Push the Pause Button

(Wikimedia Commons image)

Several years ago my team and I resuscitated a two-year-old child with fulminant meningococcemia during a night shift in a small community hospital. It was only my second case in 25 years of practice, but despite providing all the right lifelines and transfer to a tertiary care facility with a pediatric ICU…I knew the child would die.

We carried on with our duties long after the helicopter departed…steadfast yet each of us enveloped in our own sadness. It wasn’t until weeks later during the “debriefing” meant to cleanse our hearts and minds of the tragedy did we dare face the death together as a team.

I can tell you from experience this is not the way to approach a death of this magnitude…or any death. Take a short listen or read about initiating “The Pause” after a death no matter where you practice by listening to: The Pause by Reuben Strayer MD on the February EMRAP cme.

Who knew? Ever wonder where those computer symbols originated? According to Gizmodo, the pause symbol is based on a musical notation, the caesura, which indicates a-wait for it-pause.

 

 

Hyperbilirubinemia: Mellow Yellow Isn’t Just a 1960’s Song

Phototherapy for neonatal jaundice. (photo courtesy Wikicommons)

Hyperbilirubinemia: one of the most common problems seen in term newborns and warrants a periodic review to refresh our knowledge base. Consider this case: A well-appearing infant presents and is jaundiced. The baby has a cephalohematoma and is breast feeding. Everything else is fine. The child is eating well and urinating. Do you still need to send labs?

Take a listen to the MP3 podcast or read the PDF in the January EMRAP podcast: Hyperbilirubinemia by Rob Orman MD and Tim Horeczko MD.

 

Who Knew? Jaundice was observed for centuries but the earliest medical literature was by Jean Baptiste Thimotee Baumes (Baumes, J. 1806). This description was published as a chapter in a book entitled: Traite de L’amaigrissemwnt des enfans. Christian Schmorl in Dresden was the first to coin the term “Kernicterus” in 1904.

 

 

Pneumonia Reboot: Admit or Discharge Decisions

CXR of a 37-yr-old male with pneumonia and abscess. (Photo from Wikicommons).

CT scan of the chest showing bilateral pneumonia with abscesses, effusions, and caverns. 37 year old male. (Photo from Wikicommons)

The case as presented in the January 2018 EMRAP files:

A 73-year-old male with a history of hypertension, hyperlipidemia and aortic stenosis presented with cough, fever and sputum. He was mildly tachycardic but not tachypneic and was well-appearing. On lung exam, he had some focal wheezes in the left lower lobe. Swaminathan thought the patient had pneumonia. Chest x-ray confirmed a left lower lobe infiltrate.

Now what? What else do you need to know about this patient that impacts discharge planning. It’s flu season here in the USA, the ED and wards are filled with critical patients and beds are in high demand. Do you really need to admit this patient? Tie up a bed? Expose him to hospital-acquired infections?

Listen to the January EMRAP Introduction podcast or read the PDF by Rob Orman MD and Anand Swaminathan MD to find guidance and opinions.

Who knew? The CURB-65 and the PORT Score can help you make these difficult decisions.

Osteomyelitis: The Diabetic’s Skeleton in the Closet

Femur. Osteomyelitis. From ancient cemetery, Chicama Valley, Peru ; (Photo courtesy WikiCommons)

X-ray osteomyelitis 1st metatarsal joint (photo courtesy WikiCommons)

Do you admit all your diabetic patients with suspected osteomyelitis? Do you need to?

Is it acute or chronic?

Do you need to culture all diabetic foot ulcers?

What two entities will help identify patients at risk for osteomyelitis? The answer may surprise you.

Download from CMES the podcast or PDF for the December EM:RAP Diabetic Foot Ulcers by Matthew DeLaney MD and Charles Khoury MD and share your experiences or recommendations by leaving a comment.

 

Who Knew? Evidence for osteomyelitis found in fossil records are studied by paleopathologists, specialists in ancient disease and injury. It has been reported in fossils of the large carnivorous dinosaur Allosaurus fragilis.

Life Threatening Bleeds in Oral Anticoagulated Patients

Noval Oral Anticoagulant (NOAC) medications. Travelers like the convenience because they don’t need monthly blood tests. It also means they show up in your emergency departments and clinics from all over the world with minor and major bleeds. How do you know what reversal agent to give or even if there is one? Perhaps they can’t recall the name or a friend is watching their belongings at the hotel.

Check out the December Annuals of Emergency Medicine podcast: Reversal of NOACs by Jessica Mason MD, Andy Grock MD and Annahieta Kalantari DO. The simple answer may surprise you.

Who knew? Hirudin extracts from the medicinal leeches were first used for parenteral anticoagulation in the clinic in 1909, but their use was limited due to adverse effects and difficulties in achieving highly purified extracts. Published by NCBI PubMed 2012 Jun 1;9(2):83-104.

 

EMRAP: Global Worming

(Photo courtesy WikiCommons)

Fertilized egg of Ascaris lumbricoides. (Photo courtesy of WikiCommons)

Ascariasis is a common helminthic infection, with an estimated worldwide prevalence of 0.8-1.22 billion people. But it’s rare in the USA because it’s not endemic. Most often seen in travelers I’m inclined to think I missed cases during my years of practice.

Update your knowledge and listen to the EMRAP November podcast or hit the high points in the PDF file. Annals of Emergency Medicine: Ascariasis by Jessica Mason MD, Andy Grock MD and Andrea Tenner MD 

I’d like to hear from our Nepal colleagues’ pearls on recognition and the complications. Leave a comment. How often have you seen asymptomatic versus symptomatic cases? What’s the worst complication you’ve managed?

Who knew? “During our relatively short history on Earth, humans have acquired an amazing number of parasites, about 300 species of helminth worms and over 70 species of protozoa. Many of these are rare and accidental parasites, but we still harbor about 90 relatively common species.” Clin Microbiol Rev. 2002 Oct; 15(4): 595–612.

More on Migraine Headaches

What does a cotton swab and nose have in common? (photos from WikiCommons)

In August I posted on the common presenting complaint: migraine headaches…but there’s more.

Dr. Michelle Lin talks about anti-dopaminergic agents, triptans, IV fluids, routes of administration and steroid use. And who thought a cotton swab was your instrument of choice when treating a migraine headache? I didn’t. Check out the Lin Session: Migraine podcast from the EM:RAP November edition to add more skills to your headache arsenal.

Then add a chaser with Paper Chase #4 from the same edition which talks about parenteral acetaminophen (paracetamol). You’ll be surprised by the mechanism of action.

Who knew? The cotton swab is a tool invented in the 1920s by Leo Gerstenzang after he watched his wife attach wads of cotton to toothpicks. His product, which he named “Baby Gays“, went on to become the most widely sold brand name, “Q-tips”, with the Q standing for “quality”. (Wikipedia)

Time to Charge Your Battery…

With a jolt of information on button battery ingestions by pediatrician Ilene Claudius. The November 2017 EM:RAP edition has a podcast sure to shock you. From one end of the tail to the other, your patient outcomes can range from benign ingestion and passage over a few days to death.

A variety of button batteries found in toys. (Photo from Wikimedia Commons.)

The leakage of alkaline materials will cause liquefaction necrosis rapidly. (Photo from Wikimedia Commons.)

Button battery or coin? Read the EMRAP PDF or listen to the podcast to learn how to differentiate. (Photo from http://www.radiologypics.com)

 

The National Capital Poison Center posted the NBIH Button Battery Ingestion Triage and Treatment Guideline: https://www.poison.org/battery/guideline

Battery ingestions are no laughing matter but I can’t end without one bad joke: What did the depleted battery say to the judge? “Feel free to charge me.”

 

Dizziness-The Facts Will Sway You

“Doctor, I am dizzy.”

Dizziness is a common presenting patient complaint. When is it serious and when is it benign. For back pocket HINTS on how to differentiate Posterior Circulation Strokes from weak and dizzy listen to this September podcast. It’s available using your CMES thumbdrives or CMES-Pi.

Posterior Circulation Stroke vs. No Big Deal (THE HINTS EXAM) Anand Swaminathan MD and Evie Marcolini MD 

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