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EMERGENCYMEDICINE UPD TE

DEC 20131)I guess it could be that you live in a hole

(yes, Father, I have

repented I will leave Flint alone- I just chose it because it makesbeautiful downtown Ypsilanti look so pretty

I don't know what this thingis Father, but I think you may need to call a urologist) and never heard

of bath salts, but these are now making the rounds in the druggie

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But they do note that it increases extra vascular lung fluidaccumulation which means to me- ARDS. (ibid p702)TAKE HOMEMESSAGE: Albumin- still looking for a good use."Years ago I sat on twocats and that's what it sounded like. It was painful." "My advice would be if youwant to pursue a career in the music business, don't." "That was terrible, I mean just

awful"7)I guess you already knew this, but let's state it anyhow. Triptans do

cause vasoconstriction so you may want to be careful in heart patients.

They can also cause serotonin syndrome when given with SSRIs but itisn't too common (CNS Drugs 26(11)949) I would point out that theydo give triptans to kids. Also that these medications are not great once

the migraine is well established- they should be used within the firstfew hours of a migraine. Also they can help the pain of a SAH so becareful that you know what kind of headache you are dealing with

TAKE HOME MESSAGE: Triptans can cause serotonin syndrome and docause vasoconstriction. If this doesn't give you a headache-

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8)Auricular acupuncture helped relieve anxiety in patients undergoingdental procedures (Clin Oral Invest 16(6)1517) The p value was justbarely significant and the sham group did not do too poorly-although

both were much better than no treatment which means the placeboeffect was pretty important here. Furthermore, this is all based on

anxiety scores that needed to be corrected for baseline anxiety beforethey made comparisons is this score useful at all? TAKE HOME

MESSAGE: acupuncture in the ear probably doesn't help much torelieve dental anxiety, but honestly what would?

!"#$ $'()( *+,) -#**.

/012#' #' 3)*+$456 "I don't know what cats being squashed sound like in Lithuania, but Inow have a pretty good idea."

9)Iodinated contrast and gadolinium are passed on to baby throughMom's milk. But it is minimal amounts of the minimal amounts they

are given and even Mom clears it quickly. Do not stop breastfeeding if

you need to undergo a contrast study (CMAJ 184(14)e775) TAKEHOME MESSAGE: Do not stop breastfeeding for contrast studies. Youhave the personality of a handle." "I'm tempted to ask if you sang that the nightbefore your wife left you."

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10) It was at Meir Hospital in came a blue patient

and he had a trach- everyone froze when suctiondidn't help would you know what to do? Well, if you listened to

EMRAP two months ago- then you know. I am not being a copy catbut this article just showed up this month and you will see more hereany how (take that, Mel!). Firstly your mouth and nose humidify

oxygen but a tube in the throat can not- so make sure you give these

folks humidified oxygen. Bleeding soon after a new tracheostomyplacement is usually from the procedure- never take out the tube- - alittle adrenalin soaked gauze should help. Later bleeding after thetract is mature is from granulation tissue, malignancy, tracheo

bronchitis or a sentinel leak from a trachio inominate fistula. If thetrach pulsates you better be careful- call your ENT folks and have

them look at this on the inside. I would probably do this even if itdoesn't pulsate. Subcutaneous emphysema can occur after

tracheostomy from sutures that are to tight around the tube- - youjust need to remove the skin sutures. Pneumothorax can also followfrom new placement from air dissection. Tube obstruction can be

from secretions, or from impingement on the posterior wall or a

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tracheal flap. If the tract is mature- more than 7 days-take it out now-you can always replace it (this is what I did for my patient) or evenstick in a regular ET tube. (BJHM 73(10)c152) TAKE HOME MESSAGE:

Know tracheostomies- even if you are a clinic doctor-give themhumidified air, look out for bleeding and take them out if they are

obstructed. "Last year I described someone as being the worst singer in America. Ithink you're possibly the worst singer in the world.""Do you have a singing teacher? Get alawyer and sue her."

11) A scarier clinical quiz 51 year old lady with flank pain. 187/71BP and normal blood tests including creatinine. No pyuria or

hematuria. No abdominal pulstatile masses. They did a CT withcontrast. What are your thoughts??

12) OK Critical Care guys- this one is not for you. The article iswritten by a CCM physician- I'll give you that. And I actually kinda ofknow him- he works in Hadassah hospital in Jerusalem- where David

Linton heads the other ICU (Dave is an EMU subscriber- I'll give awave). He was supposed to speak about the use of low dose steroids

in septic shock. But indeed, he then makes a great point which isrelevant to all of us. An outcome effect even from the best trials

applies to the average patient- but patients are individuals and youmust guide your therapy to each case separately. As such guidelineswhich are influenced by opinions, politics, bias, industry, and just who

is sitting on the panel- should not guide treatment (ICM 38:1911) Sohere we have to quote Father Greg (who, to his credit- has never done

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a Father Guido imitation ) whobrought the case of Jilek vs Stockson where the lower court

established that guidelines do not constitute standard of care, ratherexpert opinion should. This was overturned by appellate court, but theMichigan Supreme court than agreed with the lower court- guidelines

are not standard of care. Yes Father, there is intelligent life in Michigan

TAKE HOME MESSAGE:guidelines are not standard of care. You know it is interesting, becauseanother journal made this point regarding blood transfusions- when do

you have to transfuse? We said 10 and 30 in the old days, and then

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we said that aggressive transfusion can result in increased mortality-now there studies have come out showing decreased mortality withtransfusions. (CCM 40(12)3308) So there is no threshold- even for the

heart patient with 9.8 and we need to individualize so TAKE HOMEMESSAGE: The hell with guidelines. "Not in a billion years. There's only somany words I can drag out of my vocabulary to say how awful that was."

13)I do not know what you are snorting(although I do know what Father

is drinking- listen to Risk Management Monthly and you will know too-(that s another free plug Rick and Greg) but if you are using Ketamineknow that ketamine cystitis is a" potentially explosive problem" (They

actually wrote this with a straight face.). They mention in passing thatketamine is good for neuropathic pain an indeed I have used it with

success in RSD (RPS) and fibromyalgia. Anyhow, returning to ourbladders these folks have dysuria, intense urgency, and extremefrequency and post urination pain. It is in heavy ketamine abusers but

it can happen anywhere between after only a few days or after many

years. CT is the way to image it, but the usual stuff like oxybutynindoesnt work. Hyaluronic acid worked in a case report but really, yougot to stop using the stuff and it will probably get better. (BJHM73(10)576) TAKE HOME MESSAGE: Ketamine can cause cystitis

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Now for another critic-Roger Ebert.I had a colonoscopy once, and they let me watch it on TV. It was moreentertaining than The Brown Bunny.

a. (Reviewof an early version of The Brown Bunny, when it was shown at the 2003Cannes Film Festival(4 June 2003) )

i. After director Vincent Galloresponded to the above criticism by mockingEbert's obesity, Ebert responded: "It is true that I am fat, but one day I will

be thin, and he will still be the director of The Brown Bunny." [1](4 June

200314) When ever I read these types of articles I think of Ken and I

really shouldn't -I really think these types of articles are to be ofinterest to all of us. So you made a medical error. Congratulations

you really are human. You choices: you can get PTSD, you can grieveand recover or just move on and you can grow. This article looks at

the latter. The five steps are firstly acceptance- it isn't someoneelse's fault-you take responsibility. Then there is stepping in- Go inthere and make things better- be human being and talk to the patient

and if they sue it you ( and the likelihood is less if you communicatewith the patient),well, you know you at least did the right and moral

thing. This may include an apology and may include reaching out to

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is steroid rebound once it wears off or the patient may feel so muchbetter they overdo. I have found it helped my biciptal tendonitis, butof course nothing helps these jokes of mine TAKE HOME MESSAGE:

Steroid injections- do they make things worse in the long run? In theshort term , they do well

16) Procalcitonin- oh my this can tell youwhen cancer patients have sepsis even when they are not neutropenic.(Cancer 118 (23)5823)I'll admit it- I will use CRP occasionally to

maybe help me, but not procalcitonin- the p values here are not great(I'm sorry but a p of 0.048 is barely statistically significant) and youhave to understand that there are many reasons for fever in cancer

patients-like tumor fever and mets and here the procalcitonin valueswere less convincing. TAKE HOME MESSAGE: Procalcition may help to

detect sepsis in cancer patients but then again.This movie doesn't scrape

the bottom of the barrel. This movie isn't the bottom of the barrel. This movie isn't belowthe bottom of the barrel. This movie doesn't deserve to be mentioned in the same sentence

with barrels... The day may come when "Freddy Got Fingered" is seen as a milestone of

neo-surrealism. The day may never come when it is seen as funny

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17) I do not know why but the woman above reminded me of this

woman: While she wasconnected with a politician, she was not preyed on by Bill Clinton (yes,

even he has standards). That is Martha Mitchell whose husband wasindicted in the Watergate scandal and commented that going to jail

was better than spending any more time with Martha. In any case, ifyou are still reading, Rob Orman, this one is for you (not Martha, thearticle). Rob did a worldwide survey of the knockdown of agitated

patients for EM RAP (yes, I was part of it , and gave a plug forclotiapine) These two- yes you read correctly- these two studies

looked at the combo of a benzo with olanzipine versus haloperidol withthe benzo versus olanzipine alone. All were fine with regards to

lowering blood pressure- they didn't. However, in drunk patients andonly in drunk patients (or those who drank the wine of the month)-

olanzipine plus benzo caused more oxygen desaturation. (JEM43(5)790, ibid 889)Yea, well I am not sure why you would needolanzipine more than haloperidol haloperidol is tried and true and

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dirt cheap even though the side effect profile may be somewhat worseMy peer reviewer adds:See also now publishedWilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The Psychopharmacology of Agitation: Consensus statement of the American Association for

Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West JEM. In press.. This study is important ifyou do not have an IV in agitated patient and use the olanzipine/benzo

dart-you may find yourself having to do an intubation with out an IV.Also- old reports say haloperidol makes seizures more frequent in

ETOH patientsI am not sure if that is correct- I certainly haven't

seen it-TAKE HOME MESSAGE: haloperidol and benzos are fine for theagitated patient who drank- be careful with olanzipine and benzos. Thisis a plot, if ever there was one, to illustrate King Lear'scomplaint, "As flies to wanton

boys, are we to the gods; They kill us for their sport." I am aware this is the second time in

two weeks I have been compelled to quote Lear, but there are times when Eminemsimply

will not do.18) This is for Adam and Knox for my friends down at MD Anderson

this article is a how to on palliative care in the ED- most of this you

should know- like making folks comfortable and POA and truth be told

I would have liked more pointers than the basics, but it is a start (ibidp803) Little Indian, Big Cityis one of the worst movies ever made. I detested everymoronic minute of it...if you, under any circumstances, seeLittle Indian, Big City, I willnever let you read one of my reviews again.

19) The issue of adjusting dosages of antibiotics for obese peoplehas been discussed before in these hallowed pages. Aminoglycosides

uses ideal body weight- do not go over 640mg. Vanco total bodyweigth-15-20. Teicoplanin- not known. Penicillin: if the MIC is high-consider higher dosages of the PCNs or continuous infusion.

Cephalosporins they use 2 gm for obese patients of cefazolin andcefepime. Quinolones- they use 800 IV every twelve hours in the really

really obese. Most other drugs are unknown. (Curr Opin Inf Dis25(6)634) TAKE HOME MESSAGE: If they really need antibiotics, give

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higher dosages in general to the obese I know you really want apicture of an obese person here, but I will not do it. Alright, maybe

someone famous: MamaCass Elliot from the Mamas and the Papas. Great voice- died while-

eating.Mad Dog Timeis the first movie I have seen that does not improve on the sight ofa blank screen viewed for the same length of time. Oh, I've seen bad movies before. Butthey usually made me care about how bad they were. WatchingMad Dog Timeis like

waiting for the bus in a city where you're not sure they have a bus line...Mad Dog Timeshould be cut into free ukulele picks for the poor.

20) The urologists in my factory love alpha blockers for renal colic(they also like Ypsilanti), I have reported in the past that the evidence

is poor- these folks (BMJ 345:e5499) claim the NNT is 4- who is right?You expect me to know? I still think the evidence is thin. My peer

reviewer says:I think the evidence is pretty good, but size matters. Stones >4mm goodliterature showing alpha blockers help, 4mm or less, they pass so often on their own that

one cant improve passage with meds However, Dave Newman on EM RAP

disagreed- but then again while he is brilliant- he trashes everything.Is the evidence thin? Twiggy was and she was the rage in the sixties.Her real name was Leslie Hornsby- she is still around, still thin and still

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not the sharpest knife in the drawer.if [Chicago] believesMandingoshould be shown to children, then there are no possible

standards left and the only thing to do is transfer the censors to the parks department, where

they can supervise paper-plate- throwing contests21) OK ICU guys- this one is for you. You got an end stage renal

disease patient that needs ICU care- not a patient you can just flood

with fluids. This is actually quite common being that 0.2% of thepopulation in the USA has ESRD. I am not going to go over the effectsof renal disease- they have impaired immune response, electrolyte

issues, and they have more co morbid issues than other patients-especially heart disease (didn't I just say I wasn't going over these?).

Just be careful with putting in PICC lines- a shame to ruin yourlandmarks when you can give dialysis via IJ access. Try not to put Alines in the fistula arm. And please do not use the fistula/graft for

blood draws or for continuous renal replacement therapy. Givingcontrast and then doing dialysis does not prevent acute kidney injury

actually it may worsen it. All iodinated contrasts can cause significantfluid overload. The real interesting thing is that these patients do

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better overall than those with ARF in the ICU and ICU patients overallCurr Opinion Crit Care 18:599TAKE HOME MESSAGE: Kidney patientsneed specialized ICU care but do well. You can use contrast if they are

already receiving dialysis.

o

Parents: If you encounter teenagers who say they liked this movie, do not let them date

your children. There is a scene in this film where a character is defecated on by

several people at the same time, and I dunno ... I didn't enjoy it.o Reviewof Tim and Eric's Billion Dollar Movie(29 February 2012

22) Gosh, this could have been the star paper- to me was convoluted

but in any case, the subject is important. You got a patient with afever and musculoskeltal complaints- you gotta know the

rheumatology causes of fever. Bacterial arthritis, joint infection fromprosthesis, septic bursitis, and osteo- you better know about these andhow to work them up. A form of chronic osteo is called SAPHO

syndrome and it has pustles on the hands, feet on the face and back,peripheral synovitis, and joint/bone swelling in the thorax. They

discuss lepto, HIV, and Rheumatic fever (which we discussed lastmonth). Autoimmune diseases: lupus, myositis, and vascualitis, Still'sdisease, Behcets, Familial Periodic Fever syndromes, Felty's syndrome

these all can cause a relapsing fever as can Sarcoid, but I am notgoing to make these diagnosis in the ED. (Curr Rheum 31:1649).I

think that if you have a fever that comes and goes in a patient whohasn't traveled recently just admit them and let the eggheads figure

it out. But it does point out that you do not need to give antibiotics forprolonged fevers- you do need to think. TAKE HOME MESSAGE:Prolonged fever- think rheumatology

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Rod Slater: My God, you're beautiful.

Terry Steyner (Sussanah York): Kiss me you fool.

Farrel (John Gielgud): Rod Slater, Do you know what your getting yourself into?

Rod Slater: No, No I dont the movie "Gold" in 1974.23) So the answer to 5 was indeed obvious- it was a septic

thrombophlebitis and with withdrawal of the thrombus the patientimproved. Keep this in mind especially in females after birth with

unexplained fever. Number 11 is a little stickier this was aspontaneous renal artery dissection. We would have done a non

contrast CT and could have missed this. This patient did well withconservative treatment but not all do. The severity of pain with a

normal study should raise your antenna24) Hey it is time for letters. The postman was busy and let me

remind you that I enjoy your letters don't be bashful! Mike Herraasked my opinion about the NEJM article trashing cooling after cardiacarrest. Chris Nickson has dealt with this on his ICU network so I am notgoing to add much other than the study was well done and I have tosay EMU in the far past was not so impressed with the original study.But it did make good movie material for you Woody Allen fans Sleeperwas based on a patient waking up many years later

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Thanks for writingMike. Ken is off globetrotting again- he is now in Guyana- which foryou folks who are South American Fans- is one of three formercolonies on the north coast- Dutch Guinea, - now Surinam, BritishGuinea now Guyana and French Guinea (which is still a colony)Guyana was in the news back in 1978 for the famous Jonestownmassacre, but things have been quiet there,and they still speak

English. And no, Ken, I didn't look any of this up. Here is what Ken hasto say: Hi Yosef

Happy Thanksgiving, although Im not sure anyone but Americans know about it in

Israel. (youare right- we do not eat our turkeys- we let them govern)

Ive attached two recent articles about remote medicine I published in the Journalof Wilderness and Environmental Medicine, along with links to their abstracts (below):

http://www.wemjournal.org/article/S1080-6032(13)00149-X/abstract

http://www.wemjournal.org/article/S1080-6032(13)00163-4/abstract

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I thought that youd find them interesting Thanks for sending them Ken. I willbe using at least one of them for an essay (with your permission) but if youdo not have access to this journal please be in touch and I will send youthe pdf. Hey thanks to Stan Mayer and Brian MacMurray for wishing me a

happy Hanukah.Ken also commented on our ethical dilemma last monthconcerning power of attorney. I am indebted for this Knox are you reading?Comment re: Baumrucker SJ, et al. Surrogates with conflicting interests: who makes the decision?

Am J Hospice Palliative Med2012;29(6):497-500.

There were three actors in this scenario: Patientunknown wishes/permanently comatose

POA (designated surrogate)desires feeding tube and aggressive treatment [The

patients son questions the POAs financial motives in making that request.]

Physiciansbelieve that they should only institute comfort care, since this is a futile case

The ethics committees role in such situations is to gather the facts, evaluate them, and

make a recommendation to the parties involved. If, by gathering the parties together they can get

them to agree on a course of action, they have resolved the dilemma. However, in the case

presented, both vocal parties (the patient is permanently unconscious) seem to have laid out and

informed the other of their diametrically opposing position.In these cases, hospitals can apply for a court-appointed surrogate to make the patients

healthcare decisions. Since the son raised the question of the POAs motives, a court would

probably appoint a neutral third party, such as a public fiduciary.As for your suggesting that they ask for the clergys view in this case, clergy might help

resolve the issues if they visit with the POA and the physicians. The clergys training (hopefully,as a chaplain) and the parties religious backgrounds, motivations, and flexibility play a large part

in the success of such interventions. Clergy, of course, often play an important role on ethics

committees.

Hope that helps. Ken

Nothing to add Ken- this was an excellent analysis

Well, here is Dr Axel from France. Kinda of makes me wonder about thoseFrench- maybe he has been eating too much English Food- that would makeanyone ill.Hi Yosef

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So when I visit the Dead Sea some day I'll try and remember 1- to not gulp a sip (or sip agulp) of it, 2- pay you a visit (hey this is just an idiom) since you work close by.

But is the guy who wrote "Avoid Abbreviations !" also the one who earlier wrote "

yes you heard me right- avoid benzos- and anticholinergics, and give PT" and" POA is the caregiver"?I was thinking of "person of ... of what? Mental attempted Gallicism. Indeed we have"personne de confiance" for such situations. I figured it out.

But PT? (c'est une physiotherapie, mon ami)

Well I dont look given horses into ze mouth so ...(when I was a horse dentist, I did)

THANKS !

Er... by the way , what do you smoke before you write EMUs ? (Fleet's Lite)

Thanks for writing, Axel.

Scott and Chris checked in and are working- voluntarily- on getting EMU upon the web and improving its format. I did learn computers as a college guy

but that was Fortran and APL and kinda of got lost on the technology of

today- so it is with real appreciation that I thank both Scott and Chris- folkswho I have never met- but nevertheless believed in EMU and me.

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5) Just a word on our buddies who are drug abusers-they still get this onthe tricuspid valve, they still get fungi (especially common with brownheroin dissolved in lemon juice) and mouth flora from cleaning needleswith saliva. Non druggies can get this too from cardiac surgery orprosthetic valves. Or eating English food.

6) Vegatations- they tend to be more friable and suppurative in acutedisease, and as such can cause corrosion of heart structures andabscesses, They also can travel to other places in the body

7) OK enough of the small talk- let's get to what you will see in the typicalendocarditis patient- malaise, weakness, low grade fever, and jointpains. That was helpful, no? Of course if the patient has chest pain orCHF it is easier to make this diagnosis. AMI and fever also makethis climb the charts. Splenic infarct also means you better think ofthis. But on the other side- fever may be absent in the elderly or inimmunosupressed patients, so look for chills and joint pains- thesehappen frequently and of course-check for a new murmur. You canuse the duke criteria, but you need to think of this disease to use the

duke criteria8) Basically you need to take blood culture- alot of them they like three

sets with 10 cc of blood in each bottle. Of course, an echo will help.9) Treatment is coverage for gram positives- although they like

daptomycin for MRSA more than they like vanco. They giverecommendations for pseudomonas and Candida but prayer may workbetter. Surgery does actually give good results if used for the rightindications- bad heart failure due to a destroyed valve, valvularabscess, persistent bacteremia, large vegitation (bigger than10 mm)

and bad organisms.10) Of note is they do not mention SBE.

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11) Pericarditis is a little more optimistic. Viruses are the mostcommon causes 90% of the cases. Note they are talk aboutinfectious causes not uremic, cancer or Desseler's syndrome. Whilebacteria can cause pericarditis and can commonly cause effusions, Spneumonia is much less common than in the past- even while stillbeing the most common bacterial cause. Just remember than TBpericadritis does occur in the immunocompromised.

12) Pleuritic chest pain is the key here-sitting makes this better Fever

helps. I am not a big user of pulsus pardoxicus. Nor do I think rubs arethat common.

13) EKG is helpful with the classic signs that you should all befamiliar with- the concave ST elevation seen best in II III and V5-

6 Echo can clinch the

diagnosis and an elevated ESR or CRP can help also.14) Viral pericarditis does well with NSAIDS or colchicine- they do

not mention aspirin and I am not sure why. Recurrence occurs in a

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the main point with regards to levels of CO HB. As far as I amconcerned ,the mechanisms they bring are egghead-y and you are

probably bored enough3) Symptoms will not help you too much- fatigue, confusion shortness of

breath. Cherry red skin is rare and needs a lethal level of carboxy hgb.

Carboxy hemoglobin levels greater than 3-4% in non smokers, and10% in smokers is considered suspect for CO poisoning. You can takeit arterially or venously. If your blood gas machine is old and doesn'thave a CO oximeter- the saturation will be normal. This is the casewith most pulse oximeters. However, that is of little consequence sinceCO is reversibly attached to hgb and as such all these patients shouldget oxygen.

4) Is 100% oxygen better than air? Actually there are no such studiesproving this. What ever. Once the patients carboxyhemoglobin isnormal or they are symptom free- you can let them go home

5) Hyperbaric oxygen does hasten resolution of symptoms but studiescomparing it to normobaric oxygen have been poorly constructed. Itmay lessen long term effects. It is still recommended for those at risk.

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Who are at risk? Older than age 36 (isn't everyone older than 36?)LOC, Carboxy hgb of 25% or more, or exposure for more than 24hours. The problem is that this is really extreme and lesser parametershas still given cognitive defects later on even if early effects are notseen. Pregnant women get hyperbaric oxygen seems it doesn't hurtthe fetus- but again we do not know. Kids get it too.

6) Proper dose of hyperbaric oxygen and how many treatments- no oneknows

7) Motor dysfunction and anxiety, depression memory disturbance andinability to calculate can occur even after correct treatment.

Hey that is all for this month- 2013 was a great year and we hope you

enjoyed EMU. Actually we hope that you even read EMU. Or that yourcanary did. As is our custom we use this issue to thank our dedicated

peer reviewers. These guys have given their all for EMU. Thanks guys- Iappreciate it more than you will ever know

Mike Drescher

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Attending Physician and Associate ProfessorDepartment of Emergency MedicineHartford Hospital/University of Connecticut

Tom Ashar MD FACEPED DirectorCommunity ED Group in Alabama

PegasusEmergency Group

Moshe Weizberg MD FACEPResidency Director

Staten Island University Hospital

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Chris Nickson

Emegency Phsycians and CCU specialist

Alice Springs Australia

I do not have a picture of Chris but this is what you find on

google if you put in Chris Nickson and Life in the Fast Lane

Gil Shlamovitz, MD, FACEP

Assistant Medical Director of Clinical Information SystemsHarris Health SystemDirector of Medical Informatics, Section of Emergency Medicine

Assistant Professor, Department of MedicineBaylor College of Medicine, Houston, TX

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Adam Miller MD MSMM MSCS FACEP Associate Professor, Departmentof Emergency Medicine, Division of Internal Medicine, The University of

Texas MD Anderson Cancer Center, Houston, TX

And to our reviewer in a pinch

Yechiel Reit MD FACEP (Can't copy what comes up on

google pictures for your name)

And new volunteers are always welcome! (Like the above,

they must have been featured in the New England Journal

of Great Looking Guys)

And our yearly review of policies:EMU Policies:

1) EMU is distributed free of charge2) All parties with the exception of for profit organizations can reproduce it. It can not

be reprinted for profitable purposes

3) EMU is peer reviewed4) EMU does not accept advertising5) EMU does not usually quote articles from Annals of Emergency Medicine and the

New England journal because most of EMUs readership already receives these

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