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

Tactical Emergency Medicine a Possible Career Path for EPs
​The value and importance of our specialty branching out into tactical emergency medicine are not widely discussed, but it can be rewarding to work with law enforcement. Tactical emergency medicine has expanded rapidly over the past two decades. The American College of Emergency Physicians even has an active tactical emergency medicine section. (http://bit.ly/2Dt1spl.) Its goal is to provide a forum for emergency physicians with interest or expertise in tactical medicine and to share information with the college and other organizations. Fellowships in tactical emergency medicine have been developed as part of academ...
Source: M2E Too! Mellick's Multimedia EduBlog - June 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Racemic Epinephrine Deserves More Respect
​Some medications enjoyed years of glory but later ended up on the trash heap of clinical medicine, often put there by a systematic review or small case series of adverse outcomes or complications that led to black box warnings and a culture of fear and rejection. Still, the heyday lasted for years for some medication outcasts, such as acetaminophen with codeine, promethazine (Phenergan), aminophylline, droperidol, and meperidine (Demerol).Of course, a few of these medications probably deserved their bad rap, but most of them served us well for many years when we had few other options. Medications like racemic epinephrin...
Source: M2E Too! Mellick's Multimedia EduBlog - May 2, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Enigmatic Ganglion Cyst
​Ganglion cysts are soft tissue, fluid-filled swellings most frequently found in the hand and wrist; their origin is not exactly clear. They are common, however, and can occasionally be associated with surprising morbidity despite their benign nature. The morbidity seems to be related to their tendency to localize in highly mobile and anatomically tight quarters such as the hand and wrist. Nevertheless, they can show up almost anywhere.Cysts can also have sequelae, such as sciatica from a piriformis ganglionic cyst, compression radiculopathy from a lumbar intraspinal ganglion cyst, foot drop from peroneal nerve cyst, met...
Source: M2E Too! Mellick's Multimedia EduBlog - April 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pediatric Conjunctivitis a Simple Diagnosis Until It Isn’t
​Conjunctivitis is a common condition and easy enough to treat, but several uncommon conjunctivitis syndromes require more care and should not be missed.Conjunctivitis is either infectious (viral or bacterial) or noninfectious (allergic or nonallergic). Viral infections are more common in adults, bacterial ones in children, usually caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Adults tend to have more S. aureus infections, while the other pathogens are more common in children. An adenovirus is typically responsible for viral-associated infections in conjunct...
Source: M2E Too! Mellick's Multimedia EduBlog - March 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

TXA a Late Bloomer in Bleeding Management
​Tranexamic acid (TXA) was invented by a Japanese husband-and-wife research team in the 1960s. Years earlier, this same research team had discovered epsilon-aminocaproic acid, a derivative and an analogue of the amino acid lysine. In their search for a more potent antifibrinolytic agent, they discovered tranexamic acid, a synthetic analog of the amino acid lysine. Tranexamic acid is eight to 10 times more powerful than epsilon-aminocaproic acid.The antifibrinolytic actions of TXA result from the binding of four or five lysine receptor sites on plasminogen. This binding prevents plasmin from binding to and degrading fibri...
Source: M2E Too! Mellick's Multimedia EduBlog - February 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Distinguishing between Orbital and Preseptal Cellulitis
​Some medical conditions have signs and symptoms that significantly overlap, making a diagnosis a little more difficult. Epididymitis, testicular torsion, and torsion of the testicular appendage are examples, but orbital and preseptal cellulitis are others that can cause significant diagnostic confusion.Both conditions are more common in children than in adults, and preseptal or periorbital cellulitis is more common in children under 5. The preseptal and orbital spaces are separated by only a thin membranous septum that originates in the orbital periosteum and inserts into the tarsal plates. It is only this thin septum t...
Source: M2E Too! Mellick's Multimedia EduBlog - December 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

AAP Bronchiolitis Guidelines a Mismatch with Clinical Practice
​I recently met with a group from our children's hospital to standardize the hospital management of bronchiolitis according to the latest American Academy of Pediatrics guidelines. (Pediatrics 2014;134[5]:e1474; http://bit.ly/2QIGbMX.) Unfortunately, these guidelines seem to cause confusion for experienced and inexperienced emergency physicians alike.This confusion comes from the guidelines raising unaddressed issues and new questions, most importantly not tackling important aspects of frontline clinical practice. These guidelines were developed with the best evidence currently available, and their application mostly cau...
Source: M2E Too! Mellick's Multimedia EduBlog - December 4, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Foreign Bodies in the Ear and Nose a True Test of EP Mettle
​Pediatric patients frequently put foreign bodies into their mouths, noses, and ears. The spectrum of foreign bodies that children place into their facial orifices are impressive. Paper, vegetable matter (such as peanuts), toys, beads, metal screws, and Play-Doh are just a few examples.The insertions are often done surreptitiously, only to be discovered days or sometimes weeks later. Occasionally, the retained foreign nasal bodies will ferment and present with a purulent, unilateral nasal drainage, accompanied by an unrelentingly repulsive odor. Sometimes an occasional cockroach wanders into the external auditory canal l...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Curse of Delusional Parasitosis
​Delusional parasitosis is a rare condition, but it is more common where methamphetamine and cocaine abuse is high. It is a fascinating condition to witness; patients are convinced that their skin is infested with foreign organisms or materials despite incontrovertible evidence to the contrary.This condition is known by numerous names—Ekbom syndrome, delusory parasitosis, psychogenic parasitosis, delusional parasitosis, delusional ectoparasitosis, formication, chronic tactile hallucinosis, dermatophobia, parasitophobia, and cocaine bugs—but delusional parasitosis and more recently delusional infestation are c...
Source: M2E Too! Mellick's Multimedia EduBlog - September 30, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

My Foley Balloon Won’t Deflate!
​Sometimes when it's time to remove a Foley catheter, the balloon won't deflate. This problem occurs more commonly in patients with long-term Foley catheters. Even though we have all seen nursing home patients present with penile bleeding after pulling out their Foley catheter with the balloon still inflated, that is obviously not an option for emergency physicians. The problem is that the recalcitrant balloon is sitting out of reach, deep in the urinary bladder.The cause of the balloon malfunction can be anywhere along the catheter, but it's usually found in the balloon inflation port, the balloon drainage channel, or t...
Source: M2E Too! Mellick's Multimedia EduBlog - August 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Managing All Manner of Bursitis Cases
​A bursa, a fluid-filled synovial sack, serves in the body as either a pulley or a cushion, and bursitis, of course, is an inflammatory response that can occur to a bursa. The causes of the inflammatory response can be trauma (direct or overuse), infection, or rheumatologic or crystal-induced disease.​Whether a bursa is deep or superficial ultimately determines the most likely pathophysiology and dictates the most appropriate treatment. Superficial bursae are those closest to the skin, and they are most vulnerable to direct trauma and infection—the prepatellar, infrapatellar, and olecranon bursae. Deep bursae inc...
Source: M2E Too! Mellick's Multimedia EduBlog - August 6, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Compartment Syndrome Like You Haven’t Seen Before
​The fascial planes in the upper and lower extremities play an important role in function and form, but they also make the extremities vulnerable to compartment syndrome. Emergency physicians are quite comfortable evaluating and diagnosing compartment syndrome: severe unrelenting pain, pain with passive motion of the muscle groups involved, and possibly paresthesias and pallor. The first patient I saw with this condition was at the Tripler Army Medical Center in Hawaii. A sailor dangling his legs over the dock presented after his leg was crushed between the dock and a battleship that suddenly shifted its position. I stil...
Source: M2E Too! Mellick's Multimedia EduBlog - July 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Severe Disulfiram or Antabuse Reactions
​Alcoholism has been treated with disulfiram (Antabuse) ever since the drug received FDA approval in 1951. Disulfiram is one of a number of medications that produces unwanted side effects caused by the accumulation of acetaldehyde when taken with alcohol.​The story behind the discovery of disulfiram is typical of serendipitous observations. A physician noted in 1937 that workers in the rubber industry exposed to disulfiram developed a reaction after drinking alcohol. Several decades later, two Danish researchers evaluating disulfiram as an antihelminthic developed symptoms after attending a cocktail party. (Medscape, J...
Source: M2E Too! Mellick's Multimedia EduBlog - June 1, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Small Hairs Make Big Cuts (and Consequences)
​The hair or thread tourniquet syndrome is a relatively rare condition that has evaded me in the emergency department for several decades, until past year when three cases showed up over six months. This condition has been around for as long as there has been hair or thread and body appendages. In fact, this condition may have first been described in the 1600s. (J Pediatr Adolesc Gynecol 2005;18[3]:155.)The etiology of this condition seems almost unbelievable. How in the world does a hair get wrapped repeatedly and tightly around an appendage of the body? Some authors expressed the need to consider nonaccidental etiologi...
Source: M2E Too! Mellick's Multimedia EduBlog - April 30, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Understanding Headache Classifications
​Many types and etiologies of headache and facial pain afflict our patients, and sorting through them can be a challenge. Craniofacial experts themselves, in fact, do not attempt to remember the subtle differences between the various conditions causing craniofacial pain, but instead refer to the third edition of the International Classification of Headache Disorders (ICHD-3). (https://www.ichd-3.org/.)The ICHD-3 can help the clinician manage patients presenting with headache as their chief complaint. An international panel of headache experts oversee the classification, which is currently published in a beta format so mi...
Source: M2E Too! Mellick's Multimedia EduBlog - April 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

That Darned Foreskin
​I was a practicing pediatrician before I did a residency in emergency medicine. One of the most common and sometimes most stressful decisions parents had to make in the neonatal nursery was whether to circumcise their newborn son. I have to admit that the hullabaloo about the foreskin has always intrigued me. The American Academy of Pediatrics has gone back and forth over the years on the topic of circumcision and its benefits, but the current evidence clearly establishes a benefit from this procedure (Pediatrics 2012;130[3]:e756) that is performed approximately 1.4 million times each year in the United States. (Mayo Cl...
Source: M2E Too! Mellick's Multimedia EduBlog - February 28, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Babies, Puppies, and Therapy Pets
​Recently, I acquired a little Yorkshire terrier puppy for my 15-year-old daughter who had been requesting a puppy for many months. On the way home, she silently wept with joy over the puppy sleeping in her lap. The two girls immediately fell in love, and it has been fascinating watching my daughter's maternal instincts unfold. She now gushes over babies in strollers, every dog or puppy she sees, and every other small animal that runs across the road. It has also brought out the mama bear protective instincts in her. I mean, if I turn in front of a car a quarter mile away, she admonishes me for putting the "the baby...
Source: M2E Too! Mellick's Multimedia EduBlog - January 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Tactical Tourniquets to Stop Traumatic Bleeding
​Four different tourniquets can be used to manage uncontrolled extremity hemorrhage—the SWAT-Tourniquet, the Combat Application Tourniquet (C-A-T), the SOF Tactical Tourniquet, and the Rapid Application Tourniquet System (R.A.T.S.). All four include a tightening strap that wraps around an extremity.​R.A.T.S. uses a thick bungee-like elastic cord. Both the C-A-T and SOF use an adjusting strap, but only the C-A-T uses Velcro to secure the strap and prevent loosening. The SOF has a tightening buckle that can be unsnapped to open the tourniquet and allow the strap to be wrapped around the limb rather than pulling it ...
Source: M2E Too! Mellick's Multimedia EduBlog - January 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The AAJT: Simplicity in the Face of Adversity
​There is a saying, "Complexity in the face of adversity breeds chaos." I'm not sure where this maxim originated, but it is definitely true in resuscitation settings. That's the crux of this post: Is the abdominal tourniquet simplicity in the face of adversity compared with the resuscitative endovascular balloon occlusion of the aorta (REBOA)?​We all know how futile it feels to do CPR on a traumatic cardiac arrest patient with suspected massive blood loss. Just what are we pumping, and if there is any remaining intravascular blood, where are we pumping it?I will never forget the pain of trying to resuscitate ...
Source: M2E Too! Mellick's Multimedia EduBlog - December 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Cardioverting the First Emergency Medicine Residency Graduate
​The labor pains leading to the birth of the specialty of emergency medicine began in the mid-1960s. The public demand for emergency care was growing around the country, and physicians were leaving their private practices in greater numbers and working full-time in urban emergency departments. Nevertheless, the quality of care was at times problematic, and the need for training in emergency medicine was widely recognized.The American College of Emergency Physicians was founded in 1968, and it became a driving force for the creation of the specialty. The first training institution was the University of Cincinnati, and thi...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Though Much Maligned, BVM is a Good Tool
​I’ve heard for years in emergency medicine circles that it was impossible to preoxygenate with a bag-valve mask (BVM) unless one is actually compressing the bag and forcing oxygen flow to the patient. I recently did an informal survey of my colleagues at work, and the responses varied from confident affirmation that the BVM was an inadequate tool for preoxygenation to quasi-warnings not to tread on this dogma without first consulting anesthesia or respiratory therapy. What started as a simple quest to clarify whether the dogma about BVMs and preoxygenation was true turned into a fascinating review and new personal...
Source: M2E Too! Mellick's Multimedia EduBlog - October 5, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Role for Magnetism in the ED
​Children have this strange predilection for placing small objects in body cavities and orifices. Besides putting foreign bodies in their mouths, an act that often leads to ingestion or aspiration, the ear canals and nares are their favorite locations for depositing plastic beads, toy parts, paper materials, small vegetables, jewelry, screws, and nails, and that frequently brings them to the emergency department. Unsuccessful attempts to remove the foreign bodies in the ED lead to a consultation or referral to an ENT specialist. The timing, technique, and tools used to remove a foreign body will depend on the anatom...
Source: M2E Too! Mellick's Multimedia EduBlog - September 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Desperate Times Call for Desperate Measures: Double Simultaneous Defibrillation
​Double sequential defibrillation appears to work in the electrophysiology lab, and anecdotal evidence shows that lives can be saved in the prehospital setting and in the emergency department. With all the unanswered questions swirling around it, should we use this technique? Let’s consider the evidence.Using two sets of defibrillators fired simultaneously or in a sequential pattern to treat refractory ventricular fibrillation is a relatively new concept. A number of different names for the procedure exist, but double sequential external defibrillation (DSED) or double simultaneous defibrillation (DSD) are commonly...
Source: M2E Too! Mellick's Multimedia EduBlog - August 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Survival of a Torsed Testicle
​The time for possible salvage and survival of a torsed testicle is commonly thought to be six to eight hours, a period that is expressed with confidence by the medical and legal professions. Survival of torsed testicles with and without subsequent atrophy is known to occur outside that critical window. My colleagues recently treated a 17-year-old boy approximately three days after the onset of right scrotal pain. He reported his pain constantly as 8/10 in severity. He didn't tell his mother for several days because he was scared, embarrassed, and hoping that the pain and swelling would resolve.​The patient was taken t...
Source: M2E Too! Mellick's Multimedia EduBlog - July 3, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

‘Out-the-Door’ v. ‘Kitchen-Sink’ Asthma Management
​Are you one of those clinicians who frequently finds himself frustrated with asthma patients who improve to a point but not enough to discharge home? Even though this has to be a common problem, no one seems to talk or write much about it. I was feeling deeply frustrated about these patients, and it led me to serious clinical introspection. Why does everyone write about the crashing asthma patient, but hardly anyone addresses the problematic patient with improving but recalcitrant bronchospasm?Most articles typically cover every available therapeutic option, including the proverbial “kitchen sink” for managi...
Source: M2E Too! Mellick's Multimedia EduBlog - June 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Appendagitis, a Rare Cause of Abdominal Pain
​The differential list of potential causes of abdominal pain is pretty long. Like most differentials, though, it usually boils down to a handful of more common etiologies benign and serious. Potentially life- or organ-threatening conditions such as appendicitis, diverticulitis, or ovarian or testicular torsion simply cannot be misdiagnosed and usually aren't missed.​We frequently find ourselves walking into the patient's room at the end of an extensive and exhaustive workup and announcing the good news that the cause of the pain isn't one of these more serious causes. As emergency physicians working in an uncontrolled ...
Source: M2E Too! Mellick's Multimedia EduBlog - May 3, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Mistakes that Kill during Cardiopulmonary Resuscitation
​Hanging out with cardiopulmonary researchers effectively imprinted on my psyche that we fail our patients during cardiopulmonary resuscitation in many ways. Unfortunately, too many patients who could have walked out of the hospital after experiencing death don't because of our mistakes in CPR. It's critical to find the resuscitation sweet spot for each patient and to never waver during a CPR event. These are the ways we can kill our patients during cardiopulmonary resuscitation:Too Slow or Too FastThe recommended heart rate for cardiopulmonary resuscitation was 60 compressions/minute in 1960. (JAMA 1960;173:1064.) Obser...
Source: M2E Too! Mellick's Multimedia EduBlog - March 31, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Oldie but Goodie Pediatric Clinical Concepts
​A number of older clinical concepts may be unfamiliar to younger clinicians, but these clinical concepts are useful in pediatric medicine. Some of these concepts showed up in the medical literature for the first time nearly a century ago. Physicians should feel free to question the potential value and validity of older clinical concepts that aren't at the forefront of medical education, but my experience of more than 30 years practicing pediatrics and emergency medicine has repeatedly affirmed to me that these are valuable in emergency medicine.​Parenteral DiarrheaThe concept of parenteral diarrhea has been around for...
Source: M2E Too! Mellick's Multimedia EduBlog - March 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Oldie but Goodie Pediatric Clinical Concepts
​A number of older clinical concepts may be unfamiliar to younger clinicians, but these clinical concepts are useful in pediatric medicine. Some of these concepts showed up in the medical literature for the first time nearly a century ago. Physicians should feel free to question the potential value and validity of older clinical concepts that aren't at the forefront of medical education, but my experience of more than 30 years practicing pediatrics and emergency medicine has repeatedly affirmed to me that these are valuable in emergency medicine.​Parenteral DiarrheaThe concept of parenteral diarrhea has been around for...
Source: M2E Too! Mellick's Multimedia EduBlog - March 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Varicella Virus, the Old and the New
​I want to reawaken awareness of a disappearing but highly contagious infectious disease — varicella. Thanks to immunizations for the wild-type varicella virus and shingles, or herpes zoster, younger health care providers are less aware of the appearance and clinical presentations of this viral infection.Presentations of this viral disease have markedly declined and presentations are often atypical since the advent of immunizations for varicella in 1995. This DNA virus within the herpes virus family is generally a mild childhood disease but can wreak physical havoc in adults, especially pregnant women. Immunosuppre...
Source: M2E Too! Mellick's Multimedia EduBlog - February 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Soto Saline Sign for Pseudoseizures
​Conversion reactions are commonly seen conditions in health care and come in various forms and presentations. Two common conversion reactions seen in the emergency department are conversion coma and psychogenic nonepileptic seizures (PNES). Both mimic life-threatening conditions and require rapid differentiation. Premature anchoring and wrong diagnoses can result in potentially harmful outcomes or expensive and unnecessary procedures, workups, and evaluations.​Conversion disorder, or functional neurological symptom disorder, is categorized under the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (...
Source: M2E Too! Mellick's Multimedia EduBlog - January 4, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Soto Saline Sign for Pseudoseizures
​Conversion reactions are commonly seen conditions in health care and come in various forms and presentations. Two common conversion reactions seen in the emergency department are conversion coma and psychogenic nonepileptic seizures (PNES). Both mimic life-threatening conditions and require rapid differentiation. Premature anchoring and wrong diagnoses can result in potentially harmful outcomes or expensive and unnecessary procedures, workups, and evaluations.​Conversion disorder, or functional neurological symptom disorder, is categorized under the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (...
Source: M2E Too! Mellick's Multimedia EduBlog - January 4, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Hemiplegic Migraine and Paraspinous Cervical Injections with Bupivacaine
​I recently treated a patient with hemiplegic migraines successfully with bupivacaine cervical injections, a novel therapeutic technique using paraspinous cervical injections. The technique employs deep intramuscular injections of 1.5 mL of 0.5% bupivacaine bilaterally into the paraspinous muscles of the lower neck. (Read more in my October 2012 blog and see it demonstrated in a video at http://bit.ly/2ewC5n1.)This headache and orofacial pain treatment was first described in 1996 by my twin brother, Gary Mellick, DO, a neurologist who did a pain fellowship. The exact mechanism is unknown, but the treatment appears to wor...
Source: M2E Too! Mellick's Multimedia EduBlog - December 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Post-Tonsillectomy and Adenoidectomy Bleeding Emergencies
​I have immense respect for a few pediatric emergency conditions. Post-surgical bleeding following a tonsillectomy and adenoidectomy (T&A) has given me several memorable patient care experiences over the years. Honestly, the word "memorable" is actually a euphemism for terrifying.​Part of the problem with post-T&A bleeding is the patient. Typically, it's a pediatric patient who for hours has been quietly bleeding into the posterior pharynx while quietly swallowing the evidence (e.g., blood). By the time the patient presents to the ED, a significant but unknown percentage of the child's total blood vol...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs