CITW 8: A Painful Eye

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 47 year old male with a history of DM and HTN presents to the ED with a painful and red left eye, worsening over the past 24-36 hours.  It is associated with blurred vision, photophobia, headache, a foreign body sensation, and drainage. He tried saline drops without relief. He’s never had this before. He denies any trauma to the eye, although states he did leave his contacts in two nights ago. He denies fevers, chills, or any other associated symptoms.

Vitals: BP 156/87, HR 87, T 98.9 °F, RR 14, SpO2 100 % on RA

Notable PE: Visual acuity (R 20/30 L 20/50). EOMI intact, but painful. Pupils 3 mm and reactive. Lids everted and swept revealing no foreign bodies. Visual fields intact. Normal accommodation. Left eye findings below:

What’s the diagnosis?
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CITW 7: A Swollen Elbow

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 6 year old male presents to the ED after falling about 4 feet off the monkey bars at his school playground, landing on his right arm. He’s had worsening pain and swelling of the right elbow since the fall, resulting in limited range of motion.  He denies numbness, tingling, or weakness. He sustained no other injuries.

Vitals: BP 107/72, HR 105, T 98.7 °F, RR 22, SpO2 100 % on RA

Notable PE: There is mild swelling of the right elbow, with limited active range of motion, but intact passive range of motion.  No obvious deformity. He is tender in the lateral supracondylar region. His right upper extremity is neurovascularly intact.

Plain films were obtained:

Rad Head 1

Rad Head 2

What’s the diagnosis?

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Horrid Local Envenomations

Below is the Hickory Tussock Moth caterpillar, which is quite prevalent in this region every fall (this particular one was photographed just outside my garage).  Despite the black-and-white warning coloration, children and adults often deliberately handle these insects and rapidly develop urticaria and pain at all points of contact.  This insect has multiple irritant spines, some of which may contain histamine, and while the reaction is rarely dangerous it is dramatic and very uncomfortable.

Hickory Tussock Moth caterpillar

Hickory Tussock Moth caterpillar

Treatment is supportive.  In particular, I recommend saturating gauze pads with 1% lidocaine with epinephrine and applying them over areas of irritated skin, and leave in place for at least 20 minutes.  This action will treat both the pain and urticaria.  With lidocaine, always be mindful of the total dose that the patient can tolerate (5-7mg/kg) even with topical application.  Antihistamines are also helpful, as well as brief lesson about warning coloration amongst our animal friends.

Vancomycin 1g for Everyone, Right?

From our very own ED pharmacist, Natalija Farrell:


The Issue

  • Methicillin-resistant Staphylococcus aureus (MRSA) infections and MRSA-related hospitalizations continue to increase.1
  • Vancomycin remains the cornerstone for the treatment of suspected or confirmed MRSA infections.
  • Its efficacy is measured by troughs (goal 10-20 mg/L) and troughs <10 mg/L foster vancomycin resistance.2
  • Due to the increased mortality in patients with vancomycin susceptible aureus with higher minimum inhibitory concentrations (“MIC creep”) and emergence of vancomycin intermediate or resistant S. aureus (VISA, VRSA),3-5 it is even more paramount to dose vancomycin correctly and target troughs 15-20 mg/L.
  • Emergency Departments are underdosing vancomycin in >70% of patients (especially in obese patients).
    • Most patients received vancomycin 1 g IV. 6-7

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EUS: Comprehensive LE DVT studies & LP Guidance

brownsound 2

Brown Ultrasound Tape Review – 9:17:15


ARTICLE #1  –  If “2-Point Compression” is Good, Would “5-Point Compression” Be More Good?

Srikar et al.  Isolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity. Annals of Emergency Medicine 2015; 66: 262-267

For the evaluation of DVT, the American Institute of Ultrasound in Medicine recommends compressibility and spectral Doppler waveforms of the Common Femoral, proximal Deep Femoral, Femoral, Popliteal, and proximal Great Saphenous veins.  But ever since Bernardi et al found equivalence with “2-Point Compression” plus D-Dimer, many ER physicians have been employing this faster technique at the bedside, which uses compressibility and direct visualization of the Common Femoral and Popliteal veins only.  This study questioned whether we should consider assessing more veins by investigating the prevalence of thrombi elsewhere in symptomatic patients.  This was a 6 year retrospective study of 2451 symptomatic patients who received “comprehensive” studies of the Common Femoral, Deep Femoral, Femoral, Popliteal, and Calf veins, which were interpreted by vascular surgeons. Continue reading

Medium ≠ Message

If you read one thing printed on real paper this week, make it this letter (1), followed by this response. (2)

(OK, you don’t actually have to print it on real paper, but know that it is, in fact, available printed on paper in the leading medical education journal. Or you can just point and click. For free.)

The rapid expansion of free, open-access medical edutainment has led us headlong into debate. To sum up the discussion, these two letters to the editor refer to a previously-published article by Mike Mallin, an emergency physician and EM educator in Utah, and colleagues surveying the use by EM residents of asynchronous education resources, which they define as “a student-centered modality of teaching which involves sharing online learning resources and promotes peer-to-peer interactions,” and which includes podcasts, blogs and other online shareable media. (3) Known collectively/colloquially as FOAMed (Free Open-Access Meducation), these resources are now part and parcel of many EM training programs, able to be consumed at one’s own pace, on one’s own time.

Pescatore and colleagues, in their letter to the editor, worry aloud that the messages trumpeted via asynchronous resources are at risk of being interpreted as gospel truth by unsuspecting consumers without critical consideration of their merits. Particularly susceptible to this, they argue, are the most popular of these resources and the most junior of consumers. They cite a discussion about treatment of infant bronchiolitis on an episode of the EM:RAP podcast wherein a popular contributor to that podcast made a treatment recommendation that is not supported by – and may be frankly frowned upon – by national societies in pediatrics (and which, in fact, may have been dangerous). If taken as truth rather than opinion – a real risk when impressionable listeners are swayed by the near-celebrities on popular sites – this may lead to an increase in an arguably unsafe practice. Continue reading

Twitter Tips for EM

Screen Shot 2015-09-02 at 8.30.01 PMIn #emconf (that’s EM Conference!) today, within a talk on social media and medical education, I gave a short beginner’s workshop on using Twitter for professional and educational purposes.  I recommend that you have a Twitter account dedicated to professional networking and education, which you use to engage with other emergency physicians (or professionals in other fields from whom you’d like to learn. I follow surgeons, internists, nurses, education experts–even a rheumatologist or two for good measure!)

Follow Kim Kardashian and tweet your cat pictures from your personal account. Use a separate account for your real professional persona, to follow and interact with ACEP, SAEM, AAEM, EMRA, other EM residencies, researchers, educational sources, and medical colleagues–here and all around the world.

A great place for an overall Twitter introduction is Dr. Joyce Lee’s Twitter SuperUser site.  Check it out, and the links that she provides. (This is a general introduction to the physician on Twitter, not necessarily geared towards academics and medical education.)

Here are links to the handouts provided today. The first includes a list of resources about the Free Open Access Med-ucation movement (FOAM), Continue reading