EMU Monthly – June 2015

June 2015

  • Hey it is June already and I am really pissed at the editors of EMU for pointing out the month all the time– Heck if you don’t know the month you either need a head CT or not be out in public unattended. But then again, maybe you need a head CT if you give ADP receptor antagonists – you know those – the prasugels and the like- in the ED. ED use has not shown any reduction in mortality but did increase major bleeding by 23%. This author postulates that you should just give heparin and Aspirin and get them up to PCI faster- the anti ADP receptor can wait without any loss of benefit. (BMJ 349:g6282 this is from the Oct 24 issue and for some reason is not cited in pubmed) My take- the studies for benefit also include those with repeat MIs and they may have less benefit in the ED then first time MIs it. I am not sure. Also, we end to define major bleeding- often that is bleeding that requires no intervention. Furthermore, he only speaks about NSTEMI- there is usually no rush to get them up to cath. Nevertheless – good science is important, and major bleeding always has to be a concern. TBTR: Aspirin and heparin is all you need to get that NSTEMI up to cath lab.
  • HINTS – head impulse testing – can help to differentiate peripheral from central vertigo- if your history is not enough (here are the history items you want to know: Central is usually with accompanying neurological signs, usually has no extinguishabilty, usually has no vomiting, they cannot find a position without vertigo, nystagmus which is not horizontal and it is usually subacute. HINTS is a test that is remarkably accurate- 100% sensitivity, 96% specificity but it does require some training (Ann Emerg Med 64(3)2655)- here is the video on how to do it (quoted in the article): http://content.lib.utah.edu/cdm/singleitem/collection/ehsl-dent/id/6  TBTR: If you think you may have a patient with central vertigo – try the HINTS test
  • I’ll probably get some FPs hot under the collar- but I do some FP work and when I have a renal colic patient – I do not send them packing to the ED. OK, we won’t get into the pain control protocol I use and yes you can do this without narcotics) but I do sneak over to the gyn folks next door and pilfer their ultrasound to look at those kidneys. Now the mantra has always been US can’t see the stones and the urologist will never accept a patient without a CT. But I always wondered- how is that I can find a piece of glass 1 mm in size in the skin with ultrasound but I can’t find a stone which is bigger? So they looked at this in Japan and noted that the ultrasound did pick up stones – obviously finding the bigger stones easily; the smaller stones with more difficulty. (Urology 84(2)285) I am not sure why we care. Ultrasound can help us rule out other serious causes that muddle the picture like AAA (at least you can see if the aorta is increased in size). And what concerns me as an EP/FP is hydronephrosis – which ultrasound can find, and a stone that won’t pass- generally bigger than 6 mm- but this article says I will see those also. However this study was done by special urologic ultrasound techs, so I do not know if we are as good. TBTR: Use your ultrasound for renal colic- the urologists will learn to deal with no CT. Kids do say the darndest things- here some kid quotes- and parents quotes too!:

“I’m glad I’m finally eight. This is the oldest I’ve ever been in my entire life!”

“Well, sometimes I beat up my brother, but I feel really good inside. Does that mean I’m a hypocrite?” — 7 year old girl, after a Sunday School teacher explained that a hypocrite was someone who says one thing but feels something else

  • Some things do not have to be said image001Low carb diets can cause ketoacidosis- that is SKA- starvation ketoacidosis. This diet was the Dukan diet and the patient got pretty sick. (JEM 47(4)e109) ,

“Daddy picked them up and looked underneath. I think it’s printed on the bottom.” — 3 year old son, when his mother asked how his father knew the genders of four new baby kittens

“How will that help?” — Kindergarten student, when the class was instructed to hold up two fingers if any of them had to go to the bathroom

  • I really don’t see any sickle cell anemia – we have an African population in Israel but they are from the countries of Eritrea, Sudan and Ethiopia and these countries really do not have this too often. However, if you do see this malady- this article makes the supposition that while sepsis is devastating here, some of these people who have fever are just fine and can be sent home for observation. (ibid p395) Only problem is this study of almost 400 patients was underpowered, it was retrospective, they only had one patient with real sepsis, and so – we don’t really know if this is true. TBTR: SCA- some fevers can be sent home – but who knows which ones?

“Don’t kid me, Mom, I know they’re my feet.” — 3 year old son, when his mother told him his shoes were on the wrong feet

“How do you put make up on your mind?” — Girl, when told she should make up her mind.

  • Don’t get me wrong – I am all for a number of things in life-the save the Indian Mongoose Foundation, the Weber State University football team, the gay ISIS for peace, rutabagas and not giving macrolides to everyone who coughs. This article tried to give us a score so we would know who has legionella and thus save the macrolides or respiratory quinolones for them. Basically you need 5 of these factors: high fever (39.4), CRP > 187, LDH >225, thrombocytopenia<171, hyponatremia (131) and dry cough. (AJM 127(10)1010) I had a lot of problems with this study.  Firstly – the statistical side- this was a data base- meaning it was retrospective, and they only had 37 patients with Legionella. Secondly they express the success of the score in NPV- which is not of interest to us- this tells us how well it performed in a population of people but not in patients with pneumonia. The same problem exists with odds ratio- they use that too instead of risk ration. They compile their date with AUC (area under the curve) which is a continuum but not a way to answer a yes or no question. Haven’t lost you yet? Then look at the factors. Regular pneumonia often has high fevers, and high CRP. A lot of seniors have Na of 131 or thrombocytes under 171- which isn’t much thrombocytopenia. Dry cough? Maybe but in this series it didn’t help much anyhow. Basically I don’t see where this will help us diagnose Legionella. TBTR: I haven’t found a good way clinically to say conclusively that the patient before you has Legionella. If you want something expensive, you should ask your grandparents.

If mom’s not happy, nobody’s happy

  • I mean maybe acute traumatic maculopathyimage002 I interests you but the point of me bringing this article is that few people realize the dangers of airbags. Oh, sure they save lives, but they also can cause this entity and more likely – painful burns on the arms from the exhaust products of the detonation of these bags- which generally exit from holes at the side – just where the arms are on the steering wheel (JAMA Optho 132(10)1245) TBTR: Airbags are in cars and are not your mother in law.

“You should never pick on your sister when she has a baseball bat in her hands” – Joel, age 12

“If mom says “no,” she means it. If dad says “no,” it means maybe” – Joseph, age 13


  • Hi Steve Selbst-the author of the PEC feature- Legal Briefs. I do not know why I am saying Hello because Steve doesn’t know me and doesn’t read EMU- but one case he brings we should discuss. You see, there was this young adult that had belly pain and the EP did a CT- which was read as normal. The patient was discharged. Guess what- it was appendicitis. Yea, the EP claimed that he discharged the patient because he believed the CT reading and yes, the jury agreed he wasn’t at fault but still where do you draw the line? If the surgical resident said it wasn’t appendicitis and you were still suspicious – of course you would climb the ladder. But what if you only have one surgeon on staff? Do you believe him? What often happens is that you end up getting pulled into this anyhow. What does Father have to say on the subject? (PEC 30(10)749). TBTR: If you think it is, and your consultant thinks it isn’t-saying “he is the expert, who am I to disagree?” will have you meeting the judge in your town kinda of quickly.

“If you live with five other women, you have to get up bright and early to get into the bathroom. “ – Meghann, age 13

“Parents should come with instructions.” – Shanna, age 14

  • Pancreatitis in pregnancy is pretty rare but they found 7725 cases in this data base and interestingly enough –while stones are still the most common reason- the course tends to be milder. Obviously, they are more likely not to undergo ERCP (J Perinat Med 42(5)565).

“The boys’ restroom smells, but the girls’ restroom doesn’t.”  – Devin, age 10
“All the bad things I’ve heard about algebra are true.” – Erin, age 14

  • Hey smarty pantswhat’s this? image004Oozing nodules on the legs – the nodules are erythematous and oozing a brown yellow liquid. Here is a picture image006– Any ideas? (CMAJ 184(2)E159)

““You can’t catch a hard baseball in your mouth.” – Joseph, age 10
“If you put a frog in a girl’s desk, you’re going to hear some screaming. “ – Nicholas, age 9


  • Hey want to hear about closed malpractice cases in Taiwan? image008I guess you don”t. So I will tell you about the migrating and mating habits of the platypus. They do not actually migrate, but they do mate- and lay eggs. And nurse their young. Yes, a mammal that lays eggs. Pretty interesting no? I guess not. So if platypli (platypuses) don’t interest you, they maybe we should talk about malpractice in Taiwan. Their malpractice environment is very similar to the USA and indeed to most western countries. Like most countries’, the physician wins 90% of the time if the case goes to trial – simply because it is cheaper to settle the ones that you probably will lose than go to trial. The annual risk of a suit is only 0.63% but the cases take more than 3 years in litigation. (AJEM 32(9)990) You are invited to see an essay we wrote on this not long ago – use our search function. BTW – in Germany, 2/3 of the cases get settled even if the doc was not a fault. This is probably due to the stress in Germany to lower pressure on the court system (Int J of Legal Med 128(6)1049) TBTR: Going to court? You’ll probably win, but it may take a while. I would instead recommend going to Australia and dancing with a female platypus (because of course you know that only the male is venomous).

“When teachers get old, like over fifty-five, they’re always in a bad mood.” – Lindsey, age 8

(Hi Honey – my wife’s a teacher – we won’t risk death or disfigurement by mentioning her age)

“I can never get away with feeding my broccoli to the dog.” – Joanne, age 10


  • I like the idea but you still need to be careful. We know – and this study – albeit tiny- confirms that syncope work ups as inpatients are very low yield – only in 26% do they find a reason that wasn’t discovered in the ED, and in this study less than 1% of the patients needed an intervention. So they say – why not just do the eval as an outpatient? (ibid p1113) The answer is – because repeated syncope and high risk patients are different and probably more dangerous, so you can’t just make a blanket generalization TBTR: Syncope –send them all home??

You can’t trust dogs to watch your food.  – Patrick, age 10

“I’ve learned that goldfish don’t like jello.” – Julie Ann, age 9


  • In this study they decided to use a bougie (I love that word) to push coins down the esophagus into the stomach in kids that swallowed spare change. They said they did not have any perfs at all. (ibid p1263) Could be, but using the Foley technique gets the coin out – even though it probably needs more sedation than a bougie. Simply put a small catheter in the esophagus – past the coin and inflate and take out . TBTR: You really can manage coin ingestions by yourself.

One of the greatest gifts my parents gave me was their love for each other. – Jamie, age 16

When you lick a slug, your tongue goes numb. – Bethany, age 11


  • This- to me – is more interesting than platypuses. Is an ankle fracture a risk for DVT? Well, in 2012 they did a study of a data bank and concluded that it wasn’t. image009(J Foot Ankle 519(1)63) Another article from China (Int Angiol 33(4)324) said the same. So you can go on your merry way and not give prophylaxis Not so quick. A trauma data bank still qualifies as retrospective, And in the Chinese study – they got a lot of people in China but only came up with 2347 patients in 8 years. And all these people were going to surgery – and they only did the ultrasound before surgery – the higher risk is after the surgery. And to muddy the picture- they admit that while there may be a low incidence – most have no symptoms and therefore may be missed. And maybe the height of the cast matters as it impairs the muscle functions- in a word- we do not know TBTR: DVT prophylaxis for ankle injuries .Yes. Or no. Or maybe. Or maybe not. Or go sit on a platypus.

“You’ll always get a zit on important days. – Amanda, age 14

“Life is filled with ups and downs but most of the time I’m going sideways.” – Leslie, age 11


  • This has got to be the last time I mention this – but there are still folks out there who are misinformed. What is the most common drug allergy? PCN – 8% of the USA population. Cephalosporin- maybe 1% (this was a chart review so that number may not be correct) and all other antibiotics- much rarer. They state – and this takes some testosterone secreting organs- that re challenge with PCN is not usually associated with IgE mediated reactions. (I like the word usually- they said mostly) And of course- and I see this a lot – people who have PCN allergy and took some form of PCN and nothing happened- I am sorry – they do not have a PCN allergy. Cephalosporin, and Monobactams, and Carbipenems can all be safely used in PCN allergy. (Curr All Asthma Rep 14(11)476) This is an expert opinion in a pretty poor journal. I agree with the part about cephalosporin but would exercise caution in patients with florid anaphylaxis. TBTR: PCN allergy – all you need to know.

“You should never chew on an opened tube of crazy glue.” – Teri, age 13

“You should never hold a dustbuster and a cat at the same time.” – Jennifer, age 15


  • Because we all like to deal with urologists (this is basically women’s revenge for us inventing the speculum) here is our urology article of the month. – I didn’t know this but if you have patient with a uretral stent –expect blood and WBCs in the urine. This is due to the stent being treated as a foreign body by the body. As such, you cannot diagnose a UTI by UA alone in these patients. (Am Fam Phys 90(8)542) TB TR: Oh read it yourself. However, for all you lovers of urine out there I will give you a preview of the Lancet article that just came out stating that Tamsulosin does not help renal stones that were small to come out any faster than placebo (Lancet May 18 2015).

“No on notices what I do until I don’t do it.” – Lorie, age 14

“The world is a wonderful place and everyone should shut up and enjoy it every once in a while.” – Sarah, age 12


  • The name of the article: “Rational Imaging of Neck Lumps”. The subject of the article – red flags for head and neck cancer. The imaging part- well, go to ultrasound whenever possible as a first test. Now what are the red flags? Hoarseness for more than six week. Ulceration of the oral mucosa for more than three weeks. All red and white patches of the oral mucosa. Dysphagia for than three weeks, Unilateral nasal obstruction, particularly if the discharge is purulent (isn’t that everyone?) .Unexplained tooth mobility without dental disease. Neck masses for more than three weeks. Orbital masses. Smokers, drinkers, males over 45 and people who chew tobacco or betel nut. (BMJ 349:g6136) This may not be related to EM – but it could be. TBTR: Red flags for head and neck cancers-see above.

“Childhod is not preparation for life. It is life.” – James, age 9

My young grandson called the other day to wish me Happy Birthday. He asked me how old I was, and I told him, “62.” He was quiet for a moment, and then he asked, “Did you start at 1?”

  • There is a lot of good statistical analysis in this article, but it isn’t going to make you forget Kim Kardashian anytime soonimage011 (or Betty Grable  for Father Greg) so we can’t be sure, but there seems to be some concern for sudden death with TMP- SMZ taken together ACE/ARBs. Theoretically they both get the K up. And don’t forget, TMP- SMZ is still widely used in the USA because it is effective versus MRSA- a smaller problem in some other countries. After all the statistics (and the fact that Kim Kardashian is married and therefore off limits to you) (and Betty Grable is deceased) you still can’t be sure, it pays to monitor the K if you do use these two antibiotics. By the way Kim the Platypus is still available.(ibid g6242) TBTR: Careful with TMP SMZ and ACE ARB- they can cause sudden death.

A little girl was diligently pounding away on her grandfather’s word processor. She told him she was writing a story. “What’s it about?” he asked. “I don’t know,” she replied. “I can’t read.”

A Sunday school teacher was discussing the Ten Commandments with her five and six year olds. After explaining the commandment to “honor” thy Father and thy Mother, she asked, “Is there a    commandment that teaches us how to treat our brothers and sisters?” Without missing a beat, one little boy answered, “Thou shall not kill.”

  • Another clinical case- I blew this one – but I always miss this diagnosis. This 45 year old male presented with upper limb weakness. But they did some blood test. WBC 11000, HGb 9.2 Plt 28, Cr 0.87. No fever, no bleeding. Not so hard- what is this? ( ibid g6472)

“When I go to heaven, I want to see my grandpa again. But he better have lost the nose hair and the old-man smell.” – Age 5

“I once heard the voice of God. It said “Vrrrrmmmmm.” Unless it was just a lawn mower. “– Age 11

  • Corneal foreign bodies aren’t hard to remove – most are uncomplicated. Most are followed up 2 more times by the ophthalmologist and this may be unnecessary- most heal really quick- within 4 days without any complications (Cornea 33(11)1193– where did you expect this to be? in the journal “Anus”?). This is true in my opinion but they cannot say it from their data- they only had 60 patients and one had a serious infection. That is still 1.667%. However I do agree with their supposition that patients can return if they have continuing pain or redness. TBTR: You can deal with the removal of corneal forging bodies without optho follow-up.

“It would be terrible if the Red Cross Bloodmobile got into an accident. No, wait. That would be good because if anyone needed it, the blood would be right there.”–Age 5

“The only stupid question is the one that is never asked, except maybe “Don’t you think it is about time you audited my return?” or “Isn’t it morally wrong to give me a warning when, in fact, I was speeding?”
–Age 15


  • Yea I know all about Holland- you better get out of the Netherlands if you want medical care and you are elderly. In France – well, they may let you live after this study. 95% of patients with out of hospital cardiac arrest left the hospital with a good outcome even if they were over 75 years old (CCM 412(11)2446) . This all depends on what a good outcome is (they did not use Rankin scales but a different scale- the cerebral performance scale). Also, it could be that in France – you need to be in pretty good shape to even get into the ICU – since beds are at a premium. TBTR: Do CPR in 75 year olds. And if it is me – even older.  image013
  • NSAIDS are a fair choice for pain relief. So is acetaminophen (paracetomol). So both together would be even better. Seems like a good idea if you are a dentistimage015 (JADA 145(9)967) But no one likes dentists and that may be because they are so bad with pain relief- but to be truthful, they took this from the Anesthesia literature (Anest Anal  110(4)1170) This is an older article but is a good lesson. Yes, they do claim that both are better than either alone. But this is a meta-analysis of some really tiny studies of which the NSAIDS that were used varied, and the meta analysis did not evaluate the quality of the studies – they used every study they found- none were rejected. This is a good example of what the eggheads call “garbage in, garbage out”. Curiously, this study was never done. TBTR: Is the combo of NSAIDS and paracetomol better than either alone?
  • IF you are still reading- and I certainly hope you aren’t –these clinical cases get even easier. Here what got an AIDS patient who is floridly psychotic- no fever. CT was normal. A little ankle clonus, and maybe some cog wheeling in the flower extremities. He got better with PCN- and was never psychotic again. This is, of course…..(Can Fam Phy 60 (9)818).image019
  • Why do you bother reading EMU? – this is also old stuff. I can’t explain why you read EMU – could be part of a psychosis you have that will also respond to penicillin, but we should dedicate a minute to oxygen for headaches. They looked at this in a literature search and found that it helps in 54-82 % of the cases at 6-7 liter a minute. Maybe HBO helps even more. But admittedly, the studies are poor, but the author says- hey, why not, it is cheap and safe. (Cepahlagia 34(13)1079) Truth be told, Cochrane looked at this already back in 2008 and was not impressed with the evidence. (Cochrane CD005219). Want my opinion- go back and take that PCN tablet. And be more careful next time TBTR: Oxygen is a headache treatment without a lot of evidence. While we are on the subject- if you want to use migraine drugs and your patient is involved in post-partum dairy production and dispersion- these are what you can use.(Eur J Clin Pharm 70(11)1313)  (truthfully, it was too much for me to reprint all the drugs, so I just cut and pasted them: According to our review, AMDs safe during breastfeeding are as follows: low-dose acetylsalicylic acid (ASA), ibuprofen, sumatriptan, metoprolol, propranolol, verapamil, amitriptyline, escitalopram, paroxetine, sertraline, acetaminophen, caffeine, and metoclopramide. AMDs compatible with breastfeeding but warranting caution are as follows: diclofenac, ketoprofen, naproxen, most new triptans, topiramate, valproate, venlafaxine, and cyproheptadine. Finally, high-dose ASA, atenolol, nadolol, cinnarizine, flunarizine, ergotamine, methysergide, and pizotifen are contraindicated.

a long car ride back from vacation, a 10 year old boy told his 8 year old sister, “If you were Mrs. Potatohead, I would take your mouth right now.”

  • Everyone – and I mean everyone loves calcium channel blockers- they are giving chocolate a run (like George Burns once said- “when wine women, song and calcium channel blockers get to be too much- give up singing) but there is a limit to everything- and calcium channel overdose can be a doozy. Surprisingly – there is very little that is proven that helps. This article (Clin Tox 52:296) reviews the literature and these are the main points: firstly, gastric decontamination does not help after vomiting has ensued. High dose insulin does help improve hemodynamics but survival – not as clear. Here is the main point- beta blocker and calcium channel blocker ODs can look similar- calcium channels are the ones that make you hyperglycemic. Calcium may help if your dog OD ed but human data is inconsistent. Then again, it is very safe. Glucagon – is like calcium- no evidence but fairly safe. Lipids helped animals only if it was a IV OD but not an oral one. One case series showed more mortality with lipid emulsion. 4 aminpyridine may help. ECMO looks the most promising but the literate on this subject is really poor, TBTR: Calcium channel blocker OD- insulin, ECMO- probably the best ideas.

“The quickest way for a parent to get a child’s attention is to sit down and look comfortable.” – Lane Olinghouse

“When my kids become wild and unruly, I use a nice, safe playpen. When they’re finished, I climb out.” – Erma Bombeck


  • We don’t see a lot of articles like this, and yes, I didn’t see Rick and pals pick this one up nor Mike and Sanjay. But EMU picked it up and reflects well on our reading choices for when we are on the throne. They checked 6 methods of keeping a cast dry and discovered that double plastic bags over the cast fastened with duct tape or two commercial products were the best-plastic wrap or a plastic bag with a rubber band didn’t work so well. (J Bone Joint Surg 96(12)e99) Obviously fiberglass may be the best choice but it is hard to work with and is not cheap. TBTR: Duct tape that cast to prevent it from getting wet.

“You know your children are growing up when they stop asking you where they came from and refuse to tell you where they’re going. “ – P. J. O’Rourke
“I was cesarean born. You can’t really tell, although whenever I leave a house, I go out through a window” – Steven Wright

  • Did I get lazy? I don’t know – I just stopped using calcitonin for vertebral compression fractures. The literature does however support its use and efficacy (Osteopor Int’l 23(1)17) Seems it may help for coccyx fractures as well. (Pain Phys 17(2)e229) Be aware that no one claims this works for chronic pain from fractures. I spoke now with my orthopedists- they too don’t use it. TBTR: Calcitonin may help fracture pain. Do you use it?

“The most remarkable thing about my mother is that for thirty years she served the family nothing but leftovers. The original meal has never been found.” – Calvin Trillin

“Sex education may be a good idea in the schools, but I don’t believe the kids should be given homework.” – Bill Cosby image020

  • Case report-pregabalin helped for intractable hiccups (ibid241) May not help with Thunderbird induced hiccups.

“Adolescence is perhaps nature’s way of preparing parents to welcome the empty nest.” – Karen Savage and Patricia Adams

  • Yes you can inject a finger with epinephrine for anesthesia and a bloodless field- but the amount of epinephrine used in commercial combos of lidocaine and epi are small. On the other side- and injection of an Epipen into a digit is a lot more epi. Now it is true that no ischemic finger cases have been reported by this route, but Epi pens have only been around since the eighties. However, they bring a study where the investigators themselves injected their fingers and noted what has been reported previously – most do just fine- a few have persisting neuropraxia sometimes lasting up to a day. The usual treatments include warm soaks or NTG paste. They speak about some other treatments including phentolamine (I used this once and almost dumped the BP in a kid) – but why bother – they all do well (Can Fam Phy 60:726) TBTR: Accidental Epi pen injection – don’t worry.

“Everybody knows how to raise children, except the people who have them.” –  P. J. O’Rourke

“The biggest thing I remember is that there was just no transition. You hit the ground diapering.” – Paul Reiser

  • This was part of a point – counter point image021 about the use of US in ICU medicine. While the US geeks will laugh me off-I am not worried- my kids laugh at me – the dog too- but here are some salient points: US is limited in the lung because of the interaction of air and the beam in lung disease. Therefore they cannot see deep lesions and cannot provide panoramic views of the chest. As a result, consolidation and interstitial pathologies may be missed. In the abdomen- US is great for fluid (although it cannot detect what kind of fluid) and also is better than x rays to see free peritoneal air under the diaphragm. US can find cholecystitis as the cause of sepsis, but will miss many other intrabdominal and retroperitoneal sources. As well, it will miss many retroperitoneal bleeds. It can tell hydronephrosis. image022(ICM 40:1766) TBTR: Ultrasound – great for some things, not so good for others.

“I want my children to have all the things I couldn’t afford. Then I want to move in with them.”- Phyllis Diller

“Having children is like living in a frat house – nobody sleeps, everything’s broken, and there’s a lot of throwing up.” – Ray Romano

  • AMS- acute mountain sickness (headache, nausea, fatigue, sleep disturbance) – standard treatment (and prophylaxis) is acetazolamide which is a ventilatory stimulant and dexamethasone whose actions are less clear. Inhaled budesonide which provides much lower levels of steroid to the brain works just as well. They want to postulate that AMS comes from the lungs and not from the brain. (AJM 127 (10) 899)Could be, but we need to understand physiology a little better – this in the end seems to me to be another example of steroids work – give some more and damn the reason. TBTR: could be that inhaled budesonide helps acute mountain sickness.

“Like all parents, my husband and I just do the best we can, and hold our breath, and hope we’ve set aside enough money to pay for our kids’ therapy.” – Michelle Pfeiffer

“What a kid I got, I told him about the birds and the bees and he told me about the butcher and my wife.” ― Rodney Dangerfield

  • Ken – you are still reading, aren’t you? Jerry Hoffman – whom I am sure you know, is on a new soapbox- and this time I agree with him. He says that the shame and blame for making mistakes in medicine is misplaced. Medicine is not a perfected science and the public must come to expect mistakes. This is not just a CYA issue – even in places with low rates of lawsuits, malpractice reform (Texas) or no fault (New Zealand) – doctors are still way over testing and practicing defensive medicine. He then praises the Choosing Wisely campaign and in the UK the Too Much Medicine campaign. JAMA also has a Too Much Medicine section. (BMJ 2014:349g5702) This feeling of perfection of doctors was perpetuated by shows such as Dr. House and Scrubs where the main characters were pompous – and always right. Furthermore, while legal challenges may have become less due to reform, punishment by government authorities continues unabated although this issue is rarely mentioned(from what I heard, NY and Florida are particularly bad with this). Part of this may also be related to the respect many cultures give to the medical profession – supermen must be supermen.image023 TBTR: Mistakes are part being of being human.

There are two things that a child will share willingly – communicable diseases and its mother’s age.” – Benjamin Spock

“I don’t think my parents liked me. They put a live teddy bear in my crib.” – Woody Allen

  • This is weird stuff- there is something called phantom organ pain syndrome which occurs after surgery – usually after removal of an organ. The pain continues despite a negative workup, but gabapentin seems to help. I can not tell you how this works. (AJEM 32:1152:E2)

“Think of stretch marks as pregnancy service stripes.” – Joyce Armor

“Little League baseball is a very good thing because it keeps the parents off the streets.” – Yogi Berra

  • A good example of statistics. This study was really well done- randomized, double blinded, placebo controlled, and with a cross over design. OK, they were allowed other anti emetic drugs as needed which m ay have muddled the results, but they found transdermal clonidine did help for hyperemesis gravadarum. (BJOG 121(12)1556) However, they only had 12 friggin patients- the result of that is high type I error and confidence intervals that are huge. What is type I error? This is when the null hypothesis (or that the intervention doesn’t work) is falsely rejected. The confidence intervals do not indicate the lilkihood that the correct answer point falls within the interval but rather the reliability of the answer provided. Here they are unbelievably wide 0 for example 2.17 -12.83 on VAS scores. TBTR: This study can not help you, but understating how to read can help you.image024
  • Letters: Well May was delayed since the website was downed by a virus that killed a number of EM sites at once.
  • Yes, you nailed it in number 10– this is pancreatic panniculitis- this is a dermatologic manifestation of pancreatic inflammation – can be caused by infection, medications or drinking. Just make the connection. And number 19 was of course TTP –use our search –we have written about this in the past. And number 23- c’mon that was an easy one – that was Syphilis. You probably know all about that one.



The sources for these are Cleveland Clinic 81(7)411 And Ped Clinic N Am 61:1049 .


  • I don’t know much about RSD which is reflex sympathetic dystrophy; but that doesn’t bother me much because no one else does either. And furthermore it isn’t even called RSD anymore –it CRPS – complex regional pain syndrome. I would have included the autonomia in the name of this syndrome – i.e. complex regional autonomic pain syndrome but I guess the initials bothered people.
  • These folks have severe pain, limb edema, joint stiffness, atrophy of muscles, vasomotor disturbances such as erythema and temperature gradients; local loss of calcium in bones in the vicinity and sweating. Indeed light touch causing pain, and rolling a pen cover over the arm (sweaty skin in that one area will impede the movement of the pen cover) are pretty good indicators of CRPS.
  • There are criteria for this and this is probably the best way to diagnose it-blood tests are not needed, x rays will later on show the demineralization, CT will not help. MRI may help, as may a bone scan. EMG will show nerve damages- sometimes.
  • So here are the criteria-they are the Budapest criteria: these are as follows: Sensory: allodynia or hyperesthesia. Vasomotor: temperature asymmetry, skin color changes or asymmetry. Edema/pseudomotor- edema and sweating changes or asymmetry and Motor trophic: decreased ROM of the limb, motor dysfunction (weakness, tremor, and dystonia) or trophic changes in skin hair and nails.
  • So how do you treat theis? Stellate ganglion blocks get a lot of press but they can also make this worse. I would agree this is still controversial. Immobilization makes it worse. Steroids only make the edema worse. Amitriptyline and pregabalin can help. Biphosphanates help with bone resorption.
  • Once the disease progresses and includes brawny edema and muscle wasting it becomes more complicated to treat. Ganglion blockade, epidural clonidine, TENS spinal cord stimulators- all have been tried with varying success.
  • Even minor trauma can set this off
  • There is an association with stroke and MS- but this is just an association – nothing proven yet


Yes, JD means juris doctor, and I am dealing with my lawyer obsessions again. (Hey Father- when you see a carcass on the side of the road in Texas- how can you tell if it is a dead armadillo or a dead lawyer? If it was an armadillo, there will be skid marks.) True most folks will skip this article because it involves kids and the legal system in the USA, but there is always something to learn from our legal colleagues.

  • This article deals with child maltreatment. The first issue is mandatory reporting. However, to broaden this subject, this can be also applied to battered women, seizures and reporting to the DOT etc. In many locales there is a law requiring reporting all cases of suspected abuse to the authorities. However, in many cases, this can be anyone – not just a medical provider. Indeed, NJ and Wyoming require reporting regardless of profession.
  • The question is what is “reasonable suspicion” that would mandate the reporting process. The US supreme court ruled in Ill vs. Wardlow that this must be “a reasonable articulate, suspicion” and more than an inchoate and unparticularzed suspicion or hunch”. While that doesn’t make it any clearer for me (I don’t even know what inchoate means); what is clear that without reasonable doubt- reporting is not necessary
  • If you are mandated to report why don’t people report? Many people do not feel the system will help (or that the system will just take their children away) many feel that they can handle it on their own. Many don’t want to go to court to testify. Patient confidentially –even under HIPPA is not an issue; the provider is protected. But then again, it seems to me that there is still a gray area here and I wonder where the protection extends if the case is less than reasonable suspicion but more than a hunch. Sometimes, administration tells you they will take care of it and that doesn’t leave you off the hook – they have many reasons to sweep this under the carpet (i.e. kids of a major contributor to the hospital or major community figure- or medical colleague- would you report your colleague knowing you would have to see him day in and day out?)
  • Expert witnesses: we have discussed this in the past. Most states and countries for that matter have very broad definition of what an expert can be. This brings us to Frye and Daubert challenges- Frye requires that the information presented must be acceptable to the general medical community. Nowadays a Daubert challenge is more common- this is similar but much more detailed. Here is Wikipedia’s quote of the rule: RULE 702. TESTIMONY BY EXPERT WITNESSES

A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if:

(a) The expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue;

(b) The testimony is based on sufficient facts or data;

(c) The testimony is the product of reliable principles and methods; and

(d) The expert has reliably applied the principles and methods to the facts of the case

  • Another note that is important is that a subpoena is not a blanket permission to breach confidentially – this should be reviewed by those issuing the subpoena.
  • Remember that sometimes a practitioner is called as a fact witness and not an expert- fact witnesses must just say what they saw- they are not there to educate the court or jury. An expert is.
  • Expert qualifications vary. The AAP requires a license in the state of testimony (may be problem if the expert in the field is not a citizen of the country or licensed that state); boarded in a field relevant to the testimony ( es that means a neurologist is not better suited in a neuro case than an ED physician if the event occurred in the ED), actively engaged in the practice of medicine relevant to the testimony and not a “professional expert” that is, most of his time he can not be doing expert work. The courts are very happy about the fact that professional societies are getting involved in censuring flippant expert testimony


  • Liability is always a question when you examine a minor, or someone unable to give consent. Even more so when you do a work up for abuse. Informed consent can generally be waived if there is a serious and immediate threat to life or health, and there is no available option to obtain informed consent or delaying care is dangerous, and even then you only treat the emergent conditions. With regards to an abuse examination, many places absolve a physician who did medically relevant tests (question what is that?), photographs, x rays, physical exams and getting children’s services involved.
  • An important point they make in passing – informed consent doesn’t require the disclosure of every remote risk. As well, another important point- a minor can not be considered emancipated without documentation. A child under foster care requires foster parent consent and not biological parent consent.
  • Another word on liability issues. Only 26 states in the USA provided immunity to reporters of abuse- what is the law where you reside? On the other hand, only Wee, NC and MD have no penalties for failure to report. In practice – most of these cases are thrown out and it is uncommon to have someone found guilty and punished for reporting.
  • 42 USC 1983 has been used against reporters invoking violation of civil rights and this could incur penalties to reporters. However, the courts are not happy about this. Still it involves needing a lawyer- make sure you have coverage through your malpractice policy



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