Subcutaneous Emphysema

The other day we had a patient with the most profound subcutaneous emphysema any of us had ever seen. The patient stated he’d just stumbled and hit the edge of a chair with his chest wall several days prior to presentation, then noticed he was “slowly getting bigger”. The family at the bedside all agreed that he was much bigger than usual.

On physical exam, he had normal vital signs, was in no distress, but had ‘the SQ crackles’ (crepitance) everywhere, and that’s not an exaggeration. Crepitance due to subcutaneous emphysema feels like popping tiny packing bubbles when compressed, and is usually limited to a fairly small area unless the patient is on the ventillator or getting positive pressures in the airway for some other reason.

Our patient got a CT to find where the air was coming from, and if there were other injuries. Here’s 3 slices from his CT:

upper chest
So, in the upper chest he has a respectable amount of SQ air, a pneumomediastinum, and air in other places.

mid-abdomen
In the mid-abdomen the air continues, as well as being found in the back muscles.

oh, no
Here’s the part we didn’t expect: air in the skin of the penis, along with more SQ air.

He had crepitance literally everywhere, down to the tops of his feet. He got a right-sided chest tube for a pneumothorax that was felt to be the cause, and went upstairs.

Liars ‘have more white matter’

Oh, dear. The BBC are at it again. This time it’s a simple error, and one that’s a little hard for med students to get straight. Well, perhaps slow med students.

In the article Liars ‘have more white matter’: “The brains of habitual liars differ from those of honest people, a study in California suggests.”

Which is all well and good until you get to the heart of the problem:

“White matter is the brain’s thinking part – grey matter the wiring – and may provide the capacity to lie, it said.”

Grey is white, white is grey..

Oops. White matter is called that because its insulating coat (myelin) makes it look white, and shiny. Grey matter is made up of the nerve cells that actually do the thinking. It’s not a big error, but who’s proofreading their medical stories?

Update 9-30-05: the offending sentence has been corrected:

White matter transmits information and grey matter processes it. Having more white matter in the prefrontal cortex may aid lying, the researchers said,

dangling comma and all.

AAEM and ACEP join together to help a little guy

…also, dogs and cats living together.

Today I got an email from AAEM, and it makes me hopeful for the future of the individual doc in my specialty. Basically, a working EM doc was going to be screwed by a restrictive covenant meaning a job change equals a significant geography change.

AAEM went to bat for the doc, as did ACEP. The two of these groups working together is a very nice change, and bodes well for both academies. The end result is that the doc can change jobs without involving a moving van, which is how I think it should be.

The email is in the extended entry.
[Read more…]

MedBlogs Grand Rounds 53, or 2:1

It’s only two days late, and he didn’t include my submission, but here it is: Family Medicine Notes: Grand Rounds #53 Published

Best Proposed use of Drug Rep pens

via MedPundit comes this best use of drug-rep pens I’ve ever read.

I got to talk today

Yesterday I was honored to be the speaker at a lunch meeting of the Texas College of Osteopathic Medicine for their Emergency Medicine Interest Club. I talked to them last year, and inexplicably was asked back again this year.

One thing’s for sure: you can get medical students to show up for anything if there’s a free lunch, so it was well attended. I spoke about why I think EM is the best career for a physician, and what med students need to do to prepare for an EM career, and what it’s like actually doing the job. And, plenty of gross pictures.

It was well received, and I enjoyed talking to a nearly-captive audience. I had two surprises after the talk: a student told me he actually reads this blog (!) and I met a young woman on Navy scholarship, who was happy to have met anyone who had been where she’s going.

I enjoyed myself, and hope there’s a class of EM docs in their future.

Design Aid in Sundance Square

Tonight the Fort Worth Creative Art Guild is having Design Aid in Sundance Square.

 

Sundance Square and the Fort Worth Creative Art Guild invite you to a concert on the patio of 8.0 Restaurant & Bar at 6 p.m. Admission is $10 and all proceeds will benefit the Tarrant Area Food Bank’s local Katina Relief Fund. In the spirit of New Orleans, the concert will feature prominent Fort Worth jazz bands and a silent auction showcasing various works of art from talented North Texas artists.

And, they have a nifty graphic (what would we expect from an art guild?):

Design Aid

First Aid On Your MP3 Player

via MedGadget:

First Aid on your iPod

St. John Ambulance from the United Kingdom introduced iFIRSTAID, a website from which you can download first aid tips onto MP3 players, phones and CDs. Guidance available for people when they need it, where they need it, in the format they need it.

Hurricane Rita Evacuee Story

We’ve all been aware of Hurricane Rita, and here in the Metroplex we’ve noticed the influx of folks from Points South, very wisely getting out of the weather hazard.

Sometimes, leaving one hazard exposes you to another.

Last night I cared for an evacuee from the Houston area who was shot (in an alleged drive-by shooting).  The patient will recover, but the irony wasn’t lost on any of us, the patient especially.

BBC Invents New Germ: the E. coli “virus”

E.coli airlift for four-year-old: "A four-year-old boy suffering from the E.coli virus is airlifted to hospital as the number of cases rises to 108 ."

 

The BBC invents a new Germ

 

(Via BBC News.)

They describe E. coli, a bacteria, as a virus. Twice. This is not to make light of their outbreak, but makes me wonder about the basics of medical reportage.

Update 9/25/04 @ 0845: the story has been significantly rewritten.  Viruses are no longer referred to, but E. coli isn’t described as being a bacteria, either.

VP Cheney’s Popliteal Aneurysm Surgery

From CNN, comes the good news that VP Cheney’s popliteal aneurysm surgery was a success. Their article has good information in it, including something I hadn’t known, that he had bilateral (both side) aneurysms, and they did them both at the same time.

Since popliteal artery aneurysms aren’t very common complaints in the ED, I decided to read about them, and here’s some good information from "Aneurysm Center":

Popliteal artery aneurysms are the most common peripheral artery aneurysms, comprising 70% to 85% of the total aneurysms in the periphery.1-3 More than 95% of peripheral artery aneurysms occur in males, and the average age of patients at presentation is 65 years. ….Although the standard treatment of popliteal artery aneurysms has been open repair, there are increasing reports in the literature of endovascular management.

At the time of presentation, approximately 50% to 85% of popliteal artery aneurysms are symptomatic, and most are 3 cm to 4 cm in diameter…

And, why do we need to fix these? They cause thromboembolisms (clots inside the vessel), and:

Amputation rates of approximately 25% have been reported with thromboembolism.

Aah.

I’ll let you read about the types of repair in the article, and I didn’t see what type of aneurysm Cheney had.

CNN went a little nuts toward the end of their article, saying he was at risk of blocking circulation in the leg or causing a stroke. The first is correct, but there’s no way a popliteal aneurysm could cause a stroke.

 

PS: I wrote this on the mac mini, using MarsEdit, which is one slick little program. Unfortunately, it wouldn’t post from there. so it was cut-and-paste. I’ll figure it out, eventually.

I found my answer here: Submit Response. Darn clever security people.

Interesting Search Phrases

A phrase used to find this blog recently:

"if my patient has abnormal vitals and i dont call an ambulance will i lose my license"

 

Well, it depends.  Depends which vital sign was how abnormal, and what happened to the patient.  There you go. 

Fort Worth International Airshow 2005 Cancelled

Well, it’s not a big surprise:

Media Alert
International Airshow Canceled

The International Airshow scheduled for this Saturday and Sunday (Sept. 24 & 25) at Alliance Airport in Fort Worth has been canceled due to the severe weather forecasted to hit North Texas this weekend from Hurricane Rita.

The U.S. Air Force Thunderbirds notified Airshow officials this morning that they have been ordered to fly all planes and crew out of Fort Worth on Friday morning.

The safety of the general public is the primary concern of the Thunderbirds and the Airshow.    

The Airshow will not be rescheduled this year. It is the first time in the 17 year history of the event that it has been canceled.

 Tickets purchased in advance are non-refundable, as explained at time of purchase. Advance tickets purchased are donations to the Fort Worth Aviation Heritage Association, organizers of the International Airshow.  

"I want to thank the hundreds of volunteers who have donated their time and energies to put on the Airshow," commented Jim Hunt, Chairman of the International Airshow.  "It was the decision of the Thunderbirds, the other performers, Alliance Airport officials and Airshow organizers to cancel the show in the best interest of public safety. The Airshow will be back next year,"  Hunt said.

The Airshow officials noted that hundreds of hotel rooms and rent cars have now been made available in Fort Worth for the Texas coast evacuees.

We’ll get it next year.

I’ve been cursed

The other night I saw a patient with, to be blunt, the most blatant drug-seeking behavior I’ve ever seen.  That’s neither here nor there (no prescriptions would be forthcoming), but it’s the prelude to The Curse:

"I wish you Earthquake Damage!" said this patient, and it surprised me.  Frankly, sailor-talk is the usual, and I’ve never had a natural disaster wished on me by anyone.

So, if there’s an earthquake in North Texas, it’s my fault.  No pun intended.

Delaying Health Care for the Big Game

from ABC News: Delaying Health Care for the Big Game:

Sept. 23, 2005 — It’s down to the final play of the Super Bowl and you’re choking on a pretzel — what’s a sports fan to do?

You’re more likely to watch the game-winning kick than seek medical care, according to a new report.

Physicians at Children’s Hospital Boston, who collected data from emergency rooms in Boston during the Red Sox’s run to the World Series in October 2004, found that patient volume dipped significantly during the most important postseason contests.

The authors used the Nielsen television ratings to determine the magnitude of a sporting contest: the higher the rating, the more important they considered the game. The findings, published in today’s edition of Annals of Emergency Medicine, indicate that the games with the highest Nielsen television ratings — Game 4 of the World Series and Game 7 of the American League Championship Series, both of which were series-clinching contests for the Red Sox — were associated with lower emergency department volume than games with lower television viewership.

Based on their data, the authors believe that one can predict how busy an emergency room will be based on how "big" the game is. This does not come as a surprise to many emergency medicine physicians, who have found they see far fewer patients in their hospitals at times when there is a major sporting event being played.

Anecdotally, I do notice a slightly lower volume in our ED during Cowboys games, but not Rangers games.  I do know that a lot of the staff would like to be watching the "Big Games" they cited, like the ALCS or the Super Bowl, and we wonder, sometimes aloud, why someone would pick that time to bring their six months of abdominal pain to the ED.  Ahh, well.  At least there’s Tivo.