September 2021: Agonizing Belly Pain
“I need something for this pain. I think I need surgery."He looked like he was in agony. This 20-something patient looked like a kid, and he didn't seem like he would be crying unless it was excruciating.But his belly seemed pretty benign. I wouldn't have been surprised if he had had rebound because he motioned to his xiphoid. The picture could have fit a perforation. An ulcer could have done this to him. He didn't drink alcohol, so that put pancreatitis lower on the list.Kidney stones can make men look like they are giving birth, but no blood was in the urine, and he had only mid-abdominal pain. It did seem like...
Source: Lions and Tigers and Bears - September 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
August 2021: What You Get is More than You See
“I want you to look at this guy's finger," a resident said. “What do you think?"Looking at the tiny bubble of blood in the teeny puncture wound, my response was, "Depends. What happened?"There must be way more to this story for this guy to be here. Was he brought in against his will by the police or an insistent wife? Was something lodged in there? A mishap with a BB gun? Perhaps a work injury, and he needs paperwork to be able to get his paycheck?No matter which, this small puncture wound hardly seemed big enough to garner such attention. There was only one thing that looked like this and could ...
Source: Lions and Tigers and Bears - August 2, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
July 2021: A Belly Button Problem
My first thought when I learned a patient had presented with a belly button problem was a belly button ring issue. But the patient was male, so it probably was not that. But I thought it would be interesting. I couldn't ever remember a guy with a belly button concern in 30 years of practice.I examined him: Yep, this was interesting. It looked like an abscess, and it was quite tender. It was not draining, despite its appearance.This only led to more questions. How do I numb that area? It was like a firm olive in the navel. He had never had this before, so should I look further? Was this just a weird skin abscess or s...
Source: Lions and Tigers and Bears - July 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
June 2021: Will This Patient Need a New House?
I love to test myself to see if I can guess what I am going to see with the minimum number of films. I played this game recently when looking at this man's knee film. He had been drinking and slipped walking down a set of stairs.With one glance and one film, I knew I had to order another film. The patient was distraught about his recent knee replacement. He was sure he had messed it up. He could barely contain his frustration that I went straight to his ankle. I explained about potential other injuries as I palpated the medial malleolus.He did not have much swelling, but I rationalized it away by thinking it might ...
Source: Lions and Tigers and Bears - June 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
May 2021: The Elusive Tibial Plateau Fracture
"Can you check this guy's knee? He was hit by a car," the APP said, adding that she hadn't seen anything on the x-ray.The patient winced when I touched the area around the fibular head. Images flashed in my mind from 30 years ago when I missed a lateral tibial plateau fracture. The patient walked on it, displacing an undisplaced fracture, and he required surgery. I hadn't forgotten about him decades later.This patient's AP film looked fine: no break in the cortex. The trabecular pattern looked normal, but it was just one view.The oblique raised a tiny question—or was I just imagining things? Was there re...
Source: Lions and Tigers and Bears - April 30, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Elusive Tibial Plateau Fracture
"Can you check this guy's knee? He was hit by a car," the APP said, adding that she hadn't seen anything on the x-ray.The patient winced when I touched the area around the fibular head. Images flashed in my mind from 30 years ago when I missed a lateral tibial plateau fracture. The patient walked on it, displacing an undisplaced fracture, and he required surgery. I hadn't forgotten about him decades later.This patient's AP film looked fine: no break in the cortex. The trabecular pattern looked normal, but it was just one view.The oblique raised a tiny question—or was I just imagining things? Was there re...
Source: Lions and Tigers and Bears - April 30, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
April 2021: Name that Fracture
Growing up in the ’70s, I loved the game show, “Name That Tune.” I was enthralled by the challenge of guessing the correct answer with the barest of clues. I marveled at the knowledge of those contestants who said they could name a tune in one note and who were proved right when the entire song was played. I wanted to have the expertise to say the answer with conviction before all was revealed.I never got that good with music, but I found a corollary in the emergency department in which I wished to excel. How many radiographs did I need to know where the fracture was? Could I know from subtle signs on just one view t...
Source: Lions and Tigers and Bears - April 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
March 2021: Injury Without Trauma
She was actively holding her arm against her side, her hand wrapping around her wrist. Any attempt to move her shoulder, actively or passively, brought an involuntary wince of pain. Tears quickly followed.My patient, a woman in her 40s, described increasing diffuse shoulder pain over two days. There was no trauma, but she described excruciating pain. She couldn't raise her arm at all, so I thought about a rotator cuff injury.She had had no injury, but rotator cuff tendons can give way to repetitive injury that thins the tissue until one day it just it breaks. It seemed more agony than this etiology would give. Maybe there ...
Source: Lions and Tigers and Bears - March 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
February 2021: The Rule of the Ring
"I think they broke my wrist. It hurts all the way up my arm."Responding reflexively, I said I would get a wrist x-ray. Given the odds, I immediately guessed this might be a Colles fracture. The patient said his wrist hurt all over, but pointed specifically to the distal ulna. That's atypical. Not the distal radius?We would see when the x-ray was done. Then we would know. The distal ulnar neck fracture was obvious. The break was close to the distal radioulnar joint (DRUJ). Should I be concerned? I ran through my DRUJ checklist:Is the ulna snuggled in the sigmoid notch? Check.Is the radioulnar joint li...
Source: Lions and Tigers and Bears - January 29, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Finally, an Elusive Fracture
"Can you give this
lady pain medicine?" the nurse said as she pointed to a room.I didn't even know who
she was talking about. I didn't have a patient in that room. But wails emanated
from that location, and the nurse was advocating for the patient's relief.As I made my way to the
room, the nurse added, "She fell and broke her arm." Unwrapping the
EMS splint, I knew she was right. I felt the sickening sensation of bones
moving above hands. That doesn't happen often in the forearm, and I wondered
what the x-ray would reveal. Both
the radius and the ulna were broken and grossly unstable. Three of u...
Source: Lions and Tigers and Bears - January 5, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Don't Just Rely on X-Rays
A woman in her 50s reported
four days of left-sided pleuritic chest pain in her lower ribs. No other symptoms:
no fever, trauma, shortness of breath, cough, or wheezing. It's COVID times, so
who knows? A chest x-ray and labs were ordered. The x-ray appeared clear.
Perhaps it was pleurisy. The white blood count was more than 17 mL! Still no fever:
99.2°F.Then the D-dimer came back
elevated. A chest CT angiogram was obviously the next step. Maybe it was a pulmonary
embolism.Surprise! It was pneumonia,
and it wasn't a little one!Chest x-rays are used as a
screening tool for pneumonia. They require le...
Source: Lions and Tigers and Bears - November 30, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Fracture That’s Rarely Alone
"The guy with the ankle pain was brought back from x-ray. What is going on there?""A fibular fracture," my colleague said.I am always looking for radiographic images of orthopedic injuries. It is a passion. I believe that plain x-rays of bony injuries must be in the wheelhouse of an emergency physician. We tend to see them first, and we need to know what to look for and what to tell the patient to look for.With those words—a fibular fracture—time stopped. She had my full attention. I went to see the screen. "What do you mean a fibular fracture? Where?"My mind raced. It could just be a r...
Source: Lions and Tigers and Bears - October 28, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Mind the Gap
This 20-year-old right-handed patient came in with an obvious deformity of his hand after hitting a wall. Can you see two clues to the injury with just this AP film?I'd surmise that your eyes are drawn to the fifth metacarpal, which is good because this looked like a boxer's fracture. Boxer's fractures, however, are most frequently at the fifth metacarpal neck. There was no fracture, but the fifth metacarpal head seemed way too close to the fourth. The angle of the bone was all wrong. It should be pointing out, not in.I'll give another hint: The deformity seemed to be at the base of the fifth metacarpal. Now what do...
Source: Lions and Tigers and Bears - October 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Good Story
That was the chief compliant. Right away, I was skeptical because it seemed rare that something was actually stuck in a patient's throat.Long ago, I had moved away from plain x-rays to CTs for this complaint. Direct visualization was fraught with problems. I just didn't do it enough to feel confident that I would be able to see an embedded fishbone among the glistening saliva. It was possible that it could be so buried in soft tissue that I could not see the top.I thought I had already seen the future path before I drew back the curtain.Lying comfortably on his side was a 22-year-old man with rock solid vital signs, an ...
Source: Lions and Tigers and Bears - September 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
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
