Serotonin syndrome/toxicity and NMS

Dear All,

Further to my talk this morning a couple of links :

A very good review of serotonin syndrome/toxicity here

A 'Practice' article from early 2014 in BMJ here

The original study deriving the Hunter criteria for serotonin toxicity here

Monograph on serotonin syndrome including comparison with neuroleptic malignant syndrome here



The Infamous Barbie Doll Story

If you haven’t already, listen to self-proclaimed “hottie” Liz Crowe, social worker from the Mater, delivering a blistering smaccTALK on ‘swearing your way out of a crisis‘.

I met up with her just before the session for a bit of advice on swearing before my own smaccTALK; she did suggest that gratuitous use of the c word in the checklist debate would be better re-phrased as ‘C U next Tuesday’. I think I managed to weave this into the debate…listen yourself when the Checklist debate is put out to air (unless it gets edited)…

Liz gave a hilarious talk, not least because she acknowledges the use of humour & swearing in medicine – as a form of metaphorical armour, as a psychological re-set mechanism and way of stepping back from the horror of critical care. She also made repeated reference to an unfortunate episode of rectal Babushka dolls …

Which made me remember a story on rectal FBs of my own.

I have deferred putting this story out for some time. It refers to the issue of rectal foreign bodies…in particular, one memorable episode. Of course this incident happened in a hypothetical hospital to a hypothetical patient. If it DID ever happen, it was certainly in a different country…and over 10 years ago. And of course I was NOT involved.

So…hypothetically…here is the infamous ‘Barbie Doll’ story.



Somewhere in an ED many years ago

I am a big fan of triage nurses and paramedics. They are generally hard-as-nails types, unfazed by adversity and have ‘seen it all’. Which is why this particular Friday was odd. I was the Emergency Registrar on, and became distracted from the hassles of simultaneously managing seven acute patients and supervise the RMOs queueing up to discuss their cases. There was an audible kerfuffle going on over at triage…

So I ambled over. And there was Jude, the tough-as-nails Kiwi triage sister, doubled up in tears of laughter. And the cool-as-cucumber ambos were similarly giggling. Laying between them was a young chap, face down on the barouche.

What the?” I mumbled. “Is this what I think it is?”

RN Jude nodded vigorously…still laughing.

Pulling a curtain around, we moved the barouche into the resus room. Things like this don’t come up every day. With good light and 360 access, I performed a careful examination…

Sure enough this unfortunate chap had managed to wedge a Barbie Doll up his arse. Head first. All that was visible were poor Barbie’s feet…and with every painful spasm of his sphincter, Barbie’s legs would waggle as if to say “Get me out of here!”

Attempts to pull Barbie out with some sedation were unfruitful – pulling on the legs caused Barbie’s two arms to extend, rather like a fancy corkscrew device. She was embedded.

We rang the surgical registrar who was, of course, scrubbed in some abdominal horrendectomy and not going to be available for at least another 2-3 hours. This was not untypical. The Surgical Registrar on duty that day had a reputation as a “bit of a cock” – generally obstructive to referrals, usually uncontactable in theatre and usually very brusque with ED. There was bad blood between the Surgical and ED tribal leaders that day…

Meanwhile we placed the poor chap in a side cubicle and carried on with our work, enjoying the humour of the occasion. By this stage the poor chap had become the “butt” of all our jokes (groan). X-rays were taken, conversations were had and general humour was enjoyed.

Finally, getting on towards midnight, the surgeon appeared. He refused to listen to the elaborate but somewhat sarcastic verbal referral that I had been crafting all shift, but instead disappeared behind the curtain.

I’ll sort this out myself if you amateurs in ED can’t” he announced to the ED.

Wanker” I muttered, whilst the assembled registrars, RMOs, RNs, ENs, orderlies and students assembled behind the curtain to listen.

Bugger me! The usually terse surgical registrar took a crisp, concise surgical history. He EVEN took an anaesthetic history! He explained in calm and non-judgmental words the nature of the problem, the need for surgical removal and the potential complications. His clerking was a model of empathy, concern. I am not 100% certain, but I am pretty sure he even used #HelloMyNameIs, a good 10 years before this meme became a phenomenon…

By now we were all pretty chastened. I was feeling very guilty about the earlier behaviour and inappropriate humour of the ED team.

On the plus side, our patient had certainly brightened up – after several hours of being the focus of everyone’s attention and the laughing stock of the shift, here at last was a doctor who was prepared to take him seriously…thank heaven for the professionalism of the surgeon!

And then the denouement…

Well Mr X” said the Surgical Registrar “I have explained what we need to do – I’ll push your trolley upstairs myself…the anaesthetist is ready…we’ll have you fixed up in no time. Do you have any questions?

Dumbfounded with gratitude the poor lad just stammered “No…thank you…for looking after me

No worries” says the surgeon “Just one LAST question….I can see what you did with Barbie….but where’s Ken?

With that the assembled masses in ED erupted with laughter. The surgeon emerged, grinning, pushing ahead of him the poor lad on the trolley. That day the surgeon became a hero to us all – from then on the surgical and ED tribes were at peace.


Wanna learn more about rectal FBs?


Well, I daresay there is always Google….but that might not be safe for work! Perhaps better to stick to the journals. Try this classic :

Management of Rectal Foreign Bodies from Coskun et al (2013) World Journal of Emergency Surgery

Rectal Foreign Bodies from Goldberg & Steele (2010) Surg Clin N Am

I daresay there are more. More importantly, listen to Liz Crowe’s talk on humour and swearing from smaccGOLD. It’s a beauty.

See you next Tuesday!




JC: Tranexamic acid – does the evidence stack up?

St Emlyns - Meducation in Virchester #FOAMed

Here at St.Emlyn’s we are big fans of Tranexamic Acid in trauma. We believe that it makes a difference to overall mortality in patients likely to be bleeding and also that there is some evidence that it seems to work across a range of illness severities. We honestly believe that as the evidence stands, at […]

The post JC: Tranexamic acid – does the evidence stack up? appeared first on St Emlyns.

EMU Monthly – May 2014

The EMU Goodness for May 2014. Need a print version? Click Here for the PDF.

Chemical Sedation

The knockout punch is what Rob Orman calls this (Rob are you still reading?) and he did a survey of people’s preferences world wide – an antipsychotic with a benzo is still the most popular – but in this study they tended to use higher doses of benzos and antipsychotics with good results – but they would have done just fine with lower doses and would have had less side effects (BMC Psych 13:225).  The problem here was this was a study of psych patients between 15-80. You can not compare the two extremes of an eighty year old with a teenager, and in addition, this was observational – meaning you couldn’t control the patients (poor pun on my part). Some of these may have really needed the higher doses; also the groups may not have been similar. But I will go on record saying that lower doses are usually better in general, and with the knockout punch – I would tell you to try clotiapine – it works faster than the 20 minutes it took in this study to knock the patients down.


Turns out these two women were at a party wearing the same outfit.

TAKE HOME MESSAGE: Lower doses to knock down unruly patients are preferred.

Clinical Quiz #1

Clinical quiz early on – you may not know the name of the disorder but you should jump on it. This is a 90 year old lady with bilious vomiting and cachexia – and you guessed it- cholelithiaisis in the past. She is very uncomfortable.  Here is her abdominal film . A CT was performed. What does she have? (JEM 45(4)e135)



In case you were wondering, Cannabinoid Hyperemesis Syndrome can be caused by synthetic cannabinoids (ibid p544). This guy could give you some suggestions on what to smoke instead to get high:


Our quotes of the month come from our colleague nurses who have their own view on things.

One of my coworkers always liked to say, “You can’t cure [or fix] stupid.” (I actually had a chainsaw – vs.-thigh patient jokingly say something to me like, “My stupidity keeps you employed/pays your mortgage.” LOL)

Creepy Crawlers

Maggots – um delicious! There has been some concern about wild maggots in wounds causing infection (commercially bought maggots for debridement are free of disease), so they suggest using a Yankauer suction to remove these (other deeper larva will emerge when the superficial ones are sucked out so do a few passes) (ibid p585).  It should be pointed out, however, that there is no evidence that wild maggots cause more infection .

TAKE HOME MESSAGE: Winos with maggots – try the Yankauer to get them out.

Cut a wedding ring off a penis once…pt stated, “I just wanted to see if I could get it in there.” Wife was bright red in the corner :-)

Acute Coronary Syndrome

A very important study. Patients do get ACS even without obstructive coronary disease. People even with no CAD at all have less MIs but still have the same rate of death and admissions for ACS and stroke as those with CAD (AJC 112(2)150). This is probably due to spasm in my opinion or small vessel disease.  So do take patients with normal caths seriously. If you do not read anything else this month – and I certainly wouldn’t – do read this one.

TAKE HOME MESSAGE: Do take patients with normal caths seriously.

I’m an ICU nurse – I heard this one on my last trip to ER as a patient: from triage nurse to the mother of twenty-something year old male having a tantrum in the ER waiting room, “He wants to go home if we don’t take him back to the main ED immediately.”  Triage Nurse: “Drive carefully!”

To err is…

Want to decrease door to balloon times? Get rid of the physician and the paramedic as well – get the EMT to do an EKG and have the automated reading call the cath team in if it says MI. They really liked this, and it did reduce door to balloon times (AJC 112(2)116). However, the automated reading misread MIs almost 20% of the time. I am surprised with the technology we have today but it seems that this is not going to work.

TAKE HOME MESSAGE: EKGs used automatically to bring in the cath team err.

Now an editorial in Circulation, 128(4)322) looks into this and notes despite all the progress in lowering door to balloon times, a study showed no benefit if the ED was bypassed. Is this due to us taking it more seriously? Or that it takes time for the cath team to come in in any case?

TAKE HOME MESSAGE: Door to balloon time reduction has not shown benefit if the ED is bypassed.

My ER director will say “Well, we aint tried nothing and were all out of ideas.”

Influenza and the Cardiovascular System

Influenza affects the heart – okay, we all know it can cause myocarditis, but also it increases rate of MIs (vaccination helps lower it), and patients with pre existing CAD have more mortality during influenza outbreaks.

TAKE HOME MESSAGE:  Has to be – get these folks vaccinated! ( Int J Card 167(6)2397).

TAKE HOME MESSAGE: see the TAKE HOME MESSAGE above (doesn’t matter which – they are all important).

New construction worker wondered if nail gun would actually nail his fingers together. Yep it did.

Renal Calculi

I practice in the kidney stone capital of the world. Honestly, I think everyone who comes to my ED is stoned. You – family doc – can keep your patients away from me (a good idea I might add) by downloading this EBM article on preventing kidney stones. Obviously the evidence is poor – we are after all speaking about urologists – but thiazides, citrates, or allopurinol are the way to prevent calcium kidney stones – with allopurinol being the most effective, but only if you have hyperuricemia or hyperuricsemia. Fluid hydration is always useful for prevention, although soft drinks may increase the rate of stones – but the evidence is poor (Ann Int Med 158(7)535).

TAKE HOME MESSAGE: Citrate and fluids is still the way to go to prevent stones.

Years ago my sister had a severe allergic reaction that caused her ENTIRE face to swell up beyond recognition. In the ER, right in front of all of us, the nurse – being dead serious – asked my mother “does her face always look like this?”

Intraosseous Access

Yea, so she has a mastectomy on the right side and gets dialysis on the left side. She is also 150 kg and the last time she has had a vein that anyone saw was 1952. Now, you got it-you’ll get venous access via an IO – but that is going to hurt and she slap you. Well, they quote a study here that with lidocaine – there is only a pain score of two (CMAJ 185(5)e238). I am not sure. The references they give- one had only 22 patients and was checking flow rates and not pain, and the second doesn’t exist. Furthermore – where do you inject the lidocaine? Under the skin or do you try to anesthesia the periosteum – which isn’t easy.

TAKE HOME MESSAGE: IO in alert patients doesn’t hurt much if you use lidocaine. Or maybe it does.

If you could fix stupid we would all be out of a job

Tramadol – the good, the bad, the ugly

I am not a big fan of tramadol, although my German readers love this stuff.  My experience: IV it is a mild pain reliever but PO – it causes dysphoria and nausea. They report here that it is also just a modest pain reliever, and it can cause seizures even at low dosages. Tramadol can cause dependence. It should be used carefully in patients taking anti-depressants – it can cause Serotonin Syndrome (ibid p e352).

 TAKE HOME MESSAGE: Tramadol – you do not get much over NSAIDS and there are serious side effects including Serotonin Syndrome.

I am allergic to all pain medication, except the one that starts with a D.

Antibiotics and AKI

At one point in this study they say that there is a 2 fold increase of acute kidney injury after the use of quinolones. Afterwards they say that in cases of ARF – there is no increased incidence of quinolone use. The only way this can be true on both sides if this is rare – and it pretty much is, but can happen. I think what you need to take home from this is the concomitant use of quinolones and ARB/ACE-Is increases the possibility of ARF. But then again, they only studied men who were admitted with ARF – what happens in the community? Furthermore – since this is a registry – the best you can say is that it is an association, but not necessary proven (CMAJ 185(10)e475).

TAKE HOME MESSAGE: Quinolones may need to be used with caution in patients taking ARB/ACE-Is.

Want to use clinda instead? Well this study – where they actually biopsied the patients showed that clindamycin can cause renal damage as well and hematuria. It is reversible ( Am J Neprho 38 (3)179). However, they only had 24 cases and I do not know the denominator – but in general – Chinese studies are huge – so it must not be so common. Also the dosages were a little higher than most of us use. I like clinda and feel we should not shy away from it – in young people; severe C difficile infection is uncommon.

TAKE HOME MESSAGE: Clinda may also cause kidney damage – ATN.

Charge nurse assigning patients: “Do you want the smurf, or too drunk to live?”

Decision Rule for SAH

Ian Stiell is back at again. I owe Ian a debt of gratitude – he wrote a commentary versus Jerry Hoffman on the C spine rules (NEXUS vs Canadian) in the Israeli Journal of EM many years ago. But this rule of how to rule out SAH is well – a little trite – if a little guy like me may say so.



The rule was – anyone over forty, neck stiffness, occurred during exertion, and witnessed loss of consciousness, and a thunderclap headache. The problem was that this firstly was done in tertiary centers – will that help the little guy? They only saw 1323 SAHs – is that enough to make conclusions? Furthermore – this is pretty basic – a thunderclap headache, and “occurring during exertion”- these are things you better know without a rule. Also – many of the patients did not get the gold standard tests of CT and LP – as Stuart Swadron points out. Lastly – the sensitivity was 100% – but at a cost of a 15% specificity – part that is the age over forty. Sorry, Ian – I don’t find this too helpful. After all, patients who have no danger signs generally do have dangerous condition (JAMA 310 (12)1248). To tell you the truth – I do not find the ankle rules to helpful either. If they have no trouble walking – why would I x-ray them? I do not know – I just am against rules replacing medical knowledge and physical exam. But then again – I am just a little guy.



TAKE HOME MESSAGE: SAH can be ruled out via rules – maybe.

Charge nurse while triaging an indigent pt requesting a bed:

CN: “Sit over there and we’ll get you a food tray.”

IP: “I just want to die.”

CN: “Don’t you want to have a food tray before you die?”

Transfusion Reactions in the Critically Ill

This is a crucial article and yet no one has heard about it. Until now – here is your chance to be the star of your medical staff (be sure you tell them where you read it) (congrats to Mike and Rich and all my other Conn readers).


Transfusing incompatible blood in an emergency (which is O negative) very rarely causes any problems. Alloimnmunization only occurred in three percent and acute hemolysis never happened in this series. If they need it – don’t think about – just do it.


TAKE HOME MESSAGE: You should give the O negative blood in an emergency – it is unlikely that you will cause a problem.

“You have to stop being so nice to them. It just makes them come back next time.”


Vasopressin was not inferior to norepinephrine for achieving optimal MAP in patients in septic shock (Ann Pharmoc 47(3)301). However MAP is a surrogate marker (besides this study was retrospective). The NEJM studied this in the past and found no mortality difference in severe septic shock (mild septic shock – vasopression was superior) (Nejm 358 (9) 877). However, both these studies were really small. I will continue to use norepi with vasopressin as an add on if I do not succeed with norepi - there are still too many questions with vasopressin – it is quite a strain the splanchnic circulation. And I have no control over it – it is not a drug that we can give with adjusting the rate. (Thanks Carmi).

TAKE HOME MESSAGE: Vasopressin may be equivalent to norepi.

“This patient’s stupidity is incompatible with life.”

Anticoagulants and Bleeding Risk

Aspirin, Plavix…..and the new anticoagulants – be careful. Increase of bleeding of course can happen which I would expect – the same thing happens when you add Coumadin to these two. However, this was a Medline search and these were phase two trials. A randomized trial has never been done – and probably won’t be (Ann Pharm 47(4)573).

TAKE HOME MESSAGE: More bleeding with the new anticoagulants when using with other anti-platelet agents.


I actually forget that often we have an antidote to a lot of drugs. No, I am not talking about charcoal


but rather lipid emulsion that can be used for verapamil, beta-blockers, and a host of other meds. It does work in neonates and kids – often dramatically (ibid 479(5)735). However, this is just a collection of case reports – we still need to gather more to know true safety profile and proper dosage.  On the subject as well – beware of lab values being erroneous when this therapy is given (AJEM 31(10)e1).  So they claim in this case report, but other than saying this can happen on the Siemens machine, I am not sure as to what extent this can happen and if on all machines. Truth be told – I have never used this – anyone have any experience with it?

TAKE HOME MESSAGE: If you remember intralipid, you may save lives-even kiddies. Keep an eye on lab tests – or ignore them if they make no sense.

 To a drunk patient who fell and had a head lac:

“This is your tetanus shot.”

“I don’t want a shot!”

“Well it prevents lockjaw.. so you can keep drinkin’!”

“Oh, okay.”

Overdose of Medications for ADHD Treatment

A lot of drugs are used for ADHD – although the most popular is by far the stimulants (no one, and I mean no one could write EMU without a bad case of ADD – if you haven’t noticed) (how many people with ADD do you need to screw in a light bulb? Hey, let’s go catch lunch). Generally overdoses of stimulants- that is amphetamines- cause a sympathomimetic syndrome. The effects are mainly neurological and cardiologic and there may include hallucinations, psychosis, agitation, seizures, and mydriasis. Modanifil is often also used for ADHD and the overdose is usually milder with dizziness, and dystonia being the main features. Overdose with both groups is supportive with benzos as needed. Non-stimulants like clonidine and guanfesin are often also used – their overdose is already in Tinntinali – so look there – or look in the article (CNS Drugs 27(7)531).

TAKE HOME MESSAGE: Overdose of ADHD drugs can cause a sympathomimetic syndrome.

Anything can be a suppository if enough force is applied

Cardiac CT Scans

This is an “at this point in time” paper (Father Greg loves that line). CT-A – that is cardiac CT is being touted for patients with low risk for cardiac disease. I am not going to stick my head between Judd Hollander who is for this and Jerry Hoffman who is against. But at this point in time – there is a lot of radiation with this test, it also over estimates stenosis and has a poor PPV in patients with expected coronary disease (Cor Art Dis 24(7)606).  I also have no experience with this either – too expensive of a test for my ED -anyone want to comment?

TAKE HOME MESSAGE: Cardiac CT is not a very good test in patients thought to have some degree of coronary disease.

“So I decided to clear out the guttering and because it was such a lovely day I decided to take off my clothes. I slipped off the ladder and fell, yes, miraculously fell from roof height without sustaining so much as a bruise, but landed on the bunch of carrots I’d just pulled out of the veggie patch and that’s how it got there.” Really?

Diagnosing Pneumonia without Imaging

They try to give a spin on this paper that Dutch GPs can diagnose pneumonia clinically, but their sensitivity was a poor 29%. The chest film is a low risk cheap test – go for it (Eur Resp J 42(4)1076).

Patient comes in to triage being carried by his buddy shouting “WE NEED HELP!!” Well, immediately I see ABC’s are ok, so I bring him in and he says he was “sitting there minding his own business and some guy comes up and stabs him in the leg.” He is writhing, cussing, crying, you name it. There is some blood on his pants, so I cut his pants leg up to the wound site and there is a very superficial, barely 1 cm lac with a single drop of blood on it. So with a straight face I look at him and say…

“Sir, what you have here is a boo-boo. Have a seat in the lobby.”

Urinary Catheters and Urethral Strictures

We have been very negative about putting catheters in people and I was surprised that short term catheterization can cause strictures in 3.4% of catheter insertions (Ann Int Med 159(6)401). I think you are best to leave people’ reproductive equipment alone.


Well, maybe except for that.

My personal favorite line that is surprisingly effective with folks who are reluctant to provide a urine sample is to walk into the room with a cup in one hand and a cath kit in the other, hold ‘em up and say:”we need a sample. You can provide it or we’re going in after it. We don’t need much but we need something.”

tPA Use and INR

An INR of less than 1.7 in patients that take heparin products does not preclude use of TPA in stroke- there is no increased bleeding rate. (Ann Neuro 74(2)266) Problem is that this is a registry not a RCT. Furthermore, 1.7 is not very remarkable- how high can this be pushed? We may never know – How many cats does it take to change a light bulb?


We may never know.

Registration: “The self-pay co-pay is $400. How would you like to take care of that today?”

Patient/frequent flyer: “$400???? That’s crazy!!”

RN: “The walk to the door is free.”

Imaging Pediatric Patients after UTIs

We have dedicated 2 essays in the last 10 years to imaging after UTIs in kiddies and things were still not clear – probably because the guideline keeps changing. Now – after the first UTI in kids up to 2 years old – they are recommending only urinary tract ultrasound, and only if it is abnormal – to proceed to VCUG. This reduced the use of the second test drastically. (Peds 132(3)e749) This is all good – the VCUG was not a very nice thing to do to introduce kiddies to the world, but this is still incomplete – as we have pointed out in the past. Does this really need to be after the first one? Many peds are recommending after the second and beyond. Do little girls need this at the same rate as little boys? The intuition seems to say no. And how much of a danger is renal scarring – sounds bad but the evidence doesn’t support alot of long term clinically relevant implications.

TAKE HOME MESSAGE: After UTI in kids – an ultrasound is enough.

Kevin – are you and your wife still laughing at me?

RN: Here let me help you stand up, wouldn’t want you to fall.

ETOH patient: Ya I might get hurt.

RN: Well that and it’s an UNBELIVABLE amount of paper work for me if you fall.

Being Nice

Hey, you gotta love the JGIM- they always tackle the difficult stuff in physician behavior. Here they looked at 34 patient encounters that were recorded covertly and discovered that in 41% of the cases the physician disparaged the care the patient had received by another physician ( JGIM 28(11)1492). Indeed, there must be another way to improve care given previously without labeling the physician a moron – although he may be one.

TAKE HOME MESSAGE: You probably talk bad about your colleagues to patients – but it is okay since I do the same about you.




First time I assisted with rapid sequence intubation. My adrenaline was flowing. I drew up all the meds, finished giving etomidate and was about to give the succinylcholine. I said, “I’ve always wanted to give succs!”

Everyone paused, the room got quiet, then everyone started laughing at the same time (except the patient).

Ketamine for Analgesia

Ketamine is effective pain control for cancer patients – and you should consider this when standard opiates fail. The side effects were feelings of hallucinations and insobriety but overall the med was successful in pain treatment. They used sub dissociative dosages of 0.05- 0.5mg/kg and 0.2-0.5 po three times a day not exceeding 50 mg in any one dose. (Pain Med 14(10)1506). Problem was that this was a literate search of rather poor studies. Furthermore, I think the point should be made that while I have never used oral Ketamine – but IV for pain control I have used and found wide variations in the individual response to being dissociative.

TAKE HOME MESSAGE: Ketamine is great for those hard to treat pain cases – (cancer, fibromayalgia, RSD).

 From my ER doc, “Prostatitis is the common cold of the pelvis.”

Steroid Injections – yes or no?

Shoulder injection helped me – but there really isn’t any science there is a 667 mg difference in steroid doses in this questionnaire among orthopedists (we’ll ignore the 24% response rate) and only 9% of those surveyed said they based their decision on a scientific reference (Orthopedics 36(9) e1141).

TAKE HOME MESSAGE: We still do a lot things based on mentors without much science.

My favorite thing to say to the Medicaid mom who brings (via EMS, of course) the youngest of their brood to the ER with “trouble breathing”.

Me: Mom, do you smoke?

Mom: Yes, but we never smoke in the same room as him.

Me: So, if we are in a pool together, is it okay if I swim to the other side and poop

Lumbar Punctures in the Obese

Did you see this article? What? You don’t subscribe to this journal???? Where do you live? Detroit? This article pointed out that a lot of folks are just too fat for the normal LP needle which is 9 cm long – they used radiology to compute this distance and also asked docs – most never knew there exists longer needles than 9 cm for LP (I didn’t know that either and have no idea where to find these) (Eur Rad 23(11)3191).  The radiology business is a little suspect – I think that computing the distance by ultrasound doesn’t take into account the compressibility of adipose tissue that may still allow a LP with a normal needle.

TAKE HOME MESSAGE: Did you know there are longer LP needles for fat patients?



Dabigitran and Bleeding

Yes, so older patients have a higher rate of bleeding when taking dabigitran. So what do you want to do – dialyze it out? Theoretically that would work, but who has the guts to insert a dialysis catheter in such a patient that could bleed like a pig? (Clin J Am Soc Nephrol 8(9)1591) However, they did not read a previous article where they did do dialysis and it actually increased drug levels due to large volume of distribution and a rebound effect (AJKD 61(3)487).

TAKE HOME MESSAGE: Dabigitran – good luck with bleeding – dialysis isn’t a wise idea for a number of reasons.

An exchange with a brand new intern after a woman coded and expired.

Intern: So, what do I do now?

Me: You declare the death.

Intern: How?

Me: Poke her with a stick and see if she moves. If not, declare the time of death.

Intern: You’re crazy.

Me: I know.

Feeding the Patient with Acute Pancreatitis

Nasal gastric feeding (zonde) for patients with acute pancreatitis reduces admission rates, and less opiate use than patients who are NPO (Clin Nutrit 32(5)697). This was a tiny study, but it confirms what we have begun to believe – that you have to feed these patients. Overall hospital stays were the same. However – what advantage does NG feeding have over regular feeding by mouth?

TAKE HOME MESSAGE: Start your feeding of pancreatitis patients within 24 hours.

ED chief complaints: A neighbour of a newly wed couple was worried when she didn’t hear her rather noisy neighbours for a while. A few days later, she peered through their letterbox and through the windows. But there was no sign of anyone. Concerned for the young couple, she called the police. The officers promptly broke down the door, then searched the house. Only to find the young women gagged and tied to the bed. Her husband was lying unconscious on the floor, wearing a Superman Outfit. They later explain that they had been engaged in a superhero role-playing fantasy, and the costumed husband had knocked himself out attempting to jump onto his wife from atop the dresser. Of course, the woman was unable to help him.

Colloids Versus Crystalloids

Yea, so colloids are dead, right-  no influence on survival; more kidney failure. And yes, the Europeans have taken them off the market. But the starches have improved, and there is indeed less need for fluids when they are given. The author goes over the studies against colloids and the flaws are pretty elemental. I won’t bore you with the numbers but they correctly point out – tailor it to each patient, and be sure you monitor hemodynamic status – over use of fluids and starches can both be treacherous (BJA 111(3)324).

TAKE HOME MESSAGE: Colloids may not be dead. I give you that colloids are less filling.



A slender 45-year-old man from Georgia reported broken ribs after having to literally escape from his 300-pound wife. Apparently, she had accidentally rolled onto him while sleeping, crushing his ribs. Ashamed by her weight problem and what she had done, she refused to let her husband leave the house. But he broke out a few days, whilst she was sleeping and went straight to the hospital.

Nerve Blocks for Migraines

This little paper was missed last time around – it is actually an old paper (2010) but you should get this paper to add to your armamentarium -nerve blocks can be useful in migraines. While this illustrated article shows many nerve blocks, the most widely used is the only one that has literature that it works – although the literature is weak. We are speaking about the greater occipital nerve block (Journal of the American Scociety for Experimental NeuroTherapeutics 7:197). Actually their picture is better.


TAKE HOME MESSAGE: Nerves blocks can be useful for migraine treatment.

She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.

The patient has no past history of suicides.

The patient refused an autopsy.

Social Media

Facebook and Twitter can be fun, but be careful; professionalism should maintained, and be careful about posting with regards to patient privacy. Pretty obvious but 70% of students and residents were seen on Facebook with some type of inebriation (JAAD 2013 69:305).

The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.

On the second day the knee was better and on the third day it had completely disappeared

Infantile Colic

Wish I could add something to this issue – this EBM discussed infantile colic and I will summarize by saying that – you want to stay away from meds with the exception of simethicone which won’t hurt baby – but won’t help either. Oh, you can play with the formula – cow’s milk allergies may respond to hydrolyzed milk, and lactase may help. Hypoallergenic mother diets do not. Complementary therapies – only Lactobacillus Reutri as a probiotic showed any promise. Chiropractic does not help and I cannot understand how you would do that to an infant (BMJ 51 (1) 6). Actually, behavioral modification showed the most promise in my opinion.

TAKE HOME MESSAGE: Not much help for infantile colic – you can try the occipital nerve block (only kidding).

Patient has chest pain if she lies on her left side for over a year.

The patient has been depressed ever since she began seeing me in 1983..Discharge status: Alive but without permission. The patient will need disposition, and therefore we will get Dr. Blank to dispose of him.

Examining the Rotator Cuff

JAMA has a rational clinical exam and here they are trying to teach you how to check a rotator cuff. The best are the painful arc test and the external rotation test, and for a full thickness tear – the lag test, but despite my custom, I will not show you how to do these since they are all pretty poor tests (JAMA 310 (8)837). I would go straight to ultrasound.

TAKE HOME MESSAGE: Good pictures here for rotator cuff tears but no test is that great. Well, I’ll be nice – here are the two tests


and external rotation.


Love and Marriage

Lean on me – how well do physician’s spouses give support to their overworked and pressured husbands/wives. Actually, and I had trouble believing this – physicians married to physicians have strong support and low divorce rates – they just understand each other. In other cases – there is a strong discrepancy between actual support and perceived support. Many do not realize the support given to make the marriage work (Psycholog Health and Med 18(5)543). In my opinion – if you need support:





Only one letter this month – from Thailand – as I no longer see who subscribes (due to our great new website, I am not sure who the writer is, but thanks for your compliments on how useful EMU is. What is doing Ken? BTW- EMU goes to 34 countries as of today – so let’s hear it for international EM – we can teach the yanks a thing or two.

Answer to Clinical Quiz #1

Number two was Bouveret Syndrome; which is when a large stone causes gastric outlet syndrome. This picture from the article shows how it works.


The abdominal film actually showed air in the biliary tree.

EMU LOOKS AT: Constipation and the Law

If that title doesn’t catch your eye – what will? The sources for these articles are CMAJ 185(8)663 and Chest 144(1)306.

Constipation in Older Patients

1)   This is common in old people (If you speak Yiddish you are familiar with the term alter cocker – if you don’t – check Google Translate); 50% of adults over age 80 have it (Father Greg – what’s it like? – hey, think of it – you can do the milk of magnesia of the month). Diagnosis should be made by asking about straining– do not rely on amount of bowel movements per day – most patients underestimate them anyhow. What is normal for bowel movement per week is variable – so won’t help much to ask that question.

2)   Causes that can be corrected are opioids, calcium channel blockers, iron, NSAIDS, antihistamines, diuretics, TCAs, and antipsychotics. Diseases include diabetes, diverticulosis, dementia, MS, depression, hypothyroidism, and Parkinson’s disease. Be careful if there is bleeding, anemia, vomiting or weight loss.

3)   But this is pretty basic – let’s get straight to agents. Osmotic agents work by – osmosis. Lactulose is the most popular in my country, but propylene glycol is getting its share of the limelight as well. They actually work well. However; bloating, flatulence and overly sweet taste make lactulose a sticky subject. PG can be gritty tasting, but can be mixed with better tasting fluids (like beer???) magnesium and phosphate based laxatives work well; but, there can be over absorption especially with renal patients.

4)   Bulking agents – I use these mostly to prevent constipation. We are talking about fiber – however studies have not shown a lot of benefit, but the studies have been small. There is a lot of gas with these.


5)   Stimulants increase colonic secretions and motility – they basically irritate the bowel. Amazingly – there have only been two studies and they were herbal mixtures that showed significant benefit – but biscodyl has not been studied. They have a propensity for abuse in my experience and also decrease in efficacy over time.

6)   Stool softeners have been studied once in 1968. They worked in 12 out of 14 patients. Docusate has been used for ear wax removal and does work, but that is a different orifice.

7)   Prokinetic agents include cisapride which is rarely used because of cardiac effects but it has been supplanted by prucalopride . Evidence so far would not justify its use for constipation.

8)   Enemas, suppositories – there are no RCTs. It was once studied against lactulose with no difference seen, so there seems to be no benefit to enemas.

9)   Physical activity, drinking a lot of fluid – did not show any benefit. They state physical activity probably helps; we just do not have any evidence for it. Biofeedback in the only RCT did apparently help to train muscles.



THE LAW – this is an unbelievably good read, but it is a historical piece that could help all our international readers by seeing their own systems and what malpractice reform entails – in short – what works and what doesn’t.

1)   Reform number one – cap damages. But this is been struck down as unconstitutional by four of the states – Mo, Ga, Ill, WI.

2)   So there are first generation attempts at reform. Here are some of the attempts. Firstly, they tried to limit the statute of limitation. This was a problem – how can you limit the time for injury claim for a medical mishap, and not for a car accident.

3)   Pretrial screening and certificate of merit was another attempt. This meant pre-review by the medical experts to screen out cases without merit or cases that could not be proven. Fee control of plaintiff’s lawyer’s fees was also attempted.

4)   Other attempts included expert witness qualifications – for example in many states – but not all – you need to be in the same field as the defendant to provide expert testimony. This is not the case in my country. Many retired physicians use expert witness as a good way of making a living. They also changed informed consent rules to be more a long the lines of professional custom, ignoring the patient’s need for facts.

5)   Payouts were also affected. California for example limited payouts for pain and mental suffering to $250000 – a figure that has not changed since 1975. Some places have caps on all payouts, others on non economic ones alone. Common law joint and several liabilities principal: means that if one of the defendants lacks the resources to pay – the other defendants pay – like the hospital. That has now been eliminated and you pay what you can according the percent you are found liable.

6)   The collateral source rule: if there are benefits that the injured will receive aside from the award- such as medical insurance or unemployment insurance payments- these are subtracted from the award. Defendants in essence are taking from the plaintiff’s foresight in securing insurance – but this has all become less relevant as insurers have taken the initiative to provide less or no coverage if an award has been given through an outside source like a settlement.

7)   Other first generation attempts have included allowing judgments to be paid out through spaced out payments. This reins in plaintiff’s lawyers from obtaining windfalls based future expenditures.

8)   Many states have rules for binding arbitration – this reduces the amount of cases going to court and litigation time. However, it may allow plaintiff’s to sign away rights to better awards.

9)   There have also attempts for catastrophe funds to cover awards beyond coverage by the insurance. I worked a while in Pennsylvania and the costs of maintaining this fund was spread out to the physicians working in the state and was very expensive for us.

10)  Now we have gotten to more creative solutions – we are up to second generation malpractice reforms. The sorry laws were a major step forward. 36 states have sorry laws – where a doctor can express remorse and this is not admissible as evidence in trial. This encourages reducing lawsuits over anger.

11) Disclosure and early offer proposals encourage hospitals to disclose errors for lesser payments but these are faster and more certain payments which would be attractive for the patients. New Hampshire has enacted this law – the trial lawyers were not pleased.

12) “Health courts” are led by judges with special training in health issues and experts are paid for by the courts. Japan has this; I thought New Zealand had this as well. NY has enacted something similar.

13)  Safe harbor means that physicians who prove they adhered to established guidelines are never liable. Obviously if you read EMU you know the problems with guidelines which are usually based on little or old evidence or are too vague. It doesn’t allow patients to benefit from non-guideline care that may actually be better.

14) A new concept is enterprise liability – kind of like “incorporated” or “limited.” This focuses attention on the system and makes the hospital pay for errors of its employees. Enterprise insurance is insurance for non-hospital employees – who can still be sued but the hospital is the insurer.

15)  Lastly no fault. France, NZ, Scandinavia and Japan have forms of this (so have Va and Fla for obstetrics); compensation is standard and not related to physician error. More patients will receive compensation but compensation must be lower to avoid bankrupting the system

16)  And of course the best: New Zealand has abolished malpractice litigation entirely

17)  So the question is – what has worked? You may need to refer to the previous paragraphs to remember the terms, caps on plaintiff lawyer’s fees and on punitive damages have had little or no effect, shortened statues of limitations have had mixed results – basically lawyers have learned to adapt to these changes by changing the way they practice. Collateral source may have reduced payments band claim frequency

18)  Damage caps however are a different story. They have definitely reduced payouts and claim rate. However, states without caps have also reduced rates of both in the last 20 years so a different explanation is necessary. Also, more cases will now go to court to get the maximum. The question is will doctors take less safety measures as a result. I claim – this will lead to less unnecessary defensive medicine measures caps on non-economic damage also affects certain subgroups more.

19)   Safe harbor has not had much of an affect and indeed limits the way doctor’s practice in a way that could damage patients. All other second generations have no evidence as of this time, no fault has looked encouraging. Of course from an ethical viewpoint- disclosure seems the most worthwhile.


The post EMU Monthly – May 2014 appeared first on EMU Monthly.

Una sencilla manera de comunicar los objetivos del tratamiento a pacientes con diabetes (y a algunos médicos y enfermeras)

El nivel de glucosa en sangre es la característica definitoria de la diabetes mellitus. Históricamente el tratamiento se ha centrado por tanto, en la reducción de los niveles de glucosa en sangre. Sin embargo, cada vez esta más claro (en base a pruebas de alta calidad) que el control de la glucosa ya no debe ser el foco principal del tratamiento.
Un nuevo enfoque para el cuidado de adultos con diabetes tipo 2 hace hincapié en las intervenciones probadas que mejoran la calidad de vida y alargan la duración de esta. Los estudios más recientes han demostrado que el tratamiento intensivo dirigido a disminuir los niveles de glucosa en sangre, ni afectan la mortalidad, ni disminuyen las complicaciones de la diabetes tipo 2. Por el contrario, intervenciones como dejar de fumar, control de la presión arterial, y la reducción de los niveles de lípidos, son especialmente eficaces en prolongar la vida en estos pacientes.
Una forma sencilla de ilustrar este nuevo enfoque a los pacientes se define como ” echar una mano  y se puede ver en la diapositiva a continuación.

Tomado de Primun non nocere