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Case Reports from the ED

The EMBER Project.002

Note the subtle venous congestion and edema of the right hand and wrist in this patient with an upper extremity deep venous thrombosis (Paget-Schroetter Disease),

Here is a slightly different twist on Virchow’s triad, and one that I had not seen before until yesterday:  a spontaneous upper extremity DVT (Paget Schroetter Disease) in an otherwise healthy person with no risk factors.  It’s uncommon, but not a complete zebra.  The pathophysiology and subsequent management also differs from your traditional DVT, so I thought it was worthwhile to highlight some of the features that make it unique.

The EMBER Project.003

The EMBER: as always, a collection of interesting information about this topic from around the web.

Paget–Schroetter disease – Wikipedia

First rib resection for Paget-Schroetter Syndrome – YouTube

Spontaneous upper extremity venous thrombosis (Paget-Schroetter syndrome) - Up To Date

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It’s De-lightful, it’s De-lovely, it’s De-winter?

New STEMI equivalents keep showing up all the time.  What is a STEMI equivalent you ask? For those ECG nerds out there (you know who you are, yes the one’s with the calipers in my ED) it is the rapidly expanding number of ECG patterns, beyond the traditional ST elevations, that suggest an acute coronary occlusion and therefore require emergent revascularization..  Here is one I was unaware of until just recently. Add it to your list.

Photo from Dec 3, 2012


Dr Smith’s ECG Blog  Back Pain Radiating to the Chest in a man in his 40′s

Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction

Can Anyone Tell Me How I Got Here?

Tales of the Cunningham technique and one EP’s eventual journey to success through reverse engineering

The successful practice of medicine hinges on two things. A detailed grasp of medical knowledge, and being able to translate that knowledge into a positive patient interaction. For the emergency physician sometimes it’s a crash intubation, sometimes it’s talking to an elderly patient who lives alone about nursing home placement after their 4th visit to the ED in a week.

Whatever the road to a positive outcome for our patients, all physicians experience the nausea of staring into the dark chasm between knowledge and practice. Like neural dendrites gingerly reaching out to make a connection, the journey starts as a tenuous thread in the dark and can eventually become a well-lit pathway with clear signposts if given the right encouragement.

Giovanni Battista Piranesi

Giovanni Battista Piranesi: 1720–1778. An Italian artist famous for his etchings of fictitious and atmospheric “prisons”. He was a strong influence on the work of M.C Escher and his “impossible constructions”.

For me today the path comes in the form of learning the Cunningham technique for shoulder reductions. It’s no secret I’ve always liked doing joint reductions. Ask any of my colleagues and they’ll tell you I’m the first to jump in and help putting a displaced body part back where it belongs. I take satisfaction in doing them quickly, efficiently, and with minimal pain. I also like my patients to be happy with the whole experience; so it’s been a natural evolution for me to become enamored of a technique that requires less time, sedation or analgesia, and that makes my patients happy.

I started using the Cunningham technique about a year ago and I’ve refrained from writing about it until I had enough reduction attempts under my belt to make a post worthwhile. I think I’ve done about two dozen shoulders or more this way now, and I’m four out of five in the last two months (five out of five if you count some scapular manipulation added to one of them).

Like anything new I had plenty of failure in the beginning, and when I did achieve success I had no idea why, and couldn’t have reproduced it even if you put a gun to my head. Now I’ve reached a tipping point, and the Cunningham technique makes doing shoulder reductions feel almost like magic. Often I can see the signs of success begin to appear even before the humeral head slips gracefully into place. No secondary trauma, time-outs, sedation, traction/counter-traction, twisting, pulling or other nonsense.

How did this tipping point happen? Of course that’s the challenge of learning and subsequently teaching medicine.  It has never been a straight line from medical knowledge to clinical practice. Success requires absorbing a skill-set distributed across a multitude of strategies. Within these strategies are embedded a deep understanding of context, relationships, and timing; a detailed knowledge of our tools, and the logistics required to employ them. That “magic” experience of success is the emotional summation that all the pieces coming together to achieve a something good for one of your patients.  It’s one of the reasons I love my job.

However that “magic” experience of success is also why the signposts to it are so often invisible and thus difficult to teach. The signposts were there, but before you were in the dark. Now, you look back and wonder why you didn’t see them before.  It’s so obvious. But it’s the mind’s illusion that suddenly the light just went on.  In fact, a closer examination reveals an unconscious accumulation of multiple tools arranged across an array of skill-sets that allow you to consistently reproduce good outcomes.

How do you illuminate some of those signposts for yourself and others walking the path?  I don’t know exactly, It’s one of the reasons the EMBER project was started – a reverse engineering process in education.  Here are some of the signposts I’ve marked along my path with this particular technique that have helped me improve my success rate. They remind me that being a physician is about knowledge and skill, but also about context and relationships, pattern identification and intuition, resource management and logistics.

  1. Get the patient on board. Like most procedures on awake patients it requires co-operation, so explaining what you need them to do before you start and talking them through it is key. I like to think of it as a coach/player relationship. They are doing the work, you’re simply encouraging, leading and imparting knowledge. I also find that many patients find this active participation very satisfying and empowering. They get to share in the success.
  2. A little tincture of analgesia is never a bad thing, but once you get comfortable doing this you need very little or none at all.  The key is sizing up your patient.  Since there is no significant force or traction applied, if your patient is comfortable before the procedure, they will likely be comfortable during it. If they are uncomfortable before you start you’re going to have trouble, so give them something.  If they’re anxious treat the anxiety, if they’re in pain, treat the pain. Removing these barriers to success prior to an attempt at reduction just makes sense.
  3. Work on visualizing the anatomical and mechanical obstructions to reducing the shoulder. Surgeons have the advantage of being able to review this anatomy frequently in the operating theater, but we don’t have that luxury, so we must work with palpation, surface anatomy, and a visual image in our minds of the anatomic relationships. Use your eyes, your hands, and your mind to “see” the position of the humeral head and the barriers to slipping it back in place.
  4. The ideal position for the glenoid fossa is achieved by moving the scapula posteriorly and rotating it inferiorly.  This is achieved by having the patient sit up straight, adducting the rhomboids and having the patient drop their shoulders towards the ground. This is why having the patient sit in a chair is helpful and also reminding them repeatedly to sit up straight. It’s also why a touch of scapular manipulation by a partner can help in resistant reductions.
  5. The ideal position for the head of the humerus is to place the humerus in adduction with gentle internal rotation to present a greater articular surface to the glenoid fossa superiorly and laterally. This is why having the patient in front of you with your body to the outside of their affected arm is helpful to allow gentle physical reminders to keep their elbow in towards their body. Often I will stand or sit close to patient’s elbow to unconsciously force them to keep their elbow in and their arm internally rotated.
  6. Once the bones are in position it’s all about relaxing the muscles of the shoulder to overcome the dynamic forces that are pulling on the humeral head and trapping it, usually in a sub-glenoid or sub-coracoid location. This is why flexing the elbow and having them rest their hand on your shoulder is effective.
  7. Massaging the biceps, upper trapezius, and deltoid are equal parts physical and emotional. It is comforting, and it relaxes the mind and the muscles of the patient allowing the dislocated humeral head to “unlock” itself from its current uncomfortable position.
  8. Resist the urge to pull.  Remember muscle spindles?  Those sensory receptors within the belly of the muscle will actively resist excessive traction and make the spasming worse.  Once you are in the cycle of pulling and feeling resistance you are in a battle that can only be won at the cost of more force and likely sedation. There is also a psychology to this. If you radiate a relaxed and calm persona your patient can feel this and also begin to relax.  If you have sweat pouring from your face while you grimace and pull how can you expect anyone near you to be relaxed. Slow and gentle is the key.

Occasionally I have to revert to another method of reduction, or supplement this technique with scapular manipulation, but this is definitely the option I pick before anything else now. Once you feel the beauty of a non-traumatic reduction requiring no force you will never want to go back.  In my career I’ve gone from Conan the barbarian with heavy sedation, and traction-counter traction to Jedi mind trick:  “This is not the Propofol you’re looking for…”

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So You Have a Plan Right?

I saw a patient on the Big Island of Hawaii with serious intracranial bleeding on Pradaxa. Now it’s rural here, which means a dearth of specialty care. And so three months ago when his brilliant doctor in a major city on the mainland, switched him to Pradaxa for his atrial fibrillation (so he wouldn’t have to check his INR while he got settled comfortably into his retirement in Hawaii) his fate was sealed.  He arrived at the nearest hospital to him which had no intervention other than Vitamin K.  No platelets, no FFP, no neurosurgeon. Rapid diagnosis and a flight to Oahu for neuro/icu care was still meant several hours of continued bleeding. Things did not go well for him.

After I got home that night I watched the news about BP settling its federal lawsuit and I thought, what do the Deepwater Horizon disaster and Pradaxa have in common?  It seems obvious that any endeavor with a potential for serious risk should have a clear plan to deal with the most likely adverse outcome(s). In the case of offshore drilling, you shouldn’t be looking for oil at 1800 feet below seal level if you don’t have a viable plan to contain an oil spill.  In the case of Pradaxa, you shouldn’t be giving anticoagulants to patients if you don’t have a viable plan for  the most likely adverse outcome, bleeding. It’s really just asking for trouble.

To highlight this problem, the management of an overdose with the new oral anticoagulants was recently published and then discussed on one of my favorite blogs, The Poison Review, and the most notable revelation about these collaborative guidelines is that the best option ten organizations who focus on thrombosis and anticoagulation could come up with was, wait for it, wait for it….SUPPORTIVE CARE.

I understand that anticoagulation in certain patients is a valuable tool. But we all know the rapid spread of highly marketed medications to questionable patient populations is a given, and we already have an effective anticoagulant, it’s called Coumadin. Coumadin is far from perfect and the search for safer, more user-friendly medications is a worthwhile endeavor, but let’s be honest, we’re still far from a perfect solution.

Is Pradaxa safer? Did it show benefit over Coumadin? No. But when you watch the  ads for Pradaxa it sounds like huge benefit. Of course the fine print is that the benefit was found in patients with sub-therapeutic INR.  Maybe it’s not as “convenient” as the newer drugs, but even with reversal agents this medication causes a lot of morbidity, hospitalization, and death. So please explain to me how an expensive drug gets mass marketed before there is a way to appropriately treat the potentially fatal side effects when there is an equally effective drug we can reverse?  Never mind, I know the answer…


(As always, a collection of emergency medicine focused resources for our topic)

Guidelines for reversing overdose of dabigatran (Pradaxa) and other new anticoagulants

Anti-coagulated Patients In The ED – LITFL

Dabigatran (Pradaxa®) Principles and Guidance for the Reversal of Effect and Management of Life Threatening or Major Bleeding

Paucis Verbis: Overanticoagulation and supratherapeutic INR

Anticoagulation Reversal – ERCAST

iPhone Apps Now On Pinterest

1944, Howard Hathaway Aiken completes development of the Harvard MKI “Difference Engine

Medical technology has come a long way in the last century. It’s also become more personally useful. I love my iPhone and the peripheral brain it allows me to carry around.  I ask it questions all day long: “what’s the dose of that medication?  What is the starting rate for that drip? How sick is this patient with pancreatitis? Does this patient need a head CT? What are the normal vitals for that 11 pound infant? Where’s the nearest 24 hour pharmacy? Is my favorite coffee shop still open?”

Image of my current iPhone medical applications

The problem is it’s almost impossible to sift through the thousands of medical apps now on iTunes and find the ones that are good for working EPs.  I’ve written about some of my favorite apps before, but now with the advent of Pinterest I can collect them all for you in one place.  Check out the “Tools to Live By” board and find links to the full collection of medical apps I currently have on my iPhone.  If you have others you love, please leave it in the comments, or send them my way so that I can add them to the collection or review them here.

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All Together Now

Some of you may have noticed an upgrade to The EMBER Project’s Facebook page. The rapidly changing internet landscape opens up incredible opportunities for emergency physicians to learn and share online. It also presents challenges on how to stay up to date effectively in a wired world. The Facebook page is rapidly becoming the solution by acting as a nexus for The EMBER Project’s various social media platforms.

Currently The EMBER Project’s Facebook page is the central repository and distribution site for updates from our Blog as well as feeds from Twitter, Instagram, Pinterest, and Evernote. Each of these platforms offers a different learning opportunity; a chance to share information in exciting new ways that make emergency medicine online more interesting than ever before.

Now, when you go to our Facebook page you will continue to see all blog posts and other updates on the timeline, but you will also see links to each of the various feeds (Pinterest, Twitter, Instagram, Evernote). If you LIKE us on the Facebook page you’ll get regular updates from our various platforms all in one place.

The EMBER Project is almost six months old and continues to evolve; I’m excited to explore the various possibilities of our new updated online presence.

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A post here has been long overdue.  For those of you who know me, the month of July has been my transition from a busy urban medical center in New York to a busy rural ED on the Big Island of Hawaii.  My new colleagues are wonderful, and the nursing staff is great (the first time I went in to repair a lac and found the wound already irrigated, prepped, with the suture tray completely set up I nearly fell over).

The most notable change is of course the acceptable attire for a day in the emergency department.  Amongst the things I’ve discovered in my first month is that the pattern on Aloha shirts can actually hide a great deal, Moray Eels are not to be trifled with, Wana (pronounced Vana) is painful, and waiting on the air rescue team during inclement weather while you watch over your deteriorating STEMI patient is anxiety provoking. Some of this will be part of the upcoming educational posts I have planned for August.

Aloha. The Ember Project moves to Hawaii

One of the traits that drew me to Emergency Medicine as a specialty is the resilience and creativity of its practitioners in the face of an endless array of unexpected and challenging clinical situations.  Nothing epitomizes this more than the rural emergency physician.  I’m already very impressed, and looking forward to growing as an EM doc in my new home.

Happy Independence Day

The Devil is in the Details

If you look to the right on this blog you will notice that I recently retweeted a great pearl from the Critical Care guys (@critcareguys) about hanging the Zosyn before the Vancomycin in severe sepsis patients.  They remind us that Zosyn has a broader antimicrobial spectrum and goes in faster, potentially offering greater benefit to your sick patient.

This has always been my practice, but I can’t tell you how many times early on in my career I found the Vancomycin hanging first. This used to drive me crazy, until I figured out what was going on. As it turns out this seemingly simple tenant of good care is one of those “devil is in the details” problems that no one tells you about.

Vancomycin is pre-mixed and quickly available in most EDs.  Zosyn is also readily available, but has to be reconstituted, which as any nurse will tell you is a pain in the ass.  Now in the age of EMRs the orders for the Vancomycin and Zosyn are placed together and no face to face communication happens with the nurse.  Now they’re busy too.  They see the antibiotic orders, grab the Vancomycin because it’s premixed, and they have 15 other orders to take care of.  That gives them an hour before they have to shake and bake the Zosyn.  Ta dah! Now you walk into the patient’s room 45 minutes later to see your septic patient with the slow drip of vitamin V instead of Z.

I have a method for dealing with this problem (it’s number 2), but it becomes an issue again if you work with residents or mid-level providers when I ask the dreaded question, “did patient x get the Zosyn?” And the all too common answer comes back “yes, I ordered it”  (which actually means no, or I don’t know to me until proven otherwise).  So unless you know your resident or PA, make sure they know what you want and what they have to do to make it happen.

So there you have it.  I have tried all three of the methods below to make sure the Zosyn goes in first.  Anybody else have a method?

1.  Put the Zosyn order in first,wait 20 minutes, and then put in the Vancomycin order. (Time consuming, inefficient, and not guaranteed to work)

2. Just talk to your nurse and tell them what you want first and why. (your best bet, and it fosters communication..if you like that sort of thing)

3. Hide the Vancomycin until the Zosyn is hung. (just childish)

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Lessons From One Hot Joint

One thing I love about Emergency Medicine is that no two cases of the same disease are ever exactly alike.  Yes this can be anxiety provoking, but I prefer to think of it as akin to great jazz tunes – it nostalgically reminds you of other versions of a song you’ve heard before, but the players and the riffs are distinctly unique.

A case in point, the hot joint has presented some interesting challenges to me on a number of cases.  Most recently, a thirty something intravenous drug user with several days of increasing pain, redness, swelling of her left shoulder appeared for all the world to be a septic joint.  She had a great history, classic presentation, and initial labs showed and white count, ESR, and CRP through the roof.  Now I love doing taps, but in our ED we involve orthopedics for many of them, particularly the shoulders.  The talented orthopedic resident to my surprise was not interested in tapping it.

My initial response to him was that no matter what you tell me the pretest probability that this IV drug user has a septic joint is so high, no test other than an arthrocentesis is going to satisfy me.  But the orthopedic resident had some interesting and valid concerns, and the more I thought about it the more I recognized that there were some interesting clues along the way that led away from a septic joint:

1. The pain began after direct inoculation with a needle into the shoulder (rather than by hematogenous spread of bacteria to the joint from an intravenous needle) so it seemed unlikely to me that the patient had jammed a needle all the way into her glenohumeral joint.

2. The patient really didn’t want to move the shoulder at all, and was guarding it gingerly, but in fact with gentle passive range of motion there was a few degrees of flexion and extension, in contrast the patient did not want to abduct at all, offering the possibility of an infected subacromial bursitis

The orthopedic resident was concerned that putting a needle into the joint through an infected abscess or bursitis would potentially seed a sterile joint with bacteria and make things worse, so we agreed on a quick initial ultrasound. This was read by radiology as a septic joint, with increased joint space fluid and surrounding reactive hyper-vascularity.

At this point we tapped the joint.  Our posterior approach was a dry tap.  Frustrating as this was, it was clear we were in the joint space, but there was nothing.

So what now.  If this was a deltoid abscess, having orthopedics open up the joint would be a mistake.  An MRI would have been nice but she actually had an old needles embedded in her shoulder from prior injections so that made radiology put their foot down on that one…

So a CT of the shoulder was done which again was read as a septic joint with fluid around the joint space.  Remarkably the joint space itself was well-preserved on my read of the CT, which seemed odd to me.  My only thought at the time was that the direct inoculation of the joint had made a tract anteriorly through which the pus was draining and surrounding the joint capsule externally.

Ultimately orthopedics took her to the OR.  There they found a septic bursitis that had ruptured anteriorly and surrounded the joint capsule with pus and fluid.  The integrity of the joint itself was well maintained.  Ultimately, the patient did very well and went home several days after admission on antibiotics.

The take home points for me.

  • Think about abscess or infected bursitis before sticking a needle into a joint.  You could make things worse if you plunge a needle through infected tissue into a sterile joint space.
  • Any inflammatory markers in this situation are utterly useless.
  • Imaging can be falsely positive and may again lead to attempted arthrocentesis.
  • Complex infections around a joint are still best served on orthopedics.  There was some discussion about general surgery involvement for abscess drainage, but given the high likelihood of joint involvement in an equivocal case like this orthopedics is better equipped to debride and wash out around joint structures.

Until recently most of my thinking about red-hot and swollen joints are “what fun I get to tap it” and second I think, “when do I get to tap it”.  This general teaching holds true for most cases, but I have recently been humbled by missed taps, indeterminate taps which turn out to be infectious not inflammatory, and the reverse, cases that got unnecessary wash-outs.  So my belief that the hot joint is the last bastion of simple diagnostic procedures in the ED has been finally crushed.  There you are, you either love jazz or you don’t…


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