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. How ...
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...
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 app...
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...
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 fi...
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 29, 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 maybe...
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 of the po...
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 brand-...
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 waitin...
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 ...
Source: Lions and Tigers and Bears - January 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
