“How anxious should I be?”

Our Anxiometer is a symptom checker aimed at helping you to assess yourself. Hopefully it will give you a better idea for when to call 911, Pre-R or your primary care doctor. If no red flags and if all the happy words seem to apply, then it’s probably ok to patiently “don’t just do something, stand there!”

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!

Abdominal Pain

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.

Red Flags:

  • Fever
  • Vomiting (especially absent diarrhea)
  • Bloody vomit or BMs
  • Nothing similar in the past
  • No appetite
  • Diabetes
  • On dialysis
  • Jaundice
  • Cancer
  • Associated light headedness or syncope
  • Frail/elderly
  • Immunocompromised
  • Pregnant 
Happy Words:

  • Similar to past episodes with known diagnosis (like gastritis)
  • Slowly improving already
  • Better with Tums
  • “Vomiting and diarrhea right after eating the caesar salad.”
  • “I no longer have an appendix, gall bladder, uterus or ovaries.”
  • “I ran out of my Prilosec.”
  • “I have an exam tomorrow and I’ve been awake all night and hydrating with Coke.”
  • “While studying at the Frontier I ate their green chili deluxe cheese Taco, then drank a bottle of red wine to calm down at home, then passed out, then woke up late for my exam with a sore stomach, and now can I please have a doctor’s note?”

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.)

  1. Epigastric – (upper belly just below the ribs)
    Your doc may request a CBC, CMP, lipase level and may offer viscous lidocaine, Maalox, Pepcid … maybe an EKG too for elderly, diabetic, females … maybe an ultrasound to look at the gall bladder and liver. (Diagnosis of “gastritis” will probably get you home fastest.)
  2. Right upper quadrant – (top right below the ribs)
    Approach similar to epigastric, with ultrasound more likely to hunt for cholelithiasis (gall stones) and cholecystitis. It’s important to know that very rarely do gall stones themselves lead to rapid surgery. So if this is your known problem, expect disappointment if you come to an ER hoping for immediate surgery.
  3. Right lower quadrant – (bottom right)
    Expect a CBC and urinalysis at least, and a pregnancy test for women with a sliver of a pregnancy chance. You’ll be lucky to escape without a CT, unless you say the magic words: “I don’t have an appendix.” While bread and butter for surgeons, it’s far better to catch appendicitis early than late. For women, ectopic pregnancy, twisted ovary or tuboovarian abscess are other considerations.
  4. Suprapubic – (right over the bladder)
    I believe l speak for most of us in healthcare in saying we love cystitis. “Dirty urine” in a non pregnant woman, with no fever or back pain, is turn and burn medicine. No scans required and a variety of antibiotics are quite effective.
    Vaginal complaints, however, may send you down the long road earning you a pelvic exam along with antibiotics for both you and your partner.
    In men, we think of STDs too. If you say things right, a rectal exam may earn you a diagnosis of prostatitis as well.
  5. Left lower quadrant – (bottom left)
    Similar path for right lower quadrant pain, with maybe a little less urgency. Diverticulitis is a common finding on CT, which is generally treated with antibiotics.
  6. Left upper quadrant – (left upper and below the ribs)
    Remarkably rare and generally boring. For those with mononucleosis, sometimes a large spleen may prove interesting. Sometimes kidney pathology can appear here. Or stomach gas perhaps?
  7. Periumbilical – (around the belly button)
    We often wonder if this could be early appendicitis. Other rarities may include twisted intestine (“volvulus”) , mesenteric ischemia, aortic dissection… black widow spider bite?… oh yes.
  8. Flanks – (sides)
    Kidney stones or infections? Urinalysis with CT very often provides clarity.

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.

Red Flags:

  • Fevers
  • Exquisite pain (we say “pain out of proportion to the exam”)
  • Red streaks
  • Swollen lymph nodes
  • Altered mentation
  • IV drug use
  • Endocarditis
  • Diabetes
  • Immunocompromise (AIDS, hep C, cancer, chronic steroid use, etc.)
  • Frail/elderly
  • Neonatal
  • Rapid onset and rapid progression
Happy Words:

  • “I’m 16 and these pimples are driving me crazy.”
  • “This happened before and got better after drainage.”
  • “I’ve had this cyst for years, but yesterday it started getting red and tender.”

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.

Accidental Overdose

Toxicology is a field in and of itself. Any element or molecule you can put in your body by swallowing, snorting, smoking, applying, injecting, inserting, or bathing in (Did I miss any?) is a topic for toxicologists. And because there are a lot of particles out there, it’s a big field. (We’ll skip radiation.)

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.

Red Flags:

(similar for alcohol poisoning)

  • Unconscious
  • Shallow or no breathing
  • Recent ingestion… concerning for meds like Oxycodone or Ativan
  • Hours since ingestion… concerning for meds like aspirin or acetaminophen
  • Choking/vomiting
  • Unable to walk
  • Hyperthermic
  • Slurred speech
  • Kids, female, elderly, or anyone generally smaller
  • GI bleeding
  • Belly pain, chest pain etc.
  • Coingestions
  • Diabetes
  • Epilepsy
Happy Words:

  • Acting entirely normal
  • No evidence for intentional OD
  • No missing pills
  • Relatively benign ingestion… “I took an extra Neurontin today.”
  • “Tox center says will be fine. A sip of dish soap won’t hurt.”

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.)

Alcohol Poisoning

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.

Red Flags:

  • Not responding to painful stimulation
  • Not walking
  • Not speaking
  • Choking or not breathing
  • Coingestions
  • Underage, female, small and/or “just turned 21” in SLO, where first drinks at bars are free… (End that please!)
Happy Words:

  • Laughing
  • Jabbering, blathering, shouting, or just generally irritating
  • Weekly ER visits for the same
  • Sober, awake friends able to help monitor at home
  • British (remarkable capacity)

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!

More here: ER Visits for Alcohol Intoxication Are Going Up.

Allergic reaction

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!)

Red Flags:

  • Rapid onset
  • Tongue/lip/neck swelling
  • Wheezing
  • Shortness of breath
  • Dizziness
  • Unconsciousness (obviously)
  • Past hospitalizations/intubations for the same
Happy Words:

  • Itchy
  • Localized rash
  • Improving since onset
  • Gradual progression over days
  • No past serious allergic reactions

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.

Altered Mental Status

With our current political climate, maybe this axiometer post could have merit.

Just about every ER shift patients are brought in by family or by ambulance because they’re not thinking straight. They may be answering questions unusually or inappropriately, or they may be blathering and barely conscious. Our job in the ER is to determine what may be acute vs. chronic, and also to find ways to actually help.

The line between delirium and dementia can be subtle, but it’s a useful distinction. Frankly, I think we take more interest in delirium in the ER, perhaps because there are generally more opportunities to intervene and make lives better. Dementia lacks good solutions. Once patients improve, often with saline and antibiotics, they still leave with dementia and uncertainty.

Red Flags:

  • Rapid deterioration
  • Recent head injury/trauma
  • Associated sudden headache
  • Kids… altered mentation in kids is always concerning
  • Recent intoxication
  • Seizures especially with no previous history of seizures
  • Brain cancer or other known brain masses
  • Other cancers with suspected metastases
  • Pregnant or postpartum
  • Diabetic
  • Fevers
  • Hypothermia
  • Neck stiffness
  • Staggering
  • Slurred speech
  • One or both sided paralysis
  • IV drug use
  • Known or suspected overdose
  • Known shunt or past neurosurgical conditions
  • Hallucinations with no previous psychiatric illness
  • Alcohol withdrawal
  • Evidence for suicidality
  • Recent travel
  • Recent diving or high altitude climbing
  • Recent long distance racing
  • … and hyperhydration with just water
  • Recent prolonged sun exposure
  • Recent meth use, followed by a car chase, followed by a dog chase, followed by getting tazed, followed by getting hog tied face down.
Happy Words:

  • Frequent similar episodes that resolve spontaneously
  • Still breathing, drinking, eating, peeing, pooping properly
  • Recent alcohol use and already improving
  • Recent medication change
  • “Grampa recognizes us and seems fine in the day, but at night he just paces around mumbling and can’t sleep.”
  • “Junior just had dental surgery and really liked the nitrous.”
  • (Not a lot of happy words with altered mental status.)

Expect IVs, EKGs, urine/blood tests, a drug screen, medication levels, a head CT, maybe even an MRI or spinal tap if you arrive altered with no obvious cause. Happily many conditions resolve with time +/- saline though. Sometimes antibiotics help if we find a source of infection. Occasionally simple medication tweaks do the trick, or naloxone if the problem is narcotic overdose, or sugar if it’s hypoglycemia. Unless there is a clear fixable cause, however, hospital admission is generally the path.

All that being said, clearly Pre-R is not your best bet for patients who are altered with no clear cause. But still feel free to call if you’d like to talk through the decision tree.

Lastly, and I don’t want to get too political here, but I’ve a hunch excessive Tweeting may one day be added to the red flags list. Though it will be challenging to tease out correlation vs. causation.

Altitude illness

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.

Red Flags:

  • Rapid ascent
  • Headache (AMS)
  • Nausea/vomiting (AMS)
  • Disorientation (HACE)
  • Slurred speech (HACE)
  • Unsteady or staggering (HACE)
  • Unconscious (HACE)
  • Coughing… absent an infectious cause (HAPE)
  • Bloody, frothy sputum (HAPE)
  • Underlying heart or lung disease
  • Anemia
  • Cancer

Happy Words:

  • “I just flew from Miami to Cusco and I’m really tired and can’t climb steps as fast as I’d like.”
  • “It usually takes me 2-3 days to acclimatize. I’ll be fine.”
  • “I’m not in a hurry and I don’t mind ascending slowly.”
  • “I drank a bottle of wine at the summit.” (…bad idea, but drunk is a better diagnosis than HACE.)

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.

Animal bite

A couple weeks ago I got a call from someone parked outside an ER who had suffered a dog bite… his dog. It was about 2 inches long on the inside of a finger. This kind of call is red flag city, but he was terrified to walk into the ER, because he got hit with a $2,700 bill after his last hospital visit with no insurance. I read him the red flag/happy words lists and he insisted we meet up for a bathroom repair.

Red Flags:

  • Bite by any animal
  • Exposed joint, bone, tendon
  • Associated fracture
  • Tendon laceration
  • Weakness/numbness
  • Hand, neck, eye or joint penetration
  • Suspected foreign body (tooth?)
  • Spurting blood
  • Unknown or stray animal
  • Strange acting animal and unprovoked
  • Old (>24 hours) bite with signs of infection
  • Chronic medical problems like diabetes, AIDS, cancer, transplants, taking steroids, etc.
  • Patient or animal with no past immunizations
Happy Words:

  • Skin tear rather than puncture
  • Easy to explore wound completely to its depths
  • “It was my toothless cat and she gummed me when I reached for her toy.”
  • “My dog still seems to have all his teeth after the bite.”
  • “I can move and feel everything just fine.”

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.

Ankle sprain

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.

Red Flags:

  • Bone broke through skin
Obvious deformity (shortened, twisted, bent)
Poor blood flow (cool, pale, pulseless)
Nerve damage (can’t move, can’t feel)
Wound infection (fever, pus, redness)
Pain can’t be controlled with splint, sling and analgesics

Happy Words:

  • Feels better with acetaminophen/ibuprofen, ice, elevation, air splint, crutches
Back to laughing and fighting with siblings.


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:

  1. If something is broken will management be different? (cast, surgery, release from sports, etc.)
  2. Is it worth the radiation, time and expense?

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.

Red Flags:

  • No appetite
  • Fever
  • Vomiting
  • Pain anywhere from the belly button to the right lower abdomen. (Some would say abdomen pain anywhere.) 
Happy Words:

  • Wolfed down some Taco Bell, then developed vomiting and diarrhea a few hours later
  • Feeling hungry for more Taco Bell now
  • Walking and jumping around easily
  • Urinating/defecating no problem
  • History of frequent problems related to kidney stones, menstruation, ovarian cysts, UTIs, pregnancy

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

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.

Red Flags:

  • Cancer … Metastasis or pathologic fracture?
  • IV drug use … Epidural abscess?
  • Osteoporosis … Fracture?
  • Elderly +/- light headed … Aortic aneurysm?
  • Fever … Pyelonephritis or infected kidney stone?
  • Short of breath … Pneumonia or pulmonary embolus?
  • Can’t walk or move lower limbs … Transverse myelitis?
  • Urinary/bowel incontinence/retention +/- “saddle numbness” … Cauda Equina Syndrome?
  • Lost feeling in my leg … Herniated disc?
  • Falls from the second floor or higher onto feet … Associated spine fracture?
  • Car accident with lost sensation or strength … Fracture + cord compression?
  • “Launched from my four-wheeler and got a sand enema at the Pismo Dunes.” 
Happy Words:

  • “This has happened before.”
  • “I was curling in the gym and all of a sudden my back went out.”
  • “I have chronic back pain and ran out of my meds.”
  • “I can stand up from sitting easily.”
  • “I’m pregnant.”
  • “I’m constipated.”
  • “Whenever it cracks I’m much better.”
  • “Ibuprofen does the trick.”
  • “The bones don’t hurt. It’s more the muscles on the sides.”

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.

Bloody Stool

Exciting I know. But it’s all different when you’re the one hovering over the reddened bowl.
I’ll start with the take home points:

  • Chances that I diagnose your colon cancer in the ER are next to nil. Pre-R can help with a few outpatient studies, but you really want to find a GI doc.
  • Unless you are one click from dead, the chances you’ll meet an excited GI doctor in the ER with colonoscope in hand are sub-nil.
  • Chances are considerably higher that the source of bright red bleeding are from a hemorrhoid or fissure.
  • Bright red means lower source with active bleeding. Dark red or “coffee grounds” suggest a higher source (often stomach) with slower bleed.
  • A single drop of blood explodes in water. So focus on red flags instead of bowl appearance.
Red Flags:

  • Lightheaded
  • Syncope
  • Abdominal pain
  • Concurrent bloody vomit
  • Taking blood thinners like Warfarin or Plavix
  • Underlying anemia
  • Hemophilia
  • Liver failure
  • Dialysis
  • Elderly
  • Prior need for transfusions
  • Known intestinal cancer
  • Alcoholism / cirrhosis / hepatitis
  • Esophageal varices
  • Chronic NSAID use (ibuprofen, naproxen, aspirin)
  • Associated fevers and diarrhea
  • Community outbreak of infectious diarrhea
  • “Colon cancer runs in my family.” 
Happy Words:

  • “I’ve had anal fissures ever since my surgeon gave me Norco after my hernia repair without any Colace.”
  • “I’ve had hemorrhoids for years.”
  • “I’m constipated and have been straining for a week.”
  • “This seems like my diverticulosis.”
  • “I had a clean colonoscopy two weeks ago.”
  • “I ate Pepe’s homemade green chile last night, and it hurt more going than coming.” 

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:

  1. Return if light headed, fevers, pain, worse bleeding, etc.
  2. Follow up with GI for possible colonoscopy/endoscopy.
  3. Limit use of ibuprofen.
  4. Avoid spicy foods.

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.

Bloody Vomit

Our anxiometer needle moves a little higher when patients arrive in ERs spewing blood, but the buzz words are virtually the same as they are for lower GI bleeding.

Red Flags:

  • Lightheaded
  • Syncope
  • Abdominal pain
  • Fevers
  • Concurrent bloody stool
  • Taking blood thinners like warfarin, Xarelto or Plavix
  • Underlying anemia
  • Hemophilia
  • Liver failure
  • Dialysis
  • Elderly
  • Smoker
  • Prior need for transfusions
  • Known esophageal or stomach cancer
  • Known ulcers or H. pylori
  • Alcoholism / cirrhosis / hepatitis
  • Esophageal varices
  • Chronic NSAID use (ibuprofen, naproxen, aspirin)
  • Chronic steroid use
  • Recent GI or neck surgery, especially around carotids or aorta
  • Community outbreak of infectious gastroenteritis 
Happy Words:

  • “Pretty sure I ate something bad at a party yesterday. I puked up food all night, and then noticed some red streaks.”
  • “Vomiting has stopped and no more pain.”
  • “I’m otherwise healthy and taking sips of Gatorade now.”
  • “Lots of guys in my frat vomited after that pasta. It’s either blood or sauce.”
  • “I had a nose bleed all day yesterday. It finally stopped today.”
  • “I just had a tonsillectomy and can taste blood oozing down.” 

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.

Red Flags:

  • Pain that can’t be controlled by ibuprofen and cool wet soaks
  • Signs of infection – fevers, pus, cellulitis
  • Circumferential burns (around entire limb)
  • … Not many red flags really because pain is the main driver. Of course you’ll seek help for charred skin, exposed bone, lost vision etc. 
Happy Words:

  • No pain now and back to playing
  • Small blisters not really causing any problems
  • Full range of movement of any affected joints

(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.”

Chest pain

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.

Red Flags:

  • Past heart attack
  • Past coronary artery bypass
  • Past pulmonary embolus
  • Past spontaneous pneumothorax
  • Past thoracic aneurysm surgery … (notice a trend?)
  • Pacemaker
  • Diabetes
  • High cholesterol
  • High blood pressure
  • Smoking
  • Family history of early heart attacks (sub age 60 gets me interested)
  • Recent travel
  • Known clotting disorder
  • Recent cocaine, meth or other stimulant use
  • IV drug use +/- endocarditis
  • Never had this pain before and getting worse
  • Elderly/frail
  • Out of breath
  • Pain radiation to the jaw or down the arms
  • Fevers
  • Irregular heart beat
  • Lost consciousness 
Happy Words:

  • “Like past heartburn pain that also got better with Pepcid.”
  • “I’ve been studying all night and I’m really nervous about my final tomorrow.”
  • “I just had a cold and this cough is really bothering me.”
  • “It’s usually worse after I eat fatty or spicy foods.”
  • “Feels better sitting up.” (pericarditis?)
  • “Only hurts when I take a deep breath.” (pleurisy/pleuritis?)
  • “Hurts to move my arm around and especially when I’m bench pressing.”
  • “Goes away with exercise.”
  • “One spot on my chest hurts… o yeah!… when you press there that’s it!” …(Sometimes I’ll inject these spots with lidocaine. If the pain goes away completely, we’re golden.)
  • “My doctor says I have anxiety. If you’d just listen to my chest, I’d feel a lot better.”
  • “Sleep deprived new dad.”

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!

Common Cold

Antibiotics for colds is the never ending discussion.

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.

Red Flags:

  • Difficulty breathing (that doesn’t equal persistent cough)
  • Frail
  • Elderly
  • Diabetic
  • Smoker
  • Asthmatic
  • Neonatal
  • Immunocompromised (chronic steroids, chemo, lung cancer)
Happy Words:

  • Drinking, eating, breathing, peeing, pooping properly
  • Relief with ibuprofen or acetaminophen
  • Relatives with the same all survived and recovered
  • “No matter how much I surf I just can’t shake this thing.”

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…

Red Flags:

Amnesia or poor recall for the event
Persistent vomiting
Perseveration (Asking the same question over and over)
  • Ataxia (Can’t walk a straight line)
  • Taking blood thinners
  • Loss of consciousness… “How long were you out?” “I don’t know. I was out.” (We get most hung up on “LOC”.)

Happy Words:

  • Eating, thinking, walking, talking properly
Better with Tylenol (Steer away from ibuprofen or aspirin at least on day 1 to limit bleeding.)
  • Good social support (Someone sober nearby who can think, dial 911 and speak.)
Proximity (Short hop back for a CT if anything changes)

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.

Red Flags:

  • Fevers
  • Pain
  • Vision loss
  • Pouring pus
  • Red/swollen eyelids
  • Neonatal, Elderly, Diabetic
  • Immunosuppressed (chronic steroids, asplenic, HIV, chemo, corneal transplant, etc)
  • Contact lens use (Don’t sleep with your contacts!)
Happy Words:

  • “Junior has been sniffling all week and when he wakes up I have to wipe gunk from his eyes. Then he starts playing again and doesn’t seem to care.”
  • “I can see with no problem, but my eyes just itch, tear and burn after staring at my screen all day.”
  • “My nose and eyes just won’t stop itching and running with all the pollen lately.”

Noninfectious causes for red eyes worth mention include:

  1. Chemical conjunctivitis, which is caused by a chemical splash. The solution is dilution… and quick. Stop reading and don’t wait for advice from your nurse hotline. Rinse now! (As an aside, one of the most caustic chemicals is hydrofluoric acid. If you ever get that in your eyes, 911 is your next step. Don’t call Pre-R!)
  2. Welder’s keratitis is essentially sunburn of the eyes. Pain and redness will ramp up gradually and eventually become excruciating. Ibuprofen with food, wet compresses and rest usually suffice. But beware prolonged exposure to UV light whether from welding, tanning booths, or direct sunlight, especially at high altitudes.
  3. Allergic conjunctivitis comes hand in hand with other allergy symptoms like runny nose, rash, itching etc. It’s treated with meds like diphenhydramine or loratidine, sometimes steroids.

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.


Pretty regularly, patients come to ERs because they can’t poop. Those of you with bird-like regularity are amazed. Those of you with anaconda-like regularity get it. My worst blockage happened at a week long scout camp as a kid when the latrine was a plank with holes, and my butt said “not happen.” I hadn’t yet learned the hover, and I was miserable. So today, I’m sympathetic.

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.

Red Flags:

  • Vomiting… This is probably the biggest. Bowel obstruction is our concern.
  • Fevers… diverticulitis? appendicitis? peritonitis? mesenteric adenitis?
  • Localized pain above and beyond typical cramping… “Pain out of proportion to exam” is our description for mesenteric ischemia, which is like a heart attack, but for the intestines.
  • Abdominal surgeries… distant past or recent
  • Hernias
  • Abdominal cancer
  • History of diverticulitis, colitis, Crohn’s disease
  • Chronic steroid use
  • Frail, elderly or pediatric
  • Immobile or wheelchair bound
Happy Words:

  • Recent narcotic use… likely to resolve with movement, time and no more narcotics
  • Sedentary at home or at work… likely to resolve with activity
  • Still passing gas
  • Still eating easily
  • “It’s been 24 hours since my last poop… and no, I haven’t tried anything yet.”
  • “My CT scan last week said I was FOS (full of stool).”
  • “I’m constipated all the time and just need a little help.”

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 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:

Red Flags:

  • Shortness of breath
  • Fever
  • Frail/elderly
  • Bloody sputum
  • Smoker
  • Underlying cancer, CHF, COPD, asthma, cystic fibrosis, TB etc.
  • Recent hospitalization or intubation
    (BTW: Greenish sputum doesn’t really push us toward thinking bacterial.) 
Happy Words:

  • Less than 3 week duration
  • Better after a steam bath, shower or cool air outside
  • “Everyone at home had the same cold.”
  • “I just need something to help me get some sleep.”  

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.

Dental Pain

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.

Red Flags:

  • Fever
  • Tongue swelling, facial swelling
  • Breathing problems
  • Dehydration
  • Diabetes
  • Smoking
Happy Words:

  • “My teeth are sensitive to hot and cold”
  • “Ibuprofen seems to help for a few hours at a time”
  • “I have 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. 


Another fun topic, but pretty relevant on the Central Coast these past few weeks.

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:

  1. Carbonated or recently boiled drinks only
  2. Steaming food only
  3. No ice, thank you
  4. No salads, thank you

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.

Red Flags:

  • Abdominal pain (… above and beyond gurgling and cramping)
  • Vomiting (… more concerning for dehydration)
  • Bloody vomit or stools (… though bloody streaks after a day on the pot aren’t particularly shocking)
  • Fevers
  • Frail, elderly, pediatric
  • Chronic medical problems (… diabetes, renal failure, liver failure, heart failure, etc.)
  • Recent travel or concerning exposures (… cholera, C. difficile, etc.)
  • Recent antibiotic use (… concerning for C. diff)
  • Past history of C. diff (Notice a pattern? This is a big topic these days.)
  • Recent hospitalizations or surgeries
  • Already taking diuretics
Happy Words:

  • Still able to drink liquids
  • “I’ve only had it for a couple hours.”
  • “Loose stool only, and getting better already.”
  • “I’m fine when I take Imodium.”
  • “Everyone in the family had it, and they’re better now.”
  • “Everyone in town has it and Flagyl seems to work. Can I have some?”

I think about four things when I meet patients with diarrhea:

  1. Is this life threatening?
    IV fluids are most useful. Sometimes we’ll do a CT if pain or fevers are a component looking for diverticulitis, appendicitis or other serious pathology. Studies looking for C. difficile, Salmonella, Shigella, E. Coli may be sent as well, though cultures generally take days. If we’re really concerned we may check electrolytes as well for some fine tuning.
  2. Is there a public health threat?
    Have multiple patients arrived from the same sushi bar, tour, ship, etc? Is a call to public health warranted?
  3. Is there time to watch and wait?
    Waiting is preferred, because use of antibiotics can turn a relatively benign, self limited problem into something more serious like C. diff superinfection, allergic reaction, hemolytic uremic syndrome… not to mention worse stomach pains.
  4. What’s the social dynamic?
    Can the patient spend a day or so near a toilet, or are they about to take a long bus ride through notoiletsville? Only then do I suggest use of OTC Imodium. Even more rarely do I consider prescribing Lomotil (basically never).

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.”

Ear Pain (Pediatric)

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.

Red Flags:

  • Fever not controlled
  • Lethargy
  • Failure to improve with antibiotics
  • Underlying immunocompromised
  • Tender, red, swollen, soft, bone behind the affected ear (super rare)
  • Unvaccinated 
Happy Words:

  • Better after sitting up
  • Better with children’s ibuprofen/acetaminophen
  • Still playful
  • Eating and urinating normally
  • Pressure equalizer (PE) tubes already in place
  • “I just finished surfing and feeling sore and plugged.” 

For ear pain in kids… and adults follow these steps:

  1. Sit up and point the plugged pipe down (affected ear up). Sleep inclined on a Lazyboy on your side if needed.
  2. Open the pipes with steam, Vicks, Sudafed, tea or grandma’s favorite home remedy.
  3. Pain control with acetaminophen or ibuprofen (15mg/kg and 10mg/kg respectively)

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 

Eye injury and foreign bodies

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:

Red Flags:

  • Lost vision (Blurry just from tearing and rubbing is not so concerning.)
  • Direct blow from a small object (squash ball, paint ball, etc.)
  • Past eye surgeries
  • Possible rupture from high velocity projectile (metal striking metal, grinder use, shrapnel, etc.)
  • Double vision
  • Animal bite or scratch (particularly cat)
  • Contact lens use (suspect infection)
  • Fever
  • Surrounding redness or pus
  • Herpes/shingles lesions near the eye
  • Chemical splash
  • Persistent pain for multiple days
  • Hyphema/hypopyon (blood or pus collection between iris and cornea)
  • History of glaucoma, macular degeneration, detached retina
  • Eye bulging out with associated infection or trauma (obviously)
Happy Words:

  • Normal vision
  • “Got better after getting washed out.”
  • “Pain is gone now. I just wanted to get checked… and can you fill out this workers comp form?”
  • Seasonal allergies
  • Eyelid infection (stye)
  • Recent welding or high altitude sun exposure (hurts, but very likely to heal)

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.

Fainting / Syncope

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.

Red Flags:

  • Underlying heart disease
  • Pacemaker
  • Sudden onset during exercise
  • No preceding symptoms
  • Onset while seated or supine
  • Associated worst headache ever
  • Prolonged duration, even after supine
  • Pregnant +/- bleeding
  • Recent bloody vomit/diarrhea
  • Diabetic
  • Frail/elderly
  • Taking warfarin (Coumadin)
  • “He was racing down the basketball court and suddenly just dropped.”
  • “My implanted defibrillator keeps firing.”
  • “Papa was eating and talking, and next we knew, his face was in the pasta.”
Happy Words:

  • Stood up fast, then hit the deck
  • Missed lunch
  • Sleepless
  • Upset
  • Longer than usual church services
  • Happened while peeing (called micturition syncope)
  • “Standing for an hour in the hot sun
  • … on graduation day during a boring speech
  • … after being awake all night partying”
  • “Drank a 5th of JD” (btw – Mortality jumps if you speak in 5ths.)
  • “Was screaming at a Beatles concert”
  • “Woke up with diarrhea, then rode the centrifuge at the state fair”

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. 

Fever (Pediatric)

“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!”

Red Flags:

  • Dehydrated (not urinating, dry lips, no tears)
No interest in drinking (BTW We don’t really care about eating. But if junior’s eating McNuggets, we’re just about done.)
Fever not controlled by properly dosed acetaminophen (15mg/kg) or ibuprofen (10mg/kg)
Immunocompromised (cancer, HIV, asplenic, chronic steroids, post transplant etc.)
Neck stiffness +/- rash
Short of breath
Painful urination +/- back pain
  • Unusual or painful rash (cellulitis, abscess, blisters, etc.)
  • Listless and lethargic
Happy Words:

  • Eating, drinking, peeing, pooping, playing normally
All siblings have the same cold
Short 1-2 week duration
No past hospitalizations
Vaccinations up to date
Full term, and more than 3 months old

(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.

Finger Dislocation

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.

Red Flags:

  • Bone through skin
  • Lost sensation
  • Lost perfusion
  • Extreme pain
Happy Words:

  • “This happens all the time”
  • “Doesn’t really hurt that bad, just looks jacked”
  • “Just put it back in doc!… Go for it…I’m ready.”

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!)

Flesh eating bacteria

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:

Red Flags:

  • Pain worse than what you’d expect (If a lesion looks minor, but the patient is writhing in agony, then we have a much closer look.)
  • Fevers
  • Red streaks
  • Pus
  • Multiple weeping blisters
  • Rapid progression
  • Extension over joints
  • Multiple sites of infection
  • Altered thinking
  • Unconscious (naturally)
  • Frail, elderly, kids
  • IV drug use
  • Recent surgery
  • Chronic illness (diabetes, renal failure, liver failure, etc)
  • Immunosuppressed (HIV, steroid use, cancer, organ transplants, etc)
  • Past history of necrotizing fasciitis
Happy Words:

  • Localized to one spot
  • Lesion unchanged for multiple days… and not dead yet
  • “It itches more than it hurts.”
  • “I’ve had this before and it got better on its own.”
  • “My flipflop was rubbing, and that blister bothered me in the pool. I just want do be sure it’s not that flesh eating infection.”
  • “I popped the blister yesterday and it feels better already.”
  • “I think it’s fine, but my wife told me to come get it checked.”
I group terrible medical problems into those that explode and those that ramp up. For you math brains, explosions are step functions. Some aneurysms, strokes and pulmonary emboli fall into this category. Things that ramp up get worse exponentially. Infections like appendicitis, meningitis, cholecystitis and necrotizing fasciitis (flesh eating bacteria) fit here. Every bad infection starts off as a not so bad infection. So the question for patients is where/when on the curve is it time to seek help. And the question for doctors is when to go nuts with testing and treatments.

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.


This one inspired by a midnight call to a psychedelically painted bus parked outside a hotel. The bus was part of a documentary focused on marijuana and its legalization in California. My patient, along with some colleagues, had tried an “edible” that apparently had some punch. My patient was a long time connoisseur, but this one sent him stratospheric. When I arrived he couldn’t speak a word, and was sitting bolt upright just rolling his head with eyes clamped shut. A “bad trip” indeed. After a couple liters of saline and a little ondansetron (Zofran) for nausea he was back in the game; or a least back to speaking and able to describe some of his hallucinations. Amazingly, nobody was filming!

Red Flags:

  • Elderly, pediatric, or generally frail
  • Vomiting and dehydration
  • Fevers and suspected infection
  • Underlying psychiatric illness
  • Chronic liver or kidney disease
  • Suspected accidental or intentional overdose
  • Head injured
  • No previous history of hallucinations
  • Alcohol withdrawal (delirium tremens)
  • Hyperhydrated with straight water after a marathon
  • Bad mushrooms mixed in? (amanita)
  • “Dry as a bone, red as a beet, blind as a bat, hot as hades, mad as a hatter” (Google “anticholinergic toxidrome”), Jimsonweed, Benadryl, Haldol, atropine, benztropine…
Happy Words:

  • Breathing, walking, talking, peeing, pooping properly still
  • “I took some LSD, edible MJ, ‘shrooms, peyote, ayahuasca, ibogaine…”
  • “I was hallucinating, but I’m better now.”
  • “I spent all night studying for my exam, and then started seeing shadows crawling up the walls.”
  • “I took some Tamiflu, Ambien, Lariam… and had some wicked crazy dreams.”
Honestly, hallucinations in someone no longer hallucinating is not particularly exciting. And even for those who are actively hallucinating, the large majority resolve with supportive care. In the absence of other life threatening symptoms or red flags, just find a comfortable chair, dim the lights to whatever level feels best, tune in some soothing music, hydrate with dilute Gatorade, coconut water, or a water/saltine/applesauce combo pack… Then watch and wait. (And keep my kids far away.)

Most hallucinating folks I see in ERs have taken something. And many are well on the mend by the time they drift in or are delivered by ambulance. Our goal is to rule out bad things in the brain, and anything metabolic we can change. If the problem is ongoing, we’ll typically order head CTs, electrolytes, drug screens, and of course pregnancy tests for anyone with a nanoscopic chance for pregnancy. If we suspect infection, then lumbar puncture (spinal tap) may be in the mix as well.

Rarely we’ll order MRIs too, but never expect one emergently (nor desire one if you’re hallucinating!) One day MRIs may be as easy to order as CTs, but they’re still long, loud and mostly daytime studies.

As for therapies, IV fluids help if there’s associated vomiting. Plus they give a sense that something is happening as we wait for labs and CT results. Sometimes we’ll use sedatives or antipsychotics.

On occasion hallucinations represent the “first schizophrenic break” especially in a teen in the absence of overdose. But far more frequently they represent the brain and body needing some time to rest and metabolize.

As for legalized marijuana, as with all medicines, we here at Pre-R recommend you tread lightly. Thumbs up for legalization, letting sick people feel better, ending the war, skimming some tax revenue, letting a plant be a plant. Thumbs down for cannabinoid hyperemesis syndrome, and bad trips in parking lots.


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.

Red Flags:

  • Sudden onset
  • Confusion
  • “Worst headache of my life” (unless that was said 5, 10 and 15 days ago with normal CT, MRI and spinal taps)
  • Fever
  • Neck stiffness
  • Ataxia (staggering, unsteady walking)
  • Taking warfarin or other blood thinners
  • Recent high impact head injury
  • Syncope
  • Seizure
  • One sided weakness
  • Unconscious (of course)
  • Cancer
  • No previous headaches
  • Family history of aneurysms
  • New pupil asymmetry
Happy Words:

  • “I have chronic migraines and just need some saline and Toradol.”
  • “I ran out of my Norcos.”
  • “I missed my morning Starbucks.”
  • “I have an exam tomorrow and I’m very stressed.”
  • “Everyone at home is sick and I’ve been sniffling all night.”
  • “Normal MRI last week.”
  • “I couldn’t get in to see my pain management doctor.”
  • “I always get headaches with my periods.”
  • “I need a work note.”

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.

Red Flags:

  • Pain (above and beyond usual discomfort)
  • Fevers
  • Vomiting
  • Constipation
  • Abdominal distension
  • Redness and swelling over the lump
  • Diabetes, obesity or other chronic illness/frailty
  • Multiple past bowel obstructions and surgeries
  • “I’ve stopped passing gas.”
  • “I can’t eat anything.”
  • “I can’t push my hernia back in and it’s killing me.”
Happy Words:

  • “It goes away when I lie down.”
  • “I’ve had this thing for years.”
  • “I can push it back in no problem, but it keeps jumping back out.”

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.


I remember as a kid a variety of adults advising me to drink hot beverages to help beat the heat. The mechanism is to stimulate more sweat and evaporative cooling. Might work in dry Albuquerque, but likely less useful these days in Houston. For me, I still say heck no to hot drinks on hot days. And I’ve certainly never handed a hyperthermic patient in an ER a cup of tea. In any case, given the current heat wave in CA, hyperthermia seems about right for an Anxiometer post.

Medically speaking we talk about heat exhaustion and heat stroke. But for readers here, that’s neither here nor there. To be honest I don’t much care about the distinction either. Too hot is the problem… what are the buzzwords… and how best to make folks feel better.

Red Flags:

  • Altered mentation
  • Not urinating
  • Unable to walk
  • Seizures
  • Hot, but not sweating
  • Suspected infection
  • Frail, elderly, kids
  • Diabetic
  • Taking diuretics
  • Concurrent vomiting/diarrhea
  • Underlying kidney problems, or already on dialysis
  • Long distance running, biking, etc.
  • Prolonged associated dehydration/malnutrition (lost at sea, etc.)
  • Suspected “street” drug OD (meth and other stimulants)
  • Prescription drug OD (antihistamines, antipsychotics, antidepressants, anti Parkinsons meds)
  • Jimson weed OD (look up the “anticholinergic toxidrome”)
Happy Words:

  • Normal temp now
  • Able to hydrate orally
  • Walking, talking, peeing, pooping, breathing properly
  • “The IV bag from the medics helped a ton.”
  • “I got too hot at practice, but I feel better now.”

The large majority of hyperthermic patients I see are nearly better by the time they get to the ER. Time spent resting in the shade, or getting hydrated in the back of an air conditioned ambulance, generally helps real quick.

For folks who improve more slowly, we’ll check electrolytes, urine studies, and we’ll look for evidence of muscle breakdown and kidney injury. For anyone not thinking straight, we’ll look for other problems, such as overdose or stroke.

To cool people we consider the four main paths for heat transfer, which are radiation, convection, conduction and evaporation. Ice baths utilize conduction. But not particularly practical. So generally we stick with evaporation using sprayed/misted water, and convection using fans. (No rocket science here.)

IV fluids are fairly standard as well, with brisk urination as the target. Patients can get quite dehydrated in the heat, and they’ll sometimes need 3-5 liters of saline to get the kidneys back in the game… sometimes more. We may supplement with potassium too if low. (Why you’ll see bananas at most finish lines.)

If you have time to read this you probably aren’t facing the more serious forms of hyperthermia. But even if you are, your best bet while waiting for an ambulance is to find shade or AC, use a combo of cool sprayed mist, and fanning. Soaking lightweight clothes may be more effective at transferring heat than stripping down as well, depending on the clothing.

Hydrate with more than just water too. 50:50 diluted Gatorade is pretty good, or water plus Saltines and an apple/banana. Some folks over shoot with gallons of water, and their issue may actually be hyponatremia instead, which can be deadly.

Tylenol is the added finesse.

Feel free to call Pre-R for guidance from a distance, or if you think some IV fluids may be in order.

But probably best to beat the heat with a good book in the public library or a visit to the San Luis Obispo Children’s Museum. They’ve both got great AC.:)


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.

Red Flags:

  • Loss of motor control
  • Confusion
  • Slurred speech
  • Absent shivering
Happy Words:

  • “I still want to keep racing even though my teeth are chattering and my lips are blue.”

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.

Joint Pain

A few weeks ago I officially became old. After kneeling to place an IV in a patient’s arm I stood up and felt a shooting pain in my leg. I hobbled out of the room without the patient noticing. The next day my knee expanded to grapefruit size (not the knee pictured). Four weeks later I’m back to slow running with some twinges, but it seems my ultimate fighting days are coming to a close.
Patients land in ERs with new or recurrent joint pains all the time. Rarely are they emergencies that warrant $1000+ bills. However, exceptions do exist.

Red Flags:

  • Fever
  • Redness
  • Previous joint infection
  • Concurrent STDs
  • IV drug use
  • Direct trauma
  • Multiple affected joints, esp in kids
  • Associated rash
  • Associated tick bites
  • Suspected abuse
  • “I can feel something crunching in there.”
Happy Words:

  • “This is gout and I just need a shot.”
  • “Twisted wrong and felt a sudden pain.”
  • “I just ran a marathon.”
  • “My doc usually injects cortisone which makes it better.”
Quick fixes in the ER are few. Mainly we try to rule out the life threats, and then take the edge off. If we suspect fracture we’ll order an X-ray. If infection, maybe we’ll order “CBC, CRP, ESR” blood tests. Rarely are these particularly helpful, but they give future caregivers baseline numbers should the pains get worse. Plus they show we care.

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.

Red Flags:

  • Exposed bone, cartilage, tendon, ligaments
Open fracture
  • Animal bite
Probable joint penetration
Dirty or anything embedded (gravel, wood, metal, fish bones… organic matter being worst)
  • Arterial bleeding (though this usually stops with pressure too)
Lost sensation or strength suggesting ruptured tendon, muscle, nerve
  • Frail, diabetic, immunocompromised etc.
Happy Words:

  • Clean
  • Shallow
  • Otherwise healthy
  • No circulatory, sensory, motor loss

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.

Limb Swelling

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).

Red Flags:

  • One sided limb swelling (more common in the legs)
  • One sided limb pain
  • Shortness of breath
  • Chest pain
  • Recent surgery
  • Recent injury
  • Recent prolonged sitting (bus, plane, train, truck, car)
  • Wheel chair dependence
  • Cancer
  • Heart disease
  • Hypertension
  • Past history of DVT/PE
  • Family members with “clotting problems”
  • Smoking
  • “Lost my warfarin.” 
Happy Words:

  • “Bad valves in my veins and I lost my compression stockings.”
  • “Both legs swell periodically after walking.”
  • “I ran out of my Lasix.”
  • “Gets totally better with elevation.”
  • “I just got off a cruise and fell off my diet.”  

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

Limp (Pediatric)

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?

Red Flags:

  • Fever
  • Miserable
  • Red swollen joint
  • Other findings like belly pain, neck pain or rash
  • Trauma history
  • Any suspicion for abuse
  • History of infected joint
  • Multiple affected joints
  • Recent tick or other insect bites
  • Recent travel
  • Days to weeks duration
  • Sickle cell disease
  • Cancer history 
Happy Words:

  • “Limping for less than a day.”
  • “He doesn’t seem to mind.”
  • “She has three older siblings and they wrestle all the time.” 

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.

Motion sickness / sea sickness

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.

Red Flags:

  • Past strokes or heart attacks
  • Blood thinners like warfarin
  • Pacemakers
  • Frequent falls
  • Cancer
  • Diabetes
  • Pregnant
  • Fevers 
Happy Words:

  • “I get sea sick on every cruise. But my family loves these daggum reunions.”
  • “I’m able to keep ginger ale down ok.”
  • “The cool air helps.”
  • “I felt waaay better after I finally puked.”

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:

  1. Head to the part of the ship that moves the least, but that also offers cool outside air. For a ship parked at sea, lower decks, mid ship will move the least like the middle of a see-saw. But under way, the rear of the ship will move least. (This applies to your speed boat on a lake as well. Those up front get bounced all around, while those in back have a softer ride. The jostling is just higher frequency.)
  2. Visual fixation on fixed points in the distance can be helpful as well. So in light of the first point, I consider the best spot to be way back, outside on a recliner, watching the horizon. Just try not to get a nose full of ship or passenger smoke/exhaust.
  3. Ginger in any form seems helpful – ginger ale, ginger beer, ginger tea, ginger candy or straight ginger. No idea why.
  4. Avoid fatty, spicy foods and alcohol. People usually figure this out quick.
  5. No idea if the wrist pressure bands works, but some folks swear by them and acupressure in general.

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. 

Narcotic Withdrawal

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.

Red Flags:

  • Red flags
  • Underlying heart disease
  • Elderly
  • Diabetic
  • Dehydrated (not urinating, no sweating, hyperthermic)
  • Comorbid psychiatric illness
  • “I take 100+mg of methadone per day”
Happier Words:

  • “I’ve been through this before and just need some clonidine.”
  • “I feel better with exercise.”
  • “I can still keep liquids down no problem.”
  • “I only recently was started on methadone, and currently I’m at 20mg a day.”

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.

Pre-R maybe can help through your acute withdrawal. But consider Ken Starr MD Addiction Medicine Group and ENDORPHIN POWER COMPANY for your remaining days.

There is an older video that pretty well captures the prison of narcotic addiction, “Detox or Die“.

Neck injury

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.

Red Flags:

  • Weakness/numbness of arms/legs
A sense of “being stuck” (Joints in the neck can also dislocate.)
High speed accident
  • Other major injuries


Happy Words:

  • No midline neck pain – meaning the bones don’t hurt when we push on them directly. (Sore muscles on the sides aren’t particularly concerning.)
  • No intoxication or confusion that could mask injury
No neurological problems like weak or tingling fingers
  • Low speed accident
No other concerning injury that may distract attention 
“I felt fine after the accident, but when I woke up today it was super tight.”
“I tried to work out after, but when I did curls it went right up my neck.”
  • “My boss sent me here to get checked and for a work note.”
  • “Yeah the car isn’t damaged and drives fine. I just hit the breaks too hard.” (I kid you not.)

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.

Nose bleed / Epistaxis

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.

Red Flags:

  • Blood thinners like warfarin
  • Head injury
  • Elderly
  • Anemic
  • Syncope
  • Bleeding down both nostrils and the throat that won’t stop with a good pinch …(suggesting a posterior bleed)
Happy Words:

  • Bleeding from one nostril
  • Stopped already
  • Stopped with proper pinch
  • “This happens when I’m in dry climates.”

Epistaxis - Nose bleed | Pre-R Musings

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. 

Nursemaid Elbow (Pediatric)

“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?

Red Flags:

  • Direct fall onto arm
  • Obvious deformity
  • Bruising, swelling around elbow
  • Sense of bones crunching inside… “crepitus”
  • Concurrent injuries like broken wrist or clavicle
  • Can’t move hand or wrist
  • Exposed bone (obviously)
Happy Words:

  • “Kid refuses to use the elbow ever since getting tugged.”
  • Previous nursemaid’s elbows

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:

HELP! I Accidentally Dislocated My Daughters Elbow (Nursemaid Elbow) | Dr. Paul and What is nursemaid’s elbow?


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.

Red Flags:

  • Chest pain
  • Syncope (especially during exercise)
  • Light headedness
  • Shortness of breath
  • Existing pacemaker
  • Underlying cardiac disease (heart blocks, cardiomyopathy)
  • Dialysis
  • Endocrine disease (diabetes, hypo/hyperthyroidism, pheochromocytoma)
  • Heart rate in the 100s (practice checking your own pulse)
  • “My defibrillator keeps firing.”
  • “I have a history of A. fib, V. fib, SVT, etc.”
  • “I died once and they had to shock me.”
Happy Words:

  • Exhaustion
  • Emotional upset
  • Inebriation
  • Dehydration
  • Chemical hyperstimulation (caffeine, diet pills, cocaine…)
  • Situational hyperstimulation (“The Beatles!”)
  • “I have mitral valve prolapse and PVCs.”
  • “I have a physics exam tomorrow I haven’t studied for.”
  • “They arrested me for using meth, and I’d rather be in the ER than in jail.” 

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.

Red Flags:

  • Any animal bite or clawing
  • Associated fracture
  • Tendon laceration
  • Weakness/numbness
  • Hand, neck, eye or joint penetration
  • Suspected foreign body (tooth/claw?)
  • Suspected deep neck, chest, abdomen penetration
  • Spurting blood or expanding hematoma
  • Old (>24 hours) bite with signs of infection like fevers, pain, pus, redness
  • Chronic medical problems like diabetes, AIDS, cancer, transplants, taking steroids, etc.
  • Through lip into mouth
  • Rusty nail through shoe into a numb diabetic foot
  • Puncture through clothing with embedded fabric
  • High pressure water jet puncture
Happy Words:

  • Skin tear rather than puncture
  • Easy to explore wound completely to its depths
  • Superficial wound
  • Vaccinations already up to date

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.


(Dermatology for dummies… and ER docs)
My favorite rash story comes from a cruise ship. One of the filipino band members visited the ship’s clinic with pus dripping from sores all over his face and body. I treated him for presumed staph, and it actually seemed to help quite a bit. Unfortunately, his roommate and fellow band member appeared with a rash about a week later, and I got a look at the earlier stages of the lesions. This time I got the diagnosis right – adult chicken pox. After a third band member contracted it, we clearly had a public health situation, and a lot less music.

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.

Red Flags:

  • Fever
  • Pus
  • Red streaks
  • Swollen lymph nodes
  • Pain, especially if “out of proportion to exam”
  • Stiff neck
  • Local meningitis outbreak
  • Blisters/sores, especially associated with recent new medications
  • Swollen tongue
  • Wheezing
  • Asthmatic
  • Light headed
  • Recent tick bite
  • Joint pain
  • Taking warfarin
Happy Words:

  • Itch
  • Chronic problem, such as eczema, psoriasis, venous stasis ulcer, rosacea
  • No past hospitalizations, intubations or anaphylaxis
  • “I’m allergic to dogs… and I just pet a dog.”
  • “This is herpes and can I have a Valtrex prescription?”
  • “This is poison oak and can I have a prednisone prescription?”
  • “I’ve had chicken pox already.” 

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:

  • Fever, neck pain, blotchy lesions? Head to the ER or get a ride. Meningitis is the fear. So you get a sense for probabilities, however, since 1993 I’ve never had a patient myself with classic bacterial meningitis. Thank you vaccines. Viral meningitis is far more common.
  • Pain which comes on rapidly, associated with fever and rash, is also concerning. The phrase “pain out of proportion to exam” suggests a deeper infection, which may be life threatening. Google “necrotizing fasciitis” if you suffer from narcolepsy.
  • While itch can be exasperating, it is preferred over pain. Most causes of itch can be helped greatly with antihistamines +/- steroids. These represent the majority of our Pre-R derm-related calls.
  • One sided severe stabbing pain, followed later by rash, especially with a previous history of shingles?… Call us sooner than later for a Valtrex prescription. This isn’t like amoxicillin for ear infections and sinusitis. Early treatment of shingles or herpes with Valtrex really works. But it’s less helpful over time.
  • Is the rash associated with generalized illness or is it a local problem? If no associated tongue swelling, wheezing, light headedness, pain, then there is generally time to think. Give us a call. Very often these can be solved with phone conversation, or Skype/Facetime.

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.

Sea Urchin Sting (Wana)

Every practice setting has its specialty. For Poipu Mobile MD it appears to be “Wana” stings. Patients often arrive after surfing, or walking on shallow rocks. They generally describe a sudden stabbing pain, which ramps up far beyond what you may feel by stepping on a nail. Puncture by the spines causes one level of agony. But it’s the venom from the spines and “pedicellaria” in between that crank the pain up to 11.
Patients call regularly with this problem. The most recent victim to call said it was the worst pain he’d ever experienced, and far worse than when he broke both bones in his lower leg. He said it was like a wave that took over his whole body, then he couldn’t think straight and nearly passed out. (Naturally, all the mothers in the room rolled their eyes.)
The quick fix in this case was a bupivacaine digital block. That bought time for conversation and a little digging.

Red Flags:

  • Weakness
  • Breathing problems
  • Lost consciousness
  • Fevers
  • Pus
  • Red streaks
  • Protruding spines
  • Suspected joint involvement
  • Frail, elderly, kids, diabetics
Happy Words:

  • “I got the spines out, and the pain’s gone. I just wanna be sure it’s ok.”
  • “It happened a couple days ago, but the black marks are still there.”
  • “Sure, I can take a few days off work to elevate my foot without walking. Can I have a work note?”
  • “The pain got better when I peed on it.”
While horrible in appearance, most of these stings resolve with time and TLC. Soaking in vinegar can help to dissolve the calcium carbonate spines, while warm (approaching hot) water can help to neutralize the toxins as well.

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.


A couple months ago I was working with Vanessa in a coffee shop, when it seemed all eyes had turned to the floor under one table. The group gaze pointed to a student who was having a seizure. I went over to hold him on his side to keep him from choking on vomit or saliva, and also to protect his head and limbs from banging against the metal window frame. That’s it. That was cutting edge bystander first aid for seizures. Checking for a pulse is just added finesse to build bystander confidence.

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.

Red Flags:

  • No past seizure history
  • Ongoing uncontrolled seizures
  • Multiple
  • Head injured
  • Signs of infection
  • Cancer
  • Taking blood thinners
  • Hydrated with 3 liters of water after running a marathon
Happy Words:

  • Uninjured
  • Brief
  • No longer post ictal (meaning confusion has resolved)
  • Back to normal
  • “I have epilepsy and this is like my past seizures.”
  • “I ran out of my Dilantin.”
  • “I decided to stop drinking cold turkey.”

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.


Slishman’s Unified Theory of Human Emergencies “SLUTHE” (joking)… However, I do have an odd take on the word “shock,” which gets thrown around quite a bit.

Shock comes in a variety of flavors, but “I was in shock when another car backed into mine at Trader Joe’s” isn’t one of them. If you want to talk about “shock” also consider these:

Red Flags:

  • Chest pain
  • Hard to breathe
  • Hypo/hyperthermic
  • Light headed or unconscious
  • High-speed accident
  • Paralyzed
  • Elderly/frail
  • Diabetic
  • Immunocompromised
  • On dialysis
  • Excessive bleeding from any route
  • Excessive vomiting/diarrhea
  • Accidental or intentional overdose
  • Previous heart problems
  • Recent surgery
  • Past anaphylaxis from bee stings and just got stung
Happy Words:

  • Walking, talking, breathing, thinking, peeing, pooping properly
  • “I think I was in shock when he backed into my car… No I wasn’t in the car, I was walking to it with my cart and saw the whole thing!”
  • “I sprained my ankle sliding into first base and I felt a pop, and then went into shock.”
  • “She’s pregnant?! But I just had a vasectomy! Ok hold me. I’m going into shock.”
  • “I got my hospital bill, went into shock, and so my husband called 911.”
Having been raised on physics, with a later shift to medicine, it’s still hard for me to shake the laws of Ohm (V=IR) and Joule (P=VI). The first says that voltage in a circuit is proportional to current and resistance. The second says that power is proportional to voltage and current.

So when I hear blood pressure, I think voltage. Can’t help it. Heart rate (times “stroke volume”) to me means current. Vascular resistance is like electrical resistance, but just not as easy to measure with our basic vital signs. So to me, when someone is in shock, it means his or her bulb (brain) has gone dim. These analogies help me to think about underlying problems and possible solutions.

Shock can be “psychogenic” too, but in the ER we try to eliminate other life threats first. Here are a few:
Hypovolemic shock means a patient’s tank has run low. Excessive bleeding from trauma, excessive vomiting or diarrhea, excessive urination from uncontrolled diabetes can be causes. Surf all morning in the cold, pee a bunch, forget to hydrate, remove your wetsuit, then stand for an hour in a warm church… you may experience the same. For all these, the heart typically races along, but there just isn’t enough fluid to get oxygen up to the brain.

Cardiogenic shock is more of a pump problem. Heart attacks and arrhythmias are a couple causes. Blood is there, but the pump just isn’t moving it on up to the brain. Heart rate may be fast, irregular, or slow, and in worst cases, blood pressure drops as well.

Septic, anaphylactic, neurogenic, or medication induced shock have a common thread… vascular resistance is diminished. Causes may include severe infection, allergic reaction, spinal trauma or beta-blocker overdose, respectively. For these, the heart flies along trying to keep up. But when severe, blood travels everywhere but the place that matters most, namely the brain. And again, bulbs go dim.

While all these terms may seem complex, all roads lead to similar advice. At home, if you suspect shock for whatever reason, let gravity be your friend; head down and legs up for starters. And hydrate if at all possible.

If bleeding, then apply direct pressure or a tourniquet. Use insulin and hydration for hyperglycemic diabetics, or sugar if hypoglycemia is suspected. Use oxygen if it’s nearby and available or descend if you’re at altitude. If you suspect anaphylaxis, use an EpiPen if possible and add Benadryl for bonus points.

If you’re traveling and you suspect sepsis, don’t wait hours in line in the Cusco ER to find out which antibiotic is best. Take a dose of what you or a friend may have on hand, because for sepsis the clock ticks fast.

Long story short, if you suspect ongoing shock with associated red flags, then brain low, legs high and call 911. But if you think you or your loved one were “shocked, shocky, or shocking,” then feel free to call Pre-R, and we will try to talk you through and brighten your bulb.

Shortness of breath (Pediatric)

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.

Red Flags:

  • Retractions (Each breath seems to be sucking in the soft tissues between ribs and collar bones.)
  • Leaning forward onto extended arms, and refusing to lean back (We call this “tripoding.”)
  • Color change (Bluish lips being quite concerning)
  • Neonates (Congenital heart problems may take a few weeks after birth before becoming apparent.)
  • Lethargy and exhaustion (Bad markers)
  • Apnea (No breaths for 20 seconds or more)
  • Drooling
  • Struggling to speak
  • Unvaccinated (Epiglottitis is all but history thanks to the H.flu vax. Whooping cough, however, is enjoying a resurgence.)
  • Cystic fibrosis or other underlying lung disease
  • Neuromuscular illness (Guillan Barre, muscular dystrophy, etc.)
  • Neonates and honey (botulism)
  • Allergic to bees and just got stung
  • “Junior was sucking on my coins a minute ago. Now one’s missing.”
Happy Words:
  • Better with one neb
  • Better with cool mist
  • Better sitting up
  • Better after leaving uncle Murray’s tobacco den
  • “He was barking like a seal at home, but the drive here in the cool air seems to have helped.”
  • “The hot steam bath helped.”
  • “He seems to get better when I hold his head up to the freezer.”
  • “Everyone has a cold at home and junior lost his inhaler. Can we get one today?”
  • “We have a neb machine at home, but just need the drops.”
  • 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. 

    Sinus pain

    For some infections we’re sold that antibiotics help. UTIs, kidney infections, and skin infections are a few examples. People with these frequently get better over hours. I myself had a MRSA cellulitis back in 2005. Keflex failed, Clindamycin failed. Bactrim knocked it out in 24-48 hours. I became a believer in the right drug for bug.

    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.

    Red Flags:

    • Prolonged fevers
    • Diabetes
    • Past sinus surgeries
    • Congenital sinus abnormalities
    • Smoker
    • Associated vision problems
    • Associated skin infection 
    Happy Words:

    • “I just had a cold and I’ve been sniffling for a week.”
    • “My doctor always gives me antibiotics, but I don’t really know if they help.”
    • “I feel better sitting up or after a long hot shower.”
    • “My Neti pot makes me feel better.”
    • “The pain goes away with ibuprofen.” 

    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.

    Skin Infection / Cellulitis + MRSA

    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.”

    Red Flags:

    • Fevers
    • Exquisite pain
    • Red streaks
    • Swollen lymph nodes
    • Altered mentation
    • IV drug use
    • Endocarditis
    • Diabetes
    • Immunocompromised (AIDS, hep C, cancer, chronic steroid use, etc.)
    • Frail/elderly
    • Neonatal
    • Rapid onset and rapid progression
    • “I work in an ER.”
    • “I work at the jail.”
    • “My spouse has MRSA.” 
    Happy Words:

    • Non painful
    • Small area of redness
    • Better with elevation
    • Similar to past episodes that improved with Keflex 

    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. 

    Snake Bite

    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.

    Red Flags:

    • Immediate symptoms
    • Punctured skin
    • Light headed or unconscious
    • “Metallic taste”
    • Previous bites (yes indeed)
    • Rapid local swelling and bruising
    Happy Words:

    • Scratches in the shape of a horseshoe bite
    • No symptoms
    • No problems hours since bite
    • “I didn’t hear a rattle, head was round, no pit, two rows of scales under the tail, and round pupils” (yeah right)

    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.

    Spider Bite

    For starters, I’ll say this… I/we frequently don’t believe you. Even if you actually saw the spider rearing its head, when you head to the ER it’s probably best just to say “feels like something bit me.”

    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.

    Red Flags:

    • Fevers
    • Abdominal pain
    • Multiple painful lesions
    • Rapid expansion
    • Red streaks
    • Swollen lymph nodes
    • Draining pus
    • Skin ulcer development
    • Immunocompromise (Cancer, chronic steroids, elderly, etc.)
    • “I coincidentally also inject heroin.”
    Happy Words:

    • Itchy
    • Localized to one small lesion
    • “I didn’t see the spider.”
    • “It’s getting better already.”
    • “I hate spiders.” (Insectist!)

    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.

    Strep Throat

    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.

    Red Flags:

    • Dehydration
    • Fever not controlled by ibuprofen or acetaminophen
    • Associated breathing problems
    • One sided swelling to suggest peritonsillar abscess
    • Unvaccinated (specifically for H.flu).
    Happy Words:

    • Runny nose
    • Well hydrated
    • Urinating normally
    • Drinking easily

    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.”

    Red Flags:

    • Difficulty speaking
    • One sided weakness
    • Unconscious
    • Past strokes
    • Hypertension
    • Atrial fibrillation
    • Cancer or other problems causing clots
    • Pregnant
    • Elderly
    • Smoker
    • Relatives with past strokes
    Happy Words:

    • *not really “happy,” but rather anything that may suggest another cause.
    • Intoxication
    • Diabetes
    • Psychiatric illness
    • Isolated sensory loss
    • Fever
    • Isolated facial paralysis (Bell’s palsy)
    • “I ran a marathon, and I’ve been hydrating with water, and I take diuretics.” (hypokalemic paralysis)
    • “I sat with my legs crossed too long and now I can’t feel them.”

    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 


    Since mental health coverage seems headed the direction of women’s health… and actual women in the Trumpcare room… I thought suicidality might be the right next Anxiometer post.

    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:

    Red Flags:

    • Suicidal with a plan
    • Access to weapons (guns in particular)
    • Access to potentially toxic medications (tricyclics, narcotics…)
    • Actual actions taken (like overdose, hanging…)
    • Psychiatric comorbidities (mania, depression, schizophrenia…)
    • Concrete reasons (terminal illness, isolation, bankruptcy, recent loss…)
    Happy-ish Words(meaning lower chance for success):

    • Good social supports at home
    • An actual home
    • Intoxication
    • Numerous previous failed attempts
    • Well connected with a psychiatrist and/or case manager
    • “I’m not really suicidal, but I’m hungry and it’s cold out.”

    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: 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.

    Thermal burns

    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:

    Red Flags:

    • Blistering
    • White with no sensation in the middle (suggesting deep with burnt nerves)
    • Circumferential (around an arm, leg, neck, chest, etc)
    • Over a joint
    • Face, hands, genitals involved
    • Uncontrolled pain
    • Older burn with signs of infection
    • Comorbidities like diabetes
    • Kids (We look extra close for abuse.)
    • Elderly (We try to ID ongoing hazards at home.)
    • Concurrent inhalation injury (singed nose hairs, wheezing, facial soot)
    • Indoor fire with carbon monoxide or cyanide exposure
    • “I was hit by lightning and you can see the entrance wound. The exit wound blew off my shoe. And I’m not sure how long I was unconscious.”
    Happy Words:

    • Localized injury that doesn’t inhibit movement
    • “I spilled coffee on myself. Doesn’t really hurt but just thought I’d get it checked.”
    • “This is a worker’s comp injury. I’m fine.”

    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.

    Red Flags:

    • Fevers
    • Neck stiffness
    • Engorged tick embedded for a long time
    • Bulls eye expanding rash, aka “erythema migrans”
    • Joint pains
    • Rash/spots on hands/feet or elsewhere
    • Paralysis
    • Deer tick (amazingly tiny)
    • Hiking in New England 
    Happy Words:

    • “Definitely wasn’t there a few hours ago”
    • “Tick isn’t engorged yet and still seems to be settling in”
    • “Otherwise healthy and no symptoms at all” 

    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.

    Urinary Discomfort / Dysuria

    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.

    Red Flags:

    • Fever
    • Back pain
    • Vomiting/dehydration
    • Diabetes
    • Pregnancy
    • Past infected kidney stones
    • Past antibiotic resistant UTIs
    • Structural anomalies like ureteral/urethral strictures
    • Kidney transplant
    • Ureteral stent
    • Indwelling catheter
    Happy Words:

    • Symptoms just started
    • Infrequent
    • “I’m on my honeymoon” (honeymoon cystitis)
    • “I have never had a UTI with bacterial resistance.”
    • “Macrobid, Bactrim, Keflex, Cipro all work just fine.”
    • “No I don’t want to wait for urine culture results, I want an antibiotic!”

    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.)

    Vaginal Bleeding - Early Pregnancy

    Some medical problems may appear only once in a career; alligator bites in SLO for example. Then there are the bread of butter problems of emergency medicine that arrive every 2nd or 3rd shift. Vaginal bleeding in early pregnancy is one of them.

    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.

    Red Flags:

    • Syncope
    • Lightheadedness
    • Abdominal pain
    • Fever, vomiting, dehydration
    • Underlying anemia
    • Excessive bleeding (I get interested after a couple soaked pads an hour for 4+ hours. More interesting is a statement of increasing, rather than decreasing bright red bleeding.)
    • Past ectopic pregnancy
    • “I’m Rh negative.” 
    Happy Words:

    • “I noticed a little spotting so the hotline nurse told me I should come get checked.”
    • “I’ve already had an ultrasound that showed a normal fetal heartbeat and I’m Rh+.”
    • “My next OB appointment is tomorrow at noon.”
    • “I didn’t know I was pregnant and don’t really want to be.”
    • “I’m not bleeding anymore, but would just like an ultrasound to be sure.” 

    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”:

    • If you’re pregnant with no prenatal care and feeling sick and/or terrified, then head to the ER.
    • If you have some questions, or would like an outpatient ultrasound or lab work, feel free to call Pre-R.
    • If you have prenatal care, if you know your baby is in your uterus, if you know your blood type is Rh+, if the bleeding isn’t severe, then consider waiting to see your OB. I don’t want to be spanked by my ER, FP or OB friends here. Of course the ER is always an option, but just realize you’re getting the OB JV team… and we may use a bedpan to prop up your bottom if the special “pelvic bed” is taken. Apologies in advance.

    Vaginal Bleeding - Later pregnancy

    As Vanessa and I sit here waiting for baby two to arrive, it occurs to me that this area of medicine is really a black box for me, and partially of my own doing. You see most hospitals send women who are 20+ weeks pregnant directly to the obstetrics floor. This is good patient care, but not good for my education. So I generally only meet these women after car accidents, stubbed toes and anything else unrelated to their pregnancies.

    And when women arrive who are in active labor I’m especially motivated to roll them through the ER straight to OB for three reasons. First, I’m not an Ob/Gyn. Second, there aren’t many ways to better gum up an ER. Third is selfish… Any ER delivery = two daggum charts and a thousand buttons! (The miracle of birth is a lot less miraculous in the ER.)
    All that said, here are third trimester buzzwords:

    Red Flags:

    • Fevers
    • Bleeding
    • Sudden abdominal pain (abruption)
    • Shortness of breath/chest pain
    • Lightheaded/syncope/unconscious
    • Hypertension
    • Headache, vision changes, belly pain (preeclampsia)
    • Seizures (eclampsia)
    • Jaundice
    • Vomiting/diarrhea/dehydration
    • Painful urination or suspected kidney infection
    • Direct abdominal injury
    • Known placenta problem (placenta previa, vasa previa)
    • Many preterm deliveries/miscarriages
    • Uncontrolled diabetes
    • Bleeding or clotting disorders
    • Still smoking/drinking/injecting etc
    • No prenatal care
    • “Water broke” (ruptured membranes) esp if more than a day ago
    • Preterm contractions
    • Crowning, breech, partially/fully delivered already (obviously)
    • “Oye!”
    • (What’d I miss OBs?)
    Happy Words:

    • “I can still feel the baby moving in there.”
    • “The IV fluids from the medics made me feel way better.”
    • “Tylenol solved my headache.”
    • “My OB said to come in for a liter of saline, and she’ll see me in the office tomorrow.”
    That last point is one of the reasons we started PreR. IV hydration solves an awful lot, but just isn’t so easy to find outside an ER. Ask your OB/midwife/doula where they’d send you for IV fluids after hours, or even during business hours.

    If you land in an ER during your third trimester, expect a good size workup… because someone was worried enough to not send you along to the obstetrics floor. IV fluids, blood/urine tests, ultrasound and fetal monitoring are fairly standard.

    Hopefully Vanessa and I will be able to bypass the ER very soon. If for some reason we deliver in the ER or the parking lot, I just won’t be able to look my unlucky colleague in the eye as they click through our two charts!


    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.

    Red Flags:

    • Gradual progression
    • Fevers
    • Confusion
    • Altered mentation
    • Cancer history
    • Head injured
    • Vertical room spinning instead of horizontal (never met anyone with this)
    • Associated neurological deficit, like facial droop, arm or leg weakness
    • Doesn’t improve with a fixed gaze 
    Happy Words:

    • Sudden onset
    • Associated viral illness
    • Associated ear infection
    • Ear ringing or loss of hearing
    • “I have Meniere’s”
    • “I’ve had this before and it got better with meclizine”
    • “One ear feels full”
    • “I got hammered last night”
    • “I’m so sick of these cruise ship family reunions!”

    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”.

    Vomit (Pediatric)

    Like most folks this season I’ve developed a hack, and a couple days ago my toddler Max joined along. He’s still super active, breathing, eating, peeing, pooping, so not too concerned. But last night before bed I thought his stomach looked a bit more plump than usual. He then added 10 ounces of uranium laced milk to the reactor. When fully topped up he coughed and spit up a bit. So I picked him up and tapped his back as you do. That’s when the cork blew.

    Never in any ER have I seen such well distributed vomit. He soaked not only our bed and his pants and shirt, but the front and back of my shirt as well. We skated straight into the shower fully clothed, and Vanessa became hazmat director.

    Why tell you this? Well it made me think of all the parents I’ve seen in ERs with vomiting kids. If vomit volume was a red flag then I too should have called 911. But it’s not. In fact, Max never even cried. He looked surprised, but then thoroughly enjoyed clothed showering and pushing undigested wagon wheel pasta (complete wheels!) through the strainer.

    So here are other shades worth considering:

    Red Flags:

    • Abdominal pain
    • Dehydration (not urinating or drinking and generally listless)
    • Fevers
    • Speaking/thinking/acting strangely
    • New unusual headache
    • Breathing problems
    • Bright red blood with the first puke, and high volume. (Flecks of blood after the 5th heave, a bit less concerning.)
    • “Projectile emesis” in an infant (Suggests pyloric stenosis or other obstruction downstream from the stomach. Picture a garden hose. Max was more like Niagara.)
    • Accidental or intentional poisoning
    • Recent abdominal surgery
    • Not passing gas
    • Bloody stools
    • Diabetes, dialysis, cancers or other comorbidities
    Happy Words:

    • Drinking, eating, peeing, pooping, playing properly again.
    • Associated diarrhea absent pain, dehydration and ongoing vomiting. (The problem is the solution.)
    • “Post tussive emesis” (What Max had.)
    • “Jimmy eats Hot Cheetos three meals a day and his fingers are the color of his puke.”
    • “My child vomited yesterday. He’s fine now, but I just want to get him checked out. And can I have a school note?”
    • “My child bit a deodorant stick. I then stuck my fingers in his mouth to clear it and he puked all over daddy.” (My greatest soaking up to yesterday.)

    Parents are often concerned that their kids won’t eat after a good round of vomiting. But really, hydration is what we care about. If kiddo only wants blue Otter Pops for three days, then so be it. Your gauge is urination. Food happens later.

    For kids who land in the ER we often start with Zofran and Pedialyte, or Otter Pops. If we choose to get blood tests then we frequently run saline as well to limit the needle sticks. Oral or IV hydration can be remarkably effective. Kids in particular just seem to blossom.

    If abdominal pain remains a component expect a CT scan, or ultrasound first if time permits. Head CT on occasion reveals surprises too if there are associated neurological problems. But we really try to limit the radiation.

    Long story short, most vomiting resolves with TLC, +/- Zofran. It’s not the vomiting so much as the dehydration which causes concern. Feel free to give us a call to talk it through, or maybe for some IV fluids. Or head to an ER if you want to chase faster diagnostic testing and treatment.

    As for Max, he’s well on the mend, but Zak has started sniffling. We’ll see. On the bright side, being soaked in someone’s vomit really helps gauge a relationship. Having not minded, I now realize how much I love those two.