Hemoptysizizer

Actually had a sick patient the other day. 40-ish female coughing blood every minute or so, about a teaspoon each time, breathing in the 40s, sats in the 70s. The picture of respiratory distress: retracting, scalene muscles pulling the whole rib cage up, abdomen tensing with each expiration, retracting--the whole body working to move air.

They always teach to go through the ABCs; the patient could say her name, and had an obvious B problem. No tracheal deviation, breath sounds equal but 'wet'. Good periperhal pulses and her pressure was 147/86.

History? Gosh darn if she didn't have a history of asthma, COPD as well, tuberculosis (the MAI kind, not the typical TB), pseudomonal pneumonia, and aspergillosis, a fungal infection that can grow in old TB cavities. Well, at least it wasn't unprovoked hemoptysis.

She did well, actually. A non-rebreather got her sats up, duonebs times 2 and then a continuous neb decreased her work of breathing. Her CXR showed new opacity where an old cavitary lesion in the upper lobe had been. Who knows. Those cavities can erode into the bronchial arteries without warning; massive bleeding can occur and we transfuse, specialists embolize.

Her follow up is revealing. Her lung history started with an exposure to tricholoroethylene, which, oddly enough, doesn't mention anything about lung injury, but this poor lady needed a VATS procedure--laparoscopic resection of part of her lung. Wonder what it did to her kidneys. Come to think of it, that was the main reason we couldn't get a CT scan. She underwent embolization because she wasn't a surgical candidate, and recovered well.

Cases of the Priviledged

She parks her wheelchair in the hallway, glowering at the nurses. We're all watching the board; new 'red' (needs to be seen') in 13, and the chief complaint is a post-op leg infection, started bothering her today, normal vital signs. We try and see everyone within ten or fifteen minutes of coming back, and sick ones of course right away. By the time I get in there, Mrs. not sick and her husband are irate. Why did they have to come to the ED? Can I call Mr. Bones and have him come in and see her personally to avoid the wait? No, you have to see the resident. Well, what's taking them so long?

The ortho resident that night was awesome. We gave her sandwiches out of the patient fridge, she was doing so much. I had first-attempted a reduction of a complicated ankle fracture dislocation that literally had no solid structure connecting the leg to the foot, and that was one of four of her cases currently in the department.

I'm sorry for your inconvenience, ma'am, but we have to see people here based on how sick they are and I know of at least four other serious fractures right now.

Still didn't work; they backed off but passively kept trying to see how they could jump the line.

Last night, a guy came in with decreased sensation to bowel movements, buttock numbness, thigh numbness, and new erectile dysfunction. He got an MRI for possible early cauda equina syndrome. His question? How long will this take? I can always come back. I was like, dood, you're getting a stat MRI. Do you know how hard that is to do?

Also affluent, he had been told to get an MRI by his golfing buddy who was, you guessed it, a doctor.

I don't disagree with the call, I advocated it. He did have anesthesia and decreased rectal tone (although, ahem, there were 'other' reasons for that in retrospect and on full social history), and the new ED was alarming. But his status led him to expect certain things. Quick emergent service by the best, and full answers, and the best scans.

Over at M.D.O.D., God love them, they discuss the entitlement of the freeloaders. I'm as scared of the entitlement of the upper classes.

Some days you eat the bear...

Some days, the bear eats you. I only saw eight patients in ten hours, couldn't get a fem stick on one guy to save my life, was slow to order meds that had to be ordered from the pharmacy, blah, blah, blah.

About my only victory was guessing Radon for environmental contaminant that is a degredation product of uranium during toxicology jeopardy during grand rounds. I got the next one wrong, though. We lost.

Sigh.

You got an MRI for a stress fracture?

There's a new article in the NYTimes that talks about the error rate in MRIs. The article is written fairly well, but totally misses the mark. Why?

The story says that MRIs have variable quality based on who reads them--sure--and that if your MRI is read by someone inexperienced it might miss something. OK. Then it quotes someone from U Mass who says 'we don't miss things because we have a 3 tesla MRI and radiologists who only read musculoskeltal MRIs', essentially. I'm guessing on the 3 tesla thing but I'm sure U Mass has at least one, probably more.

So? So, the author had a new stress fracture. OMG! Get an MRI! Have it read by a specialist at an academic medical center! Or, take a plain film to ensure adequate alignment, and put your foot in a boot with close primary care follow-up. Good God. To be fair, she finally gets around to the idea that we rely on scans too much and should just talk to the patient, but it's buried at the end. No wonder we spend trillions.

Meanwhile people living on Indian reservations in New Mexico don't even have an ambulance within 30 minutes, let alone an Emergency Room.

The scariest part? It was the number 1 e-mailed article of the day. I guess I'll brace for MRI requests.

WTF?

No joke, the chief complaints of the previous night.

I have a bruise. Of course, by ambulance.

I have a cold. For 3 whole days. Nyquil just isn't cutting it, but the Tylenol I had in triage cured me.

My doctor saw that I have a hemoglobin of 9.3 (we transfuse in the ICU below 8) and thinks I need an emergent transfusion. I have NO SYMPTOMS. AT ALL. This one was great. I called the doc and they actually suggested I do a rectal exam for an occult GI bleed on a 24 year old woman who was having heavy menstrual periods, even though she had been in her doc's office ONE DAY AGO.

And the really sad one; I'm having weakness in both legs, bowel and bladder incontinence, I can't feel my groin...and it started a week ago. True neurologic emergency. Too late.

Sigh.

True

'By the way,' says the attending, 'she doesn't have guarding. So in your note, no guarding, no rebound. Got it?'

'But she did have guarding', I said.

'What's guarding?'

'Involuntary contraction of the abdominal muscles with palpation', I said without hesitating. I had felt it, although it was brief.

'She didn't have guarding. If you distracted her, she didn't do it. It's a peritoneal sign. Maybe you're just a such a terrible brute,' he said, in fun.

'True guarding is rare', said the other resident, a year ahead of me.

This is why we have residencies. This is why Osler said that seeing patients without reading was going to sea without a rudder, and reading without seeing patients was like never going to sea at all. The 'true' signs we read about are dramatic and real. Guarding is a peritoneal sign; that is, some abdominal catastrophe is occurring. This lady either had reflux or gallstones. Neither one is a catastrophe. Annoying, painful. Not a full-blown catastrophe. I got schooled, but I can take it easily from that attending. He was taking night call on the floors at Beth Israel when I was still eating crayons and pureed carrots.

Is That What I Think It Is?

Guy came in the other night, older, with MS, very anxious and cachectic but claimed he had been injured since Vietnam, was just fine, let me go home. The story was that he had aspirated a bit of pork chop, coughed it up, and was being evaluated for aspiration.

In acute aspiration pneumonitis a patient should present with respiratory distress if they've really aspirated something caustic like gastric contents; this guy was breathing normally, had emphysematous lungs, but otherwise was OK. So I staffed him, and the doc was all, fine, but where is the pork chop now? Are you sure it's out? Where could it be? Hmmm. Lungs, or, esophagus. So get a chest x-ray, and do a bedside swallow study. If he swallows and has a normal CXR, he can go.

So I go back in the room with a cup of water. "I can drink fine", he says. Takes a drink, 'swallows', then spits it back in the cup. Three times we try. I get new water each time because he doesn't want to drink his own spit. The third time he's all, 'I'm fine', but I can hear the gurgling because the water won't go down. Note to self: ALWAYS check swallowing on an aspiration risk.

But it gets better. We pull up the x-ray and I start going through my system-A for airway and lungfields, B for bones, C for cardiac, D for diaphragm and OH LOOK THERE'S A RAZOR BLADE FLOATING IN SPACE. Actually probably stuck in the GE junction, but still. Not supposed to be there. We get his clothes off and gown him and re-shoot. Still there. Call the scope monkeys (hey, my father-in-law is a GI doc, it's a term of affection).

Meanwhile, the dood's sister arrives and says no he doesn't live at home he lives at the mental health complex (and I slapped my forehead internally for not reading the documents that were on the chart) and WE CAN'T FIND A RAZOR BLADE we had there. I didn't even ask why they had a razor blade. The poor guy ended up getting a consult from surg and going upstairs. He looked so sad. And so earnest when he was saying 'I'm fine'. Poor dood.

FMOE: How To Not To Screw Up Headache Patients

Headaches are a very common complaint in the ED--3 to 5%--and only about 1% of those have a serious underlying cause such as meningitis, subarachnoid or intracranial hemorrhage, mass effect, carbon monoxide poisoning, or hypertensive encephalopathy, according to Rosen's, the bible of EM I'm working my way through.

This morning I had a oh crap in retrospect moment wondering if I missed something, so I'm going to use a case to illustrate how to go after this problem.

48-yo african-american female with hypertension, comes in with a BP of 202/104, a dull HA on the top of her head with no focal neurologic deficit for 2 days. How do I decide if this is a scary headache or not? My gut says not. So?

Red Flags:

1: sudden onset.

2. "The worst headache of my life."

3. altered mental status.

4. true meningismus. See this post for what 'true' means.

5. unexplained abnormal vital signs.

6. focal neurological deficits.

7. worsening under observation.

8. new onset of headache with exertion.

9. history of HIV.

She didn't have any of these, although the hypertension was a bit worrisome. Still, it's in her history so not 'unexplained'. So I have a textbook backing me up. That helps me avoid badness. Now, are there signs that she's all clear?

All Clear Signals:

1. previous identical headaches.

2. normal alertness and cognition for exam and for history.

3. normal neck exam. Our Brit attending does this well. Patient actively ranges chin to chest and looks up, looks side to side. Then, he supports the neck and asks the patient to go all floppy. He then gently but quickly turns the head side to side, for so-called 'jolt accentuation'.

4. normal vital signs.

5. normal or nonfocal neurologic exam.

6. improvement under observation.

The trick is that the patient gets flagged if they have any one of the red flags, and cleared only if they have all of the all clear signs, and she doesn't have normal vitals. So we observed this patient, and worked her up for hypertensive emergency--hypertension with evidence of end-organ damage by altered mental status, EKG changes, or elevated creatinine. Three hours later, after diltiazem, which she had not been taking for four days, and a gram of tylenol (which by the way is a wonder drug), she was better. Bye bye. The only thing bugging me was an EKG finding--she had mildly inverted T-waves in V4, V5, and V6 in the setting of left ventricular hypertrophy--enlargement of the heart due to the increased pressure it has to push against in the setting of hypertension. Why would that bug me? Because a web search of EKG findings in sub-arachnoid hemorrhage, the kind of headache I was worried about in her, showed inverted T-waves in V4, V5, and V6! Oh no, right?

Not really. This is like that 'true' meningismus or 'true' guarding. Inverted T-waves occur after major neurological events that should manifest themselves on exam, and are more impressive--see this example at a great ECG wiki site. Plus, these changes can even be seen during migraine headaches, a common and NOT life threatening presentation in the ED. Last but not least, the wiki site mentions deep T iversion in the precordial leads, i.e., V1 and V2, which correspond to the septum of the heart. This lady's EKG finding was in the leads corresponding to the anteriolateral portion.

So does LVH cause inverted T's? Sure does. See this link, first example. Phew. Fare well, nice headache lady. PLEASE take your diltiazem as instructed by your primary doc. Next time I might see inverted T's in you with altered mental status and severe, thunderclap headache, seeing as how you have hypertension too...sometimes I feel like I'm a pappa bird watching tiny little baby birds jump out of the nest when I discharge. I'll have to get over that, I suppose. Get jaded for my own protection. We'll see how it goes.