First week of 6 12 hour shifts under the belt at the new hospital. Well, 5 shifts, as the tradition of getting violently ill every time I start a new hospital and exposed to the local flora of disease held true and I had to call out for one. But holy hell what a different setting that last year. Last year, was a major urban academic hospital in one of the countries biggiest cities. This year it’s a community hospital, with ER and Medicine as the only residencies present, set in a community that doesn’t exactly have health insurance. So gone are the handful of guys every night who were too drunk to get into the homeless shelter who just want a sandwich, replaced with people who haven’t seen a doctor in 10 years and now have some serious pathology going on.  The learning curve has been amazing. I felt like I learned more in this past week then I did in a whole month last year. The best thing? Maybe it’s cause it’s a real hospital, maybe it’s because we’re R2′s now, but we’re treated like colleagues by the attendings and not 4th year med students, which was the case last year.  And it’s a pretty great feeling. I feel like I’m a “working” doctor for the first time, finally getting an idea of how this is going to all work out in the real world.

There are few issues that divide my colleagues more than fish hook removal techniques.

Some like to push, some pull, some use a complex string tension technique.  Then there is the large piece of metal that you yank…. Out it pops.

So I want to know – what is your preferred technique for pulling out barbed hooks?

Let me know on the comments, or link to a video / diagram

Do you have a trick to share?     Casey

A Morel mushroom from wikipedia

So, I’m back after 2 1/2 weeks away in the wilds of Yorkshire near the Gothic town of Whitby. It was quite a marvellous holiday with lots of mountain biking, body boarding and walking……but no Internet! This was both a tremendous relief as peace descended in the digital part of my brain, but also an interesting reminder of just how much we rely on digital access to stay in touch and to get things done. No worry though, despite my out of office messages I came back to >1500 emails, roughly 30 would be regarded as important…anyway. I could have written about repetitive strain injury to my delete button finger, but rather I am thinking back to the wonderful mountain biking in Dalby forest and the sort of injuries that I might have sustained whilst attempting the more difficult routes.

So enough of my Jollidays, back to medicine and possibly one of  my favourite diagnoses in the ED, I’m not sure why, possibly because I’ve seen quite a few in cyclists (and ED docs love cycling), but more likely I just like the name. I also think that is an under-diagnosed condition with clinical signs attributed to other conditions such as haematoma.

So what is it? Well, if you don’t know the name you might recognise the condition because I’ll bet you will have seen it at some point if you’ve been around the ED for a few years or so. A Morel-Lavallée lesion occurs when the superfical fat and skin separate from the underlying fascia to produce a potential space which then fills with fluid. These are often initially mistaken for simple haematomas but you can usually clinically distinguish them as they are more mobile, more ‘squishable’ and often demonstrate fluctuating size through the day as activity or posture changes. They are often tricky to spot in the early stages, and they may be missed on first presentation with signs becoming more obvious over days, weeks or sometimes months.

So, in the ED you might see this when a patient first comes to you having sustained a shearing injury with a subcutaneous swelling, but more likley you would suspect this injury in someone who returns days to weeks later with a persistent, fluctuant swelling that does not seem to be going away.

In the literature it is commonly described in relation to severe pelvic injuries, particularly those involving patients being run over where there are severe shear forces applied to the pelvic area and they are of particular concern to pelvic surgeons as they can interfere with operative management. I’m not so concerned with that group in this post as those patients will be heading to theatre under the care of the Orthopaedic surgeons. Rather I’m interested in those lesions that we might see and manage in the ED.

The separation of superficial tissues from fat requires a fairly significant shearing force that drags and tears the skin and fat from the underlying fascia. I guess that’s why we have seen in cyclists as the typical fall at speed, followed by an impact at an angle (as one hits the road or track) lends itself to this sort of injury. Typically they occur around bony protuberances such as the hip and knee as these are areas where the underling tissues are relatively fixed yet the skin is not. The advent of artificial pitches and hard surface playing environments may also be a factor, but that’s just my opinion, no evidence to back that up really…

The sort of crash that might cause this sort of injury is not uncommon in cyclists, particularly track cyclists, and as  Virchester is home to the greatest Velodrome in the world we have seen many riders from first timers right through to Olympic champions over the years. The description attributed to Sir Chris Hoy’s injury back in 2009 is of a Morel-Lavallée lesion and if you look at the footage from the crash you get a real idea of the shear forces involved in the injury mechanism. If you don’t watch the entire Kierin then skip to 2:50 & then slo-mo at 3:45 to see the crash.

There is also an absolutely fantastic personal account of a bicycle sustained M-L lesion on this blog by Fatheral, plus the blog has a great series of personal photos of what an M-L lesion looks like – although their lesion ended up with surgery (not always needed  – see below).

From Radiologia Brasilera

Although MR is advocated by radiologists as an optimal way of looking for these lesions I have found USS to be an excellent tool to define the nature and extent of these lesions. There are a few nice examples of what you see on USS in this paper from the Journal of Ultrasound Medicine, but you should be able to predict what you would see. A fluid collection superficial to the fascia that is easily compressible. Some good pics here as well. The one thing to think about when you are attempting ultrasound is that these are very ‘squishable’ so you can miss them if you are heavy handed. A very light touch may be needed to avoid ‘squashing’ the fluid away from your field of view.

So what to do about it? I have not found definitive advice on treatment but there appear to be a number of options.

• 1. Simple compression – reported as successful in some case series.
• 2. Serial aspiration under USS (done this several times and works well – but time consuming as daily repeats with compression bandaging between times).
• 3. Insertion of surgical vacuum drain.
• 4. Sclerodesis with something a tetracycline/doxycycline

So my personal plan with these lesions is, as always, dependent on the patient characteristics and size of the lesion. In patients with very small lesions then I would go for compression, particularly around the knee where compression is easy to achieve. For lesion around the hip it’s pretty difficult to get a compression bandage on in any effective manner so I tend to go straight for aspiration in those lesions, repeating on a daily or bi-daily manner under USS guidance. USS also gives you a really good idea of whether you are winning and if not then it’s a referral over to the surgeons for a vacuum drain.

So, a favourite diagnosis and although not common it is one that we can do something about and it’s got a great name….what more do you want

….well, to be honest I’d like to see someone do a proper review of this lesion for the FCEM exam. I think it would make a great CTR.

vb

Simon Carley

Further reading.

• Nice review on the radiological features on MR here
• Bio of Morel-Lavallée here
• Paper on sports related knee M-L injuries here
• Sclerodesis therapy here

…and thanks to Nat for sorting my accents out

Unbelievable.

FORT WORTH CBSDFW.COM - With hundreds of human cases of the West Nile Virus being reported across Texas and more than a dozen related deaths in North Texas it seems some people are overreacting and calling 911 when they're bitten by a mosquito.In short, health officials say a mosquito is not a health emergency."We understand peoples concerns regarding the West Nile Virus, but in the absence of any symptoms of West Nile then a simple mosquito bite is really not a reason for someone to call 911," said Matt Zavadsky, public affairs director for MedStar Emergency Medical Services.One woman called Fort Worth 911 requesting assistance because her young nephew had a bump on his arm.

via Health Officials: No Need To Call 911 For Mosquito Bites « CBS Dallas / Fort Worth.

We’re seeing some of this in the ED, people with bug bites coming straight in ‘to get checked out’.

Sad.

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3 out of 5 stars
A Fatal Case of Thallium Toxicity: Challenges in Management. Riyaz R et al. J Med Toxicol 2012 Aug 4 [Epub ahead of print]

Abstract

This case report emphasizes an important clinical point. The case describes a 36-year-old man who presented to hospital with vomiting and abdominal pain 45 minutes after ingesting an unknown amount of thallium rodenticide.

Treatment included supportive care, Prussian blue, and multidose activated charcoal. Despite this therapy, he developed increasing renal insufficiency on day 3, and then shock and acidosis on day 5. At that time continuous renal replacement therapy. Two hours after CRRT was started, the patient suffered a ventricular fibrillation arrest from which he could not be resuscitated.

Thallium is an extremely toxic heavy metal. Although its marketing as a rat poison has been banned in the U.S. since 1965, the patient apparently had access to an old container.

Aside from supportive care, there are three possible specific treatments for thallium toxicity. Since thallium undergoes enterohepatic and enteroenteric circulation, and binds readily to charcoal, multidose activated charcoal offers theoretic benefit and has been proved effective in animal models. Prussian blue can trap thallium in exchange for potassium; oral doses will maintain a concentration gradient and promote diffusion of thallium into the gut.

The third possible treatment is hemodialysis. Although thallium is not protein bound, it has a relatively high final volume of distribution of 3.6 L/kg, suggesting limited benefit from hemodialysis. However, it is important to realize that thallium has complex kinetics, and during the first hours after ingestion much of the poison will be in the central compartment where it could be susceptible to hemodialysis. The use of hemodialysis was not considered in this case until the patient became too unstable to tolerate it. The authors conclude that although the efficacy of dialysis in thallium toxicity has not been established, “[i]f hemodialysis is to make a difference, then logic would dictate that it be started as early as possible”.

Needles, one of the tools of our trade.
We use them every day. But have you ever wondered how they are made?
How exactly do they get that teeny tiny hole in a 25G needle?

Well hang on to your sharps bin, ’cause I am about to get straight to the point and tell you everything you have never wanted to know about hypodermic needles.

Interestingly, in order to manufacture the those tiny tubes of steel needed for most medical needles, the process begins with a big thick tube.
To begin with, a large piece of sheet metal is fed into a series of rollers that bend it over and around into a tube. The tube then passes through a welder to seal the seam.

Alternatively, 'seamless' tubing is produced by taking a chunk of metal known as a 'billet', heating it and boring a hole through the center. In some instances this is done with a with a laser.
You would think that laser technology would be quicker and more accurate, but apparently the gold standard for producing these incredibly high tolerances and precise measurements remains the welding method.
Old school rules.

Tubular:

Where were we? Oh yes, the tube. This large tube is then heated to soften it (a process known as annealing), after which it is drawn by significant forces through a tool (or die) that has a much smaller diameter hole in it.
Think of those Play-Doh toys that squeeze out spaghetti worms of various shapes and diameters.
It wasn’t until I was 5 or 6 that I realised Play-Doh wasn’t one of the 5 food groups.

The tube is then extruded through smaller and smaller dies right down to the final diameter. Sometimes a rigid length of wire known as a mandrel is placed inside the tube to maintain its integrity during the process.

The final die pass is often done without any heat. This cold working of the tube increases its strength and rigidity.
The metal of choice used for needles, of course, is surgical steel, which is a type of stainless steel.
During the manufacturing of surgical steel, alloying elements of chromium, nickel and molybdenum are added to the mix. It is the molybdenum that gives the finished needle greater strength and a sharper cutting edge.

Molybdenum. Anyone about to have a baby girl and looking for a unique name?
Move over Shaniqwa and Shumonte there is a new girl in the class....

BD needles:

OK. I’m sure you have all seen BD syringes and needles, but did you know what the BD sands for?

Becton Dickinson is one of the largest manufacturers of medical devices and instrument systems in the world. But it all began back in 1897 developing syringes and needles (in fact it was BD that patented the luer lock connection).

BD use a 3/4 inch stainless steel tubing that is rolled and welded, heated, and drawn down to the required size with a final cold-draw.
This tubing is cut into the correct lengths and then the bevel is sliced across the end.

The very tip of the needle is known as the lancet and various shapes are used depending on the application.
From the lancet, the cutting edge sweeps elegantly back across the bevel to form the shoulder.

The actual shape of the bevel is also a highly specialized bit of kit. Check out the A-bevel, B-bevel, C-bevel, Bias, Chiba, Crawford, Deflected Tip, Francine, Hustead, Huber, Trocar, and Tuohey. Collect the whole set.

Finally, the hub is attached. These can be made from metal or plastic and are bonded to the needle by a crimping process or using an epoxy.

The final product is sometimes coated with a low-friction lubricant to create a smoother penetration that is less painful.

Gauge:

The diameter of the needle is referred to as its Gauge and is based on the 'Stubs Needle Gauge'.
Smaller gauge numbers indicate a larger outer diameter. The Stubs Iron Wire Gauge system (also known as the Birmingham Wire Gauge or BWG) was adopted in Britain in 1884 to specify the thickness of metal wires. Although it was not used much anywhere else in the world, an Act of Congress in the US made it the only wire gauge system used there (and so here).

The other scale used to measure gauge is the French scale often written as FR or Fg.This is usually used to measure the external diameter of catheters.

• 1 French = diameter of 1/3mm. Therefore you can impress your colleagues by quoting the diameter of any catheter in millimeters by dividing the Fr guage by 3.

So now you are a bit of an expert on the old hypodermic.
Perhaps you can meducate your patients all about them to help pass the time as you are digging around looking for that recalcitrant vein.

Me comentaba un colega: – tienes abandonado el Blog.

Yo le respondía: – lo tengo en barbecho.

Realmente pensaba: si no tienes nada que decir no digas nada.

Estamos en VERANO: época de vacaciones.

Yo ya me he fundido las mías, disculpadme que no os las cuente.

Ahora de vuelta al cole/curro, conectado a la WEB, me he encontrado con un video en Qué se cuece? que me ha encantado (real como la vida misma):

The current issue of The New Yorker magazine carries an amazing piece (subscription required) by author and neurologist Oliver Sacks detailing his extensive drug use while a neurology resident at UCLA and a young attending physician in New York.

Sacks -- who meticulously describes the drug effects he observed in himself --started with marijuana, but soon escalated to taking 20 pills at a time of the antimuscarinic drug Artane. This caused dry mouth, mydriasis, and anticholinergic delirium, as he found himself having absolutely realistic encounters with friends who weren’t there, as well as a conversation with a spider who inquired if he thought that the philosopher Bertrand Russell had disproved Frege’s paradox.

Early on, Sacks took drugs only on weekends. “During the week, I would avoid drugs, working as a resident at U.C.L.A.’s neurology department.” Some of these weekend episodes involved cocktails of LSD, amphetamine, and hashish. When LSD was not available, Sacks substituted morning-glory seeds, which contain lysergic acid amide, causing drug-induced Capgras Syndrome. (Sacks points out that today these seeds are commonly coated with a pesticide to discourage ingestion.) Injecting intravenously a “large syringe” of morphine produced a 12-hour hallucination of the Battle of Agincourt acted out on the sleeve of his dressing gown. (I did  wonder at points -- as I have reading some of Sacks’ books such as The Man Who Mistook His Wife for a Hat -- if he was indulging in some literary embellishment.)

When Sacks withdraws from massive doses of chloral hydrate he develops delirium tremens. Finally, after taking a huge dose of amphetamines (causing “a sustained pulse rate close to two hundred and a blood pressure of I-know-not-what”) while reading a 19th-century treatise on migraines, he decides on his life’s work (physician/author) and “never took amphetamines again” -- although he doesn’t say if he continued taking other drugs.

A very strange article, but worth reading.

[Photograph of Oliver Sacks from wikipedia.org]

This is a really slick website and mobile app I found called Docphin. This is a huge help in staying up with the latest EM literature (...except a certain podcast you know and love!).

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