All the EMU goodness for May 2015
- May – the month I was born. The significance of the event was not wasted on me. Because of this day, I was able to succeed in my life’s work as a menace to humanity. But of enough of the small stuff- let’s talk about another banner event in a person’s life- cardiac arrest. Should paramedics take folks in cardiac arrest to the hospital? This BMJ article (349:5659) discusses both sides. The side against says that the tool used to say someone is really dead-the BLS TOR tool (we mentioned this a few months ago) has sometimes missed on even “the neurologically intact at discharge” patient. Also misapplication of the rule occurs frequently. The money saved (at least in the USA) by not transporting these patients is negligible. The con position says that paramedics in the field can do everything we do in the ED and also mentions death with dignity. My thoughts: both are right (what did you expect me to say?) but they address different issues. In Israel- we allow paramedics to use their discretion TBTR: Transport arrest patients to the hospital? Two sides to everything.
- My name is not Jerry Hoffman. Honestly. And while Jerry did help me write an article arguing against the use of TPA in strokes in 2005 in the Israeli Journal of EM- no one listened to me and I now do actually believe there may be a use for TPA in selected populations. The problem is that TPA can cause intracranial hemorrhage- which occurs 6 % of the time and kills half the patients. In addition, the bleeding most often occurs in the infarcted tissue leading to a delay in diagnosis since the neuro findings are the same as before the TPA administration. Who is likely to get this? Not clear yet, but the elderly, those taking anticoagulation and those with high blood pressure seem to make the AHA a little jittery in giving TPA. TPA lasts 24 hours and you cannot really reverse it, (JAMA Neuro 71(9)1181). You know we all tend to get cavalier when we give meds and think they always do their job. But one untoward outcome is enough to give you religion. TBTR: TPA be careful. My peer reviewer suggested Haxacaproic acid- but that stuff is very weak- and hasn’t been studied for this.
- This study – I think – does change our approach to septic shock. You don’t want to give too much fluid – this can increase mortality; but you don’t want them to be in negative fluid balance either. Giving less fluid combined with vasopressors also increase mortality. They conclude here that the best way is copious fluids to start, than after six hours – moderate fluids and start the vasopressors in the 1- 6 hour time period. (CCM 42(10)2294) This study was not an RCT but rather analysis of 18 years of septic shock –and our ways of treating sepsis have changed since then. But to adapt this to the ED – don’t worry about positive fluid balance if you will get the patient up to the ICU within 6 hours. TBTR: Fluids in sepsis- important – not new to you? Well, see what I wrote. Quote time – over a year ago we featured Dr. House- now it is time for the Scrubs crew and Dr. Cox – just as cantankerous (Dr. Kelso is Cox’s boss, and Jordan is his wife/ex wife. Carla is the head nurse Dr Elliot is a female doctor despite the male name): Cox: Everyone! This is my sister Paige. Paige I’d like you to meet random people I don’t care about
Jordan: Have a good day. Try not to torture anyone so much that they take their own lives.
Dr. Cox: I’ll try. You know, you’re not looking as processed and overly-medicated as usual.
Jordan: That is so sweet
- OK, you see someone’s patient and it is clear that that physician clearly made an error- do you disclose the error? This is supposed to be a pro and con debate in this journal, but it is really straight forward- you gotta tell them that something needs to be fixed and that you feel this is what needs to be done. The con basically said – don’t couch the words as “the previous doctor erred”. Ken? I am sure you have written on the subject (Ann Thor Surg 98(2)396) TBTR: To disclose or not to disclose some else’s boo boo. That is the question. Carla: Miss Myers is ready to have her bandages removed now.
Cox: Who do you mean, dashboard-face?Carla: Yeah, I think she prefers “Miss Myers.”Dr. Cox: Well then she probably shouldn’t be checking her e-mail while she’s driving ninety miles an hour.
Dr. Cox: There’s no way in hell that I’m gonna listen to you complain about the rest of your life for the rest of my life, you got that?
Jordan: Yeah, not listening. By the way, now that we’re married again, we’ve gotta make out new wills in case one of us dies.
Dr. Cox: Oh, God, I hope it’s me.
- I think this is important just as a reminder-this article said that gender is not important in shared decision making- whether you are male or female – the same percentages desire this.(BMC Med Inform Dec Mak 14:81) OK, But I think Americans who are so into shared decision making have to know that it is not accepted in all cultures and in all countries. I try to do it all the time, but often find blank faces. TBTR: Shared decision making isn’t for everyone. Cox: Mm-hm. Why don’t you just…
Dr. Clock: Mind my own business. I know, your life is your life, and it’s not my job to fix it, unless of course you ask me to. And, man, would I get in there, ’cause I’m a good shrink and you, my friend, are a walking disaster. Shall we?
Dr. Cox: Yeah, I make it a point to never enter a shrink’s office unless I’m planning on grossly overpaying somebody for telling me something that I already know. Dr. Clock: Look, you’re obviously really distracted by the situation with your marriage… Dr. Cox: Something I already know, what do I owe? Will ten bucks cover it?
- Good study for you EPS and FPs. Below knee casting seems to increase your chances of DVT- and most of these occurred three months afterwards. True some were immediate but some did take their time ( J Thrombo Haemo 12(9)1461) OCs obesity and non O blood group (why?) all increased the danger. Seems like a well done study but the numbers are somewhat small. Also this was garnered from a bigger study TBTR: Casting increases DVT.
Jordan: Will you say good bye to Jack before I drop him off at preschool?
Dr. Cox: [pets his sons head] Bye, little man.
Jordan: Perry, this is your son, not a pitbull. Give him a kiss.
Dr. Cox: Jordan, he’s starting to look like a guy. And I’m just not real big on kissing guys. I mean, when my father wanted to show me affection he would just purposely miss when he threw bottles at my head.
Jordan: You are gonna be a much better dad than your dad was. Now give him a proper goodbye!
Dr. Cox: [shakes Jack’s hand] Son, always a pleasure. No more kissing!
[Cox walks off]
Jordan: You’re crazy
- Men can’t easily access emergency contraception in NY (for their ladies- don’t get kinky on me now ()(Contraception 90(4)413)
- Really that doesn’t concern me-but I did like the second author’s name:
Elvis Camacho- a combination of the “King” + Hector Comacho
Carla: Dr. Cox won’t kiss his son.
Mrs. Wilk: What is wrong with you?
Dr. Cox: Ladies, I hate to disappoint but my quota for women who bug the living bejeezus out of me has been met for the next billion years
Lonnie: Dr. Cox, would you help me with a central line.
Dr. Cox: Fine, Lonnie. But hand to God, if you so much as look at me for the next month I will mummify your head in surgical tape.
Lonnie: Thank you Dr. Cox
I practice in the kidney stone capital of the world. And I am amazed at the work up that is done in the community- basically nothing. Now I know you are EPs, but we got to know how to counsel our patients on how to prevent recurrences. Now I could not get access to these guidelines via the J of Urology – my library doesn’t get it – but you can get the whole article via the national clearing house for guidelines (I am sure this is the most visited site by the legal profession (They recommend a PTH level, and analysis of the stone if it is caught (Which it never is). Imaging is important but interestingly enough – they do not insist on CT although this is a very good test. I don’t see any utility in IVPs or any contrast study. Do a 24 hour urine collection for volume, pH, uric acid, calcium citrate, potassium, sodium and creatinine. I often add magnesium also. They recommend fluids to make 2.5 liters of urine a day. Here are the rest of the dietary and pharm logic recommendations: Diet Therapies
- Clinicians should recommend to all stone formers a fluid intake that will achieve a urine volume of at least 2.5 liters daily. (Standard; Evidence Strength Grade B)
- Clinicians should counsel patients with calcium stones and relatively high urinary calcium to limit sodium intake and consume 1,000-1,200 mg per day of dietary calcium. (Standard; Evidence Strength Grade B)
- Clinicians should counsel patients with calcium oxalate stones and relatively high urinary oxalate to limit intake of oxalate-rich foods and maintain normal calcium consumption. (Expert Opinion)
- Clinicians should encourage patients with calcium stones and relatively low urinary citrate to increase their intake of fruits and vegetables and limit non-dairy animal protein. (Expert Opinion)
- Clinicians should counsel patients with uric acid stones or calcium stones and relatively high urinary uric acid to limit intake of non-dairy animal protein. (Expert Opinion)
- Clinicians should counsel patients with cystine stones to limit sodium and protein intake. (Expert Opinion)
- Clinicians should offer thiazide diuretics to patients with high or relatively high urine calcium and recurrent calcium stones. (Standard; Evidence Strength Grade B)
- Clinicians should offer potassium citrate therapy to patients with recurrent calcium stones and low or relatively low urinary citrate. (Standard; Evidence Strength Grade B)
- Clinicians should offer allopurinol to patients with recurrent calcium oxalate stones who have hyperuricosuria and normal urinary calcium. (Standard; Evidence Strength Grade B)
- Clinicians should offer thiazide diuretics and/or potassium citrate to patients with recurrent calcium stones in whom other metabolic abnormalities are absent or have been appropriately addressed and stone formation persists. (Standard; Evidence Strength Grade B)
- Clinicians should offer potassium citrate to patients with uric acid and cystine stones to raise urinary pH to an optimal level. (Expert Opinion)
- Clinicians should not routinely offer allopurinol as first-line therapy to patients with uric acid stones. (Expert Opinion)
- Clinicians should offer cystine-binding thiol drugs, such as alpha-mercaptopropionylglycine (tiopronin), to patients with cystine stones who are unresponsive to dietary modifications and urinary alkalinization, or have large recurrent stone burdens. (Expert Opinion)
- Clinicians may offer acetohydroxamic acid (AHA) to patients with residual or recurrent struvite stones only after surgical options have been exhausted. (Option; Evidence Strength Grade B You can get the rest of the guideline here– remember this is not for ED treatments. Also note that alpha blockade was not mentioned – this guideline was for prevention not treatment (if alpha blockers even work but that is different story) Patient: I’m a Jehovah’s Witness, I can’t get a transfusion. We believe that blood should not be passed from person to person
Cox: Well I’m a doctor and we believe that without surgery a patient in your condition can suffer from a major case of deadness.
Carla: Don’t worry, he will figure out another way to treat you
Dr. Cox: [laughing as he walks off] Hehehe! No he won’t
Dr. Cox: Your endocrinology fellowship lasted all of five days. Granted, to you five days may seem like an eternity as it’s roughly five times as long as any of your pasty relationships have lasted. But trust me, that hardly makes you an expert.
Elliot: Oh really? Because you never went to assface school, but you seem to be an expert at that. Am I right
8) So this guy comes to your community ED with rope burns around his neck, with 50 empty blister packs of paracetamol and scars over his wrists. He politely informs you he is interested in dying. You, not being one easily swayed, pull out your MD CALC and apply the sad persons scale: Modified SAD PERSONS Scale
The score is calculated from ten yes/no questions, with points given for each affirmative answer as follows:
- S: Male sex → 1
- A: Age 15-25 or 59+ years → 1
- D: Depression or hopelessness → 2
- P: Previous suicidal attempts or psychiatric care → 1
- E: Excessive ethanol or drug use → 1
- R: Rational thinking loss (psychotic or organic illness) → 2
- S: Single, widowed or divorced → 1
- O: Organized or serious attempt → 2
- N: No social support → 1
- S: Stated future intent (determined to repeat or ambivalent) → 2
This score is then mapped onto a risk assessment scale as follows:
- 0–5: May be safe to discharge (depending upon circumstances)
- 6-8: Probably requires psychiatric consultation
- >8: Probably requires hospital admission
I am with you, friend, but there is one problem with this scale – it isn’t sensitive enough to rule out every case. The false negative rate here reached 2-6 %-( EMJ 31(10)796) Truth be told, the scale itself is quite clear that it is just a guideline and uses strange recommendations (“maybe safe, “probably”) which is unusual for a guideline. But this just emphasizes the uncertainty in these cases. I believe that most times it isn’t that hard, and the uncertainty comes from people who need medication and stop it on their own. But we can’t be sure. Be on the safe side. Discharge this guy and tell him not come back until he gets it right. TBTR: SADPERSONS is not very senstiveto predict suicide risk. Visiting the ISIS in Syria is more efficient.
Jordan: It’s Jack’s first birthday, I want it to be special. I got a petting zoo for the kids, and we need to figure out something great for the adults.
Dr. Cox: How about a Russian roulette booth? And here’s the kicker, we put bullets in all the chambers, that way *everybody* wins!
- Alcohol and trauma – they get more severe brain injuries and their ISS is much worse, but their mortality and hospital stays are similar to people who were not drinking when traumatized.(ibid p813) Could be but there were few patients in this study, and the data is old – if that really matters. Furthermore- all the injured patients had been drinking Father’s recommendations for wine of the month. TBTR: Alcohol may have a neuroprotective effect in trauma. Here is a peer review moment: I’ve heard this may be a result of increased muscle tension in sober people prior to an accident, versus those who are drunk. For example, limp bodies might absorb blunt trauma better than a stiff board. John ‘J.D.’ Dorian: [voice over] If Murray could look past his dad’s imperfections and appreciate all the time he’d given him, maybe I owe Dr. Cox a thank you for the same thing.
Dr. John ‘J.D.’ Dorian: [aloud, to Dr. Cox] Hey, I just want to take a second to thank you for constantly berating me, doubting my abilities, and the overall devastation of my self-esteem. Dr. Perry Cox: My pleasure
Dr. Perry Cox: Hey, Newbie? Just in case you didn’t actually notice, I have been covering all your patients, answering all your pages, and doing pretty much everything shy of picking up your sundress from the drycleaners.
J.D.: Well, I didn’t ask you to do any of that, did I?
[he storms off]
Dr. Perry Cox: Outstanding! You’re walking away like a pissy little ingrate. I mean, bravo!
Dr. Perry Cox: Bravo, ah!
[He whistles as Ted walks up and joins him in applauding. Cox stops clapping]
Ted: What are we clapping for?
Dr. Perry Cox: His dad just died.
[Ted’s applause trails off]
Dr. Perry Cox: Dammit
- Do D Dimers go up during menstruation? Probably not. But this is such an easy study to do, I am appalled that there is rotten evidence.(ibid 863) Not even the Brits in their BETS(Best Evidence Series – I forgot what the T is for) could come up with an answer to the bloody question. TBRT: menstruation probably doesn’t cause the D dimer to go up. D.: Come on, man, it’s our last week together! The J.D. and Cox train is pulling into the station. You must have a metaphor you want to use; hit me with it!
Dr. Cox: I suppose I could riff a list of things that I care as little about as our last week together. Lemme see, uhh… Low-carb diets. Michael Moore. The Republican National Convention. Kabbalah and all Kabbalah-related products. Hi-def TV, the Bush daughters, wireless hot spots, ‘The O.C.’, the U.N., recycling, getting Punk’d, Danny Gans, the Latin Grammys, the real Grammys. Jeff, that Wiggle who sleeps too darn much! The Yankees payroll, all the red states, all the blue states, every hybrid car, every talk show host! Everything on the planet, everything in the solar system, everything everything everything everything everything everything – eve – everything that exists – past, present and future, in all discovered and undiscovered dimensions. Oh! And Hugh Jackman
Dr. Cox: [when Turk and JD huged each other after Turk just came back from his Honeymoon] Oh wo, wo. What do we have here? The newlyweds… oh and hey Carla. Mark my words he first year of marriage is just a real treat!
Dr. Cox: Sweetheart, do you remember ours?
Jordan: The silly fighting for control!
Dr. Cox: You broke my jaw!
Jordan: You gotta stop that back-talk early. Come on, glass jaw.
- How many times need I tell you this? Will you ever listen? Are you drinking the wine of the month also? Macrolides are crappy medications. They are bacteriostatic not bacteriocidal, and there are high resistant rates. Indeed –according to this study- Group A strep – depending on the strain was often resistant to these meds- 87.1% in one strain! (Only two of these strains were susceptible out of all studied). So they suggest you do antibiotic sensitivity on the strep if you have a PCN allergic patient. (Microb Drug Resisit 20(6)431) OK, this is Japan, and also there were only 363 samples, but keep it in mind. Put that Z pak away already and use a cephalosporin or clindamycin for Goodness sake. TBTR: Macrolides- need to be given to patients who take theophylline, and use mustard plasters. Cox: Good God, Fantasia. You – you don’t actually think I’m done teaching you, do you? D’you not understand the only difference between today and tomorrow is that you wake up tomorrow and start coming in here and killing people, that no one can say, “It’s no big deal, he’s just a resident.” Instead, what they’re damn sure gonna be wondering is who tried to educate your sorry ass. And when that finger of blame starts pointing in my direction, I had damn sure better be in a coma from the anger stroke I suffered from the last time you tried to hug me. Oh, and, uh, don’t be late tomorrow… Doctor
Dr. Perry Cox: Let’s bear in mind that we are shorthanded: There are only four doctors here.
Dr. Christopher Turk: I counted more than that.
Dr. Perry Cox: I’m talking legitimate doctors, turtle-head. Here pee-pants is a pathologist, so he doesn’t count. Johnson is a dermatologist, which is Greek for “fake doctor,” and please don’t even get me started on you four surgeons.
Dr. Todd Quinlan: There’s only two of us.
Dr. Perry Cox: You are so very useless, I counted you both twice.
- This is a reminder only. You – yes you – yes even you – can measure intraocular pressure in the ED. You do not need a Shoitz tonometer-, you don’t even need a slit lamp machine. You can do this by just pressing on the eyeball or buying a handheld tonometer. Here is a peer reviewer comment: We use tono pens regularly at our shop. Very easy to use. Just don’t use it when globe rupture is still in the differential!) Nothing new here. (PMJ 90(1068)603) But I just wanted to remind you that with in the DDX of vomiting in an elderly person is also glaucoma. And dig toxicity for that matter which you can’t measure with a tonometer. TBTR: Remember glaucoma as a cause of vomiting.
Dr. Perry Cox: So, Nurse Gandhi-rella, I need you to suction this guy, do a wet-to-dry dressing change, and, oh, what the hell, go ahead and top him off with one of your special, special sponge baths. Happy ending optional – his choice, not yours.
Dr. Christopher Turk: This guy’s in a coma.
Dr. Perry Cox: Not all of him.
- I am not going into it here. Throwing can cause serious and chronic effects in the elbow region, but since this is mainly a problem in baseball, and most of the world doesn’t play this sport I will just give you the reference (Ortho Clin NA 45(4)571) Curiously, we almost never see these injuries in soccer( football). Not clear why. Perry Cox: Hand over your stethoscope. J.D.: What? Dr. Perry Cox: In victory, I get your stethoscope. It’s a trophy. You’re lucky we’re not back in olden times, I would have made a necklace out of your teeth. J.D.: I find this highly unproffesional. [J.D. gives Dr Cox his stethoscope] Dr. Perry Cox: Now I’m going to check on Mr Jenkins, your war hero. I feel he too deserves a competent doctor. In fact, I’m gonna take all of your patients. And consequently your only reason to get out of that lassie over pillowed 4 poster virgin cocoon you call a bed every morning
Turk: J.D., this is an intervention. First off, I just want to say everyone here loves you, this is a safe space. But you’re such a committ-a-phobe! Every time you date a girl with potential you wind up ruining it over some trivial reason. Let’s think about some of the great girls you let slip through your fingers: Kylie, Jaime, Gift Shop Girl, Minnie McSkinny, Mole Butt, Tina Two-Kids, Rumplefugly… I’m forgetting someone…
Carla: [narrating] Oh, my God, Turk… if you forget Elliot she’s gonna cry.
[out loud, while nodding towards Elliot who’s starting to moan]
Carla: Turk, aren’t you forgetting the greatest girl of them all?…
Turk: [snapping his fingers] Heidi Horse-Face!
Elliot: [almost crying] Me, Turk… she’s talking about me, OK?
J.D.: Relax, Elliot… you’re Mole Butt
- This article admits it – finally- Eply doesn’t work in the ED because it doesn’t work well in horizontal vertigo. They liked the forced prolonged postion technique which I couldn’t find and if that doesn’t work – try the Gufoni technuqe which helped everyone else(could ask why not go stright to Gufoni? I don’t know(Otol Neuro otol 35(9)1621) Can you just try Gufoni for everything? I don’t know but it does look enough like Eply that it is worth a try. TBTR: Gufoni is the way for horizontal vertigo. [JD is making a video project to send to his mother]
D.: Dr. Cox, do you have anything you’d like to say to my mom? Dr. Cox: No, but I have something I’d like to say to her uterus, because it brought you into this world. [Smacks camera and shakes finger] Dr. Cox: Bad uterus! Don’t do that anymore
Nurse Carla Espinosa: Wow… aren’t you the big bad ass attending?
Dr. Elliot Reid: Yeah, well, it’s time for them to sink or swim. I got to where I am on my own, OK?
Nurse Carla Espinosa: Nobody helped you out in the beginning, huh?
Dr. Elliot Reid: Dr Cox was my attending. He was nice enough to keep track of the times he made me cry.
Dr. Cox: [passing by, counting and moving his fingers] 27, counting this morning.
Dr. Elliot Reid: Mh… yeah. I’m PMSing and he made fun of my shoes.
- Pregnant ladies should exercise. Peer reviewer (I agree with this too) (if they exercised regularly before! Getting pregnant and then starting a serious exercise regiment is not recommended!) Deep sea diving is probably not recommended. Did I just ruin your day?
(Obs Gyn Survey 69(9)551) (Yes that is the 2011 Moscow High Heel Race. The lady in the front has lost her footing when her shoe broke.)I don’t have heels, but I have been one.) [after Dr. Cox announced that J.D. and Elliot are both gonna be chief resident]
J.D.: Uh… What now?
Dr. Cox: Well, I figure with her being ridiculously booksmart to the point where she has almost no interpersonal skills and you being warm and cuddly as an unpotty-trained labradoodle and about as useful in high-stress medical situations as an unpotty-trained labradoodle, together the two of you would make one barely passable doctor… slash labradoodle…
AIDS Worker: Excuse me, could you spare a few minutes for AIDS research?
Dr. Cox: Yes, I can, but I’m not sure how much we’ll get done. I’ll tell you what, we’ll go over there and brainstorm while we wolf down these sandwiches
- Weight lifting (also not for pregnant ladies) injuries are unusual but it is possible you will see one. Basically they can have all types of dissection- celiac, carotid, coronary – and this is probably due to acute BP elevation – which can reach 455 / 350. This BP may also be the cause of rare things in weight lifters like SAH, and acute paraplegia. They also recommend not to allow people with Ehlers Danlos syndrome to lift weights, but I think that would be kind of neat (THI 41(4)453) TBTR: Weight lifting dangers- see above.
Cox: Oh, whoa, now. What happened to – what happened to feisty Barbie, huh? You know, it took me a helluva lot to shake off that tongue-lashing you gave me yesterday.
Elliot: Yeah, well, yesterday I had a mentor, but she turned out to be insane. I mean, how am I supposed to take professional advice from somebody who can’t even hold together their personal life?
Dr. Cox: Look, I know you and I have never really connected – maybe that’s because you’re relentlessly annoying, or maybe it’s my fault because I can’t tolerate relentlessly annoying people – I don’t know. But answer me one question: Do you think I’m a good teacher?
Elliot: To some people.
Dr. Cox: Fair enough. Why don’t we go ahead and take a look at my personal life? I am in love with a woman that I hate, my two-year-old son calls me “Pewwy,” and – this is something that I’ve never actually shared with anybody before, but – on Saturday nights, I like to throw on a nice dress, go out to dive bars, and insist that everybody call me Mrs. Haberdasher!
Elliot: [laughs, then thinks] No, you don’t.
Dr. Cox: Well, even if I did, it wouldn’t really matter since that has nothing to do with how good of a teacher I am. Stick with me here, Barbie. The point is that if you finally found somebody who makes you believe in yourself as much as you did yesterday, well, I would think twice before I wrote that person off.
Dr. Cox: I will tell you one thing, though. If you even want to have an outside chance of reaching someone nowadays… you damn sure better speak from your heart.
Dr. Kelso: Thank you, Perry.
Dr. Cox: Blow it out your ass, Bob.
- No chance. Really. No chance here. Here is a case of a man with new onset delirium and fever. He is 78 years old. Sepsis, right? But then he gets worse- and develops neuro symptoms consistent with an ACA stroke. CT and MRI were normal. They gave him antibiotics and he got all better. What in tarnation is this? (Age Aging 43(5)727)
Perry Cox: Look, if you get up there and start kissing Kelso’s ass, all your fellow attendings will forever think of you as a brown-nosing toady. On the other hand, if you don’t pucker up, Kelso will make your life a living hell. You’re officially trapped. J.D.: I’ll just say something nice about him that’s actually true. Dr. Perry Cox: You go do that. And I’ll go quit drinking, get in touch with myself emotionally, and we’ll meet right back here at half past impossible. Mm’kay?
- These are four EKGS that if you miss them – the patient could die. The problem is- if you have a brain or once did have one, you are not going to miss these. Brugada, Long QT, WPW. OK you might miss HOCM, but you really shouldn’t. But the reason I bring this article is to diagnose long QT – you need to compute the QT length. And many folks don’t realize that this is from the beginning of the Q wave until the end of the T wave. Corrected QT is calculated with Bazzet’s formula which is QTc = QTm / √(RR)) (JFP 63(7)388) Then again, you could just have your computer do it. In which case, it is not necessary for you to read this paragraph in any case.
TBTR: skip this paragraph.
John ‘J.D.’ Dorian: Listen, I know you hate everything about Miss Broderick, but her father is in need of medical care, and it’s our medical obligation to treat him whether his daughter is a murderer, a drug addict, or a terrorist.
Dr. Perry Cox: I know, but a lawyer?
Dr. John ‘J.D.’ Dorian: Even a lawyer.
Dr. Cox: I wanted to tell you that you’re doing a great job. Boy, that meatloaf today, it was virtually hairless
- Mallet fractures can be missed and they really shouldn’t be. I guess you have to know what it looks like if you do not want to miss it-see here is what it looks like:
This is Pippa’s bottom. Kind of gets me really in the mood for colonoscopy. OK, let’s get off the ADD moment, the treatment for this is rarely surgical (mallet finger, not Pippa’s buttocks) – surgery has a high rate of AVN, and stiffness- consider it only for displacements that are volar. Six weeks in a simple splint is all you need, but best results are in the preformed ones.(J Hand Surg AM 39(10)2067) TBTR: Mallet finger—know about them, treat them yourselves-and quickly.
Cox: …And bam! The shine’s off the apple. And that’s when you find out that that pretty little girl you married isn’t a pretty little girl at all. No, she’s a man-eater. And I’m not talking about the “whoa-whoa, here she comes” kind of man-eater. I’m talking about the kind that uses your dignity as a dishtowel to wipe up any shreds of manhood that might be stuck inside the sink. Of course, I may have tormented her from time to time; but, honest to God, that’s what I thought marriage was all about.
Dr. Perry Cox: How’s about we act like adults here and lay our cards on the table. You know that you’re not exactly my favorite person in this dump, and I say that knowing full well that you feel the same way about me.
Dr. Elliot Reid: I started an “I Hate Cox” chatroom. Hasn’t really worked out the way I planned – it’s me, two interns, and 14,000 lesbians
- This is a procedure I never did nor did I ever want to –This article says we should be more ready to do it and the salvage rate is not bad for baby. We are talking about postmortem cesarean delivery. This article pushes for it, and is an Israeli study, but I still do not know how to do one. (Acta Obstet Gyn Scand 93(10)965) Actually, Medscape has a nice description on how to do this – go through it once, so you won’t have to Google it when you need to know how to do it. http://emedicine.medscape.com/article/83059-overview#a15
TBTR: Perimortem C section – know how to do it so you never will need to do it. While we are on this tasty subject- CT has probably replaced the classic autopsy – it sees much more and is non invasive. There is even a roller (not sure how it works) to distribute the contrast material as there is no circulation. (Radiographics 34(3)830)
- I think they reviewed this article on Risk Management Monthly which is Father’s Henry’s pontification on how to get your own bottom (not Pippa’s) into the courtroom, but I think it is important to mention here. Of course you have document, and explain everything and document you explained everything and that they had the capacity to understand. But also remember- just because they left on their own doesn’t mean they don’t get discharge instructions. Also they must get the treatment options. And even if he is a dirtball (I couldn’t find a good picture of a hospital administrator) you still must protect him from harm. They give a mnemonic AIMED (access, investigate, mitigate, explain and document) which I didn’t find too useful (AEM 21(9)1050) I would add that the preprinted AMA forms written in totally unintelligible language are usually worthless.
TBTR: Instructions regarding AMA patients- it isn’t all that simple.
Carla: You know, maybe Jordan’s right, maybe it’s time you start dealing with your anger issues.
Cox: Carla, for something to be an issue, it needs to cause a problem. I mean, honestly, aside from having to, by-law, remain thirty feet away from a certain telemarketer who I visited while he was eating his dinner, I don’t see the downside.
- Tramadol may have low abuse potential but that isn’t the case in the UK – they take it. 44% of the respondents in this study use it regularly and all these folks were working people. They take it to relax, get high, sleep or to forget about Pippa’s bottom (Int J Clin Pract 68(9)1147) TBTR: Tramadol can be abused. Bob Kelso: Hiya! My name is Bob Kelso and I like whores! Now… why don’t I introduce myself like that? Because there is a time and a place for the truth. Now you take Dorian’s intern Brendan, for example: he told his patient that it was the first time he was performing a spinal tap; and what did the patient do, Doctor?
Dr. John ‘J.D.’ Dorian: Oh, well, oh… she… she started to hyperventilate, a-and then she reached for a hit of what she thought was an oxygen tank; it turned out to be a helium container from paediatrics. The she screamed [in a very high-pitched voice] Dr. John ‘J.D.’ Dorian: “I’ll kill you, bitches!”, [in his normal voice again] Dr. John ‘J.D.’ Dorian: which, frankly, we all thought was hilarious. Dr. Bob Kelso: Oh, indeed it was. But you know what wasn’t? When she ran for the door, tripped and fell and broke her femur. Now she’s suing the hospital, and since Ted is our lawyer, what’s going to happen? Ted Buckland: [reading his newspaper] Girlfriend’s gonna get paid… Dr. Christopher Turk: So you called this meeting to say we should lie more? Dr. Perry Cox: Sorry there, Bobbo, but I’m gonna go ahead and tell the truth whenever I damn well please. For instance, your tie: it’s hideous. In fact its only redeeming quality is to divert attention from the very visible outline of your man girdle. Dr. Bob Kelso: Too mean. Dr. Perry Cox: Sorry.
- So they want you to believe you can lower BP in hemorrhagic strokes without affecting the ischemic penumbra. So they did CT perfusion scans and viola – they show no reduction in perfusion to these areas (Stroke 45(10)2894) But in 75 patients – you cannot tell me much. Also, the average blood pressure was 183 – these folks therefore were not that sick. Also I am not sure this tells us the whole story. Maybe the danger to the penumbra is from small vessel ischemia and we won’t see that on a CT perfusion scan. Maybe an MRA would have been a better test. And while it might sound reasonable- lowering blood pressure may not make a difference in outcome – hematoma volume is a surrogate marker which has not proven itself as very relevant. (then again, I haven’t proven myself very relevant either)(wife’ s comment- you got that right) TBTR: You can safely lower blood pressure in hemorrhagic strokes. Maybe. If you want to.
Jordan Sullivan: What’s wrong with Jennifer Dylan?
Perry Cox: You named our daughter J.D…
Dr. Perry Cox: Why would you do such a thing?
Jordan Sullivan: I was hoping that you would hate the name so much that you wouldn’t be able to hide your spite from your daughter and she would love me more than you.
Dr. Perry Cox: I’ve got to go.
Jordan Sullivan: Don’t forget: momma’s coming home tomorrow, so the fridge needs to be restocked with rice cakes and vodka.
Dr. Perry Cox: Jordan, while you were on bed rest for the last two months, I served as mother, father, butler, breadwinner and, thanks to our son’s penchant for eating nickles and your irrational fear that they’re never going to pass through his system, poo-poo sifter. I was hoping that, upon your return, you would start to assume some domestic responsibilities.
Jordan Sullivan: Pass!
Dr. Perry Cox: Each and every one of you is going to kill a patient. At some point during your residency you will screw up, they will die, and it will be burned into your conscience forever.
The point is, the harder you study, the longer you just might be able to hold off that first kill. Other than that, I guess cross your fingers and hope that the guy you murder is a jackass with no family. Great to see you kids. All the best!
- It is already summer here in Israel, so I get a kick out of discussing a paper on Frostbite. Truth be told, there isn’t much new here. We do know that humans are tropical animals and when the temp goes below 15 C (for you cretins that is 59 degrees or about the temperature in San Francisco year round) the body responds with alternate vasodilation and constriction. Just remember smoking, immobilization, previous cold injury, and thyroid or adrenal disease can be risks for frostbite. And oh, did I forget? Nipping the Thunderbird a little too much Other than that, the usual applies – do not rewarm if there will be a re freeze of the area, don’t start taking off viable tissue which may not be obvious until weeks later, – etc- you can read the books. There may be some role for aloe vera and TPA – but we need good studies and these guys are surgeons, so forget that. (J Hand Surg AM 39(9) 1863) TBTR: Frostbite- a little review.
Kelso: What the hell’s with her?
Dr. Cox: She’s mad, but she can’t give me the “silent” treatment because she knows I actually love that, so she’s giving me the “talk-until-I-want-to-commit-suicide” treatment.
Dr. Kelso: Sucks to be you.
Dr. Bob Kelso: See, this is why you shouldn’t get emotionally invested in your patients.
Dr. Cox: Hey, Bobbo, now when the Dark Prince does finally call you home, please promise me that you’ll donate your body to science. And I don’t mean medical science, I mean NASA. Because when those buzz-cuts have all but given up on trying to figure out just exactly what a black hole is, and they get one look at that space where your heart was supposed to be, well by-gum, you know they’re just gonna say – Aww, shucks! That’s what it is!
Dr. Bob Kelso: Hey, champ! What has two thumbs and doesn’t give a crap?
[holds up thumbs, pointing in at himself]
Dr. Bob Kelso: Bob Kelso! How ya doin’
- Yea, here is a case we see everyday –sometimes even three times a day. A guy is picking his nose and has a stuck booger and when he finally succeeds in removing it, he has a partial amputation of the digit. So here is a nice review on how to put it back together (how you are going to get it out of the guy’s nose is beyond the scope of EMU – or any normal person who is disgusted by this paragraph already). I will give them credit – they say you can do the nerve block with epinephrine. Also they correctly point out that the nail is important because it makes scratching possible. Basically, if no bone is involved it is a pretty simple if not time consuming affair. If bone is exposed, you should know that removing the nail can cause hook nail deformity as the support for the structure is lost. Skin grafting ceases persistent problems, including persistent tenderness and poor neuro sensation. There is a good argument for secondary intention healing even with exposed bone, likewise; some advocate reimplantation of clean albeit not viable tissue to act like a biologic band aid if you will (ibid 39(10)2093) TBTR: Fingertip amputations – try not to remove bone, otherwise just put skin back together.
[ Cox and the pregnant Jordan are walking through towards a Nurses’ Station]
Dr. Cox: Yes, hello? Could we please get my hormonal, extremely annoying ex-wife’s amnio underway?
Jordan: Wow, I can’t wait to write that down in the baby journal.
[Dr. Cox grunts]
Jordan: Could you be a bigger ass right now?
Dr. Cox: Could you *have* a bigger ass right now?
Dr. Cox: [in response to something J.D. just said] Oh, my God! I care so little, I almost passed out!
- So now let’s go to a related subject: practical points on laxative use. (So you see there was this doctor doing a disimpaction of hard stool when he suffered a partial amputation……). I am not going to define constipation but you can look into the Rome III criteria (the article brings it from Gastro 2006 130(5)1380) if you are in doubt Firstly, correct the correctable: hypothyroidism, encourage more fiber and less MacDonald’s (unless , of course you order, the psyllium burger on a whole wheat bun) and more exercise although the evidence that this will work is limited at best. Fiber is interesting(if you into that sort of thing). On one side it does cause more frequent bowel movements, but it does not reduce painful defection or use of laxatives. Other studies show it is superior to lactulose, bisacodyl and senna). But there is little against trying out fiber first for constipation- there are virtually no side effects. Next: stimulants which work by targeting the myenteric plexus. They are effective – the ones that seem to work the best include sodium picosulfate and bisacodyl. Senna may work less well, the studies are mixed. These can cause cramping, and melanosis coli (who actually cares?). Osmotic laxatives are my personal favorite but be careful with phosphorus in renal patient. Lactulose works this way, but we are all aware of the pesky side effect of le peter (look that one up in your French dictionary). PEG derivates are more effective and with fewer side effects and at least in my country are pretty cheap. There is no role for Docusate; it doesn’t work for constipation. While cisapride is rarely used anymore; a new pro motility agent is now available in Canada and Europe (it is called prucalipride). Let’s tie it all together. Pregnancy and breast feeding – go with fiber. This is not a good idea in terminal patients who need a lot of fluids to go with fiber; use senna or PEG. Diabetics- avoid lactulose and sorbitol. Ditto with patients with IBS. (BJHM 75(8)c114) TBTR: All you need to know about feces and getting your muffler to work.
Perry Cox: Hats off there, Barbie… that was one potent combination of verbal diarrhea and stunned silence…
Nurse Carla Espinosa: You should have just asked him out. Men love that.
Dr. Perry Cox: No, Carla, men don’t love that. It turns out we don’t love picnics, foreplay, candles, baths, photo albums, or when you drive so we can relax; and, as always, we’re not that big on Hugh Jackman. Look there… the only thing men care about as far as dating is concerned is the chase; if you want that guy to look your way, listen me carefully… ignore the living hell out of him.
Nurse Carla Espinosa: That’s the worst advice I’ve ever heard!
Dr. Perry Cox: Good point, Carla. Say, you don’t happen to have any other gems before you run off to couples therapy to sift through the wreckage that is the first year of your marriage, do ya?
Dr. Elliot Reid: Look, Dr Cox, I’m sure that you are fantastic at picking up men, really…
Nurse Carla Espinosa: Ah ah!
Dr. Elliot Reid: …but I can handle this one on my own. Thank you.
Elliot: Dr. Cox, this is the most painful thing I’ve ever done and I was a cutter for a week in high school. My shop teacher thought scars were sexy, but that’s a whole other story. The point is, your advice really worked with Jake and I’d really appreciate it if you would give me some more help.
Dr. Cox: Oh, no problem Barbie, let me just finish writing this prescription and you’ll be all squared away.
[hands Elliot the prescription]
Elliot: This is a prescription for ‘no’.
Dr. Cox: Correctomundo. To be taken with food every Saturday night while you’re eating alone.
Elliot: I don’t think you understand the severity of the situation here. I am dangerously close to giving up men all together!
Dr. Cox: Then on behalf of men everywhere-and I do mean everywhere
[makes a circle with his hands]
Dr. Cox: -including the ones in the little mud huts, let me be the first to say thanks and yalleluah
- This is an update on a rare disease – would have been a good essay but it is too esoteric. Vasculitis– these are dangerous because they clog vessels with inflammation. They come in large vessel, medium vessel, and small vessel flavors. Large vessel – the famous one is GCA – usually temporal arteritis, but Takayasu is also a large cell. Medium vessel is Kawasaki and polyartetis nodosa. Small are less well known – sure there is Henoch Schonlein but also Goodpasture and Wegner’s, Churg Strauss and IgA. Some pointers- GCA- you can – and should start the steroids immediately but also don’t put off the biopsy too long- after 10 days the biopsy is often (40%) un interpretable. Takayasu is more often in Asian people and often has fever and tenderness over the affected artery. Kawasaki – we spoke about this enough in the past. With the disappearance of hepatitis B- poly arteritis is going down- but with skin rashes, and organ infarction – think this disease. Small vessel – ANCA is a good test but can be high for many reasons. All of these have fever, weight loss, and pain. The problem is to diagnose these- most of the tests you need you will not find in the ED or the clinic. All can be treated with steroids (except Kawasaki where the treatment is gamma globulin and aspirin) and biologics. Prognosis is much improved – used to be 80% mortality – we have succeeded in reducing that to 79.5% (only kidding- it is below 10% now) (BJHM 75(8)432) TBTR: Vasculitis – you now know all you need to. John ‘J.D.’ Dorian: Dr. Cox…
Dr. Perry Cox: Newbie, if the next two words out of your mouth aren’t ‘see ya’ then the third word will be ‘oh my god, my crotch, you’ve punched me in the crotch.”
Dr. John ‘J.D.’ Dorian: See ya
- Letters: First a correction – in the Jan issue – number three – the point was when compared to Amoxicllin; levo and azithryo cause more death. Thanks Dr. Donna for pointing that out. Here is what Ken says-Great quotes from Dolly. No, definitely not the dumb blond.
One concern: the abstract about “Status Epilepticus” barely mentions propofol and ketamine and the ketamine dose is different than what you listed. Also, the article talks about using it after they’ve been in resistant status for a week or more. However, this does suggest some lines of research for EM. Gosh, I thought I made it clear that ketamine and propofol are the news drugs for status. And the dose was what was in the article- did I err?
- Remember the clinical quiz in number 18? This is actually a bug –one that causes Facklamia Languida. I googled this, I pubmeded it- and couldn’t find much. I just mention it to remind you that fever and neuro signs means meningitis, and encephalitis in the first place, but can also be garden variety sepsis. Perry Cox: You know what else I hate about Kelso? His hair smells like a pet store.
The Janitor: Actually, that’s my fault. I filled his hair spray bottle with dog sweat.
Dr. Perry Cox: Dogs don’t sweat.
The Janitor: They don’t? Then what the hell am I putting in there?
Dr. Perry Cox: You. Tell me this, how’s that super sexy mother of yours?
Ron Laver: You know, your crush on my mom was cute where we were 14, but the woman’s 85 now, you need to back off… or you ask her out to dinner: I’ll have her pop in her “going out” teeth you can see if there’s a real spark…
EMU LOOKS AT: Necking
This month’s deep dives are two articles on the neck. The first is from Stroke 45(10)3155 and the second is from the BMJ 349:g5827. Just to get you in the mood – here is some necking: Were you thinking about something else? You pervert!
- I was listening to EM RAP on the way to work today and heard on their own literature review (Sanjay and Mike who are funny – but still have a ways to go to make it to EMU’s level of sophisticated comedy.) and they were whining about how hard it is to detect carotid dissections- they all look great when they get to the ED. They are rare, but if you are seeing a stroke in someone under age 45 – up to one quarter of the patients will have this as a cause. ICA is about twice as likely as vertebral artery dissection.
- Here are things you got to consider-they increase the risk of dissection- well trauma for sure, use of OCs, migraine, Turner syndrome, infections and that old favorite- moya moya disease. You can see this after coughing or vomiting- but they spend four pages on the dangers of cervical manipulative therapy as a big risk for this.
- Classically this will present with pain on one side of the face neck or head, and a partial Horner’s syndrome. Later there will be signs of cerebral or retinal ischemia. But like all classic triads- you won’t see this too often- only one third of the cases. Fifty percent of the time there will be facial pain, dental pain or orbital pain, and almost always there is an ipsilateral headache. The head ache can look like almost anything – thunderclap, migraine, occipital, or none of the above. The key here is that the neuro effects can take on average nine days to develop and the outliers include up to 3 months later. Horner’s is rare because the anhydrosis isn’t seen – that is mediated by the ECA. But if you do see a partial Horner’s- it is an ICA dissection until proven otherwise. 10% describe losing taste. This is the ICA dissection
- Vertebral dissection is different. Here it is pain in the back of the neck with posterior circulation ischemia signs. The headache here is always in the back of the head and is often ipsilateral. Here the neuro symptoms are seen usually by two weeks. Usually it knocks off the thalamus, the cerebellum or the lateral medulla which is Wallenberg syndrome. It can also knock off the spine. If you forgot what Wallenberg is click here. If you want me to steal all your money and give you viruses, horses and worms click here (did you really click there?)
- So how do you diagnose this? Since no test is 100% -see below- this requires a pretest probability like PE and actually all illnesses. If they are young and have no vascular risk factors- run with it. Your choices here are duplex, CTA, MRI. MRA and digital subtraction angiography (DGA). US works well in stenotic vessels, but if the stenosis is only mild the test has a 40% sensitivity- that is for the IC. Duplex seems to do better with VA dissections. Obviously it misses small tears, is limited by the cranium, and it can’t discern between stenosis and atherosclerosis. CTA seems pretty good, even beating MRA in one study in eight cases, but it is radiation, you need normal kidneys and it is less good for the posterior fossa and in finding infarcts than MRI. It also can be affected by boney artifacts. MRI/MRA is a great test, but you won’t use this for your PPM patients and it isn’t that available. DSA is the old gold standard but it can be falsely negative 17% of the time and is not used so often any more,
- Treatment – nothing has been RCT’ed. The principles for VA and IC seem to be the same, but the VA – if it is an intradural tear, or an extra cranial with extension into the cranium – these have a high brain bleed rate and endo vascular repaired is recommended. We just do not know if these even work and if there are any long term complications from endovascular repair.Here is a bombshell- TPA very rarely causes bleeding in dissection and should be used in acute ischemic stroke according to this article.
- After the event –they recommend anticoag for six months. Know that except for traumatic dissections, in at least the VA- there is recanulization most often without a problem. Late strokes are uncommon.
Here is our second necking essay: Laryngitis
2) Above in number one: the sound of someone with laryngitis
3) What is your larynx? Why, your chatterbox. And a hell of a great place to slide an ET tube through. But aside from chattering and breathing, it is necessary for a good cough and even has some immunological and hormonal functions.
4) It can get inflamed. First and foremost make sure the patient is breathing. Grade their voice – do they have dysphagia? Are they stridorous? Watch out for red flags.
5) Hey what are the red flags? Well, stridor, recent neck surgery, recent ET tube, radiotherapy to the neck, smoking, professional voice user (what we call a singer), weight loss, dysphagia, and otalgia. These aren’t true red flags in the sense that you need to jump but they do suggest different etiologies
6) Causes of acute laryngitis- viruses, fungi, bacteria, inhalation injury, excessive coughing.
7) Can’t say much about viruses that you don’t already know other than Herpes can eat away that larynx in a patient with immunosuppression.
8) Bacteria are an important cause, but it often occurs with the viruses and it isn’t clear what requires treatment and what is causing more of a problem. Doesn’t seem that antibiotics help much here, but in under developed countries consider antibiotics for laryngitis caused by mycobacteria or syphilis (I am not asking where that larynx was that it got syphilis). High fever, drooling, stridor – remember epiglottis. Less severe cases do not necessary need intubation, but do need antibiotics, humidification and inhaled adrenaline.
9) Fungal – well that can occur in immune competent patients- but this is a select group – those who get chemo, or over use inhalers (I think they mean steroid inhalers) and those with reflux- more on that later.
10) Phonotrauma – yea hitting those high notes or serenading can make you sound like Rod Sterwart (if you remember who that is) Endoscopic findings may be minimal. But constant insults can cause long term effects. It isn’t just singing- also habitual throat clearing, or chronic cough can cause phonotrauma and permanent changes.
11) So what is the treatment? They call it vocal hygiene- voice rest, hydration, humidification and not drinking caffeine. They should rest their voice until they can hum comfortably. Caffeine increases reflux and makes snoring worse- they limit you to two espresso a day. Actually there is no literature that says this works
12) No studies say antibiotics work. Purulent sputum- they say do start them, I say nay.
13) Lasts more than three weeks – do laryngoscopy. Now there are lots of bad things this could be but one that isn’t so bad that I have seen a lot of recently is this GERD deal. The Brits call this GORD since their esophaguses( esophagi?) are spelled oesphagus. There is acid that comes up and then falls on the larynx causing chronic mucus production, or voice change and the like. But indeed laryngeal reflux may have nothing to do with esophageal reflux. There is no test for this. Many of these folks have no heartburn. PPIs most of the time do not seem to work. Gaviscon does seem to work –why? Not clear to me.