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Altered Mental Status and Intussusception
I recently spent some time with a group of academicians in Raleigh-Durham, NC. Jonathan Singer, MD, a recently clinically retired pediatric emergency medicine physician and faculty at the Wright State Emergency Medicine program, was part of the group. He has impressed me over the years as a tough, no-nonsense academician with a penchant for clinical photography and writing poetry and Broadway plays. The group got into a discussion about pediatric bowel intussusceptions during the meeting, and I was surprised to learn that Dr. Singer wrote one of the first papers describing the altered mental status associated with intussus...
Source: M2E Too! Mellick's Multimedia EduBlog - January 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Cannabinoid Hyperemesis Syndrome
Thankfully, cannabinoid hyperemesis syndrome isn’t a life- or limb-threatening condition. Malpractice attorneys would be having a field day if it were. I have been attuned to this condition only for the past several years, but it’s apparent that this condition remains diagnostically elusive. Every new case I pick up has presented previously to my or another community emergency department multiple times without anyone making the diagnosis. And the patient almost always has a trail of CT scans, abdominal ultrasounds, and other imaging studies as well as hundreds of dollars in laboratory testing. It’s known that th...
Source: M2E Too! Mellick's Multimedia EduBlog - December 3, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Cannabinoid Hyperemesis Syndrome
Thankfully, cannabinoid hyperemesis syndrome isn’t a life- or limb-threatening condition. Malpractice attorneys would be having a field day if it were. I have been attuned to this condition only for the past several years, but it’s apparent that this condition remains diagnostically elusive. Every new case I pick up has presented previously to my or another community emergency department multiple times without anyone making the diagnosis. And the patient almost always has a trail of CT scans, abdominal ultrasounds, and other imaging studies as well as hundreds of dollars in laboratory testing. It’s known that this...
Source: M2E Too! Mellick's Multimedia EduBlog - December 3, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Anaphylaxis and Epinephrine
I have a personal interest in anaphylaxis and epinephrine. My wife nearly died after being stung by hornets in 2009. Unfortunately, I was on a mission trip to Honduras, and it was up to my 7-year-old daughter to find the EpiPen and help administer the lifesaving injection to my wife. (A video of another patient with anaphylaxis from a wasp sting can be viewed here. It includes the 911 call from my daughter.) Two major problems occur with anaphylaxis: recognition and management. The recognition problem is related to the very confusing and complex diagnostic criteria that have been established. (Ann Emerg Med 2006;47[...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Testicular Torsion Tripwires
A tripwire is usually a wire stretched near ground level to ensnare someone or to activate a booby trap or detonate explosives, and some chief complaints come with their own built-in tripwires that should cause emergency physicians to stop dead in their tracks. Acute scrotal pain without a doubt is one of those chief complaints. Torsion of the testicle is not the only cause of acute scrotal pain, but it is the one that emergency physicians cannot afford to miss. Unfortunately, this condition comes with an impressive number of tripwires capable of bringing down even the most experienced clinicians: • Clinical Overlap:...
Source: M2E Too! Mellick's Multimedia EduBlog - October 3, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pediatric Nasal Foreign Bodies
Many of my pediatric patients with nasal foreign bodies present to the emergency department for chief complaints unrelated to the nose. The young man shown below, for example, presented several years ago for the evaluation of dog bite wounds to the face. I could see the telltale signs and symptoms of a chronic unilateral nasal drainage the minute I walked in the room. (Figure 1.) Figure 1. Nasal drainage is the telltale sign of a nasal foreign body. I questioned the patient and his father, and they offered no history to confirm insertion of a nasal foreign body. Nevertheless, a wad of mummified Halloween candy wrapping...
Source: M2E Too! Mellick's Multimedia EduBlog - September 3, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Zipper Release Myth
This study advocates using a new technique to release of entrapped penile skin from a zipper by cutting the zipper tape and teeth immediately superior and inferior to the zipper connector and using a needle holder to pull the zipper apparatus apart following the application of lubrication and appropriate use of local analgesia. Dr. Mellick comments: The technique described involves completely cutting out the zipper leaving minimal zipper tape, lubricating and then tugging on the remaining zipper tape while stabilizing with your hand. We recommended separating the zipper mechanism with a flat head screw driver, but this ...
Source: M2E Too! Mellick's Multimedia EduBlog - July 24, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Code Team Leadership
The experiences in trauma team leadership that initiated my interest in code team organization and leadership began several decades ago when I was an emergency medicine resident at Brooke Army Medical Center. Our setting was somewhat unique because the emergency medicine senior resident and attending were responsible for the leadership of all traumas. Surgery residents were part of the team, but they did not formally function as trauma team leaders. This, as one might expect, did not sit well with the surgery residents. Consequently, they did everything in their power to function independently, usurp team leadership, an...
Source: M2E Too! Mellick's Multimedia EduBlog - June 29, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pediatric Laryngoscope Blade Length Selection
Whenever I research on techniques for selecting pediatric laryngoscope blade length, I continue to find that the only English article ever published on the topic was the one I did in 2006. (Pediatr Emerg Care 2006;22[4]:226.) I have to admit that this apparent lack of interest in the subject has caused me to have fleeting thoughts that maybe I am the only emergency physician insecure about his ability to select the most appropriate laryngoscope blade length for a pediatric intubation. I doubt that is the case, and I recently found an Iranian article that appears to duplicate my study and results in 60 pediatric patients. (...
Source: M2E Too! Mellick's Multimedia EduBlog - May 31, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Lessons Learned from a Medical Mission
Nurses can serve as excellent physician extenders.My mentors in austere medicine warned me that with an interpreter I would be lucky to see 30 patients per day. That concerned me because the local missionaries indicated at our first organizational meeting in the Dominican Republic that we were expecting to see 100 patients per day. On top of that, 100 cards were being handed out at each of the four locations we would be visiting. As the single physician in the group of 19 team members (seven nurses), these seemed like very high expectations. Working in a setting that uses physician extenders and emergency medicine resid...
Source: M2E Too! Mellick's Multimedia EduBlog - May 2, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Increasing Success with Infant Spinal Taps
I think infant lumbar punctures are actually easier than spinal taps on older children and adults. Unfortunately, success, as measured by acquiring sparkling clear (nontraumatic) spinal fluid, is sometimes elusive. Twenty to thirty percent of spinal taps in the training setting, in fact, can be traumatic or unsuccessful. (Pediatr Emerg Care 2010;26[7]:487.) Three easy steps, however, can increase one’s odds for success. Use Local AnesthesiaThe evidence shows that the success rate is improved when injected or topical anesthesia is used, but this practice is commonly ignored by practitioners. The literature clearly supp...
Source: M2E Too! Mellick's Multimedia EduBlog - April 3, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Controversy over Video Laryngoscope and Direct Laryngoscopy
Don’t get me wrong, being a teaching center, our shop loves new airway technology, and we have one of about everything. In keeping with the M2E Too Blog’s name, I’m jumping into the fray over the predicted early demise of direct laryngoscopy in favor of video laryngoscopy. I have a few observations about the new airway technology that are worth, ahem, airing. The more complicated the technology, the greater number of things that can go wrong and parts that can malfunction. The days of worrying about blade handle batteries being dead or light bulbs being burned out are being replaced with equipment failures that in...
Source: M2E Too! Mellick's Multimedia EduBlog - March 5, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Chest Tubes Deserve an Unnecessary Roughness Penalty
Chest tube placement borders on the barbaric. I am specifically referring to the large-bore chest tubes that continue to be placed in emergency departments for spontaneous and iatrogenic pneumothoraces. I have personally performed or watched the trauma service place chest tubes, and wondered why large-bore chest tubes remain our tool of choice. The insertion process is painful. No matter how much anesthesia is administered, the patient still screams out in pain as the pleura is violated or the opening is expanded by blunt dissection. Aren’t the smaller, kinder, gentler drainage catheters equally effective as the large...
Source: M2E Too! Mellick's Multimedia EduBlog - February 8, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Trigger Point Therapy in the Emergency Department
Patients with myofascial pain conditions or trigger point pain commonly present to the emergency department seeking therapeutic relief. It is not rare to see patients with specific areas of unrelenting muscle spasm who have undergone multiple medical therapies and expensive imaging studies without diagnostic or therapeutic success. Unfortunately, the outcome of most emergency department visits for these patients is another failure to accomplish definitive therapy. We usually prescribe more ineffective therapies that simply perpetuate the therapeutic delay. This blog hopes to present hard-hitting therapeutic interventions t...
Source: M2E Too! Mellick's Multimedia EduBlog - January 7, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs