I am becoming quite expert in navigating the look of confusion on my colleagues’ faces when I tell them that I am completing my master’s in anthropology. I can see behind their glazed eyes, in real time, the exotic mental images they are conjuring of the famous cultural anthropologist Margaret Mead or the comical similarities in social functioning between me and fictional physical anthropologist Temperance Brennan. A few remember that Paul Farmer is an anthropologist ...
You are in the middle of a fast-paced trauma activation. The patient is awake, and mostly cooperative. The x-ray plate is under the patient and everyone stands back as the tech gets ready to fire the x-ray machine. At that very moment, your patient reaches up and places his hand on his chest. Or one of the nurses reaches over to check an IV site.
The x-ray tech swears, and offers to re-shoot the image. What do you do? Is it really ruined? They have an extra plate in hand and are ready to slide it under the patient bed.
The decision tree on this one is very simple. There are two factors in play: what do you need to see, and how hard is it to see? The natural reaction is to discard the original image and immediately get a new one. It’s so easy! Plus, the techs will take heat from the radiologist because of the suboptimal image. But take a look at this example of a “ruined” chest xray.
It’s just the patient’s hand! You can still see everything that you really need to.
Bottom line: You are looking for 2 main things on the chest x-ray: big air and big blood. Only those will change your management in the trauma bay. And they are very easy to see. Couple that with the fact that an arm overlying the image does not add a lot of “noise” to the image. So look at the processed image first. 99% of the time, you can see what you need, and will almost never have to repeat. [Hint: the same holds true for the pelvic x-ray, too. You are mainly looking for significant bony displacements, which are also easy to see.]
This is the first post in the Elemental EM series, a rapid review of core emergency medicine topics. The goal is to present high yield facts as a foundation for practice and fundamentals for board review. Please enjoy the following bullet point summary on myasthenia gravis.
Author: Courtney Cassella, MD (@Corablacas, EM Resident Physician, Icahn SoM at Mount Sinai) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)
0.15-0.7% of the population, Most often 3rd to 6th decade
Autoimmune: Acetylcholine receptor antibodies
Causes receptor degradation, dysfunction, and blockade
Impairs function at neuromuscular junction (NMJ) → decreased muscle strength
Dysfunction of thymus gland or immune response to infectious antigens → abnormal thymus → often thymoma present
Facial or bulbar muscles: Ptosis, diplopia, dysphagia, dysarthria, dysphonia
Worsens: as the day progresses, with prolonged muscle use, hot temperatures, stress, infection
No deficit in sensory, reflex, or cerebellar function