Growing Wings: The Challenge of Teaching Our Trainees to Fly Out of the Nest in the Current Healthcare Environment
“Tombstones? Do the EKG changes look like tombstones?” were the first questions I asked my 4th year medical student subintern when he called me. I took a deep breath and tried to suppress the sick sensation in my abdomen when he answered, “Yes, I think so”. The moment of truth had transpired with the initial literal and figural spreading of my immediate post-intern wings. I’m not sure how my newly minted PGY-2 vessel actually transported itself from the housestaff quarters at the community hospital to the patient’s bedside but I think a business card handcrafted paper wings that were awarded to me in a ri...
Source: DB's Medical Rants - February 9, 2014 Category: Health Medicine and Bioethics Commentators Authors: Darilyn Moyer Tags: Medical Rants Source Type: blogs
45 year old with chest pain
A 45-year-old male was in his usual state of health until three hours prior to arrival, when he developed left-sided chest pressure with radiation to the neck while walking. His pre-hospital ECG is identical to the first emergency department ECG shown in Figure 1. Based on this, the paramedics activated the cath lab, administered nitroglycerin, and the pain resolved.There is at least 2-mm ST-elevation at the J-point in leads V2 and V3, but the morphology of the T-wave is typical of early repolarization (slow upstroke, fast downstroke). There is minimal ST elevation in leads I, aVL, V5, and V6. There is no inferior ST-depre...
Source: Dr. Smith's ECG Blog - January 26, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
5 hours of chest pain. How acute is the STEMI?
A male is his 30's with h/o HTN presented after 6 hours of chest pain. The pain was crushing and substernal, associated with nausea, vomiting, and diaphoresis, radiating to his back, 10 out of 10 in intensity, the "worst pains ever experienced". He described the sensation as "an elephant sitting on chest". Here is his EKG by EMS:Obvious anterior STEMI with very large T-waves. Is this consistent with 5 hours of injury?The cath lab was activated prehospital. Patient received 324 aspirin and 3 nitroglycerin tablets sublingually prior to arrival to the ED with mild improvement of pain. Here is the ED EC...
Source: Dr. Smith's ECG Blog - January 24, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
ST Elevation and Positive Troponin. Is it STEMI? No. And it is not even ACS.
A male in his 60s complained of constant chest pain for 12 hours. He has a h/o DM and HTN and has been off his meds, including clonidine, for 3 days. His first two BP measurements were 176/108 and 191/126, with a pulse of 100-112. Here is his initial ECG:ED ECG with pain:There is sinus tach at a rate just above 100. There is profound LVH, with deep S-waves in V1-V3 and a large R-wave in V6. There is left atrial enlargement, with a very large negative deflection of the P-wave in V1, also supporting LVH. There is 3-4 mm of ST elevation in V1-V3: this is classic for the ...
Source: Dr. Smith's ECG Blog - January 15, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Ischemic Chest Pain and Hypertension: Use of Adjunctive Anti-ischemic Therapy
A middle aged male with several CAD risks has had several months of exertional angina relieved by rest and nitro. He had the onset of chest discomfort at rest and presented by ambulance about 3 hours later with "severe crushing chest pain," with a blood pressure of 200/100 and pulse of 100. The prehospital ECG cannot be found. Here is his initial ED ECG:Sinus rhythm, nearly tachycardia. Left axis deviation with QRS of 90 ms, R-wave peak time in aVL perhaps reaches 45 ms, so possible left anterior fascicular block. There is minimal ST depression (but also a wandering baseline) in V3-V6.Exam was...
Source: Dr. Smith's ECG Blog - January 7, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
CHF Exacerbation with Old LBBB: Is There New Infarction or Not?
In this study by Hands et al., QRS criteria were quite specific for MI of indeterminate age.It is unlikely that a fragmented QRS on an isolated ECG with LBBB has good diagnostic utility for acute MI, but it is much more likely to be significant if there is NEW fragmentation. Here is the initial ECG again, annotated:There is sinus rhythm and LBBB. There is still left axis deviation and the QRS is now 193 ms. There are multiple signs of new, acute ischemia. --The black arrow shows concordant ST depression in V3, and it is also clearly changed from the previous.--The blue arrow shows even more co...
Source: Dr. Smith's ECG Blog - November 25, 2013 Category: Cardiology Authors: Steve Smith Source Type: blogs
Arrhythmia Masquerading as Cardiac Ischemia
A 45-year-old woman with a history of medication-controlled essential hypertension, stage 2 chronic kidney disease, type 2 diabetes mellitus, and a pack-a-day cigarette habit presented less than 60 minutes after acute onset of severe shortness of breath that awoke her from sleep. She had felt well the previous day, and went to bed with no complaints.
Around 4 a.m., she woke up from sleep very dyspneic, with moderate chest “discomfort” over her left chest that radiated to her back and was unchanged by position or respirations. She denied other symptoms such as fever, cough, nausea, vomiting, numbness, or abdominal pa...
Source: Spontaneous Circulation - September 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Arrhythmia Masquerading as Cardiac Ischemia
A 45-year-old woman with a history of medication-controlled essential hypertension, stage 2 chronic kidney disease, type 2 diabetes mellitus, and a pack-a-day cigarette habit presented less than 60 minutes after acute onset of severe shortness of breath that awoke her from sleep. She had felt well the previous day, and went to bed with no complaints.
Around 4 a.m., she woke up from sleep very dyspneic, with moderate chest “discomfort” over her left chest that radiated to her back and was unchanged by position or respirations. She denied other symptoms such as fever, cough, nausea, vomiting, numbness, or abdominal ...
Source: Spontaneous Circulation - September 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Myocardial Infarction with Dual Culprit Lesions
A 59-year-old man without prior cardiac history presented with three hours of severe upper sternal chest pressure that radiated to his throat, which he described as “strangulating.”
An ECG was obtained, and is shown here. It demonstrates a sinus rhythm at rate of approximately 75 bpm. The PR and QT intervals are normal.
There is concerning 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3, suggestive of a posterior myocardial infarction.
The initial ECG was concerning for 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3. This is suggestive of a posterior myocardial...
Source: Spontaneous Circulation - July 18, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Myocardial Infarction with Dual Culprit Lesions
A 59-year-old man without prior cardiac history presented with three hours of severe upper sternal chest pressure that radiated to his throat, which he described as “strangulating.”
An ECG was obtained, and is shown here. It demonstrates a sinus rhythm at rate of approximately 75 bpm. The PR and QT intervals are normal.
There is concerning 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3, suggestive of a posterior myocardial infarction.
The initial ECG was concerning for 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3. This is suggestive of a posterior myocardial inf...
Source: Spontaneous Circulation - July 18, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Funny Allergy Quotes, Jokes, Stories and a List of Crazy Reactions.
If you're looking for funny allergy quotes, jokes and stories you've come to the right place. I asked my readers from facebook to provide me with their experiences they've had regarding crazy allergy reactions and they did not let me down. They relayed dozens of incidents they've experienced through the years. Over the years I've discovered several funny allergies myself, including allergies to prednisone, diet products and the color red. Some patients have dozens of allergies. My experience is that most of these allergies are not allergies in the physiological sense. The te...
Source: The Happy Hospitalist - July 2, 2013 Category: Internists and Doctors of Medicine Authors: Tamer Mahrous Source Type: blogs
NitroMemantine Reverses the Loss of Brain Connections in Alzheimer’s Disease
"NitroMemantine brings the number of synapses all the way back to normal within a few months of treatment in mouse models of Alzheimer’s disease. In fact, the new drug really starts to work within hours."
+Alzheimer's Reading Room
The first experimental drug to boost brain synapses lost in Alzheimer’s disease has been developed by researchers at Sanford-Burnham.
The drug, called NitroMemantine, combines two FDA-approved medicines to stop the destructive cascade of changes in the brain that destroys the connections between neurons, leading to memory loss and cognitive decline.
Subscribe to the Alzheimer's Readin...
Source: Alzheimer's Reading Room, The - June 19, 2013 Category: Dementia Authors: Bob DeMarco Source Type: blogs
Chest pain, SOB, Precordial T-wave inversions, and positive troponin. What is the Diagnosis?
In conclusion, the presence of negative T waves in both leads III and V1 allows PE to be differentiated simply but accurately from ACS in patients with negative T waves in the precordial leads."See this post for more detail on the ECG in pulmonary embolism. Still more cases are here.The patient was treated for NonSTEMI, including ACS dosing of heparin and including nitroglycerin, which could be hazardous in pulmonary embolism. He was admitted to cardiology where he immediately underwent an echocardiogram, which showed RV strain, alerting the clinicians to PE. A CT pulmonary angiogram confirmed multiple pu...
Source: Dr. Smith's ECG Blog - March 8, 2013 Category: Cardiology Authors: Steve Smith Source Type: blogs
Not Heart Failure
I wasn’t giving in to the patient who wanted a prescription for Levaquin after the standard ZeePack didn’t cure his cough. He had a normal chest x-ray and labs the day before but was convinced that he had pneumonia. I tried explaining the difference between bacteria and viruses. I used the “RAID doesn’t work on dandelions” routine. He wasn’t convinced.
“I NEED a stronger antibiotic to break this up. Levaquin has worked in the past.”
“You know, I think I’m going to start you on some heart medications, instead. Some nitroglycerin and some Lasix for your heart failure.”
“Whaaat? I don’t have heart pr...
Source: WhiteCoat's Call Room - January 18, 2013 Category: Emergency Medicine Doctors Authors: WhiteCoat Tags: Patient Encounters Source Type: blogs
Male in his 40's with chest pain.
A male in his 40's was in his usual state of health until 3 hours prior when he developed L-sided chest pressure, radiating to the neck, while walking. He called 911. His prehospital ECG is identical to the first ED ECG shown below. Based on this, the paramedics activated the cath lab, administered nitroglycerin, and the pain resolved. This ECG was then recorded in the ED: There is at least 2 mm STE at the J-point in leads V2 and V3, but the morphology of the T-wave is typical of early repolarization (slow upstroke, fast downstroke). There is minimal ST elevation in I, aVL, V5 and V6. T...
Source: Dr. Smith's ECG Blog - January 16, 2013 Category: Cardiology Authors: Steve Smith Source Type: blogs
