The Lit Whisperers

As a blogger (first time I’ve ever called myself that, weird…), one of the best things about the EM/EMS/CC blog-o-sphere is that the opportunities for new projects and collaborations are endless. Given the theme of my past few posts to this blog, you’re right to assume I’m about to announce my involvement in yet another site…

The Lit Whisperers is the brainchild of Brandon Oto, creator of EMS Basics, probably my favorite pure-EMS blog on the net. It also happens to be dedicated to the kinds of stuff accessible to all levels of emergency responders and extremely well written. It might call itself “Basics,” but the content is of extraordinary quality and you would never guess the author is “just a basic;” my words, not his.

Enough gushing. About a year ago Brandon invited me to become involved with a project he was working on called the EMS-Basics Digital Research Library. In essence, the goal was to collect a list of EMS-pertinent research and compile it in one place as the go-to place to find references on topics like Spinal Immbolization or Cardiac Arrest without having to wade through a hundred different abstracts on PubMed.

In the course of working on that we quickly realized that we wanted to discuss about the literature we were compiling but had no good platform.

Thus, The Lit Whisperers was born.

I must admit, I’ve been a horrible editor since its inception almost a year ago having just now written my first piece. I’m hoping to rectify that in the coming months but, for now, I’ve got my first post up. It’s the lead in a multi-part analysis of a recent article in Resuscitation concerning epinephrine dosing in cardiac arrest. Let me know your thoughts and if you have anything you’d like to see discussed on the site; we’re always open to suggestion.

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The EMS 12-Lead Blog

It seems like all I do these days on this, my personal emergency medicine and critical care blog, is announce other projects that I’m working on. It’s no different today as I’ve started a whole new adventure in the #FOAMed world. I’m now an Associate Editor at the blog that first got me excited about EM and EKG’s: the EMS 12-Lead blog!

If it wasn’t for this blog (formally known as the Prehospital 12-Lead ECG blog), I don’t know if I would have ever become quite so interested in electrocardiography, which was the gateway-drug that got me hooked on EM/CC education, social media, and FOAM. I always list it as the first site folks should check out if they want to learn about prehospital ECG’s and I couldn’t be more excited to now be a part of what they are doing.

I’ve been over there a few weeks and I’m already halfway through my first case, so head on over and check out Part 1 and Part 2. The conclusion is soon to follow.

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My Ultrasonic Hearing Beats Your X-Ray Vision – Part 1

The official title for this is “Case Report of a Radiologically Occult Avulsion Fracture of the Fifth Metatarsal Diagnosed Using Bedside Ultrasound,” but that’s no fun and I think I just nodded-off while typing it.

The first vital piece of information for this story is that my girlfriend’s dog loves sticks. Here he is with one, certainly not running around like a crazy-person.

Gratuitous dog photo

I lied about it being vital info, but that gave me an excuse to post this picture.

One evening I was walking out of her house carrying a box and didn’t see that he had left one on the front steps, as he is wont to do from time to time. Unable to see in front of me, I stepped down with my right foot directly onto the stick. Lightening-quick reflexes weren’t enough to reverse my momentum and my full body-weight traveled downward onto my supinated and plantar-flexed foot, accompanied by the stereotypical CRACK of a badly rolled ankle. I was on solid ground (and still upright!) before I even knew what happened, but my foot wasn’t working quite right. I could bear mild weight but it certainly wasn’t comfortable. I managed to hobble to my car and make it home, deciding to evaluate the ankle the next morning in the hope that it would miraculously heal overnight.

Upon waking I could still bear mild weight, but the pain was significant and my foot exceptionally tender at the base of the fifth metatarsal. Realizing that I failed the Ottowa Ankle Rules, I figured I should head on over to the walk-in for evaluation by a real medical provider. Over there they shot some X-Rays, which were read as normal by the radiologist. Take a look if you don’t believe me.

Dorsal-Plantar View

Lateral View

Oblique View

The PA informed be that I had probably sprained my ankle, but if I wasn’t better in a couple of weeks I might have something more going on and may end up needing something like an MRI. He didn’t realize he was playing right into my plan…

Some folks reading this will know that a plantar-flexion/inversion injury is the classic mechanism for an avulsion fracture of the styloid at the base of the fifth metatarsal, also known as a pseudo-Jones or dancer’s fracture. Feeling pretty confident this had happened to me and having the day off, I stopped by my emergency department on the way home and stole-away with the ultrasound machine for a bit.

Using the linear array probe, I positioned myself as follows (those with an aversion to feet should note that I staged this photo a few days later at the end of a 12-hour shift, so you’re welcome). It’s a bit hard to see, but there’s a pretty significant amount of swelling that outlines where the probe should go; that’s always helpful. As expected, what we’re looking at is the base of the 5th metatarsal with the probe marker pointing proximal.

And here’s what I saw…

Right 5th metatarsal, avulsion fracture of the styloid.

Base of the right 5th metatarsal, avulsion fracture of the tuberosity.

These clips show a clear avulsion fracture of the 5th metatarsal styloid, visible as a discontinuity in what should be the otherwise smooth cortex of the bone. I apologize that the last two clips are backwards; I didn’t realize the screen automatically flipped when I switched from the “musculoskeletal” to “superficial” setting to play around with the image.

Just to be sure, I also shot some views of my uninjured left foot as well.

Base of the left 5th metatarsal, no fracture visible

Base of the left 5th metatarsal, no fracture visible

In case the anatomy was in doubt, these comparison shots of my healthy left foot show an intact cortex with no weird discontinuities.

How cool is that?? I’ll tell you that it’s pretty cool, but the big question is whether knowing there is actually a fracture present changes management. Some might argue that a patient in my position would be going home with supportive treatment and possibly even a diagnosis of occult fracture without the ultrasound confirmation. With good return and follow-up instructions and a bit of rest he or she would universally end up doing well from this very common and typically minor injury, so why waste time in a busy department doing this yourself?

While I can’t disagree with most of those points, I still think it’s worth the two minutes it takes to make this diagnosis with ultrasound. First, you can confidently tell the patient that they have a fracture, which reduces the chances of them forming a bad opinion of you when a repeat X-ray (or, God-forbid, more advanced imaging) confirms the diagnosis that was initially occult.

Second, patients will invariably be more cautious in how they handle a foot that’s broken as opposed to one that’s “just sprained.” I actually had a football game (not the American kind) planned for the night following my injury, and I can guarantee I would have been out there trying to play if I didn’t know I had a fracture. Understanding there was a legitimate fracture resulted in me taking something like 6-8 weeks off running until I was finally pain-free, though I continued to work in an emergency department spending 8 hours on my feet at a time so that wasn’t helping too much. Maybe the injury would not have taken any longer to heal had I tried to push through the pain and continued running on that foot, but I have a hunch that taking it easy for a bit was a good thing, especially since it gave me pain for far longer than the 4 weeks I was initially expecting.

Finally, I’m not exaggerating when I say it takes two minutes to do this exam. You ask the patient to point to where their foot hurts and stick the probe there. I’ve had absolutely no formal ultrasound training and had never even performed a musculoskeletal exam before the trying this on myself and still had no trouble finding and seeing the fracture. There’s a few pitfalls to keep in mind and you need to know your anatomy to do a fracture exam, but it’s still stupidly easy.


I’ve gone on too long already in this post, but Part II will feature a discussion of the anatomy involved in a pseudo-Jones fracture, while part III will feature a collection of clips taken at various points in the healing process for the curious. Please let me know if you have any questions or comments below or on the Ultrasound+ community page.

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Examples of Rapid Atrial Flutter

My first post on 2:1 atrial flutter turned out to be one of my most popular and successful contributions to the FOAM world over the past few years, so I thought I’d go ahead and build on that a bit. Collected here are 50 different examples of rapid atrial flutter. Some are easy, most are a bit tricky, and a few a near-impossible; but they’re all atrial flutter. So, without further ado, get to it and start seeing atrial flutter.

EDIT (2013.11.21): Thanks to the keen eyes of EKG mavens David Richley and Ken Grauer, a couple of possible errors were spotted in the collection. #1134 is definitely NOT atrial flutter but rather AVNRT, though the patient was definitively in atrial flutter only 1 hour prior to that tracing. Also I will be taking another look at #0585, 0737, and 0808 to make sure those weren’t incorrectly included as well. A formal update and correction will be out this weekend.

0129 0131 0133 0134 0136 0139 - 01 0139 - 03 0142 0528 0539 0585 0594 - 02 0594 - 06 0640 0675 - 01 0675 - 02 0675 - 03 0675 - 05 0689 - 01 0689 - 03 0707 - 01 0707 - 02 0737 0758 0788 0808 0834 0910 0925 - 01 0925 - 03 0925 - 05 0928 0949 - 01 0949 - 02 0951 - 01 0951 - 02 0951 - 05 0959 0986 1007 1056 1079 1080 - 01 1080 - 03 1084 1102 1134 1146 1178 1182

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The Ultrasound+ Community

Hey there folks!

I’ve been away from this particular blog for a while, but I’ve been far from quiet in the #FOAMed and social media world. In fact, my electrocardiography discussion forum ECG+ has been so successful that I’m starting up a sister-group: Ultrasound+ (read as “Ultrasound Plus”).

Ultrasound Plus

If you’re interested in learning about bedside ultrasonography or sharing and discussing cases, click the link above to come on over and join. It should be a lot of fun.

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The ECG+ Community

A couple of weeks ago Google+ introduced the concept of “communities,” where like-minded individuals can meet up to discuss their common interests. So, with great fanfare, I’d like to formally announce the creation of the ECG+ community!

Image - ECG+ - 01 - Logo

Click our logo to check out ECG+

We’re already a few posts deep, so check out the cases and comments and please share your own!

Although I’m an ECG-o-phile, I’ve always been reticent to turn The Medial Approach into a “ECG cases” blog. For one thing, folks like EMS 12-Lead and Dr. Smith’s ECG Blog already do that, and quite well I may add. They have giant readerships, and rather than try to match their success with this small blog, I’ve been fortunate that my friends at those sites have graciously posted any of my ECG’s I felt warranted significant dissemination.

On another front, medical discussions on Facebook have taken off over the past couple of years thanks to the creation of great groups and pages like:

The one downside to having these discussions on Facebook is that there’s no real way to archive, index, and sort out posts. You may vaguely recall a great case of papillary muscle rupture secondary to acute inferior MI that was shared on some Facebook page a year ago, but with new posts daily and no real way to sort through them, it would take a lot of work to find. The conversations we have on Facebook are always interesting and enlightening, but they’re far from permanent.

Which is where Google+ communities come in. I’m far from familiar with how this is all going to shake out, but after a little reading on the new feature it seems like the best social media option for just this sort of thing. In addition to all the benefits that come with Facebook groups or pages, tracings, cases, and discussions will all be indexed, searchable, and discoverable. It’s a much more permanent, professional, and user-friendly way for us to learn, share, and grow.

So, without further ado, come check us out and let me know what you think!

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