TWITER 1.2

twiter1A mom brings in her 5-year-old daughter to the ED for a persistent cough of over 2-weeks.  She states the cough gets so bad at times that the patient has difficulty breathing.  The patient is nonimmunized based on religious belief.

Diphtheria Pertusis (Whooping Cough) in an Unvaccinated Child

  • Bordetella pertussis is the causative organism.  It is highly contagious and spread by contaminated droplets
  • Infection typically occurs in nonimmunized or partially immunized children and adolescents.  It is also known to occur in adults since the immunization series does not guarantee life-time protection.
  • Clinical presentation is divided into 3 stages
    • Catarrhal (up to 2 weeks) – mild fever, rhinorrhea, conjunctivitis
    • Paroxysmal (2 to 4 weeks) – unremitting paroxysmal coughing followed by a “whoop” (listen here).  May occur 40x per day.  Post-tussive emesis is common.  Listen to a more severe case. Apnea and choling spells are not uncommon.
    • Convalescent (weeks to months) – residual cough
  • Older children commonly misdiagnosed with “chronic bronchitis”
  • Treatment
    • Erythromycin-based antibiotic (azithromycin, clarithromycin)
    • Hospital admission (with isolation) for patients < 1-yr-old or any patient in respiratory distress
    • Monitor for valsalva-induced-bradycardia and hypoxia
  • Highest mortality in children less than 1-year of age (highest in first month of life)

TWITTER notes (This Week In The ER) is an educational resource that presents high-yield, case-based information from actual patient presentations in the ED.

radER 3.1 Answer

rader new

Winners

Brian Junnila           Claire Jensen             Krisit Bernath

Shereaf Walid          Rob Klever                  Kyle Perry

Devon Moore          Mike Fernandes        Katie Ohlendorf

Bao Dang               

Case

A 33-year-old man presents to the ED complaining of left thumb pain after he fell from his horse during a polo match.  There is swelling and tenderness at the base of the thumb.  You think the patient may have sustained a fracture of his proximal thumb so you order radiographs.  One of the radiographs is seen below:

thumb1

Questions

1. What is the eponym for this fracture?

2. Which tendon is responsible for displacement of the thumb?

3. What is the ED management for this fracture?

Answer:

1. Bennett Fracture – fracture-dislocation involving the articular surface of the base of the thumb metacarpal.  The metacarpal base is displaced dorsally and radially by the abductor pollicus longus tendon.

thumb1a

2. Abductor pollicus longus tendon

3. ED management includes placing patient in a thumb spica splint

– You should also refer the patient to a Hand Specialist because the fracture usually requires operative fixation

radER is a weekly contest consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

radER 3.1

rader new

Case

A 33-year-old man presents to the ED complaining of left thumb pain after he fell from his horse during a polo match.  There is swelling and tenderness at the base of the thumb.  You think the patient may have sustained a fracture of his proximal thumb so you order radiographs.  One of the radiographs is seen below:

thumb1

Questions

1. What is the eponym for this fracture?

2. Which tendon is responsible for displacement of the thumb?

3. What is the ED management for this fracture?

Please click on the “comments” link or post your answer in the “reply box”. You will not see your answer post until next week when all of the submitted answers will be posted. Good luck!

radER is a weekly contest consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Hand Case 3.1

Hand Icon

Presented by: Mike Fernandes, MD

Chief Complaint: “My thumb is swollen ”

History of Present Illness:
This is a 47 year-old male presents to the emergency department’s ARC.  His primary complaint is that his right thumb is swollen.  He states that he bumped his thumb about two weeks ago on some furniture.  He  had some pain and a little swelling but nothing else.  The pain had improved after a few days, however, it started to hurt again and swell.  After a about a week and half he started to notice some purulent drainage from a little sinus at the tip of his thumb. He has some difficulty flexing his thumb at the interphalangeal joint, he is however, able to oppose his thumb.  The digit is erythematous, and swollen.  The remainder of his hand and digits are completely unaffected, the swelling and erythema is limited to the thumb.

Past Medical History: Denies, any hypertension or diabetes mellitus
Past Surgical History: Eye surgery in 2007
Medications: Eye drops
Allergies: NKDA
Social History: He denies any drug use.  He does admit to smoking 1 pack of cigarettes every 2 days, and occasionally consumes alcohol.
Family History: Significant for heart disease and diabetes

Physical Exam:

Vital Signs: BP: 142/88, P: 84, RR: 18, SpO2: 99%RA T: 36.3

Extremities: FROM, strength is 5/5 proximately and distally in both upper and lower extremities.  He is able to flex and extend at the wrist joints without any difficulty.

Hands: His MCP, PIP and DIP are completely intact with full extension and flexion from the index to the pinky finger on both hands.  He is able to oppose this thumbs bilaterally.  He is able to fully extend and flex this left thumb at the IP joint as well as abduct and adduct.  His right thumb is swollen up almost to the MCP it is  not uniformly swollen and erythematous, or warm to the touch. He is able to abduct and adduct his thumb, however, can fully flex at the IP joint because of swelling. He has pain to palpation at the distal phalanx of of the thumb; there is a whitish discoloration to the tip of the distal phalanx with a draining sinus, which did not appear to extend beyond the distal phalanx.  The nail bed appears to not be involved.  He did not have pain on passive extension of the digit, he did not have tenderness along the tendon sheath.

Radiographs
X-ray of the right hand was completely within normal limits, no bony abnormalities were noted no fracture, dislocations, or signs of osteomyelitis.  Patient did have some soft tissue swelling of the first digit, which is evident on the x-ray film.

Discussion:
A Felon is an infection of the distal pulp space of the finger.  The culprit organism usually is S. aureus or S. pyogenes, which enters the pulp space following minor trauma.  Patients present with exquisite pain, erythema, and swelling of the finger pad that overlies the distal phalanx.  This is a suppurative infection, so an abscess may develop.

By definition, a felon does not include the DIP crease.  If the edema and erythema extend that far, there may be a more serious complication; the infection may have spread to the bone and joint, invaded the tendon sheath, or formed a sinus tract to the skin.

A felon usually is caused by inoculation of bacteria into the fingertip through a penetrating trauma. The most commonly affected digits are the thumb and index finger.  Common predisposing causes include wood splinters, bits of glass, abrasions, and minor puncture wounds.  A felon also may arise when an untreated paronychia spreads into the pad of the fingertip.  Felons have been reported following multiple finger-stick blood tests.

Early infection is characterized by inflammation alone and may be treated with an oral anti-staphylococcal antibiotic such as cephalexin (Keflex) (250 to 500 mg PO QID) or dicloxacillin (250 to 500 mg PO QID).  If penicillin-allergic, erythromycin (250 to 500 mg PO QID) or clindamycin (150 to 300 mg PO QID) can be used.  If a patient is hospitalized because of comorbid or other condition, either nafcillin (1 to 2 gm IV q4-6h) or cefazolin (Ancef) (1 gm IVq6h) is recommended.  If there is suspicion for MRSA, then vancomycin should be administered.

In general, patients present for medical care after the development of an abscess.  Treatment requires incision and drainage, but incisions of the distal finger can result in painful scars or damage to the nerves and vasculature of the distal finger pulp.

The pulp of the fingertip is divided into small compartments by 15 to 20 fibrous septa that run vertically and attach the skin to the periosteum, forming the compartments that serve as the nidus of infection.
Abscess formation in these relatively non-compliant compartments causes significant pain, and the resultant swelling can lead to tissue necrosis.  Because the septa attach to the periosteum of the distal phalanx, spread of infection to the underlying bone can result in osteomyelitis.

1.   When an incision and drainage procedure is performed, it is important to open these compartments to drain the abscess effectively.  There are several techniques for draining felons; however, most practitioners have narrowed it down to two.  These two techniques are thought to be most effective in controlling infection and minimizing the risk of neurovascular injury and painful scar formation:

Felon
Felon

Midvolar technique: images (A and B)

midvolar
Unilateral longitudinal technique: images (C, D and E)

2. Most abscesses point to the middle of the finger pad, making the midvolar approach ideal.  If a sinus tract is present, the incision should include it.  This facilitates complete exposure of the abscess and prevents necrosis of the skin between the incision and the sinus tract.

The incision is made in the midline of the finger pad over the area of maximal swelling and tenderness (distal to the DIP) crease).  The incision should be made long enough to allow drainage of pus and blunt dissection of the compartments of the pulp space, with care taken not to injure the underlying flexor tendon.
The unilateral longitudinal approach is recommended when a sinus tract is not present.  This incision is made on the unopposed of non-border surface of the finger (radial aspect of the thumb and little finger and the ulnar aspect of the index, middle, and ring fingers).  The incision is made 5 mm distal to the DIP crease and just volar to the nail fold, whit is to avoid the neurovascular bundle.  The incision should extend to the subcutaneous tissue, allowing complete drainage of the space.  Blunt dissection just like the midvolar approach is a component of this unilateral longitudinal approach, the goal is to break up the loculations of pus and to explore for foreign bodies, if deemed necessary.

3. After the incision and drainage, area is irrigated thoroughly and packed with sterile gauze.
Antibiotics are given, as previously discussed, and the wound should be reevaluated within 48 hours.
When the patient returns, the gauze is removed, the patient is instructed to soak the wound twice daily and to cover it with dry dressing after each soak; the incision is to heal by secondary intention.  Also, encourage the patient to perform range of motion exercises.

Case Conclusion:
The patient had a Felon, a digital block was performed to provide anesthesia.  Then the area was steriley prepared for incision and drainage.  The thumb was incised using the midvolar approach, drained and thoroughly irrigated in emergency department.  The wound was then packed with sterile gauze, and the patient was educated and sent home with Keflex and follow up in 3 days.

References:
1. Tintinalli Emergency Medicine: A Comprehensive Study Guide, 6th ed: Chapters 44, 268, 269
2. Emergency and Primary Care of the Hand (ACEP Hand Book): Hart, Uehara, Wagner
3. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed: Chapters 46, 47, 48

“Hand Case Discussion” is an educational module that focuses on the diganosis and management of Hand pathology that commonly presents to the Emergency Department.

Interview: Dr. Larry Schwartz

Schwartz pic

Dr. Larry Schwartz graduated from Wayne State University School of Medicine in 1975 and completed his Residency in Emergency Medicine at Henry Ford Hospital.  He has won numerous awards for his dedication to medical student education and humanism in medicine.  Dr Schwartz is a national leader in medical education.

Receiving: You are an icon in medical student education, how did you first get involved in this area?

Dr Schwartz: In 1989, while working at Beaumont Hospital, I started working a few shifts a month at the University of Michigan’s University Hospital. That lead to a stint as a physical diagnosis volunteer at U of M that I did for 1 or 2 seasons. I somehow became more involved in some other medical student teaching at the University of Michigan. In 1992, when I decided that I wanted to change jobs, I talked to Dr. Bock and told him how much I enjoyed working with medical students. At that time he was interested in establishing a mandatory EM clerkship and getting the EM faculty involved with physical diagnosis. It was a natural fit.

Receiving: What are some of the changes you have noticed in medical students from the 1980s to today’s medical students?

Dr Schwartz: I haven’t noticed too much difference. The students, by and large, are still energetic and idealist for the most part. They get excited by clinical medicine. They are caring to patients because they identify many times more with the patient than with the doctor. I find their enthusiasm contagious and they are like a breath of fresh air.

Receiving: In 2006, you were inducted into the Gold Humanism Honor Society.  With increased ED patient volume and the reliance on advanced technology (i.e. multi-detector CT) is “humanism in medicine” fading?

Dr Schwartz: Most patients go to the doctor to see the doctor not the CT machine. The problem we have is the decreased amount of time  we spend with out patients. We need to build up trust in the short time available,  The patient has to feel that the doctor cares about him and his well-being. As healers, we must be able to project a caring attitude. The patient doesn’t leave the ED saying, that state of the art CT machine was terrific! He or she states that the doctors and nurses were kind, caring, professional, and knowledgeable. I’d go back there if I  needed medical care in the future. Or, if unsatisfied with the care, I’d die before I’d go back to that dump again! They never praise or complain about technology, it is the providers and the cleanliness of the environment that make an impression on our patients.

Receiving: What are some of the biggest challenges that today’s medical students are going to face when they are practicing physicians?

Dr Schwartz: I think that the medical care system as we know it is going to change dramatically within 5-10 years. Today’s medical students are going to be at the vanguard of this change. Unfortunately, I don’t know what the changes are going to be. I think they will be imposed from without instead of arising from within Re-imbursement is going to be reduced. Students will come out of med school with huge debt and lower re-imbursement than we have been accustomed to. Unfortunately physicians have lost the role of managers of medicine. Our broken system is going to collapse and need to be rebuilt. That will be painful. Once rebuilt, however, I think it will be more just.

Receiving: Should emergency medicine be a core clinical rotation for medical students nationwide?

Dr Schwartz: YES! Every inpatient room in the hospital is an emergency room when the intern is called because the patient is having an emergency. The house staff must know how to handle these emergencies. Therefore a core EM rotation is necessary for all medical students.

Receiving: Can you tell us one of your secrets to being an influential teacher?

Dr Schwartz: Students have to feel that you respect them, your patients, and that you really care. They want a role model that they can look up to, one that can walk the walk as well as talk the talk. I have tried to meet the same standards I hold the students to. It is very important that we model the behavior we preach. If not, we have no credibility as teachers and mentors.

Receiving: Do you remember a time when “educational research” in medicine was unheard of?

Dr Schwartz: We’re finally realizing that although we may be good doctors, we may or may not be good teachers. I think that medical education research is growing exponentially because we have so many new modalities to study and ways to study them. The introduction of simulation and parts trainers into medical education is a huge new arena to study. Distance learning and interactive computer based training are also a new technologies. As we introduce things, we are studying them. This has opened the door to more and more educational research in medicine.

Receiving: Who is your role model?

Dr Schwartz: I have several. Our own Dr. Dayanandan, or Daya as we used to call him at DRH ED, was a great role model. He was always even-keeled, smart, and kind to everyone. He was well respected by all of the physicians, nurses, students, and patients.  Dr. V. Vaitkevicius, a retired oncologist, is another remarkable man. He is one of the most humanistic doctors I’ve known. He would give his personal telephone number to his patients and was available to them at all hours. Dr. Ronald Krome has been a mentor to me. He taught me about hospital administration and how to be a champion of emergency medicine, the emergency department, and emergency physicians. I learned an incredible amount from him.

Receiving: As the medical student clerkship director for emergency medicine, you were one of the earliest directors to employ “web-based” education by utilizing “Blackboard” and putting the clerkship “on-line”.  How will the web impact medical education?

Dr Schwartz: Dr. Rosh, you can answer that one better than I since you are using the web constantly in your work with the residents. I found that putting a multiple choice exam on Blackboard allowed for immediate scores, better images, and evaluations of the exam. What I didn’t know when I first put the exam on blackboard was about security. Our exam was purloined within the first month or two by a med student who copied, pasted, printed, and distributed it. I found this out about a year or 18 months later. The web is a great aid. However, I don’t think anything takes the place of face-to-face contact in  medical education. The web is a great addition, but it can’t take the place of the apprenticeship model where the more experienced teach the novice.

Receiving: If you were going to practice medicine in a remote village, what is the one medical textbook you would bring with you?

Dr Schwartz: A tough question! I like the Tintinalli book probably because I wrote a chapter in it. These days, I must admit that I go more to the web when I have to look something up. I guess I am going kicking and screaming into the 21st century.

“The Meeting Room” is devoted to interviewing leaders in Emergency Medicine.  Please email me with suggestions on people you would like to see interviewed or if you would like to conduct an interview.

Mini-me

mini-me

“Not just veterinary medicine”

Ah yes, this is of the more common epithets ascribed to my profession.

When spoken disparagingly or jokingly I don’t mind.  But I have often heard this phrase used in a peculiar context, as an excuse for not getting a good exam on a patient.  As in: “was the abdomen soft?”  resident shrugs and says aforementioned quote.  I am no expert on the clinical skills of those who care for animals, but I can say that just because a patient cannot speak to you it does not turn the entire physical exam into a guessing game.

True, many of the subtleties of the pediatric physical exam come with experience.

Without even laying hands, most experienced PEM physicians can tell you when they suspect a child may have a c-spine fracture or peritonitis with a decent sensitivity (*hint 2 year olds with c-spine injuries don’t thrash around and try to rip their collars off).

So if the pediatrician is not worried about it (and we worry about everything) then chances are you don’t need to irradiate the child.  But even without years of experience once you recognize the idiosyncracies of various pediatric presentations, you will be on top of your game.

When you see a pediatric patient first it is important to stop and shift gears.  If you view them through the “grown-up goggles” they may all just look like runny noses.  But remember the trick is not recognizing really sick or really not sick, the trick is to pick up those needles in the proverbial haystack that are on the slippery slope towards being sick but don’t look it yet.  Or to realize that sometimes, even though a patient is not on death’s door it is a serious ailment may lead to complications, and in pediatrics our threshold of monitoring and trying to prevent complications is, well, different.

Everything is relative.

Yes, children also get liver failure, cancer and other serious illnesses, but they also get simple pneumonias.  And sometimes a simple pneumonia will progress to a really bad pneumonia and a para-pneumonic effusion and a lifetime of chronic lung disease if it is not properly managed or picked up early.  Think about each child as if it is your own, and you’ll have the right perspective.

Here are some common perspective pitfalls I’ve seen:
“4-year-old male, mild intermittent asthma, got 1 neb –is running around the room—looks great.”

From around age 4 to 8 there is some sort of idiot gene that makes children run around the room despite their growing respiratory distress.  Don’t forget to focus on the facts, respiratory rate, retractions, oxygenation and breath sounds.

“3-yo female with vomiting.  Was crying for my abdominal exam so I can’t really localize.   I want a CT to r/o appendicitis.”

One of the luxuries of an ER is that you can always play the “wait and watch” card.  My last posting had some tips for the getting a good exam from a child.  But sometimes you can’t stop the tears.  Usually after a little time, the tears dry up the juice box comes out and the child appears miraculously better.  If the child persists in being miserable, then let the detective work begin.  When watching a child it is important to watch them!  Don’t leave them in a room with a closed door, because every time you open it they will cry.

“6-yo male, tells me it hurts diffusely wherever I press”

Most toddlers and young children will tell you that something hurts if you ask them.  In medical school we are taught the gospel that if a patient reports pain we must document it as medical fact.  For me, it doesn’t count as tenderness unless the child is distracted with sponge-bob questions and jumps off the table with a slow pressure on the spot of interest.  If the child is verbal and you want to test their reliability go ahead and ask them a rapid fire of “does this hurt” questions and include queries about their nose, eyeballs and tail.

Ok, I promise next time, tips for IV access in children.

Keep sending me feedback on what you want to read about!
minimeblog@gmail.com

Mini-mə is an educational resource that highlights the essentials in pediatric emergency medicine care. Each entry will focus on ways you can improve your practice in pediatric emergency medicine.