EMU Monthly – October 2015

All the EMU goodness for October 2015

  • Remember Mevacor? Staimage002tin change likes like the weather. Lipitor used to be the best selling drug in the USA – now that honor has gone to Crestor (although hereon probably brings in more money) due to heavy advertising. The problem is that this med causes a25% increase in the risk of diabetes and as well, rhabdo and proteinuria and hematuria. Apparently they based all the advantages of Crestor on a study that was stopped prematurely.(BMJ 350:h1388). This is just one man’s opinion but this is precisely the reason I do not use simvastatin with dosages greater than 20mg even though it is dirt cheap because I want to avoid Rhabdo- so why go to Crestor? And there are so many statin options now too. But again – this is just one opinion. TBTR: Crestor may be a poor choice for a statin.
  • So I really do do alot of exercise. And we spoke about this last month so I won’t go over it again – but I will use it as a shameless plug for going up on the website and seeing the article (emumonthly.com). Exercise will also help depression.( Am J Prev Med 48(3)281) Now nothing new here but just wanted you to have in article to wave in front of your patients .TBTR: exercise can help in depression
  • Handoffs (i.e. physician to physician) are a nightmare for us- and to tell you the truth I avoid them at all costs. I close all my patients whenever possible- but what about EMS- physician handoffs? EMS is ready and willing – but – it seems this is a problem worldwide- no body among the ED staff is that interested in speaking to them (image003) They would also love to have feedback on patients but this rarely occurs (Ann Emerg Med 65(3)310) There could be many reasons for this. We are very busy and many times staff has the impressions – right or wrong – that the EMS has little useful information – or background to be relevant. But just wait to bitten in the derriere when they document a suspected AAA in a patient that tells you they came for an ingrown toenail. Every piece of information is important. TBTR: we gotta improve the EMS-EP handoff. Shall we quote? We now go back to the seventies to visit two TV shows- the first was Hollywood Squares where Peter Marshall – the host of the game show would ask a question and the celebrities would give an answer- often a joke answer first. Here we go: If you’re going to make a parachute jump, at least how high should you be? A. Charley Weaver: Three days of steady drinking should do it
  1. True or False, a pea can last as long as 5,000 years. A. George Gobel:

Boy, it sure seems that way sometimes.

  • Time for a stroll through the world of dermatology. Don’t worry – I will wake you when I am done.image004 Ever have a pruritus that all the antihistamines and steroids in Uzbekistan won’t help? Here may be the answer. This was an absolutely terrible study – retrospective and only 96 patients of which 33% had to discontinue treatment due to side effects and 65% has side effects. But desperate times….you can try azathioprine. Seemed to work really well when it wasn’t doing in the patients. (JAAD 72(3)439) TBTR: Azathioprine for pruritus. According to Cosmopolitan, if you meet a stranger at a party and you think that he is attractive, is it okay to come out and ask him if he’s married? A. Rose Marie: No wait until morning
  1. Which of your five senses tends to diminish as you get older? A. Charley Weaver: My sense of decency
  • Dysplastic nevi image005 are not a cause for concern. The risk of melanoma in a dysplastic nevus is the same as in a common nevus. Furthermore people with a lot of dysplastic nevi have no higher risk of melanoma than people without. (JAAD ibid 507) Seems all good- but also seems to be too good- how many dysplastic body parts in other areas are not a risk to become cancerous?   What are ‘Do It,’ ‘I Can Help,’ and ‘I Can’t Get Enough’? A. George Gobel: I don’t know, but it’s coming from the next apartment
  1. As you grow older, do you tend to gesture more or less with your hands while talking? A. Rose Marie: You ask me one more growing old question Peter, and I’ll give you a gesture you’ll never forget
  • A couple years ago we discussed the article about CT done early in suspected SAH is reliable and we also discussed the CT with contrast debate and decided in both of these we didn’t need an LP. But many of us still do LPs and we are always questioning ourselves- when was it a traumatic tap or the real thing. Ian Steill wants us to know that if there is no xantochromia and less than 2000 cells in the supernate, this is not an SAH and you can discharge them. The methods – as can be expected were excellent but I had one question – why aren’t less than 2000 cells enough? Isn’t it likely that less than 2000 cells won’t cause xanthochromia? Anyone have an answer for me? So I got an answer from my neurologist- xantochromia is due to the time from bleeding and not from the amount of cells (BMJ 350 H568) TBTR: Less than 2000 RBCs on LP and no xantochromia – it is not a SAH. Charley, you’ve just decided to grow strawberries. Are you going to get any during the first year? A. Charley Weaver: Of course not, I’m too busy growing strawberries
  1. It is considered in bad taste to discuss two subjects at nudist camps. One is politics, what is the other? A. Paul Lynde: Tape measures..


  • Really this isn’t new stuff but it seems no one is really listening. Regular boxed gloves are just as good as sterile ones for minor surgery – and there are about as many infections with both. (MJA 202(1)27) You are probably thinking – these are clean wounds n office surgery. But the Ann Emerg Med43(3)262 looked at this already and found that even in lacerations you can use non sterile gloves. Honestly, I don’t know the last time I sewed a laceration with sterile gloves. TBTR: Boxed gloves do not increase infection rates. Used gloves probably do. During a tornado, are you safer in the bedroom or in the closet? A. Rose Marie: Unfortunately Peter, I’m always safe in the bedroom
  1. Can boys join the Camp Fire Girls? A. Marty Allen: Only after lights out
  • Henna is commonly used by many Arab tribes around me- but it doesn’t affect pulse ox results. (EMJ 32(3)248) If you were pregnant for two years, what would you give birth to? A. Paul Lynde: Whatever it is, it would never be afraid of the dark
  • Le Meirre’s syndrome has been mentioned in these pages before – this is a catastrophic disease- it is a septic thrombosis of the jugular vein- and it can be confused with a garden variety sore throat. Well, actually, according to this article – that isn’t that much of an issue. Sore throat is not the prominent initial syndrome in Fusobacterium infection, and Le Meirre’s can complicate not only sore throats, but dental infections, mastoiditis and otitis. There is no testing in the community for the causative agent – Fusobacteriaum Necrophorum and it isn’t the only bacterial cause for septic thrombosis. I liked his conclusions- use the Centor score, selectively do rapid antigen testing, consider Lemierre’s in patients not improving on antibiotics, and use PCN as the first line. IN this study – surprise — strep only has a incidence of 10% of all sore throats- fuso bacterium had a 20.5% incidence –meaning it is more common- at least in U of Alabama students. (Ann Int Med 162(4)311)  TBTR: More on sore throats. I you are not doing what is in this paragraph – you should be. According to Ann Landers, is there anything wrong with getting into the habit of kissing a lot of people? A. Charley Weaver: It got me out of the army.
  1. If you were pregnant for two years, what would you give birth to? A. Paul Lynde: Whatever it is, it would never be afraid of the dark
  • We have mentioned sleep often in these pages and the evidence for the medications that are generally used is fairly scant. Melatonin will give 24 minutes more sleep but will not cause onset of sleep to be faster. Zopiclone doesn’t really cause any difference in sleep outcomes. Modanifil will cause more headache and nausea but will also cause more alertness during the shift. (JAMA 313 (9)961) TBTR: Taking meds for shift work? Read this.
  • Migraines- these Canadians- Dr. Orr- image007(for you young’uns- that’s Bobby Orr- star defenseman for the Bruins from back in the seventies)– did an extensive review of the treatment of these disorders, and since I am suffering through one right now, I was especially interested in this. The evidence according to them shows the all-time best for migraines is prochlorperizine. The problem is that this medication is not available in all countries (including mine) and there have been production issues in the States. The second best is lysine acetylsalicylic acid (LSD?) but I have never seen that drug and can’t believe there is that much evidence on it. Sumatripitan and metoclopramide are also recommended although not strongly, but Sumatriptan is not that effective in my opinion after the migraine is well established. Ketorolac works but the evidence is poor. They claim DHE, intranasal lidociaine and meperidine – also have poor evidence but they still recommend them. They recommend against dexamethasone based on moderate evidence and grasitatron, and haloperidol based on weak evidence. Ditto for morphine, droperidol, IV lidocaine, propofol and tramadol (Cephalagia 35(3)271). This is insanity in my opinion. Migraine is still a nebulous entity, but this goes against most of the evidence I have seen. Droperidol for years has been the standard for migraine relief, and the studies on steroids are more for the prevention of rebound. And to even think of using narcotics for migraines is also against most guidelines. I use my experience here, and I have found that haloperidol and droperidol often do the trick. NSAIDS help as well. I say – get us some good evidence and we’ll see. Want to see more on migraines?- read the essay. TBTR: This article will turn your treatment choices in migraine upside down. I must add one more note. As much as I put in every Ian Stiell paper I find, and Paul Marik paper on ICU stuff, you gotta know that the bigwig in headache in Lipton. He points out that if you ineffectively treat the acute migraine, you may find yourself with a patient with a chronic migraine. Now that article is a little design challenged but consider looking at it. (Neuro 84(7)688) It is the most abused and neglected part of your body, what is it? A. Paul Lynde: Mine may be abused, but it certainly isn’t neglected
  1. When a couple have a baby, who is responsible for its sex? A. Charley Weaver: I’ll lend him the car, the rest is up to him

12) Hi Scott and Chris-as you guys know – and the rest of the world who reads EMU –(assuming the world has three people in it) ECMO is the rave at the moment, although I have never worked in a hospital with the resources to dedicate a machine to the ED(although we are free to borrow the one from ICU – but obviously it doesn’t usually happen) but just know if you are treating a patient with lipid emulsion for a poisoning – this can clog the circuits and cause more blood clots. image008TBTR: ECMO and lipid emulsions – be careful. Want more on ECMO? See number 27 below. Q. Jackie Gleason( he was kind of chubby) recently revealed that he firmly believes in them and has actually seen them on at least two occasions. What are they? A. Charley Weaver: His feet.

  1. According to Ann Landers, what are two things you should never do in bed? A. Paul Lynde: Point and laugh

13) This is a definite “Hey Martha” article- you know – those tabloid sensational articles like “Bigfoot treated my hemorrhoids” or “Aliens control my pancreas”.  The question on the table- is there a difference between bacteriostatic and bactericidal antibiotics. This excellent methods systemic review says – with respect to the clinical cure and mortality – they are the same. (J Atimicrob chemo 70(2)382) But this is a great example of garbage in garbage out. Most of the studies were on serious patients and those where it may have mattered – may have been too sick to even think of using bacteriostatic antibiotics. Also – what about host response- in healthier people- it may not make a difference. TBTR: May not make a difference if the antibiotic you use is bacteriostatic or bacteriocidal. Peter Marshall: Eddie Fisher recently said, “I am sorry. I am sorry for them both.” Who was he referring to?

Paul Lynde: His fans.

Peter Marshall: Your sheep has a temperature of 102. Is she normal?

Burt Reynolds: People think I’m not normal because I keep taking her temperature


14) Yea, so you have this patient you think may have carpal tunnel. How are you going to prove it? How are you going to treat it? If you read EMU you know that Phalen’s sign and Tinel’s sign are not worth much. EMG – this is what we usually do but it hurts and so reminds me of voodoo. What about ultrasound? It can show pressure on the median nerve, it can show enlargement of the median nerve and in good hands (ah, the kicker) image009(is 97.9% sensitive. (Rheumatology 54(1)9)  This is definitely a move in the right direction – a good paper to wave in front of someone. TBTR: US for CTS – way to goimage010

Peter Marshall: You’re a 71-year-old man who has lost interest in sex. Does your doctor have anything to help you?

Charley Weaver: No, but his nurse does.

Peter Marshall: Paul, how many fingers in the girl scout salute?

Paul Lynde: Gee, I don’t remember. The last time I saw it was when I didn’t buy their cookies


  • For the last three months we have been speaking about ketamine and this month we will too – but to reduce of little of the luster of this shining star. Pain scores and distress scores in two of the trials did show improvement with sub dissociative ketamine. But there were only four trials.(Acad Emerg Med 22(3)251) This calls in question the use of ketamine for pain relief although it always did help for my patients. TBTR: sub dissociative ketamine may not be ready for prime time.

Peter Marshall: According to Amy Vanderbilt, what is the maximum length of time you and your fiancé should be engaged?

Rose Marie: Engaged in what?

Peter Marshall: Charley, what do you call a pig that weighs more than 150 pounds?

Charley Weaver: A divorcee



  • Depilatory agents (Nair for example ) do work fast (a few minutes) on hair tourniquets but do not work at all on cotton, polyester or rayon(Ann Emrg Med 65(3)256) Peter Marshall: True or false, George: experts say there are only seven or eight things in the world dumber than an ant.

George Gobel: Yes, and I think I voted for six of ’em.

  • Hey talk about great journals – you got put down that Playboy and start reading Circulation. True the centerfold is not of the same quality, but in any case you just read Playboy for the articles and Circ is great for that. Here they look at MINOCA – MI with non-obstructive coronary arteries. It seems common but it isn’t – only occurs 6% of the time (although it could be that if we consider silent MIs – which obviously we can’t- the prevalence would be higher) and occurs on average at age 55. Most of these are still male, but when you compare to standard MIs- those with coronary disease- MINOCA is more likely to occur in females with standard cardiovascular risks (except less hyperlipidemia) and they tend to be younger. Mortality was less with MINOCA. Causes were hard to come by. Myocarditis, spasm (how did they know?) thrombophilia but most of the time they didn’t find a cause even with cardiac MRI. (Circ 131(10)861) This may not help us much in the ED, but we need to know how to the counsel our patients and if they have clear coronaries- what to do further. I asked my Cards guys and they said – spasm you can sometimes tell if it was Prinzzmetls- ST elevations that resolved. They would not give beta blockers if LV function was preserved but ACE and aspirin they would give. TBTR: MINOCA- Mi s without coronary disease –all you need to know about who gets this but not how to treat it

Peter Marshall: Your baby has a certain object which he loves to cling to. Should you try to break him of his habit?

Joan Rivers: Yes. It’s daddy’s turn.

Peter Marshall: In the Shakespearean play “King Lear”, King Lear had three of them – Goneril, Cordelia, and Regan? Who were they?

Paul Lynde: King Lear had Goneril


  • Burnout in doctors- when is anyone going to do a good paper on this? Here they cased 47 papers and found that being female, younger, having low job satisfaction (duh!) long working hours (Doulbe Duh) and negative marital status all contributed, and wellness programs helped. But the results could not prove causation (Occup Med 65(2)117). This is also a function- in my opinion- of the medical systems and cultures so it may be hard to pinpoint. Ladies – why do they burnout more often? Could be as they mention in the article – the reasons are interrelated? We did progress much here but we need to TBTR: Burnout – some very limited causes.

Peter Marshall: Whose motto is “Do Your Best”?

Paul Lynde: I guess we can rule out Jimmy Carter..

Peter Marshall: Back in the 1870s, Emile Berliner invented something, and without it, I wouldn’t be able to do my job. What was it?

Paul Lynde: Let’s see… toupees? Facelifts? Contact lenses?

Peter Marshall: Now cut that out!

Paul Lynde: …Makeup? Capped teeth? Loud sports jackets?



  • Routine urine – for example pre op – that grows out some bug – leave it. Only pregos need treatment for asymtomatic bacteruria. ( JAMA Int Med 175(3)344)

Peter Marshall: What’s the one thing you should never do in bed?

Paul Lynde: Point and laugh!

Peter Marshall: True or false, having a good memory is a sign of a well-adjusted personality.

Karen Valentine: What was the question?



  • CPU- chest pain units- they are on their way out –why? Because most of the patients we admit are low risk or no risk for coronary disease. They only had 0.33% MI rate in pateints in this study who were admitted with the label – chest pain even after 190 days of follow up – so why do we need to stress them from the ED or the CPU? ( ibid 175(3)436)  Peter Marshall: Paul, does Ann Landers think there is anything wrong with you if you do your housework in the nude?

Paul Lynde: No, but I have to be terribly careful when I do my ironing

Peter Marshall: True or false, Paul Revere had 16 children?

Paul Lynde: From *one* midnight ride?



  • Frequent fliers image011Why do they love coming on my shift? The reason people make multiple visits to the ED according to this article are: EDs are convenient, patients think that they have a problem that cannot wait, they do not know how to make a clinic appointment, they thought ED care would be better than the clinic and it would be cheaper. (Am J of Man Care 20(11)506) This study was in Bellevue but since I practice in a socialized medicine country let me present some ideas on this survey. EDs are convenient but care is expensive in all countries. Urgi centers are helping out here, but still the other concern about the quality of care – at least in my country – the ED is truly a better place for quality of care. Urgi centers are often staffed by physicians with little training. Thinking it is a real emergency – well better patient education is necessary. In my country they must have a complaint that is from a Ministry of Health list of complaints that could be serious if they want to go to the ED without a referral – if not they pay – and it ain’t cheap. Clogging emergency care with patients that do have other options is in my opinion – a negative thing but Americans are still into this safety net thing. TBTR: Frequent fliers – why are they coming to the ED near you?

Peter Marshall: True or false, massaging the feet helps some people with hot flashes?

George Gobel: So that’s why Rose Marie wears battery-operated shoes.



  • I really believe you gotta stop eating rat poison but if you insist on it- rat poison today are super warfarins- they are two times more potent than Coumadin and they last for weeks. You need massive doses of vitamin K that may be necessary for weeks or months. (Blood 125(3)438) TBTR: Treatment of rat poison ingestion – read all about it. <-This is a rat:image012 This is a ratatouille->image013 gotta know the difference. time to switch quotes: we now proceed  to another seventies serial from the seventies – Bewitched- about a normal man married to a witch. A lot of mother in law jokes( Endora wsa the Mother In Law, Darren was the man) , but why not? image014Endora: Samantha, I will not stand here and be insulted by something which is 94 percent water.

Darrin Stephens: Oh, yeah! Well, what about something which is a hundred percent hot air?

Endora: Young man!
Samantha: Mother, don’t.
Endora: Very well. Just consider yourself lucky that you are not at this moment, an artichoke. So from now on, watch your step, young man. Mother is watching you


  • To pierce (image015) or not to pierce. Well, we all know that a greater than 50% subungal hematoma will result in a loss of the fingernail – but do you take off the nail and suture or not? What if there is an associated tuft fracture? Well they looked at the evidence which was evaluated for ridging and final cosmetic appearance and they found studies that were all over the place – and of course with the minimum of patients. Bottom line – just trephine them for pain control and no need for suture until there is more evidence (J Hand Surg Am 40:581) TBTR: Subungal hematoma- no need to suture.

Endora: I detest sounding like one of those mothers who thinks they know it all. But unfortunately, I do.

Endora: Why do I have to leave?
Nurse Kelton: [refers to Sam] Because we are about to take our nap.
Endora: “Our nap”? Are you going to climb into bed too?
Nurse Kelton: I was using the royal “we”.
Endora: Are you a member of royalty?
Nurse Kelton: Yes, I’m queen of this floor. That means I can tell you when to visit and when note.
Endora: When did you get out of charm school?
Nurse Kelton: Well, let me put it another way: Get the hell out!
Endora: You bring him back or I’ll make your life miserable for you. And you know I can do it. I’ll move in with you.

  • I gotta really give it to Dr. Stancyzk and Dr Vanessa Hussey (is she real a hussy?) for an article we do not see too often. Mosquito repellants- what works? The four that are around in the market at this point are DEET- the standard, it repels mosquitos for 6- 13 hours (when we say mosquitos, we mean the bad ones – Aedes, Culex, and Anopheles). For you natural buffs PMD is a byproduct of lemon eucalyptus and it lasts less time than DEET but is effective 100% of the time during those hours it does work. Icaridin works up to six hours, and IR 3535 works for 7- 10 hours, but much less against Anopheles, so this is not for those folks travelling to malaria areas. All of these are safe when used appropriately (no, DEET does not cause encephalopathy in kids – that has been disproven).  Inappropriate use includes ingestion, inhalation, eye splash etc. Just be aware that the other three have been less well studies.  Basically the same applies to use in kids and pregnant women (aren’t all pregnant people women?) However, DEET does reduce the effectiveness of sunscreen. All other products are very variable in effectiveness– including dietary changes (mosquitos cannot tell the difference) and citronella. (BMJ  2015:350) TBTR: Mosquito repellants- DEET is still the gold standard but here a natural alternative may work. I am still looking for a therapy for annoying people.

Endora: Oh, Samantha, the Salvation Army wouldn’t even send a truck out for your husband



Samantha: He’s a dear, sweet, wonderful, perfectly marvelous man.
Endora: Oh, my poor baby. He sounds simply horrible

  • You may own a dog (image016) but you should consider investing more in in your other pet- H. pylori- which currently is the most infectious bacteria in the world – affecting 50% of the population – and it has been implicated in a whole group of other extra gastric problems such as ITP, anemia, (iron deficiency) CV disease, and inside the stomach – lymphoma and gastric Ca. They go over all sorts of treatments for this: sequential, hybrids, concomitant- and then they through in all sorts of risk ratios and Forest plots and to cut to the chase: the best – as of today- is the seven day concomitant- which is seven days of a PPI, amoxcilllin, clarithryomycin and flagyl- basically what was what I use, but they are substituting bismuth with Flagyl. (BMJ 2015:351:h4052) TBTR: Wanna kill Heliobacter- Look inside for all the murder details!

Endora: How would you like to spend your wedding night with a bull frog


Endora: Well, it was just an idea.
Darrin Stephens: Let’s keep it that way. I’m afraid you’ll just have to count us out, Endora.
Endora: Oh, don’t give up so easily. I don’t.
Darrin Stephens: You know the trouble with your mother? She’s here today and here tomorrow. See you tonight.

  • I’ll make this quick but it isn’t going to be painless. Three terms you for sure have heard of- p value, confidence interval and statistical significance. Here as usual start with a case which is never useful in my opinion. I just want to add a little to the picture. When statistics are expressed in terms of rations- risk ratios, hazard ratio, odds ratio, check out the confidence intervals- if they cross one- there will be no statistical significance ( example – a relative risk that the CI are 0.45- 1.26 – crosses unity – therefore it is not significant. Similarly the same can be said for absolutes numbers or percentages that cross zero – it means the same. Examples- -15-3.6 CI – it means it is not significant. (ibid h113) TBTR: Some easy to understand tidbits on confidence intervals and significance.

Endora: She’s not the kind of girl one takes home to mother, is she.
Samantha Stephens: Only if mother’s not home

  • This is one of the rare times I didn’t condense the articles for you, but here is just no way with this one. ECMO is the future- but you need a lot of expertise to run one. This article can get you started. (Circ 131:676) And let’s finish with some quotes from the Classic TV show of the seventies- All in the Family which featured a bigot and his trouble understanding the world. His wife was Edith, and Daughter was Gloria and Son in Law was Mike Stivic: Mike Stivic: We’re going to see something you know nothing about: culture.

[Shows him the art exhibit book]

Archie Bunker: Oh ho ho, look at this. No wonder he’s getting himself so excited, it’s one of his own here: A Polack art exhibit.

Mike Stivic: That’s ‘Pollock’. Jackson Pollock. He happens to be a great American artist.

Archie Bunker: Well he sure paints Polish. Look at this: he splashes and smears the paint over everything here. What do you mean? A monkey could do that. A great American artist? There ain’t a tree or a flag or a president in the whole damn book.

Mike Stivic: I’d explain it to you, Arch, but first you’d have to move your brain ahead two centuries.

Archie Bunker: Why don’t you go take a short walk on a long pier?

Mike Stivic: Ha, you can’t even get that right! It’s take a long walk off a short pier.

Archie Bunker: Then do that.


Mike Stivic: In today’s society, people throw things out because they don’t work.

Archie Bunker: Well you don’t work, maybe we should throw you out

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  • Can we talk? Two quickies. These folks in Brazil use nerve blocks for all sorts of headaches and the techniques are actually pretty well described. However, some of these are fairly close to sensitive areas, and kinda of make me think you may want to get some training before you try them. Two which I do and have some success with are the Greater and lesser occipital blocks Here is some anatomy for you image017this may be worth a try if you  have no other options. (Headache 55:S1 59)TBTR: Nerve blocks for headaches- here some practical advice.

Archie: Free treatment for VD. VD. Do you know what *that* means, Edith?

Edith: oh, yeah. V-D day.





Edith Bunker: [Archie’s in the bathroom] Archie! When are ya comin’ out?

Archie Bunker: Why, ya sellin’ the house?

Edith Bunker: You’ve been in there for 20 minutes.

Archie Bunker: Who are you? The official time-keeper?

Edith Bunker: What are ya doin’ in there?

Archie Bunker: I’m changing the tile. One more word out of ya and I ain’t never comin’ out!

  • The year was 1986- I remember it well. (1986- the first PC virus started to spread. The bears beat the patriots tow in the Super Bowl, Chernobyl occurred, Expo 6 opened in Vancouver, I celebrated one year of matrimony) We had this lady with low sodium and by Golly (or in those days- heavens to Mergatroid) she got better with demeclocycline. Well, we aren’t using that any more for hyponatremia and this review will give you details on how to treat this. Now, you could also learn how to do this by reading Tinninnali, so we will just add some pointers that I have forgotten over the years. Hypovolemia can definitely cause this, so be careful with Tegretol and SSRIs which can cause fluid losses. Alcohol (beer especially) and Ecstasy can also cause hyponatremia. Have a severe case? Three percent is the treatment of choice given slowly- 150 cc over 20 minutes; they do not mention Normal saline plus diuretics (where free water is supposed to go out in the urine) and are against the use of Vaptans for hyponatemia- too many fluctuations. Desmopressin is another option, 1-2 mcg given every four to six hours. As a special bonus they also have a section on the treatment of hypernatremia also (AFP 91(5)299) TNTR: Treatment pointers for hypo and hyper natremia

Archie Bunker: God can do anything! He can turn your jawbone into an ass!


Mike Stivic: That’s what’s wrong with this country; nobody asks questions any more!

Archie Bunker: Can I ask *you* a question?

Mike Stivic: Sure.

Archie Bunker: Why don’t you shut up?


  • Hemoptysis is another tricky one we see in the ED a lot and a lot of us swing and miss on this one. Yea, there can be scary reasons for this – TB, cancer, pulmonary embolism, pulmonary endometriosis (imagine hacking up blood every month) Goodpasture syndrome and foreign body aspiration. However, here the approach is much simpler than GI bleeding, If they have no high risk cause for bleeding, no anticoagulant use, no low saturation or rapid respiratory rate, no hemodynamic instability, no respiratory co morbidities (like COPD) and no massive bleeding, these cases become basically treat and street. Just do a chest film and if it is normal- observation at home. Most common cause will be URI (ibid91(4)243) I think this is a little oversimplified from one aspect- I think you have got to think about PE a little more. But if that is unlikely and the patient is stable and the X ray is unremarkable – it seems you can send them home. TBTR: Hemoptysis – management.

Edith (it’s Edith’s 50th birthday) Don’t you know what today is?
Archie: Oh, my goodness, how time has flew. Today is the first day of National Spay the Cat Week


[Edith is going through menopause, and Archie is planning a trip]
Edith Bunker: I wanna talk about where we’re going.
Archie Bunker: Well, that’s fine, there, Edith. If you want to talk about Florida, let’s talk about Florida. And by the way, we ain’t confirmed about going there yet.
Edith Bunker: No, no, no! Not Florida! I want to go to Scranton.
Archie Bunker: Scranton? Edith, uh, what is in Scranton?
Edith Bunker: My cousin Emily.
Archie Bunker: Your cousin Emily?
Edith Bunker: You hate Emily!
Archie Bunker: No, no, no, no, I don’t, Edith. I don’t hate Emily. I never said that, I never said that at all. No, I like her, and I like their little home in Scranton, there, and those four cute teenagers. I think her husband is a real nice guy, and I, I can’t say that… I can’t go on like this, that’s one thing I can’t do! I can’t believe a word of anything I’m saying around here! This ain’t natural! No, I don’t like her, and I don’t like her husband! He’s a bum, and he always was, and she’s a crank, and she always was! And I hate their four rotten kids! And the only way you’re gettin’ me to go to Scranton is if some screwball hijacks the airplane! I know all about your women’s troubles there, Edith, but when I had the hernia that time I didn’t make you wear the truss!
Michael ‘Meathead’ Stivic: Come on, Archie!
Gloria Bunker-Stivic: Daddy!
Archie Bunker: No, no, no, Edith! If you’re gonna have the change of life, you gotta do it right now! I’m gonna give you just thirty seconds. Now, come on, change!

Letters: Here is an old one from our pal Kobi Metzger: he quotes EMU from July: I call it one of two things- either this is a doctor who doesn’t read EMU or he is an idiot. (Although to make things clear- you can still be an idiot and read EMU. Or even better- you can be an idiot and write EMU)


When you write “either or” it means you are not an idiot unless you read EMU, and if you do read you are definitely an idiot.

Now the causal relation has to be confirmed yet. Are you an idiot because you read or you are reading because you are an idiot.

A double blind study where people would be randomly assigned to read EMU is required.


As to myself I am only a partial idiot because I don’t read all of it and some times I give Augmentin for sinusitis

I didn’t follow this but what the hell – I read all of EMU so I am an idiot although I think I may have progressed upward to moron. Thanks for pointing this out Kobi

Sam Sussman from Ottawa comments on a patient that had a heart attack: Two weeks before MI blood work showed…good glucose level…LDL and HDL aok, cholesterol OK and BPressure normal.

My theory…which has not really been explored is that the 32 mgs of nicotine from 1970- on vis NICORETTES- nicotine gum did the patent in.!! 8 gims at 4 mgs a piece

There have been two articles which revealed plaque like arterial substance due to straight nicotine.

No one wants to fund studies on nicotine alone

Sam is a psychiatrist and I agree with him – we have very little research on addiction medicine.   Thanks Sam for writing and I hope the patient has a full recovery

Ken is back in Antarctica and writes us:  Liked the new (August) EMU and very sorry to hear that your site was attacked. Glad it’s back up.


If I haven’t told you, I’ve listed you in the Acknowledgements for the second edition of “Improvised Medicine: Providing Care in Extreme Environments” (McGraw Hill). Among my many sources, I review and then use some of the articles from EMU for my new material. I am just finishing reviewing the proof pages and the book should be out in January 2016

Readers- you gotta to buy this book –

Another plug for a good project from Jorge Muniz: I hope you’re having a great week. I’d like to share an educational art project that benefits all students of medicine. It’s an innovative series of illustrations that combines humor and medicine to make studying fun. Professors are also utilizing these illustrations as a visual learning tool to teach medicine.

I’d love to get your thoughts on the project:



EMU is based on the same principles and I did check this out – it is a fun project!  And that catches us up pn all our letters- keep on writing, friends!



The sources for the two essays this month are Headache 55:313 and AJM 128:239


  • Again, the basics can be found in any EM or IM book. We will just go over some salient and often forgotten points. The most common cause of this is primary hyperparathyroidism and this occurs slightly more commonly in females. Since calcium is ubiquitous (ooh, it hurts to use such big words)- since it is found all over the body) it affects many organs systems. In the GI tract it can cause constipation, vomiting, nausea and abdominal pain.   Pancreatitis is common in crisis and can be severe. Neuro – clouded sensorium and fatigue. It can also kill the kidneys and of course – cause kidney stones.
  • Well cancer can cause this due to bone lysis,(Multiple myeloma and breast cancer seems to do this alot)but did you know that cancer can causes elevation of PTH and can also cause production of vitamin D??
  • Other causes to consider include immobilization, over indulgence in vitamin D – (hey those pills can taste pretty good) , thiazides, lithium and calcium containing antacids. (Tums taste pretty good too.)We will mention milk alkali syndrome but it is really rare. Oh sure we could give you the whole list – including berylliosis and leprosy, but I don’t think you are ever going to see these.
  • This is all pretty boring so let’s get straight to the treatment. We will not enter into surgical treatments. The first treatment remains saline but it will never bring the calcium level back to the normal calcium. Also loop diuretics help but make sure they have the volume for this. DO NOT USE THIAZIDES!!
  • Biphosphonates can help in hypercalcemia of malignancy but are less effective in other causes (including I assume berylliosis).The approved ones are zoledronate and pamidronate. The former works faster and according to some head to head trials is better.
  • No use for gallium, IV phosphate, and mithramycin. They are now in the Natural History museum next to the mastodon.image018
  • Calcitonin works quickly and they like it- it can be given with biphosphates. It can really speed up the process of lowering calcium – but only when used in combination with the biphosphanate. Alone there is tacyphylaxis within 48 hours so they recommend it for emergent use with diuresis until the bisphosphonate can start to work.
  • Steroids – will work if the tumor is multiple myeloma. Some of the lymphomas will also respond but otherwise it is ineffective unless the tumor produces also vitamin D.
  • Dialysis can be rescue therapy.



Migraine Mimics

  • Yea I know what you are thinking – what a headache- all migraines look like something else. And truth be told, why do I care – if they respond to a triptan or a NSAID so I am done, no? Here are some that may need something different. image020
  • A daily throbbing headache- almost always one sided can be a migraine or it can be Daily Persistent Headache (no sh*t Sherlock) image021but it can also be Hemicranias MRI will be normal This is a rare condition that occurs much more often in females It has triggers- stress , alcohol, bright lights, bright lights, . They often have autonomic symptoms – usually tearing. Indomethacin is the treatment and they usually respond to dosages between 50 -300 mg daily.  You can also try nerve blocks (see above) or topiramate. Other NSAIDS don’t work as well.  This can also be confused with, cluster migraine but as I said – I don’t care.
  • AVMs are something you also don’t want to miss. Saccular aneurysms get all the notoriety but 50% of the time AVMs present without bleeding, just pain. These are also one sided. Also do not forget cerebral artery dissections – they look like migraines but present with neck pain and head pain only in 8% of cases. Only 20% of the time is the headache thunderclap. In contrast, ICA dissection does present with a headache and it precedes neuro symptoms by about 4 days.  Horner’s syndrome only occurs in 25% of the time.  Vertebral artery dissection does cause headache 70% of the time  and is often ipsilateral but doesn’t usually have normal migraine features
  • You cannot forget cerebral venous thrombosis although I have either missed all them or only seen one in my career. Mostly unilateral, these can present with headache alone. However, don’t despair if your headache patients have suddenly all become vegetables image022you can get an idea that this may have been the cause if they had a thunderclap headache,  pain worse with straining, sleeping, lying down  or Valsalva.
  • Reversible cerebral artery vasospasm – how did they find this one? This is usually post-partum or after use of drugs: SSRI, triptans, and IVIG (IVIG? Is nothing sacred??).  These resolve within three months on their own. Vomiting may be a prominent feature
  • Temporal arteritis. This is older individual and usually a female- think it always occurs in the temporal fossa? Guess again – it can cause pain all over the head. Old and female? She was beautiful and had a great voice and made allof us drool in the Seventies- Olivia Newton John-image023 Here is what she looks like todayimage024. And to be fair to our three (is it that many?) female readers- here is her costar- John Travolta- image025 Here is how he looks todayimage026.
  • SAH – you wouldn’t miss this, would you? They present 19% of the time with a gradual onset, and without stiff neck in 36% of the time. This can also trigger a migraine and can also improve with Triptans.
  • Here is one for that cute bookish type you are trying to impress at the next neuro mixer- you can mention how you made the diagnosis of CADASIL. This is Cerebral Autosomal Arteruiopathy with Subcortical Infarcts and Leuko encephalopathy. You’ll see this on MRI and these folks get headaches before sliding into dementia
  • Heypertension can cause a headache but this needs to be acute and fairly high. I am dubious- how do you know which came first – theheadache or the hypertension?
  • Cardiac cephalagia- only 36 cases of this – occurs when the patient is exercising and goes when they rest. It is like what women have said about us men all the time – there are definite connection of the brain to other organs in the body
  • Neoplasms-can cause migraine symptoms but beware of the pituitary hemorrhage – this makes a migraine like headache without neuro symptoms – and will be missed on CT- (MRI will catch this rascal)
  • SMART syndrome – only 40 cases of stroke like migraine attacks after radiation therapy. Do you like numbers? This occurs 1- 35 years after radiation therapy and lasts from less than 2 hours to 23.5 months with full recovery. These numbers do not help much. They do have quite pronounced neuro syndromes like dysphagia, visual loss, hemiparesis or confusion.
  • Sinusitis – you knew that but do not forget sphenoid sinusitis which can be subtle. This sinusitis can present with vomiting and often has unexplained fever
  • Viral Meningitis- can occur without fever. There is also Benign Recurrent Meningitis also known as Mollaret ‘s syndrome but no one knows what causes that
  • Headache Associated with Neuro Deficits and Cerbrospinal Fluid Lymphocytosis (HaNDL syndrome) – often caused by a viral prodrome. They can have hemiparesis and language disorders and vomiting and photphobia.   They all get better but let me see your muscles and have you explain to me how you know this is not viral meningitis. Then again – most viral meneigitis ( if not herpes) gets better too.
  • Brian Abscess-no fever and neuro abnormalities in about half the cases.
  • Pseudo tumor Cerebri, Hydrocephalus, Spontaneous Intracranial Hypotension – not much for me to say on these – CSF leak can look like the latter which gets worse on standing
  • Epilepsy can cause a headache and sometimes it is the only manifestation
  • Glaucoma –I have picked this up
  • And lastly- Alice in Wonderland Syndrome- remember that cute neuro resident you were trying to impress- try this one on her. These patients have distortion of perception of their own body parts- they perceive that some are huge and some are diminutive and the sufferers know that the perception is not real. Topiramate seems ot help here
  • Have I made an utter mess of these?? Yes I have, but before you MRI every migraine sufferer- remember that common things are common and also –with the exception of bleed and infections, most of these are sub-acute and can await more intense workup making you into the Dr. House star you always wanted to be. And help you get the cute bookish neuro resident.image027



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