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 ou...
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 remembered t...
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 wa...
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
