Is a Missing Lip an Emergency Condition?

The medblogs are buzzing about University of Chicago's decision to treat a boy attacked by a pitbull without surgery.

Shadowfax has posted multiple times, most recently here; WhiteCoat has picked up on it here; and Scalpel has replied with a vigorous, bracingly conservative ripost here.

These three and others have framed the question as an EMTALA violation; is this a patient dump, or not? Is it illegal, or not? I'm more interested in how it framed the plight of modern EDs. I don't think, from what I've read, that there was an EMTALA violation. The boy was 'treated', and although his cosmetic outcome may well have been better, according to Dr. Grevious (no joke) once mom carted him across Chicago for immediate surgery, I think UCMC has a case.

More interestingly, the question is how can overwhelmed EDs possibly respond to crushing patient loads, the loss of subspecialty coverage, the mandate to see any and all regardless of pay, and all of this increasing as more and more EDs close and the federal government that forces us to see everyone subsidizes less and less? This on top of California's recent court decision that legally prevents EM groups from seeking additional compensation for services rendered from the patient. From our perspective, what exactly are we supposed to do? Chicago was trying to dispo out people who don't need emergency care. That's OK with me; tons of people abuse the ED although they are overall the minority. I think they picked a horrible time to do it with this kid--but, then, maybe they did it on purpose. No plastics available? Fine. No subspecialty care? Fine. America, this is what you get from us, they are (possibly) saying. You get the care you pay for. And when co-pays in the ED are zero, medicare reduces payments towards zero, states disallow collection of fees, we all end up with...well, zero happy stakeholders.

It's easy for me to say I care about cosmesis and wound outcomes and I'll fix a lot. I didn't see the kid, it might well have been beyond me, and besides, I work in a pediatric ED sometimes with triple attending coverage and three or four residents for twenty rooms, and we still have visit times up around four or five hours. I can see UCMC's side, easy--even if I also feel for that poor kid who couldn't get his lip sewn after he was a chew toy for a pit bull. If we can't take care of that, we're in trouble. Maybe UCMC is just pointing that out to society.

Undue Influence?

Thought this was a great shot. On anesthesia at the VA, one of the retiring PAs brought in his pen mug from his office and these were my top choices for classics. Interesting how long big pharma has been plying MDs with free pens--not that we should be interested, it seems like we could afford our own pens. I still don't understand why MDs are interested in these. The trip to Hawaii I understand.

I've taken an oath here to avoid pharma influence. So far it's been easy. The county where I went to medical school outlawed drug reps, and my residency program has a policy of not taking any money or gifts from pharma. Just wait for the community, right?

I think the Versed pen is my favorite. I was tempted to take it, I admit.

Rant

This is a rant. Fair warning.

OK. Reasons NOT to bring your kid into the spanking new high-quality 20 bed pediatric only ED with 6 resuscitation rooms and triple attending coverage.

Number 1. My kid's foot jerks in his sleep sometimes. I videotaped it. It happens, like, every five minutes. He keeps sleeping but he, oh my GOD, like rolls over. I brought him in here, not so you ED docs could look at him because you don't know what seizures are, but so he could get an MRI and a STAT Neurology consult (I didn't tell her that was an oxymoron). Yes he has a fever. Yes he has a cold. Yes he's 18 months. So, A, that's not a seizure, it's sleep myoclonus, and B, even if it were a seizure and it were generalized, even up to 3 or four minutes, it would be a febrile seizure and he wouldn't need an MR. Let's say you're right and he is having focal seizures, just for the sake of argument; if that were the case, he has a fever so I have to 1, CT him, which is radiation which you don't want, and 2,tap him which you obviously won't like if it bothers you that his itty bitty widdle foot twitches in his sleep. Honestly. I'm not trying to deprive you of your God-given right to a stat MR for sleep myoclonus. I'm trying to avoid giving your kid leukemia (now thought to be perhaps as high as 1 in 1000 for early CT exposure). Sigh.

Number 2. My otherwise well kid really didn't sleep well last night and he has a runny nose. Guess what? My kid didn't sleep last night either, because despite stripping at the door and sprinting to the bathroom to wash my hands, I still am covered with stinky-germ-goo from people like you and all my kids, my wife, and I, are sick. I still came to work. My kid is at home. He woke up ten times too. My wife, who feels sick, is at home taking care of three sick kids so I can have the joy of telling you it's a virus and you should, like, suction his nose and let him rest. Christ.

Number 3. On to annoying primary docs (many are good, I'm not yelling at them). My patient is totally fine, but she has a bump on the back of her leg that doesn't hurt at all. She fell a MONTH ago on her shin and couldn't walk for a day and now is better. She has NO feverchillseasybruisinglossofappetitenauseavomitingdiarrheacoughheadachemalaise. You, smart PMD, told this poor lady and her two kids to come DIRECTLY to the ED for EMERGENCY hematology consult and EMERGENCY orthopedic consult. Apparently small, painless, barely noticeable calf bumps are outside the scope of practice for this particular generalist pediatrician.

Number 4, a special shout out to the receptionist. Thank you, oh thank you, for telling the chronic abdominal pain patient who, to their credit, is not requesting drugs or mega work-up, to come DIRECTLY to the EMERGENCY DEPARTMENT (so named because it is for emergencies, not clinic visits) so that we EM docs can arrange for your doctor to see you in the ED because he's over at the hospital today. Please, please don't tell the patient they can be seen in clinic by one of the doc's colleagues. Please, please don't tell them to make an appointment, God forbid, tomorrow when the doc is back in clinic. No, no. Send them directly here. I'll see them right after the runny nose, the calf bump, and the jerking foot kid.

Airway Tip O' The Day

A colleague on flight had a horrendous trip the other day to a blast site. One victim was talking, had normal vital signs, but was hoarse and covered in black soot from the neck up due to the blast.

An indication for a tube if ever there was one; it had only been sixty minutes or so from the time of the blast and already she was unable to pass a tube a full size smaller than needed, and saved his life with a rescue device instead (a King LT). Which leads to the airway tip o' the day.

A bougie is a long, flexible plastic thingee used to find the trachea by feel and by the bend at its end, over which you can then pass a tube. Usually I think of it as a means to improve an airway with a bad view. She had a great view; he was just too swollen.

The tip is to use a bougie even with a great view in the setting of airway edema; if you can't pass a tube over the bougie, leave it in place, go one size down, continuing until you pass something.

Of course, this being the great frozen north, it was seven degrees where she was trying to intubate without the windchill, so the bougie probably would've snapped. The O2 tubing had already frozen. Sweet. Can't wait to start flying.

GCS of Seven

Most kids aren't that sick in the ED. Some are downright well. After working there for a while, you're sicker than most of them because they've given you GI junk and URI junk and maybe some rash junk, too.

When they ARE sick, good God, it's scary. We had an ambulance call, not a trauma call, come in the other day, of a 3 year old, head versus TV, and 'altered'.

To prepare in my head, though I would never be the one to do it as an Intern, I reviewed RSI doses--0.2 mg/kg etomidate, 2 mg/kg succinylcholine, estimate for a 3 year old about 15 Kg, so 3 mg and 30 mg.

He came in moaning, not in a C-collar, his right arm flexed, eyes closed. GCS? 1 for eyes, 3 for pediatric moaning, 3 for flexion posture--seven. Needed a tube.

We took him into the trauma bay, and held C-spine precautions while I realized I didn't know how to work the C-collars we have at children's because I've never done it. Having never done a peds trauma resuscitation, I was sort of useless--I could hold the bag on and do the ATLS algorithm in my head, but so what?

IV in 2 minutes, intubated in 5, CT scanner in 10. Pretty good. The kids are so small and everyone is so intense, pediatric traumas are frenetic. Everyone is close together. The sphincter tone in the room is incredible.

His CT scan showed a skull fracture and air all over, with 2 mm of midline shift. Hopefully he'll do better.

That's Peds EM this month--95% BS snot and wheezing or their leg looks funny but doesn't hurt, and 5% holy crap.

I'm Sorry, Man

The picture here is from the first page of Beowulf--not the CGI version that was produced with Angelina Jolie but the oldest surviving piece of English literature. It's a testament to how important words are, and for how long we've struggled as people to get our meaning across.

Imagine, then, not being able to find your words. Imagine speaking in truncated sentences, stopping in the middle, fumbling. This is a finding called non-fluent aphasia. Sudden onset of speech difficulty is often listed as 'slurred speech' in stroke education, but that is actually dysarthria and comes from loss of control of the muscles of the mouth and tongue to some extent. Aphasia is a stroke that somehow involves the higher cortical functions of language, and patients literally cannot find the words they need.

A gentleman came in with this last week. It had first happened in Mexico, on vacation, and then resolved somewhat; it had returned four hours before arrival and it was his only presenting symptom. Histories like this make me sad. It was no doubt what he had. There was an upside--he had very few deficits. But imagine not being able to find words anymore.

Imagine being mute not from some physical ailment but from literally not being able to get to that word or phrase that is dying to come out. It happens to all of us (ironically, for me the other day when I was trying to remember the word 'dysarthria')--but this is different. He stopped in the middle of almost every sentence, and he made grammatical mistakes normally heard in an ESL class.

His main question? When can I go back to work? He worked in business, had meetings all day. Not soon, dude. Not soon.

Shaken or Stirred?

When James Bond says how he wants his martinis, both choices are refined, the choice is a test of internal character, of dashing charm. In the ED, though, it never seems to work out that way...

Part 1: 'Stirred'

A middle eastern fellow comes in complaining of 'twitching' and a funny feeling in his chest, and, sitting on the gurney, shakes his extremities violently and spasmodically, going red in the face. He still responds, asking, 'what is it, what is it' that makes him do this between episodes, and even throws up a couple times. He gets pads, monitors, a non-rebreather, and serum and urine tox.

History reveals that he's had 3 full-size Red Bulls that morning alone (it's about 10:30). He also says 'someone blew smoke in his face' and he didn't know what it was, right before he started jerking all the time. Riiight. U Tox comes back with...hmmm...cannabinoids. I go to tell him and have to excuse his father and older brother; his mother, covered head to toe in a hijab (they're Jordanian) doesn't speak English and just looks at me with a smile while I tell her son he's a pothead (which he denies, must have been that guy blowing smoke at him) and it doesn't mix with Red Bull. His father wants to know if he's doing drugs. I said, "I can't tell you, but as a father, you should parent him as you would based on your own impressions". The dood (thanks Nurse K) denied any pot use. Right.

Part 2: 'Shaken'

I'm walking down the hallway minding my own business when an uptight lady standing next to a gurney says, 'Are you an attending?' then before I answer, says 'I'm doctor so-and-so from the Children's hospital ICU, and I need to talk to you right now.' The Children's hospital is adjoining ours, and corridors connect us. She then gives me sign out about this guy who started having 'a seizure' in the cafeteria of Children's. Later the nurses said she was totally rude and I wish that I had told her something about EMTALA violations (since he was on Children's premesis) but I didn't. The guy is still shaking all over but looking at us.

'Sir, can you hear me?' He can. 'Can you stop?' He can. Sweet! Cured.

I start examining him briefly and tell him we're going to get a few tests--and he refuses blood draw. My staff comes in, and says--'Hi, Howard. We're not going to play these games today, OK? You give us blood and let us evaluate you, or you leave now'.

Howard starts shaking again, this time on his feet--miraculous how he can do that--then pretends to fall. Refuses blood draws. He gets put in a wheelchair, and says, 'I'm going right back to the cafeteria to have a seizure!' 'Go ahead', the attending says. He starts shaking in his chair again. 'Knock it off, Howard', says the tech, and he does. To myself, I'm thinking, did that ICU doc even look at this guy? Probably not. Way too old.

So the ED shaken or stirred question, not so glamorous. But way, way more fun.

How Much Does She Drink?

Sometimes, I'm a dodo and it's good that I'm supervised.

Sixty-ish African-American lady who came in seeing mean white bugs on the walls, and colored squares on her body that came and went, as well as a new tremor, shortness of breath, and minimal chest pain, BP 210/120, HR 130, SOB. She was diaphoretic, tremulous, anxious. She had been seen at another ED and diagnosed with anxiety.

I did a careful history and physical. She was seeing squares at the time. 'Are they friendly?' I asked. I can't help but mess with psychotic people. 'I'm not sure', she said. My differential included thyroid storm, encephalopathy 2/2 the hypertension. The attending asked, 'does she drink?'

Well, @&*%$#!, I didn't ask. Back to the room.

Ma'am, do you drink alcohol?

Oh, yes.

How much, would you say, on average?

Oh, four or five drinks a day.

When did you drink last?

Well, New Year's Eve; that was five days ago.

Peak for DTs. I'm an idiot. 2 mg ativan IV and dispo done. Sheesh. Thyroid storm.

FMOE: Toxicology Case Answers

Case 1. 21 year old genius shows up in the ED. His girlfriend is concerned because he seems weak, acts like he's drunk, and is unsteady on his feet as well as slow in his responses. She is holding a plastic bag with what smells like model glue in it. Afebrile, RR 23, HR 80, BP 120/68.

1. What chemical element was this genius probably exposed to, given the odor?

Toluene is desired by high-seekers for its rapid CNS absorption and quick high; the toxicity here is obtundation, which usually clears quickly. Chronic users kill brain cells and become demented. Hydrocarbon ingestions typically damage the lungs more, but toluene goes straight for the CNS.

2. What secondary disturbance is likely causing his symptoms, especially the weakness?

Toluene can simulate a renal tubular acidosis and lead to hypokalemia and hypophosphatemia.

Case 2. A 25 year old sportsman was golfing when he felt a prick in his finger with some scant bleeding after searching for his golf ball in long grass. He finished the round, and now has increasing pain and swelling in his hand. He is starting to feel a bit weak. Temp 99.5, BP 85/50; right hand is tender, swollen, and bruised.

1. What happened? What are you worried about next?

This case best fits the effects of a snake bite; rattlesnakes are most common, and local tissue necrosis is common to most varieties. Some rattler varieties, specifically the Mojave rattler, will cause neurotoxicity, but only in the SW US, where you also find plague, hantavirus, and various other sundry complaints like coccidiodomycosis.

2. What is the treatment?

Crofab, so named because it affects crotalid venom, the main genus of snakes in the US.

Case 3. A 4 year old girl is brought to the ED by her worried grandmother (mothers always let grandma take over these days). She has not been her self; she is sleepy, and vomited once earlier. She found an empty bottle in the girl's room. She gives it to you; it smells like Icy Hot (NO USING GOOGLE!) There isn't a label. Temp 38.2, HR 130, RR 36. Exam reveals a drowsy, slightly diaphoretic child, with coarse rhonchi bilaterally.

Basic labs: sodium 142, chloride 104, potassium 3.4, bicarb 15, glucose 78, creatinine 0.8, BUN 12.

1. What did the kid drink?

Although med students all know that aspirin overdose gives a classic metabolic picture, I didn't know until I smelled oil of wintergreen that the oil is chock full of salicylates. In fact if you look it up on wikipedia, it's the main ingredient. So don't keep it in your medicine cabinet where your kids can get to it.

2. Med students, what is the disturbance seen in the labs and vitals? What can you do to treat her?

Med Students will be able to tell you better, but salicylates create a mixed metabolic acidosis and respiratory alkalosis through direct stimulation of central breathing centers beyond physiologic compensation. There's some computations to do...maybe later. As far as treatment, you can start patients on a bicarbonate drip to alkalinize the urine and trap the acid in an ionic form. ASA is also dialyzable.

Case 4. Three sixteen and seventeen year old males (automatic geniuses, I was never stupid when I was that age) arrive in the ED, combative, mumbling, and completely incoherent. Found by the fuzz drinking funky tea. A representative exam on genius 1, temp 102.5, HR 140, BP 140/70; agitated, small pupils, with red, warm, dry skin.

1. What is the toxidrome (for non-medical readers, mostly my parents, a recognizable set of symptoms that identify a specific toxin)?

This is a classic case of jimson weed ingestion. This plant, believe it or not, grows all over the US and, when boiled, is a mild hallucinogen and a strong anticholinergic. The toxidrome is dry, flushed skin, tachycardia, dry mucous membranes, fever, slurred speech, hallucinations, tiny pupils, urinary retention, consipation.

2. What is the antidote? When you would you use it? When would you NOT use it? What else can you give them?

Physostigmine is a direct cholinesterase inhibitor, thus increasing the level of acetylcholine and reversing the 'anti' choliergic effects. It does, however, prolong the QT interval and precipitate VT, I think, in cases of TCA overdose, a class which has anticholinergic effects. So, in a kid who got into the cabinet, it's not a good choice unless you like coding little kids. You can also use benzodiazepines and bicarb. I'll have to look up why bicarb works.

Case 5. 3 year old Max is brought in by his father reeking of garlic, vomiting garlic, and not acting like his usual self. Temp 37.4, HR 145 and regular, RR 42. Hyperactive bowel sounds, coarse rhonchi, constricted pupils.

1. What did Max ingest? Why is it not illegal?

The garlic odor is characteristic of carbamate insecticides which reversibly bind to cholinesterase and cause the opposite of jimson weed--or DUMBBELS, defacation, urination, miosis, bronchorrhea, bradycardia, CNS excitement, lacrimation, salivation. Atropine works (see below), and so does benadryl in large doses theoretically. The other toxins in this class are organophospate insecticides, which are irreversible but take time to convert, and Sarin gas, which is irreversible and converts almost right away. I think these should be illegal. They're poison.

What is the treatment? Hint: he should talk to the geniuses above and get some of their tea.

Electrolyte Emergencies

The Cancun congress on EM had a great lecture available for download on electrolyte emergencies. I had wanted to look at these when I was on medicine, but they had a, well, different approach that took forever. This is much more EM specific.

Hyperkalemia is the most dangerous abnormality; the most common cause is 'not', that is, a lab draw error, hemolysis with the draw, and so on. An EKG guides how we treat the patient, so the first step in a work-up is re-draw and get an EKG.

Causes: Not; renal failure with acidosis; drugs over weeks or months (ACEI and ARBs, NSAIDs; and cell death (burns, tumor lysis). There are other causes, but these are the big ones.

EKG changes: tall T, loss of P, QRS widening, PR lengthening, sine wave (um, bad).

Treatment: calcium is only used in an emergency, defined by a widened QRS on EKG. Calcium for QRS (calcium chloride, it's faster), 2 amps of d50 and 10 U insulin, bicarb if acidotic but only if acidotic, albuterol nebs, fluid if hypovolemic.

hypokalemia=prolonged QT with U waves.

hypokalemia=hypomagnesemia, and K always goes with mag. We must replete both. If you don't give mag the K will stay intravascular and be excreted. The deficit is always worse than you think.

So, if you give K, give mag. Treat with EKG changes.

Hyponatremic emergencies manifest as altered mental status. Causes include runners drinking too much, women more than men, X use with dancing all night--water intoxication and hyponatremia. The big worry with hyponatremia is seizures and the AMS; the big worry with repletion is central pontine myelinolysis, or the so called 'locked-in syndrome', which is truly awful. Never correct a patient with symptomatic hyponatremia faster than 0.5 an hour or 10-12 a day. Seizures with Na below 120, like 100 or 110; intial 3% NaCl MAX 200 cc total, start with 100 cc bolus over 10 minutes. Must be previously healthy. So, the gorked out nursing home resident on diuretics and who knows what else who comes in 'just not themselves' with a sodium of 118 should not get 3% NaCl. The 19-year-old clubbing person with an empty water bottle seizing at 5 am with a sodium of 105 should, in two boluses, as above.

See? Much easier than the old hypovolemic-euvolemic-hypervolemic triad just for sodium and so on for each electrolyte...see this post.