Diagnosing PE in the ED
Most of you do read the Annals if you live in the USA – but a lot of my foreign readership does not, so I will take the rare step and mention a couple of Annals articles which actually dealt with interesting issues. So this guy Penaloza wanted to see if clinical gestalt was better than the Well’s score and the revised Geneva score. Indeed clinical gestalt triumphed – both in identifying low and high risk patients and also actually presence of pulmonary embolism (Annals Emerg Med 62(2)117). I want to agree, but there is a problem here — whose clinical gestalt was this? And all of us agree we use clinical gestalt that has some of the elements of the scores; like Well’s score for example – many of its components probable are ingrained in our clinical gestalt. At this point I would like to echo
Prof Hoffman’s comment – that many people think if you thought about PE – you must rule it out. He says – there is a difference between low risk and no risk. No risk needs no rule out.
TAKE HOME MESSAGE: Best score for considering PE – your brain. My peer reviewer adds – a negative PERC rule is a less than 1.8% chance for PE. This is great as it would reduce the need for that D dimer test that I personally detest – it is frequently positive and takes so long to come back.
Imaging Undifferentiated Abdominal Pain
Well you know that you do not need oral contrast for CT to evaluate undifferentiated abdominal pain in the ED. And it really decreases throughput. Use of oral contrast just does not change ED diagnosis (Emerg Rad 19(6)513). The difference is that this article was done by radiologists in their journal. So pass it on to your rays guys – if they need some convincing this fellow can help. Or maybe this fellow:
TAKE HOME MESSAGE: No oral contrast in undifferentiated abdominal pain in the ED.
Is he…dead?
Back to the Annals – when is a person really dead? We used to say when we see no cardiac activity on ultrasound, then the patient is dead, but in this article there was a survival rate of 2.4% even for those with no activity on ultrasound (Annals 62(2)185). If you are in doubt – a simple procedure will confirm death with 100% reliability – decapitation.
TAKE HOME MESSAGE: Ultrasound is not 100% in detecting cardiac standstill.
Well it is quote timec- after last month’s fiasco with late nite quotes, it is time for world leader quotes – let’s start with everyone’s favorite Prince Phillip -
the husband of the Queen of England.
“If it has four legs and is not a chair, has wings and is not an aeroplane, or swims and is not a submarine, the Cantonese will eat it.” (1986 statement as quoted in “Long line of princely gaffes” BBC News (1 March 2002))
“People usually say that after a fire it is water damage that is the worst. We are still trying to dry out Windsor Castle.” (Said on a visit to Lockerbie in 1993 to a man who lived in a road where eleven people had been killed by wreckage from the Pan Am jumbo jet)
“You managed not to get eaten then?” Said to a British student in Papua New Guinea
Urinary Tract Infections
Honestly, could I say anything new on UTIs? We know the basics – don’t use TMP SMZ; when UTIs recur it is due to wiping the wrong way, wearing nylons, and not drinking enough cranberry juice. All of these are actually wrong. TMP SMZ is still a good antibiotic in some places; cranberry juice works very modestly and the rest are just plain not true. Recurrent infections are due to the ability of good ‘ole E coli to infiltrate cells in the bladder and stay dormant there until the opportunity comes knocking to come out again. With ESBL here – this is even more significant. So now we are looking at medications that do not allow this penetration to happen. Also, they are working on a vaccine – however, still with no success (CID 57(5)719). I would like to know how this explains why UTIs are more common in females – does the velocity theory that pushes these bugs out still hold?
TAKE HOME MESSAGE: UTIs – they stick around – this is not a drop in the bucket.
Honestly, could I say anything new on UTIs. Yeah well, this wasn’t the only article this month on UTIs. We said that nylons, delayed urination (urination – what they told Israel in 1948), wiping, warm baths – none of that causes more infections – but all the studies that proved this wrong were small – could be a bigger study will show benefit. Spermicides and condoms do make more infections. What you may think about to help older women is topical estrogens to help when they have relations (aunt, uncle, etc). Another thing I didn’t know was that even though quinolones are not the first line – ciprofloxacin is better than Augmentin for UTI – even if the bug is sensitive to Augmentin.
TAKE HOME MESSAGE: Having relations is a dangerous thing (Med Clin Nor Am 97(4)581).
“You are a woman, aren’t you?” After accepting a gift from a Kenyan woman, as quoted in “Long line of princely gaffes”
“How do you keep the natives off the booze long enough to get them through the test?” Asked of a driving instructor in Scotland
Can you hear me now??
Mobile phones do not increase your risk of glioma. Or any other brain tumor either with the exception of acoustic neuroma. This huge study had almost 800000 people in it and was prospective (Int J of Epid 42(3)793). Want to have quality time speaking with your teenage daughter – just call her on the cell phone – if it isn’t busy all the time.
“Do you know they’re now producing eating dogs for the anorexics?” Said to a blind, wheelchair-bound woman who was accompanied by her guide dog .
In 2003 he told a robed president of Nigeria, Olusegun Obasanjo: “You look like you’re ready for bed.”
Refractory V-fib
I have this fantasy (actually I have many fantasies but I can’t speak about them now) that some where this information may help someone – it did for someone in Australia. So you got this guy with dilated cardiomyopathy and a 20% ejection fracture. So he has this annoying habit of going into Vfib- so they start amiodarone and put in a ICD. He develops thryotoxicosis so they stop the amiodarone – ablation didn’t work, so they ripped out his thyroid and put him back on amiodarone – but the shocks continue so they give him lidocaine and he gets looney, so they stopped that. They haven’t got Mexiletine or Tocainide so they come up with a fine idea – use phenytoin – what we used to use for Torsade. And it worked (MJA 199(3)209). It is indeed a 1B drug so you can use it – if you still can find it in your ED.
TAKE HOME MESSAGE: Phenytoin may still be a good antiarrythmic.
On seeing an exhibition of “primitive” Ethiopian art, he muttered: “It looks like the kind of thing my daughter would bring back from her school art lessons.”
The Duke said to Tom Jones-the singer – after his Royal Variety Performance: ”What do you gargle with, pebbles?”
Access to Medical Journals
And for our last foray into the Annals- but this is so important- Open access journals are important. We– who strive to be the best physicians we can be (that’s why we read EMU) – should have access to the many journals that are relevant to us and have all the information we need to serve our patients. On the other hand who is going to pay? The old system was the ridiculous pay per view – where access to an article from 15 years ago remained as expensive as a new one. Want to subscribe to Ovid yourself and get access to 100 journals – be prepared to pony up a few thousands of dollars. Industry should not pay – that is like getting your wife and your mother in law in the same deal (EMU will remain one access until we find someone nuts enough to pay for this stuff). So many open access journals have pay per article – put on the author. PLoS has provided a quality journal this way, as has BMC, but now many junk journals (think – EMU) are coming out charging for article submission (EMU doesn’t but it should), and then publishing without even peer review. This is advantageous to authors – they get published which helps academic advancement (the only way to become a professor in my country), but is morally wrong (actually IMAJ works this way too). Indeed, in this article someone created a program to produce a grammatically correct article with no content. It was submitted to the Open Information Science Journal and after getting their $88 fee – they published it – despite there being no content and the author’s claim to be affiliated with the Center for Research in Applied Phrenology (check out the first letter of each word and put it together) (Ann Emerg Med 62(2)14a). Personally, I think the government should pay for this – it is a small price to pay for good physicians.
TAKE HOME MESSAGE: Medical research should be open access – but watch out for junk journals.
On being offered fine Italian wines by Giuliano Amato, the former Prime Minister, at a dinner in Rome, he is said to have uttered: “Get me a beer. I don’t care what kind it is, just get me a beer!”
“If it doesn’t fart or eat hay then she isn’t interested.” - speaking about his daughter, Princess Anne.
Ankle Sprains
I tried- I couldn’t find access to this article (see above, huh!) but if you deal with sports medicine – it is guidelines for trainers on the management and prevention of ankle sprains as well as when to return to play ( J Ath Train 48(4)528). Just recall complete rest is no longer recommended. Dan Qualye was actually a vice president of the USA,
He had a little trouble with his brain – here are some examples:
“If we don’t succeed, we run the risk of failure.”
“Republicans understand the importance of bondage between a mother and child.”
CT versus V/Q in the Pregnant Patient
Let’s clear this up: PE in pregos – the V/Q scan has more radiation than CT, but has less if you only do the perfusion – which is all we do in many places. The CT has less danger to the fetus, but more to the breast. CT of course provides more detail. With the V/Q scan – the isotope concentrates in the bladder – not a great idea for the fetus. Of course – in all stages of pregnancy- a chest film is safe. If it is abnormal, V/Q is not a good idea (Sem Perinat 37(4)225).
TAKE HOME MESSAGE: Do CT in pregnant patients if you think there might be a PE. Chest films can be done freely.
“One word sums up probably the responsibility of any vice president, and that one word is ‘to be prepared.’ “Welcome to President Bush, Mrs. Bush, and my fellow astronauts.”
Clinical Quiz #1
Hey here is an easy case for you-we’ll give you the harder one soon. So you have this Asian fellow who was just working out, and starting feeling really weak. He is healthy other than having Graves’s disease. You probably know what he has, but be careful treating this (JEM 45(3)338).
“The Holocaust was an obscene period in our nation’s history. I mean in this century’s history. But we all lived in this century. I didn’t live in this century.”
Hand Sanitizer Ingestion
Those ethanol based hand sanitizers- they present a case where a wino drank a bottle – got himself to an alcohol level to 526 and died (ibid p358). I do not believe this will be featured any time soon as wine of the month by father Greg, but I am sure he will want anything that will get him to 526. As for me – that was my total SAT score.
“We’re going to have the best-educated American people in the world.”
“We have a firm commitment to NATO, we are a part of NATO. We have a firm commitment to Europe. We are a part of Europe.”
Fresh versus Salt Water Drowning
I can not say this article added much to drowning – I just do not think there is anything new in the treatment. However, in their study- salt water drowning was an independent predictor of poor survival, although this may be a hard one to call – as fresh water includes a lot of pools where there may be more people around to start resuscitation faster (Resusc 8498)1114).
TAKE HOME MESSAGE: Drowning in salt water causes a worse prognosis
“I love California, I practically grew up in Phoenix.”
“We are ready for any unforeseen event that may or may not occur.”
The CHADS 2 Score
CHADS 2 scores – we have gone over this before, and in this study they want to use it to predict left atrial thrombi. A noble idea and indeed the higher the score – the higher the risk for a thrombus (AJC 112(5)678). However, even they admit an EF of less than 20 is the best predictor, and what is more worrisome – a CHADS of 0 still had a 2.3% chance of having a thrombus. Where will you use this? Where you do not have TEE available and you want to cardiovert a patient – I would say even in those less than 48 hours of PAF although they do not say so in the study – but if your CHADS is really high – you may want to be careful.
TAKE HOME MESSAGE: CHADS 2 scores that are high are correlated with higher risks of having a LA thrombus.
“[It's] time for the human race to enter the solar system.”
“The American people would not want to know of any misquotes that Dan Quayle may or may not make.”
Specialty-Based Intubation Success
We would like to kick out all the non EPs from the ED however, we must be realistic – many ED s are still manned by non EPs – Fps, IMs, and various other animals. In this study from an ED in Vienna staffed by IMs, they missed intubations about 25% on the first time, which isn’t great – considering that in other studies EPs missed only about 4% of the time (AEM 11(1)66). But this is a little unfair – the study of EPs measured airway failure and our study was first time failure. What is encouraging is that only 10% were intubated in our study with out RSI. And as can be expected-more problems were encountered with airway abnormalities and in physicians with less experience (AJEM 31(9)1338).
TAKE HOME MESSAGE: Get experienced at intubations and you will be good at it no matter what specialty you are.
I purposely did not speak about the Glidescope and the King etc. because many people don’t have the resources for these and also, they too take experience to learn how to use. Now let’s proceed to Winston Churchill -
one of the great quote makers of all time.
“A fanatic is one who can’t change his mind and won’t change the subject.”
Bessie Braddock: “Sir, you are drunk.”
Churchill: “Madam, you are ugly. In the morning, I shall be sober.”
Ruling Out Pediatric Appendicitis
This is a joke.
They decided to use a marker system to rule out appendicitis and therefore save kids from evil CT radiation. They used WBC, CRP, and myeloid related protein complex (ibid 1368). But it still missed 4%, and the specificity looked terrible. Of course negative predictive value and negative likelihood ratios looked great but this is not what we want to know – those measures are great for the total population but not for the particular patient before our eyes. My solution? Just do the ultrasound!
TAKE HOME MESSAGE: Do the ultrasound to rule out appendicitis, not scoring systems.
Nancy Astor: “Sir, if you were my husband, I would give you poison.”
Churchill: “If I were your husband, I would take it.”
Clinical Quiz #2
OK, here is the case you have absolutely no chance at. If you get this right, you get to write EMU next month – I quit. This Hispanic fellow has been in the ED a lot for the same thing and no one got the diagnosis yet – he has chemosis in his eyes and visiual loss as well as hearing loss. OK, genius I s- what is this? If you do not know, you got to stop working in the ED and doing intubations( ibid E1). If you are going to go through hell, keep going. It is a good thing for an uneducated man to read books of quotations (or EMU).
LBBB
I told you so! Remember our little discussion about LBBB last month? (no, not the one with laughter induced LBBB). These cardiologists are scared. The new AHA guidelines left out new LBBB as an indication for TPA or rapid PTCA, and many folks could die – so these docs want to make a new algorithm. Which they do – and the first thing is – an unstable patient with an MI or CHF in MI. This is exactly what we told you last month – new LBBBs in MI look bad because they are bad – it is a high grade obstruction in a major vessel (LAD or left main). Their second criteria is to check Sgarbossa criteria which most of us do not find useful (AHJ 166(3)409). I think that you should just leave it to the cards guys to worry about it if the patients looks good and has a normal troponin – LBBB could always be old as far as I am concerned.
You have enemies? Good. That means you’ve stood up for something, sometime in your life. You can always count on Americans to do the right thing—after they’ve tried everything else. Hi Axel – this is what you wanted but it comes from a Brit.
Antidepressants and Suicide Risk
I hesitated to bring this article – most of you already subscribe to this journal (I think it comes in a plain brown wrapper) but it raises a good point between the girlie pictures. Bipolar suicide risk is not increased by antidepressants – it was suggested in some articles, but the evidence is really flawed. Antiepileptics – no evidence here either that there is an increase in suicide risk. Only lithium will reduce suicide risk. So yes –we need better studies (Bipolar Disorders 15(5) 594).
TAKE HOME MESSAGE: Antidepressants may or may not increase suicide risk – we just do not know.
A modest man, who has much to be modest about. (On Clement Atlee)
I am ready to meet my Maker. Whether my Maker is prepared for the ordeal of meeting me is another matter.
Long Acting versus Daily Antipsychotics
Let’s get out of bipolars and switch over to schizophrenia – long acting antipsychotics – injected once a week or month are more effective in preventing ED visits and hospitalizations than daily oral doses (BMC Psych 13:221).
The best argument against democracy is a five-minute conversation with the average voter.
Hitler knows that he will have to break us in this island or lose the war. If we can stand up to him, all Europe may be free and life of the world may move forward into broad, sunlit uplands. But if we fall, then the whole world, including the United States, including all that we have known and cared for, will sink into the abyss of a new Dark Age made more sinister, and perhaps more protracted, by the lights of perverted science. Let us therefore brace ourselves to our duties, and so bear ourselves that, if the British Empire and its Commonwealth lasts for a thousand years, men will still say, “This was their finest hour!”
Cover Your Mouth.
If you do not read anything else this month – read this article. If you can’t read – then skip this paragraph. You are a slob if you cough and do not cover your mouth – that used to mean your hand –then it meant your forearm – but none of this is too effective- the viruses are winning this battle; considering you only need about 5-10 particles to infect your neighbor (BMC Pub Helath 13:811). That’s it -we gotta double mask no matter how ugly she is.
TAKE HOME MESSAGE: Cough on those folks who bother you.
Now to Ronald Reagan who had an interesting way of expressing himself.
“A hippie is someone who looks like Tarzan, walks like Jane and smells like Cheetah.”
“I have left orders to be awakened at any time in case of national emergency, even if I’m in a cabinet meeting.”
Treating Acute Pulmonary Edema
Just when you thought it was safe to go out – there really is no evidence that NTG is any better than furosemide for acute pulmonary edema, nor does it work any faster (Cochrane 8:5151 2013). But don’t go for this yet. This is based on only one study that used NTG with NAC compared to Lasix and morphine. And the convoluted abstract says in one place that NTG causes fewer side effects at three hours than placebo, and in another – more side effects. I was always taught that diuretics take their time to work – NTG works fast.
TAKE HOME MESSAGE: I still like NTG. I never allow the facts to get in the way of what I like to do.
“Government is like a baby. An alimentary canal with a big appetite at one end and no sense of responsibility at the other.”
“The nine most terrifying words in the English language are, ‘I’m from the government and I’m here to help.’”
IV Antibiotics at Home
Try giving those IV antibiotics at home. Bone and joint infections, endocarditis, cellulitis – all these do well with home administration of IV antibiotics if the patients are healthy otherwise and stable. These antibiotics are especially well suited because of their longer duration: ceftriaxone, teicoplanin, ertapenem, and daptomycin (Eur J Int Med 24(7)617) . I have to say, it has been along time since I admitted a cellulitis patient.
TAKE HOMEMESSAGE: IV antibiotics at home – at least the food is better than in the hospital and the patients do fine.
George Bush – one of the favorite orators of the English Language:
“I couldn’t imagine somebody like Osama bin Laden understanding the joy of Hanukkah.”
“I know how hard it is for you to put food on your family.” – Greater Nashua, N.H., Chamber of Commerce, Jan. 27, 2000
Patient Advocacy
Hi Ken. Here is a nice story about the patients in a waiting room being observed by a physician who is waiting for the physician as well. I will not tell you the conversations that went on, but the conclusions are – don’t be afraid to intervene on your patient’s behalf – even if it is against another doctor (just do it courteously), and be patient centered. Understand your patients needs and be aware of patient advocacy groups that are intervening for this purpose (Acad Med 88(9)1191). This is all good, but I see two problems – one is that when we get to be “patient centered” we often enforce our own values and become paternalistic. I’ll just throw something at you – last week I got a frantic call from another doctor about a patient that refuses to follow up with him. The patient has rectal cancer and refuses to get treatment – he wants to treat it with natural meds. I invited the patient to come speak to me but he wasn’t interested. I left it – I can’t force my values on someone who isn’t interested – or can I? Secondly, many patient advocacy groups in my country become referral mills – receiving kick backs to channel the patients to certain doctors. I will also add to this article another one on how to handle difficult patients – but like most articles on this subject – it ignores different cultures and I do not think false empathy can control very abusive patients. I have yet to see one article that acknowledges that there is just sometimes that nothing works – and don’t feel bad about it (JFP 62(8)414).
TAKE HOME MESSAGE: Put your self in your patient’s shoes – but don’t make them wear yours.
However I do agree that we should get involved and not sit silently when we know something is not right. Not all the world is New York. And difficult patients – these pointers of empathy, nodding, and self disclosure may help but don’t feel bad if you fail. It happens.
“I know the human being and fish can coexist peacefully.”
“They misunderestimated me.”
Metal Fume Fever
Just a short reminder: welders – especially smokers – who arrive with shortness of breath – please consider metal fume fever. Not that the treatment is any different – they will need bronchodilators – steroids are of questionable benefit. However, what is interesting is the chest film – it often shows opacities that are just iron oxide deposits – and do not cause any problems (JEM 45(3)408).
TAKE HOME MESSAGE: Metal workers and welders with SOB and fever – think of metal fume fever.
“Families is where our nation finds hope, where wings take dream.”
“People say, how can I help on this war against terror? How can I fight evil? You can do so by mentoring a child; by going into a shut-in’s house and say I love you.”
The Changing Demographics of Bacterial Meningitis
This is really interesting – bacterial meningitis is becoming a disease of older adults. In 1986 – the average age for this malady was 15 months. This increased to 25 in 1995 and now stands at 42 (that’s an average, silly – it doesn’t imply that these are older adults). In the elderly, only 50% have meningismus and/or HA. Since confusion with fever is fairly common in old people – be more liberal with LPs. They add to be careful with Strep pneumoniae – it can be resistant to cephalosporins and PCNS, so consider Vanco or moxifloxacin (Curr Treat Neuro 15(4)477). In our country we use chloramphenicol – not clear why they did not mention this. And of course – do not forget the steroids.
TAKE HOME MESSAGE Meningitis is becoming a disease of older adults and not just kids.
Rarely is the question asked: Is our children learning?
“Too many good docs are getting out of the business. Too many OB-GYNs aren’t able to practice their love with women all across this country.”
Seizures in the Pregnant Patient
So she seized. That can be a sign that she really likes you or – if she is pregnant – eclampsia or maybe she has a seizure disorder – how do you tell? Proteinuria is not a help – there is plenty of preeclampsia without proteinuria. However, liver enzymes and the CBC are usually not normal. That may help (or HELLP as the case may be) ( J Ob/Gyn 33(6) 630).
TAKE HOME MESSAGE: Pregnant seizure – blood abnormalities will help tell you the sources.
Our enemies are innovative and resourceful, and so are we. They never stop thinking about new ways to harm our country and our people, and neither do we. Throughout our history, the words of the Declaration have inspired immigrants from around the world to set sail to our shores. These immigrants have helped transform 13 small colonies into a great and growing nation of more than 300 people.
Morbidity and Mortality in Female Patients Using Ecstasy
Women and ecstasy –this is not what you think – but for some reason in the 15 to 30 age group many – even after the first time – they can have a severe headache, coma, seizure, and death. Their sodium falls quickly below 130. This is all due to AVP and estrogens in the brain – but get chasing that Na if you see young women in coma after a rave ( Neprho Dial Transplant 28(9)2206). This may give us some more insight into the female brain – but it remains a mystery
TAKE HOME MESSAGE: Ecstasy and female – can be fatal even after the first time. Same goes with either by themselves.
While on the subject – ever use tropicamide for eyes? You know that mydriatic – well if you inject it, you get a rush, and that is now happening in Russia and Italy. They may get hallucinations, be comatose, get kidney pain, and of course mydriasis (Gen Hosp Paych 35(5)571).
“I remember meeting a mother of a child who was abducted by the North Koreans right here in the Oval Office.”
“We’ve got a lot of relations with countries in our neighborhood.”
Delta Troponin
I want to make this clear even though everyone should really know this. Delta troponin is acceptable already – even though we do not do this in our shop. What is delta troponin? You took the first troponin after six hours – but one is not enough- do a second an hour to an hour and half later- if it is the same or less: this is not an MI and if the story for acute MI is weak – you can let them go home. But this only works if the first troponin is normal – even if the second falls to zero. There are many people walking around with high troponins all the time and you can not use this for that (JACC 62(14)1239).
TAKE HOME MESSAGE: Use delta troponins only if the first one was normal.
Now to Ed Koch – former NY mayor – who died a year ago —
“I’m not the type to get ulcers. I give them.”
”If you agree with me on 9 out of 12 issues, vote for me. If you agree with me on 12 out of 12 issues, see a psychiatrist.”
The Fish Pedicure
Garra Rufa – these are foot pedicures by fish that will only eat dead skin.
They are the rage in Europe but in the USA – because of fear of infectious complications – they are illegal but there have never been reported infectious complications! Until now? Well here is a poor person who got MRSA in their toe from those critters (Infection 41(5) 1013). There is actually no proof from the article at all. They have no documentation of previous status and the patient just returned from Spain where he could have had gotten from anyone. So you can continue to get your feet chewed on by fish.
TAKE HOME MESSAGE: A fish pedicure – can life be any better?
“If they want a parade, let them parade in front of the oil drums in Moonachie.” After the New York Giants, who play in New Jersey, asked for a permit to hold a parade in the city after winning the Super Bowl in 1987.
”I know that nothing happens here on this Earth that wasn’t ordained by God. I know that. You know that. And therefore, while I know that it was the people who elected me, it was God who selected me.” In 1985, during an Easter Sunday worship in Harlem explaining why he thought he was selected by God to be mayor. The next day, Koch stressed that it did not necessarily mean he was endorsed by God.
Drink at Your Own Risk
Are energy drinks toxic? These authors think that it is the caffeine that is the problem-. But the numbers are not convincing. Red Bull only has 75 gm of caffeine while a Starbucks coffee on average has 180 gm. ENERGY has 200 gm – the toxic dose is 400 (Clin Tox 51 (8)729) . This would be fine but they ignore taurine which is converted to caffeine in the body – something that Starbucks does not have.
TAKE HOME MESSAGE: Energy drinks are probably not dangerous. Or maybe they are.
“The People have spoken … and they must be punished.”
The Fascia Iliaca Compartment Block
We have mentioned it before and I thank reader and all pro-educator Al Sachetti for first introducing me to it – the fascia iliaca compartment block which helps for pain control in hip fractures. Here is the schematic of the block
- simply puncture at the 2/3 mark starting from the pubic tubercle to the anterior iliac spine, and 2 cm caudal (see picture), after the first loss of resistance, continue to the second loss of resistance and puncture. The pictures in this article will help you. Do this. It isn’t too hard. P.S. Ultrasound can also help and makes it much easier to do.. (J Orth Sci 18:793) Here is how the FP notebook sees it:
Anatomy: Landmarks
Iliacus muscle
Originates at the ilium and joins with the psoas to form the iliopsoas muscle
Iliopsoas muscle runs under the inguinal ligament and inserts on the lesser trochanter of the femur
Iliacus and iliopsoas muscles are covered in a dense fascia (Iliacus Fascia)
Femoral nerve
Originates from the L2 to L4 nerve roots
Travels under the Iliacus Fascia (along with the lateral femoral cutaneous nerve and the obturator nerves)
Injection into the space beneath the Iliacus Fascia provides anesthesia for all branches of the the L2 to L4 nerve roots
Injection landmarks
Divide inguinal ligament into three equal parts
Mark lateral border of pubic symphysis (0 cm)
Mark at one third (approximately 3 cm)
Mark at two thirds (approximately 6 cm)
Mark anterior superior iliac spine (approximately 9 cm)
Injection site should be near the two thirds mark
Mark approximaly 5-7 cm mark (or 2-4 cm from the lateral margin)
Confirm position by palpating the femoral artery
Should be at least 2 fingerbreadths medial to the injection site
Images
Preparation
Technique
Efficacy
References
TAKE HOME MESSAGE: FIB is a better way to achieve pain control in hip fractures.
Marion Barry was the former Mayor of DC – he also had a little trouble with the English language:
“The contagious people of Washington have stood firm against diversity during this long period of increment weather.”
“The laws in this city are clearly racist. All laws are racist. The law of gravity is racist.”
Subsegmental PEs
Subsegmental PE – didn’t we just speak about this? Yes last month we did. But I can’t believe I was sober when we discussed this. Actually I can’t remember the last time I was sober. So here is an article on this by the Italians – although the one from Blood last month was more earth shattering. They claim – unlike the Blood article – that these have no influence on survival – but this article is from2011 and a lot of studies have happened since then. Furthermore, all the evidence they bring is all speculation and I am still unimpressed that these are benign. They also say that CT is more radiation than V/Q scan but I have heard articles that say opposite. It also depends where that radiation is distributred. Is MRI the answer? Probably not in my eyes as now we’ll find even more embolisms that we do not want to know about. Or do we? (Radiol Med 118:901)
“I am making this trip to Africa because Washington is an international city, just like Tokyo, Nigeria or Israel”
“I am a great mayor; I am an upstanding Christian man; I am an intelligent man; I am a deeply educated man; I am a humble man.”
Bad Doctors
This is pretty scary stuff. After last month’s issue, I definitely do not want to get into politics – but this article is too hard to ignore. Doctors described this ophthalmologist as extremely kind and warm. He had a wonderful manner with patients. We of course are describing Dr. Bashir Assad. Ikuo Hayashi was one of the five perpetrators of the Tokyo Sarin attack – he was a cardiac surgeon. Hamas had Rantissi – a pediatrician. Bosnia’s Radovan Kradzic was a psychiatrist. Other physicians who have been involved in murder include Michael Swango, Harold Shipman, and countless others. Many of us have taken chances with our own health to help people in trouble, and to hear about these physicians is disconcerting. It was Sherlock Holmes who noted “When a doctor goes wrong, he is the first of criminals; he has nerve and he has knowledge.” As high as we can reach as physicians – we can go pretty far down (BMJ 347 f5455).
TAKE HOME MESSAGE: You owe it to yourself to read this paragraph in its entirety.
Here is David Dinkins – former Mayor of New York,
I haven’t committed a crime. What I did was fail to comply with the law.
Jim Hightower was the Secretary of Agriculture for the state of Texas:
Even the smallest dog can urinate on the tallest building.
ICU Patients’ Perceptions
Did I get through this whole issue without an ICU article? The is something called CP gaps- meaning that we often are far away in our perception of what we think ICU patients feel and what they are really feeling. Patients’ perceptions in the ICU include worries about abilities to deal with future health needs at home, trust in staff, anxiety, hallucinations (delirium can be scary), anger about not being understood, being informed, privacy, weakness (Acta Anest Scand 57:1032). This was a German study and I am not sure that these patients were all patients that we would put in ICUs in other countries – I imagine that intubated patients have their own set of concerns – how would you like to be restrained with a tube in your nose and a tube in your throat? But this is the first article I have seen that considers these issues.
TAKE HOME MESSAGE: ICU patients have issues that we often are not in touch with.
But, as my mother used to tell me, two wrongs don’t make a right. But I soon figured out that three left turns do.
And lastly two quotes from Arnold – the former governor of California.
“To those critics who are so pessimistic about our economy, I say, Don’t be economic girlie men!” – at the Republican convention.
“It’s the most difficult [decision] I’ve made in my entire life, except the one I made in 1978 when I decided to get a bikini wax” – announcing his gubernatorial candidacy on “The Tonight Show With Jay Leno”
Letters
Letters – after the last issue we expected the French to attack and they did. Now I am not going to get involved with why the Americans do not care for the French and vice versa (after all, it was Stormin Norman Schwarzkopf who noted that when the French declined to fight in the first Iraq war: going to war without the French is like going deer hunting without your accordion) but they were not happy. Here is what Dr. Axel has to say (my comments in caps)
Yosef,
Bwahahahaha! Google Translate couldn’t find this term- is this like OOO LALA?
“In France, the law is you have to use French words. For example, there aren’t any French words for surfing the Web, there aren’t any French words for chat session, and there aren’t any French words for hacker. Of course, a lot of other words don’t translate into French either: military victor, shaving legs…”
I TAKE EXCEPTION!!!!!
Slih’a ( ? מצטער) but untrue my friend:
There is no such law.
There are words for surfing ze web (naviguer)
Chat session = session de tchat ou de tchatche
Hacker is pirate informatique
And unshaved legs ? Actually the quote was underarms but I changed it because I thought it was a little crass, you know You mean Frenchwomen don’t shave legs? You bet!
The women (that can be dead pretty and I’ve seen a few) with unshaved legs are in Tchermany and Poland, in my experience.
As for the rest I’ll ascribe it to your sleep deprivation.
And OK down with the Brits ! At rugby, I mean.
MMMM about the former:
I just realise the Google search for “french military victories ” points to different results nowadays (the “did you mean defeats ,” answer has disappeared) No, I think they were also speaking about world cup victories.
There are even counter attacks on youtube
And Anglosaxons that come to the rescue:
http://listverse.com/2012/04/21/7-french-military-victories-of-the-20th-century/
http://en.wikipedia.org/wiki/Militaryhistoryof_France
http://www.militaryfactory.com/battles/frenchmilitaryvictories.asp
How touchy we can be!!
One important forgotten victory was on the soil of North America (independance) but there again t’was only to piss the bloody English off! Yes, you Americans should be thankful – the French gave you General Lafeyettte, Peierr L’enfant, and Chef Boy ar Dee.
Now, as a genuine Gaul (25% Andalusian — the worse origins may be suspected there — 25 % Prussian, 25% Southern France, 25 % Eastern France) I find the untoward offensive part in your post was on unshaved legs. Don’t take it too hard. I personally don’t shave my legs either. Unshaved legs! Good grief !
There will be revenge !!!
Axel Ellrodt
France
Wanted also to thank Dr. Geoff who commented he liked our website. Greg didn’t write this month – but then again – he was all stressed out after writing for the last issue.
Clinical Quiz Answers
So clinical quiz #1 was Thyrotoxic Periodic Paralysis, and this is seen mostly in male East Asians (this case was with a Filipino – Hey Ken – why do we spell Phillipines with a Ph and call the inhabitants Filipinos with an F?). But be careful – while serum K seems low, total body potassium is high, so give K – you have to, but do not overdo it. Acetozolamide does not help actually it can make TPP worse; even though in the familial variant it is indicated. Just remember to consider measuring TSH in acute paralysis. Clinical Quiz #2 is Vogt Koyanagi Harada disease, named for Drs. Vogt Kayanagi and Harada who all were pitchers for the LA dodgers. It is in darker skinned Asians and Americans and is probably HLA related although we are not sure. They often have headaches and CNS abnormalities as well skin findings and granulomatous uvieitis. Steroids makes this get better real quick.
EMU LOOKS AT: ** Hinges and Holes**
This month we look at the acute swollen knee and tympanostomy tubes. The sources for our articles are J Royal Soc Med 106:259 and Clincal Peds 52:899.
Acute Swollen Knee
Ever noticed the knee is not a cup and ball joint? This means that it is easily injured because it is weight bearing and has just tendons and ligaments holding it together without the benefit of bony protection. Poor thing.
Some things help us in deciding what to do here when the knee is acutely swollen – pain at twisting: think meniscus or ACL /MCL instability. Pain when going up or down stairs: think patello femoral ligament.
Night pain – be careful – this may just be DJD in adults but can be infection or neoplasm in a younger person.
Most important to remember – knee pain can be referred from the spine or the hip- I picked up a SCFE once this way (slipped capital femoral epiphysis)
Now let’s focus on swelling. If it occurs immediately after an injury – think about hemarthrosis. If it takes a day – think about a sympathetic effusion or a slower hemarthrosis like from a meniscal tear. Hemarthosis is usually a sign of a bad knee injury- my experience is an ACL. Fat fluid levels on x ray are a pretty good indicator of an intra articular knee bone fracture.
An acute locked knee can be caused by loose bodies, i.e. pieces of cartilage or an ACL piece that inhibits extension
Much has been said about knee tests in the past – I have written on this, but the anterior drawer – which tests ACL, should be done in 80 degrees of flexion and make sure the hamstring tendons are relaxed. However, the Lachsmans test is considered more sensitive. That is done at 20-30 degrees. See the article if you do not know how to do these tests. Truth be told – they test different pieces of the ACL – so I would do both. Valgus and Varus stress should be done at 20 degrees- these test the collateral ligaments. MacMurray’s tests the menisci.
They recommend MRI only if you took an adequate history. Indeed pathology on the MRI may not be the cause of pain in the elderly for example. They do not mention arthroscopy.
I aspirate the joint a lot – they like the superolateral approach- I usually go pretty much laterally, Sometimes, I find using a small syringe to aspirate creates less of a vacuum and is more successful but if it comes easy – I use the ten or twenty cc syringe.
Treatment: Meniscal tears – if the knee is locked – they need arthroscopy to clean out the knee. If it is not locked – conservative treatment suffices. If pain continues – arthroscopy. Tears that are peripheral and longitudinal are the most manageable for repair. ACL – athletes and young people are surgically managed if there is a tear. BMI greater than 30 – less likelihood to succeed. Autographs – as opposed to allographs are the best choices in tears. OA – physiotherapy – this frequently ends up with a total knee replacement
TYMPANOSTOMY
I just know Kevin is laughing at me, and Lisa will write me a polite letter, but she is probably giggling as well- – what is the big deal about these little tubes in little ears? Or as Kevin’s wife told me “I have nothing against adult doctors – expect when they take care of kids.” So Lisa and Kevin – I don’t mind being a moron, but I don’t want my readers to be. So here we go.
When are these put in? Otitis Media with effusion which led to hearing loss was the first major indication for tubes. Now that has been extended to include recurrent OM, atelectasis and deep retraction pockets although the evidence is less for this.
So let’s discuss this deeper. Most kids with effusions will get better with in three months, but 5-10% will persist with symptoms. Recurrent OM is hard to say because no one can agree on what the criteria are for this diagnosis, furthermore, many of these do well without antibiotics. But if they have more than 4 episodes in a year OM- consider tubes. Also If their attacks are severe.
After all these years little has changed in the procedure – laser can be used-for example to make the incision but offers no advantage. There is a gun that can insert tube rapidly, which saves the child from general anesthesia. Two other devices are now being tested- one which blows air into the nasal cavity which keeps the Eustachian tube open and one which uses a sonic vibration thorough the mastoid – nothing proven yet – but at least the second is made here Israel.
Tubes can be long term or short term. Long terms work for – guess- longer, but there is higher rate of perforation of the TM. Coating tubes with silver to reduce biofilm and infections has not panned out. Just be careful with cerumen removal in these kids and do not use ototoxic medications that now have a straight path into the TM.
Tympanometry can be used to show function of the tube.
Tubes do get blocked – acetic acid seems to work well but it is not clear yet if this is safe.
Otorrhea happens a lot. This usually begins two weeks after surgery, but surgical technique is not related to this. It can also be due to URTI and Eustachian tube malfunction, but there it is not a painful condition, and no antibiotics are required. Sometimes people use topical drops but not clear if they are needed. Antibiotics by mouth may be required in malignant infections. Of course in fungal or cholesteoma otorrhea- antibiotics are of no use. If you are going to use antibiotic solutions – the FDA approves cipro and oflox –with or without cortisone.
Water is not the enemy any more- these kids can go swimming and shower- the orifice is too small to allow large entry of fluid. They do still recommend against head dunking in non chlorinated pools of water.
Tubes are usually extruded with time, and then come out of the canal by themselves or are encased in cerumen. Even short term tubes can get stuck in the OM and need surgery for removal. If not removed there is danger of biofilm development and perforation
While uncommon, sometimes tubes need to be replaced if the problem is not taken care of by the first tubes and the first ones fell out already.
Perforation is usually watched expectantly – surgery is really necessary.
So Kevin and wife – Here’s looking at you, kids.
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