All the EMU goodness for March 2015
Hydrochlorothiazide for Acute CHF Exacerbation
Many of you may have noticed that patients taking Furosemide for CHF excite the cardiologists when they make a lot of urine. Problem is as they get to the end of their road – it takes something like 40 liters of furosemide to get them to pee.
Enter HCTZ which can promote the production of a lot of urine. Especially if you give it IV – which they apparently have at Ohio State University (Pharmcotherapy 34(8)882). I was amazed that they did this study retrospectively – those who got HCTZ were at physician discretion – maybe they were sicker? Furthermore, if you did not get it IV, the effects were modest. Also, while they peed more, their weight didn’t change much. Also, IV HCTZ is really expensive, and the most important problem – the amount you pee is not related to any patient oriented outcome.
TBTR: Addition of HCTZ may help in CHF – or maybe not.
Gamma-Butyrolactone Withdrawal
This was done in nurses but applies to paramedics and all who work shifts. I mention this because the majority of nurses are still female, and I am convinced no upstanding woman would ever lower herself to read this drivel. Or marry me either. But the latter did happen, so I guess anything is possible. Did my ADD get a hold of me again? How many people with ADD does it take to change a light bulb? Answer – hey, let’s go get lunch. Does that mean I will now get letters from people accusing me of being anti-ADD people? Could be but I have a good alibi – I was probably high on GBL drugs. Which is the subject of this article. Withdrawal from GBL (gamma-Butyrolactone ) induces the usual – delirium, rhabdo, confusion, agitation, but here benzos don’t work so well – benzos work on different GABA receptors. Seems that the receptors for these drugs are influenced more by barbs (J Psych Pract 20(4)294).
TBTR: GBL is a new drug of abuse and barbs will help the agitation and withdrawal. Also ADD can drive you crazy.
Sleep Hygiene
Ah yes, so there is a way to further abuse you with shift work. Make you work eight hours, give you eight hours off, and then bring you in for the night shift. Sounds barbaric? It is. This rather large study showed significant amount of health problems at one year in nurses (yes – this was the study we were supposed to discuss above) (Occup Envir Med 71(8)555). Maybe true – no it is true – but most of these health problems were fatigue and sleepiness. Depression also occurred which is understandable. Do you do the schedule? Are you a hospital administrator? If so – you belong in the same very hot place.
TBTR: You need some time between shifts.
Quote time. This month we are dedicating our quotes to Father Greg. Father has been working in the legal field for 127 years, and we present funny courtroom transcripts.
Lawyer: “Now, Mrs. Johnson, how was your first marriage terminated?”
Witness: “By death.”
Lawyer: “And by whose death was it terminated?”
Healthcare Expenditure
This was so interesting, but I couldn’t understand the study – why do some nations spend more on health care than others? We in Israel spend little, and doctors are overworked and paid like bus drivers (yes, Americans, Obamacare is bringing you there). Read this article and tell me what they are talking about (Soc Sc Med 114:161).
Lawyer: “Can you describe what the person who attacked you looked like?”
Witness: “No. He was wearing a mask.”
Lawyer: “What was he wearing under the mask?”
Witness: “Er…his face.”
Imaging Studies and Radiation Exposure
I love radiation. Heck; I even worked in a nuclear power plant (I was the core).
This is an opinion piece that encourages you to do that radiation filled, alpha emitter spiced, anti-matter study. Let’s firstly give you a little background. A chest x ray is about 0.05 millisieverts. CT of body parts can range from 8– 20 mSv although lower radiation attempts are being tried in Canada. Now we have many folks we do not want to irradiate – kids, pregos – but you should know the risk is low. The average 10 year old that underwent a body CT scan (more Sieverts than a head CT usually) has a 1/3000 chance of cancer mortality (if she is a girl) and 1 in 4700 cancer mortality in a boy. The same child has an overall 1 in 5 possibility (in the USA at least) of dying from cancer without radiation exposure. In other words, there is a 99.75% chance that this will never happen, or the same probability that a flipped coin will come out heads 12 times in arrow. Indeed, an exposure of 50-100 mSv may be non-detectable and of no consequence. However, EMU reader Al Sachetti in 2011 quoted at ACEP a Health Physics report that less than 50 mSv is not teratogenic – more than 50 may require caution – which is more than we will give in the ED in one shot. They also quote a study that head CTs in kids after minor head trauma show clinically important finding’s –even incidental ones 1-8% of the time which is 100 times greater than the dangers of radiation induced cancer. They then speak about the dangers of sedation to do an MRI which is without radiation which I think is a bunch of bunk – especially since they feel a serious side effect of sedation is desaturation. But I do agree with them that there is a risk benefit here and we shouldn’t take CT pictures of everyone with a body (unless they are really really cute) (Thorax 69:782).
TBTR: Radiation dangers from imaging are overblown according to this opinion piece.
Lawyer: “What was the first thing your husband said to you when he woke that morning?”
Witness: “He said, ‘Where am I, Cathy?'”
Lawyer: “And why did that upset you?”
Witness: “My name is Susan.”
Ketamine and Intracranial Pressure
Let’s put this one to rest. Ketamine does not increase ICP – well maybe it doesn’t – but there are no good studies that say it does, and indeed there are three prospective studies that say it even lowers ICP (Neurocrit Care 21(1)163). The Israeli army medics carry ketamine for head injured soldiers and they teach in military ATLS that it has no effect on ICP.
TBTR: Ketamine – no proof it increases ICP.
Lawyer: “Did you blow your horn or anything?”
Witness: “After the accident?”
Lawyer: “Before the accident.”
Witness: “Sure, I played for ten years. I even went to school for it.”
Rhabdomyolysis
CPK can be high for many reasons – trauma, heart attack, statin use (actually, in Israel, we saw a rash of high CPKs from a group of Thai workers who killed and ate a wild boar and ended up with trichinosis) – in this retrospective study they found an 8% hemodialysis and death rate in patients with rhabdo – and this was in 400 patients. However, this was all in patients with CPK above 1000 (AEM 21(6)631). This needs validation – it may depend on the age or the health of the patient – but I in practice don’t do much with patients with CPKs under 1000.
TBTR: CPK under 1000 is probably not too worrisome. And over 1000 – most of the time does well.
Lawyer: “Trooper, when you stopped the defendant, were your red and blue lights flashing?”
Witness: “Yes.”
Lawyer: “Did the defendant say anything when she got out of her car?”
Witness: “Yes, sir.”
Lawyer: “What did she say?”
Witness: “‘What disco am I at?'”
Methoxyflurane
This is a well done study with only one flaw I can identify. Methoxyflurane – an inhalational anesthesic that has strong analgesia properties even after the anesthesia wears off – can be administered as an inhalation in lower doses and is effective for acute pain. Sure it can cause nephrotoxicity, but that is in high doses (EMJ 31(8)613). The flaw? Guess who paid for it?
TBTR: An inhalational anesthetic is soon going to be marketed for acute pain.
Lawyer: “Doctor, before you performed the autopsy, did you check for a pulse?”
Witness: “No.”
Lawyer: “Did you check for blood pressure?”
Witness: “No.”
Lawyer: “Did you check for breathing?”
Witness: “No.”
Lawyer: “So, then it is possible that the patient was alive when you began the autopsy?”
Witness: “No.”
Lawyer: “How can you be so sure, Doctor?”
Witness: “Because his brain was sitting on my desk in a jar.”
Lawyer: “But could the patient have still been alive nevertheless?”
Witness: “Yes, it is possible that he could have been alive and practicing law somewhere.”
PO Ketamine for Pediatric Sedation
The oral route would be great for sedation, and this Israeli study showed that oral ketamine at 5 mg/kg + midazolam 0.5 mg/kg by mouth was much more sedating and less likely to need additional IV supplementation than oral midazolam alone (EMJ 31(8)649). I will give a different spin than they did. OK, I don’t treat a lot of kids anymore, but oral midazolam as far as I am concerned is inferior sedation. Poor tasting, variable sedation, paradoxical excitation, and possible respiratory depression make this a less desirable form of sedation. I think ketamine is an excellent choice and the oral route- now being reported more often – has to be studied as a possible lone sedation agent. Now we still think you should put in an IV in most sedations, so I don’t know what you would gain with oral ketamine, but ketamine is so safe, perhaps one day we will give this orally without an IV. Kudos to Eran Kozer and Ilan Shavit on their study.
TBTR: Oral ketamine seems to work – maybe.
While we are on the subject of pediatric sedation, dexmetetomidine does work well before surgery, but takes time to work, and lowers blood pressure and heart rate (Ped Anesth 24(8)863). I have no experience with this drug – it isn’t approved yet in Israel or Europe for that matter, but it seems to work at the same level as nitrous as sedation. But his study also said it trumped midazolam – again I am not sure what we need midazolam for in sedations – we have better agents.
TBTR: Dexmet – the new kid on the block.
Lawyer: “What happened then?”
Witness: “He told me, he says, ‘I have to kill you because you can identify me.'”
Lawyer: “Did he kill you?”
Witness: “No.”
Pediatric Intubation
Miller versus Macintosh – well, we all know that small kids should intubated with a straight blade – that is a Miller. This study says,both are fine thank you (Ped Anesth 24(8) 825). Know you are all going to say – hey just Glidesdcope them – but I am one of those old fashioned types that find the Glidescope hard to use – I do not like the angle.
TBTR: All blades can be used to intubate children.
Lawyer: “Now sir, I’m sure you are an intelligent and honest man…”
Witness: “Thank you. If I weren’t under oath, I’d return the compliment.”
Blood Pressure Measurements
Should you wait one minute between repeated BP measurements or just take it again immediately – this study says it doesn’t matter (Blood Pres Monit 19(4)203). Get this journal it is really a fun journal and will help your reputation as a fun academic
My experience is that the second reading is usually lower but that can be from a lot of reasons.
TBTR: Repeated BP measurements – no need to wait.
Lawyer: “Do you know how far pregnant you are now?”
Witness: “I’ll be three months on November 8.”
Lawyer: “Apparently, then, the date of conception was August 8?”
Witness: “Yes.”
Lawyer: “What were you doing at that time?”
Takotsubo Cardiomyopathy
Speaking about stretching to find a journal – Takotsubo’s CM does occur in kids, but we are still in the case report stage. What occurs in this syndrome in kids? I wish I could tell you – this was one of the few cases I couldn’t get accesses to this journal (Card Young 24(4)580). However, we can speak more about this syndrome.
Lawyer: “Do you have any children or anything of that kind?”
Honey for Promotion of Wound Healing
We have mentioned it before, but honey does have antimicrobial properties (flavonoids, acidity, lysozymes) and as such does seem to help healing of wounds (Am J ther 21(4)304). I am still skeptical – while the theory sounds great, the research is not. We need a good study.
There was a similar article more than ten years ago that reported the same in the Journal of Wound Ostomy Nursing. So maybe it could be used on ostomies and stomas – just don’t lick it off.
TBTR: Honey may help wound healing.
The evidence for it is not quite a category B (bee) – (that was terrible Leibman).
Alright, we’ll say it needs a lot of support:
Playtex 36DDD underwire bra style 4732 full coverage beige See original listing
Playtex 36DDD underwire bra style 4732 full coverage beige
Photos not available for this variation
Item condition:Pre-owned (from Ebay)
Lawyer: “Have you lived in this town all your life?”
Witness: “Not yet.”
Hand Hygiene
I guess there is hope – after last month’s article about no one washing their hands – this study from Bangladesh did find that bar soap or soapy water or even water alone significantly reduced coliform counts. (although water alone did the worst among all the other forms – I think that might be related to the power of the water coming out of the spigot). Interestingly; time of scrubbing – as long as it was for more than 15 seconds – didn’t make a difference (Am J Top Med Hygiene 91(2)415). This of course is not a patient oriented outcome – did this really reduce disease? But it is progress.
TBTR:
Lawyer: “Are you married?”
Witness: “No, I’m divorced.”
Lawyer: “And what did your husband do before you divorced him?”
Witness: “A lot of things I didn’t know about.”
Urinary Tract Infections
Gosh I wanted this article years ago. Know anyone with smelly urine? This could be Aerococcus urinae – a cause of smelly urine in adults and now in kids – although not thought to be dangerous (there are a few case reports of sepsis from it). Most assays will miss this – but consider it. Penicillin treats it just fine. Interestingly enough – it has only been reported in boys. Wonder what it smells like? Well, the article says like smelly fish, or I would say – like honey on an osteotomy site (Eur J Peds 173(8)1115).
TBTR: Know someone with smelly urine – poor you – give them PCN.
Lawyer: “Did you ever stay all night with this man in New York?”
Witness: “I refuse to answer that question.
Lawyer: “Did you ever stay all night with this man in Chicago?”
Witness: “I refuse to answer that question.
Lawyer: “Did you ever stay all night with this man in Miami?”
Witness: “No.”
Hybrid Cars and Motor Vehicle Accidents
I just got a hybrid car – a Honda Jazz
and indeed these are subject to safety debate – they are so quiet that pedestrians can’t hear them and this could lead to accidents. The solution? Add noise making devices
(Ann Emerg Med 64(2)196). Maybe, but these do increase noise pollution and are unlikely to help much on busy urban streets with lots of background noise. My solution? Drive carefully and realize that bicyclist under your fender has a right to the road as well.
TBTR: Hybrid cars are so quiet they may cause more accidents to pedestrians.
Lawyer: “How did you happen to go to Dr. Cherney?”
Witness: “Well, a gal down the road had had several of her children by Dr. Cherney and said he was really good.”
Loop Drainage Technique for I&D
Listen to this wild idea – loop drainage for abscesses.
Well, it isn’t so new, and they feel this is less painful since there is no need for packing changes, less follow up visits and less pain from packing (JEM 47(2)188). Hey wait a minute – who says abscesses need packing in the first place? Or packing changes at all? Or follow up visits?
TBTR: Loop drainage is an option in treatment of abscesses.
Lawyer: “Mrs. Jones, is your appearance this morning pursuant to a deposition notice which I sent to your attorney?”
Witness: “No. This is how I dress when I go to work.”
Trauma Surgery
Here is another bunk article – hey – trauma is a surgical disease from cradle to grave according to them. Do these surgeons read their data before they publish it??? 54.6% of trauma admissions needed surgery – I ask – did they really need the surgery?. They also ignore that this is a big drop in trauma admissions from 10 years ago and the trend continues. But when they analyze this – most of these surgeries were orthopedic – trauma surgeons were involved only in 17% of the other cases – not too impressive (J Trauma 77(2)219). Best bet – avoid reading this journal.
TBTR: I don’t care what anyone says – trauma is not exclusively a surgical disease.
The Court: “Now, as we begin, I must ask you to banish all present information and prejudice from your minds, if you have any.”
Cortical Processes Underlying Decision-Making
Here is our Ken article for the month. Someone who seems to know how the brain works points out that consciousness lags a half a second behind brain activity. Basically that means that we don’t act first with our conscious – rather with our subcortical mesolimbic system. Risk/reward reigns here, or in other words – emotion is the first step in our decision making. So this author makes the point that even in medical decision making – emotion is first – that is; it has to feel right as well as make sense (JGIM 44:704). This journal seems to have great articles and they are free access – although they have little on IM for an IM journal.
Lawyer: “When he went, had you gone and had she, if she wanted to, and was able, for the time being excluding all the restraints on her not to go, gone also, would he have brought you, meaning you and she, with him to the station?”
Other Lawyer: “Objection. That question should be taken out and shot.”
Metronidazole for Mononucleosis
Neat study although way too small to conclude without a doubt – but it may be worth a try. Metronidazole – in patients admitted for mono – improved their outcomes and led to fewer days of admission (Clin Micro Inf 20(7)O450). This may be, but it only saved a day. And it isn’t clear to me who get’s admitted with mono in Ireland – where they did this study. Still, they feel there is some interaction between the virus and the bacteria on the tonsils – including causing the immunoglobulin to fall off the bacteria and allowing them to go wild (but this may be worth a chance).
TBTR: Flagyl for mono? Could it be?
Lawyer: “And lastly, Gary, all your responses must be oral. Ok? What school do you go to?”
Witness: “Oral.”
Lawyer: “How old are you?”
Witness: “Oral.”
Suturing Techniques and Cosmetic Outcome
This article looks at the best cosmetic results – it seems that sub-cuticular sutures produce the best results. (J Drugs Derm 13(8)967). I checked in my Barry Brenner’s Emergency procedures book and also on lacertionrepair.com and they all agree with this article – it still gives the best outcomes. Basically what this is is using your nylon completely underneath the skin with it exposed only at the beginning and the end of the laceration. However this requires a lot of time and effort, the sutures also must enter and exit the dermis at the same level – not easy. Also – the website asks – this may be irrelevant nowadays when we have glue closures. Also you will still need extensive subcutaneous work to close deeper lacerations. My opinion – do sub-Q work and then close it with glue. Will it bill the same? I do not know – in my clinic I can bill the same as if I closed it with nylon sutures.
TBTR: Have the time? Sub-cuticular sutures give the best results.
Lawyer: “Now, doctor, isn’t it true that when a person dies in his sleep, in most cases he just passes quietly away and doesn’t know anything about it until the next morning?”
Pyelonephritis in Pediatric Patients
Here is some Cochrane for those who really need to get a life. Pyelo in kids can damage kidneys. However, shorter courses of IV therapy followed by oral and even better – oral therapy from the start (which is just as good as IV) will make your child healthy and happy. If you do go IV; genta once a day is fine (maybe even consider IM) (Cochrane Database 7:3772).
TBTR: Pyelo in kids – treat like adults.
Lawyer: “Did you tell your lawyer that your husband had offered you indignities?”
Witness: “He didn’t offer me nothing. He just said I could have the furniture.”
Whooping Cough
I guess if you do not know much about whooping and want a good journal article to make you brilliant this may help (in my case nothing helped to make me brilliant but I had a lot of help to be stupid). They make a few salient points but most of them we have reviewed in the past. It is caused by bordetella pertussis but other cousins – like b. parapertussis and b. bronchieseptica can also cause a milder version of pertussis. B. holmesii affects adolescents and b. brochispetica can cause kennel cough which may interest you if you are a dog.
It has a long incubation period and people are most infectious during the catarrhal and spasmodic cough stage, but this is a hard call to make in most adults and by the time you do, the patient has infected a lot of people and it is too late to treat anyone. Macrolides and TMP-SMZ are the treatment but they have no role as prophylaxis (Chest 146(1)205). I think the key here is just to think about this in adults with an extended cough (although probably little you can do about it and furthermore, cough is normal for three weeks after any respiratory infection including viral), but more importantly, consider in parents of young children. And remember, new guidelines dictate the immunization of pregnant women (aren’t they all women?) between the 27th and 36th week. This for every pregnancy. This is thought to restrain the spread of this disease.
TBTR: Some new stuff (not really) on pertussis).
Lawyer: “Any suggestions as to what prevented this from being a murder trial instead of an attempted murder trial?”
Witness: “The victim lived.”
Takotsubo Cardiomyopathy, continued…
I would really be surprised if you didn’t know about Takotsubo’s cardiomyopathy (especially after reading number 12 above) – it would just break my heart – these are basically patients that have a severe transient cardiomyopathy which is usually brought on by stress. However, most criteria require absence of obstructive coronary disease, and this article says that there is now evidence for this syndrome in patients who do have a prior history of cardiac disease (Int J Card 174:408). Hard for me to understand how they can tell this, but the echo may help – since it takes the shape of the Japanese fishing pot – called Takotsubo in Japanese (the syndrome was discovered by a Japanese doctor but his name was Sato). Probably – this is all a continuum.
TBTRR: Takostubo’s can occur in patients with cardiac disease.
Lawyer: “The truth of the matter is that you were not an unbiased, objective witness, isn’t it? You too were shot in the fracas.”
Witness: “No, sir. I was shot midway between the fracas and the naval.”
Pleural Effusions
Pleural effusion – let me just give my emergency viewpoint – I don’t care if they have an exudate or a transudate – if they are short of breath I am tapping them, if they are not, I will admit them for further workup. Just recall that there are some causes that tend to get forgotten – for example, pancreatitis, endometriosis, Meig’s syndrome, ovarian hyperstimulation syndrome (there is also something called testicular over-stimulation syndrome – I think this is what Bill Clinton has). Interestingly – guidelines advise ultrasound to help the tap, however, a recent study showed no benefit of using ultrasound. Of course, this all depends – on small effusions, I would like ultrasound, on big ones – it really doesn’t matter. All that stuff they taught you in med school is rather useless – friction rubs have a sensitivity of 5.3 %. Fremitus is the only one that breaks the 80% sensitivity. Here are some meds that can cause pleural effusion – amiodarone (that rat – I hate that medication), beta blockers, ergots, methotrexate, nitrofuratoin, and phenytoin (AFP 90(2)99).
TBTR: Some pointers on pleural effusion.
Lawyer: “Could you see him from where you were standing?”
Witness: “I could see his head.”
Lawyer: “And where was his head?”
Witness: “Just above his shoulders”
Letters
Kudos to Debbie West who I bumped into (she’s wasn’t hurt) in Beer Sheva and she was kind enough to tell me how she enjoyed the January EMU. Gosh, if she reads this stuff what does that say for our Boy’s Club?
Clinical Quiz
Well there was none this month so you probably did very well.
Judge: What’s the problem?
Bailiff: Nothing your honor, just a cockroach on the table
Defense Attorney: Motion to quash
Judge: Granted
EMU LOOKS AT: The Purim Issue
Yes, it’s that time of the month. Actually of the year. The Purim issue is our chance to laugh at the medical literature. Everything you see here is completely true and has been published in real journals. Wanna have more fun? Read the old Purim issues. Let’s get started:
Lets’ start by poking fun at our stuffy source for all medical articles – this is a real page from Pubmed:
See comment in PubMed Commons below
Ann Intern Med. 2014 Mar 18;160(6):JC12. doi: 10.7326/0003-4819-160-6-201403180-02012.
Review: some clinical tests performed by specialists identify rotator cuff disease or tears.
Margo K.
Comment on
Use of oral fluconazole during pregnancy and the risk of birth defects. [N Engl J Med. 2013]
Use of oral fluconazole during pregnancy and the risk of birth defects. Mølgaard-Nielsen D, Pasternak B, Hviid A. N Engl J Med. 2013 Aug 29; 369(9):830-9.
PMID: 24638178
[PubMed – indexed for MEDLINE]
In case this was too subtle for you – see the name of the article (something about shoulder tears) and the comment on this article (antifungals in pregnancy – now do I have to explain everything to you??)
Hey which would your kid prefer from a blown up glove in the ED – the Jedward or the Mohawk? Relax, you don’t have to talk to your kids (especially if they are over thirty), just read this article which gives unconvincing evidence that kids like Jedward. (EMJ 31:327)
Really have no idea how they proved this but if you are taking clozapine – lay off the BRAT diet, I mean this drug can cause you to have constipation and that can cause a respiratory arrest, man! Med Sci Law 54(2)105. Yea, so there is another dangerous cause of asystole – head scratching (Heart Rhythm 10(11)1728). This lady discovered this while at the beautician. Beauty parlors are dangerous places – I avoid them!
Ah yes, those French – a clever bunch. 6 French investigators watched 18 episodes of Dr. House and determined that it is not a realistic show. Sacre Bleu! They did an MRI in nearly every episode! Why should this bother us? Because the French, the authors explain, may get confused and not realize that we are not all like Dr. House. Well maybe except for the Vicodin thing (Am J Med 126(2)171).
If you remove your pubic hair, your incidence of lice is going to fall precipitously. So will the lice fall on to the floor? “Pubic Lice: An Endangered Species? (Sex Trans Dis 41(6)388). Doesn’t mean you won’t find a different reason to itch there. Just don’t scratch your head! Speaking of uteruses: Hi dear!
Do I have to continue? Summer Penile Syndrome -yes that edematous, itchy penis you weren’t sure what to do with (we are speaking about edema, don’t get the wrong idea – I know you know what to do with one that is edamatous for other reasons). This is due to chigger bites and little boys get this (JEM 46(1)e21). Just be careful not to get bitten. On a not similar subject at all: Size Matters (Injury 45:232). It is talking about traumatic wound size, you pig!
Gentlemen, we have to have a serious talk about pains in the a** Yes I am talking hemorrhoids. Heard about the THERESA-3 Trial? They found that streptokinase worked so much better for hemorrhoids than phenylneprhine. Since thrombolytics are often used for stroke, I think we can easily deduce that if your head is in your a** you can treat both with the same remedy (World J Gastro 20(6)1594). But everyone prefers natural meds so try this one from Nigeria (Trop Doc 43(4)158). They send up a wine bottle to treat hemorrhoids. And they don’t always succeed in getting back down. They made a slight mistake here too – the docs did a digital rectal exam and the finger of the examiner was lacerated by the bottle which broke inside. I think I have said enough. But we aren’t done yet. Diaper dermatitis can be tricky – so some places use hydrocortisone – like in Iran. But these guys thought of a better idea. How about just rubbing some breast milk on the area- and voila! Worked just as well (Ped Derm 30(6)725). I cannot say if that would work well on hemorrhoids but it may be worth a try.
Time for the other side. What they told Israel in 1948, the USA in 1776 – urination! (if you didn’t get that please write me immediately – and do not go out in public by yourself). Pissing bullets is not just a sign of a urinary tract infection – you can really pass one if you have been shot in the past. This guy was shot in the buttocks and they couldn’t find the bullet. Then again if you are being shot in the pelvic region, perhaps you need to worry about other things besides pissing bullets (JEM 45(3)e59). While we are in the neighborhood, amiodarone may also cause epididymitis – shows where your heart is (Cardiology 128(4)349).
Dedicated to everyone’s friend W Rick Bukata whose obsession with titles has made this part of the issue possible
Doctors: Caring Extroverts or Self Deluded Chocoholics? (BMJ349:g7623)
With apologies to John Steinbeck: Of Lice and Men (JAMA Derm 150(3)250)
Queer Challenges to Evidence Based Practice (Nurs Inq 21(2)101); This is actually about the Queer Theory – I better not continue.
Diabetes Damp Casts and Hair Dryers Are Not a Good Combination (J Am Pod Med Assoc 103(3)243). Here is the real use for your wife’s hair dryer and iron. This article is a follow to my article in the same journal: shoes, teenage daughters, and my credit card are not a good combination.
A novel trauma model: Naturally Occurring Canine Trauma (Shock 41(1)25)
Renal Failure in A Soldier taking NO-xplode (J Am Board Fam Med 27(4)565)
Pattern of Spine Fractures After Falling from Walnut Trees (World Neurosurg 80(5)e41). Man, you just got to be careful.
An in Depth Analysis of a Piece of Sh*t (PLoS 6 (12)e1969). This is speaking about Schistosoma eggs and not your hospital administrator.
Shock whilst Gardening – Implantable Defibrillators and Lawn Mowers (QJM 107(2)147)
Are We Drunk Yet?(Alcohol Clin Exp Res 38(2) 538)
Some Fine Wines…
Father Greg on his Risk Management monthly program (couldn’t miss giving a plug for it) ends each episode with the wine of the month, so we will as well – being that this issue is dedicated to him. . He did not like when I suggested my personal favorites – Ripple and Thunderbird. Here are some real reviews for these classic wines. This is the type of wine review we need to see on RMM, Father (from proudstallions.com).
An Evening of Bumwine or We Never Learn
I’ve always had a fascination with skid row alcohol, starting with my first bottle of Thunderbird wine when I was 20. Joking around about it with Chris from Morbidpig, one of us came up with the bright idea of having a bum wine tasting party.
The two of us perused the wine selections of the finest Gas Stations and Mission area Liquor stores across the US and came up with our selection.
Wine #1 : Black Cherry Cisco
Chemicals, that’s the best word I can use to describe the smell of opening up a bottle of this crap. It made me queasy while we were pouring it. The taste is unbelievably discordant, a mixture of melted records, cough syrup,vodka and more cheap grain alcohol, just for good measure.
I accidentally managed to give myself a Texas sized portion of this junk. Thinning out my last gulp with tonic water made it milder. When we were done, I noticed my head was spinning terribly, this was my first drink. My “after beer” was the best beer I ever had.
Over All Rating: F – “Out of my House you spawn of Satan!”
Wine #2 :MD 2020
“Mad Dog” 2020 has a reputation that precedes itself; most people know it by name. I don’t have an appreciation for red wine but MD 2020 is actually not half bad. Chris even had a second helping. I’m not going to bring it to my next family function or anything but it was a refreshing change from Cisco.
Over All Rating: C – “The prettiest girl in the bar”
Wine #3: Thunderbird
Ah, the American classic, I’ve had this bottle for as long as I can remember, so it’s a nice vintage. I had forgotten just how rough a wine Thunderbird really is mostly because it looks so pleasant. A bastard product of the Gallo wineries, Thunderbird has a strong kick and it burns all the way down. Comes in a bottle, belongs in a mason jar. At this point, I was feeling no pain.
Over All Rating: D – “This bird pooped in it’s own nest ”
Wine #4: Strawberry Cisco
Chris had purchased three bottles of this, possibly the most insipid flavor ever. If either of us had forgotten the Cisco of earlier this was gut punch to our memory. Not only is this the worst wine ever, it makes you feel like you’re licking a Strawberry car air freshener. I was smarter this time and poured myself less, it still felt like gallons.
Over All Rating: F – “Tastes like the blue stuff you dip combs in ”
Chris had similar experiences the next day and we both agreed that this in one idea we’re not going to repeat. Unless we find a bottle of vintage ripple that is…
Overall Rating: D “This bird pooped in it’s own nest”
– hey they fit my budget and they come with a free paper bag. But I’d like to start a new feature in EMU –write me with the whine of the month – here is the first – “My burps smell like farts.” From a 16 year old girl, accompanied by her “I’m a lawyer” father. Symptoms since birth. Came to ER for diagnosis since “none of the other quacks know what is going on.”
Well that’s this year in review of the literature, we at EMU have always found the literature funny – so we will continue to bring you the best of medical articles – sincerely – the editorial team here at EMU. And just to leave on a high note, let us quote Randall Powell from the movie, Life in the Doghouse:
Randall to co-star Jane Stewart: Why is it that when men do it it is like the fourth of July and for women it is like having brussels sprout juice on the Rocks?
Randall trying to convince Jane: You know when I married you there where thirty other females I could have chosen – some were even mammals.
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