EMERGENCY MEDICINE UPDATE

JUNE 2013 EMU- at least to me- is like a family. To subscribe to EMU, you must write me personally, and that gives me a little connection with all of you. I shared with my readers the passing of my parents and those who replied gave me strength. Now we share some more rites- my son Avi Dovi has gotten engaged. The wedding is in two months. If you are in the neighborhood- drop by! 1) Not that clinically relevant (I know what you are thinking-you already skipped to next paragraph) but this opinion piece takes US medical education to task and rightly so. But since this is an international forum let's compare it to what the rest of the world does. American medical education is a graduate degree- meaning you need an undergraduate degree to get into medical school. Sure there are courses you must take (his point- organic chemistry is one of them- but who ever uses it in their day to day practice?) but you can major in ancient Middle Eastern laundry and still go to medical school. Oh, you do have to take a test called the MCAT, but most candidates take a course on taking this test and can do well. The fellow writing this opinion piece puts down that we

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should be taking more social sciences of course, he is a family practice guy- and be less reliance on the MCAT and USMLE. He thinks not everyone should finish in four yearssome need more time some less. We shouldn't allow the choice of career to be wily nily but he doesn't say how he proposes to get people into underserved specialties. Also researchers and clinicians should have different tracts. (JFP 61(7)382). I will just point out that in most countries in the world; med school is a six year investment coming right out of high school. True, folks aren't that mature yet, but longer residencies can make up for this. In residency in most countries you stay in residency until you can pass your tests and you are found fit by the program director to finish. I must add that on the positive side of the USA- they do recertify which doesnt happen in a lot of countries. On the other side, a lot of their CME is a joke- but I think this is changing. It must be, as more and more programs are getting EMU. (Another reminder- if you are finishing up your training- give us a new address to forward your EMU.) TAKE HOME MESSAGE: Medical education reform would be good for our

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patients- let's put emphasis on treating patients and not alternating benzene double ring bonds. Or savings bonds. Or Bon Appetit. 2) Hey not just one but two clinical challenges. 22 year old Chinese lady with discoid eczema presents with a weepy vesicular rash. Fever to 38.5 and vesicles all over her face trunk and limbs. This is? (Annals of Singapore Academy Medi 41(8)366)(you can come out of the closet now- we all know you read this journal- and I heard they have a centerfold) PS

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this is not chicken pox. Or small pox. Or monkey pox. Or

bagels and lox. 3) I know you love those rashes so here is another clinical quiz that you can really learn something from. 21 year old fatso who brushed he leg against steps 2 weeks earlier. He has ulcerative colitis (this is after all the GI literature) and gets azathioprine and balsalazide. He had a relapse recently and is getting high dose prednisolone. It was debrided and just got worse. All sorts of antibiotics did not help, but infliximab did help- somewhat. What in tarnation is this?
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(Gastro 143:e11)I don't know who Dr. House is and I have never seen the show, but I heard his lines were pretty pithy, so he is our quote master for the month. Let us get started (this is all from the first two seasons, so that leaves us room to re visit him for more quotes) Dr. Cuddy:
Your reputation won't last if you don't do your job; the clinic is part of your job. I want you to do your job.
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Dr. House: Ah, yes, but as the philosopher Jagger once said, 'You can't always get what you want.

4) EMU is the only EM periodical that comes in a brown paper wrapper to your door. And like most people claim, you only read it for the articles. I do not want to embarrass you but you know our secret love for Lactate. (Please don't tell my wife). But while lactate is good as a measure of what is going on in sepsis, and it may help in a septic joint if you send the fluid for lactate, it is not a great test for mesenteric ischemia. It will go up eventually, but then it will be too late. There is a difference between the isomers of lactate you measure, but we won't go there right now (Digest Surg29(3)226). Guess you will have to just examine the patient and take a history, huh??? TAKE HOME MESSAGE: Don't use lactate to help you diagnose mesenteric ischemia. It won't help. Dr. House: Everybody
lies. Dr. Cameron: Dr. House doesn't like dealing with patients. Dr. Foreman: Isn't treating patients why we became doctors? Dr. House: No, treating illnesses is why we became doctors. Treating patients is what makes most doctors miserable

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5) Somehow, and it is really scary to think about how this could have happened- in San Diego they gave 100 units of IV Insulin Glargine push and the patient did fine and needed no extra glucose. They suggest maybe 6 hours of obs is enough. (JEM 43(3)435)This is a real dilemma, because they want to assert that IV is way less dangerous than SC. That would be good if it is true because there is a case report in the same journal two years ago that a massive SC dose did result in profound hypoglycemia (JEM 41(4)374) and two years before that same thing (JEM 36(1)26). And just for a change of scenery, the same thing reported even back to 2004(Pharmcotherap 24(10)1412). All of these are case reports, so let's just say we don't know and we should just see insulin as what it is and does. If you do not live in San Diegodon't send these patients home until they have been observed for 24 hours. BTW I did speak to my nurses and they said that at least in Israel this would be a rare event as Insulin is one of the drugs that is double checked by two nurses before it is given to the doctor for administration. TAKE HOME MESSAGE: Lantus does cause hypoglycemia in overdose. IV

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and SC. Dr. Chase: It doesn't necessarily have to be that bad. If we exclude the night
terrors it could be something systemic: his liver, kidneys, something outside the brain. Dr. House: Yes, feel free to exclude any symptom if it makes your job easier.

6) Headaches- my usual history taking includes whether this is a thunderclap headache, associated symptoms like vomiting and neck stiffness and fever, and whether they have headaches in the past. You should however ask if the headache is positional. No I am not speaking about sinusitis, but there is a headache that worsens when the patient sits up- this is a CSF leak headache. There are many treatments but a blood patch is probably the most relevant treatment. Cause is speculative (JEM 43(3)486) TAKE HOME MESSAGE: a headache that gets worse on sitting upon- think CSF leak Dr.
House: [talking to Wilson about a patient and quickly changing the subject as he sees Dr. Cuddy coming] the cutest little tennis outfit! My God, I thought I was going to have a heart attack! Oh my! I didn't see you there - That is so embarrassing... Dr. Cuddy: How's your hooker doing? Dr. House: Oh, sweet of you to ask, funny story, she was going to be a hospital administrator, but hated having to screw people like that.

7) We used to admit all DVTs we don't now. And probably the same could be said by PE- the problem is with all the
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scores available- none are reliable enough to identify where the subset is located. Troponin, BMP, echo- all can help (Eur Resp J 40(3)742). I really believe this is true, but I have seen many PEs that looked OK and ended up crashing and burning, so we still need more info here- a lot more info. TAKE HOME MESSAGE: PE can be sent home sometimes- we just know when that sometime is.
Dr. Foreman: Occam's razor. The simplest explanation is always the best. Dr. House: And you think one is simpler than two? Dr. Cameron: I'm pretty sure it is, yeah. Dr. House: Baby shows up. Chase tells you that two people exchange fluids to create this being. I tell you that one stork dropped the little tyke off in a diaper. Are you going to go with the two or the one? Dr. Foreman: I think your argument is specious. Dr. House: I think your tie is ugly 8) I am going to say a lot about this subject so if you are

bored already (and who wouldn't be?) just skip this paragraph, and have a drink on me at Archie's Barf and Grill in Ypsilanti. The old days when you went the ED- you were seen by your doc or by a family practitioner who was moonlighting and then admitted to the hospital if need be
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to be taken care of by the nurses who contacted the family

doc if there were any concerns . This has changed. There are now EPs and hospitalists doing this job and coincidentally; both work shifts and both are responsible for the patient-so why not cooperate? This is especially important in light of ED overcrowding where EPs must now be internists and ICU docs. In some places patients will be admitted through the ED and actually discharged from there a few days later. So why not establish dialog to see who will be responsible for these patients and make protocol for their treatment. This could also affect the cost of care and increase the use of EBM. As far as I know this dialog does not exist. And in many ED s I worked in admitted patients boarding in the ED get no or
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really poor care. I may be controversial, but I learned how to cast and take care of an acute abdomen. I did not learn how to work up inpatient syncope- just some food for thought. (AJM 125(8)E1) TAKE HOME MESSAGE: Collaboration between wards and the ED on boarded patients is essential. Dr. House: This is our fault. Doctors over-prescribing
antibiotics. Got a cold? Take some penicillin. Sniffles? No problem. Have some azithromycin. Is that not working anymore? Well, got your Levaquin. Antibacterial soaps in every bathroom. We'll be adding vancomycin to the water supply soon. We bred these superbugs. They're our babies. And they're all grown up and they've got body piercings and a lot of anger 9) You will thank me one day. What are the causes of a

swollen uvula? Well here is the list- hereditary angioedema, drugs causing the same (like ACE, NSAIDS, and cocaine), infection (s pneumo, H flu), traumatic (intubations for example that did not go well), myxedamtous infiltration due to hypothyroidism, granulomatous infiltration due to Sarcoid, and uvular hydrops caused by opiods. Epi and steroids is what most people use for this, although intubation is rarely needed (Clev Cli J Med 79(9)600.). This article came out of my old home town so hey, let's give a
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big Hello to my pals out in north Philly at Albert Einstein hospital where Steve Parrillo practices. TAKE HOME MESSAGE: Want to know what causes uvular swelling? See above. Here is a word from our peer reviewer: Well The most common cause of uvular edema I see (This months peer reviewer, Gil Shlamovitz) is idiopatic ie: Qinckes Disease or ENTs Saturday Night Palsy (Snoring, ETOH & uvular angioedema), both dont require epinephrine or steroids and respond well to sucking on ice chips and time Dr.
House: See, this is why I don't waste money on shrinks, cause you give me all these really great insights for free. Dr. Cuddy: [smiling] Shrink. If you would consider going to a shrink, I would pay for it myself. The hospital would hold a bake sale, for God's sake

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10) Those rollicking guys over at Stroke (43(9)2539)

(no, I won't test you on this one- this is the butler "Lurch" from the Adams' Family) discussed the role of hemostatic therapy in anticoagulation associated intracerebral bleed, and actually came out with a pro and con They basically ask the question whether or not PCC should be added to FFP and Vitamin K or not. PCC is expensive and if anything, I would use it without the other two, but that isn't my point here- why wasn't tranxemic acid considered? It is super cheap. Does it work well? Well even in trauma patients in the CRASH -2 study it
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works a little, but the side effects are minimal TAKE HOME MESSAGE: Tranxemic acid may have some role in the bleeding. Lucas Palmero: This is a good hospital?
Dr. House: Depends what you mean by "good". [looks around] I like these chairs Dr. House: Ah! The husband described her as being unusually irritable recently. Dr. Cameron: And? Dr. House: I didn't know it was possible for a woman to be unusually irritable. Dr. Cameron: Nice try, but you're a misanthrope, not a misogynist

11) The debate gets exhausting. I'll just summarize it. Lactated Ringer's (also called Ringer's Lactate and Hartmann) is often used for volume expansion, but it does contain lactate which may cause elevated lactates and confuse you in septic patients. Normal saline can cause a hyperchloremic acidosis. However, the amounts of lactate in Ringer's is minimal, and acidosis in Normal Saline is not usually a problem although a recent study (which we will review in the future said there is more ICU mortality). Now this article reports that LR is hyposmolar which may not be the healthiest thing in brain
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injury (Curr Opin Anest 25(5)556).Why they can not invent a physiologic fluid that is osmolar and contains other goodies like potassium and calcium and anything else that is floating around in most people's systems? - I do not know. TAKE HOME MESSAGE: Crystalloid is the way to go- which one? I dunno. Dr.
Foreman: The kid was just taking his AP calculus exam when all of a sudden he got nauseous and disoriented. Dr. House: That's the way calculus presents. Dr. House: I assume "minimal at best" is your stiff upper lip British way of saying "no chance in hell." Dr. Chase: I'm Australian. Dr. House: You put the Queen on your money; you're British

12) I think we really need to know about this subject- and this paper is not the practical how-to go to guide, but if you care about your patients you need to care about palliative medicine as well. It was a panel discussion lead by a Dr. Quest (fitting name I think) and the points are: you need to know about this in the ED because these patients will come and competency and understanding are crucial. Now this isn't just a pitch to get the chaplain and social worker involved, but
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that you have to be really good in pain management and presenting the possible therapies. (J Palliative Med 15(10)1076) I just want to bring out two points. Firstly they describe an encounter that occurred in a filthy room off to the side. Investment in a calming atmosphere and not using the supply room is humane .Another point, in some countries; hospices are paid by patient turnover making them dreadful places to be in. Home hospice seems to be a better option if all care needs can be met. TAKE HOME MESAGE: Palliative care must be part of everyone's practice- and Knox Todd- one of the panelists- was kind enough to add a few words for EMU:
Thanks for covering the palliative care article. I would like to highlight both the palliative care and pain medicine fellowships offered by MD Anderson. These programs are very interested in emergency physician applicants and all can be found through links on our website (www.mdanderson.org/emergency-medicine).Thank you, Knox. I will just

mention that palliative care was just announced as Israel's newest specialty. Now just to add a practical point- many advanced cancer patients end up with intractable hiccups which are extremely uncomfortable. Lidocaine gel that was swallowed did help here in this case series so anti psychotics such as Thorazine may not be necessary ( Supp Care Cancer
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20(11)3009) TAKE HOME MESSAGE: Try lidocaine gel for intractable hiccups. Dr. House: [to Georgia] I'm sorry, but the fact that the
sexual pleasure center of your cerebral cortex has been over-stimulated by spirochetes is a poor basis for a relationship. Learned that one the hard way

13) We know that blood pressures rises and falls during the course of a day so why are we so quick to label them with hypertension based on office readings? Really, you should Holter BP all those who you suspect, or do a number of measurements in a claming atmosphere such as at home or a side room where it is quiet (not the supply room). Using automated machines probably scares patients less (J Hyperten 30(10)1894) Blood pressure meds are not always without significant side effects and the NNT is actually over 100. TAKE HOME MESSAGE: HTN is a disease that should be diagnosis by Holter or repeated measurements at home. Dr.
Foreman: You assaulted that man. Dr. House: Fine. I'll never do it again. Dr. Foreman: Yes, you will. Dr. House: All the more reason this debate is pointless.

14) I dabble a lot in flight medicine and this Israeli study showed a drop of about 2% in sats when going up to an

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elevation of 725 m- which by the way is way less than the cabin's pressure on a commercial flight (Respir 84(3)207). These however, were healthy volunteers; it would probably be worse in people who were not healthy. You can arrange oxygen for flights never rely on the oxygen they have on all fights the canister they have will last only a half hour- so it is always a good idea to prearrange it TAKE HOME MEMSSAGE: Sats drop on even moderate elevations.

Student: You're reading a comic book. Dr. House: And you're calling attention to yourself by wearing a low-cut top. [the student covers her chest with her clipboard] Dr. House: Oh, I'm sorry, I thought we were having a state-the-obvious contest. I'm competitive by nature.

15) Stop, family doc- this article is relevant to you too. NICE guidelines: Fever in neutropenic patients is always a challenge-admitting these folks expose them to bad hospital bugs but sending them home could result in sudden death. Usually we define neutropenic fever as less than 1000 ANC. I
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am just going to review the points that I did not know. These folks should be started on empiric antibiotics but not aminoglycosides. Also- this is a surprise- no routine chest films either. Is there such a thing as an occult pneumonia? I am beginning to think not. They like CRP and Lactate levelsnot really sure why the first. Their empiric antibiotics of choice- Tazobactam/Pipercicillin (Tazocin)._Hooray for my shop that is what they use too. No GSF is necessary in most cases- and here is the surprise for family docs- you may want to consider an empiric p.o. quinilone during the period of expected neutropenia (BMJ 345:e5368). TAKE HOME MESSAGE: No CXR or GSF in a neutropenic fever as matter of routine. If you know the patient will be neutropenic- give antibiotics as an outpatient. Dr. House: His liver is shutting down.
Father: What? What does that mean? Dr. House: Means he's all better, he can go home. Father: What? Dr. House: What do you think it means? He can't live without a liver, he's dying. Father: What is your problem? Dr. House: Bum leg, what's yours?

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16) I mean seriously- when do you see an article like this? Some people- now that tattoos are so popular are considering a tattoo on their chest that says DNR. Now they say that people doing resuscitation may not know what DNR means (Department of Natural Resources?) but aside from that- which is unlikely- what are the legal implications? Was it a joke? Did you change your mind? Would you have changed your mind under these circumstances where resusc would result in a normal life? (J Gen Int Med 27(10)1238) Perhaps you should have the whole DNR contact printed on your chest with date and notary's signature? And we as health care providers- what do we do if we see one? Lawyers and ethicists out there (yes, that is you Sandy and Ken) what do you say? TAKE HOME MESSAGE: Tattooing DNR on the chest may not have any meaning. Patient #3: I can't get my contact lenses outDr. House: Out of what? They're not in your eyes. Patient #3: But they're red. Dr. House: That's because you're trying to remove your corneas.[moves to next patient] What's wrong with you? Patient #4: Uh, lately, my wife has noticed that...

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Dr. House: Yeah, yeah. Symptoms, [gestures at Cuddy] we're working on a personal best here. Patient #4: Numbness in my feet and hands, constipation... Dr. House: And? Dr. Cuddy: Maybe he doesn't feel comfortable talking about his private matters... Dr. House: Well, neither would I, if I was having trouble controlling my pee pee! [to patient] Dr. House: You're a dentist. Nitrous oxide poisoning, which means you're either dipping into your own supply, or you've got a bad valve in the office. Laughing gas rehab's probably more expensive than the plumber. Meanwhile, get yourself some B12. [moves to college student] Dr. House: Who's left? College Student: I can't see. [House and Cuddy look appalled] Nah, I'm just screwing with you. [House looks at Cuddy, who smiles] It's a hangover, my English Lit professor told me he'd fail me next time if I didn't show up with a doctor's note. Dr. House: Well, make friends with the dentist. He can give you a note, and maybe a little nitrous to take the edge off. [he looks at the clock and walks out]

17) I guess the adage is anything that can be abused will be abused-and now Baclofen joins the growing list. I couldn't figure out from the article exactly what it does other than give "a buzz" but for you as the health provider- know that Baclofen can give pretty bad seizures- including non
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convulsive ones (Eur J Peds (171 (10)1541)TAKE HOME MESSAGE: Baclofen is a drug of abuse and can cause seizures

(now this is not a seizure but rather the challenge of giving a dog a bath. Come to think of it, you may want to take one too) Dr. Cuddy: You put him on Lupron.
Dr. House: Uh-huh. Dr. Cuddy: And, you told them it was like milk. Dr. House: Yes. Dr. Cuddy: Is there any way in which that is not a lie? Dr. House: It's creamy. But, I had three reasons. Dr. Cuddy: Good ones? Dr. House: Well, we'll see in a minute; I'm just making them up now
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Dr. Chase: How would you feel if I interfered in your personal life? Dr. House: I'd hate it. That's why I cleverly have no personal life

18) I know you all read this journal, so I was hesitant to bring this article- but it is a problem you may face so let's do it. Missing IUD strings is quite common. The way you found them in the past was using a cervical brush to tease them out of the os or colposcopy. Both methods are pretty poor. This retrospective study- methods are probably not that important as it easy to pick up these cases from the charts) showed that most of the time they were in position. A few times they were expelled, and rarely; they had perforated. How can you determine this? Simple- do an ultrasound. (Contraception 86(4)354) TAKE HOME MESSAGE: lost IUD strings- don't waste

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time with maneuvers- check to see if you see them, and if you

don't do an ultrasound.
Jeffrey Reilich: You're treating him for both diseases? Dr. Foreman: Covering all the bases. Jeffrey Reilich: What, throw everything against the wall and see what sticks? Dr. Chase: Works for spaghetti. [Everyone stares at him} Dr. House: But the patient's getting better. Dr. Chase: In spite of the Cytoxin. Dr. House: On the other hand... getting better.
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Dr. Chase: Cytoxin makes him more susceptible to infection. The anthrax could relapse and be more resistant. Dr. House: Better! Dr. Chase: You want a negative test on every autoimmune disease known to man? Fine! Dr. House: Be home by midnight or you can't have the car this weekend

19) I'll just mention this briefly- don't you wish I would say that all the time- low tidal volume reduces mortality in ARDS and acute lung injury, but can result in hypoxemia, atelectasis, and hypercarbia which could be bad in head injured patients. So like Prof Hoffman always says- "just do the right things". What is that? Anyone want to volunteer an answer? (Ann Emerg Med 660(2)215). Now before I get it on the head from Scott- and I know its coming- let me say I do know the answer- work with your plateau pressures and keep them under thirty. However, for some of us- that is hard to measure on some of the machines we have. Is this a plea for a machine that can tell us the plateau pressure at a glance? Well in a word- yes. TAKE HOME MESSAGE: Maybe a TV of 8

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ml/kg is a better start. [about Vogler being appointed board chairman of the
hospital] Dr. Cameron: That's not necessarily bad news. Dr. Foreman: Do you ever watch "Gilligan's Island" reruns and really, really think they're going to get off the island this time? Dr. House: No pneumonia, no bacterinia, no hep B or C or any other letters Dr. Cuddy: Substance abuse? Any hist... Dr. House: No alcohol, no drugs Dr. Cuddy: Any psychological conditions, history of depression? Dr. House: She's a little blue...but it turns out she needs a heart transplant

20) This has been reviewed on EM RAP but is such an important topic. Also the lead author is an EMU reader and a great guy. We know what causes TTP now- it is a lack of ADAMSTS13 which cleaves the von Willebrand factor in to little pieces. If it is not cleaved they began to clog things up. That results in the classic pentad which is really a triadhemolytic anemia (that is a low hemoglobin with spherocytes), some kind of neurologic complaint which may actually clear before they are seen and thrombocytopenia. The fever and renal damage are helpful but not always there.
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HUS can look similar but it is seen more often in kids and there is diarrhea. Causes include autoimmunity, medication related (think Clopidogrel), cancer, pregnancy and infection. Plasma exchange is the treatment but in the interim you can give FFP or cryoprecipitate and steroids. Rituximab will help as will cyclosporine if nothing else helps or if you have no plasma exchange. But then again- try to get plasma exchange as mortality without it is high. Platelet transfusion is contraindicated- although maybe not- we always thought it was but it seems that some recent studies have questioned this (JEM 43(3)538). TAKE HOME MESSAGE: Low platelets and anemia- you better at least consider TTP.
Dr. Cameron: They just stopped Carly's heart. And your dumb patientDr. House: They're all...oh, the guy who can't talk, right. Dr. House: Why are you doing this? Dr. Cameron: I'm not doing anything. Dr. House: You're manipulating everyone. Dr. Cameron: People... dismiss me. Because I'm a woman, because I'm pretty, because I'm not agressive. My opinions shouldn't be rejected just because people don't like me. Dr. House: They like you. Everyone likes you. [he starts to walk away] Dr. Cameron: Do you? I have to know.
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Dr. House: No. Dr. Cameron: [smiles quietly] Okay

21) There have been a lot of articles recently that say we shouldn't teach intubation to pre hospital folks- it is costly, skills need to be maintained and it hasn't shown survival benefit. And besides we have lots of supraglottic devices that can hold people over until they get to the ED- like the LMA, the combi tube and the laryngeal tube. This is an editorial on a paper in Resuc 83(9) 1061 which actually showed benefit to intubation in EMS hands. David Cone- the editor in Chief of AEM gives his opinion here and while he doesn't like the study, the objections are rather skimpy. It is an observational study and there is a lot of missing data. Furthermore there is no record as to whether the patients who got SGA (supraglottic airway) were failed intubation and of course did worse. (Resusc 83(9)1047) I think the issue isn't so clear but it would make sense to go with scoop and run and not delay with ET tubes in the field especially since the SGA may be enough in many cases like CHF. TAKE HOME MESSAGE: Intubation in the field may not be advantageous

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over the LMA- however this study said it was. Bill: His name's Joey,
he's my only brother. Dr. House: He's important to you. Got it. No placebos for him, we'll use the real medicine Lucille: I'm not pregnant. Dr. House: Sorry, you don't get to make that call unless you have a stethoscope. Union rules

22) Hey, you are just not hip (the sixties) if you aren't using awesome (the eighties) amounts of vitamin D for just about everything. It is really beat, (the fifties). You would think that since it h as an immune function that it would help for the common cold. Well, it doesnt and joins inhaled steroid, echinacea, vitamin C, fluids, anti viral and zinc as things that Cochrane says that don't work (JAMA 308 (13)1375) I mean totally (eighties) groovy( seventies). TAKE HOME MESSAGE:

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Vitamin D does not help in the common cold. Psychedelic!

(sixties)

Vogler: So, there is some hope. Dr. House: Always. But just in case, I special-ordered a jumbo-sized coffin. Vogler: Hey ... Dr. House: Don't thank me. It's just who I am. Dr. Wilson: You're not going to be happy with anyone. Dr. House: So what, your advice is... hire someone I'm not happy with and be happy? Dr. Wilson: No, my advice is much more subtle. Stop being an ass 23) What you bring home on your next trip abroad could be a

mug or a T shirt but I would advise you to be more exoticwhy not bring home an arbovirus? Yes these fun, playful arthropod borne viruses are not available in any store, and
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come free with that ginseng knife. I thought this article would be an interesting read, but indeed other than letting me know that Dengue is still the most common virus you will get abroad ( and we have discussed dengue in the past) all the others are pretty uncommon and most importantly- they have no real treatment options. And of course the most dangerous animal of them all remains the mosquito (J Clincial Virilogy 55:191) TAKE HOMEMESSAGE: Fever, joint pains after a nice trip to the tropics- think arbovirus Dr. House: It is in the nature
of medicine that you are gonna screw up. You are gonna kill someone. If you can't handle that reality, pick another profession. Or finish medical school and teach. Dr. House: Straight from the bladder, that's as fresh as it gets 24) This is a really important article but because no body is still

reading at this point anyway, I decided to sneak it in here. Azithromycin is a risky drug. While it is rare, azithro has shown much more mortality than with amoxy, especially in patients with cardiac disease, QT prolongation, and those using amiodarone or sotalol. Considering that most common uses of this drug are for sinusitis and bronchitis where numerous studies have clearly shown it doesn't work) and we
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do know that it is weaker than the penicillins in treating strep (Penn allergic- go to cephalosporins- see April EMU)- maybe you should be like me (a good idea in any case) and never use this drug (NEJM 368(18)1665) TAKE HOME MESSAGE: Azithro joins its brother erythro as being a bad boy- this time with cardiac deaths. Dr. House: [closing the blinds so he can't see Stacy] What?
Mommy and Daddy are having a little fight, it doesn't mean we've stopped loving you. Now, go outside and play. Get Daddy some smokes and an arterial blood gas test

Dr. Cameron: Black defendants are ten times more likely to get a death sentence than whites. Dr. Foreman: Doesn't mean we need to get rid of the death penalty, it just means we need to kill more white people

24) PICC Lines are not safer than conventional IVs. Bloodstream infections and thrombosis are not that all uncommon. (AJM 125:733) Dr. Foreman: Her oxygen saturation is normal.
Dr. House: It's off by one percentage point. Dr. Foreman: It's within range. It's normal. Dr. House: If her DNA was off by one percentage point, she'd be a dolphin

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Dr. Cuddy: Dr. Sebastian Charles collapsed during a presentation at Stoia Tucker. Dr. House: Really? Crushed under the weight of his own ego

25) Lower GI bleeds- guess what? They have longer hospitalizations, more resource use and higher mortality than Upper GI bleeds. True 85% are self limited but they can be treacherous. Is the upper GI tract still the most common cause of lower GI bleed? Probably not- they still like putting NGTs (zonde) in but it is not associated with any mortality benefit. I would use it in severe bleeds. CTA is the diagnostic tool of choice, colonoscopy is another weapon (that was terrible) at your disposal, but you need a good cleaning which may take a few hours. It can however often stop the bleeding, other times embolization or surgery may be necessary. Video capsule endoscopy has some utility but here is the surprise for methose red blood cell nuclear scans are useless- that was a holy cow from when I was a med student (back when Father Greg was a young man of 65 (I graduated in 1986). Causes- the classic teaching is still true- painless- think diverticulosis (an arterial bleed which can be massive), hemorrhoids, AVMs
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(usually less severe, ischemic colitis, all the diarrheas (don't forget C difficile), neoplasms, and anal disorders which are usually much less bloody and painful. Don't forget chemo and meds can cause bleeding- if your grandma is on cocaine- that does cause an ischemic colitis. (Drugs Aging 29:707) Here is a picture of some druggies so be careful

Actually that is Irene Ryan the grandmother from the Beverly Hillbillies. TAKE HOME MESSAGE: LGI bleeding can be serious and
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embolization is the treatment in most cases if it is serious. Dr.
Chase: You were right. Dr. House: Now there went three wasted words Dr. Cameron: It's kind of a long shot. Dr. House: Yeah, but it's been over an hour since we poked the patient with something sharp. Get him a lumbar puncture Dr. House: [after injecting the cyclist] Tensilon erases the symptoms of MG for five or six minutes. [patient falls to the ground] Sometimes less. This is exactly why I created nurses. [yells out the door] Cleanup on aisle three

26) Time for letters. Firstly from ICU guru Scott Weingart- I have

never met Scott personally (Scott- when you coming to visit Israel?) but he is a great guy and I appreciate his answering my questions and participating in a round table discussion not too long ago. Scott was recently quoted as being a drug pusher. He is in favor of this and actually has done this many times. Oh, I guess I should be more explicit- we are talking
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about push pressors- those quick solutions to get BP up when you over sedated a patient or until you can get in a CVP. Barry Brenner- another good friend in the old days just opened the dopamine wide open, and Scott is in favor of phenylephrine and epinephrine but what about Terlipressin? Or just pushing norepinephrine? Scott answers- that Terlipressin has a rather long half life- about a half hour- so not much room there for overshoot. (phenylephrine lasts about seven minutes). My ICU guys say Teligpressin works fine the first time, but additional pushes give less of a response. Also it really causes a lot of splanchnic ischemia. Pushing nor- he is all in favor- but there are no studies. I also asked him about ET tubes that were put into the esophagus (darn medical student) and my fast thinking of throwing an NGT (zonde) down the ET tube to drain out all the baked flamb this guy has eaten in the last three hours but then getting laughed at by the nursing staff as the ET tube can not clear an NGT. Well the only solution is to use a hook knife or a stitch cutter and cut off the ET tube- I was thinking perhaps cutting off the head of the NGT and using an adapter but I

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couldn't find one. In other letters: Alxel Ellrodt from Hopital Americain in Paris immediately identified the bubble gum scene from last month's movie quiz- but let's see if he remembers in what picture you will find Rick's Caf Americain? Thanks for writing. Father Greg does write. Father; please be careful what you write- Im a little sensitive about Billy Carter- he was my Grandmother. Here is part of Gregs letter-I couldnt print it in the entirety because Greg is a legal kind of guy and might bust me for the Mann act (transportation of medical information across state lines for immoral purposes) This is Father Henry commenting on the May issue
of EMU. First, I got all 3 famous people right off the bat but thats because Im DELETED! I probably have shoes and belts DELETED than a lot of your readers with Ken DELETED being the exception. Thank you for your DELETED endorsement of Risk Management Monthly. Next month we are doing a special on DELETED. I must say that Israel seems an odd place to be commenting on US country music. DELETED Just to add to your great country lines there is one that combines hillbilly music with dermatology : your father can put me in jail for loving you but he cant stop my face from breaking out. Keep the faith. Thanks Father for writing,

27) The rash in number 2 was eczema herpeticum which likes the face. The lesions often become pustular. This is caused
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by our old pal Herpes using other skin diseases as an excuse to reappear. The Acyclovir family is the treatment and patients do well if they are treated- but not if they do not receive therapy. This is what it looks like later on- this is not

impetigo Number 3 is pyoderma gangrenosum. This is made worse by debridement. It is often seen with IBD but you will see it in RA
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and SLE too. Anti-inflammatory treatment is recommended, steroids usually but not always help. Dr. House: [To a patient who's been
using strawberry jelly as a spermicide, and got an infection from it] You probably shouldn't have relations for a while. Patient: For how long? Dr. House: On an evolutionary basis, I'd recommend... forever. Dr. Cameron: How would you describe my leadership skills? Dr. House: Nonexistent. Otherwise excellent

EMU LOOKS AT:Chucks and Up chucks

The source of these two essays are JFP 61(7) 384 and AJEM 31:859. For those trying to figure out what I am talking about, the first essay will make you want to use a chuck (an American word for an absorbent covering of a bed sheet), the latter is a word from the eighties that is a term for regurgitation. First Essay: Come on, you don't fool me. And now I am going to get revenge on you- I am going to publicize to all the EMU readers who you have been sleeping with. Here we go the hootchie's (gigolo's) name is Cimex

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1) Yes cimex. Let me show you a picture of this beauty.

Yes that is a bedbug. These fellows were pretty rare in the nineties so much so that they couldn't even collect specimens for medical purposes. That has changed obviously as insecticides are less effective and this bug is extremely resilient. They can live a year with out feeding (Gosh, can't they make a teenager like that?) and they are small enough that they can travel with your luggage or through cracks to new destinations. They use the Al Capone method- feed early and feed often. They do

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2) this as they can not get to the next stage without doing so. Since they only feed off of humans- they are hard to bait or trap. Fortunately they do not spread any disease that we know of-but their bites are very pruritic. Scabies can look like this, but they burrow and like skin folds- bedbugs are less fussy. Flea bites, mosquito bites and spider bites can all look the same- a linear three bite pattern may help to suggest these little folks- but it is not specific enough. Treatment of bites is easy- the usual antipruritics. They do leave a lot of debris so discovering them as a biting source shouldn't be too difficult. Have a doubt? There are bug detectors machines and even specially trained sniffing dogs. You can get rid of these pests by desiccant dusts such as silica; heating or freezing for an hour, sealing cracks in the room, and perhaps taking ivermectin which poisons the bug when they use you for dinner. It should be noted that there is little research on the use of ivermectin. You can also trying killing the bacteria that live in the bedbug's bodies and whom they need for survival. When you travel, wrap your luggage in plastic. Store it in the bathroomless chance the bugs will get there. Cover your bed and box springs Buying used furniture? Fumigate it! Have no bedbugs where you live? Don't say I didn't warn you, these creatures are nightmares in bed.
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3) 4)

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Second essay: Two points- this is no joke- there are no good guideline for these patients and their cases are sad- young ladies who sometimes die. I am speaking bout eating disorders. I will also just mention that if you are an EMA listener; Jerry and Billy spoke about this earlier, but they used an article from the Int J of Eating Disorders (45(8)977) and ours is of course newer. But then again- the literature police strike again- our article was written by two of the same authors. 1) Well the two culprits here are anorexia and bulimia- well know to us but actually they have DSM V definitions for these and indeed there is overlap between the two syndromes. We all know this is a disease primarily- but not limited to- females, but I didn't know that after asthma and obesity- it is the most common chronic condition in female teens. 2) These people have co morbidities- self esteem, high concern parents, perfectionism issues, history of sexual abuse, depression, substance abuse or weight loss for athletic reasons. Anorexia shouldn't be too hard to identify- these folks are very cachectic. They will also have brittle nails, thinning hair and fine lanugo hair on the arms and face. Blood tests are usually not helpful unless they in a severe stage. Amenorrhea is common.

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3) While anorexia often have some form of bulimia, the opposite is rarely true. Bulimia is-again a disease of females. The same co morbidities are often present 4) Bulimics may have physical findings- such as hypertrophied parotid glands, poor dentition and erosions on the hands- known as Russell's sign-are signs of purging. Hypokalemia and metabolic alkalosis may be found on blood tests. 5) This severe malnutrition results in decreased cardiac mass, contractility and cardiac output. They have bradycardia. And dysrhythmias are common. Purging may cause pneumomediastinum 6) So be careful- fluid management is critical- too much into these weakened hearts and your patient will slide over to CHF. Refeeding syndrome is also a concern as this will cause a lot of insulin to be released reducing potassium, magnesium and phosphorus stores. Here is an example they give- a female ingesting only 500 calories a day can be overwhelmed by 1000 cc of D5 which contains 200 kcal So they need to be re fed slowly. And this is not to be done in the ED but on the floor. However, feel free to give vitamin supplementation. I should just mention that this syndrome can be seen also in alcoholics and in hyperemesis gravidarum.

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7) Bulimics can also abuse ipecac leading to a cardiomyopathy as ipecac contains a cardiac toxin. They can have a pseudo Bartter syndrome. These folks also should be given fluids judiciously as aldosterone levels take time to fall and they will go into CHF. Spironolactone is an excellent agent here for mild diuresis and potassium supplementation. As bulimics abuse stimulant laxatives- they may have a rebound constipation- use PEG. 8) The SCOFF questionnaire will help identify who is an anorexic but these patients are in denial and while suicide is common, there is little the system can do. They cannot in most jurisdictions be admitted against their will unless they are in really bad shape. 9) Curiously, the article did not mention SKA- a mild acidosis of starving treated by fluids. Carmen, a patient with schizophrenia is being treated by Dr. Randall Powell Carmen: There are bugs all over this room! Powell: Where do you see them? Carmen points to the wall. There is nothing on the wall Powell: Point exactly on one on the wall Carmen points to a spot on the wall. There is nothing there Powell slams his hand on the wall.
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Powell: There, I killed it. Youre cured. Next! (Yes, this actually happened)

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