We love the iFixit philosophy and want to help you understand the guts of medical decision making as well. If we can help you solve a medical problem yourself, we’re more than pleased!
Medicine is a sea of grey. Because of this you’ll find “happy words” vs. “red flags” throughout these posts.
A red flag for back pain is urinary incontinence, whereas happy words may be, “my soreness goes away after I go to the gym and stretch.” With every assessment scale the medical world tries to push medicine from art to science. Spend some time on MDCalc to dig deeper. These tools have their place in helping doctors to assess patients.
We love the iFixit philosophy and want to help you understand the guts of medical decision making as well. If we can help you solve a medical problem yourself, we’re more than pleased!
Back during residency we used to tell people that 50% of patients who walk in with abdominal pain, walk out without a definite diagnosis. Often we’d recommend a return follow up in 24-48 hours if not entirely better. Today I’m sure we’re doing better with 24/7 high resolution CT and ultrasound availability. However, the range of possibilities remains enormous. When someone says “my belly hurts,” it’s anything from fear of PE class, to too much turkey, to too much marijuana, to ruptured aorta, etc.
Unlike for headaches, “worst belly pain of my life” really doesn’t push us in any direction. Patients who wheel in with belly pain generally rate it a 10/10 and look miserable. Magnitude of pain doesn’t help nearly as much as history and location of pain. The exam itself adds really only a little more than history. Abdominal scar patterns from past surguries can be particularly useful.
I remember a surgeon once splitting belly pain between “writhing and rigid.” Those who can’t stay still on the gurney are writhing, and in this category he listed kidney stones, aortic aneurysm and mesenteric ischemia. The last one is rare, and is described as “pain out of proportion to exam.” This makes sense, because the problem isn’t inflammation, but rather lack of intestinal blood flow… analogous to a heart attack or stroke.
“Rigid” abdominal pain means that it hurts to twist, bounce or move, and the problem is typically due to inflammation, which causes pain when organs slide past one another. These patients will do whatever possible to limit that movement, and rigidly contracted abdominal muscles helps to hold those organs in place. For parents at home, a good test is to ask junior to jump up and down a few times. If no problem, then there’s likely time to think.
Location of pain is another useful bit of history. Here are the regional categories and diagnostic tests they may trigger. (It helps to drill an imaginary hole and add “-itis” to whatever organs/tissues you may find… gastritis, pancreatitis, cholecystitis, hepatitis, pleuritis, etc.)
By now, most of you are bored and have stopped reading. Some ER docs and surgeons are cringing. Obviously I can’t make you an abdominal pain expert with a fb post. But just try now to imagine emergency medicine pre-CT? Ultrasound has improved care enormously as well. I’ve only scratched the surface.
Now bringing it home to Pre-R… The thing we lack most in ERs is time. Not only are we tasked with nailing diagnoses and making people better, these have to happen fast. As such, we often order everything at once. Blood and urine tests, CT/ultrasound, pain meds and saline are frequently ordered together.
However, despite all this, in most cases saline (+/- Pepcid, Maalox, Toradol, Zofran) are the solution. It’s fairly amazing to me how much people can improve from misery to all better after a relatively short time, with the majority of people eventually going home.
So all that said, if belly pain is your problem and you want to have a chat, then give call. If no red flags and you’d like to try saline and some simple therapies first, maybe we can help. If not, then head to an ER and buckle up for a ride.
On occasion we get calls from people who have skin sores, or pus pockets, that they feel need draining. Most of these are abscesses and we’re happy to help. Strangely, very few things in medicine are simultaneously so revolting and pleasurable for nearly everyone involved. When I drain abscesses in ERs, nurses, family and patients alike routinely say “oh, can I watch?!” It’s a mystery. Psychoanalyzing myself only, I like them because patients usually improve quickly, and they’re very hard to make worse.
Sometimes abscesses are attributed to “spider bites”, but many of us feel spiders are probably getting a bad rap these days. Generally, the precise cause is unknown. Whether caused by spiders, ingrown hairs, ingrown toe nails, community hot tubs, injection drug use, long distance rowing with buttock marination in salty sweaty shorts, or just adolescence, all roads typically lead to incision and drainage.
An abscess that’s white already is essentially “ripe”. Patients often drain these on their own. If you choose this path, be sure to clean the skin well and use a sterile needle or scalpel. (The #11 blade is king in the ER.) Drain the abscess, wash the wound, and wash your hands vigorously afterwards. Allow to dry, but keep covered in public to limit transmission. (I’m not advocating self drainage, but just acknowledging it.)
For those of you who want a hand, the finesse is drainage with limited pain. It’s really quite difficult to fully numb an abscess, but slow injection of lidocaine is certainly less agonizing. I sometimes instruct patients to pinch my other arm for feedback. A harder pinch means slow down. Then wait! It takes time for lidocaine to kick in. So I typically step out for 5-10 minutes.
Once drainage is under way, we’ll rarely send pus for culture… mainly for sicker patients or for wounds that have already required multiple “I+Ds”. But generally, drainage itself is sufficient. Rarely are antibiotics required, however, I sometimes use them for higher risk patients or for those who seem to have deeper/faster spreading infection. The nice thing about Pre-R is we can decide 12, 24, 48, 72 hours later. Follow up is not so easy from the ER, so I sometimes send people home from ERs with prescriptions, and suggest they take them only if they feel they’re getting worse.
“Packing” is a mixed bag, and I’ve never found consistency among colleagues in any hospital. Some try to break up “loculations” with extreme vigor, almost like they’re teaching heroin users in particular a lesson. Others, pack with rolls and rolls of gauze like it’s a magic trick. I prefer the golden rule. Let’s just get the pus flowing, keep the wound edges from sealing over with a little gauze packing and we can reassess over time.
Of all Pre-R’s services, this tops my list of problems that should be cared for at home. From a public health standpoint, attracting infectious pus to a central structure in any community that also cares for newborns, diabetics, people with cancer, transplants, prosthetic hips, heart valves, etc. is just downright kooky in my mind.
We ER docs do what we can to simplify. Whether we know about the offending particle or not, we typically call the poison hotline too for generally great advice… and also because it looks good medico-legally on a chart. In CA the number is 800-222-1222. In parallel we try to stabilize the patient.
The first real conversational branch point in overdose care is determining “accidental or intentional.”
Intentional is a toxicopsychosocial combo pack for some long future post. So let’s stick with accidental.
Here’s a real example from that realm. My pediatric patient’s mother was just diagnosed with depression and was then prescribed Zoloft. She hadn’t yet taken a single tablet when she discovered her infant on the carpet surrounded by pills, and an empty bottle, while suckling a couple in his mouth. After a close recount, 6 pills were missing, which led to an ER visit, followed by an ambulance ride to a children’s hospital for treatment and monitoring.
When we talk about medication “side effects” this scenario may sometimes be neglected. Two ER bills and an ambulance ride plus guilt can’t be good for depression. Luckily the kid turned out fine.
(similar for alcohol poisoning)
You may be surprised to learn how much our care for overdoses is shaped by acetaminophen (Tylenol). Of the countless particles in your medicine cabinet and garage, it’s the one weirdo that will keep you in the ER far longer than you may expect. Acetaminophen overdose is easily treated if caught early, but life threatening when discovered 8-12 hours later.
Ipecac was once used for inducing vomiting, but it has since died, thankfully, along with “stomach pumping.” Today patients are instead frequently treated with charcoal, which is our favorite molecular sponge. It works well for most big molecules/meds, but less so for smaller particles like lithium, iron, antifreeze, acids, some of which require dialysis or more specific antidotes.
As we wait for patients to drink charcoal we typically check electrolytes and blood counts, and sometimes blood levels for meds like acetaminophen, aspirin, phenytoin, valproic acid, digitalis, ethylene glycol and others. EKGs, pulse oximeters and cardiac monitors are used as well to keep an eye from a distance. Pregnancy tests and drugs screens may be done too for fine tuning.
The large majority of overdoses do just fine if patients arrive alert and breathing. Of course, less so if not.
Long story short… lock away your pills and take only those you absolutely need. My father’s mantra is to “take the minimum dose needed to get the job done.” (He’s a math guy. Would have lost his mind in medicine.)
In honor of Super Bowl weekend…
Back in high school I worked on a social studies project with a friend. The day before it was due, however, he never showed up to my house. So I had to pick up the slack. This was pre-texting era, so it took a few days for me to discover that he, instead, had been busy getting his “stomach pumped” by the local FP.
News flash… Stomach pumping days are long gone. Since my intern year in 1997, I’ve never pumped a stomach for alcohol ingestion.
So what, you may ask, do we do when you stagger into an emergency department, or when you are delivered by friends, ambulance or police? The answer is virtually nothing. We monitor heart rate and airway, change urine soaked sheets, then send massive bills. Sometimes we infuse IV fluids. Occasionally we do head CTs and labs if we think there could be competing problems, like brain bleeds or coingestions (meth, cocaine, Percocet, heroin, etc). Rarely do we intubate and send to the ICU.
While some inebriates do die the way of Bon Scott, the vast majority simply wake up, and walk back to the wild the next day. Sober, awake, caring friends, who know the buzzwords, can make all the difference.
So all that said, on this joyous weekend, if you or your friends happen to overshoot and feel wilted, and perhaps need some watering, then give us a call. We’ll make sure you’re safe. You’ll awaken among friends. You’ll save some cash. And you’ll speed care for ER patients with other emergencies… (like the flu). Be safe folks!
A recent patient of mine went camping in Big Sur and returned with swollen arms, body and face – the picture of poison oak misery. So thought I’d post on allergic reactions.
Rash and anaphylaxis lie on opposite ends of the allergy spectrum. My heart weeps for anyone who gets an ER bill for the simple local rash. Topical OTC hydrocortisone or Benadryl +/- oral Benadryl +/- prednisone are cutting edge care, and quite easy to deliver even with telemedicine. For added finesse, add Technu (or Dawn dish soap) to remove the poison oak oils if that’s the problem.
On the other hand, ER’s earn their keep when allergy migrates to anaphylaxis. Such reactions, though infrequent, are life threatening, and are the reason for EpiPen and Auvi-Q autoinjectors. These are two products that help you inject 0.3mg epinephrine, which is remarkably effective. (Simultaneously they suction your cash costing ~$2-300 each… with1-2 year shelf lives!)
People suffering allergic reactions are everything from mellow to miserable to moribund. But their treatment paths are fairly similar. Depending on urgency, we consider topicals, then orals, then IV meds. For adults unimproved by topicals, 50 mg Benadryl, 60 mg prednisone and 20 mg Pepcid are a common approach. Sometimes we try IV Solumedrol. If your doctor uses epinephrine it means he or she is concerned. Your heart will race, and expect to be observed for a few hours or admitted. Intubation happens in the extremes.
Whether caused by bees, plants, peanuts, shrimp, cat hair or meds, our approaches in the ER really don’t vary. But following up with an allergist to help nail down the culprit makes good sense. In my med kit I carry a $6 1 mg epinephrine vial with syringe as well. Quite a markup for the EpiPen, eh?
911 for the red flags… Pre-R for everything else.
Maybe not so relevant down here at sea level in San Luis Obispo, but since I’ve had two calls in the past couple weeks from friends headed to high places, I thought I’d hit some altitude medicine high points. Back when I lived at 5000 feet in Albuquerque with a few mountains nearby, altitude was more of a topic, especially among travelers with heart or lung problems.
For starters, there’s no fixed altitude above which you may expect altitude related problems, and each person is different. Hydration status, caloric intake and fatigue are other factors to consider. Diarrhea in Cusco on your way to Maccu Picchu can add another wrinkle. Also, a 14,000 footer at the equator isn’t the same as a 14,000 footer far north or south, because our atmospheric blanket is thicker around the equator. (If Everest was as far north as Denali, its summit may still be out of reach.) In general, the more time you have to adjust the better.
The three medical acronyms you’ll hear most are “AMS”, “HACE” and “HAPE”, for acute mountain sickness, high altitude cerebral edema and high altitude pulmonary edema, respectively. Sleep disturbance at altitude and “HAFE” (high altitude flatulence expulsion) are other nuisances to expect up high. AMS and HACE are considered two ends of a brain swelling spectrum. But that’s all neither here nor there. More important than knowing acronyms is knowing red flags and solutions.
When it comes to altitude illness, one solution solves all, DESCENT. And it doesn’t have to be far. Dropping 500-1000 feet down hill can make enormous difference. If you can’t get there yourself, you may be lucky enough to find someone with a “Gamow bag”. It’s basically a hyperbaric sleeping bag that let’s someone outside with a pump lower your effective altitude inside.
As for medicines, people commonly take a diuretic called acetazolamide (Diamox) if they expect some altitude illness. It’s much more useful when started a few days ahead of the climb, however. Also, beware that it’s not for people allergic to sulfa, it’ll cause urination and possible dehydration, and it kills the taste of anything carbonated. Persoanlly, I’m not a fan for just a quick trip up and down a 14er.
Gingko is a popular non prescription supplement to prevent AMS. Steroids like prednisone or dexamethasone are also something to bring along in your first aid kits to manage illness at the extremes of altitude. Nifedipine and surprisingly Sildenafil (Viagra) may also be helpful for HAPE. And of course oxygen if you happen to have a bottle nearby.
If you want to dig deeper, have a look here. Very much of medicine is taking the edge off of self inflicted injury. My advice from down here at sea level when you’re struggling with altitude is to just come on back down for some oxygen below tree line, where the birds are chirping. Heroes are those who know when to turn back.
Human and dog bites are bad; cats, bats, raccoons maybe worse. Bears, alligators and sharks even worse, but for reasons beyond infection. No matter the animal though, it doesn’t really matter much in the end. We do all we can to irrigate these like crazy to limit the chance for infection.
The decision whether or not to repair with glue, suture or staple is very much weighted against. However, for wounds where every nook and cranny can be cleaned well, sometimes we will still repair these to limit scarring and speed healing. When in doubt or when there is suspicion for a foreign body, like a tooth, we leave these open. Sometimes we’ll consider closing these wounds 3-4 days later after swelling and infection risk go down, but that’s pretty rare.
X-rays can have some value if a foreign body or fracture are suspected. But frankly, these are often for medicolegal proof that we care. I usually give patients the option to X-ray or not with plenty of disclaimers. Frequently I’ll send patients home with antibiotic prescriptions, Augmentin being the most common.
However, I often say what I say for ear infections, sinusitis, and coughs… “Wait a couple days and skip the antibiotics entirely if every day is a little better than the last.” As long as no pain, redness, pus, fevers, red streaks, then healing is likely. Even if signs of infection develop after repair, it’s often helpful to just remove some sutures to allow drainage.
Invariably the question of rabies comes up. I have yet to see rabies or initiate the vaccine series, because it’s just so rare. Old Yeller has become hard to find these days. Like tetanus it’s making its way into the medical history books. That said, I do think if the rabies vaccine were a single shot instead of a long series, we’d probably be still be vigorously vaccinating for rabies as we do for tetanus today.
Whenever you get down in the mouth about US politics and policies, give thanks at least to our folks in public health. There’s a good chance you’ll spend your whole lives never seeing or experiencing rabies and tetanus. It’s still worth knowing the red flags though.
Here’s a great listen if you want a deep dive into rabies: Rodney Versus Death by RadioLab.
A friend with limping daughter just appeared at my door with the age-old question: “Do we need an X-ray?” She’d twisted her ankle.
If all happy and no red, it’s often OK to watch and wait 24-72 hours despite a limp.
Regarding X-rays, consider these questions:
In many ERs, despite “Ottawa ankle rules“, very often injury = X-ray. If after a few days watching and waiting you’d like to chase an X-ray, I’m happy to sign the Selma Carlson X-ray request. They’re great folks with quite reasonable self-pay prices.
On my last shift three roughly equivalent appearing patients arrived in a two hour period all worried about appendicitis. The one who was least comfortable on arrival ultimately went home. The one who felt she was getting better over the last 3 days, and only felt pain with deep pressure over the appendix, went to the OR. The last one just got better over an hour with no meds and went home.
The more appy ultrasounds and CTs we order the less I feel like I can predict the outcome from my exam. I really feel for surgeons pre-CT who had to make the hard calls on exam alone. History, however, remains critical.
The textbook appy is someone who says they initially felt mid abdominal pain followed later by tenderness to the right lower belly. But patients don’t read textbooks. If the appendix perforates expect lots of pain, vomiting and difficulty moving. A “rigid” abdomen may develop as the surrounding muscles attempt to limit movement of the inflamed contents within. Some patients weather this period as the infection gets walled off to form an abscess. Kids in particular may arrive this way with vomiting and diarrhea as their bigger complaints. Pregnant women with appendicitis don’t read textbooks either.
My only other tip would be to consider an ultrasound first followed by CT to save a some radiation. But very often that leads to a longer stay and bigger bill. Appendectomy seems like a trivial snip on the surgical spectrum, but getting there can be a winding journey.
Back pain – or what I call “the human condition”
If you get through this life having never suffered back pain, consider yourself blessed. I myself wrestle with it about 2-3 times a year, usually from doing something stupid in sports, but a bag of Home Depot cement can lay me out just as well.
When patients come to the ER with back pain, they’re typically miserable, and time spent in the waiting room or lying on stretchers generally doesn’t help. Our goal in caring for these people is to rule out life threats and to take the edge off the pain. Nobody goes home ecstatic, but we hope they at least leave comforted.
Patients often strongly desire X-Rays, but very rarely are spine X-Rays helpful. They pick up fractures, but miss injuries to ligaments, tendons, muscles, nerves, organs. They also provide a pretty big dose of radiation to the pelvic organs. CT scans may be offered because they’re much better at catching minor fractures, dilated kidneys, kidney stones, and even those rare dilated aortas, cancers, gall stones, pneumonias or pulmonary emboli from left field. Unfortunately, CTs also offer a radiation wallop.
Really the best study is the MRI. But sadly, this is available only on occasion during daytime hours from most ERs. I suspect this will change in the coming years as MRIs get faster and less expensive.
As for pain management, after I’ve scanned for red flags, I very often palpate for one point of maximum pain on the back. If we’re lucky, we find something. I then offer to inject 10-20 cc of bupivacaine which is an anesthetic that helps to take the edge off for 6-12 hours (could be shorter or longer, but much longer than lidocaine.) I’ve been told by a pain management doc that just the act of putting a needle into a spasmed muscle can relieve spasm. And that alone can break the pain-spasm cycle. However, I’ve never tried it because, frankly, the needle is there and the medicine is too. Plus I want the relief to last.
If we knock out the pain completely following local injection, then we’re even more reassured that the pain is not from a fracture or other life threat, and it is likely to resolve with basic TLC + ibuprofen. Actually, I put that on my list of happy words – “Got better with local anesthetic.”
Some people swear by muscle relaxants like Soma, Norflex or Flexeril. Some insist on narcotics like Vicodin or Percocet. I try to stick with ibuprofen (always with food), because it’s anti-inflammatory as well.
There’s my ER perspective. As for Pre-R, just give us a call from your favorite couch. We’ll come by with some bupivacaine and ibuprofen. We can talk about red flags, massage, stretches, warm or cold packs, Salonpas patches, and then perhaps organize an outpatient MRI at your leisure. We’ll also work to find you a good PT. Or a chiropractor if you prefer. Surgery generally won’t be considered until you have that MRI, and we’re happy to help you find a good surgeon as well.
Rest assured, you’re not alone.
Bleeding from the bottom scares a lot of people, and rightly so. Patients of all ages land in ERs wide-eyed at all hours following any amount of blood in the bowl, with cancer probably their biggest fear. Unfortunately, however, the ER is a terrible place for a workup. Sometimes the source is obvious with a glance. Rarely an anoscope proves helpful. However, more often than not the source remains a mystery. We’ll keep you alive. Maybe you’ll be admitted for stabilization and inpatient colonoscopy. Maybe you’ll get some saline rehydration or rarely a transfusion.
If your blood counts are ok, if you aren’t vomiting blood, if you don’t have a bleeding disorder that needs to be addressed, or signs of an infectious cause, then you’ll very likely be sent home with instructions to:
Before you head to an ER, I’d recommend you first buy a hand held mirror for a closer DIY look. For a hemorrhoid or fissure, with no other red flags, stay put. Call your doctor. Call a GI doc. Call Pre-R.
If you do choose to head to an ER, just realize that diagnosing the source of your bleeding is about as hard as understanding the inner workings of a kaleidoscope with a glance at the lens. Without a deeper look inside, it’s a tough nut to crack.
Despite the dramatic and sometimes startling appearance, most folks who throw up a little blood get better with nothing more than hydration +/- Zofran to control the nausea. Wounds inside the nose, pharynx, esophagus and stomach are prone to heal just like wounds to our skin. Unlike external skin bleeding, however, direct pressure to limit internal GI bleeding isn’t as easy. Plus there are some bleeding sites like esophageal varices, which are like ticking bombs.
We do the same studies that we might for lower GI bleeding, which include tests for anemia, and tests for liver and coagulation problems. If you put on a good enough show, you may be offered a nasogastric tube, or “NG.” This can be both diagnostic and therapeutic, because it tells us how much you may be bleeding while helping relieve some nausea associated with a distended stomach. However, insertion is not fun.
A rectal exam is useful to determine degree of bleeding as well. If no blood we feel comforted. If trace dark bloody stool, we suspect an upper GI source. If bright red blood from below combined with active bleeding through the NG, then we call in the cavalry.
A “urease breathe test” may help to determine if H.pylori is the cause of bleeding and discomfort, though this is largely an outpatient study.
Zofran and phenergan are popular to slow nausea and vomiting. Less vomiting also means less tearing and bleeding as well. OTC Zantac and Pepcid may prove helpful if you can keep pills down just to limit acid production in the short term. Prilosec and other “PPIs” help for long term stomach acid reduction. Addition of antibiotics for H.pylori has probably been the single most important reducer of bleeding ulcers in the past couple decades.
A chat with your PCP or Pre-R may be helpful to determine best next steps, but the ER really is the best place for stabilization and possible transfusion if you seem to be heading south quickly. That said, a GI doctor is your best bet to diagnose and solve the problem definitively.
Lastly, perhaps more important than anything here is to mention problems caused by NSAIDs. Most of you know not to drink to excess or inject heroin, in part to avoid hepatitis, liver failure, varices and vomiting till you bleed to death. However, while ibuprofen is one of my best friends, it too can wreak GI havoc. Therefore, always always take with food… and preferably not high Scoville scale green chile.
On July 4th I received a call about a child who was burned by a sparkler and the level of his parents’ concern got me typing. Very few medical problems cause more pain. And when the patient is a child, often times there is a parent along feeling exquisite guilt. As a kid I grabbed the hot end of a soldering iron, which made my father feel terrible. But I’m certain I learned more about burns that day than any time in medical school.
In general, if you’re reading this page for guidance and if you wonder whether or not a trip to the ER may be warranted, it almost certainly isn’t. Pain with a serious burn is usually the driving force. If junior is back to watching fireworks, then there’s definitely time to think. I say this not to be cavalier, but because the large majority of patients I see in ERs are destined to heal well no matter what we may do.
(We also examine burns looking for signs of abuse, but that’s a different animal.)
Burn treatment has 3 general objectives – pain control, infection prevention, contraction/scar prevention.
To control pain, ibuprofen (always with a little food), wrap in a damp cloth and elevate. If that’s not enough then we move to narcotics. If you’re going to slather in butter, mayo, tooth paste, egg whites, hummus, etc. then please stay home, because it’s just more to clean up in the ER.
To prevent infection, much depends on burn depth and blister status. If blisters are intact, we typically leave those as “physiologic dressings.” If ruptured, then we debride the blisters to limit infection risk and then apply bacitracin. I’m not sure how much bacitracin stops infection, but it does limit skin cracking and stuck dressings. Deeper burns are often treated with a product called Silvadene. But beware that this contains sulfa in case you are allergic. We also update people on their tetanus vaccinations.
To limit scaring and contractions, avoid direct sun, continue to use bacitracin, aloe, or any other ointments of your choosing, and try to maintain range of motion. This could require physical therapy.
You’ll read about first, second, third degree burns and you’ll see other descriptors like superficial, partial, full thickness, etc. Basically, these are meant to convey how many layers of skin seem to be affected. Rule of thumb – if sensation is present throughout the burn that’s a good sign (glass half full) in the sense that sensory nerves have not been destroyed.
If you’re on the fence, give Pre-R a call (570) 507-7737. A simple text image may be all we need.
P.S. Do NOT Google “burns images.”
Since becoming a father I’ve had intermittent chest pain. Not sure why, but it’s worse when I lie on my left side and sometimes hurts with deep breaths. All gone when I go running however. I’m not worried (and neither should you be mom), but it got me typing.
I’ve had a few calls now from people having chest pain also. I usually lead with some version of “I’m sorry, but I have to say this… If you’re having chest pain, I’d be crazy to not point you toward an ER or 911 (…pause…) but if you’d like to have more of a conversation about how we think about chest pain, then I’m happy to have a chat.”
Unfortunately chest pain can be anything from a bent-up burp to a rupturing aorta. Probably every doctor has been surprised by findings (or lack thereof) on EKGs, chest Xrays, CTs, and blood tests. Heartburn? – nope – heart attack. Pregnancy dyspnea? – nope – pulmonary embolus. Sore ribs from a hard football hit? – nope – pneumothorax.
Red flags and happy words are useful when thinking about chest pain, as they are for any other problem. But patients really should have access to these, because they, possibly more than even their doctors, should be their own best advocates here. I’ve referred to the “principal agent problem” a few times in the past, and in this case the agent (doctors) have very strong forces pushing the principal (patients) toward every study under the sun. When doctors make mistakes with chest pain it’s more than life and death. It’s life, death, guilt, shame, paper work, law suits, etc.
If you go to an ER or urgent care with chest pain, welcome to the jungle. EKG is inevitable within minutes. If no EKG then either you’ve done this 5 times in the past 7 days, or you’ve been labelled something derogatory. Hospitals actually track “door to EKG” times so an EKG is just inevitable. This test is simple and tells us about your rhythm, and whether or not you need to be whisked to a cath lab. Mind you, a normal EKG doesn’t rule out a heart attack. It just means there’s a little more time to think.
Unless you lay on some very happy words, prepare for rapid triage and evaluation with subsequent chest Xray and blood tests (CBC, Chem 7, CK, CKMB, Troponin, Lipase, D-Dimer, BNP). Maybe you’ll get a pregnancy test if there’s any sliver of a chance. For a select few we may even do drug screens to see if meth, cocaine or amphetamines could be factors.
If you show up too soon after the pain starts, you may be watched for 4, 8 hours, maybe overnight, to see if your troponin “bumps.” If your D-Dimer is microscopically above normal you may be offered a chest CT. We love these because they rule out many many problems like emboli, pneumothoraces, pneumonias, aneurysms, esophageal ruptures, cancers, etc. However, they come with considerable radiation and expense, not to mention you get to sit in an ER a few more hours. An echocardiogram could be in your future to assess your heart valves and heart function, or for clots. If you have a pacemaker we’ll probably have it “interrogated” to check for any abnormal events.
In parallel, we may try to thin your blood a bit with aspirin, and we’ll strive to kill your pain quickly with nitroglycerin, maybe morphine. We may try to knock down your blood pressure with metoprolol. If we’re real worried this could be heart or embolus related you may even receive a heparin drip, the merits of which I’ve heard debated since the late 90s.
As noted above, if the first EKG looks concerning you may be whisked to the nearest cath lab. If you’re in a rural ER or on the high seas, you may instead receive a ~$1000+ clot busting thrombolytic… (which could also kill you via hemorrhage).
I spent about 4 years at the New Mexico Heart Hospital where most ER patients had either chest pain, shortness of breath or palpitations. It was a chest pain wood chipper. Everyone got the “cardiac panel”… (everyone except my one disoriented cage fighter with lacerations all over his forehead).
In summary, if you’re worried, find an ER and buckle up. If you’d like some time to chat, call Pre-R. I won’t tell you what to do, but we’ll talk about the workup you may expect.
Seriously mom… I’m fine!
You may be surprised by how many patients come to ERs with colds, convinced they need antibiotics. Truth is, I can’t blame them. Schools don’t routinely teach kids that antibiotics are used against bacteria, nor that the newer “antiviral” drugs like acyclovir or valacyclovir don’t help with colds, nor that colds are caused by viruses. (I’m pretty sure it took me into my 20s to learn these gems.)
So today nearly every shift I deliver the disappointing news that I don’t have a quick fix… as I pray not to receive the present. I anxiously await a day when we have an antiviral that actually works for colds. Whoever invents that magic bullet gets a Nobel Prize. However, for now we’re stuck with OTCs, along with red flags and happy words.
Until that bullet arrives, it’s chicken soup, tea, honey, ibuprofen with food, rest and lozenges (yellow label Ricola is my favorite). Also be aware that colds are typically worse at night and in the morning. So before racing to the ER, try a warm shower, yogurt, banana, tea, and maybe a little oatmeal. One good friend is a strong advocate for the attached… but I’m a little uneasy with “horehound.”
Lastly, green/yellow sputum does not = bacterial. Please don’t bring your tissues for me to analyze. That’s just gross. “Neti pots” if you’re feeling courageous.
To CT or not to CT… is pretty often the question. A friend was just concussed playing soccer, so this came to mind. At the root of the head CT dilemma again lies the “principal agent problem.” The principal is the patient who just got whacked in the head, who wants to feel better and reassured that nothing deadly may be brewing. The principal also doesn’t want brain cancer. The agent in the ER (sometimes me) wants what’s best for the principal, but also risks far more guilt and shame for missing anything deadly under the skull. No doc wants to send someone home like Natasha Richardson.
On the other hand, I’ll never feel any consequence for clicking a button that initiates a cascade of events that may one day lead my principal to brain cancer. In fact, if my hyper prudence catches even a small brain bleed or skull fracture, I’m a hero. Never mind that most of these still heal with rest and time. I’m also long gone when patients receive their bills. Even if they ask what their CT may cost, I truly have no clue. Back to being your own advocate and knowing the buzz words. Aside from the obvious (deformed skull, unconscious, bleeding from ears), here they are…
To CT is easy. Choosing no CT takes guts, observation and actual conversation (read more). Unless your bell is truly rung, you are ultimately your own best agent. Lastly, waking someone after they’ve hit their head every couple hours is just mean. Let ‘em sleep.
If you want to bounce these decisions around, or just have someone come visit for a recheck, feel free to give Pre-R a call.
Conjunctivitis and pharyngitis have many parallels. Usually viral, fairly contagious, they drive parents and daycares crazy, and typically they get better with no help from me… except for some. Whether or not to treat with antibiotics is the never-ending discussion.
Conjunctivitis, aka pink eye, comes in a variety of flavors in adults and children. Viral is by far most common. If your kid just had a cold, and the nose is still running, stand down. No antibiotics necessary. Your doc will suggest you keep junior from rubbing the unaffected eye, but we know it’s futile. Try to protect siblings and yourself with frequent hand washing, but expect resolution over just a few days.
Bacterial conjunctivitis on the other hand is more concerning, but fairly rare. Consider this if fevers, pain, copious pus drainage, and red swollen lids… esp for contact lens users. It’s not pretty and is hard to ignore.
Noninfectious causes for red eyes worth mention include:
But back to infectious causes, and probably the reason you’re still reading – “When do I need antibitiocs?!”
Even more so than for pharyngitis, history and exam are everything. No rapid swab drives our decisions whether or not to treat with antibiotics. Actually, nobody would blink an eye if I treated 100% of my conjunctivitis patients with erythromycin ointment, sulfacetamide, gentamicin or tobramycin. I see colleagues and ophthalmologists use all of these with no apparent consistency. However, for patients who have contact lens related conjunctivitis or corneal abrasions/ulcers, ciprofloxacin drops (Ciloxan), seems to be the favorite.
My approach for patients with infectious conjunctivitis is similar to my approach for pharyngitis. I deliver some version of the conversation above. I then suggest a 24-48 hour trial of no antibiotics unless the red flags are many. If better after 24-48 hours then carry on with nothing. If worse, then call me or use the prescription provided. In some cases I’ll dispense a tube of erythromycin ointment from the ER. I prefer this to sulfacetamide because it seems to sting less, it has less risk for causing a sulfa-related reaction, and the placebo effect of using a goopy ointment seems more potent. (I’m all ears if you prefer another approach.)
That said, I’m a highly biased fan of Pre-R for conjunctivitis. A glimpse in the ER is OK, but following its evolution over time makes all the difference for diagnosis and treatment.
However, here’s a true confession from the ER trenches… We in ERs offer almost nothing for constipation you can’t do yourself in the comfort and privacy of home. There is really no prescription that I provide that’s better than the OTCs. My contribution is generally to rule out life threats, then provide a list of OTCs, and then comfort patients that they too have a case of the human condition. So please know the buzz words before seeking the emergency colon blow.
Once we’ve ruled out the life threats, then our treatments are pretty much high dollar OTCs. Colace, magnesium citrate, Miralax, Fleets enemas, Dulcolax suppositories are some of our favorites. Have a look at Fleetslabs.com to see their remarkable range of offerings. Not sure why, but many nurses feel the soapsuds enema is “da bomb.” So head to an ER if you’d like that approach. (Not on the Pre-R menu.)
Personally, I think exercise is more important than all the rest + a high fiber/high prune diet + hydration. Movement is critical. Waiting in bed for constipation to resolve is like riding a roller coaster to cure diarrhea. Won’t happen. Also, do not underestimate the “impact” of narcotics. A single dose can cause a long lasting ripple effect of discomfort, bleeding, anal fissures etc.
Lastly, a shoutout to a great doc/friend in New Mexico, Dr. Justin Hazen, who invented a cocktail years back, affectionately called “Hazen’s Heavy Hitter.” If I remember correctly it was a mix of coffee, chocolate syrup and magnesium citrate. “Do not go in there!” (Name the movie.)
I’ve been postponing this Anxiometer post for at least a year. People periodically call me to chat or come visit when they are on week two or three of a cold, and they just can’t shake their lingering hacks. Finally, I’m ready to confess. When it comes to making coughs disappear, we in medicine are woefully ineffective.
Most folks seem to be aware that coughs are generally viral. However, many remain convinced that they get better quicker with antibiotics; the Z-Pak being a crowd favorite. Unfortunately, sometimes patients are right, because a small fraction of nagging coughs today do represent a resurgence of Pertussis (whooping cough), which is bacterial and does benefit.
We in medicine know that we won’t be dinged for over prescribing Z-Paks (not yet anyways). And we know it’s a drag to spend 5-10 minutes talking about viral illnesses, only to read on Yelp “… and I only got better after I went to the urgent care where I found a smarter doctor who would actually write for an antibiotic!”
Sadly, most OTCs aren’t very effective either. Read linked article “The New Cough and Cold Products for Children: Evidence is Optional and Science is Marketing“.
More important are the following:
The majority of patients who call me with a cough or who visit the ER, leave without antibiotics. Sometimes I point them to Robitussin, with hopes for a strong placebo effect. Robitussin DM or AC have a little narcotic to help with sleep at least. Rarely Tessalon Perles are helpful just to suppress the urge. On the Big Island of Hawaii I was successful a few times with nebulized lidocaine to suppress cough from the Vog (volcanic fog).
All that said, sometimes I do crumble and prescribe the Z-Pak, but generally while advising folks to take it only if worse in 48-72 hours. Unfortunately, I suspect we’ll see resistance to the Z-Pak climb a fair bit in the coming decades.
At the end of the day, cough is a bit like vomiting and diarrhea, where the problem is your body finding a solution; albeit a miserable one.
I’m sorry to disappoint.
Regularly patients with dental pain turn to ERs. Unfortunately, most leave with a little less pain, but problems that still need fixing + ER bills. Nearly all receive some form of antibiotic, whether penicillin, amoxicillin or clindamycin. For those who are writhing in pain, I typically offer a dental block for 6-12 hours of numbness and hopefully a little sleep.
We refer to dentists, but know that waiting lists can be enormously long. Sometimes I wonder why hospitals don’t set up more comprehensive 24/7 emergency dental services… and why I didn’t become a dentist.
In any case, if a dental block and antibiotic prescription will help you through, give Pre-R a call. We are happy to drain abscesses that seem ripe as well.
Three experiences over the years have taught me more on this than any textbook. The first was back in high school when giardia found the community, and I lost about 15 pounds in 2 weeks. It was a “slow burn” as I was able to keep playing soccer, and even take a painfully long school bus trip to Long Island. I still remember every pothole. From the experience I discovered the miracle of metronidazole (Flagyl), and I can recall my renewed sense of hope after just 24 hours.
Lesson two was aboard a cruise ship heading from Valparaiso to Rio with 300+ afflicted passengers. I’d really never witnessed such an outbreak before. Happily, I dodged the bullet myself, and everyone lived to tell the tale. Whatever it’s worth, I’m pretty sure it wasn’t even the ship’s fault, because a large number of passengers seemed to have brought it aboard from a tour the previous week in Peru. Since then, my policy when traveling has included the following:
Lesson three came last week when I finally got to experience a saline infusion. The Central Coast gastric typhoon first hit Vanessa, then me the following day. I was amazed by how fast dehydration set in, and how hard it was to pry my head off the floor. But what a difference that saline made. (Actually, now my mind is on IV self insertion techniques. Turns out it’s fairly easy all the way up to connecting the tubing to the IV one handed. Then it gets messy.)
Before leaving the safety and comfort of your own bowl to find an ER, know the buzzwords.
I think about four things when I meet patients with diarrhea:
My typical parting advice for people with diarrhea is fairly zen:
“The problem is the solution.”
… unless it’s giardia, in which case I say:
“Take Flagyl. It’ll give you religion.”
Why so many ear infections in kids? The short answer is bad plumbing. The middle ear drains to the throat through the eustachian tube, and in kids these pipes are smaller and more horizontal. When fluid backs up, the ear drum buldges sometimes causing maddeningly severe pain. Decongestion and drainage, even more than antibiotics, are the solution. Tympanocentesis (aspirating pus through the eardrum) used to be a common solution as well, though that’s far less common nowadays.
For ear pain in kids… and adults follow these steps:
If all else fails, pack for a rough night in the ER, or call Pre-R and we’ll try to help. But don’t count on antibiotics. Perspectives on their utility vary widely. Often I either write the prescription and strongly recommend waiting to see if things improve, or I’ll ask patients or parents to call me back after waiting a day.
Patients with ear pain pretty much never receive X-rays or blood tests. Only rarely do we order CTs to chase abscesses for patients who aren’t improving with antibiotics. And I’ve only seen a handful of patient with mastoiditis. This means that $1000 ER bills for ear pain are an absolute shame. A simple glimpse on exam usually does the trick. Whether its a middle ear infection, an external ear infection, an ear full of wax, or a nesting moth, Pre-R certainly has the tools to get you or your child through the night.
And for you gadget people, have a look at cellscope.com
In 1989 I learned about eye foreign bodies and syncope on the same day. Driving with windows down past some road construction a bit of metal found one of my eyes. A few teary days later my folks brought me to a doc who splashed a couple miracle drops into the affected eye, then flicked out the metal and drilled out the rust. I was in high school with no previous needles or drills near my eyes, so it definitely had me on edge.
When the procedure was over I left the room, saw the tunnel, and awoke next to a toilet where I also learned about smelling salts. My eye healed quick, but my pride took a few more days.
Patients routinely find ERs with “something stuck” in their eyes. The large majority of these somethings are easily removed. Luckily, corneas heal remarkably fast. However, there are exceptions. Here are buzz words for eye problems in general:
Sometimes the problem is due to infection, but often it’s from metal, dust, or just a simple scratch.
When you arrive tearing at the ER, step one will be to check your vision. You’ll squint and squirm your way through the exam. We’ll then drop either proparacaine or tetracaine into the affected eye, which seems to save the day 99% of the time. It stings initially, but then provides wonderful relief. If total relief then we’re comforted that the problem isn’t something deeper. (This is always part of my first aid kit. That said, beware overuse, as it inhibits healing and can increase the chance for further injury.)
With Flourescein strips we’ll then stain your eye orange. Using UV light this lights up abrasions, lacerations, foreign bodies, etc. At this point, dazzled family members sometimes get out cell phones for photos so patients can have a gander too.
If vision is ok, foreign bodies removed, and pain relieved after the topical medicine, we’re nearly there. If not, then we typically then refer to eye doctors for follow up. Unless, the globe is ruptured, retina detached or if other evidence for serious infection or trauma, it is extremely rare for the problem to require an eye doctor emergently. (As evidence for the rarity, I’ve only seen an ophthalmologist in an ER once in four years. And he was managing his own patient.)
Pre-R does not have a slit lamp for a great eye exam. However, if you need a hand with “something stuck” in your eye, give us a call. At the very least we have the miracle drops to take the edge off till you reach an ophthalmologist. We have a magnifier, flourescein strips, needles, eye wash and Q-tips as well, which are frequently sufficient. Eye patches too if you like. They aren’t standard of care, but some patients like the look.
However, no smelling salts. That’s old school.
In high school I first learned about syncope after waking up next to a toilet in an ophthalmologist’s office. He’d just removed some metal from my eye. When I stood up, the room went dim, and somehow my body found itself next to the toilet. I still remember the smell of ammonia and pushing someone away. Luckily, those were the days before syncope… 911… ER.
Later during my residency, I recall standing on one side of a gurney talking with a patient while a nurse was placing an IV on the other, with some young woman behind her. In the corner of my eye I saw what looked like a tree falling… the young woman. It gave me a bit of vertigo, not knowing if I was moving or she. When patient (#2) awoke, she gathered her wits, had a seat, some water, a laugh and recovered just fine.
If you think of your brain as a light bulb and red blood cells as electrons, then “near syncope” = brownout and syncope = blackout. For whatever reason, the electrons just aren’t getting through the bulb. In both cases above, the causes were pretty clear and no call for alarm. Usually the change in position to splayed out flat is therapeutic, as long as it’s a padded landing.
Unless the cause is clearly positional, emotional or alcohol, most folks who pass out and land in an ER get an EKG and are placed on a monitor. If they have a pacemaker, we try to have it “interrogated.” If suspicion for brain bleed, then likely a head CT. If suspicion for electrolyte imbalance, then we check electrolytes. If bleeding from anywhere, then blood counts and maybe coagulation tests. If female, maybe a pregnancy test. If diabetic, we check the glucose. For the elderly or for athletes who collapse without warning, expect echocardiograms +/- carotid dopplers. Often we’ll check blood pressures supine, sitting and standing (orthostatics) to help assess whether the tank needs filling.
Despite all those considerations, the large majority of patients I see who pass out recover without a hitch. Head low, legs up, cool air and hydration very often do the trick. If your bulb went dim, or you “done fell out,” and want to chat about next steps, feel free to give Pre-R a call.
“Treat the patient, not the numbers.” At least once a shift I’m handed a chart that says something like “pediatric fever.” It’s usually assessed and solved by the triage nurse long before I arrive and my whole job then is to determine sick vs. not sick, and to offer reassurance. To mom who’s been up all night wrestling junior, “of course the kid’s sick!”
(Totally different recommendations for neonates. For one month olds with fever, expect the full “septic workup.” Usually viral. Usually resolves. But occasionally not, so we go the distance and hate it every time.)
Back to the title… Don’t go crazy checking temps every 30 minutes if all happy words apply. The large majority of kids I see in any ER leave with the diagnosis “viral syndrome,” and live on to sniffle another day. Fevers in kids are frequent and expected, but there are some lethal causes out there. So beware of red flags and realize that childhood is immunity boot camp.
Also, have a look here to properly dose acetaminophen and ibuprofen. Give us a call with questions or for your house call requests. Seeing kids in their own beds is way more pleasant for everyone involved.
I received a call a few days ago from someone sitting in the parking lot of a closed urgent care. He said his finger was bent at a crazy angle after playing some ball. Unfortunately, I was seated at a wedding, and during our conversation the music started suggested a groom en route! Terrible timing. So this one is for all you ball players.
Very few medical problems give me more joy than dislocation reductions, because very little that I do makes patients feel better that rapidly. Try to think of anything that moves patients from one extreme of pain and anxiety to another so quickly. Fingers, toes and patellas are tops, followed by shoulders. Elbows and hips are tougher, and often need sedation, so not nearly as enjoyable.
While it can be hard to differentiate between fractures and dislocations sometimes, the treatment paths are very often similar.
In my early years of practice I had the impression that each of these limb deformities needed X-rays pre and post reduction. However, over time I’ve come to realize that the golden rule mandates a faster reduction. If I’m the patient, I absolutely do not want to wait around for a pre-reduction X-ray (and two X-ray bills!) If there’s a fracture so be it. That said, if a patient requests that first X-ray, I’m happy to oblige. I’m also happy to do a digital block to take the edge off.
For fingers specifically, a gentle, but firm pull to open the joint, followed by realignment, very often does the trick. For reductions in general, we say to “reproduce the accident in reverse.”
Please don’t call me irresponsible for instructing people to reduce their own fractures/dislocations. But if you’re ever stuck in a parking lot of a closed urgent care, with no Pre-R to come running, then put this on your list of options along with any ER.
After reduction, if no pain, with full range of motion, and normal sensation and perfusion, you can be pretty confident no fracture. And with a nice finger splint there’s time to X-ray at your leisure.
This first video is dull but informative: Dislocations Of The Finger – Everything You Need To Know – Dr. Nabil Ebraheim
These, however, had me in tears:(Language warnings.)
Dislocated Finger – Bizarre ER
How To Treat A Dislocated Finger At Home!! Great Exercises That Help…
Setting a dislocated pinky
(The youtube rabbit hole runs deep!)
I recently got a call related to a blister; a healing blister. But the real reason for the call was to ease worry about possible infection… “I went swimming and I don’t want get that flesh eating bacteria.” So I thought I’d type.
The concern is legit, and we’ve seen plenty of news stories about people needing skin grafts and losing limbs. An ER doc friend of mine had to stop practicing medicine years back because of such an infection. So it’s real. Unfortunately, I think the news doesn’t properly convey the medical buzz words; just the fear.
When it comes to small blisters from dancing in tight shoes vs. life threatening deep tissue infection, here is what drives our decision making:
One hard part about emergency medicine is that we have limited access to those illness progression curves. We have a brief moment in time to make decisions. Of course, we can hang onto patients for hours to watch their illnesses progress, but that generally gums up the conveyor belt. So if there is any concern for serious infection, we go deep and fast. IV fluids, blood counts, blood cultures, wound cultures, lactic acid levels, X-rays, antibiotics ASAP…
The broader topic is called “sepsis,” and today our care for sepsis is being highly scrutinized. So if you arrive with an elevated heart rate and fever, you just might be launched down this path. Maybe we’re saving more lives with our rigorous protocols, but we’re certainly amplifying the bills.
In any case, one reason that I like Pre-R is because I have more time to assess “slopes.” That’s another way of saying that I like follow up over days, and being able to work with patients to see if their problems are getting better or worse, quickly or slowly.
And that blister… It healed just fine.
How I’ve waited this long to type about headaches is unclear. This is another in the category called “probably gonna be fine… could be deadly.”
My perspective on headaches was shaped more by one patient in 2001 than any other. I was a new attending, and an intern told me about a patient sitting in the noisy hallway with his family. The patient had a headache and thought it may have been from welding. I went to see him and he really didn’t seem too uncomfortable. He certainly wasn’t the picture of headache misery. That picture often includes sunglasses, a dark room, and a tearful, moaning patient curled up in the fetal position. This patient was sitting up and just squinting a bit. I really don’t like ordering excessive imaging, but because his family said he’d been a bit confused, I asked the intern to order a head CT. We both thought it was a reach.
About an hour later the wide-eyed intern with CT results found me saying the patient had a subarachnoid hemorrhage, or a bleed in his brain. A couple hours later he was in the OR having neurosurgery. My intern and I were fairly shocked. I hate to admit this, but the experience made me question my entire physical exam for such patients from that point on. This guy was normal and only a little bit of history triggered the scan. At least for headaches, I’m convinced now that history is the show.
In the emergency department our first goal is to pluck out the life threats. Fine tuning after that is icing on the cake. When we hear “headache” we think of bleeding into the brain and infection. Rarely we are surprised by tumors, cysts, or other unusual lesions. While MRIs give much more information, they just aren’t rapidly available and they certainly aren’t comfortable. So if you have enough red flags, your next stop may be the CT scanner. Radiation is the downside, but for rapidly detecting life threatening bleeding, a head CT is excellent. If your headache persists, a lumbar puncture (spinal tap) could be next in search of bleeding or infection, but these are infrequent. Blood tests are virtually worthless to us in the ER in our search for the cause.
While chasing a diagnosis, in parallel we usually try to knock down the pain with a variety of medications, sometimes saline, and generally a dark room. However, unlike treatments for wheezing or allergic reactions, which are fairly consistent between doctors, the range of medication choices and approaches for patients with headaches is much more variable.
For me, I try to let patients drive as much as possible within reason. If I think there could be bleeding, then I avoid medications like Toradol or Aspirin before results of a CT. I try to steer patients away from narcotics as well to limit their side effects and addiction potential. On occasion I’ll try to inject a region behind the neck with local anesthetic which sometimes helps. Otherwise, I follow patient lead.
Those with chronic headaches generally know what works best for them. Regardless of medication choice, the hope is that after an hour or two of treatment and rest, they will soon be back on their feet and requesting to rest at home.
As for the naming of headaches, here’s a true confession… I still struggle. Migraine vs tension vs cluster vs anything else, it just isn’t an easy diagnosis to make, and there is plenty of gray in between. More important is finding solutions that work and that keep recurrent headaches under control.
My impression is that most people who suffer from chronic headaches spend a long time with over the counter medications like acetaminophen, ibuprofen naprosyn, Excedrin first. Once they’ve exhausted these, some then dabble with the medications of their relatives to see what may work.
Phenergan works for some while Imitrex works for others. Birth control pills can be life changing for women with monthly debilitating headaches. Sometimes a simple Starbucks coffee does the trick for caffeine hounds. Those at the ends of their ropes often move on to narcotics like Norco, Percocet, morphine, Dilaudid. But unfortunately, tolerance can build rapidly and withdrawal can be sheer agony. Sadly, patients with chronic headaches begging for Dilaudid injections are fairly commonplace nowadays.
I’ve had close friends who cycle through ERs with headaches, and it’s a real struggle… and expensive! Happily, some have found solutions. Topamax, seems like a popular migraine suppressant used by many.
Perhaps most important of all is to find a PCP, and possibly a neurologist or pain management specialist. If you call Pre-R with a headache, we may be able to help in a pinch. But realize you will have to speak mainly happy words. With even one or two red flags, I’m sorry we’ll be inclined to point you towards an ER. Until I develop X-ray vision, I suspect patients with headaches will forever make me nervous.
A few days ago I got a call to evaluate someone’s “new belly lump,” so here’s a short bit on hernias. First off, many people live with these for years. They don’t always have to be a straight shot to the ER or operating room. However, they are a drag and can be life threatening as well, so the buzz words are important.
Most of us think about heavy lifting related inguinal hernias. But they can appear wherever the abdominal wall may be weak. Your abdomen is essentially a guts-filled sac, where internal pressure may push the contents out through any areas of weakness. Examples include congenital (Bochdalek, Morgagni), inguinal, ventral, umbilical, Spigelian, femoral, obturator, hiatal… inguinal and umbilical being most common, visible and palpable.
You may be able to postpone surgery by dropping some internal pressure with weight reduction. Or give your belly wall some support with a “truss,” a support belt, or neoprene abdominal wrap. However, most hernias eventually do find a surgeon. My father, being a scientist, had one inguinal hernia repair with the “open” technique and another laparascopically. Choice B won for him hands down. (Does HIPPA apply here? Sorry Dad.)
Two other terms to consider are “incarcerated” and “strangulated.” The former means that the abdominal contents are stuck in the hole. The latter means that blood supply to those abdominal contents are being cut off. Both are concerning, but a strangulated hernia is much worse and a definite trip to the ER.
Call Pre-R if you’d like help “reducing” your hernia or for advisement. If you think red flags apply, then head to the hospital.
P.S. Opiates don’t make these better. If anything, they slow the bowels and can mask serious pathology. So steer clear.
The Dawn to Dusk adventure race in SLO (April 2015) was exciting to watch, but medically boring… which is good. Barely a stubbed toe to report.
That said, the kayak leg definitely posed the greatest threats. Many boats and racers were munched by the waves on Grover Beach. But my bigger concern was hypothermia. So I thought I’d list some red flags and happy words to help assess what cold is too cold.
If someone’s shivering, while still thinking and moving properly, their prognosis is great. Changing from wet clothes and getting out of the wind is cutting edge therapy. Assisting the body to rewarm itself this way is called “passive rewarming.”
“Active rewarming” is the use of external sources of heat to rewarm. Low budget approaches include a car’s heater or a cup of tea. More vigorous measures include warmed IV fluids or the Bair Hugger found in most ERs.
If we’re really concerned, maybe we’ll “tap the joint.” This means we’ll withdraw fluid using a needle and syringe to then send it for analysis and culture. Sometimes we’ll discover crystals to suggest gout, pus to suggest infection, or blood to suggest injury. Drainage itself can sometimes be extremely therapeutic as well. It’s actually one of my favorite services because of the immediate relief.
If no tap needed and we’re not so worried for infection or fracture, we’ll try to kill the pain with medicines, then recommend “RICE” for rest, ice, compression and elevation. Frequently we’ll offer crutches, splints or slings. Ibuprofen (always with food) is our go-to NSAID. Folks with gout may receive colchicine, though that’s getting fairly expensive now. We try to limit use of narcotics, but sadly, for some patients it’s their only relief.
For pains that persist or where we suspect serious ligamentous injury, then physical therapy and MRIs may be next in line. However, rarely are these organized through the ER. In general, if patients say it “hurts when I do that,” we counter with “then don’t do that.” This may sound snide, but it’s actually good advice. However, as in my case, more often than not, time is the best medicine.
Give Pre-R a call if you have joints giving you grief. Unless you’re suspecting deep underlying infection, I bet we can help. Even if infection is suspected, or if you may need an orthopedist or rheumatologist, PT or an MRI, we’ll do our best to point you the right way.
“Does this need stitches?” The key word here is “need,” and for perspective I’ll start with a story. About 20 years ago I was an exhausted medical student on my gynecology/oncology rotation “prerounding.” Those are the rounds you do at 4am before the more painful actual rounds where you’re the dumbest bug in the swarm. My job was to gather vital signs, lab and X-ray results, and remove post-op staples to replace them with steri strips. One extremely obese patient was 2 weeks post-op and had a foot-long vertical abdominal incision with staples theoretically ripe for removal. I got to the last staple and then, to my horror, watched a centimeter gap turn into a fully unzipped incision. (Lesson for med students – Apply steri strips as you unstaple.) Luckily, she was too large to see the wound, and it was too dark for her to see my expression.
I ran to my resident. We returned to apply some dressings and I was told the wound would heal “by secondary intention.” I was amazed to find out I wasn’t fired, and the rounding team was actually quite reassuring. Because of her size and her need for chronic steroids nobody seemed surprised. I was skeptical. But they were confident, and over time I came to realize they were probably right. The human body is just incredibly good at closing itself up… kids especially. So back to “need.” Technically the answer is “rarely.” Far more important than stitching is cleansing.
The happy words describe the large majority of wounds that find the ER. As I said, by far the most useful thing we do is cleanse. But believe or not, high flow tap water has been shown to be as effective as our high tech solutions, probably because the mechanical removal of debris and microbes is most important. In fact, high concentration solutions like Betadine can actually inhibit wound closure. (So for anyone who calls me at home with an “owie,” my first suggestion is to get it under the running sink or shower.)
Back to the opening question… The decision whether or not to suture is based largely on likelihood for infection vs. desire for smaller scars and faster healing. If we use glue, steri strips, sutures or staples, that means we’re confident that the wound is sufficiently clean, and we’re unlikely to be trapping anything that may cause infection. If not clean, then no closing. In 3-4 days, we may consider “delayed primary closure.” As for bacitracin, I’ve a hunch it’s one of the best placebos we peddle. At the very least it keeps bandages from sticking.
And don’t forget Tetanus! I’ve only come across it from a distance in Haiti. If you’ve had a booster in the last 5-10 years, no worries. If not, we can help there as well.
In summary, if you’re on the fence about a wound, feel free to give a call or text me an image. If you’re even considering whether or not to get help, my bet is you won’t “need” much.
More here on wound care.
A super athletic and fit friend just had knee surgery. Shortly after she developed exquisite pain and leg swelling, and today she’s on blood thinners to treat a deep vein thrombus (DVT), more commonly known as a clot. The hope is for the clot to fade into the night. The fear is for it to dislodge and travel north to her lungs to be renamed a pulmonary embolus (PE).
You may think of your blood as a stream of oxygen delivering red cells, and pathogen battling white cells, but that’s barely the half of it. To keep the stream flowing properly your blood walks a tight rope, balanced between “thrombosis” and “thrombolysis,” or clotting and liquefying.
Forces that lead to clotting are captured by “Virchow’s Triad,” which include injury, stasis, and hypercoagulability. We’re most grateful for clot formation with injury. This is what keeps blood in your body when you cut yourself shaving or have an operation. For you mountain bikers, the clotting factors in your blood are the “Slime” of your inner tubes.
Clotting with stasis is more of a drag, but not very surprising. Think of ice forming over a river versus a pond. Simply put, high flow makes clotting less likely, and is one very good reason for daily exercise. This is why you’ll hear recommendations to take a stretch every thirty minutes or so on a flight, or have a walk at rest stops on long drives. It’s an ongoing challenge for surgeons as well, because while they’d like you to stop bleeding following their procedures, they also hate DVT/PEs.
The last one in the triad, hypercoagulability, essentially means predisposition to clotting. There are genetic conditions including Protein C or S deficiency, or Factor 5 Leiden thrombophilia, which you may have without knowing. Cancer can cause hypercoagulability as well. Believe it or not, simply eating foods high in vitamin K like green leafy veggies, can also nudge you in the direction of hypercoagulability (just don’t tell your kids).
What you can do from home with a painful, swollen leg is fairly limited. Exercise, elevation and aspirin are probably the biggest bang for buck. Compression stockings compress superficial veins in hopes of increasing flow through deeper veins. If you head to the hospital, expect a doppler ultrasound. Not every clot is equal, however. Our concern increases for clots that are in the deeper veins and for those which are larger and closer to the heart and lungs. (Backed up traffic on Route 1 in Big Sur is a lot less likely than a crash in San Jose on the 101 to cause problems on the peninsula.) Once a DVT is defined, then you’re in the realm of high dollar blood thinners including Lovenox, Coumadin, Plavix, Xarelto, etc… a deep bag of worms for some future post.
Many a med student has lost sleep over the “clotting cascade”. No need for you to do the same today, but suffice to say there’s more in the soup than just red cells and white cells.
All that being said, if you’re ever feeling nervous and want an ultrasound? We’re happy to order one for you through our friends at Selma Carlson Diagnostic Center
Adults who limp generally give a story, but toddlers typically keep the story to themselves. On my last ER shift a mom was sent by her pediatrician because her two year old had a limp. The pediatrician had done a knee X-ray which showed nothing, and he decided to send our way for further evaluation. I stood on one side of the room and put my arms out asking the kid to come toward me. With a big smile she decided to run instead, but tripped a couple steps in. She then sprang up and hop-skipped-limped over to me, laughing the whole way. Her affected knee was entirely non tender. She just didn’t wanna use it. What to do?
Kids with limps from seemingly out of nowhere can be a challenge. We first chase the low hanging fruit with X-rays, but this only reveals fractures. Rarely do we find pathology like bone cysts, cancers, or old healing injuries raising concern for abuse.
Blood work including the “CBC, ESR, CRP +/- blood cultures” may be next in line, but these rarely prove useful as well. Really we do these for general reassurance and to prove we care. If we truly suspect underlying serious pathology, then a bone scan, MRI and/or joint aspiration may be next.
Mom’s eyes got huge when we ran this list with her in the ER the other day. Ultimately she declined the works. I gave her my number and she decided to watch and wait and call me if worse. Three siblings, and no red flags, it was just too tough to chase this happy limping child down with a needle. No calls as yet. Luckily, kids heal quick.
In another life I worked on cruise ships for a few weeks a year. The longest trip in 2011 lasted 3 months. (Shortly after, I moved to San Luis Obispo and “got settled”.) Ship life planted some of the first seeds in my mind leading to Pre-R, because house calls (cabin calls) were routine. Being able to go with nurses to visit sicker passengers in their own rooms just seemed right. It always gave a better sense for their environments and social support, and felt much easier to just have a chat. Follow up was plentiful, and frequently happened in buffet lines… and sometimes at the bar. For anyone too sick, we transferred to port hospitals and generally got great follow up there as well. Basically, I thought of ships as hospitals where I could admit to myself, and do rounds at reasonable hours… with the goal of helping passengers to survive a few fun weeks at sea rather than forever.
Naturally, the most common topic at sea is sea sickness, which has a variety of approaches, but one therapy that solves all… port. Before labeling as sea sick, however, it’s important to consider problems that can sometimes look similar like strokes, heart attacks, gastroenteritis, intoxication.
More often than not patients tell you their diagnosis, and the next step short of getting back to land, is to take the edge off with some simple tips and maybe meds. Here’s my list:
As for medications, meclizine is over the counter and often found in bins on ships for the taking. It’s also called Antivert and Bonine. Somewhat helpful for vertigo and motion sickness, passengers seem to grab handfulls, with 25-50mg being the recommended dose. Some people prefer over the counter Dramamine (dimenhydrinate). Others prefer Zofran (ondansetron), which doesn’t cause as much sedation, but unfortunately isn’t yet OTC. If those don’t work, on occasion we’ll inject Phenergan (promethazine). From my vantage point, the goal for bad sea sickness is sedation till port. I have the same approach for vertigo and migraines as well. There’s something about sleep itself that’s more therapeutic than any molecule out there.
Treatments for sea sickness can cause problems too. Scopolamine patches make for a great example. Before departing on one trip from Vancouver a couple came to the clinic saying they thought the guy was having a stroke. His vision was blurry, mouth was dry and he felt unsteady. I noticed the scopolamine patch and we removed it. They seemed like good folks and I didn’t want to kill their vacation on day one. So instead we headed to the buffet. Literally 2 hours later he he was back to normal and no problems the rest of the trip. With cruise medicine, as with Pre-R, you get to know people.
Lastly, I’m convinced mindset makes a huge difference. Embrace the waves! Give us a call before your next trip for travel tips or your other last minute medical needs.
Periodically patients appear in emergency departments seeking methadone. During my residency I recall one in particular who said he was traveling cross country, but unfortunately had run out of his methadone. My attending and I informed him that most ERs don’t dispense methadone.
He left angrily, and without his suitcase. He must have said something provocative en route, because a short time later the ER was evacuated as the bomb squad arrived. They gently moved his suitcase outside, and with a water cannon they nebulized his skivvies. No bomb.
For those of you unfamiliar, methadone is a narcotic used to help people stop using other narcotics like heroin, or medications like codeine, Percocet, Norco, Oxycontin, MS Contin, Demerol, Dilaudid, etc. It has a long half-life and apparently doesn’t deliver the same highs. It permits those addicted to try to living semi normal lives again, and it falls under the “harm reduction” umbrella… i.e. It’s worse to be injecting an illegal substance than to be addicted to a legal pill.
Methadone has helped many people, but I have mixed feelings about it because the withdrawal is considerably more prolonged and difficult than from heroin. Plus, much like dialysis, life soon revolves around methadone clinics. I remember the debate about giving methadone to addicts in jail when I lived in New Mexico. While free to inmates, it cost $7 a day when they were released independent of dose.
While narcotic withdrawal can be one of the most painful experiences on the planet, it is not considered life threatening (unlike alcohol withdrawal). However, there are some points to consider.
The large majority of people who withdraw from narcotics live to tell the tale, and it’s usually harrowing. Expect rapid heart rate, sweating, vomiting, insomnia, cramps, generalized pain and emotional distress.
Our approach in the ER may include IV hydration, clonidine, antiemetics, ibuprofen, sometimes muscle relaxants, sometimes sedatives. I usually congratulate patients for taking their first steps down the road to recovery just to spread a bit of positivity. But once through the withdrawal, a few days to weeks later, then reality and life sets back in… bills, warrants, children, hepatitis, HIV, work, relationships, etc. I believe this is where we as a society often fail.
There is an older video that pretty well captures the prison of narcotic addiction, “Detox or Die“.
Patients periodically arrive in the ER after fender benders concerned they’ve broken their necks. Or sometimes 24-48 hours later they appear after someone not paying the bill says “you really gotta get that checked.” It’s easy to order X-rays. Much harder to say “fear not, and have a nice day.” So more important are the happy words.
After any hard workout, muscular discomfort often peaks the next morning, and the same applies for whiplash. And as with all injuries, there are two general types; those which will heal no matter what we do, and those that could use some assistance beyond rest, ibuprofen, gentle massage, gentle stretching. Even for fractures, there are stable fractures such as spinous process fractures for which ibuprofen, rest and PT may suffice, and crush fractures or dislocations (Christopher Reeves) which may lead to permanent disability.
In general, if you’re still walking, talking, breathing, peeing, pooping, driving, after 24-48 hours your chances are excellent. But if you want a neck X-ray we’re happy to order one for you as well. $60 at Selma Carlson is downright reasonable.
Not sure where the rumor started that it’s best to pinch the bridge of the nose to stop a nose bleed, but I’m typing now to end it. You’d be amazed how often I meet freaked out patients, with rolls of tissue jammed up their noses, while clamping down on their nasal skull.
Instead, please pinch the softer nose low so the bleeding actually stops. If you feel air passing through your nose, then you get an F.
Typically we instruct patients to blow clots out of their nostrils into a sink or emesis basin, and then we spray in some Afrin (oxymetazoline). This constricts blood vessels and hopefully gives time for coagulation. Then we use either a low tech or high tech clamp as shown. Then we prop patients up with the hospital bed (use your lazyboy at home) and wait, preferably with dim mood lighting and some soothing music.
Most nose bleeds are anterior, meaning from the front of the nose. If bleeding is from only one nostril this is likely the case. The large majority of these resolve on their own with or without a pinch. Some eventually receive a packing. Very, very rarely a “posterior pack” is required.
If you’re on the fence for which way to proceed, just give us a call.
“I think I broke my kid’s elbow!”
On occasion I’ll meet a distraught parent who was happily swinging junior by the arms one minute, only to have junior whimpering and refusing to use an arm the next. Whether it was happy swinging or an irritated or protective yank, the guilt is immense in either case.
If they arrive in an ER, an X-ray followed by a long nervous wait may be the path. However, that wasn’t the case for a dad who called me this weekend. I was out of town when he called so was unable to come by for a visit. But it seemed like dad had read the textbook on “nursemaids elbows.” I told him as much and suggested he spend some time on Google and Youtube to see if that diagnosis seemed about right before heading to an ER. 15 minutes later I got a call back that he’d actually fixed the elbow himself and junior was back in the game. Neat, right?
There are a few approaches to the reduction. If the injury is to the right elbow, then I shake the kid’s right hand (gently) with mine. With my left hand I put a thumb on the radial head to feel for a click when I hyperpronate the kid’s right hand. That almost always gets the job done. But I follow with supination and elbow flexion to be sure. Some docs go straight to supination and flexion, but I have a “non-evidence-based” hunch that approach causes a bit more pain. Either work though.
Very few problems in medicine are more enjoyable to fix, because the kids go from whimpering to smiling in minutes.
I’m not sure what the California medical board thinks of me pointing a parent to Youtube. But I do know what that dad thinks! So here it is:
A neighbor came a-knocking just last night with the sense of a racing or “flipping” heartbeat, aka “palpitations.” Most immediately useful when someone has this symptom is the EKG, so I sent her to Sierra Vista – outpatient – for an EKG and some labs (CBC, BMP, TSH, pregnancy test). If you stop reading here, remember this: It’s best to address palpitations in less than 48 hours. Explanation below.
When patients have palpitations, our minds go straight to cardiac arrhythmias. Quite honestly, we we hope to find something fixable on EKG, with supraventricular tachycardia (SVT) our favorite for being so easily fixed. Atrial fibrillation is another common arrhythmia, but it’s a little more involved. That’s the one we like to discover in less than 48 hours. For patients in “AF” longer than 48 we start to worry about clots forming in the atria, which could then lead to strokes. So these patients are frequently put on anticoagulants like Coumadin or Xarelto first… a big drag. Under 48, many “convert” in the ER with medicines and/or electrical “cardioversion.”
There are a variety of other arrhythmias and conditions to consider, Wolff-Parkinson-White Syndrome being an interesting one. Also Takotsubo cardiomyopathy or “broken heart syndrome” for those of you who want to dig deeper.
For patients who have intermittent symptoms, they may get a “Holter monitor,” or perhaps an “event recorder” which enables patients to record when they feel their symptoms.
While we like to find easily fixed problems on EKG, often we find nothing. Occasionally we discover low or high potassium levels, anemia, thyroid pathology or even pregnancy. But when labs also come up normal we have to actually listen and think. Happily, the simple act of listening can be quite therapeutic. Calm conversation followed by a good, alcohol-free, night sleep, very often does the trick.
“Clawed by tiger” is not something you get much in the ER, and meeting the tiger never happens. However, Pre-R is a different game. I was called to visit someone whose bengal tiger punctured his face, and following the repair Vanessa, Max and I got to meet the cuddly assailant. Every day’s different.
As for the handling of puncture wounds, the buzz words are a combo of what you’d consider for lacerations and animal bites, with even greater fear for trapped foreign matter and infection.
We do our best to clean out punctures, but thankfully the days of “coring” wounds to clean them are gone today. We’re pretty liberal with X-rays or ultrasounds too unless we’re certain nothing is trapped.
Ultrasound is sometimes superior for organic matter like wood or sea urchin spines. If we’re certain something is trapped, we may go digging, but that’s often a path to swiss cheese. Watchful waiting is an alternative option. Foreign bodies often find their way out, or a pus pocket makes their location pretty clear. Bullets and shrapnel are frequently just left in place unless they’re easy pickings.
For most puncture wounds a topical antibiotic like bacitracin is applied along with a dressing. You’ll likely get a prophylactic antibiotic prescription as well. I’ve provided hundreds of these, but hard to tell how much good they’ve done. I wonder how much I’m actually treating charts more than patients. My gut feeling is that elevation of injuries, daily dressing changes, and close monitoring for infection, along with basic TLC, are most important. Certainly avoid walking on punctured feet.
And lastly, did you know you can get a tetanus shot at most pharmacies without a prescription? I learned that only this year through Pre-R.
Since the US started vaccinating kids for varicella I haven’t seen chicken pox in years, and certainly not in adults. (We still see shingles, but that’s varicella resurrected.) In the Philippines, the vaccine is much less prevalent and apparently many adults never have chicken pox as kids.
Eventually when we landed in Halifax, their public health department was kind enough to give us (imagine that) a box of varicella vaccine, which I used for the remaining band members, and others on the ship who’d never come in contact with chicken pox or the vaccine.
Since then my life in dermatology has been far less exciting. We see an enormous number of skin problems in emergency departments, and I get quite a few skin related calls through Pre-R as well. However, the large majority of patients improve, or they seek smarter dermatologists elsewhere. No rash in years has had me racing a bicycle across a foreign city with a backpack of vaccine.
Dermatology can’t be taught in a post. However, here are a few points to consider. Broadly speaking, every med student hears the lines, “If it’s wet, dry it. If it’s dry, wet it.” Pretty good advice, as long as you don’t consider wet to mean water only. “Wet” includes topicals, and within that realm you’ll find ointments, which last longer than creams, which last longer than lotions.
The majority of derm problems we see in the ER land within the categories of allergic, bacterial, viral, fungal or infestational (not sure if that last one’s a word… but scabies, bed bugs, ticks, etc). Poison oak is a big topic here in California. Jelly fish and centipede stings are interesting on Hawaii. New Mexico… hard to say. With drier climate and higher altitude, skin cancers seemed more prevalent. Cancers, autoimmume and vascular problems find their way to ERs less frequently, being more chronic though.
Here are some more points to help you make decisions about which way to turn:
I could drone on and on, but suffice to say that dermatologists see some interesting problems. Dermatology really does lend itself to telemedicine though. So rather than take your lesions to a waiting room, give us a call. Hopefully we can help.
My approach is initially focused on killing the pain. Local anesthetic generally does the trick. Then I aim for the low hanging fruit. Any spines that are still sticking out I’ll try to remove to limit additional penetration into deeper tissues. Lastly, I’ll trim calluses to help remove whatever possible without turning the affected limb into hamburger.
Bacitracin and a loose dressing along with crutches are a nice touch too. I’ve never heard of anyone getting tetanus this way, but we still make sure patients have had their vaccinations. Oral antibiotics are considered as well, especially if we suspect joint penetration. But generally not needed. Soaking, NSAIDS with food, and Netflix binging with feet up are probably the most important steps.
911 was called by another bystander and I tried to help the student regain consciousness in time to save him an expensive ride. But no luck. He was transported to the ER where I’m told he eventually awakened and left after a thorough workup. He’d had seizures before apparently, and he’d had a particularly energetic night prior.
This experience made me realize how challenging a life with epilepsy must be. One minute having a coffee with a friend enjoying a pleasant weekend, and the next minute waking up in a hospital, and out a few thousand dollars for ambulance transport and ER care.
I’d be called wreckless for advising against transport, but it’s safe for me to reveal my inner sense of worthlessness for patients who arrive having had a seizure. “Ran out of my meds” and “recently stopped drinking” are the top two reasons I encounter.
Brains are webs of wires in a chemical soup. A disturbance in one region can cause perceptions/feelings/actions as small as a brief hallucination, a tingling hand, or a brief fixed gaze (“absence”). Such disturbances rarely make their way to ERs. It’s the “tonic-clonic, grand mal” seizures that draw a crowd and paramedics. However, while dramatic, the large majority of these still resolve on their own.
From the ER I’m stuck and I’ll keep ordering electrolytes, sometimes Dilantin, Valproate, Tegretol levels and the occasional head CT, because batting 1000 is expected of us. However, if you are with someone who just had a seizure, or if you just had one yourself and you’d like to have a chat, feel free to give Pre-R a call. Most likely we’ll suggest rest, preferably near loved ones, no stimulants (or intoxicants), and perhaps taking another dose of your regular anti-seizure meds. At very least we’ll let you know what you may expect should you call 911.
More plumbing… Just like eustachian tubes, pediatric lungs and tracheas are simply smaller than they are in adults. As such, any bit of inflammation can lead to all kinds of difficulty breathing. Colds, fevers and ear pain are some of the top reasons for late night pediatric ER visits. Parents of these kids often look exhausted. Parents of kids struggling to catch their breath have a look of terror mixed in.
The majority of kids I see in ERs who are short of breath have wheezing or “stridor” when they inhale (e.g. croup). Or sometimes the wheezes come with exhalation (e.g. bronchiolitis, asthma). For those with fevers and crackling lungs with productive coughs we start to think about bronchitis or pneumonia.
If we hear what sounds like a barking seal at triage, then cool mist with prednisolone or some other steroid is often very effective. Rarely do we use epinephrine as well. For kids with expiratory wheezing, we often nebulize albuterol which can be remarkably effective. If that helps, then these kids may leave with inhalers and steroids as well. Addition of a “spacer” is the added finesse. Depending on the history, if we suspect bacterial infection, an antibiotic may be chosen, such as amoxicillin or rarely azithromycin. Chest X-ray may also be offered, though I try to limit these as much as possible.
For kids who improve in the ER, I think follow up is more important than anything. So often I’ll give these parents my number, because parental fear itself can amplify any of these conditions.
Of course there are many other causes of dyspnea, including caustic inhalations like the “vog” on Hawaii, aspirin toxicity, anaphylaxis, pneumothorax, pulmonary emboli, congenital, or neurological problems. But these are quite rare.
I’d love to conclude with the usual “Call Pre-R,” but in this case that’d be gutsy. Of course I’m happy to help with albuterol refills and conversation. But if your kid is truly short of breath with any red flags, the ER really should be your next stop. Consider 911, or if there’s time, then drive with car windows cracked or down for some nice cool breeze. Maybe play some Jack Johnson for some background soothing, because fear itself can be half the battle.
Then there are infections where we struggle to determine whether the problem is viral or bacterial. And even if bacterial, we’re still not certain whether an antibiotic will actually help. Ear infections, coughs, sore throats and sinus pain are all in that same camp. When it comes to sinus pain, knowing the buzz words can be very helpful.
I’m often asked when best to start antibiotics for suspected sinusitis. Honestly, I still don’t know. But I can tell you all my own colds have a very consistent pattern, which invariably go through a phase with miserable sinus pain. (Sore throat… fever… achy… a little better… ridiculous nasal congestion… sniffling… pounding headache… sinus pain… lingering cough… done.) So sinus pain alone isn’t my trigger to prescribe an antibiotic.
For patients with sinus pain, I usually try to buy time; 24-48 hours even. I often suggest ibuprofen with food (6-800 mg 2-3 times a day for adults). I suggest Sudafed to open the pipes and promote drainage. If they have a Neti pot, I give a thumbs up. I’m also a fan of long hot showers to decongest, followed by sleep with head elevated by pillows or a Lazyboy. I also recommend steering clear of antihistamines, which can turn a river of snot into an ooze of concrete. Afrin too is my friend, but only for 2-3 days. For me it helps mainly to get to sleep. You may also try simple saline spray. Flonase is OTC now and worth a try too.
When all else fails and patients are convinced it’s time for antibiotics, I frequently crumble. But I try to make it clear that the risks may not outweigh the benefits. When I say “risks,” I mean more than the rare anaphylaxis, “Stevens Johnson Syndrome” or “Toxic Epidermal Necrolysis.” There’s also C. difficile overgrowth in the gut, stomach aches, diarrhea, photosensitivity. And then there is the time and money wasted chasing down prescriptions at the pharmacy… not to mention what they may pay me for the Rx.
In summary, sinus pain or “sinusitis,” like otitis media, is really more of a plumbing topic. When the air spaces in the skull become inflamed or packed with fluid, the pain can be immense. The goal is to facilitate drainage and to limit inflammation and pressure.
If antibiotics do not suffice, an ENT may next in line along with a CT. Surgery or stents may be offered to those who suffer chronic sinus infections, which is a curse for many.
Read more here Acute Sinusitis by Mayo Clinic.
… and slightly related, for those of you who like internet rabbit holes, Google “Empty Nose Syndrome.” If ENS is your problem, sadly, I fear a call to Pre-R may disappoint.
A patient of mine last week made me think of my own personal experience in 2005 with “MRSA,” so I thought I’d type about cellulitis today.
Having once been a teen age male I thought I was quite familiar with skin infections ranging from pimples, to carbuncles, to athletes foot, to jock itch. But in 2005 I upped my game. Initially I noticed a bump on my chin that felt like a familiarly annoying pimple that could blossom into an abscess. (Probably shouldn’t have stretched that razor for 3 months.)
The swelling got worse, but the pain was above and beyond any I’d felt before. I tried to lance it, but no luck. I treated myself with Keflex, but nothing. Tried clindamycin + Keflex, but the infection spread even further. A colleague a few years prior needed grafting of his arm after contracting “necrotizing fasciitis,” which we associate with the phrase “pain out of proportion to exam,” so I started to panic.
Finally I used Bactrim and then noticed improvement that very same day, though by now my chin was swiss cheese from all my failed attempts at drainage.
MRSA is no joke and if you want more info listen to this episode of Radio Lab called “Staph Retreat.”
Cellulitis is infection of the skin most often caused by Staph or Strep. When penicillin first arrived it was an incredibly effective miracle drug. But over time Staph in particular has developed resistance. “Methicillin Resistant Staph Aureus” isn’t one particular superbug. It just describes a feature of the Staph Aureus that may be causing an infection. It’s like saying “blue eyed Staph Aureus.”
In other words, your brand of Staph cellulitus may be resistant to clindamycin, while someone else’s may be resistant to Keflex and/or Bactrim, and someone else’s may be only sensitive to IV antibiotics such as vancomycin.
This brings us back to Pre-R. Today patients who are resistant to multiple antibiotics periodically receive IV vancomycin in the ER. They are then instructed to return day after day until their wound cultures demonstrate their sensitivity and resistance patterns. Sometimes the patients are admitted for nothing more than twice daily IV vancomycin dosing.
This to me is crazy, both for patients and for public health. Patients are charged hospital admission fees, basically to sit with their wounds elevated in beds, with IVs dripping, while playing on their iPads. To invite these resistant bacteria into hospitals to be around other fragile patients is ludicrous.
As such Pre-R now offers home vancomycin IV treatment. I know vancomycin resistance is increasing as well, and I really don’t want to be speeding that along with my own practice. But killing MRSA at home is just far more logical.
More pain, less pus… Think MRSA.
Primal Quest included a 600 foot ascent up Calaveras Dome. However, fear of falling wasn’t the issue. It was fear of rattlers which were prevalent in that area. Happily, no bites, probably because the racers were distracted and too fatigued to try to play with them.
For whatever reason, men seem to be at much greater risk than women, and upper extremity bites seem more prevalent than lower extremity bites. It’s a mystery.
You’ll find many pages in wilderness medicine text books dedicated to snake identification. “Red on yellow kill a fellow, red on black venom lack.” However, that’s neither here nor there for me. I’m dazzled by the way they move, and feel no ill will towards them. But I’m still quite happy to keep my distance.
Sprinting to the nearest hospital isn’t recommended for fear of circulating venom faster. But if a venomous bite is suspected, then transport ASAP to anywhere with antivenom is still top priority. While waiting for transport, keep the bitten extremity low and irrigate if possible to wash away any venom, dirt or bacteria. However, no slicing, sucking, squeezing or tourniquets. A light pressure dressing to limit lymphatic flow may be useful.
Lastly, no need to apprehend and kill the snake to bring with you to the hospital. Crofab antivenom is useful for the majority of bites in the US (rattlesnakes, cottonmouths, copperheads). Bites in India and Australia are another game. If you’re a snake handler, keep this in mind and do not call Pre-R. Actually, I take that back. If you’re a snake handler interested in an EpiPen or a couple vials of Crofab ($6300), then maybe we can help. Telemedicine only.
There are two interesting spiders in the US, the brown recluse and the black widow. The first causes lesions that are remarkably awful. I’ve only seen a handful of these and mostly back in St. Louis. On the other hand, the toxin from the black widow can actually cause severe belly pain. These seemed more prevalent back in New Mexico.
However, spiders in SLO are like the people, generally pretty gentle. The majority of our spiders are busy bodies that just want what we want… dead mosquitoes. (Vanessa believes otherwise.)
All that said, here are the buzz words for suspected spider bites.
In the ER we see if there is an abscess to drain. We look for signs of systemic infection. If we suspect bacterial infection we likely treat with antibiotics. If we suspect brown recluse bite, then we call internists, toxicologists, ID docs and maybe eventually plastic surgeons. These bites are rare and folks get excited.
For black widow bites, an antivenom exists, but I have yet to use it. During my residency I remember talk of someone using it once.
Essentially, we treat spider bites based on the buzz words with main goals being to limit infection and discomfort. All that said, the story is entirely different down under. In Australia, your killer instincts are spot on Vanessa.
Read about the funnel-web spider if you suffer from narcolepsy.
“The final stages of severe envenomation include dilation of the pupils (often fixed), uncontrolled generalized muscle twitching, unconsciousness, elevated intracranial pressure and death.” Crickey! Australian funnel-web spider
ps Surely some of you in SLO have your stories and will side with Vanessa. Please be gentle.
I’ve received a number of calls lately from patients certain they have strep throat. This link is a useful tool to estimate the likelihood. With fever, tender lymph nodes below chin along the neck, white spots on the throat, and NO cough your chances are about 50%. Less likely if you’re older. And kids less than 2 pretty much never get Strep. But Strep or no Strep, here’s what should drive your level of concern.
More interesting is what happens when left untreated. Rheumatic fever and “post strep glomerulonephritis” (kidney injury) are two concerns, but for whatever reason these are becoming quite rare. Whether or not to use antibiotics, for sore throats of all varieties, ibuprofen, Ricola (yellow wrapper), and chicken soup are my go-to nostrums.
If you are desperate to know, feel free to call Pre-R for a rapid strep screen in the comfort of home.
Very few decisions in emergency medicine are as challenging as whether or not to give a “thrombolytic” to someone suffering a stroke. This hasn’t changed at all for me since residency, though the window of opportunity has stretched a bit beyond 3 hours now. There are a few more interventions available today by interventional neurologists as well.
Stroke centers are popping up with “time is brain” as their mantra. However, in reality, patients who arrive shortly after their symptoms appear face one of the toughest choices they may ever make:
Behind door one – “You probably won’t get worse. You may stay this way forever. Maybe you will slowly get better. Or perhaps you’ll be better quickly and we’ll call you a TIA.”
Behind door two – “You may get better quick. You may get worse quick. Or you may die.”
Patients who arrive less than 3-4.5 hours from the start time of their slurred speech, weakness, numbness, altered mentation, etc. are typically whisked to a CT scanner. We look to see whether bleeding in the brain is evident or not. This defines “hemorrhagic” vs. “ischemic” stroke. The former are relatively boring, because generally there is very little to offer other than admission and monitoring. (Giving these folks a thrombolytic is a very bad idea.)
On the other hand, patients suffering ischemic strokes are the folks who face the decision of a lifetime. While many will improve with thrombolytics, some fraction may convert to hemorrhagic strokes, and some fraction of them will die. Personally, I’ve seen patients improve rapidly or remain unchanged. I’ve been lucky. I also know a neurologist who refuses entirely to offer thrombolytics, because of witnessing patients who have died.
For doctors, it boils down to comfort with sins of commission vs. omission. Which is worse, to be the person who gave a medicine that killed someone, or to be the person who didn’t give a medicine that could save someone? It’s hard to know, but that’s why I type. Patients and families need to know this dynamic exists, because ultimately it is their choice.
My last ER shift was neurologically heavy: One stroke, followed by a large intracranial bleed, followed by a child with a seizure, fever and possible tumor on CT. My stroke patient got me typing today, and this is how I frame her options: “Would you be comfortable living the rest of your life with your current weakness and slurred speech? If the answer is no, then are you comfortable taking the risk that our medicine could kill you?” My patient chose door 1. She was already improving, probably thanks to the aspirin she took at home before heading in.
If you want to dig dipper read TPA Contraindications for Ischemic Stroke
As for chest pain and belly pain, Pre-R shouldn’t be tops on your list of resources to call if you’re feeling suicidal. However, similarly, it’s worth knowing your local resources and what to expect should you take your suicidal thoughts, or your distressed loved ones, to an emergency department.
Frankly, I’ve been avoiding this Anxiometer post because it’s a sensitive topic. We all bring our own baggage, beliefs and histories. Perspectives on suicide itself are all over the map. My aunt with end stage MS killed herself in the early 90s. I can count three doctors who I’ve worked with who have also taken their lives. While shootings get plenty of press in the US, unfortunately, our suicide rates exceed homicide.
Here are the words that push us one way or the other in the ER:
For anyone feeling low and seeking help through an emergency department, prepare for a turbulent ride. If you weren’t suicidal on entry, you may be by the time you leave hours later. Frankly, I believe our current approach to the topic may amplify suicidality.
We treat patients with mental health problems like radioactive matter with lawyers. We guard them closely and sometimes we involve “sitters,” who are people who will literally sit in a room for 8 or more hours to make sure patients don’t succeed when we step out. However, I’ll admit that we rarely go deep. Time to reverse what may be causing suicidality is limited in the ER with numerous competing forces, like patients with chest pain, fractures, vomiting, and the like… not to mention complicated EMRs.
We do what we can to deal with medical emergencies. Then when “medically cleared,” suicidal patients are generally sent to people and buildings far away. In 20 years I can count on my fingers the number of psychiatrists I’ve physically seen in ERs. Maybe that’s best for patients, but personally, I’ve always wished for more face time with these docs.
If a patient has overdosed or ingested some poison, we do what we can to limit its effects. Often we ask patients to drink liquid charcoal to absorb the toxin. If patients don’t cooperate then sometimes we’ll insert a tube from nose to stomach to pour charcoal in directly. Most patients cooperate. Sorbital or magnesium citrate may be added to move the charcoal and toxins along.
Urine is collected and blood levels drawn for what are commonly called the “psyche panel.” Sometimes EKGs are done as well. Presence of alcohol or other drugs greatly impacts subsequent care. Surprisingly, drunk or high may mean no future psyche care at all. So we wait until patients are sober to see if they still feel like ending it. If patients wake up saying they are no longer suicidal, they’re often released into the wild. In some hospitals, ongoingly suicidal patients can wait for multiple shifts, or days even, to be transferred to mental health facilities.
Long story short, mental health services are suboptimal even under Obamacare. Improvement under the new team doesn’t feel likely. So if you’re struggling, find out your local suicide prevention hotline line number. The San Luis Obispo mobile crisis team can be reached at 800-838-1381. Incredible people take those calls. For relatives or friends, research what else may be available in your communities.
Another option is: https://suicidepreventionlifeline.org/ The ER should be a last resort. Of course, you can try Pre-R as well. I can be a good listener. But realize that mental health medications and services aren’t our forte.
This post, inspired by a smiling patient with a sub 1st degree, coffee burn that found me in an ER. There are bad burns and everything else. The above injury fit the latter. Here are what we use in ERs to separate wheat from chaff:
Rule of thumb: If you’re wondering whether or not to call Pre-R, you’re very likely going to be fine. People with clinically significant burns don’t spend a lot of time Googling urgent cares or scanning Yelp reviews. Serious burns are some of the most painful and horrendous injuries you can imagine and most lead to 911.
If you do find an ER, here’s what to expect… First off, we’ll try to help your pain. This will probably be done with narcotics like morphine, but NSAIDs like Toradol or ibuprofen can be quite helpful too. We’ll try to cool your injury as well, sometimes by running it under cool water. Some burns may need cleaning, for example those splashed by acid or hot tar.
Few ERs have a product called Water-Jel, but I’m a big fan. If you work in a setting where burns are possible, you may want to have some on hand. It certainly beats butter, mayo, crisco and other home remedies that some folks apply.
Blister debridement is something else we’ll attempt once pain is controlled. This means we’ll try to cut away any dead or hanging tissue to limit infection. Sometimes we’ll leave intact blisters to form a “physiologic dressing,” but for blisters over joints, we’ll generally remove the dead skin and cover with bacitracin and non stick dressings. Silvadene is popular for severe burns, but beware for those with sulfa allergy.
For the worst burns we also hyper hydrate with IV fluids, because burns are like holes in a boat. It’s amazing how much fluid can be lost through weeping burns in the first few days. (For med students here, Google “Parkland Formula.”) Urine output is our main guide for hydration.
And expect a tetanus booster.
Pre-R rarely gets burn related calls. However, I suspect we could have saved my coffee burn patient $500-1000 bucks. Actually, nah… He was workers comp.
I never thought I’d be typing about ticks this Saturday, but it feels suddenly and strangely important. A student called a few days ago after a hike to tell me he had a tick stuck in his back. His girlfriend tried to remove it, but she left some bits behind. I paid them a visit, excised the remnants, and got on with the night.
Not 30 minutes later, another call from another hiker with another tick embedded in the same part of his back after a hike! His girlfriend was a little more timid, however, so the complete tick was still embedded. Same procedure, but this time I rescued the tick as well (no charge), though missing part of a leg. They kept him as a momento of their SLO visit.
The debate continues about best ways to remove ticks, but one common thread is that it’s better to lift from the neck than from the body to avoid injecting tick contents back into the patient. From my vantage point, because I own lots of lidocaine, my preference is a touch of lidocaine followed by small excision. For you at home with tweezers, credit cards, olive oil, battery acid, cigarettes, and lighters, just aim for the tweezers and go slow.
Lyme disease is the illness most talked about. Back east, frequently you won’t even need red flags to receive prophylactic doxycycline. The deer ticks are everywhere and fear of the illness is immense. Ticks cause plenty of other illnesses as well. If you want to dig deeper look up Rocky Mountain Spotted Fever (not only in the Rockies), ehrlichiosis and, amazingly “tick paralysis.” Apparently the treatment for tick paralysis is to remove the tick, though I’ve never made that kind of save. (If you’re paralyzed at home, don’t call Pre-R hoping it’s a tick.)
More important than anything is the daily/nightly “tick checks” especially following hikes or rolling around with animals. Even more effective is to have a baby, never leave home, and sit typing on a Saturday!
Lots more to read here.
If men got UTIs as often as women there’d be antibiotic vending machines.
Very little that I do seems to spread more relief (sometimes sheer joy), than the destruction of UTIs. And unlike for the common cold, patients in this case are usually right… “I just need an antibiotic!” Nobody leaves feeling ripped off by a diagnosis of “viral UTI.”
Dysuria means painful urination. Sometimes the problem is complex, but much more often the problem is easily and rapidly solved. Urinary tract infection is frequently caused by bacteria like E. coli. Less frequently STDs like chlamydia or gonorrhea are the culprits. Sometimes there are mechanical causes as well for dysuria, like exiting kidney stones, or fissures that sting with the passage of urine. Rare causes of dysuria include bladder or prostate pathologies including a variety of cancers.
However, the large large majority of patients with dysuria in my world suffer the simple UTI, which is a pleasure to treat. Only rarely are urine cultures required. Actually, it’s borderline embarrassing, given that patients usually know exactly their diagnosis and treatment. “I’m on my honeymoon, and I get UTIs about once a year that always get better with Bactrim. And can you please include Diflucan to treat the yeast infection I may get after the antibiotic?” Patients who call me at 7pm are often ecstatic to receive their first antibiotic dose along with Pyridium for discomfort before bed, without having to pace in an urgent care or ER.
Hydration is important. OTCs like “Azo” take the edge off. And cranberry juice should probably be standard at every wedding.
If this NPR article “Should Women Be Able To Treat Bladder Infections Themselves?” fortells the future, Pre-R will definitely lose value across California. But the world will be a happier place. (Uncertain what will happen to bacterial resistance, however.)
Personally, I find this problem to be a bit fatiguing; not because I’m a burned out ER doc lacking empathy, but because I know that an OB office is such a more comfortable place for these patients. “If you have bleeding, then go to the ER” is the message many pregnant women hear, but I think they often don’t realize the reasons. Patients arrive hoping we may be able to save a fetus. But in the first trimester, we in the emergency department mainly strive to save mom.
There’s very little variability or creativity when caring for these patients. We check Mom’s hematocrit to look for anemia. We check her blood type to see if she is Rh negative or positive. If negative, she gets a dose of Rhogam which hopefully limits sensitization by a potentially Rh positive fetus… and theoretically limits rejection of a future Rh positive fetus. (Look up “erythroblastosis fetalis” if you want to dig deeper.)
We check a “quantitative HCG” which helps to assess how far along the pregnancy may be in the first trimester. It’s frequently rechecked in about 48 hours to see that it is increasing appropriately. If it’s going down rather than up, we suspect something’s amiss, but rarely do we get that follow up in the ER. We’ll also do a pelvic exam to gauge the level of bleeding, and to see if any fetal tissue may be present.
What matters most, however, is the ultrasound. Walking in with vaginal bleeding in early pregnancy and no previous ultrasound, your chance for miscarriage is about 50/50. Walking out following an ultrasound that shows a moving fetus with beating heart, your chance for miscarriage drops dramatically to sub 5-10%.
“Am I having a miscarriage,” is mom’s main question and we do what we can to answer that. However, we do essentially nothing to prevent it, other than possibly IV fluids if we suspect dehydration. Miscarriage is a frequent occurrence unfortunately, but it prevents quite a bit of future suffering.
As an ER doc my main task is to rule out an ectopic pregnancy, or pregnancy that lands outside of the uterus, generally in the Fallopian tubes. Tasks #2,3 and 4 are to comfort mom.
As for Pre-R, sadly nobody has donated an ultrasound to us as yet. But we’re happy to order one for you through Selma Carlson Diagnostic Center if you like. Their charge for a pelvic ultrasound is $270, and transabdominal is $135. Pretty reasonable.
In summary for vaginal bleeding in early pregnancy, aka “threatened abortion,” or “threatened miscarriage”:
I recently was called to a hotel to see someone with such bad vertigo, he was stuck on the floor with eyes closed and head pinned to the side of the bed for stability. He and his family didn’t want to call an ambulance, because he couldn’t take any movement at all, even to get up onto his bed. It felt like cruise ship medicine.
In that position on the floor we infused a couple liters of saline, gave another Zofran, then gradually got him onto the bed and talked about red flags, happy words and options.
When patients say the room is spinning we try to decide whether the problem is “central” or “peripheral”, meaning deeper in the brain, or further out toward the ears, where we get our sense of position. ENTs do a better job of distinguishing between “vestibular neuronitis” vs. “labarynthitis” vs. some other “itis”. In ERs (and for Pre-R) I mainly focus on getting people through the acute crisis while ruling out life threats. You may hear mention of “semicircular canals” and “otoliths” during your vertiginous spell, but when your brain is spinning like a top, it’s in one ear, and out the same.
Antivert and Bonine are brand names for over the counter Meclizine, which you’ll find in bins on every cruise ship. This availability means it’s both effective and relatively benign. Benzodiazepines like Ativan are also quite effective, with the primary goal being sleep, because very often vertigo greatly improves with rest alone.
There are a variety of tests to distinguish between central and peripheral causes. Google “Dix-Halpike” if you’d like to go deep or read the article attached. The “Epley maneuvers” are also helpful in theory, but I can’t say I’ve had much luck with them. Some patients improve, while others toss their cookies. So being a fan of the golden rule, my approach for someone pinned in position with vertigo is sedation, hydration and hands off. If the vertigo improves and they want to experiment, I’m happy to oblige later.
That said, I do point some patients to this vertigo treatment video, which I consider to be a gentler approach. It’s also more consistent with my DIY whenever possible philosophy.
If symptoms persist, I usually refer to an ENT first. But going straight to an MRI isn’t unreasonable if a central cause is suspected.
My hotel patient improved the next day. He followed up with an ENT, because this was his second bout in 3 weeks. The cause was ultimately attributed to “some bug”.