Dropping Like a Rock
"Hey, I think I can send this guy home with a knee immobilizer, crutches, and ortho follow-up. He hurt his knee when he fell during an altercation. I don't see a fracture on the x-ray. Can I get him out of here?" asked the resident as he documented the x-ray reading.Glancing at the images, I replied, "Let me look at him because that doesn't look quite right."The patient was lying in a bed with shorts on, so I could already assess that the knee overall looked relatively normal. No significant effusion, abrasions, or obvious deformity were present.I asked him to lift his leg off the bed, but he refused. I...
Source: Lions and Tigers and Bears - October 3, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Coolest Wrist Injury Ever
"This is the best I can do," said the x-ray tech as he pulled me into the room. He added, with some exasperation, "I can't position him because he won't move his wrist."Defensively, the patient countered, "He doesn't understand. I can't move my wrist."The images were not what I expected. I had expected to see an obvious fracture. This was a simple case, a FOOSH injury with limited wrist range of motion. The distal radius clinically appeared deformed, prominent, and swollen. He was supposed to have a Colles fracture. I tried to coax more images by promising more pain medicine. With a hint of an...
Source: Lions and Tigers and Bears - September 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Perils of Bike-Riding While Drunk
As this young man found out, it is not wise to ride a bike across trolley tracks at night while intoxicated. It's not shocking that he complained of ankle pain. With the deformity apparent, the trimalleolar fracture with lateral dislocation hardly needed an x-ray to tell us where we were headed. The radiology tech documented the devastation while we rounded up the necessary supplies.I think a four-person team event tends to give the best results: one to give pain medication or sedation and to observe the patient's status, two to splint the leg (one to hold and one to wrap), and one to hold the toes. I always ch...
Source: Lions and Tigers and Bears - August 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Beware the (Previously) Seriously Agitated Patient
"What do you think about this VBG from last night?" I asked, thrusting a ribbon of paper at my colleague.Initial VBGpH <6.80pCO2 47 mm HgpO2 59 mm HgNa+ 149 mmol/LK+ 4.2 mmol/LCl- 99 mmol/LCa++ 1.27 mmol/LGlu 211 mg/dLLac >20.0 mmol/LCO-OximetrytHb 16.3 g/dLsO2 &#...
Source: Lions and Tigers and Bears - July 2, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
FOOSH It Good
A young woman came in after a FOOSH injury complaining of difficulty moving a painful shoulder. The Y view was difficult to obtain, but the AP view is below. What three radiographic signs help make the diagnosis?The signs include:n The light bulb sign is when the humeral head is rotated internally so it looks more like a lightbulb than a club.n The rim sign where there is an increased distance (more than 6 mm) between the arc of the glenoid and the arc of the humeral head. The distance is much closer at the top of the glenoid than the bottom in this image.n There is an angle in Moloney's arch. There s...
Source: Lions and Tigers and Bears - June 2, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Eye Wide Shut
"I'm going to get a facial CT on this guy because his eye won't open," the resident said to me as he came out of the patient's room.Suddenly aware that a lateral canthotomy might be in our immediate future, I asked, "What do you mean? You can't get his eye open? What happened?"Changing directions, I entered the room to find a surprisingly cooperative patient with a grossly deformed face. The peri-orbital contusion prevented him from voluntarily opening his eye. So is that pre-septal or retro-orbital? We needed to take a look.Touching the upper lid, the immediate sensation of bubble pop burst forth under...
Source: Lions and Tigers and Bears - May 2, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Hitting the Slopes
A man hobbled into the emergency department complaining of continued ankle pain and increased swelling after falling from a ladder the day before. Ankle images were ordered. The mortis, syndesmosis, and malleoli appeared normal, but the massive medial soft tissue motivated a continued search. Was there something wrong with the lateral talus?The subsequent CT scan delineated a comminuted fracture of the talar lateral process extending to the subtalar joint — a snowboarder's fracture.Fractures of the lateral process of the talus are relatively uncommon, frequently missed, and can end up with long-term disability. It has be...
Source: Lions and Tigers and Bears - April 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
'Don’t Do That Again!'
It's 2 a.m. I glance up from my computer screen where I have been diligently clicking boxes on the EMR to see a 20-something man hobble down the hallway following the nurse to a hallway bed. His left foot had a normal heel strike, but the right always came down on the ball of the foot. Curiosity piqued, I opened a new tab to consider this patient's problem.The 28-year-old jumped over a fence to get away from a dog, landing on his right heel. He said he had not been able to put pressure on the back of his foot since the injury occurred an hour earlier. It was a pleasure to have something so straightforward.I checked for an ...
Source: Lions and Tigers and Bears - March 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
