December 2022: Something's Missing
"Can I get a turkey sandwich?"I heard this exchange between a patient and a nurse. It's not an unusual request for patients experiencing homelessness. But this patient's chief symptom was that he couldn't eat. Something must be missing here.The patient confirmed to me that he wanted a turkey sandwich and that he had been losing weight because he couldn't eat. His loose pants requiring a new hole for his belt supported his words. Looking closer, I could see a left thoracotomy scar. He told me he had gotten it on his last hospitalization, but he had no idea why. Something was definitely missing here.Reviewing hi...
Source: Lions and Tigers and Bears - November 30, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
November 2022: More than Broken
"I have this older patient who fell on his buttock at home," said my resident. “He has shoulder pain, but didn't come down on the shoulder and was here within the month with an adhesive capsulitis. He had x-rays and is to see the orthopedist this week. I was only going to x-ray the hips. What do you think?" "Let me take a look," I said while pulling up the old images.The glenohumeral joint space looked rough and narrow. Perhaps there was a calcific tendonitis seen between the acromion and the humeral head. Given the extent of degenerative joint disease, certainly this patient could have chro...
Source: Lions and Tigers and Bears - October 31, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
October 2022: A Case of Ankle Annihilation
“Has your ankle been a problem for a long time?"I felt a sense of déjà vu looking at my patient's foot. I had seen this before: Someone with diabetes who had worsening, long-standing ankle pain, and had seen various doctors over the years.As before, my patient's foot was swollen, without ulcerations or signs of cellulitis or acute trauma. Perhaps we would do better this time. We could optimize our resource utilization, have him spend less time in the emergency department, and offer better care.Still, we began with an x-ray, and predicted that this symptom was one that some people with diabetes develop chronica...
Source: Lions and Tigers and Bears - October 6, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
September 2022: An Unclear Diagnosis
"Stroke alert! Unstable vitals. Will be here in three minutes."Those words came from the charge nurse, and the team assembled. I was now on the stroke alert train. Moments later, the patient arrived unconscious on the stretcher. This elderly woman had been well 20 minutes earlier when she vomited and developed an altered level of consciousness. She had a history of hypertension and hadn't taken her medications because she felt sick all day.She had agonal respirations, and I intubated her on the EMS stretcher. The Accu-Chek was normal. We were all thinking it as she left for CT. With that pressure, she had a...
Source: Lions and Tigers and Bears - August 31, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
August 2022: A Video Game or a Wrist?
Why does that lunate look like Pac-Man?I guess this was the first visual that came to mind because I grew up in the 1980s. Looking for the three Cs of the base of the capitate, the lunate, and the radius on the lateral happens without thinking after decades of looking at lateral wrist x-rays. You never want to miss a perilunate or lunate dislocation. A lunate dislocation is almost always volarly. Can you have a spilled teacup when the lunate seems nestled in the distal radius?The PA film makes it clear what happened here.This patient has a lunotriquetral coalition, the most common congenital carpal bone fusion. It is...
Source: Lions and Tigers and Bears - August 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
July 2022: Locked
"Can you order this guy some pain medicine?" the nurse asked me. “He looks like he's in agony."He had tipped over while standing on top of a step stool. Now he couldn't straighten his knee. It was unyieldingly bent at 90 degrees, and any attempts to extend it met with resistance.The presentation seemed classic. I had seen this once before; it had to be a bucket handle meniscus tear. We would get a precautionary x-ray, but I was already explaining how a bucket handle tear was analogous to a rug being stuck under a door. I asked him to imagine how hard that makes it to move the door. The same thing was ha...
Source: Lions and Tigers and Bears - July 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
June 2022: A Palpable Lump in The Neck
“Wow! You don't see that that very often anymore. Why did you get a soft tissue lateral?"My colleague had a preschool girl with a 101°F temperature and a palpable lump laterally in her neck. I understood instantly. Our community place does not admit children, so identifying sick children is of prime importance. Transfers take time. A soft tissue lateral neck may be reassuring or not.I always evaluate the epiglottis and the retropharyngeal soft tissue when using soft tissue lateral neck x-rays to look for infection. Findings are nowhere near as common as during my training more than 30 years ago because of vaccin...
Source: Lions and Tigers and Bears - June 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
May 2022: A Toe Injury that Just Didn't Heal
Her fourth and fifth toes still hurt six weeks after getting her foot tangled in her backpack strap when getting up in the dark to go to the bathroom. It wasn't purple anymore, but she was still walking on the inside of her foot. The initial assumption was that it was a fracture, and it would heal. It was just a toe after all. It would heal.But doubt crept in that maybe a dislocation had been there all along.Nope. No dislocation. Just two healing toe fractures. It would just take more time, but they would heal. They were just toes after all.Six months later, the pain was more severe than ever. The toes were intermittent...
Source: Lions and Tigers and Bears - May 2, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
April 2022: Above and Below
Wait! What happened there? I had just taken signout, and my colleague was shutting down the x-rays on her computer. This image flashed across the screen.My passion for orthopedic radiographs took over. Fractures of both forearm bones are not something I see often in my non-trauma center community shop. These are most likely from motor vehicle crashes or falls from heights.My mind jumped to the rule of the ring. It had already been fulfilled with the two fractures. Still, my eyes were drawn to the joint to look for a dislocation. My mind was sorting through the eponyms—Galeazzi, Monteggia, Essex-Lopresti—when my g...
Source: Lions and Tigers and Bears - April 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
March 2022: Is It Really a Seizure?
The EMS notification was that a 71-year-old man was going in and out of seizures. His vital signs were stable.I followed the stretcher into the room when they arrived five minutes later. The EMS crew reported that he had previously had a stroke, but he wasn't on any medications for seizure. The family called 9-1-1 because he had been going in and out of seizures for 20 minutes. He suddenly became unresponsive during these episodes, but came back to himself immediately.The patient had another episode while being placed on the monitor. He stopped talking and his limbs shook, and it seemed that his eyes deviated to the left. ...
Source: Lions and Tigers and Bears - March 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
February 2022: Knowing Normal from Abnormal At a Glance
One must know what normal looks like to recognize abnormal.I believe it was more difficult decades ago when I went through residency. The hard films were placed on an x-ray Rolodex that essentially forced us to look at many more images as they went rolling by until we stopped at the film we wanted. I had an hour of x-ray lecture every week during training. The spaced repetition and low-stakes quizzing imprinted the difference between normal and abnormal at a glance.This is abnormal! Something is seriously out of place. If one knew normal, it would be obvious.The most proximal of Gilula's arcs is completely disrupted....
Source: Lions and Tigers and Bears - February 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
January 2022: Not Everything is Anxiety
A 30ish-year-old woman had been shopping and felt dizzy. The shop owner called 911. She said she had a history of anxiety. This is her ECG. Her heart rate was about 125 bpm with a blood pressure hovering around 110 systolic. She didn't have specific complaints, but said she just didn't feel right. No P waves were seen on the ECG. Adenosine for this narrow complex tachycardia.The nurse had questions, though. Didn't supraventricular tachycardia usually have a rate between 150-250 bpm? This patient's rate was slow; was adenosine really the right choice? Shouldn't she be able to handle a rate of 125? The ans...
Source: Lions and Tigers and Bears - January 4, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
December 2021: Check Out Checkpoint Inhibitors
"Hey, can you check out this rash? It is all over," a nurse said to me."What can you tell me?""He has metastatic cancer. The rash started a couple days ago.""It's probably a checkpoint inhibitor rash. I'll check it out."Medicine has developed an entirely new approach to cancer since I went to medical school. Therapeutics were all about direct toxicity to rapidly dividing cells a few decades ago. Now we have an entirely new classification of treatment: immunotherapy.Immunotherapy tries to increase the body's ability to use its own defenses against cancer. One group of agents is...
Source: Lions and Tigers and Bears - December 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
November 2021: Fleshy Lumps on the Scalp
Nausea and body aches. Probably COVID. Unvaccinated. Definitely COVID. After all, what else are we seeing?The 20-something young man was eating and talking on his phone. He passed the look test. His vitals were pristine, but he regaled me with myriad symptoms he had had for months. He hadn't taken any medicine. I was at a loss for what drove him to come to the emergency department. He thought for a minute and said, "I want to know why I have all these."He pointed to a spot on his head, which drew my attention to a fleshy lump. Then he moved his hair around, causing others to appear. "You can feel lots more,&...
Source: Lions and Tigers and Bears - November 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
October 2021: Washing Your Hands: Even More Important Than You Think
No pictures this time. I wish I did have images. At the time, I was focused on getting my patient out of there and thinking that I would probably sound like an idiot talking to the ophthalmologist. Fanning up and down, I could see unattached whiteness floating in the vitreous between the lens and the retinal lining of the globe. I didn't think it was blood, but there was no trauma, the patient wasn't diabetic, and he had no bleeding dyscrasias or anticoagulants on board. Frankly, I wasn't sure what I was seeing.The transfer center picked up on the first ring. "I have this patient who says he can't see out of his ri...
Source: Lions and Tigers and Bears - October 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
