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SEPT 12 I like to start out EMU each month with a useful article that goes against the grain but this one was too interesting to pass on for the number one spot. And it comes from JEM 41 (2)124. MRSA is the rage these days and they studied their ED for MRSA on all sorts of surfaces- is this monster going to be on telephones, computers, desktops, in your living room telling you what you can watch on TV etc etc? The answer is actually no. They only found it in one place. However, do not jump on this study so fast. They only tested forty places and the one place that was positive was multi drug resistant. Furthermore, this study was done back in 2006 why it took five years to publish-is beyond me- and MRSA was a lot less prevalent in the community in those days. So in my opinion this guy is just weaiting to mug you even in the ED. And while you are probably carrying around this bug for years (interesting idea for a study) - protect your patients by washing your hands and changing your clothes often (No not in the middle of the ED). However that last recommendation is flawed also (no; not that part about changing in the middle of the EDunless you are really cute). This article compared newly washed short sleeve white jackets with the old lab coat you have been wearing every day for about three years. The MRSA rates were similar after an eight hour work day
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Drip and Ship- can you do it? Question to ask firstwhat am I talking about. If you believe in TPA for new CVAs so do you really need to keep them in the ED until the process is completed? Well in this study they all did well but the authors do admit it was a tiny study (ibid 135). However, since the TPA guidelines are so restrictive these patients are generally very healthy and have a low risk of bleeding in any case. TAKE HOME MESSAGE: You probably do not need to hold stroke patients getting TPA in the ED until the drip is done.
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Counterfeit medicines and supplementsposean enormous public health threat. The World Health Organization estimates that 10% of global pharmaceutical commerce is in fakes [1].Apart from counterfeit prescription medicines there are products labeled "natural supplements" that are illegally
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This will never fly in the ED, but perhaps will help our FP readers. If a pregnant woman knows her blood type and Rh status, there is no need to repeat it unless you are about to transfuse her.(ibid 223) While there were no serious misses on the Rh side (one woman thought she was negative when she was positive) the few misses on the blood type may have serious consequences. Use it as a guide however. TAKE HOME MESSAGE: Probably do not have to repeat Rh status in the clinic in pregnant patients if the patients know their status. 5) I really do not know how EMS folks are trained- and when we have our EMS roundtable we will know more- but in my country the EMS guys get no driving instruction. In this article EMS deaths were most commonly due to aircraft fatalities and vehicle crashes. They often have strains and sprains as causes of non fatal injuries but I am unaware of any conditioning programs that EMS guys do in my country. In short it is a dangerous job. (J Prehosp Care 15(4)511 ) Despite all this, I am unaware of any fatalities in my country. TAKE HOME MESSAGE: EMS personnel are exposed to musculoskeletal injuries and vehicular injuries that make
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interesting. I got an 81 year old fellow taking colchicine, aspirin, enalalpril, norvasc and bisprolol for hypertension and gout. He takes nothing for his hyperlipidemia. His blood tests reveal a WBC of 1.52 where it was normal (8.1) three months ago. His hemoglobin is stable at 11.9 Chemistry reveals a sodium of 138, potassium of 4.4, urea of 79 and creatinine of 2.1 which is new. He has less than 500 neutrophils but they are normal. There is no fever. Not such a hard case, but ... 7) Post thrombotic syndrome occurs in patients with DVT who get better with anticoagulation but remain with swollen legs with a 3-5% risk of ulcers. We have all seen such patients and there is little we have to offer them- but this article gives a simple although relatively unproven way of dealing with DVT that avoids this syndrome- catheter
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here is something similar : OK, guys- do not get on my case- I know this is a picture of a skin fold and a pneumothorax- but that doesn't change the point. (Courtesy of USUHS) TAKE HOME MESSAGE: Blebs and skin folds can cause pneumothorax pictures- CT if you aren't sure. 9) I liked the idea but as usual it leads no where. Troponin can tell us about the MI in patients with normal EKGs, so it would follow that there should be good markers for TIA just like with the heart. The problem is that TIAs by definition cause very little damage and the blood brain barrier prevents the leak of any enzymes into the general circulation. Now they have found a genetic test to find who
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There is an assay to determine a person's tetanus status and this would save us some much in those patients that do not know their status. This Iranian study was problematic however. (AJEM 29(7)721). Firstly, this does not take into account an amnesic response. Secondly the cost of an immunization is so cheap and the side effects of an unnecessary immunization is so low, it probably doesnt justify doing the test. And of course, we do not know who paid for the study. TAKE HOME MESSAGE:
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Islam. And there is no truth the rumor that his real name was Steven Katz and that he was Jewish, Actually his real name was Steven Georgiu and he was actually Greek (although he lived in England). 25) Yawn- case reports. But I want to use this as a reminder for the "if all else fails, pull this chain"
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. Lipid emulsion has been used for local anesthetic toxicity, lipid soluble drugs (such as lamotrigine) and also calcium channel blockers, beta blockers and anti depressants- all ferocious overdoses. Since cocaine is both an anesthetic and lipid soluble they tried it on an unstable drug overdose and it worked wonders. (Anaesthesia 66(12)1168 ). Just keep this in mind I think we are still evolving as to where and how we can use this stuff. TAKE HOME MESSAGE: Lipid emulsion may help for cocaine overdose. 26) This idea has been thrown around and they want to say that empathy as perceived by the patient results in improvement in colds in patients that have them- and ergo may help other conditions (Pat Ed Counsel 85(3)390 ). They measured disease oriented outcomes- interleukin levels which doesn't help us much but they also studied severity and duration - which are patient oriented outcomes- and
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So while you are being a genius- what is this? Hint: it isn't blistering dactylitis. But you knew that. Just don't open it and don't give antibiotics. (Ind Ped 48(8)665 ) By the way we have one reader from India and I wanted to say that this journal has been quoted often in these pages because it really is a good journal. Try it out sometime. 30) If you really do not know how to handle fingertip and nail bed injuries then this basic article may be a good one to read, but we will highlight some points that were perhaps less obvious. Subungal hematomas I thought- do not need exploration. They say it is controversial. I think there really is no reason to do so. Using glue if you do want to close a laceration on the nail bed seems like a better idea then attempting suture repair- the skin is very friable in the nail bed. Fingertip lacerations- re attach the
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If I may add my thoughts- it is true we see a lot of vestibular neuronitis in the ED, and many of us have not found re positioning maneuvers to help much in the ED and end up admitting a lot of these patients. But I do believe recurrent BPPV does occur just like biliary colic and do succeed in sending some of these folks home. Thanks Rick for writing. And yes-if you do not yet know who Rick is-go up to the CCME website and get a hold of his monthly programs. If you are a primary care doc- he has audio programs for you too. 36) And Dr. Simcha sends us a listing of articles that recommend vitamin and mineral therapy for many serious conditions. The letter is too long to print but here are some of the articles: Vitamin B 12 given parentally can blunt the response to sepsis (this article checked surrogate markers of inflammation and sepsis), Vitamin C given IV once at the start of sepsis can attenuate the sepsis (also same problem of surrogate markers). Ditto for melatonin in
result in a person begin hospitalized for symptom control. Cause is really unknown.
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Scott and Simcha- thanks for writing, and Scott if you are still reading let me quote HL Mencken for you as you do practice in New York: Every great wave of popular passion that rolls up on the prairies is dashed to
spray when it strikes the hard rocks of Manhattan. H. L. Mencken
And a warm Hello to Dr. Y , our cardiology consultant (unfortunately efforts to get Amal Mattu to subscribe to EMU have not been successful but we are still trying) whose comment on last months' article about ST elevation with Q waves- I commented that they also do not know when it is real and when it is an aneurysm. His comment was **&%$#@+)~@@!
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Winchester
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by Gary Burghoff,
Harry Morgan
Wayne Rodgers
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Farr,
Loretta Swit.
This article had a real bent towards Australian indigenous children and I am not sure how that applies to the rest of the world (apparently there is a difference between indigenous and not indigenous children in Australia) but aside from that caveat- a well done article. Otitis media is defined as a spectrum of three separate entities. Acute otitis media, otitis media with effusion and chronic suppurative otitis media. And if you understand that that is quite an accomplishment. In a recent survey of 165 clinicians they got 147 different clinical definitions of AOM, with no definition agreed on by more than six clinicians. So this says: if you just say I do not know what this so I'll just slide them over to an ENT- you're are an idiot and he probably is one too, being that he is probably one of the 165 clinicians. Let's use their definitions. AOM requires acute onset- less than 48 hours; fever, and middle ear fluid bulges or absent movement of the tympanic membrane (you need a pneumatic otoscopy) and redness. Think about the last time you diagnosed AOM and tell me if you had all three of these criteria. Effusion is shows signs of fluids. Chronic suppurative OM shows pus though a perforated tympanic membrane- but this is a persistent problem and usually isn't called CSOM unless two weeks have passed. 2) Who is at risk for OM? Cleft palates, day care, tobacco smoke, pacifier use, and breast feeding and lack of breast feeding. Confused? All of these "risks" are modest. And what they meant with breastfeeding is that breast fed but not for a long time or not
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And in case you are afraid you might confuse it with another entity here is the most confusing similar condition
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so I dedicate this picture to him: (and yes- Greg stills wears the suit jacket that this fellow is wearing) 9) And lastly one last M*A*S*H quote Frank: I am a great doctor- just ask any of my patients. Trapper John: Frank, We cant dig people up just for that.
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