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May 20131) Syncope is a pain and I will not rail on more about how muchwe hate it, although I am positive you have already seen thefirst word of this paragraph and skipped the rest of theparagraph. Here they say that folks without CHF who areunder the age of 60 will have little risk of death in 30 days, sosend them home. (AEM 19(5)488). Let us look a little closer atthis study. First of all it was a retrospective study based onICD 9 codes; although that shouldn't be much of an issuehere, as syncope doesn't have many imitators. But it will missthose who syncopized and had a good reason- likehypoglycemia which wouldn't kill most people, but also v tach,and MI so we cannot know true mortality. However, if we goby their numbers- they had almost 24000 ED visits and foundonly 307 deaths within 30 days. Again, we cannot be sure thatthey found everyone who died but the mortality was about 1%which I believe is probably true. Now they found higherhazard ratios with DM, and CHF. However, the hazard ratio willbe higher in the above 60 group simply because they havemore of a preponderance of these illnesses. Basically you can

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probably send home the under sixty set if they have no EKGfindings and no CHF. Above sixty, if they are really healthy- Istill admit them if this is a first time event. TAKE HOMEMESSAGE: exactly what I wrote in the last line

2) New usages for Superglue- I am sure Ken Iserson will haveeven more- but this article says- use it to anchor in IV lines-the IV will not be damaged by the glue nor by the agents toremove it like paraffin (but do not use acetone). There wereno skin irritation problems and no bacterial growthunderneath the glue (Anest Int Care 40(3)460). Add this to thelist of new usages for glue which will also include temporarybracing of subluxed teeth and to anchor in avulsed nails (tokeep the germinal matrix open- if you really need to do this)

Yes this is a picture of someone who fell in to the bubble gumvat. And you will get a big star if you know the movie this

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comes from TAKE HOMEMESSAGE: Use Hisotacryl for anchoring in those IVs. Workswell for diarrhea too!

3) America is now being overrun with new drug issues- it used tobe herion, then it was designer drugs and I am not saying thatthese have disappeared but now it is prescription drugs. Oh, Iknow you were shocked to find out that those 450,678 pills ofPercocet that you prescribed for Mr. Handley for his renal colicfell into the hands of other law abiding folks but be careful-the swallowing of whole fentanyl patches is now on theupswing. (JEM 42(5) 549). They saw 76 patients in their series

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and 80% of them required admission- nearly all to the ICU (ofcourse we can not be sure of what criteria were used todecide that) We still do not know if Narcan is enough andwhat the duration of toxicity is, but it seems that this doeswork for a high. TAKE HOME MESSAGE: fentanyl patches canbe swallowed for a high- think about that when patients keeprunning out of their patches. Five points too if you canpronounce the last name of the author of the paper

Time for quotes- actually titles. Country music is very popularin the rural areas of the USA and is known for its twang-yrhythms, banjo and fiddle accompaniment and corny "blues"type titles to their songs. Let's look at some of these(all ofthem are real): Here's A Quarter--Call Someone Who Cares--Travis Tritt Fax MeA Beer--Hank Williams, Jr.

4) Let's put this to rest. Penicillin allergies do not translate toCephalosporin allergies. What was thought to be a 10% crossreactivity is probably less than 1% and only with thosecephalosporins that have an R1 chain- and even then- theallergy is to Amoxicillin or Ampicillin whom also have an R1

chain. Now I know you know which cephalosporins have an R1

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side chain, but I will repeat it here for the benefit of the onemoron who forgot. They are Cefaclor, Cefadroxil. CeftatrizineCefpozil Cephalexin and Cephadrine. Now while you arepraising the genius that decided that all cephalosporinsshould start with the prefix cephlet me remind you thatthose who use second and third generation cephalosporinsare usually safe. (JEM 42(3)612) TAKE HOME MESSAGE: Mostcephalosporins can be used in Penn allergic patients "How Can IMiss You When You Won't Go Away"--Dan Hicks and the Hot Licks. David Frizell's "I'm

Gonna Hire A Wino To Decorate Our Home"

5) I really do not know what to do with epidemiology studies- it iskind of like philosophy class-at the end of the day what areyou left with? In any case they crunched the studies andfound that Amoxicillin in early pregnancy increases your risk

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for cleft lip. (Epidemiology 23(5)699) Maybe.

Probably is that R1 chain6) Maybe this is just a problem in Israel, but I doubt it. We have

been railing about (aren't I always railing about something?Well, you know there is a haloperidol shortage) catheteroveruse that is finally now getting attention. There is pressureto reduce the amount of patients walking around with theseawful contraptions, and in this study they found that in thehospital, the place were most catheters were inserted was the

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OR (makes sense to me, since urologists do this after everysurgery) but the second most common place was the ED(although admittedly a lot less than the OR). (Inf Contr HospEpid 33(10)1057) Now I can hear for BPH you may want toscrew in one of these things, but in my country all intubatedpatients must go up with an NGT and a catheter. True that ithelps for measuring input and output, but that isn't necessaryfor all intubated patients. Does it help for COPD patients?Let's be a little more flexible and judge each case individually.

TAKE HOME MESSAGE: Those who routinely insert cathetersfor admitted patients should themselves be catheterized I amnot sure why I thought of this- but let's dedicate this to manyUK readers who know what I am talking about- the sport of

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ferret legging- yes sticking this: inyour

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pants:7) OK clinical quiz time. This old disease is making a comeback

and is as angry as a ferret in your pants. If the diseaseprogresses you can commonly see Higoumenakis sign(unilateral enlargement of the sternoclavicular joint),mulberry molars (extra cusps on the molars), Olympian brow

(frontal bossing) and less commonly clutton joints (sterile

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effusions of major joints) saber shins (bowing of the tibia). Ilast saw this disease at Jacobi Hospital back in the eighties-want to guess what we are talking about? (Am Fam Phys86(5)433) I Don't Know Whether To Kill Myself or Go Bowling. If I Can't Be

Number One In Your Life, Then Number Two On You.

8) I guess this information may help someone- birds are oftenpets (although who wants to deal with Q fever and psittacosis-don't you detest words that have a silent p? You should see apsychiatrist) and yes, you do have to know microbiology.Parakeet bites can inoculate salmonella and the ever popularStaph Aureaus- you will need Cipro and TMP/SMZ to coverthem. They also have E coli. Cockatoos carry bacillus speciesand their bites will require clinda coverage. Parrots pass onPasturella and Pseudomonas so consider Cipro andAugmentin. Conures require cipro. This information waspassed on to me from a presentation at the InternationalVirtual conference of Veterinary Medicine by Dr. Jesus- whom Ido not know, but I am sure Father Greg does. (J Hand Surgery(am) 37 (9)1925) TAKE HOME MESSAGE: Bird bites are not

innocuous and require serious antibiotics especially to the

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hand. Reminds me of a quote from sickie Jack Handey "why isthe dove the symbol of peace? It should be the pillow- you getmore feathers and do not have to deal with those nastybeaks"

9) Aren't too many articles about this subject, but I will justhighlight the things you got to know. Scromboid poisoning iswhen someone eats a fish that has been improperly storedand contains high levels of histamine from bacterialdegradation. As such, this is not a seafood allergy. While it iscalled scromboid poisoning since it was found originally inscrobmoids (which are tuna and mackerel) it can be seen insardines and anchovies as well (although that is a littlemisleading since sardines can be different fish depending onwhich country you come from) . The symptoms are those ofhistamine release and this is usually treated well with antihistamines. The need for steroids or adrenalin is rare.However, the fish may smell normal (although it still smellslike fish- yuck) and as histamine is heat stable- cookingfreezing smoking or canning does not destroy the histamine.(CMAJ 184 (6) 674) TAKE HOME MESSAGE: Scromboid

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poisoning can be found in tuna and sardines and is not anallergy. Antihistamines are enough. The fish will have nosigns of histamine excess. Mama Get A Hammer (There's A Fly On Daddy'sHead). I Still Miss You Baby, But My Aim's Gettin' Better

10)And yet another clinical quiz. Fever, red eye, hypopyon (pus inthe anterior chamber) and a macular lesion on the palm in alady with mitral valve prolapse, obesity and hypertension.

(JACC 60(12)e21) Kind of easy, no? IWouldn't Take Her To A Dog Fight, Cause I'm Afraid She'd Win. I'm So MiserableWithout You; It's Like Having You Here.

11) I don't know when you will use this information- maybe totreat a bird bite- but Tramadol can be used as a localanesthetic and aside from local irritation works just as well (J

Cut Med Surgery 16(2)101) Maybe- the p values verus

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lidocaine were not significant but Tramadol is more expensiveand true lidocaine allergies are rare. But I included this just incase you give this med IV and it infiltrates. However I wouldoffer this caveat- diphenhydramine can also be used as anlocal anesthetic but it can also cause local necrosis which wasonly noted on a later bigger study.- we need a bigger studyhere too TAKE HOME MESSAGE: Tramadol can be used as alocal anesthetic too. But why? My Head Hurts, My Feet Stink, And I Don'tLove You. My Wife Ran Off With My Best Friend and I Sure Do Miss Him

12)They did very well with just needling pilonidal abscesses andthen sending them home with antibiotics. They then returnedmuch later for the elective procedure of removing the tract.

True this was a small study but we have been trumpeting fora while the idea of just needling abscesses and not openingthem. (Dis Colon Rectum 55(6)640) My question is- did theyreally need the antibiotics?? The abscesses were needled untildry. TAKE HOME MESSAGE: a Pilonidal abscess can also beneedled and discharged for a definitive procedure later on. SheGot The Ring and I Got The Finger

13)A little twist on ultrasound for our geeks: ultrasound can breakup clots although the mechanism is not well understood. You

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can use ultrasound alone to break up a CVA clot, you can useit with glycoprotein IIb/IIa inhibitors or you can use TPA with it.I want to emphasize this is not ready for prime time yet butmaybe safer than TPA because you may need lower dosagesof TPA when you use ultrasound (Stroke 43:1706) TAKE HOMEMESSAGE: ultrasound may be used to break up clots- with orwithout meds You're the Reason Our Kids Are So Ugly.

14)Hopefully Father Greg did not miss this article why oh why isit in the cardiology literature? Spirits- I am assuming thatmeans whiskey and the like and not Casper the Ghost contains 20 ml of alcohol in the house bottles you get on theplane for outrageous process and 300 cc of alcohol if you buythe 750 ml bottle in the store. Wine bottles on the airplanecontain 25 cc of alcohol and in the stores 100 cc of alcohol.Beer in the USA is about 5% alcohol so it contains on 18 ml.So you can drink 285 ml of beer to get as sauced as 120 ml ofwine and 30 ml of spirits. Now there are 7 calories per ml inalcohol- you can do the math, but it doesn't look good.

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(AJC 110:761) I would enjoyFather's input on some of the finer wines available in FlintMichigan (actually I have hit up on Flint enough- let's hit up onthe Day glo plaid jacket capital of the world- nearby YpsilantiMichigan) including those tried and true favorites-

Thunderbird, Ripple and Sterno. Now while I think RiskManagement Monthly is a great way to learn how to practicemedicine in the ED and not in the courtroom, I want to point

out that each issue ends with Father Greg's Wine of the

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Month. So I think EMU will match Father with the wino of themonth: Here are three that were well known for their love ofChardonnay grown in from special vintage concord grapes

from Downtown Ypsilanti. Michigan

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Whoare these guys?

15) We spoke about syncope above and now on to anotherfavorite subject: Vertigo. There are two choices here- eitherits BPPV or its a stroke. But there is a third option and that isvestibular neuritis which is an inflammation of the vestibularnerve. They state in this article that it is missed 85% of thetime (how do they know this? There is no gold standard) butthere are some hints to it. VN is a single event with rotationalvertigo. Vomiting occurs and it doesn't get better when youstand still. There is a loss of the vertibulo ocular reflex and

there is usually nystagmus when they look forward. On theother side, stroke is when people can't walk at all (VN- they

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can balance while holding on to furniture) and they havehearing loss, neuro symptoms and a headache, as well as apositive head impulse test. VN doesn't recur and takes weeksto get over. Steroids do not help. (BMJ 345:e5809) TAKEHOMEMESSAAGE: Vestibular neuritis is not BPPV. But it isn't astroke either. They get better on their own and steroids andmaneuvers don't help. "Did I shave my legs for this?" "If the

phone doesn't ring , you'll know its me"16) I couldn't get this article because it is in a journal that

only about 8.5 people in the whole world get, but they did listtheir myths about management of distal radial fractures.Firstly, that casting must include the elbow. Secondly earlymobilization leads to better outcomes. And thirdly, goodanatomic reduction leads to better function. All of these arefalse (Hand Clinics 28(2)127). This may be true- but itdepends on the level of evidence and which radial fractureswe are talking about (Galeazzi's are much different thanbuckle). However from my years of casing (casting?) theliterature I will add my own comments. Casting above theelbow is definitely not necessary in many wrist fractures but

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that is probably related to the next point. The purpose incasting one joint up is to prevent usage of the tendons andmusculature that are left free to move if the elbow isn'tincluded. But that is dependant on whether early mobilizationis necessary of not- and I believe giving as much function aspossible does help fractures. Look at osteoporosis-we knowexercise does help because it mobilizes calcium into thebones.And of course the question must be asked if you need to castin the first place- buckles and greensticks probably do not needcasting. HoweverI agree with exact anatomic reduction notbeing crucial- kids can do well with a lot of displacement andmost adults can do well as well providing that they have nohealing problems and engage in physiotherapy. (No raising awine glass to your mouth is not physiotherapy) TAKE HOMEMESSSAGE: Distal radial fractures do not need exact anatomicreduction and long casts and early remobilization is bad. Orgood. Or something."And there was Grandma, swingin' onthe outhouse door without a shirt on" Baked my sweetie a piebut he left with a tart" "Don't want that floozy in my Jaccuzzi"

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17) This study looked at the use of low dose Droperidol forheadaches and they have remarkable results- 73% hadresolution or significant improvement in their headaches. Thedosages averaged only 1.25 mg. None had cardiacarrhythmias; none ended up in black boxes however EPSsymptoms were seen in some. (AJEM 30(7)1255). True thiswas retrospective but it was from a pharmacy data base sothey can be sure the patients got the medicine. How theyknew who got better is a different story and it doesn't looklike they used a standard headache or pain scale. In addition Iam tired of Americans whining about how unfair it is that theycan't use Droperidol at will while many of us in the ThirdWorld (defined as any one over the George WashingtonBridge heading West, and anyone beyond the NassauColiseum on the east) don't have this drug. But do notdespair. A review in the CJEM says that this family does work,but the side effects are many. In truth, Haloperidal whichevery one has and is of the same family- probably works, butmost of the research has been done on Droperidol, so it ishard to say. I use Haloperidol for headaches in my patients

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and most do well (some shake but I always assumed thosewere rum fits from drinking too much) (CJEM 13(2)96) TAKEHOME MESSAAGE: Butyrophenones are good treatment forheadaches even at low doses. "Gave her my heart and adiamond and she clubbed me with a spade"" He's got a waywith women and he just got away with mine"

18) This twelve year old Indian boy came to the ED withsigns of brain death: a GCS of 3, intubated and absent cornealreflexes. This occurred after a snake bite which in India- homeof the king cobra- is not a good idea. (ibid E1) But wait thekid woke up and went home neurologically intact- seems thatis what you would expect from the neuro paralytic effects ofthe venom. I do not think brain death should be used as ameasure of inability to be functional- many of our finestpoliticians have suffered from this malady and are servingfaithfully tot his day. TAKE HOME MESSAGE: Is there one? "I

just bought a car from the guy who stole my girl, but it don'trun so I guess it was an even deal" "I wish I was a woman (so Icould go out with a guy like me)"

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19) I don't care what a genius you are, and you probably areone if you read EMU- but even the best internist has neverheard of Mondor's Disease. This is a superficialthrombophlebitis of the chest wall which is cordlike andusually goes from the breast to the axilla. Enoxaprin is givenfor a month, and a clotting workup is indicated. Predisposingfactors include trauma, surgery infections, and excessiveexercise. US does the diagnosis (ibid 30(7)1325) TAKE HOMEMESSAGE: Mondor disease- superficial thrombosis of the chestwall,- requires a clotting workup. "I got the hungries for yourlove and I'm standing in your welfare line"

20)Biostatics is about as interesting as discussing quantumphysics with Lady Gaga, but you got to know something. Afterall you want to grow up to be and strong and trash articleslike Jerry Hoffman. So every once in a while we have toinclude these types of articles. You see odds ratio around alot. An odds ratio is simple- how many people who smoke willget lung badness compared to how many people who don't.Risk ratio is how many smokers will actually get the lungbadness. As you can see, Risk ratio tells us more about the

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group we want to know about. This article made a push formore expression of RCTs and cohort studies with relative riskand not odds, although you see odds ratios all the time (CMAJ184(8)895). Now I would just like to add that absolute risktells you more than ratios do because in small groups, the riskmay be magnified. TAKE HOME MESSAGE: Risk ratio tells us

more than odds ratio21) Don't you just love neonates? You know, those cute little

creatures that just come out the oven all looking the same?Well, there are some changes as to dealing with these littleadults if they need resuscitation that go beyond just APGARand calling in the pediatricians. Temperature control,

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breathing and circulation have not changed. Assessment isimportantthe baby's color is an unreliable parameter- itcorrelates poorly with saturations and there is considerableinter observer disagreement. So you would say- well, whosays saturation is the way to go in assessment? And youwould be correct it is normal for a newborn to have adepressed saturation which over a few minutes responds.Actually the heart rate is a better parameter. The articlepoints out that babies are born naked and wet (a surprise- Ididn't know this) and therefore should be kept warm aspossible-they aren't real good at temperature modulation.However, if they are hypoxic and have low APGARS and thepH is less than seven, hypothermia seems to save lives. Butthis is for term babies. Preemies- we just do not know. Next.Suctioning out the meconium is no longer required. We donot give oxygen unless they fail to respond to air. If you douse oxygen- try to wean it fast. CPAP and surfactant can beused instead of intubation and the choice is yours- theguidelines allow both. Circulatory support- adrenalin via theET is unreliable. Give it IV or IO.(J Paed and Chidl Helath

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48:735) Beer, wine and whiskey have no role in neo natalresuscitation, but that may be changing. Then again, maybethe baby itself needs changing. I cannot be quite sure why Ithought of his quote know, but I'll use it "I love cooking withwine. Sometimes I even add it to the food "Julia Child, famousChef. TAKE HOME MESSAGE: Neonatal resuscitation haschanged- give air instead of oxygen- consider CPAP andhypothermia for selected cases. "One day when you swingthat skillet my face ain't going to be there"

22) Toxicologist- hydoxyurea is used often for thrombophiliaand for sickle cell anemia. It has been shown to be safe ininfarcts. A case report about a two year that swallowed a35day supply of this stuff said it was safe as the child had minortransient mylosuppression. (Ped Blood Cancer 59(1)170) TAKEHOME MESSAGE: Hydroxyurea is probably a benign overdose"Thanks to the cathouse , I am in the doghouse with you" Thisgun ain't loaded, but I am"

23) So there is this explorer in Africa and he hear hearsdrumming. The native accompanying him says "whendrumming stops very bad" Suddenly the drumming stops.

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The explorer turns to the native aghast and says-"what next"The native calmly says "bass solo next" So let me beat a drumI have been beating for ever. The six hour rule for closingwounds is based on lousy if any evidence (Injury 43(11)1793)So if there is no evidence let me say what I think. I think itdepends on the blood supply to the region (faces do well evenafter 24 hours) how dirty the wound is (although gooddebridement can accomplish a lot in any case) and theprotoplasm of the patient- I do not think anyone would disputethat 36 hours may be OK for a healthy child whereas even 3hours may be too long for an elderly diabetic. By the way, theabove article and this article were both done at SUNYDownstate, so let me give a shout out to Dr. Silverman whoworks there and is a long time EMU subscriber TAKE HOMEMESSAGE: Wound age is important but six hours is probablynot. "Velcro arms, Teflon Heart" "When my love comes backfrom the ladies room will I be too old to care?"

24) We have said this before but this is from the homecountry so hooray for the red white and blue. Or at least thewhite and the blue. This Israeli study showed that honey does

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have an effect on nocturnal cough in children. (Peds130(3)445). The problem here is that placebo did very welltoo- and in this case it was Silan date extract. However, sincedates also make honey, we can say this is the placebo effector we can say it was from the dates. Now Dr. Shapiro has toldme in the past that it depends on what honey you use, andhere they used eucalyptus, citrus or labiatae honey. Here is acongrats to the writers of the paper- Prof Kozer whom I knowand is an EMU reader, and Hannah Efrat. TAKE HOMEMESSAGE: Honey is effective for coughs. But so is placebo. Ifyou use the right placebo?? "You done changed your namefrom Brown to Jones and my name from Brown to blue"

25)This makes sense. Obese folks needed higher doses ofmedicines because you need to reach a larger distribution intheir bodies. There are guidelines for this and we are notfollowing them (AJEM 30:2012). The concept is sound, but thepaper is not terribly useful. These guidelines are for those whohave a BMI greater than 40 which may be on the rise but isstill not that common where I practice. Furthermore it wasonly for IV drugs and only studied Cipro (which I can't

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remember the last time I gave IV), cefazolin and cefepime.)The guidelines are also based on creatinine clearance whichfew of us compute. But say the creatinine clearance isnormal: you would give 2 grams of cefazolin IV every eighthours, Cipro 750 po twice a day and 800 IV twice a day, andCefepime 2 grams every eight in serious infections and every12 in less so. TAKE HOME MEEASGE: Give those obesepatients higher antibiotic dosages. Remains to be seen aboutother medications. Here is a picture of Nick Cole. Until he wasreleased two years by the Philadelphia eagles, he had thebiggest BMI in the NFL- a 58.

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Heck he isn't have as

scary as most mothers in law "I

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changed her oil, she changed my life"26) I thought this article had a lot of potential- but while weare on the subject of sports lot of potential usually means itdidn't go anywhere. This article explored dignitary medicine-that is; you are part of the medical team accompanyingofficials abroad. Most of this is common sense- knowing localmedical capabilities, packing a good medical kit, recognizinglocal terrain and evacuation possibilities , medicines availableand not available in the country, food and water in rural areaswithout reliable supplies of either and a good knowledge basein EM (that part I liked). (AJEM 30:1274) There are sites forthis including one for international SOS, but indeed we havediscussed a similar issue 4 years ago- how to organize yourhospital for a VIP admission. We are now featured on threesites-life in the fast lane, MD Anderson and EM Central- theymay have search function to find this TAKE HOME MESSAGE:Dignitary medicine requires careful planning and a lot ofpotential. "I knew she really missed me when the ashtray flew

past my head"27)Time for letters: Hi Yosef

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Hope all is relatively quiet there at the moment.

I suspect that the U.S. and Canadian medical students might be very interested in knowing

that I just posted 8 new YouTube videos about the specialty selection process and

residency/fellowship application process (including two on International Medical

Graduates). Two are about D.O.s. These stem from the new (8th) edition of my book,

"Getting Into a Residency: A Guide for Medical Students," that will be available in early

May. Pass on this information; I'm sure they will be pleased.

Best wishes, Yosef:Ken

Well, that's from Ken Iserson. Ken, thanks for writing- and the information has

been passed onThanks again for the excellent EMU.

I wanted to make a comment about the pediatric article on abscesses (Randomized trial comparing

wound packing to no wound packing following incision and drainage of superficial skin abscesses

in the pediatric emergency department) by Kessler. While I personally am unsure about the utility

of packing, and have begun to do more loop drainage procedures, I don't think this study should be

trusted to be good enough evidence to conclude that packing doesn't decrease morbidity. The

following weaknesses in the study make any conclusions unclear: Study was stopped early because they couldnt enroll enough patients.

Only in age 1-25 (mostly teenagers)

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We dont know how many patients were not enrolled because the physician wanted to pack the abscess

(selection bias)

Their failure rates are exceptionally high (70% and 59%)

No information on why some patients got antibiotics and which antibiotics.

18% of the patients (5/27) in the packing group werent included in the data analysis because of incomplete

data or followup

Criteria for all their outcomes were left up to the blinded physicians assessment but werent defined in the

paper.

Large confidence intervals could be missing a large effect size of treatment.

In summary, while there are some small studies that suggest that packing is painful and useless, I

don't think this study should be used to support a specific approach.

Just my opinion - most abscesses just need to be adequately drained to heal (but this study isnt'proof.)

Thanks.

Jeff Freeman MD

Jeff, that was excellent. I think that you may want to consider joining the EMU

staff (currently consists of one guy, but we can find room for you). Truth be

told, most abscesses will probably get better no matter what you do, and I

always believe that doing less is better. But you are entirely correct, the

evidence is lacking at least in this study. Unfortunately, the Kessler that wrote

this article is not the one that is an EMU subscriber, but our Dr. Kessler is a

prolific writer and one of articles that came out recently on TTP was excellent(JEM 43(3)538). We have spoken about TTP in the past but I will try to include

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it next month. Thanks for writing Jeff. And also a big thanks to DoronDusanitzky for passing on more info on the convoluted mess of fever in kids. I

beelver we are getting closer but

And lastly, we would like to welcome a new site which will carryEMU. Presently, we are featured in Life in the Fast Lane and EMCentral- now MD Anderson has picked us up as well. This is a realhonor and I am pleased. Here are a few word s from them andplease go up and visit their site. (I am sorry Knox, the picture did not copy and

paste)

In 2010, MD Anderson created the first academic department of emergency medicine in a

comprehensive cancer center. Knox H. Todd, MD, MPH, founding chair of the department, leads a

dedicated group of physicians and researchers in promoting the development of oncologic

emergency medicine as a distinct discipline. More than 22,000 patients annually receive care in

MD Andersons 44-bed Emergency Center for a variety of acute oncologic emergencies.

Department faculty have a broad range of research interests, including oncologic emergencies,

pain treatment, health disparities, palliative care, and the role of obesity and diabetes in cancer.

The Department of Emergency Medicine has established a new fellowship in Oncologic

Emergency Medicine and we encourage international applicants. We are actively recruiting new

clinical and research faculty, including a director for our ultrasound program. Links to these

opportunities appear on our website: http://www.mdanderson.org/emergency-medicine . We are

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proud supporters of Yosef Leibmans Emergency Medicine Update. Current and past editions of

EMU appear on the EMPainline website: http://empainline.org/emu .

Congratulations, Yosef!Knox H. Todd, MD, MPH

Professor and Chair

Department of Emergency Medicine

MD Anderson Cancer Center

1400 Pressler St. FCT 13.5077

Houston, Texas 77030-3722

Office: 713 745 9911

28) Answer to number 2- The Mad adventures of RabbiJacob- which was and still is a pretty funny movie. Andnumber 7 is of course tertiary syphilis- may have helped tomention saddle nose but that would have given it away. Doget yourself checked out for this before you read anotherEMU. And number 10 was easy it was an article in JACC so ithad to do with cardiology- it was infective endocarditis- StaphAureaus to be exact. The lesions is of course a Janeway lesionbut these are rare

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(About 5%(NEJM368:1425) And thefriends of Father in 14 were Dean Martin- a comedian whoteamed up with Jerry Lewis in the sixties, Boris Yeltsin who wasthe Premier of Russia and Billy Carter who actually was a beerimbiber who was President Jimmy Carter's brother and was

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famous for embarrassing him with his red neck ways. Heeventually fell from grace after taking money from our old palMoamar Ghaddafi RIP.

EMU LOOKS AT: Tunnel VisionsA few months back we looked at some neuro cases, this month we are goingto look at some eye cases. They are pretty basic but then again we do notsee many eye cases and may not feel comfortable with them. The sourcefor that essay isJFP 61(8)474.The first essay though will go into the Carpal

Tunnel and look at CTS The source for that essay is BJHM 73(4)199.Carpal Tunnel Syndrome

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1) If you are not familiar with the anatomy, here it is.

This is a problem of entrapment ofthe median nerve.

2) I know that this conjures up thoughts of fibromyalgia, RSD,TMJ, Mitral Valve prolapse and all sorts of nebulous diseasesthat the modern day personality disorder patient has at 3 AM.However there is some rhyme and reason to this condition. Theepidemiology ofCarpal Tunnel Syndrome is that it is mostcommon in females who have a smaller carpal tunnel and

occurs mostly in patients between the ages of 45 and 65. Thisentrapment is caused by tendon thickening, synovitis, fluids, or lesions

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in that area which is more common as people get older. CTS seemsto run in families. If you are pregnant, obese, or haverheumatoid arthritis you have more of a risk for CTS. M andalcoholism will also give these symptoms but here there is anerve damage problem so the usual decompression thingswon't work. Power tool use and wrist fractures can also becauses.

3) Usually one sees parasthesia in the median nerve distribution.But there is pain as well. Pain is worse at night and whengripping objects for a long time. Pain improves when theyshake their hands. Pain can radiate to the forearm andthumbs can get weak-leading to dropping objects.

4) So how do you diagnose this? Tinel's test and Phalen's test werethe classic ways of diagnosis- the former is tapping on thearea of the median nerve at the wrist and reproducing theparasthesia and the latter is flexing the wrist resulting in thesame but these tests are pretty poor both the sensitivity andthe specificity. EMG is probably the best test but it hurts; souse it only for cases that aren't clear. US and MRI should not

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be used routinely. They are best when there is suspicion of a spaceoccupying lesion.5) There are some other conditions that can look like this. Cervical

radiculopathy, deQuervains, and Thumb OA round out theDDx of common mimickers. Cubital tunnel syndrome can also look

like this. Of course, here in the cubital tunnel -

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the parasthesias will be different althoughthere will be pain and parastesias in the hand.

6) Treatment: Steroid injections (easy to do- a little proximal tothe wrist crease) are unlikely to do damage and theseinjections and cock up splints are effective. Physiotherapy canhelp to, but all of these work for only about two months.Surgery is the ultimate treatment and can be done underlocal, in the office and takes a few minutes. Oral steroids and

oral NSAIDs do not work. There is now a mini release surgery whichhas a smaller incision. Endoscopic techniques also exist. Sensitivity in

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the area can be present for a few months after ward but usuallyresolves. Recurrences are rare.Treatment of the following tunnel

problem is more difficult.Eye Cases- PainHere are the five cases- pretty basic but let's see how you do.A). 74 year old with left eye pain that stared when he turned off the light totake a nap. He has a headache, blurred vision, pain and nausea. Thereis corneal haziness and the eye is dilated and reacts poorly to light.

B) A 20 year old guy wearing contacts during a game of volleyball. Hesustained no trauma. He feels all of the sudden stinging in his right eye

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like having sand under the eyelid. Sunlight makes the pain worse.Flushing with water did not help. There is a gray spot on the cornea.What next?C) A 17 year old girl is brought in because of eye pain and vision loss inher right eye- she saw spots of light then she lost her vision. There isedema of disc margins on fundoscopic exam.D) This is a 31 year old lady with sarcoidosis- with a red eye and pain.OK, the sarcoid kind of makes it easy- but still what is this? There is noeye discharge.E) 21 year old co-ed with pain in the left eye. She of course wears contactlens. She feels like there is something in her eye and on exam you dosee an opacity.1) This is glaucoma and was precipitated by the eye trying to dilate thisacute angle closure glaucoma and not open angle which is more chronicIf you have a slit lamp- fine- you will see a shallow anterior chamber andincreased ocular pressure. Give acetazolamide, mannitol, isosorbide andget him to the optho guy fast. Key here is in a patient who is elderly anvomiting- do ask about his vision so you do not miss this. If you havethem, timolol or and pilocarpine drops will help

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2) This is a corneal abrasion or ulcer caused by the movement of thecontact lens during the game. Contact lens can cause all sorts ofinfections, especially Staph and Pseudomonas. The exam is straightforward- you have all done it. They do not like aminoglycosides as theyare toxic to the cornea (I confess I knew that for the ear, but not for theeye), but then recommend tobramycin if it is a contact lens problembecause of the danger of it being Pseudomonas. Pain control: they stilluse cyclopentolate (and we have presented studies that this doesn't help),but I like Volatren drops- they do not dissolve the cornea. They saychronic use of local anesthetics is dangerous- recent evidence calls thatinto question. Patching is not done. I think that we all agree on that- itmakes a nice warm milieu for bacteria to grow happily.3) Get this lady an MRI she has optic neuritis. Kids more likely have nopain and have blurred vision in both eyes with this; adults have pain andonly one eye affected. If you are good at fundoscopy you will see apapillitis and swelling of the optic disc, but this is only seen in one third ofthe patients. Light reflex will be sluggish. They will need IV steroids and itwill take a few weeks to get vision back.4)Uvietis is the obvious answer- but which one- anterior or posterior? We

know uvieitis can be seen in all sorts of rheum disorders like Sjogrenssyndrome, Kawasaki, JIA (formerly known as JIA) and TB, herpes and

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HIV. Visual exam reveals redness around the iris- not so muchperipherally like in conjunctivitis. Anterior uvietis has pain andphotophobia. Posterior has less pain but there can be floaters. Both havesome visual loss. Here you wan to manage the disease that caused itand give steroid drops.5) You may jump right onto the contact lens and say this is a bacterialkeratitis. And indeed it is important to remember that conjunctivitis has nopain or vision changes and this does even though both have mucopurlentdischarges. Now if I said the opacity had a branching pattern, now it iseasier- Herpes keratitis. This is treated with antiviral eye drops oracyclovir by mouth. Bacterial keratitis usually does well with antibiotic eyedrops, but if there are contact lens consider coverage for our old palpseudomonas (I always wondered if this is a "pseudo"monas- whatdoes the real monas look like?) with cipro drops or tobra drops- six toeight times a day.

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