Just Say 'No' to X-Ray
A 27-year-old woman came into the ED in the middle of the night complaining of not being able to sleep. She was sure the continuous right-sided foreign body sensation under the angle of her jaw came from a fish bone stabbing her during a late-night dinner. A CT revealed an embedded fish bone. ENT removed the foreign body endoscopically, and she was discharged on oral antibiotics, and had an uneventful follow-up visit a few days later.
The question with my residents always seems to be, "Should we get an x-ray?" And my answer now is, "No."
It is certainly possible that careful inspection o...
Source: Lions and Tigers and Bears - July 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Just Say 'No' to X-Ray
A 27-year-old woman came into the ED in the middle of the night complaining of not being able to sleep. She was sure the continuous right-sided foreign body sensation under the angle of her jaw came from a fish bone stabbing her during a late-night dinner. A CT revealed an embedded fish bone. ENT removed the foreign body endoscopically, and she was discharged on oral antibiotics, and had an uneventful follow-up visit a few days later.
The question with my residents always seems to be, "Should we get an x-ray?" And my answer now is, "No."
It is certainly possible that careful inspection of the ...
Source: Lions and Tigers and Bears - July 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
I Love This Job
We have the best stories. People are fascinated by what we see and do. Another great thing is that there is always something new to see in the ED. It's amazing that I am still seeing things I have never seen before, even after more than two decades in the emergency department.
Just the other night, this all came together when an elderly patient came in with a rectal prolapse. This had happened to the patient before, and the visiting nurse or another family member could usually get it back in. Not this night, however, and a call was placed to the surgical resident.
What was a typical night drastically changed ...
Source: Lions and Tigers and Bears - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
I Love This Job
We have the best stories. People are fascinated by what we see and do. Another great thing is that there is always something new to see in the ED. It's amazing that I am still seeing things I have never seen before, even after more than two decades in the emergency department.
Just the other night, this all came together when an elderly patient came in with a rectal prolapse. This had happened to the patient before, and the visiting nurse or another family member could usually get it back in. Not this night, however, and a call was placed to the surgical resident.
What was a typical night drastically changed when ...
Source: Lions and Tigers and Bears - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
What's a Weber?
Discussion: Virtually every fracture has some kind of classification schema. Distal fibular fractures are no exception. If the orthopedists have gone to all the trouble to have a framework for these fractures, then there must be some important key finding to consider. The emergency physician should have some familiarity with these systems. The Weber classification is easiest to understand because it is based entirely on the anatomic relationship of the fibular fracture to the syndesmosis.
Weber A: Fibular fracture below the syndesmosis.
Weber B: Fibular fracture at the syndesmosis.
Weber C: Fibular fracture above th...
Source: Lions and Tigers and Bears - May 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
What's a Weber?
Discussion: Virtually every fracture has some kind of classification schema. Distal fibular fractures are no exception. If the orthopedists have gone to all the trouble to have a framework for these fractures, then there must be some important key finding to consider. The emergency physician should have some familiarity with these systems. The Weber classification is easiest to understand because it is based entirely on the anatomic relationship of the fibular fracture to the syndesmosis.
Weber A: Fibular fracture below the syndesmosis.
Weber B: Fibular fracture at the syndesmosis.
Weber C: Fibular fracture above the sy...
Source: Lions and Tigers and Bears - May 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
An Ordered Approach
Not surprisingly, this x-ray belongs to a patient with severe wrist pain after an accident. A wrist series usually includes four views, but the PA film can be highly revealing with an ordered approach. What abnormalities can you see?
This is my standard approach to reviewing a wrist PA film:
Count the carpals.
Map the gap.
Mark the arcs.
Check the contours.
Here is a step-wise review of this image.
It becomes obvious in counting the carpal bones that the scaphoid is in two pieces and that two fragments are punched off the radial styloid.
A 2 mm or so gap should separate the sclerotic lines outlining t...
Source: Lions and Tigers and Bears - March 31, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
An Ordered Approach
Not surprisingly, this x-ray belongs to a patient with severe wrist pain after an accident. A wrist series usually includes four views, but the PA film can be highly revealing with an ordered approach. What abnormalities can you see?
This is my standard approach to reviewing a wrist PA film:
Count the carpals.
Map the gap.
Mark the arcs.
Check the contours.
Here is a step-wise review of this image.
It becomes obvious in counting the carpal bones that the scaphoid is in two pieces and that two fragments are punched off the radial styloid.
A 2 mm or so gap should separate the sclerotic lines outlining the carpal bon...
Source: Lions and Tigers and Bears - March 31, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
We All Fall Down
This guy fell down the stairs, but it happened so fast that he didn't know what exactly happened to injure his wrist. Clearly, it is messed up. What kind of information might the orthopedist want to know?
Distal radius fractures are not uncommon injuries in the emergency department. Many happen after a FOOSH — a fall on an outstretched (usually hyper-extended) hand — resulting in a dorsally displaced radial fracture called a Colles' fracture. This man's injury, however, cannot be a Colles' because the fracture is volarly displaced. It is a Smith's fracture.
I don't like eponyms, though. It is too ea...
Source: Lions and Tigers and Bears - March 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
We All Fall Down
This guy fell down the stairs, but it happened so fast that he didn't know what exactly happened to injure his wrist. Clearly, it is messed up. What kind of information might the orthopedist want to know?
Distal radius fractures are not uncommon injuries in the emergency department. Many happen after a FOOSH — a fall on an outstretched (usually hyper-extended) hand — resulting in a dorsally displaced radial fracture called a Colles' fracture. This man's injury, however, cannot be a Colles' because the fracture is volarly displaced. It is a Smith's fracture.
I don't like eponyms, though. It is too easy to m...
Source: Lions and Tigers and Bears - March 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Pictures Can Be Worth More Than Words
And they stick in the mind much longer.
This elderly patient was sent to the ED after an ultrasound for a pulsatile mass. The CT tells the story better than words can. What’s the diagnosis?
The CT showed an 8.6 cm AAA, and the patient underwent endovascular aortic repair (EVAR).
EVAR is performed by deploying a stent across the aneurysm site. The site is usually accessed through the femoral artery. EVAR has significantly decreased peri-operative mortality and morbidity because the patient is not subjected to open repair with clamping of the aorta. In fact, it has been reported tha...
Source: Lions and Tigers and Bears - February 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Pictures Can Be Worth More Than Words
And they stick in the mind much longer.
This elderly patient was sent to the ED after an ultrasound for a pulsatile mass. The CT tells the story better than words can. What’s the diagnosis?
The CT showed an 8.6 cm AAA, and the patient underwent endovascular aortic repair (EVAR).
EVAR is performed by deploying a stent across the aneurysm site. The site is usually accessed through the femoral artery. EVAR has significantly decreased peri-operative mortality and morbidity because the patient is not subjected to open repair with clamping of the aorta. In fact, it has been reported that more than ha...
Source: Lions and Tigers and Bears - January 30, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Doughnut of Truth
A middle-aged patient recently diagnosed with pneumonia came to the ED with right upper quadrant pain and fullness after a bout of coughing. A CT was obtained because of palpable swelling. What's the diagnosis?
Hernia is one of the first diagnoses that comes to mind with sudden abdominal swelling, but the location was not midline in this case nor was there an incision. A hernia just didn't make sense, so the patient was sent to the Doughnut of Truth: the CT scanner. The images clearly revealed a right rectus sheath hematoma.
Rectus sheath hematomas occur when a tear of the rectus muscle damages the ep...
Source: Lions and Tigers and Bears - January 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Doughnut of Truth
A middle-aged patient recently diagnosed with pneumonia came to the ED with right upper quadrant pain and fullness after a bout of coughing. A CT was obtained because of palpable swelling. What's the diagnosis?
Hernia is one of the first diagnoses that comes to mind with sudden abdominal swelling, but the location was not midline in this case nor was there an incision. A hernia just didn't make sense, so the patient was sent to the Doughnut of Truth: the CT scanner. The images clearly revealed a right rectus sheath hematoma.
Rectus sheath hematomas occur when a tear of the rectus muscle damages the epigastric...
Source: Lions and Tigers and Bears - January 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Rule of the Ring
A young woman was transported by EMS with excruciating ankle pain after slipping on the ice. A quick glance at the x-ray clearly shows the reason, but this should raise an additional red flag for EPs.
Always remember the "rule of the ring." The tibia and the fibula are held together by an interosseous ligament to form a ring in the lower leg. Undertake a search for a second abnormality if there is a fracture in the tibia or fibula above the ankle syndesmosis. This x-ray should beget another if you remember the rule of the ring.
This external rotation injury is a Maisonneuve fracture, in which ...
Source: Lions and Tigers and Bears - December 16, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
