EM in 5 is a weekly series of 5 minute Emergency Medicine educational videos! Look for a new video each week!
Filed under: Cardiology, Trauma
With medical marijuana now legal in 23 states and the District of Columbia — and recreational weed available in Colorado and Washington State — knowing the pharmacokinetics of THC has never been more important, both for consumers and the physicians who must counsel and treat them. Recently, the New York Times’ Pulitzer Prize-winning columnist Maureen Dowd got into trouble in Denver when she overdosed on a cannabis candy bar and experienced 8 hours of paranoia and couchlock. My recent Emergency Medicine News column describing 4 things Maureen should have known about weed before venturing to the “mile high city” has been posted online. You can read it here.
While discussing a case with one of the nurses with whom I work, I saw how once again defensive medicine had affected my medical practice.
I gave a few examples of defensive medicine in a post several years ago and I also mentioned how sometimes doctors have to prove a negative when dealing with patients. Both of those posts are pertinent to this case.
A patient with a history of a clotting disorder has arthroscopic knee surgery. He has had two prior blood clots in his leg and one prior blood clot in his lung, so he’s on lifelong Coumadin. His doctors told him to stop taking the Coumadin for the week prior to his surgery to prevent bleeding during surgery. The surgery went well and he was discharged the same day.
The following day he started taking Coumadin again. However, he also noticed some pain in his calf. The pain was there after his surgery, but it seemed to be a little worse the following day. He took some pain medication and kept ice on it.
Two days out from his operation he was still having some pain in his calf, so he called the orthopedist. The orthopedist told him to go straight to the emergency department for an ultrasound of his leg to make sure that he didn’t have another blood clot. The possibility of a blood clot worried the patient, so he followed the doctor’s recommendations.
When I saw him, based on his clinical exam I could tell – with a reasonable degree of medical certainty – that he didn’t have a blood clot. His leg wasn’t red or swollen. We measured the circumference of both legs at the thigh and at the calf. His normal leg was actually a centimeter larger in diameter than the leg that underwent surgery. The pain was in the belly of the calf muscle – where orthopedists will sometimes apply pressure to get the leg in the correct position during a surgery. There was no thigh pain and there were no palpable cords.
It was a Saturday evening, so doing an ultrasound to look for a blood clot meant that we would have to call in the ultrasound tech from home and the patient would have to sit in the emergency department for at least a couple of more hours.
I told him “Based on my exam, it is pretty unlikely that you have a blood clot in your leg. Keep taking your Coumadin, keep putting ice on the tender area, keep taking your pain medications, and follow up with your doctor on Monday.”
He said “I have a history of blood clots in my leg before, it feels like a blood clot now, and my orthopedist said I need an ultrasound. You need to do the ultrasound.”
Now if there wasn’t any concern about liability or other repercussions, I probably would have told him that the ultrasound wasn’t indicated and that we didn’t need to do it that night.
But there is a concern about liability and other repercussions.
Even if the patient didn’t have a blood clot on this visit, what would happen if the patient developed a blood clot the following day? And what if that blood clot broke off, caused a pulmonary embolism, and the patient died? How could I prove that there was no clot present when I evaluated the patient – especially when purported “expert” witnesses testify under oath that it is “grossly negligent” to miss a diagnosis of pulmonary embolism in a teenager after knee surgery? It is much easier to order a test than it is to defend your reasonable and evidence-based approach for not ordering the test in the event of a bad outcome.
What if the patient had a clot despite the lack of physical findings for a blood clot? We often hear the phrase “nobody’s perfect”, but if you don’t order testing and miss a diagnosis, there is really not much tolerance for less than perfection in cases like this. It is much easier to order a test than it is to defend your reasonable and evidence-based approach for not ordering the test in the event of a bad outcome.
I’ve seen more than a few specialists and primary care docs who send a patient to the emergency department for testing and who then complain to hospital administrators that the dumb emergency physicians don’t do the tests that they wanted.
And let’s not forget that sending a patient home without getting the tests that the patient wanted is a sure way to tank your patient satisfaction scores.
So we ordered the ultrasound and called in the ultrasound tech.
A few hours later we got back the report from the radiologist showing no DVT. The patient got to go home and I’m sure that he slept better.
I’m sure that the orthopedist was able to sleep better, also.
The whole episode didn’t have much of an effect on my sleep pattern. I knew the patient didn’t have a blood clot when I first examined him … but now I had objective proof of my clinical findings and everyone got what they wanted.
Just think, it only cost the system a few thousand extra dollars.
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me.
An otherwise healthy 30-year-old woman presents to the emergency department with a pruritic rash on her upper thigh that she has had for nine days. Thinking it was poison ivy, she had been using topical corticosteroids on the area. When the rash didn’t improve, she decided to seek care. She is otherwise well; she reports no fevers, joint pain, or tick exposure. On exam she has two lesions each about 2 cm in diameter (similar to image below). The lesions are slightly raised and scaly. She has no palpable lymphadenopathy. The emergency physician diagnoses tinea cruris and instructs her to stop the corticosteroid. Instead, he prescribes clotrimazole 1% twice daily.
She returns to the emergency department two days later because the lesions have grown four times in size. They are intensely pruritic, and she notices that they swell with the summer heat at night. Two physicians are working in the department on this particularly slow day, and both examine her. Both physicians agree with the original diagnosis.
“Is co-treatment with topical steroids in tinea infections associated increased failure or relapse rates?”
I entered the search terms “tinea” AND “topical steroids” in the Google Scholar search engine. I reviewed titles then read papers that were related. I reviewed the bibliographies and “cited by” of each to find additional papers. I also searched the Cochrane Review Database for “tinea”.
A Cochrane review (published while writing this blog post!) “Topical antifungal treatments for tinea cruris and tinea corporis” highlights that the quality of evidence on co-treatment with steroids is not strong. The meta-analysis of the corticosteroid subgroup combined data from six studies comparing azoles and azole/steroid combinations. Authors concluded that there was no difference in mycological cure rates (RR=0.99 [0.92-1.07]) between the two groups and that clinical cure rates were significantly better in the combination group (RR=0.67 [0.57-0.84], NNT 6). .
An older study by Smith et al (1992) reported failure rates of 45% (combined) vs 7% (antifungal alone) . Similarly Nada et al (1994) found a failure rate of 66% (combined) vs 4% (antifungal alone) . In both of these studies, however, the antifungal medication used was different between the antifungal alone vs combined group, which makes it difficult to interpret these results. A review from a pediatric dermatology group found that all cases of refractory tinea referred to their group were associated with topical steroid use (n= 6 cases) . Three trials show no difference in failure between combined therapy and antifungal therapy groups [5,6,7]. One  showed symptomatic benefit of steroids while one  did not. A more recent study suggests that some combinations of antifungals and steroids may even be synergistically beneficial .
AN IMPORTANT POINT: If you are not sure of the diagnosis, don’t use steroids (and if you think it is tinea don’t use steroids alone) because it complicates the picture. Topical steroids may cause the rash lose some of its distinguishing characteristic qualities. Tinea Incognito is an group of tinea infections that are misdiagnosed because of changes to the skin and tissues related to topical corticosteroid use.
When used in conjunction with antifungals, corticosteroids may improve symptoms and are unlikely to be associated with an increased risk of treatment failure.
You discuss the above evidence with the patient. She opts to use the anti fungal and also decides to restart with the steroid cream. She notices symptomatic relief during the first few days of combined treatment. Over the next couple of weeks her infection resolves!
By Seth Trueger, MD (Attending Emergency Physician at University of Chicago)
Nice summary, and quite fortuitous that the Cochrane review came out while writing it! Not surprisingly, there isn’t a lot of high quality study in this area, but the few hundred patients that made it into the Cochrane review show a pretty decent clinical improvement with the addition of topical steroids to antifungals, with a statistically insignificant increase in adverse effects. While steroids can lead to tinea incognito, if the diagnosis is clear, it makes sense to use them.
Seth Trueger MD MPH
University of Chicago
A 39 year-old woman presented with this nodular rash and an insidious onset of shortness of breath. A chest X-ray was obtained as shown above. What is abnormal finding on the chest x-ray and what is the syndrome that culminates the imaging finding and rash together?
This is Lӧfgren Syndrome, which is the manifestation of Sarcoidosis which includes
erythema nodosum, hilar adenopathy, and arthritis. With this very specific
presentation, a diagnosis of Sarcoidosis can be made without a biopsy.
Fortunately, this form of Sarcoidosis has an excellent prognosis and can be
managed with NSAIDs.
See more cases like this on Figure 1.
More FOAMed Resources:
Another great case of erythema nodosum and some clinical exam pearls: Diagnoses on Sight: Bilateral Leg Rash @ ALiEM
Great refresh on the reading a standard CXR: How to Read a Chest Xray @ EM REMS
Sarcoid can give you a low low voltage on ECG, but so can other entities: Great ECG of the Week with Amal Mattu on syncope in a patient with low voltage on EKG.