Air Everywhere
​"Wow! That is massive," I said. "What happened?"The patient had a long-term trach. I had sent her to the ICU earlier after she arrested and ROSC was obtained. Her post-code radiograph revealed a right-sided pneumothorax. A chest tube was placed. A little while later, there was air everywhere. Could there have been a tracheal injury or lung injury during CPR or a problem with the chest tube placement? I didn't know, but I did know it was getting much harder to ventilate her and her skin soft tissues were becoming tense. Respiratory embarrassment and circulatory collapse were real possibilities. C...
Source: Lions and Tigers and Bears - August 3, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Perpetual Red Flag
​As I looked over my patient's elbow images, he asked, "Is it terrible?"I sighed. "It just might be terrible."My eyes had immediately centered on the little avulsed piece of bone, then to the posterior fat pad. The pathologic posterior fat pad confirmed this as an intra-articular fracture. My focus shifted to the radial head, but I was unable to identify a radial head fracture. Still, I pondered the possibility that the assault had caused the terrible triad of elbow injuries.Isolated coronoid process fractures are rare and come in three types:Type 1: Fracture of the tip.Type 2: Fracture of about 50 pe...
Source: Lions and Tigers and Bears - July 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Tracing an Ankle Injury by Type
​"He's not sure how he did this," my colleague said. "He said he accidentally stepped on a toy in the living room, twisted his ankle, and fell to the ground. What would you call this?"I love emergency orthopedic radiography, and there was more than one answer. I would give three, but one was better than the rest:Weber C distal fibular fractureTrimalleolar fracture equivalentAn exorotation fracture, likely supinationThe Weber classification describes distal fibular fractures based only on whether the fracture is above, below, or at the syndesmosis. Weber Type A fractures are below the level of the tibi...
Source: Lions and Tigers and Bears - June 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pain from an Unknown Cause
​"My left hip has been hurting for a couple years, but it just got really bad in the past few weeks."My patient, who was in her 70s, didn't add much more to the history. No trauma. No fevers. No bowel or bladder problems. No significant past medical history. Her hip just hurt. She thought she needed an x-ray, and one was obtained.The left femoral head didn't look terrible. There was some irregularity, but there were no fractures or significant joint narrowing. This wasn't a case of neglected severe degenerative joint disease or avascular necrosis that needed a hip replacement.Some red flags started to show up t...
Source: Lions and Tigers and Bears - May 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Watch This Space
​I am relatively new to working with our advanced practice practitioners, so I often check x-rays if I have a moment.An x-ray of a wrist has a great chance of being reviewed because this is my favorite joint. I love the challenge of catching things when I don't know the case. I was definitely rewarded by this case.The thing that caught my eye was the space between the scaphoid and the lunate. It was huge, especially when looking at the sclerotic changes in the other bones of this wrist. Most of the joint spaces seem narrowed but not the scapholunate. Whether you go with the British version (Terry Thomas) or the American ...
Source: Lions and Tigers and Bears - April 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Not Alone
​"Hey, what do you think of this? It isn't dislocated, but this guy was in a fight, and has a lot of shoulder pain," a colleague said to me.It seems that the humerus gets virtually all the attention in shoulder x-rays, particularly in the Y view. Many are done with the image after determining the head truly sits in the middle of the Y between the coracoid and the acromion. There is more to shoulder films than just the humeral head's location, however. Take another look at the coracoid and the acromion.Scapular fractures account for just one percent of fractures. The vast majority of these are of the body and th...
Source: Lions and Tigers and Bears - March 2, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Air with Nowhere to Go
​I have been writing this blog for nearly six years, and my curiosity and pleasure in reviewing interesting, unusual radiographs are widely known among my colleagues. On a recent shift, a friend brightened on seeing me and exclaimed, "I want you to take a look at this!" She immediately opened PACS to this image."What's the story?""An elderly lady had a mechanical fall at home, coming down on her right shoulder.""What do you think?" I asked, glancing at my med student."The joint looks too close. There is a lot of DJD. I can't tell if there is a fracture.""Yes, but loo...
Source: Lions and Tigers and Bears - January 31, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Classic Fist Fight Injury
​A right-handed man presented with swelling and tenderness at the base of his thumb after an altercation. His range of motion at the metacarpal-carpal joint was limited because of pain. Not unexpectedly, his first metacarpal was broken. What can you tell this patient about his injury?You can say:This fracture has a name: Bennett's fracture.It is the most common fracture of the base of the thumb.His fracture is classic in mechanism; fist fights commonly produce this injury (by having an axial load against a partially flexed first metacarpal).His radiographs are classic in appearance—a two-piece intraarticular fractu...
Source: Lions and Tigers and Bears - January 2, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Screwed (Literally)
​I looked over the list of patients waiting to be seen as I started my evening shift. I was the coverage doctor for the advanced practice practitioners, so I also checked the fast track charts when I saw "screw in finger."Having some ideas, I quickly went to find a man who had been doing some home repairs when his battery-operated screwdriver skipped, causing him to drive the screw into his left index finger.The patient had tried to unscrew it himself, but it was too painful. After convincing him a digital block would provide pain relief, other options were considered:Backing the screw out with a battery-powere...
Source: Lions and Tigers and Bears - December 2, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Three of Four
I went immediately to the coronal slices when I opened the CT images. I was looking for something specific. This image made me smile. (See below.)It confirmed my clinical suspicion. "Three of four isn't bad," I said to the resident who looked at me blankly and asked, "Three of four what?""Three of four radiographic signs of orbital blowout fractures," I said.Then I felt really old. That was a thing when we used plain films to make the diagnosis and read them ourselves. The regular quiz at the weekly conferences had drilled it into me. I had to know this or suffer the embarrassing consequences....
Source: Lions and Tigers and Bears - November 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Ping Pong Balls in the Lungs
​"She's worried I had a heart attack."That was the answer I got from the 70ish-year-old patient pointing at his wife when I asked why he came to the emergency department. She quickly added, "He had terrible pain four days ago on the right side, and now he gets winded when he walks."I had already seen his ECG, so I assured her that it appeared normal. I was going to order a chest x-ray, however, because his lungs sounds were pretty quiet. She said he had COPD, and wanted to know if he needed an inhaler.The last time I had seen something like this was in medical school 30 years ago. At that time, I was ...
Source: Lions and Tigers and Bears - October 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Lunate That Died
​Everyone who works with me knows that I love joint radiographs, and the wrist is my favorite. It was no surprise when I came on shift that someone exclaimed, "I have an x-ray for you. I bet you will know exactly what it is! This 30-ish-year-old lady came in with atraumatic wrist pain."I did know exactly what it was. My eyes were drawn to the lucent lunate target. The patient was still in the ED, so I went to examine her hand. She had increased pain when I walked my fingers proximally down the metacarpal, which dipped into the carpal space. She was also not a fan of volar flexion or dorsiflexion. It made sense....
Source: Lions and Tigers and Bears - September 3, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Classic Pediatric Fracture
​"I have an 8-year-old who fell on the playground and now has elbow pain. Can you look at the x-ray?""Of course! Is it a supracondylar fracture?"Interrupting the pregnant pause, I cautioned, "You know, at the elbow, adults tend to break the radial head. Kids, on the other hand, usually break the supracondylar. A boy under 10 with a fall and hyperextended with an outstretched arm is likely supracondylar. The olecranon comes through the weakest link—the narrow part of the elbow's figure eight."When the lateral popped up on the screen, it was classic, showing the four signs of a supracond...
Source: Lions and Tigers and Bears - August 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Weak Links
​"Can you look at a knee film?""Sure, what is the issue?" I was the coverage doc for Fast Track."It's a 15-year-old who hobbled in here with knee pain. Just before coming in, he was in football practice where he forcefully hyperextended his knee and heard a pop. Since then, he hasn't been able to bear full weight on the leg. He pointed to the fibular head area as the point of maximal pain. What do you think of the fibular head, and is that oval in the femur anything?""The femur oval is likely a benign bone cyst. The fibular head is probably OK, but it is a kid with growth plates. It is ...
Source: Lions and Tigers and Bears - July 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

One for the Win Column
​"The lab called with a critical value on the woman in bed 12. Her hemoglobin is 4.8," the nurse said.That didn't make any sense. The patient didn't look anemic or pale. She didn't seem to have symptomatic anemia. Maybe she had heavy periods."Do you want a type and cross?" the nurse asked."No, I can't believe that is right. Can you draw a new CBC? I'm going back to see her again," I replied.Thirty minutes later, the EMR showed the labs were back. There was no exclamation mark indicating something was amiss, and here's what I saw when I clicked the box. "The hemoglobin's normal&mdas...
Source: Lions and Tigers and Bears - June 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

How Low Did He Go?
​At sign-out, I thrust this VBG at my oncoming colleague.Me: What do you think of this?Colleague: 6.76. That is pretty low. DKA?Me: Nope, the sugar was 107.Colleague: Post code?Me: Not that either.Colleague: Did you intubate him?Me: No, I was scared that would kill him with a worsening acidosis if we don't get his respiratory rate fast enough.Colleague: Did he go to the ICU?Me: He went to tele.Colleague: What made him better?Me: Fluids and midazolam. A lot of midazolam—5 mg IM followed by 15 mg IV. He was brought in crazy agitated after a first-time seizure. I thought he had a toxic delirium or an intense post...
Source: Lions and Tigers and Bears - May 2, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Back on Track
​The 14-year-old girl said she was running when she suddenly developed knee pain. Shortly after, she had trouble walking. She said she had not fallen before the pain, and no one was around her when it happened.Her knee was modestly swollen and diffusely tender anteriorly, and she could not lift it off the bed because of the pain.I assumed I would see a high-riding patella from a patellar tendon rupture or a transverse patellar fracture. After 30 years in emergency medicine, I wasn't expecting to see something I had never seen before—a cortical disruption at the posterior aspect of the inferior pole of the kneecap. ...
Source: Lions and Tigers and Bears - April 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

That Gissane is Insane!
​The distracting arrow could not draw me away from the critical angle of Gissane. Most people think of the Böhler angle when considering calcaneal fractures but not me. The V created by the anterior and posterior facets is what draws my eyes . The comforting V can usually be spotted in nanoseconds. There was only discomfort on this view (and certainly for the patient): The Gissane is missing!You have to know normal to know abnormal, so here is a comparison.My patient had destroyed her calcaneus. It was obvious. The anterior and posterior facets were not even connected. There was no more Gissane angle!Tip to Remember...
Source: Lions and Tigers and Bears - March 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Lesson from Three Parents of Children with Cancer
​I grabbed my cell phone to shut off the alarm even before I opened my eyes. As usual on a Sunday morning, I checked the news before my feet left the warmth of the covers so I wouldn't miss a disaster, a tragedy, a loss to remember in the prayers of the day. That day, the first Sunday of Advent, the news of President George H. W. Bush's death led the news. Tears came to my eyes as I read Marshall Ramsey's tribute to the 41st president in The Washington Post. (Dec. 1, 2018; https://wapo.st/2CqDJ8Q.) The cartoonist's tribute showed a TBM Avenger parked in the clouds with Barbara and Robin Bush waiting for his arrival.I had...
Source: Lions and Tigers and Bears - February 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

When Time Stands Still
​It was 6:30 a.m. It should have been easy to dispo the patient with elbow pain by the end of my shift at 7. He had continued pain and swelling, seemingly mostly in the olecranon area. The resident had already put in the x-ray order. A few minutes later, time stopped when I pulled up his lateral. Two decades as a nocturnist without radiology backup for reading plain films has led to my mantras: You have to have a framework to read your x-rays, and my colleagues have to mop up my errors if I don't get this right. It takes time from their patient care, and it makes me look bad.I have an unwavering stepwise approach wi...
Source: Lions and Tigers and Bears - December 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Name This Injury with One Clue
​TV game shows were all the rage in the '70s. I particularly liked one that had contestants bid against each other on the lowest number of notes they needed to guess a song after the host gave them a clue. Once in a while, one of the players would say, "I can name that tune in one note." Often, they did! I thought they must have known the answer before the piano player struck that one key.I like to play a similar game with radiographs. Can you name the abnormality in one radiograph with just one clue? Here is the clue: This 9-year-old girl complained of wrist pain after falling on her outstretched right arm.Thi...
Source: Lions and Tigers and Bears - December 3, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Rare Fracture
​Colleague: Do think that is broken?Me: Yep.Colleague: Have you ever seen that before?Me: No. Still it is broken. How did he do that?I've been writing this blog long enough that most people I work with know I love the unusual, unexpected, and even classic radiographs. Most also know that I think emergency medicine is the best of all specialties. There is always a chance of something new, something I have never seen before. We are always learning. Thus, I was drawn in by these radiographs of a patient complaining of pain at the base of his thumb after a motor vehicle crash.Typically, the hand has re are five sesamoid bone...
Source: Lions and Tigers and Bears - November 1, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Textbook Case
​We went together, the med student and I, to check the eye complaint of a man who had been assaulted a few hours before. The student quickly decided we needed a facial CT to rule out a fracture. I asked him what kind of fracture he suspected; an orbital blowout fracture, he said.I asked the patient to look toward his nose, and a prominent lateral subconjunctival hemorrhage popped prominently into view. This is truly a red flag for a more complex midface fracture. Finding zygomatic arch tenderness, I wondered aloud if our patient had a zygomaticomaxillary complex fracture.There seems to be little need to have a framework ...
Source: Lions and Tigers and Bears - September 30, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A False Appearance of Fine
​Like a million times before, the tech thrust an ECG in front of you. This one, however, grabbed every neuron's attention. Who was this?​The tech says the patient is a 70ish-year-old diabetic, hypertensive man brought to the emergency department because he has been feeling weak from a couple days of diarrhea.Where was he? Was he talking? What was his blood pressure?The tech pointed at one of the back rooms, and said, "Oh, his blood pressure is good—138/71, and he is talking to his family."He did look pretty good. His heart rate was 37 bpm as he chatted with his family. Staring back at the ECG, I think m...
Source: Lions and Tigers and Bears - August 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

See Me Now
​A young woman with known psychiatric illness and a tendency toward self-injury was sent to the emergency department for medical clearance. She had presented in the past after ingesting objects, so an upright chest and KUB radiograph were obtained.​Nothing unusual popped out at first glance, but it was an entirely different story when magnified in a dark room. The sharp square edge extending beyond the vertebral body was impossible to miss. The four holes confirmed she had almost certainly swallowed a razor blade. Inversion made it even easier to see.​Identifying the object is only half the battle. What is the next s...
Source: Lions and Tigers and Bears - August 1, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Look for the Signs
​An AP image of a shoulder flashed up on the screen. My colleagues often bring me interesting, rare, difficult, and classic cases because I write this blog. All are intellectually stimulating cases that remind me of the exciting parts of being an EP. It's a challenge to see how many clues I can find to make the diagnosis. These short interactions also help me form stronger bonds with my colleagues, a bonus for my interest in wellness.​First, my eyes were drawn to the wide glenohumeral interval. The space is huge (yellow lines in photo below). The glenoid appeared vacant. It also showed the rim sign where the glenoid ri...
Source: Lions and Tigers and Bears - July 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Inspiratory Stridor and Diaphoresis Spell Emergency
​My relief had arrived, and we were just starting sign-outs. The resident broke in, "This guy with the sore throat. I think he's sick!" Glancing up from the computer, she continued. "He's barely talking. He has inspiratory stridor. And he is sweaty."​The resident had me at inspiratory stridor. Diaphoresis on a chilly morning in our ED was just icing on the cake. Intrigued and concerned (we did not have ENT or an open OR at that time in our shop), I followed my oncoming colleague to the bedside. The experience was just as sphincter-tightening as the description. The 20ish-year-old man sitting bolt up...
Source: Lions and Tigers and Bears - June 1, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Fractured? No, Crushed
​"Doc, I broke my foot about three months ago and was in a boot. Tonight I was in a fight. When I went to kick, I twisted my foot. I can walk, but wanted to come in to get it checked out."​Simple. Straight-forward. X-ray ordered.My eyes were rapidly drawn to the two gaping fracture lines—one posteriorly in the calcaneal tuberosity and the other extending from the posterior facet through the subtalar joint to the plantar surface. Böhler's angle confirmed what can be seen intuitively: This calcaneus was crushed.​Böhler's angle is formed from two intersecting lines coming together at the apex o...
Source: Lions and Tigers and Bears - April 30, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Golfers Never Bitch (or the Rodney Dangerfield of Bones)
​The scapula is truly the Rodney Dangerfield of bones: It gets no respect. Every chest x-ray we see gives us two chances to embed in our minds what normal looks like. Few avail themselves of this opportunity. In fact, most do not have any systematic process to look at this bone at all. That will change today!​A 59-year-old man fell down some steps, landing on his left shoulder and upper back. He presented with pain in that area and difficulty lifting his left arm.The wrist has a well-known mnemonic—Some Lovers Try Positions That They Can't Handle—to remember the order of the carpal bones. I'm proposing a br...
Source: Lions and Tigers and Bears - April 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

It’s in the Urine
​"I just put a young woman in her mid-30s back in room 9," the triage nurse said. I made a mental note that that was the GYN room. The nurse continued, "She feels bad, fatigued, and just not right in her stomach." The obvious question flew from my mouth. "Is she pregnant?"​"I have the urine, but the quality controls are being run now, so it will be a few minutes."I glanced at the EMR before heading back to the room: normal vitals, no fever, no medications, a couple of kids, no surgeries, last period three weeks before. Not much there to go on, but I could see her while waiting fo...
Source: Lions and Tigers and Bears - February 28, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

DOTT Your ETs, and Cross Out Your DOPES
​The high-pressure alarm continued to ring. Endotracheal tube (ET) in place? Check. ET tube suctioned without problems? Check. Tubing not kinked and ventilator OK? Check. Chest x-ray? Ordered.​This is probably not something you ever want to see: a complete pneumothorax in a patient with an endotracheal tube. Breath entering the lungs under pressure has a high likelihood of making the collapse worse, eventually progressing to a tension pneumothorax. When the vent is screeching that high-pressure alarm, think DOPES and DOTTS.DOPES stands for the causes:D          Dislodged ET tubeO...
Source: Lions and Tigers and Bears - January 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Link Between DOACs and Cancer
​A middle-aged woman was started on a direct oral anticoagulant (DOAC) for an upper-extremity deep venous thrombosis two weeks before presenting to the emergency department. She reported that she had coughed up some blood. She had never had blood clots before and had no other testing.​The whole thing was strange and concerning.Only about 10 percent of DVTs are in the upper extremity. (Circulation 2012;126[6]:768.) One can divide them into primary (or provoked), secondary, or idiopathic. Primary ones are usually related to effort, particularly those who are performing repetitive overhead movement or have thoracic outlet...
Source: Lions and Tigers and Bears - January 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

No Fracture, No Problem?
​"It's been hurting for months, but now I'm really having pain and difficulty walking too."​The resident relayed those words said by a 60ish-year-old woman in our emergency department. Now the resident was waffling over whether to get an x-ray. On one hand, ordering radiographs will increase her length of stay, and will certainly not show a fracture. On the other hand, the patient's satisfaction might improve by taking some pictures. The resident decided to do the x-ray; adding it probably won't help much anyway.​The AP film seemed to confirm his fear of wasted time and resources.When the lateral popped up ...
Source: Lions and Tigers and Bears - December 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Two Views are Better than One
A middle-aged man was found on the highway. A concerned passerby called 911, and then EMS made him a patient of mine. Approaching the stretcher, the aroma of alcohol permeated the air. Such is my life as an inner-city nocturnist.This patient was a little different, though. He said he had been short of breath before passing out. Peeking out from the bottom of the sheet was an ankle boot. The patient provided little assistance with his history. His exam was otherwise completely normal.Just that week at the mortality and morbidity conference, a case bearing similarities struck terror in our hearts. A middle-aged man with a le...
Source: Lions and Tigers and Bears - November 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Case of Missing Teeth
​An older man presented to the emergency department for respiratory complaints, and a routine series of studies—blood work, ECG, and a chest x-ray—almost automatically appeared in the orders.​Haziness on the left side—left hilar fullness probably isn't good. A CT scan would likely confirm the fears of cancer.​The large mass wasn't unexpected, but did you see the metallic foreign body in the stomach? There was something on the left side under the diaphragm on the upright chest radiograph. The same thing appeared on the coronal CT image. Did he swallow something?Upon detailed questioning, the patient ...
Source: Lions and Tigers and Bears - October 2, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Don’t Forget that You Can Help
​Working in emergency medicine, I sometimes look through the retrospectoscope and think, "Next time I'm going to do that differently." There are cases where it's excruciatingly painful to look back and imagine what could have been. Others come with a sigh of relief knowing that I dodged a bullet but may not be so lucky in the future. This case was one of them.​It was the middle of the night. Walking into the room, the patient looked pretty good. It was a pleasant surprise, given the trepidation that came over me during the mid-shift sign-out, leaving me the only attending for the rest of the night.​The hand...
Source: Lions and Tigers and Bears - September 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Exactly What the Patient Said
​"I have tonsillitis," claimed the 20-something young woman who showed up at 2:30 a.m. because the pain was keeping her awake. She pointed dead midline between her chin and hyoid bone when asked the location of the pain. The back of her throat looks normal: uvula midline, no exudates, no vesicles, normal voice, and handling secretions. But the midline.... Should I be worried? The epiglottis sits right there. Before the Hib vaccine, it used to be almost all kids, but these days adults get epiglottitis. What to do? Soft tissue lateral neck? CT? Discharge?​I went with a soft tissue lateral neck, which was not at...
Source: Lions and Tigers and Bears - August 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Hidden Hip Fractures
​An elderly woman arrived via ambulance at the emergency department after being knocked to the ground. Right hip pain prevented her from getting up. She had bilateral hip replacements, and was concerned that the right one could have come out of place. The area she indicated didn't seem dislocated. There was range or motion of the hip, and the leg was not shortened. Certainly, x-rays would confirm this.​The prostheses were intact. She had neither a hip fracture nor a dislocation. The patient still complained of pain, and was unable to ambulate. On closer inspection, the right superior pubic rami's inferior aspect had a ...
Source: Lions and Tigers and Bears - July 3, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Fractures are Not the Only Bone Injury
​A ballplayer had jumped and stretched for the ball but missed. Descending toward the ground, he put out his right hand to protect his face from hitting the pavement. The pain in the hypothenar eminence and lateral wrist was immediate, but he thought he could shake it off. A few hours later, though, he came in with pain in the lateral wrist, difficulty with full supination, inability to bear weight on the ulnar-deviated wrist when placing his hand on the bed and trying to push himself up, and a superficial abrasion on the hypothenar eminence.​Hypothenar eminence sports injuries are well known to be the cause of pisifor...
Source: Lions and Tigers and Bears - June 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Matter of Perspective
​I have a passion for interesting x-rays. All of my colleagues know that by now. I'll have just arrived in the ED for my night shift and still be shoving my backpack under the counter when I'll hear a not-so-uncommon comment, "We had a great case today." These stories always energize me. The sharing, the learning, the awesome pickup, the right fight for the patient all remind me of why we do this job.The signing out doc (knowing my absolute favorite thing is a wrist radiograph) recently popped open some radiographs on the computer, announcing, "You are going to love this."I scanned the AP and oblique ...
Source: Lions and Tigers and Bears - May 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Mind the Gap and Smile
​A man came to the ED in the middle of the night saying he was jumped and struck on the knee with some object. He complained of severe pain, difficulty ambulating, and swelling. When the tech tried to get the standard series of four knee views, the patient said he couldn't do more than one, at least not without more pain meds. The tech, arms crossed, asked me what I wanted to do. "Do you want to give him more meds, and I'll try again?" he asked.​Popping the sole image up on the screen, I said, "I'll give him more pain meds because he almost certainly has a tibial plateau fracture. I'm going to send him f...
Source: Lions and Tigers and Bears - March 31, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs