Here is March 2014 If you are still reading (???) I’ve got to introduce our new website: emumonthly.com where you can access all the old issues and do searches . Thanks to Christie, Scott, and Tim for their volunteer work on this – more on this later…
Biowarfare
Our first article will not be reviewed. I mean we have reviewed biowarfare agents in the past. I get asked about this all the time. And yes, in Israel we get training in this too and yearly drills. So I am passing on this article but you are welcome to see it (Crit Care Clin 29(3)411) This is about as political as we are going to get: 
Preventing Medication Errors
Most of our medication errors are in dosing. Well you could always look up the doses, but in busy EDs – this isn’t so practical. So they bar coded medications and the bracelets of patients, and if there was a medication error, an alert occurred during scanning. In this study, it helped and the nurses were the ones who activated it (AEM 20(8)801). Interestingly enough – a patient that forgot to remove his hospital bracelet was priced at $14.99 at the supermarket. TAKE HOME MESSAGE: Barcodes may help reduce medication errors.
Lactate
OK, I like lactate. It’s my way of expressing OCD by speaking about it so much. And I agree that you should get it down in sick people. That is what this article by Jones says – but you knew that already. However, sometimes it can be elevated in the absence of severe sepsis – like those getting Lactated Ringers (Hartmann in Europe – it has a little – not much lactate in it, and I am not sure why they even put it in there), those with cirrhosis, and those taking Metformin (ibid p844). Time for quotes – and this month – it’s Late Night starring first the king of late night – Johnny Carson. Late night quotes may not appeal to all our world wide readers – it is a special tongue in cheek humor that is very American politically based- but let’s give it a try: On late-night television programs:
“We’re more effective than birth control pills” – to frequent quest Joan Embery, of the San Diego Zoo, after the marmoset she had brought had climbed on Carson’s head and urinated: ”I’m glad you didn’t bring a baby elephant.”
Turf Toe
I have been following sports for a long time – a generally fruitless endeavor as the Eagles last won a championship in 1960 – and this taught me a lot of medicine. Thanks to American football even the most intelligent sports fan 
knows what an ACL is. Ever wonder what a turf toe was? This is a dislocation of the MTP joint of the first toe; there may be an avulsion fracture of the first MTP head and the sesamoids may be displaced. Often, there are tears of the plantar plate and the intra-sesamoid ligament – you’ll have to do an MRI to see these. Not something easily missed, but if your rugby star or football player is out with a turf toe you’ll know why (EMJ 30(9)776). TAKE HOME MESSAGE: Turf Toe is the sports name for a first MTP dislocation.
If variety is the spice of life, marriage is the big can of leftover Spam. For three days after death, hair and fingernails continue to grow, but cell calls taper off.
Digoxin Toxicity
I am sure Rick isn’t still reading, but there are a bunch of internists that are still reading, and will wring their hands and shake their heads on this obvious case. But I think the take home is just much wider than their conclusion. Yea so let’s stop beating around the bush 
We do not use digoxin a lot, but sometimes you still see it used. Here is a case of patient with a normal dig level – 2.4 and a normal potassium level – 3.9. But she has a junctional tachycardia. So they decided she was dig toxic and the reason was that magnesium levels were very low (0.39). They gave magnesium and voila- she recovered (JEM 45(2)e31). Firstly, is magnesium an ion we should be checking all the time? I do not know, but do recognize that diuretics can reduce magnesium and potassium in tandem – here potassium was normal but that could be because the patient was taking potassium supplementation, or an ACE inhibitor, or spironolactone. But I think the main point should be that digoxin levels are not that useful – some folks do fine with higher levels, some folks can be toxic with normal levels – judge by the patient and his EKG, and not just by the levels. TAKE HOME MESSAGE: Low magnesium can cause dig toxicity. But then again – levels may not help.
On the Saturday Night Live cast – they couldn`t ad-lib a fart after a baked-bean dinner. I know a man who gave up smoking, drinking, sex, and rich food. He was healthy right up to the day he killed himself.
Antibiotics Not Necessary
If you own a brain – or can find one to borrow – please skip this paragraph. If you do not -and the fact that you are still reading this does tell me something – know that antibiotics are not for the common cold – and not for purulent nasal discharges either – the NNH is not insignificant but the NNT is (Cochrane 6:1770). TAKE HOME MESSAGE: No antibiotics for purulent discharges. Lets’ continue on to Jay Leno:
A new poll shows only 3 percent strongly approve of the job Congress is doing, with a margin of error of 4 percent, so it’s possible that “less than no one” thinks they’re doing a good job. Here’s an uplifting story. Congratulations to the Little League team from Huntington Beach, California. Yeah, they beat Japan to win the Little League World Series. That’s pretty good. See, that proves that when math and science aren’t involved, our kids can beat anybody.
Steroids and Meningitis
On the other hand- if you have a brain and want to keep it – know that steroids will reduce hearing loss (even in adults) and neurological sequela. However they do not affect mortality. Important to note that these findings were only in high income countries ( ibid 6:4405). Could it be that lack of vaccines expose low income people? to worse bugs? TAKE HOME MESSAGE: Steroids in all meningitis patients reduce neuro and hearing losses, but if they are circling the drain – they are going down it no matter what you do.
A new study found that people who are depressed have a greater risk of stroke. Well that should cheer them up. A Libyan rebel has admitted to killing Moammar Gadhafi. He said he shot Gadhafi twice in the temple, to which Michele Bachmann said, “I didn’t even know the guy was Jewish.”
From the Ambulance to the Cath Lab?
This has been argued back and forth – can paramedics identify ST elevations on EKG? Yes. So why not just by pass the ED and go straight to the cath lab – this could save precious time (Circ Cardiov Interv 6(4)399). Yet, this isn’t the first study to show this (Circ 128(4)352). This is fine if you have PTCA all the time, but begs the question – is an ED physician more available than a cardiologist in the department – this is a manpower issue in general. But the main point is if you are not bypassing the ED, make sure you get these patients to the cath lab fast. TAKE HOME MESSAGE: ED delays in the treatment of ST elevations lead to later caths and more mortality.
A historic operation occurred over in Boston. Doctors successfully transplanted tissue from a pig’s brain to a man’s brain – and the man’s brain did not reject it. That’s pretty much confirms what women have been saying about men. In France, they’re having trouble translating a lot of Internet terms into French. 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…
(My French subscribers – please don’t cancel me – I’ll insult the Brits later in this issue)
Treating Hiccups
Do you know why you read EMU? I don’t. But it could be for articles like these. We like thorazine for treatment of persistent hiccups, but at least in my country – this med has been taken off the market and even where you still have it, it is hard to find. So in this terrible journal (and yes, it is a terrible journal), they report on seven cases where Baclofen worked (Int J of Clin Pract 67(9)918). Truth is – this has been reported before as far back as 1996 (Rev Clin Esp 196(12) 831). But you better speak Spanish to read that article. Or you can just skip the whole thing and see this excellent review of the subject (Ned Tijd Gene 149(48)2658). But you got to understand Dutch. Or go Dutch. Or forget the whole thing and just go eat some Godiva TAKE HOME MESSAGE: Hiccups – nothing else working? Try Baclofen.
Case #1
Time for a case – not a difficult one. So there is this teenage girl with sharp shooting pain in her right leg. She is 15 and has no fever or chest pain. There is an abducens palsy noted, with no affect on visual acuity, but there is diplopia. No papiledema. No masses on imaging. Best goes with? (Ped Ann 42(8)315)
I went into a McDonald’s yesterday and said, I’d like some fries. The girl at the counter said, would you like some friends with that? Here’s something to think about: how come you never see a headline like “Psychic Wins Lottery?”
Nitrofuratoin in Patients with Renal Failure
I still like nitrofuratoin for UTIs – it is fairly cheap, underused so still effective and works against the mega bug ESBL. True it isn’t that strong, and not used in pregnancy and can cause pulmonary fibrosis in long term use. Seems that there was some thought that it may be less effective in patient with renal failure – even mild cases. Well, it is still effective in mild renal failure, but the pulmonary problems and ineffectiveness increase with more advanced renal failure (Eur J Clin Pharm 69(9)1701). However, these folks may do poorly with any kind of antibiotics – we do not know. TAKE HOME MESSAGE: Nitrofuratoin is still a good medicine – and so are Godiva chocolates. Now on to David Lettterman:
“If it weren’t for the coffee, I’d have no identifiable personality whatsoever.” “You have Kim Jong Il, and you have his brother, Menta Lee Il.”
Good grief- I lost all my French subscribers- now I am going to lose all my North Korean subscribers.
Gadolinium Use in Pregnant Patients
Can you use gandolinium contrast in pregnancy and lactation? Answer is a definite maybe. If the solution contains gandolinium which is not tightly bound, it can cause nephrotic fibrosis. However, tightly bound is harmless (Acta Rad 54(6) 599). TAKE HOME MESSAGE: Tightly bound gandolinium is harmless in pregnancy.
“British Petroleum has put more birds in oil than Colonel Sanders.” “I haven’t reached nirvana yet, but I’ve been to Detroit.”
There go all my English and Michigan subscribers.
Radiologic Diagnosis of Pulmonary Edema
This article is about progress, but it gave me a headache. I was trained to diagnose pulmonary edema by chest film. Ultrasound is the new kid on the block, and residents were better at this diagnosis by ultrasound than chest film. On the other hand, radiology residents were better with chest films. Also, although it was confusing – it seems the ultrasound was the gold standard which is a little violation to try to check accuracy (ibid p356). Maybe it is better. But with clinical exam, BNP and CXR I really do not need this in most cases. Ultrasound geeks? TAKE HOME MESSAGE: Ultrasound can be used for diagnosing pulmonary edema – whether it contributes anything new is debatable.
Letterman: “We’re halfway through the Winter Olympics. The American speed skaters say there’s a reason their times are off. They’re blaming it on their suits, and I thought maybe I should do that. It was my suit.” “I know climate change is a hoax – of course – but places that have never seen winter weather so bad got hit by it. More than a half a million people in Ypislanti have been left in the dark — and then the storm hit.” – Bill Maher
There we go- alienated Father also.
Subsegmental Pulmonary Emboli
There is absolutely no chance that Rick is still reading. He loves PE. If you are a deviant also – then read on. Subsemental PE is thought to be not relevant and a pox of the ultra sensitivity of CT for this diagnosis. It is thought that they need no anticoagulation. They want to say here that these patients are in between – they have some risk – just not as much as the proximal PE. They say previous results that showed subsegmental to be insignificant were in patients who had a US for DVT, and it was negative – DVT presence meant the patients did worse and had a higher recurrence rate. Moreover they have a higher tendency for malignancy. Our patients whom we check for PE often do not have an ultrasound performed. In their study – subsegmental patients had a high risk factor profile for recurrent PE and have similar outcomes to patients with proximal PE. That is to say – the subsegmantal problem is not for the next PE, but for now- they may be dangerous.They suggest: give subsegmental patients anticoagulation and do ultrasounds of the legs (Blood 122(7) 1094). Could be, but I am bothered that all patients in their study with subsegmentals got anticoagulated in all cases so we really can’t say if they truly needed it. Furthermore, the author has a lot of conflict of interests with many ties to industry. Nevertheless – something to think about. It still fans the fires. TAKE HOME MESSAGE. Subsegmental PE may still need anticoagulation. Then again – it all may be subsegMENTAL.
“The Slovenian woman who won the gold medal in alpine skiing is also a pop star in her country. So Justin Bieber is not the only pop star going downhill fast.” Conan O’Brien “There are rumors that the Russian government placed cameras in the hotel bathrooms in Sochi. Russia said, ‘Don’t worry, our cameras don’t work either.’”
Same oy vey, now I got Putin pissed off – I am in big trouble.
Healthcare
Americans don’t deal with this- yet. In the great of Britain they are weighing having the patients pay their general practitioners a fee. On the bad side – even if you exempt the elderly and indigent – people are already taxed to pay for health care and to add to that will cause anger. Doctors in England are already perceived to be overpaid (not so in my country) and this could also lead to abuse. People who pay have expectations and investment of time that can lead to a strain on the system and giving them bad medicine since they want what they want. On the other side –w hat you get for free is not valued (BMJ 2013:347:f5007). The latter is more correct in my country and we get terribly abused. But we wouldn’t want that to worry the USA – their putting skills will not suffer. TAKE HOME MESSAGE: Socialized medicine- taking money may lead to doctor abusing – not taking money may lead to abuse of doctors.
“Illinois is the only state where the present governor rides around in a car whose license plate was made by a previous governor.” “Osama bin Laden… lived in one house for, like, six years with three wives. And earlier today, they ruled his death was a suicide.” Letterman
LMAs and Laymen
They took novices- people with no medical training at all – and gave them a short course on airway management. Then they gave them a Sim man. They not only did poorly at ET tubes- as can be expected – but give them a supraglottic device – such as the LMA and Voila! They did even better than mouth to mouth (not sure if the results would have been the same with a Sim Woman) (Eu JEM 20(5)310). This means to me that this should be part of basic life support courses, and LMA s should be in the AED kits in shopping malls (where you will most likely find Sim women), etc. TAKE HOME MESSAGE: Even novices can have success with LMAs- they need to be part of our CPR courses.
“There are 12 new events in this year’s Winter Olympics, 12. The new events include women’s ski jumping, luge-team relay, and finding a working toilet.” – Conan O’Brien “Yesterday, Red Hot Chili Peppers bassist Flea admitted the band faked playing during the Super Bowl. In his defense, so did the Broncos.” – Conan O’Brien Everybody is wondering what Paris Hilton will be doing next, and hell, I’m wondering what she did before.
There we go – alienated all my Paris Hilton fan reads (are there any?) Hey five points if you know where Nicholls Ste University is. Five more points if you really care.
LBBB
If you are like me – and I hope you are not – you see LBBB and know to use the Sgarbossa criteria but rarely remember it, let alone how to spell it. You were also told that new LBBB can be an MI. Here they tell us if the ST changes were not concordant – this was not an acute MI (Int J Card 167 (4)1339). Now this is not the greatest journal and they only had 67 patients but let us paraphrase Amal Mattu who points out that the culprit lesion for an acute LBBB MI is large and if it is occluded these people will look horrible and be hard to manage. If they look great and have LBBB – they are probably fine. TAKE HOME MESSAGE: LBBB – non concordant – relax.
David Letterman’s “Top Ten Signs Sochi Isn’t Ready For The Olympics”
Caterers just cancelled
Electronic surveillance of hotel rooms not yet installed
Medals will arrive in six to eight weeks
Don’t know which currency to accept for bribes
Frantically reconfiguring luge to prevent contact between same-sex athletes
Fans encouraged to park in Armenia
Organizers waiting for Earth’s tectonic plates to form ski mountain
Plenty of Bobs, no sleds
Putin still undecided on what shirt not to wear
Housed the stray dogs and neutered the athletes
Treating Gonorrhea
Time to discuss your favorite disease – gonorrhea. This bug has developed resistance to cephalosporins such that cefixime no longer is very effective and the amount of resistance to ceftriaxone has gone up by 15%. However, all hope is not lost – spectinomycin is still very effective – remember the last time you used that stuff? – and the old standbys are becoming more effective due to lessened usage – that is the penicillins and cipro. Best bet – let’s get that vaccine out in the pubic – I mean public (Lancet Inf Dis 13(9)728). TAKE HOME MESSAGE: Cephalosporins are becoming less effective in GC. Higher dosages may what you can use for now or maybe spectinomycin.
“As you know, President Obama gave his State of the Union address last night. Obama says he wants to give ‘America a raise.’ He’s just waiting, of course, for final approval from China. As soon as they say it’s OK, then we’ll move ahead.” – Jay Leno “It seems that England’s royal family is running out of money. They are down to just $1.6 million. Well sure, that’s what happens when nobody in your family has had a job for the last thousand years.” –Jay Leno
Dengue Fever
This article speaks about local attitudes to dengue – which isn’t so relevant to most of us- but please do not forget it. Dengue – it is a very common mosquito borne disease – and with malaria prophylaxis being routinely given – probably more common in travelers than malaria. Dengue is characterized by break-bone fever and reduction of the blood lines – leucopenia, thrombocytopenia, and anemia (PLOS Neg Trop Dis 7(7)e2331). This study was done in Malaysia by a Dr. Abu Bakar – I have such a subscriber, but I am not sure if he is the same one. TAKE HOME MESSAGE: Dengue – mosquito borne, tropics, high fevers, and rarely shock.
“Iran says they want to encourage more tourism from the United States. They might want to change that ‘Death to America’ slogan. A lot of families are not comfortable with that.” –Jay Leno
There we go – alienated all the Iranians.
“According to a new study, smog is drifting across the Pacific Ocean from China and polluting our West Coast. Can’t we make anything in this country anymore?” –Jay Leno
Homeless Patients
Attitudes towards homeless are probably terrible but this study was the wrong way to go about it. A questionnaire with only a 55% response rate was given to physicians, residents, and medical students- but this is the classic Hawthorne effect – no body is really going to incriminate themselves by agreeing with statements such as “homeless are lazy,” “homeless people want to be homeless,” and the like. These folks are very hard to help – they often do not smell great and there are follow-up problems as well (BMC Med Ed 13:112). I am positive that Ken has written on the subject. Ken? And try to remember – in some manner – these are people too. TAKE HOME MESSAGE: Homeless people have special needs – show them the care that you can. I once treated a homeless patient who had type one diabetes and was poorly compliant – when asked what he takes for his diabetes – he happily said: “Alcohol.” It gave us a bit of laugh and he laughed with us.
“France’s first lady is suffering from extreme fatigue after learning of her husband’s affair with an actress. I don’t know why she’s tired. He’s the one juggling two women.” – Conan O’Brien
Hey I got to alienate the Canadians too!
Legal experts say if Justin Bieber is convicted of a felony, he could be deported back to Canada. They also say if he is found to have cocaine in his system, he could be elected mayor of Toronto.” – Conan O’Brien on the egging attack on Bieber’s neighbor’s house
Being on Your Best Behavior
One more article on being a good doctor. Remember those surgeons we loved so much – the ones that had temper tantrums and threw things and were condescending and sarcastic? No we are not talking about your husband. And some of these have made it to court. 30 % of complaints in the states of Alabama, Kentucky, and Wisconsin are on disruptive physicians. Most court cases involve revocation of privileges – a physician that told a nurse to “get off her ass” and “she was a wrench in the works” was dismissed from staff. So was a surgeon who berated anesthesiologists for starting an operation 3 minutes late. Or an OB/GYN who interfered with a lymph node biopsy being done in the OR by his rival. All three sued for return of privileges, in all of these cases and indeed in most cases – the court upheld the hospital’s decision. Indeed – in an extreme case – a physician told a nurse that a patient had hung himself in the room when indeed he was fine. He too sued – and lost. The only case they bring that the physician won was when he reported the hospital to a government body for dangerous practices (Academic Rays 20(9)1069). TAKE HOME MESSAGE: Being a disruptive physician – by acting out- can cost you your privileges with no legal recourse.
“Rodman had a media meltdown. During a satellite interview from North Korea, Rodman started screaming at a CNN reporter. There was an awkward moment when Kim Jong Un said, ‘My God, this guy is a lunatic.’” – Conan O’Brien
Analgesia Without Pain
Kids do not like needles – neither do adults – so here are some alternatives ways of giving pain control to kiddies without using a needle. Ketamine can be given PO – but it takes a while to work. The rectum will give rapid levels of diazepam and diclofenac but not paracetmol (acetaminophen) which is poorly absorbed. Indeed – rectal morphine has delayed absorption such that respiratory arrest has occurred. The nose is getting more attention nasal Fenatyl and diammorphine gives good analgesia. The dose is 1.5 mcg/ml for the former and 0.1 mg/kg for the latter. They do not mention that much of the drug in nasal administration goes down into the stomach, and kids hate it. Fentanyl in the USA is available as a lollipop. Ketoralac gives good analgesia when given by inhalation – but we have repeated in the past that morphine does not. Buccal and sublingual administration is usually not practical in kids as it needs prolonged contact with the surface. They stress that things that taste bad will not give you a second chance in most kids -meaning the lingual, buccal, oral and nasal routes (Arch Dis Child 98(9)718). I think a word to the wise – be careful. I have no problem with ketamine and NSAIDS which are safe drugs but giving opiods without the benefit of an IV to give naloxone seems dangerous. We’ll also point out the absence of chloral hydrate – which we have reported on before – don’t use this stuff – it snows the kids for 24 hours. TAKE HOME MESSAGE: There are other possibilities for short term pain control in kids that do not involve needles.
“Is Santa Claus an American? Well he is fat and wears a velvet track suit.” – Stephen Colbert
Letters
The mail bag was active this month – and before I start – again, check out our new website and format – thanks to Scott, Christie, and Tim. You can write me a letter on the site, or straight to my email. Let’s start with Aaron Brody from Detroit:
Yosef, Love your blog. My name is Aaron Brody. I did med school at Hadassah, and EM residency in Detroit. Working there now as an attending.
Hadassah is on some hard times now. Where are you in Detroit?
Remark about your critical care notes – re: the vascular access question, IO is an excellent option (as long as you push past all the anasarca). If you are concerned about hemorrhage, I would actually choose the IJ over the femoral. If you backstab the femoral vein, and you’re just a bit proximal to the inguinal ligament, then you have a retroperitoneal bleed on your hands – very uncompressible. However, the IJ is essentially a closed space – we’ve all hit the carotid, and even that stops with direct pressure after a couple of minutes. But certainly avoid the subclavian!
Very interesting. I started out my career loving IJ – then some how I switched to SC- in my shop now they like femoral’s – quick, easy and away from the action. Probably causes less infection than we first thought. But I admit I never thought about the retro peritoneal bleeding. Brush up again on the IJ, I guess. I then discussed this with my ED director – Carmi who is a genius (all CCM/EM people are) and commented that you really have to be aggressive to cause a bleed in the femoral retroperitoneum. He is OK with the IJ but in rare cases he feels – if there is a Circle of Willis anomaly – an inadvertent carotid stick may lead to ischemia. Also, the fem pop is an arterial procedure, not sure how that would impact your venous access I knew that- I just thought an inadvertent femoral artery stick may mess up the operation (infection, thrombus), also I was concerned that this may be a harbinger of generalized vascular disease. Next, ah yes – what would be a month without Father Henry checking in?
Father Henry here, Sorry I have missed a few months of sending useless comments. I made a New Year’s resolution to stop doing stand-up comedy and hanging around the low life’s at EMU Monthly. You will be unsurprised to know that the stand-up resolution lasted till 12:01 and here I am back responding to “the usual gang of idiots.” As to ACLS, one should remember more people are getting rich off ACLS than dying from it. I have in the past written about the economics of this, but confusing people with the facts always gets me in trouble. If two hits of Detroit Edison does not make you sit up and dance you’re dead. Anybody still alive after that is a statistical freak and nothing more. We have built an industry out of nothing. Speaking of something out of nothing I have now seen a lawsuit based on not cooling the patient who, to Quote The Wizard of OZ was not just dead but “really, really dead”. God protect us from thieves and fools. When the death rate stops being one-per-person let me know. And last, the comment I made to the President of the Gas-Passers was quoted correctly but omits that the fact that in the same week in 1996 I also enraged Radiology and Plastic Surgery about their supplying fee for no service. So anytime you want me to settle this Mid- East thing you can see I’m the sensitive big guy to take care of the job. Despite rumors to the contrary, I do have a heart. It’s located right behind my shoulder holster. Bless you all, Father Henry
Gosh, Father – you are way too much of a liberal for me. But no one could say it better. Father joins the usual gang of idiots in the next section. Scott writes us:
The auto-transfusion from passive leg raising lasts only about 60 seconds. Not a substitute for what we hoped to accomplish with Trendelenberg; it is only good to test response to fluids.
I knew that too!. But I just call them as I see them – I acknowledged that neither is that great. Electrical storm encouraged some comments – here is what Chris had to say:
For a description of a technique for stellate ganglion blockade to treat ‘electrical storm.’ try this from ‘Resus Review;’ http://resusreview.com/2013/ultrasound-guided-stellate-ganglion-block-for-refractory-ventricular-fibrillation/ Cheers, Chris
Chris, I do not know Chris – seems you need a little expertise here, and also the part of the persistent dysfunction is somewhat bothersome. Here is what Paul has to say on the subject:
Hi Yosef, I just wanted to mention that every time I’ve had a patient with an ICD gone haywire, that keeps firing every few seconds, I’ve used a bolus of 100mg of lidocaine and it’s worked every time. You didn’t mention it as one of the possible meds. I’ve been doing this for about 28 years now, and I’ve seen a few of these cases. Lidocaine! The old cheap standby that people don’t seem to want to use anymore, I don’t know why. I’ve always had good results with it, for v-tach as well. Paul Simcoe
Yes , I like lido also – easier to dose than amiodarone, with much fewer side effects- but I am tickled by procainamides return- I like that drug too! We used a magnet to disable the ICD in our last patient only to discover that the shocks were real! And Ken checks in also:
Below please find some of my comments, would this be helpful? Actually, I am developing several manuscripts on this topic, hopefully they’ll be out soon. I wanted to also mention, I got a new position and my current affiliation is with New York University School of Medicine (although I might still do some work at Princeton on a visiting basis). I am working on the host-pathogen interaction program, and I am also developing more towards a few concepts relevant for epidemic and pandemic preparedness. We are still not paying sufficient attention to non-pharmaceutical interventions, despite the published evidence that they are important prophylactic measures. Non-pharmaceutical interventions can save lives, but there still are huge gaps in studying and implementing them. During the 1918 influenza pandemic, differences in the way social isolation measures were implemented in different cities powerfully shaped the local outbreaks, the number of human infections, and mortality rates. Non-pharmaceutical interventions are, by themselves, a complex and a fascinating area of infectious diseases. We need to understand a lot more about school closures, for example at what stage of the outbreak they are most effective, and this is shaped by many factors, including characteristics of the virus and the timing of their implementation. Moreover, we need to better understand the dynamics of the influenza outbreak in metropolitan areas, for example how the virus is being spread on public transportation, and by commuters to suburbs, because this is relevant in many cities worldwide, and although some work has been performed on this, the topic is greatly understudied. We also need to pay attention to teachings provided by other outbreaks, for example SARS, because the pandemic taught us a lot about the higher risk of transmission of airborne viruses in hospital waiting rooms or when patients are transferred within and between hospitals. Even when vaccines work, non-pharmaceutical interventions are important; but when vaccines do not work as expected, non-pharmaceutical interventions assume even more important roles, and they provide highly actionable information for individuals and communities.
Answer to Case #1
Weird neurology goes with two most common causes if you do not find anything on CT – one’s heavy metal poring and the other is MS – and the latter is what she had. She got better with steroids, but do not forget metals – I just saw a zinc poisoning last week. And yes Nicholls State University, is in Central Louisiana – in a place called Thibodaux. Ypsilanti is more interesting.
EMU LOOKS AT: ** The Purim Issue**
Death in the Bathroom
No useful information here (was there in this EMU at all?) so if you are a staid nerd type – do not progress onward (you are probably aren’t ever going to progress in any case). For the rest of you -and especially our new subscribers – this is the time we look over last year’s odd, funny, or weird studies. If you really want a cheap thrill, you can search past issues for Purim – the one on rhinotelliximania was really cool The bathroom – restroom – WC – loo – Sherutim – lavatory – powder room – head – is the last place you want to have a cardiac arrest. This article points out that there is a delay in treatment for these types of cardiac arrest because of this being a private area (Envir Health Prev Mend 18(2)130). So next time you are waiting for a stall – maybe you should consider this reason. Or since survival is dismal, consider having an AED under the toilet seat to give shocks in case this happens. By the way, who is the most famous person who died on the commode?
Attack of the Toilet
Oh this is not funny at all – but we have to recognize our pediatric colleagues, and this study looked at injuries from toilets and toilet seats in kids. The most common cause of injury was falling toilet seats – (oh how we remember those halcyon days of toilet teats what were covered with a carpet like thing that always fell down) and male children were way over represented in this study (BJU 112(3)398). I am not sure why.
Killer Pants
Another reason for delays in getting a stall is tight pants. This lady’s pants were so tight that she ended up with a segmental infarction of the greater omentum (Int Med 51(16)2235). The kicker here was the lady was 75!!! Father – here is one for you too Yes – that’s your pal Monica Lewinsky who made Hillary stand by her man. Here’s another for you, Father: that is Bridgette Bardot who used to look like this Then again – here is what Father used to look like this.
Female Patients in the ED
OK, while we are on females – here is a study to change your practice. Immediate surge in female Visits to the cardiac emergency department following economic collapse in Iceland (EMJ 29(9)694).
Let’s Talk About Sex…
More on women and men – this Swiss study of looks back at 11 years of injuries due to a certain exercise which requires a partner called in their language Geschlechtsverskehr. They note that while most people enjoy this form of recreation, it is mechanically dangerous, potentially infectious, and stressful for the whole body. So next time you wish to engage in this activity, and request your wife get into her Geschlechtsverskehr uniform -don’t be surprised if she answers: Lassen Sie mich in Ruhe und gehen Sie fine Kuckucksuhr – Use your Google Translates for this one. And lastly on males and females – women, please tell me – are bald men more attractive than those with hair? This is a family publication and I can not tell you how they did this study, but bald men has less partners (MJA 199(11)811); either they were more faithful or less desirable.
or (for you young folks the former was Kojak and the latter was Meatloaf who sang in the Rocky Horror Picture Show- ”I will love you to the end of time (now I am praying for the end of time)” Time for great authors: Diagnosis and Management of Plantar Fasciitis (Br J Gen Pract 62(601)443) written by Dr. Thing, and Advanced Life Support and Mechanical Ventilation (Curr Opin Crit Care18(3)251) written appropriately by Dr. C. Kill.
Death in the Opera
There has got to be some cultured folks out there. Opera – you know – that stuff they show on the big screen at Joe’s Bar and Grill
People commit suicide a lot in operas. Indeed 22% of operas have at least one suicide and stabbing is the most common (MJA 199(11)783). No mention if the suicides are in the opera or in the poor guys shlepped to see these plays.
Smart Stats
There is a data base for research called NHAMCS – they have good intentions but since they use non-medical personnel to enter the data, some interesting things come out. 56% of women with ectopic pregnancy never had a pregnancy test; 9% of intubated patients were discharged home immediately. Some intubated patients were discharged home immediately with diagnosis such as photokeratitis and gastiritis. ICH and cardiac arrest were listed as discharged home (Ann Emerg Med 61(4)423).
TAKE HOME MESSAGE: If you see an intubated patient walking down the street – will you please turn on his respirator?
Cocaine is a Hell of a Drug…
So you got this patient with a cluster headache- and you are weighing the use of intranasal lidocaine. What’s funny about that? Well this is an EBM review where they found that intranasal cocaine is more effective against cluster headaches (EMJ 30(9)769). They did not study this but it could be that cocaine would have worked for many other disorders as well, including falling toilet seats.
Dangerous Territory
Returning to that delicate area just briefly
pubic hair grooming injuries do occur, and we won’t get caught up in this issue other than to inform you – thankfully – most are minor and 97% go home from the ED – about the other 3% – I don’t know and I don’t want to know (Urology 80(6)1187).
Oddities
Hey it is time for odd titles- dedicated to our own Rick Bukata’ School of Title writing
If we shoot ourselves in the foot – will EMS be there to respond? (Ann Emeg Med 60(6)800)
Euthanasia – a matter of life or death? (Singapore Med J 54(3)116)
The Story of a Physician, his bowels and beer (CMAJ 185(18)1604)
Zebra in the ICU: a metacongitive (what the hell is that, Father? – is that an opera or something?)
Reflection on misdiagnosis (Crit Care Resusc 14(3)216)
Caveat anicula beware of quiet little old ladies (MJA 192)1)9)
Hospital food can be improved only by legislation (BMJ 347:f7300
Bullet Points
Now time for some bullets a) Not one but two articles on smelling the diagnosis (Neth Med J 71(6)300 and BJGP July 2012 p378)
b) 32 year old with delirium – social history was positive for being a surgical resident – need I say more? (J Surg Educ 69(6)826) But I wil l- here is an article on how surgeons should fling malfunctioning equipment in a way that expresses their disfavor without causing injury (BMJ 347:f7363). They recommend never using alcohol before this exercise, but it is probably good idea to drink before you start the surgery
c) Massive Soy Sauce ingestion can cause – guess this-hypernatremia. I so regret I didn’t make this a clinical quiz- but this is not a diagnosis you could make by smelling (JEM 45(2)228).
Now if you want to commit suicide through food products there, are other ways
d) Who says that the Brits are staid sorts with no sense of humor? I do actually, but this article may prove what we all thought about Prince Phillip in the first place- England is really a funny place. If you have abdominal pain and it worsens as you rush over the speed bumps – there is a higher risk of appendicitis (BMJ 345:e8012). Now I know the NIH is trying to save money……..
e)Whiplash – and in this case report – he has hallucinations of hearing music since the accident. (J Laryn Oto 126(6)615) . Usually it’s the other way around now? (that was very subtle- give it a minute)
Now, Father, that is not the Grand Old Opry) and lastly -this case report – when this patient laughed- his EKG showed LBBB; it went away when he stopped laughing (J Cardiovasc Electro 23(10)1136) Then again there is the syndrome of laughter induced LPPPPP
Well I promised Father would respond – and he did – although I think he was pre menstrual when he wrote this:
Yosef,
Father Henry sending you and the readership my blessings. Understanding anyone who reads this rag is way beyond help. It's very clear that the only reason most of us do read your journal is for the jokes. They won’t let me put in a centerfold. Father, you are clearly fast frozen in the 50's and 60's. Honey, Father says you have to get rid of the hot pants but that's OK since it reflects your followers.
I have followers???? You realize that no doctor under 50 would have any idea what is being referenced. Careful there Father, my EMU is the most read periodical in nursing homes country wide.
Meatloaf, of course, is one of my hero's but we are a dying breed. But as long as you keep recycling " Uncle Miltie" I'll keep reading. Now a few comments. You are correct that Italian and French grand opera are overflowing with death. But NEVER gun deaths which confirms the fact that we are not talking about American opera. Can you picture Billy the Kid stabbing himself? It would be un-American!!! Besides you would never have the time to sing a decent aria having blown your head off with a 357 magnum. Next, you made reference to small town Louisiana. Just remember these are the people who bring us Duck Dynasty. I'll match their beards against any in the Old City and will through in Z Z Top. Lastly, despite the fact Ms. Bardot has aged, her place in my sexual maturation remains firm, so to speak.
I’m not going to touch that one, Father.
We will see how good you look at 95. The best thing to come out of France since cognac. As a matter of fact, the last good thing to come out of France.
Keep the faith.
Father Henry
That’s the weird stuff from 2013. See ya next month!
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