagree. Professionals may recognize subtle danger signs as well. But on the other side, people will be more honest to a computer than to a doctor concerning – for example alcohol use. Shut ins and mothers with small children could use this service. (BMJ 351:H3727)I think largely that telemedicine will supplant this and indeed many rural states in the USA have banded together to license such doctors in multiple states. TBTR: Patients using computers to self-diagnose- may not be so bad.

I’m trying to be a sensitive father, you unwanted moron! – Homer Simpson

What’s a wedding? Webster’s dictionary describes it as the act of removing weeds from one’s garden. – Homer Simpson


  • I don’t like statistics any more than you do – but I will let you in on what his article discussed in little bites that even I could understand. RR- that is relative risk is the number or bad outcomes in a group divided by the whole group. Example: The number of lung cancers (numerator) in smokers divided by the number of smokers (the denominator). A RR less than one implies that the first group – if there was an intervention will do worse and greater than one favors the other group. For example, intubation in pulmonary fibrosis did worse than no intubation in pulmonary fibrosis if the R is less than one.  RR does poorly when there is a need for controlling variables and also doesn’t work in case control studies where the amount of cases is by design. The odds ratio is simply the amount of people who get the vent divided by those who did not – that is the amount of people who get lung cancer divided by those who don’t.  Odds ratio doesn’t include those with the disease, while RR does; although they can be very similar when the disease is rare. They then speak about logistic regression for binary (yes/no) variables but I lost them when they started with logarithms. (J Paed Child Health 51:670) TBTR: RR, OR, and forget the rest.

This is indeed a disturbing universe – Maggie

Alright, Brain. I don’t like you and you don’t like me. But let’s just do this and I can get back to killing you with beer. – Homer Simpson

  • Do you feel lucky punk? Well do you?image031. Can you use optho drops after the expiration dates? I am not talking about grody open bottles with scale on them but bottles that were just lying around. Well, we always thought that the expiration date was just an approximation and that is true. But there could be sterility questions, evaporation issues (will affect concentration) stability issues, acid bases issues (i.e. buffering) and if the bottle was improperly stored- the drug may be not effective even within the expiration date. What I found uprising is that manufacturers do not want a short expiration time; because the pharmacies will return expired meds to the wholesalers who return it to the drug company who just eat the loss. (Ocul Surf 13(2)169) TBTR: eye drops at least should not be used after the expiration date.image032

In this house, we obey the laws of thermodynamics! – Homer Simpson 

Homer and Bart: You don’t win friends with salad

  • Bill Frishman was one of my instructors and is a pretty famous cardiologist until he turned coat and jumped to NY Med from Einstein. He is claiming something we already knew- toss out your stethoscope. US is the way the go now. He does say you will still need it for the lung exam (although US can detect effusions better) and for abdomens to hear bruits (just US the aorta) and bowel sounds (useless in my opinion.) (AJM 128 (7)668). TBTR: US learn how to use it and you will forget gallops and rubs forever.

Bart: Hi Homer, wanna eat my shorts?

Oh boy, buffalo testicles! – Homer Simpson

Some pneumothorax news. There probably is no such thing as a primary pneumothorax –as we improve our imaging we are seeing more identifiable causes – such as bleb. But still smoking, especially cannabis (gotta stop that, fellows image033cause bleb formation and significant lung destruction (especially cannabis). Of course male sex and tall folks are still a big risk factor as are Marfan’s syndrome and Birt-Hogg-Dube syndrome (yea,right). The rest of the article discusses stuff we have been pushing for years- aspiration instead of putting in a tube,  smaller bore tubes when you got to put one in, use of Heimlich valves so patients can go home, and even blood patches (Lancet  Resp 3(7)578) TBTR: Pneumothorax – new approaches.

“There’s an angry mob here to see you, sir.”

“So I said to myself: what would God do in this situation?”

  • Here is an article that was a pain in the assimage035 This article discussed oral ulcerations. Local trauma is going to be the most common cause – think from braces, fractured teeth, dentures,- these just need a little readjusting by the dentist. But do not forget meds- labetolol, alendronate, captopril, NSAIDS, methotrexate, protease inhibitors, and tacrolimus. This is independent of Stevens Johnson – which basically can cause sever ulcerations of all the mucosa from any medication. Aphtous ulcers – you should know about these. Lidocaine derivatives are the main stay, but topical steroids are often needed. Recalcitrant cases may need colchicine, or other immunosuppressants (thalidomide, azathioprine, etc). Malignant ulcers- most commonly SCC, but breast, lung and prostate also metastases to the oral cavity. Risks for SCC include smoking, betel use (quit using that stuff, will you!) and excessive alcohol use. Nothing about Birt Hogg Dube syndrome. Infectious causes, include herpes –which we are all familiar with-(not that herpes- please guys!) but cold sores and the like.  Coxsackie virus can cause herpangina and hand foot mouth disease.  Both of these are usually supportive treatment. HIV and TB can give ulcers too. All three stages of syphilis can give ulcerations.  Fungal infections are uncommon in immune competent patients. Heme disorders include leukemia, lymphoma and neutropenia. Iron deficiency and vitamin B12 or folate deficiencies are also causes.  Pemphigus is not a hard call. Celiac, and IBD round out the list but do not forget Behcet and what they do not mention – Kawasaki.  (BJHM 76(6)337). This was pretty confusing and not that helpful, and the pictures weren’t very helpful either but if you see oral ulcerations in the ED, rule out Behcet, Kawasaki, and Steven’s Johnson. If it doesn’t go away – think malignancy. TBTR: see last sentence.
  1. “Well, we hit a slight snag when the universe collapsed in on itself.”

“Yes! In your face, space coyote!” “…

  • There are many reasons to write about articles in EMU – but I liked the journal name (Maturitas 81:343) and the name of the first author – Dudley Robinson. The article discusses the management for UTIs in octogenarian women – that is a very big word but it just means women in their eighties. Which gives me a chance for one of other favorite games- here is another installment of what sirens look like todayimage036 know who this was? Here she is today: image037That was Charo – a Latin siren from the past. Well known for her signature line Cuchi Cuchi) If you are a woman (I’ll give you a minute to check) – then you have a risk of an UTI over your lifetime of 20%. Add to that that vaginal epithelium that is not under estrogen stimulation becomes colonized with gram negative bacilli and you got a perfect set up for an UTI. Truth be told there is no real good test to prove a UTI short of culture. But they did not consider symptoms (dysuria, frequency etc.) combined with other tests (leuk esterase, etch) which I believe should clinch the diagnosis.  Now I am not going to teach you much about UTIs that you didn’t know but here is some useful information with regards to those hard to manage recurrent infections. Check the urine out for fastidious organisms (mycoplasma hominis, ureaslyticum, and chlamydia). Do urinary tract imaging to rule out stones and check to see if there is a significant post void residual. Transvaginal ultrasound will rule out pelvic masses and prolapse. Uro dynamics are important (although I cannot usually find anyone to do them) and then consider cystoscopy. Management is antibiotic’s – they like nitrofuratoin as a first choice) potassium citrate and/ or post coital prophylaxis (coitus at age 80???) as preventative measures.  Vaginal estrogens should also help TBTR: UTIs at age 80 – some helpful pointers.

Man: Sir you can’t operate a boat under the influence of alcohol.

Homer: Oh, that sounds like a wager to me


Ron Howard: [pitching a movie] And it builds to a powerful emotional climax, where the father has to decide which of his children will live….and which one…will die.

Executive: Pass. What else have you got?

Ron Howard: Well, there’s one about a killer robot driving instructor, who travels back in time for some reason.

Executive: I’m listening.

Ron Howard: And this robot- He’s got a challenging decision to make about whether his best friend lives….or dies.

Executive: Ehh.

Ron Howard: His best friend’s a talking pie.

Executive: Sold! Howard, you’ve done it again!



  • I get as tired about writing about these as you get reading them, but the management of SVT (superficial venous thrombosis) has been changing. Most of these are the great saphenous vein (I don’t know why it is so great) and is often felt like a red and painful cord. But SVT is definitely a risk for DVT in the future, and often can easily extend to the deeper veins (BTW the superficial femoral vein is considered a deep vein). Often there is a DVT in a non-contiguous area from the SVT. This of course still leaves us with many unanswered questions such as anticoagulation for how long, with what (NSAID +enoxaparin? Fondaparinux?) How long? Does it make a difference which superficial vein? Are there some veins that do not need it? (J Thromb Haemo 139(supp1) S320)TBTR: More on SVT

Marge, don’t discourage the boy! Weaseling out of things is important to learn. It’s what separates us from the animals! Except the weasel

Dear Mr. President: there are too many states nowadays. Please eliminate three. Ps, I am not a crackpot


  • ARDS – this is not as nebulous as it used to be; all have some clinical risk factor. But there are ten diseases that can look like this. CHF is the obvious one. Diffuse alveolar hemorrhage is seen with cytotoxic drugs, bone marrow transplantation, and has cough and hemoptysis. Goodpasture’s looks the same. Acute hyper sensitivity pneumonitis can give a similar x ray, but they will report they have been exposed to an antigen if asked. Acute eosinophillic pneumonitis – has eosinophils on lavage – not a diagnosis you will make in the ED. And the rest? They are so subacute that they will not make it to the ED. If it truly is ARDS – do lung protective techniques on the ventilator settings and just know that optimal PEEP and the use of steroids is still controversial (Intensive Care Medicine 41:1099). TBTR: ARDS can confuse you. If you are an ICU guy, you may want to read this article on burn care in the ICU, but if you are not – just remember that shortness of breath can be from cyanide poisoning from burning plastics. (ibid 41:1107)

Lisa: Dad all the bees are dying.

Homer: Oohh no more bees! Now who’ll sting me and walk over my sandwiches?

Lisa: But without bees there would be no flowers.

Homer: (scoffs) Flowers: The painted whores of the plant world.


Moe: You gotta make me shorter doc.

Dr. Hibbert: (laughs) What do you mean?

Moe:I mean take out bones, guts, whatever you gotta do to make me a micro Moe.

Dr. Hibbert: What you’re asking is completely unethical. No licensed physician would preform that operation.

[Cuts to Dr. Nick.]

Dr. Nick: Now close your eyes and when you wake up you will be a woman.

Moe: No, no, no, no, no! I-I wanna be shorter, for a woman.

Dr. Nick: Uh oh. I mixed you up with the last guy



  • Letters : would you believe that Ken is now on his second trip as a medical officer in Antartica? Here is what he has to say inbetween surfing and drinking Mai Tais. His comments are on the Nov issue:

Hi Yosef

Okay, since I’m writing from McMurdo Station, Antarctica, I’m now the most remote EMU reader, I think. To answer your questions:

  1. I know some of the authors, but they’re all trauma surgeons—so that explains any inconsistancies.
  2. As for the pronunciation of Tucson, English is a strange language. (But aren’t all languages peculiar in their own way?) “Tucson” derives from an Indian word, “chuk son,” or “dark spring at the foot of the mountain” or “(at the) base of the black [volcanic hill.” This probably referred to what we now call the popular hiking area around Sabino Creek and the adjacent Catalina Mountains. The Spanish seem to have adopted this name as Tucson [tukˈson], Of course, American settlers couldn’t leave well enough alone, so they Anglicized it to be pronounced as “Toosan.”

BTW, the second edition of “Improvised Medicine: Providing Care in Extreme Environments” (McGraw-Hill) came out in early January!


Best wishes from the Ice, Ken

Do appreciate your comments always, Ken. Father Bulldog also wrote and here are his comments on the Dec issue :

Yosef,Yosef,Yosef. We need to clear up some points from the December EMU. It must be the US Mail’s fault that it only arrived on my e-mail today. First, Rick Bukata has always looked this way. You posted his 6th grade First Confirmation photo. But that was the After picture. If nothing else he is consistent. Second, he did not release me, I escaped!! Third, Rita and I are STILL an item but, of course, she is dead so I can now keep up with her sexually. Next, I loved you dog photo in this issue. Doggie shots should become a regular feature, since you have given up comedy,  so I have enclosed pictures of my second wife which you are at liberty to use. Your babblative attack on the low sales of sun screen products in Sault Ste. Marie, Michigan although correct was still hurtful. In fact the entire winter population of that town, all 7 of them, would take you outside and thrash you if they could go outside! Summer will be July 12th this year so I wouldn’t be in town that day if I were you.  And lastly, as this EMU issue illustrates, you have given up writing comedy, I would be slow to confront Billy Mallon to a comedy slap-down. If it does happen we would need to have categories like best expatriate American in a second banana role. All my best to my Middle Eastern friends and may God(pick one) bless  Father Greg   I gotta answer some of this. I have not kept up with all of Greg’s wives but I do know that Father has applied for residency in Utrah. As far as the Sault is concerned  I will let Ken answer that one. As far as humor is concerned – let’s look at your best lines, Father- those which I hear over and over again  “If you don’t want to read the nurses notes in the department, just be prepared to read them on the stand in court” Well I did read the the nurses notes- they said – four heads of broccoli, two bottles of milk. 3 boxes of eggs” They took me out of court in a strait jacket. “That kind of behavior went out with red meat” the Master quoter brings Tommy Smothers” red meat is not bad for you,  blue green meat is”. And lastly “being dead is not a good prognostic indicator” For Rita it was. Besides didn’t you always teach me that being drunk is? C’mon – bring on Billy and let me wipe the floorr with him!

  • Number 10 was pneumorrhachis- air in the epidural space. If there are no neuro findings- you leave these alone and the air resorbs alone. Number 18 is Benign Toriticollis of childhood. This is- as it says- benign – but there is some risk for migraines when they grow up. It subsides by itself – but most of the physicians they studies were unaware of this condition. Number 26 was erlichosis


The sources for these articles are Blood 125(23)3551 and AJEM 33:815

Going to sleep

  • Really nothing readers of EMU didn’t know already but we have a treat for you this month. This article is from Israel and we interviewed the authors on some questions that you may have had for your ED as well.
  • Background: Ketafol – the combo of propofol and ketamine was used in their peds ED. The theory is that propofol can reduce the vomiting that is sometimes seen with ketamine, and ketamine can reduce the pain which propfol can’t . Ketamine also reduces the pain of propofol infusion. They report 52 cases of serious adverse events but none of them were really serious and all resolved with at most oxygen.
  • Here are my questions to the authors:
  • 4) Itai Shavit who runs all the pediatric sedation courses in Israel was kind enough to have the lead author Eric Sheier respond (Itai is also an author on the paper):

Hi Itai
Your article will be featured in the Jan EMU. Congratulations- it was a good article.
Can I get your answers to these questions relating to the paper.?
1) You wrote that theoretically the propofol will take care  of vomiting  and the ketamine: the low BP. Both of these are rarely problems –  Many use pain relieving doses of ketamine- ie non-sedating and less propfol  for their ketofol- what do you think?
2) Were discharge times longer with ketofol than propfol alone?
3) ketamine is so safe -can it be used in the outpatient setting if one is trained in its use?
4) Why are so many ED s( at least in Israel) still resistant to pediatric sedation in the ED (My hospital does not allow the pediatric ED to use sedation(they can give oxycod_)).They send them to us.
Thanks itai

YB Leibman MD Specialist in EM


: Eric Scheier >>
תאריך: 19 בינואר 2016 בשעה 18:33:26 GMT+2
אל: Itay Shavit <
נושא: בעניין: Your article AJEM 33(6)815

נא לאשר:

Hi Yosef
Thank you for featuring our article. Our answers to your questions are as follows:
1) You’re right that hypotension and vomiting are both rare events. The hypotension from propofol is almost never clinically relevant in healthy kids and the vomiting from ketamine is almost always in higher doses, and is never more than a nuisance that prolongs ED stay. I think that the bottom line in all sedations is to titrate the drug to get the level and length of sedation you need. That’s why we preferred to dose ketamine and propofol separately and not as “ketofol”, the single syringe combination of ketamine and propofol. What I liked about the sequence was that the ketamine both induced sedation and provided analgesia, while propofol allowed us to work with better conditions. To me it’s important, when i have a scalpel in hand or when I’m suturing, that the child be as still as possible. Straight ketamine can cause children to tremor or otherwise move suddenly, and that can make the procedure more difficult for us to do. I’ve done many sedations with a fentanyl and propofol combination as well, and while fentanyl is another option for analgesia, many more of these kids will become hypoxic on that mixture. So more than treating hypotension, the ketamine seems to be a better analgesic than narcotics when it comes to treating respiratory depression. And the nausea and vomiting following straight ketamine can be bothersome to parents and patients, and can be almost entirely eliminated by propofol. As for the ketamine dose, I think that a nonsedating dose of ketamine followed by propofol and with local analgesia or a regional block is a fine idea, and would eliminate the horizontal nystagmus that can scare parents. And the minimum dose of propofol is always the dose you’ve titrated to achieve the targeted length and depth of sedation.
2) We only had 35 sedations that used propofol, so I’d be unable to come to any conclusions about length of stay.
3) This is a tough question to answer, because the line between inpatient and outpatient is blurrier than it used to be. A trained pediatric emergency physician does not need anesthesia or critical care back-up in order to perform deep sedations. Free-standing emergency rooms (i.e. not connected to a hospital) will sedate in the United States. In 2014, the good folks at Emory (my alma mater) wrote about 654 pediatric deep sedations that their sedation service (including emergency physicians) did and found a very low complication rate (Emrath ET, Stockwell JA, McCracken CE, Simon HK, Kamat PP. Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging  center. Pediatr Radiol. 2014 Aug;44(8):1020-5). So I think it’s less a question of where and more a question of how. The physician needs to be a trained emergency or critical care physician, the nursing staff need to be well trained and credentialed in deep sedation, and the equipment needs to be appropriate for the management of a rare complication. So I wouldn’t approve of its use by a general pediatrician in the outpatient clinic, but I do think that pediatric sedation can be done by trained staff in an outpatient procedure suite.
4) Resistance to sedation in the pediatric emergency department stems from a combination of ignorance and fear. Pure and simple. This is not a criticism of your hospital per se. Unfortunately, this is the case in many pediatric facilities. We should never restrain children, We should make every effort to minimize pain. We have the tools in the emergency room to do procedures quietly and comfortably, and we should be using them on a routine basis.

All the best,
Eric and Itai

Thanks guys


The second essay deals with the management of priapism.

  • For all those who were wondering, priapism comes from the Greek mythology Priapus – the one for fertility who had a big phallus.image038
  • How do erections occur? And what is the pathophysiology of priapism? This is very involved with nitric oxides and frankly pretty boring. So let’s cut to the chase recognize there are three types of priapism.
  • Ischemic priapism is the one that most interests this journal called Blood. And despite all the treatments for ED- it is still the most common cause in the USA. This is due to low flow or vaso occlusive reasons – mainly sickle cell disease (hereditary spherocytosis and G6PD can also cause this) It is like a compartment syndrome and IT HURTS! Within 24 hours there will be necrosis.
  • Recurrent Ischemic priapism (they call this RIP- love the nickname) often occurs during sleep and lasts for less than three hours before resolving on its own. Doesn’t sound too bad but in fact one third of the cases progress to ischemic priapism and even those who do not; between a third and a half will lead to ED and we do not mean emergency department.
  • Non ischemic priapism – this is the one I have seen. It can be from an injury which leads to fistulas although there may be a hematologic component to it. In these cases, the corpora are usually not hard, and it is not painful.
  • There are a lot of other causes; I will just mention the ones I would not have thought of. Obviously injectable ED agents but also alpha blockers (doesn’t’ seem fair that they can help shrink that prostate to allow someone to urinate than give him priapism to make it harder to urinate). Anticoagulants, antidepressants including SSRIs, and phenothiazines. Alcohol, cocaine and grass can cause it too. Malaria, rabies, scorpion and spider bites (they don’t mention if the sting has to be in “that” area).Neurogenic- I knew that- but think also of general anesthesia or even regional too.
  • Diagnosis may seem easy, but we want to differentiate between ischemic and non-ischemic- as we mentioned before ischemic is painful. Lab tests?? Are they serious? Yes, they are- blood gases will show acidosis if it is ischemic. US will show no or little blood flow in ischemic. Non ischemic will show normal to high blood flow.
  • You would think that ejaculation would help this, but no guys, it won’t. Exercise and warm or cold compresses do not work very well either. Actually using low dose Viagra may reduce episodes of at least RIP by modulating the NO balance. Hormonal therapies have lots of side effects, and testosterone is still being studied- no good studies for that yet.
  • RIP can be self treated by teaching men to self inject phenylnephrine. The prevalence of side effects is surprisingly low- even in heart patients.
  • The best treatment is to just aspirate and irrigate with saline. A penile block is helpful and a lateral approach is the way you aspirate. Surprisingly, most men I have done this to do not object to a large needle stabbing their “you know what”. You may have to aspirate a lot of blood to succeed.
  • Surgical management is not usually for acute cases and has a lot of problems involved with it.
  • Gosh, got through that without any puns or shady jokes. It was pretty hard.



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