Ouch! ED Physician, fresh out of residency, hit with 4 million dollar lawsuit for missing heart attack.

I don't know the details of the case but from the info in the lay press I feel sorry for all involved.  Dr. Stephen Heirendt, fresh out of residency two years ago, got hit with a 4 million dollar settlement after a 43 year old patient he evaluated and discharged home with chest pain NOS / bronchitis died of a heart attack. 

Vacation: No post today

Self-imposed, vacation day. 

I'm declaring today as one of many national "Wellness" days. Have a great weekend.

Sorry for the no-post. 

Keep a look out for Dr. Stella Yiu's upcoming poll regarding a student's behavior: "What you do if YOU were on the residency selection committee?"

What is the cause of this "white out" on the right side of the chest x-ray?

Pleural effusion.  Click image to enlarge.

CT of same patient demonstrating left pleural effusion.

A couple features suggest pleural effusion over other causes:

• homogeneous opacity with no air bronchograms
• concave upper surface producing a meniscus 
• while not really notable with this pleural effusion, some large pleural effusions will displace the mediastinum towards the contralateral side 

The "white out" is unlikely to be caused by lobar collapse because there is no evidence to suggest decreased lung volume (displacement of pulmonary fissure, elevation of hemidiaphragm, displacement of hila, displacement of mediastinum or compensatory overinflation of an adjacent lobe).   Collapse of each lobe has a characteristic radiographic appearance, click here to view.

Pneumonia is also an unlikely cause.  For one, there is a second area of consolidation at the left lung base (also a pleural effusion).  While multifocal pneumonia does exist, non-infective pathology takes a higher place in the differential when there are multiple areas of consolidation.  Additionally, pneumonia generally has a more inhomogeneous opacification with air bronchograms and ill-defined margins. Click here to view a large pneumonia.


Source

Jenkins, P.  Making Sense of the Chest X-Ray: A Hands-On Guide, 1st ed.

Lisle, D. Imaging for Students, 3rd ed.

Schwartz, D.  Emergency Radiology: Case Studies

Can you predict the motion of the slinky?

This is for the little nerd in all of us ...

Slinky starts in the position noted in the picture on the left.  The person drops it and the slinky ends up on the ground, as highlighted by the arrow, in the picture on the right.  Can you predict the motion of the slinky as it falls?  Hint: Where is the slinky's center of mass?

Watch video to see what happens in slow motion.



Explanation of the physics here.

Join.Me: A free online screenshare and phone conferencing tool

Skype, FaceTime, Google+ Hangout.

So many options!

I recently used a free online tool at Join.Me so that 3 people can discuss the statistical analysis of a paper we are working on. But it's so hard to get 3 busy people in the same room at the same time! So, we tried Join.Me. We basically needed to view one shared computer to review the statistical data and share a conference call phone line.

What I was immediately impressed by was the simplicity in the whole process. It's FREE and PC-/Mac-compatible.

1. Go to the simplistically appealing home page (see above).
2. Click on the orange"share" icon.
3. This automatically downloads a software package which you should install.
4. Open the Join.Me software app on your computer.

5. A pop-up screen (above) will appear. Now click on the Share icon.

6. This will automatically give you an URL link to share with others to view your screen PLUS a free conference call line.

Here's a sample promotional image of what a session looks like:

We had a great meeting about a multicenter (11 hospitals!) educational study on the impact of an English-based pediatric software on physician decision making in Vietnam. It was super-fast, efficient, and hassle-free.





  

Trick of the Trade: Needlestick hotline 888-448-4911

You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient's venous blood.

After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.

Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.

It's difficult to concentrate when faced with so many questions whirling in your mind.

Trick of the Trade:
Use the National Clinicians' Post Exposure Prophylaxis (PEP) Hotline - 1-888-448-4911

"The PEPline provides around-the-clock expert guidance in managing healthcare worker exposures to HIV and hepatitis B and C. Callers receive immediate post-exposure prophylaxis recommendations.  Available 24/7."

Remember this is for providers who are exposed and not the lay public.

I was not only surprised to find that this national hotline is hosted by UCSF/SFGH (my home institution!) but also helmed by my friend Dr. Goldschmidt (Professor and Vice Chair, Department of Family and Community Medicine).

For more information about the National HIV/AIDS Clinicians' Consultation Corner, which staffs the PEPline, view their website at: http://www.nccc.ucsf.edu/about_nccc/pepline/

On the website, they also feature a "Warmline" at 800-933-3413, which is staffed by physicians, clinical pharmacists and nurse practitioners Mondays through Fridays, from 5 am to 5 pm (Pacific Time). They provide up-to-date information for the care of your HIV-positive patient.

Left arm / Right arm EKG lead reversal is fairly common and easy to pick up; but would you be able to detect a left arm / left leg reversal?

Check out this great post from Dr. Mike Codagan of LITFL regarding detection of EKG lead misplacement.

Poll: Based on the chest x-ray appearance, what is the likely cause of this patient's SOB and right lung field "white out"?

click on image to enlarge

Answer to be posted Friday September 30th!

80 y/o male with history of CABG presents with SOB x 24 hours. EKG notes ST elevations in anterior precordial leads. Point of care troponin 0.4 (equivocal). Should the patient be taken for immediate cardiac cath?

No old EKG for comparison.  Click image to enlarge.

No immediate cath.  The patients history and laboratory evaluation are a bit atypical for ST elevation MI.  Additionally, the EKG harbors characteristic findings of a ST elevation MI mimic, prior MI with or without ventricular aneurysm.   EKG features of this ST elevation mimic commonly include:

• ST elevation with QS waves in V1-V4
• T waves flat or inverted 
• ST elevation relatively small relative to QRS amplitude, (less than 1/4 height of QRS) 

Source

Smith, S. and Larson, D.  "Chapter 14: What Pseudoinfarction Patterns Mimic St Elevatioin Myocardial Infarction."  Critical Decisions in Emergency and Acute Care Electrocardiography, 1st ed.   2009.

Paucis Verbis: Does this DM leg ulcer have osteomyelitis?

We sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it's the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you'll be surprised by what you find.

Several questions come up with diabetic foot ulcers:

• Is it a true diabetic foot ulcer, or is it an arterial or venous insufficiency ulcer?
• Is there underlying osteomyelitis?
• How can I best diagnostically work this foot ulcer up for osteomyelitis?
• What is the Wagner grade of this ulcer? (I think it'd be Grade 2.) 

Thanks to JAMA's Clinical Rational Examination series, there is a systematic review of diabetic leg ulcers and osteomyelitis. Here are the highlights:

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Below is the Bayes nomogram to help you plot out your post-test probability based on your likelihood ratios. The example given is if your pretest probability is 25% and your LR is 10. Your post-test probability would be 80%.

Reference

Butalia S et al. Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity? JAMA. 2008; 299(7), 806-13. DOI: 10.1001/jama.299.7.806.
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Get feedback on your PPT or PDF files: Reelapp.com

www.ReelApp.com

The smart folks at Zurb have come up with a clever app. This free Web-based app, called Reel, allows you to quickly collect thumbs-up/ thumbs-down votes on each slide or image. . Think of it as Slideshare with a "likes" feature added.

So if you are working on a Powerpoint, a series of images, or even PDF's and want feedback from friends and colleagues without having to email the large file around, think about uploading to Reel. What a great way of crowd-sourcing feedback.

For instance, here are my "Tricks of the Trade" lectures slides for the upcoming ACEP meeting in October. See how you can give a like or hate vote to each slide. Feedback is welcome but alas they already made me turn in the files a long while ago.




Note: This only works for still images, so movie files in my Powerpoint slides don't work.

Trick of the Trade: Pediatric ear exam

Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about:

• Balloonimals iPhone app to grossly assess peak flow
• Candleflame iPhone app to grossly assess peak flow
• Eye Handbook iPhone app with pediatric fixation animation targets
• Casting/splinting your buddy bear

What's your trick on performing an otoscope exam of the ears?




Trick of the Trade:
The case of the disappearing otoscope "hat"

A slight of hand can easily make the otoscope speculum disappear. Your apparent search for this missing "hat" can make it easier for you to examine the ears.


Thanks to Dr. Chris Nickson (Life in the Fast Lane) for the find!

Patient presents with severe RUQ abdominal pain 2 days status post laparoscopic cholecystectomy. What is the workup?

Check LFTs and obtain abdominal CT or ultrasound. Must exclude biloma (from biliary leak) and common bile duct stricture, two known complications of lap chole.


Source

Townsend: Sabiston Textbook of Surgery, 18th ed.

25 y/o female presents with low grade fever, vomiting, rigors and headache 1/2 hour after injecting heroin. Vitals notable for temp of 100.5. Physical unremarkable. WBC 12, other labs normal. After IV hydration and antiemetics patient feels much better 2 hours later. What is her likely diagnosis?

Cotton fever. As part of the processing of heroin prior to injection many drug users strain the drug through cotton to rid it of impurities. This process, however, can sometimes introduce other impurities into the drug such as Enterobacter agglomerans or other nonspecific pyrogenic components which produce the symptoms described in the vignette. Treatment is supportive and symptoms generally self resolve within 24 hours. While cotton fever is a benign febrile disorder, vigilance should be maintained as there are many not-so-benign causes of fever in the intravenous drug user.


Source

Ramik, D. and Mishriki, Y. "The Other 'Cotton Fever'" Infectious Disease in Clinical Practice. May 2008.

Marx: Rosen's Emergency Medicine, 7th ed.

Shannon: Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th ed.

Paucis Verbis: Legionella pneumonia

Did you know that there was an unexplained spike in Legionnaire's disease (pneumonia caused by Legionella pneumophila) during the 2009 H1N1 flu pandemic?

Since the flu season is rapidly approaching, I thought I would review what Legionnaire's disease looks like. Yes, they will have a fever, cough, and pneumonia on CXR. These patients are generally pretty sick and almost always need hospitalization. What makes it unique? The trick is to look for extrapulmonary findings, which help to distinguish it from other atypical pneumonias. Relative bradycardia is a sure tip.

Why do we want to differentiate it from other pneumonias?
Legionnaire's disease requires reporting to your state's health department to help track for outbreaks.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

More information on Legionellosis from the CDC website.

Reference
Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. 2010 Mar;24(1):73-105. PMID: 20171547
.

Interesting EKG: Inferior STEMI with ventricular bigeminy

Click image to enlarge.

Trick of the Trade: Synovial lactate in septic arthritis

A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. "It feels different than my RA flare."

Does this patient have a septic joint?

The difficulty in diagnosing this elusive disease is that the history, physical, and serum tests are typically unhelpful in ruling in or out the disease. See my previous Paucis Verbis card covering the 2007 JAMA review on Septic Arthritis.

Interpretation of the synovial fluid is also challenging. Generally a synovial WBC count <25K suggests a non-infectious process and a WBC count >100K suggests an infectious process.

What about everything in between 25K and 100K?

Trick of the Trade:
Check if the synovial lactate level is > 10 mmol/L.

A level >10 mmol/L is highly suggestive of septic arthritis. The calculated positive likelihood ratio (LR) from multiple studies was at least 10. The negative LR ranged from  0 to 0.45.

Although the quoted studies measured lactate using liquid chromatography, presumably our point-of-care lactate levels are equivalent, based on various sepsis studies.

How do you use the LR statistic? I'm no statistician, and so I love the Bayes nomogram. This requires me to have a pretest probability for the disease. In this case, let's say that I am moderately suspicious of a septic joint given the patient's history of rheumatoid arthritis (a known risk factor), significant joint pain, and low grade fever. I'm going to say that my pretest probability is 25% (see left column of numbers).

The synovial lactate level returns at 12 mmol/L (see middle column of numbers), which gives the patient a positive LR of at least 10.

This means that my post-test probability for a septic joint jumps way up to 80%, which practically rules-in my patient for septic joint.

Reference
Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based Diagnostics: Adult Septic Arthritis. Acad Emerg Med. 2011;18(8), 781-96. PMID: 21843213
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Poll: YOU are the clerkship director - What would YOU do?

You are teaching a clerkship seminar and a student kept checking her iPhone for Facebook updates. You reminded her that she probably should not be distracted and she replied, "Well, I don't need to know ACLS. I am applying to Dermatology anyways."

You happen to be meeting the Dermatology Program Director later that day...

Please feel free to type in your comments below to explain your answer.

Paucis Verbis: Distracting injuries in c-spine injuries

"Distracting injury" is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of "distracting injury". Although both are studies at different sites, both conclude the same:

• Chest injuries may be considered "distracting injuries" because of their proximity to the cervical spine.  

So let's say you are caring for a non-intoxicated motor vehicle crash patient with an isolated tibia fracture (i.e. a "long bone fracture"), no chest injuries, and no neck pain/tenderness. Per the NEXUS criteria, you might consider this patient to have a "distracting injury" because of the long bone fracture. Instead, the literature now supports your clinically clearing the cervical spine without imaging.

Wait, let's rethink this. Does this mean that you should get cervical spine imaging for ALL blunt trauma patients with ANY chest wall tenderness?! NO. That's just crazy. You should still factor in the mechanism of injury, severity of pain, and your clinical gestalt.

So for me, these "distracting injury" studies are helpful such that:

• If your trauma patient does NOT have chest trauma, it may help you avoid unnecessary cervical spine imaging, as suggested by the NEXUS criteria.
• If your trauma patient DOES have significant chest trauma, I have a lower threshold to obtain cervical spine imaging despite the neck being non-tender.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

75 y/o male with history of benign prostatic hypertrophy, but otherwise healthy, presents with acute onset suprapubic pain and difficulty urinating. Foley catheter is placed and drains 900 cc of urine. Should renal failure or postobstructive diuresis be of concern?

No.  Renal failure and postobstructive diuresis are of concern in chronic urinary obstruction which often presents with no or minimal abdominal pain.


Source

Barrisford, G.  et al.  "Acute urinary retention"  Up to Date.  May 2011.

17 y/o male presents in severe respiratory distress secondary to asthma exacerbation. Patient is intubated using combination of etomidate and succinycholine. 10 minutes later he begins to take a turn for the worse becoming rigid, febrile (108 F), tachycardic and acidodic (both metabolic and respiratory). What is the diagnosis? Treatment?

Malignant hyperthermia, is an entity often written about (as in this vignette) but rarely - if ever - seen in the emergency medicine community.  In a brief review of the literature, I found no case reports of malignant hyperthermia presenting in the ED.  While malignant hyperthermia can occur after administration of succinycholine alone, it is a more common complication in the OR where succinycholine is combined with inhaled anesthetic gases .  Treatment is dantrolene, a drug with minimal side effects, which will decrease mortality from as high as 70 percent to between 1 and 17 percent. 


Source

Litman, R.  "Malignant hyperthermia: Clinical diagnosis and management of acute crisis"  Up to Date.  May 2011.

Rosero, E.  et al.  "Trends and Outcomes of Malignant Hyperthermia in the United States, 2000 to 2005.  Anesthesiology.  2009.

There is no OB in-house to do an emergency c-section and you are presented with a prolapsed umbilical cord during vaginal delivery. What are your next moves?

1. Call to get OB in-house or initiate transfer for emergency c-section.
2. Push the presenting part off the prolapsed cord.
3. Place the patient in trendelenburg and then have the patient put her knees to her chest. 
4. Fill the bladder with 500 cc of saline to maintain cord decompression. 
5. Decrease uterine contractions by administering supplemental oxygen, IV fluids and pharmacologic tocolytic therapy (magnesium sulfate, ritodrine or terbutaline).
6. If an emergency c-section cannot be arranged in a timely fashion (with timely likely defined by your OB consultant) attempt to reduce the prolapsed cord by pushing it in a retrograde fashion and then delivering the fetus as quickly as possible while preparing for a newborn resuscitation.

Source

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Marx: Rosen's Emergency Medicine, 7th ed.

Brief survey: Need your help with my promotions!

With all of the advances in technology and social media, the "old school" world of traditional academia doesn't know what to do with medical professionals who incorporate technologies into their educational practices. To justify these past 2 years of blogging during my free time, I wanted to collect data on who my readers are and the impact of my blog (if any).

I could sure use a few minutes of your time and input to help with my promotions process. Let's push traditional academia to change with the times. Thanks a bunch.

UPDATE (9/9/11): Wow, I am overwhelmed and humbled by everyone's kind words. This survey alone illustrates the power, reach, and immediacy of social media. I've gotten 147 responses already! (see responses on Google Docs Forms). Now I know for certain that I am on the right track in pushing for social media technologies in medical education. 



This is the first time I have used Google Docs Forms to build a survey. Pretty cool.

What is the diagnosis of this ST elevation MI mimic?

69 y/o female with no significant PMH presents with intermittent atypical chest pain after her husband passed away.  An EKG, below, notes ST elevations.  Labs notable for troponin I of 8.  Patient is taken to the cath lab where she is noted to have clean coronaries but left ventricular apical akinesis and mildly decreased ejection fraction.  What is the diagnosis?  Scroll down for answer.

click image to enlarge

Takotsubo cardiomyopathy.  This is a rare ACS mimic and nearly impossible to differentiate from the real deal -  ACS -  in the emergency department prior to cath.  Criteria for diagnosis include absence of obstructive coronary disease, transient left ventricular apical akinesis and new EKG abnormalities in the absence of another cause (head trauma, myocarditis, hypertrophic cardiomyopathy, etc).  Patients, with a preponderance females, often present after emotional or physical stress.   Pathophysiology is unclear.  Outcome is generally favorable with cardiac hypocontractility usually resolving in 2 - 4 weeks.


Source

Barker, S. et al.  "Electrocardiographic ST-segment elevation: Takotsubo cardiomyopathy versus ST-segment elevation myocardial infarction - A case series"  American Journal of Emergency Medicine.  2009.

Trick of the Trade: Epley maneuver

You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous.



Is your first-line treatment meclizine or benzodiazepines?











Trick of the Trade:

Epley maneuver (Canalith Repositioning Procedure)



Although the 2004 Cochrane review states that the Epley maneuver is of questionable benefit, a 2010 systematic review demonstrated that there is a significant benefit from Epley maneuver. The trick is remembering all of the steps correctly.

• The first position is really the Dix-Hallpike maneuver in the direction (right vs left) which causes more vertigo or nystagmus.


• Wait 30-60 seconds.


• While remaining supine with the head extended 25-30 degrees, rotate the head 90 degrees until it is facing the other shoulder.


• Wait 30-60 seconds.


• Have the patient cross his/her knees and arms.


• Have the patient roll onto his/her side (same side as looking towards) while keeping the head facing the shoulder. This positions the face so that it is almost now facing the floor. If done correctly, this should exacerbate the vertigo because the canaliths are repositioning themselves.   


• Wait 30-60 seconds. 


• Assist the patient in sittting up by swinging their legs off the edge of the table and sitting up "like a windshield wiper".


• Lastly, have the patient look downward around 30 degrees.

You can recommend that your patient look at YouTube videos at home to help remind them of the steps that they can do at home every night.



Reference

Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010 May;90(5):663-78.

What characteristics of the clinical evaulation and urinalysis suggest a glomerular (nephrological), as opposed to a nonglomerular (renal pelvis, ureter, bladder, etc), cause of hematuria?

• 2+ or greater proteinuria 
• RBC casts
• presence of at least 80% dysmorphic RBCs
• elevated blood pressure

If the clinical evaluation and urinalysis suggest a glomerular cause of hematuria, then renal function should be measured and nephrology consult considered.


Source

Jimbo, M.  "Evaluation and Management of Hematuria"  Prim Car Clin Office Pract.  2010. 

Severe Sepsis Talk by Emmanuel Rivers (Originally posted in EMCrit Blog)

Early goal directed therapy (EGDT) is a series of targeted treatment measures directed aggressively and as early as possible for the first 6 hours for patients with severe sepsis and septic shock. The EGDT was first conceptualized by Emmanuel Rivers. The EGDT was well known through a landmark paper published in NEJM (looking back, this paper is already 10 years old!):




Rivers E., Nguyen B.,

Paucis Verbis: Antibiotics for Cystitis & Pyelonephritis in Women

You diagnose a 35 years old woman with uncomplicated cystitis. She is not diabetic and not pregnant. Which antibiotics should you give? What if she had pyelonephritis?

Answer: It depends on your local antibiogram.

Today, go find out about your hospital's local resistance rates for uropathogens to various antibiotics. For San Francisco General Hospital, I found our 2010 antibiogram publicly posted online. Urine isolates of E. coli demonstrate relatively high resistance rates to trimethoprim-sulfamethoxazole and ciprofloxacin:

• Trimethoprim-sulfamethoxazole resistance rate = 33%
• Cefazolin or Cephalexin resistance rate = 12%
• Ciprofloxacin resistance rate = 16%

So based on the new 2010 practice guidelines by the ID Society of America and the European Society for Microbiology and Infectious Diseases, I should give:

• Cystitis: Nitrofurantoin x 5 days, or cephalexin / beta-lactam x 3-7 days
• Pyelonephritis: Ceftriaxone 1 gm IV x 1 + (ciprofloxacin x 7 days or trimethoprim-sulfamethoxazole x 14 days)

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE, Infectious Diseases Society of America, & European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases. 2011; 52(5). PMID: 21292654
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