Should Immediate Manual Testicular Detorsion Become the Standard of Care?
​Testicular torsion is a highly time-sensitive event for a patient and the survival of his testicle. The clock is ticking the minute the retracting cremasteric muscle starts the spermatic cord twisting. Does that mean an immediate attempt at manual detorsion should become a standard of care?The technique for detorsion is straight forward and relatively simple. Detorsion is described as opening a book. The twisting or unraveling procedure for the patient's left testicle is counterclockwise and clockwise for the right testicle. Torsion events more commonly occur as an inward twisting of the testicles, and the treatment is ...
Source: M2E Too! Mellick's Multimedia EduBlog - May 2, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Mysteries of Patella Dislocations
​The patella, the largest sesamoid bone of the body, resides within the patellar tendon and gives the quadriceps muscle mechanical advantage during knee extension. It also protects the knee joint. The flat triangular-shaped patella with its apex pointed downward consists of dense trabecular bone covered with a thin compact lamina.The patella develops embryologically from six ossification centers that ultimately fuse around ages 4 to 6. The patellar tendon attaches to the patella inferiorly, and the vastus medialis and lateralis attach medially and laterally. The quadricep muscle attaches at the top and anterior aspects o...
Source: M2E Too! Mellick's Multimedia EduBlog - April 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Painless Nasogastric Tube Placement
​A 6-year-old boy presented with intermittent abdominal pain, nausea, and vomiting. Because his abdominal examination was unremarkable, the pain intermittent, and constipation a possibility, we provided an enema along with an abdominal pain workup but no radiographs. His pain improved, the abdominal labs were unremarkable, and the child tolerated an oral fluid challenge after treatment with ondansetron.The mother was advised at discharge to return if she became concerned about her child's condition. They did return a few hours later for increased vomiting and abdominal pain. A CT scan demonstrated multiple dilated loops ...
Source: M2E Too! Mellick's Multimedia EduBlog - March 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Our Canary in the Coal Mine: The Rapid Viral Testing Mini-Lab
​Like a beggar telling other beggars where to find bread, I have to talk about our pediatric emergency department mini-lab for rapid viral testing and its undeniable positive impact on our practice during the pandemic. We had begun discussions with Abbott Laboratories months before the COVID-19 pandemic about setting up rapid testing for flu, RSV, and strep. Hospital administration approved moving forward with the concept, but like most big endeavors, administrative delays and other distractions resulted in many months passing without much apparent movement on the contract. And then it happened: The COVID-19 pandemic...
Source: M2E Too! Mellick's Multimedia EduBlog - February 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Ring Removal Techniques and Challenges
​Unfortunately, rings sometimes need to be removed emergently. Other times, ring removal is more prudent than emergent, such as when further swelling may occur (i.e., after distal radius fracture), preoperatively, prior to MRI, and postmortem. Allergic reactions, anasarca, digital trauma, age-related changes, late pregnancy, and excessive weight gain are common causes of acute and chronic changes in finger circumference.Metal rings also need to be removed emergently when placed on the penis and scrotum for sexual purposes and become entrapped. Cutting is generally the first line of management for removal.Scores of anecdo...
Source: M2E Too! Mellick's Multimedia EduBlog - January 4, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Treating Supraventricular Tachycardia in Newborns
​Supraventricular tachycardia (SVT) occurs when conduction of electrical impulses travels along an accessory connection from the atrium to the ventricle (atrioventricular reentry tachycardias) or when conduction takes place within the atrioventricular node (atrioventricular node reentry tachycardia). SVT is technically defined as pulse rates that exceed 180 bpm in children and adolescents and 220 bpm in infants.Infantile-onset SVT classically presenting in the first month or two of life is the most common sustained arrhythmia with an incidence of one in 250 infants. SVT is not uncommon with congenital heart disease, but ...
Source: M2E Too! Mellick's Multimedia EduBlog - December 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Properly Naming the Sinusitis-Otitis-Conjunctivitis Syndrome
One of our nonphysician providers recently announced, “This kid has that double-sickening thing you talk about all the time." She was referring to the sudden worsening of signs and symptoms (e.g., onset of fever) in a patient who had had an upper respiratory tract infection for several days.The majority of links in a Google search for “double-sickening" are references for sinusitis, but new-onset pneumonia is another double-sickening event. The Infectious Diseases Society of America guidelines for sinusitis acknowledge double-sickening and concur that pneumonia can present similarly. I investigate for sinusit...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pediatric COVID-19 and Multisystem Inflammatory Syndrome in Children
​Since the start of global pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), at least four waves have occurred as mutations and variant strains have developed. During the first waves, adults were the primary target, but the highly infectious delta variant has been infecting children and unvaccinated adults with a vengeance.On this go-round, the delta variant is predominately infecting children. I am seeing reports of high school football games being canceled, schools deciding to go virtual, and occasional reports of teachers dying of COVID. I have never seen anything like this pandemic ...
Source: M2E Too! Mellick's Multimedia EduBlog - October 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Dreaded Cricothyrotomy
​I'll admit it. I hate the cricothyrotomy. It's not because I haven't done one for a decade or because it is a complicated procedure. Or because I dread the thought of leaving a permanent cosmetic defect on someone's neck. Or because it is a procedure performed as a last resort under extreme time pressure on a hypoxic patient who will almost assuredly die if you fail.It has something to do with the word failed, as in failed airway. That surgical airway is there because the physician could not gain effective control of the patient's airway using all of the other airway tools at his disposal. We all understand that failure...
Source: M2E Too! Mellick's Multimedia EduBlog - January 2, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Numbered Pediatric Rashes Revisited
​I have been seeing a lot of second disease and fifth disease—it's that time of year. School is back in session, and winter is just around the corner.The rash-numbering system for these diseases is now a historical footnote, but fifth disease is still commonly used by physicians to refer to erythema infectiosum, a parvovirus. I suspect that this system was created as a memory device for similar names and the obscure Latin terms used for these diseases. Erythema infectiosum is also easy to confuse with the many other erythema rashes such as erythema migrans, erythema marginatum, erythema toxicum, and erythema multiforme...
Source: M2E Too! Mellick's Multimedia EduBlog - December 2, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Breath-Holding Spells Are More Complicated than Imagined
It never ceases to amaze me how nothing is ever as simple as it seems. Breath-holding spells are just the latest of the simple and common medical conditions that turn out to be much more complex than ever imagined.It all started during a recent shift in the pediatric emergency department with a toddler who presented after a breath-holding episode. He fell after losing his balance on a trampoline.It started as a classic pallid breath-holding spell that then manifested as crying out, stopping breathing, and rapidly losing consciousness. He then had a CNS anoxic event. The unconscious child clenched his fists and arched his b...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Three Ps of Pyloric Stenosis
​The back story of pyloric stenosis is fascinating. It is a relatively minor surgical condition today, but the disease had a mortality of 100 percent before 1904, when only five operative cases were known to have been performed in the United States. The dying process was slow and painful, and parents watched their infants slowly starve to death.The pyloromyotomy procedure currently used to treat pyloric stenosis was introduced by Conrad Ramstedt, MD, in 1911 at the Children's Hospital of Munster, and is still called the Ramstedt procedure. Before surgical management was introduced for this gastric outlet obstruction, mul...
Source: M2E Too! Mellick's Multimedia EduBlog - October 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Prepubertal Dysuria Not as Simple as a UTI
​Prepubertal boys who present to the emergency department with dysuria are uncommon. The adult with burning on urination is assumed to have a sexually transmitted disease, but of course that diagnosis should not be high on your list for boys.In fact, infectious urethritis in children is quite uncommon unless there is premature sexual activity or sexual abuse by an adult. Unfortunately, a variety of noninfectious urethral pathologies may mimic infectious urethritis in children. A urinary tract infection in a prepubertal boy is an infectious cause of dysuria. Those infections, however, rarely present with the isolated symp...
Source: M2E Too! Mellick's Multimedia EduBlog - September 3, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Heat-Related Illness Not as Simple as It Looks
​Heat-related illness should be an easy diagnosis, but it is not that simple, and there are a number of tripwires.The common pathophysiology for most heat-related illnesses is heat generated from muscular activity that accumulates faster than can be dissipated via increased skin blood flow and sweating, resulting in exertional hyperthermia. Part of the challenge for clinicians is that heat illness is a continuum with a significant overlap of signs and symptoms. Granted, heat rash, heat cramps, and heat edema aren't that confusing, but diagnostic accuracy can be a little more challenging at the other end of the spectrum.S...
Source: M2E Too! Mellick's Multimedia EduBlog - August 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Don’t Treat Kids as Tiny Adults in Needle Thoracostomy
​Pediatric needle thoracostomy is a rarely performed procedure, but one must know the technique and be prepared to perform it. It can be life-saving in the face of a tension pneumothorax. This is a simple procedure, but a few procedural fine points can guarantee success and safety.Adult Needle ThoracostomyWe have learned only relatively recently that most adult needle thoracostomies fail to accomplish their mission. A 5 cm angiocatheter inserted at the second intercostal space on the midclavicular line has been the Advanced Trauma Life Support guidelines recommendation for at least a decade. Unfortunately, we now know th...
Source: M2E Too! Mellick's Multimedia EduBlog - July 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs