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EMERGENCYMEDICINE UPDATE

July 2012

1) Traumatic brain injury is catastrophic- just ask Marie Antoinette(true, that was a dislocation and not a true head injury). The questionin this study was whether patients did worse if there was a 60 minutetransit time, or they did worse when there was a need to be broughtto a level one trauma center, hypoxia, hypotension, hyperventilation,or tachycardia. They claimed they did not (Acta Anes Scand

55(8)944). The take home point here is that it really doesn't matterwhat intervention is done in head injury- they all do pretty poorly. Theproblems with his study were they only had 46 patients in 3 years, andI did not see a definition of what is a severe head injury (I am not abig lover of the GCS scale). However, where this can be relevant isthat your trauma center can function fine even if you do not haveneurosurg backup. Of course, it is the few that are not that severethat may respond well if you have neurosurg backup but those inmany cases can just be transferred. TAKE HOME MESSAGE: Severe

head injury does poorly no matter what factors are involved.2) A call for doing surgical airways, I was waiting for the answerwhy we are so reluctant to do these airways and finally found it in thelast line of the abstract- because of the perception that if you can'tintubate a particular patient- you must be an idiot. The truth is exactlyopposite. No, not that if you can intubate you are an idiot but rather ifyou can't do a surgical airway you are an idiot. A few of you may beidiots no matter what you do (no, I do not mean you; but I do meanyour boss). But if at least you know how to properly do a surgical

airway you will be an intelligent idiot. And probably save some one's

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life. (Anest Int Care 39 (4)578) TAKE HOME MESSAGE: There aredefinitely people who are intubation nightmares and you must knowhow to do a cric. And not only know how to but actually do it.3) Yucky study. You would think if you put a hand sanitizer in thehospital cafeteria, that health care workers would use it. Well, in 5500visits to the cafeteria- only 4.79% actually used it. So they used aposter to remind people- yea that is the ticket- and sure enoughfrequency of use increased- that is what they want you to believe inthe conclusion of the paper. However, this improvement was only

seen in visitors to the hospital cafeteria, not in the actual workers. (AmJ Inf Contr 39 (6)464) By the way I love to cook and now is theopportunity to give a plug for my book "You Can Make Hospital Foodat Home" TAKE HOME MESSAGE: For Goodness sake at least washyour hands before you eat in the hospital.4) This may not be relevant to your practice but it is very relevantto mine where patients often present with questionable indications forbenzo use requesting I renew their prescription for these meds. Soyou have to know this- they cause dependence, cognitive and

psychomotor impairment and ultimately possible long term brainchanges. The risk benefit ratio is favorable only with short term use.Nowadays there are safer alternatives for most of the benzoindications. (Addiction 106(12)2086). I have been told that if you readEMU you must be on drugs- try not to make them benzos. TAKEHOME MESSAGE: Benzos can be risky especially in long term use.There are safer alternatives in most instances.5) When the new residents in the USA take over in July- mortalitygoes up and efficiency goes down in their meta analysis. This is a

systems problem that requires addressing. In many European

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countries residencies open up here and there and they do not all startin July. (Ann Int Med 155(5)309). This is a very poor meta analysis asthe data is really diverse, but I believe the results. TAKE HOMEMESSAGE: Don't go to the hospital in July. Never go the Hospitalcafeteria anytime. Never be an idiot.6) OK enough already. I know you know your stuff and promisenot to call anyone an idiot anymore. But you can still prove yourself.A patient who is 25 years old comes to the ED with weakness andpainful swallowing over the distribution of the carotid artery. They

complain of chest pain and there may be hypertension. Treat thisearly and you will prevent permanent damage. (QJM 104 (9)797). Andthe diagnosis is7) The results of this study are fascinating and they are relevant toFPs as well. Often females have normal cardiac caths. Yet they stillhave chest pain and can even infarct- this is supposed to be fromulceration or plaque rupture or even spasm. All the patients in thisstudy had ST elevation and there were only a smattering that hadnormal coronaries so you can't take this study home , but it is worth

remembering- a normal cath means little when the clinical picture fitsa more serious entity (Circ 124 (13)1414) TAKE HOME MESSAGE:Normal cath means little when the clinical picture looks suspicious.8) The tile of the paper is cool, but the message is important. Doyou know what a pseudo pseudo seizure is? Neuro psychiatricsymptoms with a normal EEG that could fit a pseudo seizure do notmean you are done and this is not a real seizure. This was a case ofauto immune encephalitis due to ovarian cancer. (Psychosomatics52(6)501) You can never take much out of case reports but do not buy

the pseudo seizure concept so quick- especially because many patients

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http://www.ncbi.nlm.nih.gov/pubmed?term=%22Annals+of+internal+medicine%22%5BJour%5D+AND+155%5Bvolume%5D+AND+5%5Bissue%5D+AND+309%5Bpage%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=104%5Bvolume%5D+AND+9%5Bissue%5D+AND+797%5Bpage%5D+AND+2011%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=124%5Bvolume%5D+AND+13%5Bissue%5D+AND+1414%5Bpage%5D+AND+Reynolds%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/22054618http://www.ncbi.nlm.nih.gov/pubmed/22054618http://www.ncbi.nlm.nih.gov/pubmed?term=%22Annals+of+internal+medicine%22%5BJour%5D+AND+155%5Bvolume%5D+AND+5%5Bissue%5D+AND+309%5Bpage%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=104%5Bvolume%5D+AND+9%5Bissue%5D+AND+797%5Bpage%5D+AND+2011%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=124%5Bvolume%5D+AND+13%5Bissue%5D+AND+1414%5Bpage%5D+AND+Reynolds%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/22054618http://www.ncbi.nlm.nih.gov/pubmed/22054618

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could be using drugs that would also mimic pseudoseizures. While weare on the subject of drugs, let us mention that purpura, vasculitis andeven necrosis and eschars of the ears could be a sign of adulteratedcocaine where levamisole is the offending agent. Their WBCs start tofall as well- so look for this as well. (J Am Acad Derm 65(4)722). Untilthe FDA starts finally giving their approval to street drugs I think it isdifficult to stay abreast of all the designer drugs and adulterants. Ispeak to Mickey Arieli in Israel who is a clinical pharmacist with thehealth ministry to help me with questionable cases; you should identify

who can help you on this subject in your part of the world. TAKEHOME MESSAGE: Drugs and strange medical maladies can cause a lotof unusual syndromes, and so can medical disease. Be extremelycareful labeling people as having psychiatric illness.9) Sulfa-TMP (Resprim, Bactrim) is making a comeback and thisstudy showed that there is danger of hyperkalemia when used withspironolactone. They looked at a massive amount of patients (165754patients). They also found this to be true with nitrafuratoin(Macrodantin) but not in quinolones. (BMJ 343 5656). The methods

were excellent; I just have a problem with the fact that they claimedan association when hyperkalemia occurred within 2 weeks ofantibiotic use. I think 2 days after may be a causation, 10 days laterless so. TAKE HOME MESSAGE: People taking spironolactone can bepushed into hyperkalemia by some antibiotics.10) People do a lot of their own medicine. And part of thedeterminants that enter into their decision making is whethermedications are helpful. In this study, people beleived that if the FDAapproved the medication, it must be extremely effective and free of

side effects. This is especially important in view of the aggressive

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marketing approaches used by drug companies to the public (Arch IntMed 171(16)1463). This is rampant in my country as well, andespecially important in view of the use of HCG for weight lossprograms this medication has approval of the Ministry of Health inmy country despite reports of clots, depression and heart attacks. Andof course, no proof it helps. TAKE HOME MESSAGE: the public feelsthat medications that have government approval are both universallysafe and effective. Not!11) Hey we had our clinical case this month but this is a really neat

case. I am sure none of you know about this syndrome (well, maybeexcept for Chris but he knows everything). After jogging this guy

looks like this- yes only one side of his face is red. Itis due to this syndrome which is a disorder of thesympathetic output to that side but can be due tomediastinal neuroma, lung cancer or brainstem infarct.It is usually however benign (MJA 195(5)288). This iscalled-12) There is some new information on vertigo in

kids, but I am not so sure how much it changes things.Somatoform disorders and vestibular migraine account for most of thecases and CT is only recommended in subacute cases. (Neuroped42(4)129) We do not see many articles on the subject so it is good tohave one if you are interested on how to work this up, but theoverwhelming amount of cases are benign. I would just point out thatone of the serious causes can be dissection which we can see evenafter minor trauma. TAKE HOME MESSAGE: Vertigo in kids exists but isusually benign- Please remember dissection in teens.

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http://www.ncbi.nlm.nih.gov/pubmed/21911629.1http://www.ncbi.nlm.nih.gov/pubmed/21911629.1https://www.mja.com.au/journal/2011/195/5/harlequin-syndrome-after-jogginghttp://www.ncbi.nlm.nih.gov/pubmed?term=42%5Bvolume%5D+AND+4%5Bissue%5D+AND+129%5Bpage%5D+AND+Jahn%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=42%5Bvolume%5D+AND+4%5Bissue%5D+AND+129%5Bpage%5D+AND+Jahn%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/21911629.1http://www.ncbi.nlm.nih.gov/pubmed/21911629.1https://www.mja.com.au/journal/2011/195/5/harlequin-syndrome-after-jogginghttp://www.ncbi.nlm.nih.gov/pubmed?term=42%5Bvolume%5D+AND+4%5Bissue%5D+AND+129%5Bpage%5D+AND+Jahn%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=42%5Bvolume%5D+AND+4%5Bissue%5D+AND+129%5Bpage%5D+AND+Jahn%5Bauthor%5D&cmd=detailssearch

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13) This could have been a very helpful study. Mothers who havehyperemesis gravidarum how do their children turn out? It seemsthat they have a greater likelihood of female births (careful guys-females do not (or at least should not) make people throw up), lowbirthweight, and prematurity. There was one study that showed aslightly higher risk of testicular cancer in the boys. (BJOG 118(11)302)However the quality of evidence was not evaluated and the likelihoodratios are not that convincing- low birthweight being the most likelyalthough female offspring is the most consistent. They do admit the

little is known about the long term of effects of this disorder or even ifthis is passed down as a problem in pregnant female offspring. TAKEHOME MESSAGE: Mothers with hyperemesis gravadaum seem to havechildren with lower birth weights, and more premature births. Theyare more likely to give birth to females.14) No surprise here. A poll of EPs in Belgium showed that they hadno idea as to how much things cost in the ED nor radiation dosagesare associated with common procedures. (EJEM 18(6)344). This isprobably true for primary care docs as well. It comes to me as no

surprise because there are still significant amounts of physicians in theworld who do not read EMU. What was surprising was that theyoverestimated both costs of care and levels of radiation. Could this bethe Hawthorne effect? TAKE HOME MESSAGE: We have no idea aboutradiation in the studies we order and the costs of our products andservices. We tend to over estimate these costs.15) I have a lot of EMS readers and we will be having a roundtable inthe future on EMS issues. In the USA, EMS systems get medicalcommand from a base hospital. In Europe and Israel, physicians

actually ride on the ambulance. And in some countries nurses as well.

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Are they competent? Well they are according to this study but thescale they used has not been validated to the best of my knowledge.(ibid p322) Now the question as to whether this is cost effective oreven necessary has not been studied and still isn't clear. TAKE HOMEMESSAGE: Physicians riding on the ambulances are competent.Maybe.16) Hip fractures hurt. Wouldn't it be great to block a nerve andhave your patient wait happily until they can do the surgery? Well youmay want to try the fascia iliaca two pop nerve block. If you wish, you

can read about this and other blocks for hip fractures click here. Ifyou have youtube - then go to this linkwww.youtube.com/watch?v=eCWt3fYYV8s.If you want to know if you can really do this procedure then see thisarticle that says that it is really easy (ibid p340). If you get EMRAP oryour name is Al Sachetti- then you knew about this already, but manyof you can not afford EMRAP or Al Sachetti so here is your chance tolearn this technique on the cheap. TAKE HOME MESSAGE: This nerveblock can be very helpful in the pain control of a hip fracture.17) NSAID bashing time again. These medications cause stroke.

(MJA 195(5)488). Well, not really. They increase your risk but this isa small risk anyhow. The key is that this risk does increase even afterfirst time use. As Marie Antoinette said" Let them eat Percocet". TAKEHOME MESSAGE: NSAIDS can increase stroke risk after one exposurebut is it is a small risk18) We do not see many articles on this subject but you probablyknow the answer. Cupping is an alternative therapy for pain and theydid a systematic review with fairly good methods. Naturally the qualityof the studies was poor, some studies showed that this is a great

thing, some showed no effect. (Evid Based Alt Comp Med 2009)

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(Somehow this creeped on to my reading list in error- it was listed asbeing from 2011). Why am I wasting your time with this? The key hereis that they are starting to evaluate these therapies in a standardizedway and that is a good thing. Can this help? Well it brings to mindthe old Red Buttons joke (if you are too young to remember RedButtons that is OK- I don't really know what Justin Bieber looks likeeither) The MC comes out on a stage in Miami Beach as tearfullyproclaims that the star of the show has just expired suddenly. A littleold lady screams out "give him an enema". The MC is aghast- "Lady,

how could that possibly help? The man is dead!" The little old ladyscreams out "well, it couldn't hurt". Probably OK that you did not knowRed Buttons. That was a waste of your time. But an additional articlein the same journal actually could be helpful. There are many herbsthat interact with Coumadin- either elevating of lowering the INR. Theherbs are unfamiliar to me- red ginseng, aloe (that one I have growingin my garden), bilberry juice, Boswellia, Melissa, etc, but the charts inthe article are clear and the article is for free. Never forget to take anatural remedy history! (ibid 1-5 2011) TAKE HOME MESSAGE:

Coumadin has a lot of interactions with herbal therapies. Cupping maybe helpful for pain control. We do not know.19) Wow, talk about dropping a bomb. This is the article of theyear for the right thing to do that will bring belly slapping laughter toany hospital administrator that we know. Better educated nursesresults in a 4% better outcome (defined as reduction in patientmortality and failure to rescue) in all hospitals. Better nurse/ patientratios result in considerably better outcomes but only in hospitals withgood working environments- it doesn't help bad working

environments. (Med Care 49(12)1047) This of course is tied in to what

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a good work environment is-after a lot of searching I found the sourcefor their scale which is from an article from 2007 in Research inNursing and Health30:31. Really, I do not mean to demean hospitaladministrators, some of my best friends are hospital administratorsand I decided to allow one to say a few words here.

(If you do not know who this is- I think it is JustinBieber). TAKE HOME MESSAGE: give better working conditions and usemore educated personnel and mortality will improve. (If you really do notknow who this is- you are reading the wrong journals).

20) This article can only serve as a guide as it is a case control

study. Flying more than 12 hours within the last four weeks (and thatis crucial- this can be up to four weeks after) elevates the risk ofpulmonary embolism by three times the normal. A four hour leg in thelast four weeks leads to a two times higher risk. Another key point ispeople with risks for PE will have even a higher risk with flying. (BJH155(5)613). TAKE HOME MESSAGE: Even a flight of four hours cansignificantly increase risks for PE, even a month later. The price of theticket is not related to PE but may give you chest pain.21) This article is about leadership. While this article unabashedly

English and thus less relevant to the rest of the world, I havenonetheless extracted some important points for you. Doctors in the

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http://onlinelibrary.wiley.com/doi/10.1002/nur.20172/pdfhttp://onlinelibrary.wiley.com/doi/10.1002/nur.20172/pdfhttp://www.ncbi.nlm.nih.gov/pubmed?term=155%5Bvolume%5D+AND+5%5Bissue%5D+AND+613%5Bpage%5D+AND+2011%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=155%5Bvolume%5D+AND+5%5Bissue%5D+AND+613%5Bpage%5D+AND+2011%5Bpdat%5D&cmd=detailssearchhttp://onlinelibrary.wiley.com/doi/10.1002/nur.20172/pdfhttp://onlinelibrary.wiley.com/doi/10.1002/nur.20172/pdfhttp://www.ncbi.nlm.nih.gov/pubmed?term=155%5Bvolume%5D+AND+5%5Bissue%5D+AND+613%5Bpage%5D+AND+2011%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=155%5Bvolume%5D+AND+5%5Bissue%5D+AND+613%5Bpage%5D+AND+2011%5Bpdat%5D&cmd=detailssearch

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past were trained to be individuals having allegiance mainly to theirprofessional organizations. Other wise they stood alone in their clinics,occasionally serving on hospital committees but for the most partexisting alone. These days are over. Large HMOs, hospitalcorporations and government interventions demand that physicianshave leadership skills. They admit in this article that many- if not most-physicians are not born leaders. Being a visionary, taking calculatedrisks and having both business skills and political savvy is not therealm for most of us. (Me politically correct? Are you kidding?) They Iidentify five skills to being able to be a leader- setting direction,

demonstrating strong personal leadership qualities, being able to workwith others, and being able to improve and manage services rendered.I agree these are skills that are kind of nebulous and we could usemore practical pointers perhaps, but the point is well taken. (BMJ2011). In Israel, physicians are unionized which would be unheard ofin the USA from what I understand. Most hospital CEOs in my countryare physicians. TAKE HOME MESSAGE: Leadership is not a borntrait but a learned one and physicians must be ready to enter thisarena in view of government innervations and the big business nature

of our practice environments.22) Is this a new department for EMU? I don't know, I make this upas I go along. There was as clinical "head to head" as to whetherhypothermia does help in cardiac arrest. We will summarize the twoarticles and I have a subscriber named Marvin Wayne who is one ofthe world's experts and a frequent contributor to the resuc literature.The articles were both from the BMJ. The "for" is from thesept 23issue and the "against" was from later on in the same issue. Here arethe points in favor: strong animal studies, human studies especially in

VF, database from the Netherlands showing 20% relative reduction inhospital mortality in all rhythms in all venues. It is very safe-reperfusion

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injury and infection are the only setbacks. Against include- it is hard toblind cooled patients, and the articles are few. Few patients over manyyears characterized these studies so the conclusions are made basedon meta analysis. The level of coma was rarely measured in thesestudies. The great results in animals were in healthy animals unlikemost of the patients we see. Marvin's take:The Sept 23 articles, Yes, by Nolan, andNo by Warden highlight the difference between reasonable vs perfection. While all studies to date onTherapeutic Hypothermia have trended toward better outcomes, some still seek the "perfect" study. With anumber needed to treat of 6 vs 82 for aspirin, at little overall cost, this seems like a very "reasonable"therapeutic intervention. Our own system has treated over 259 patients with a 55% go home survival withintact neurologic function from the ICU. This is in contrast with a similar group and a 30% survival priorimplementing TH. The cost in dollars vs the improved outcomes strongly favor implementation of this important

therapeutic intervention

23) The diagnosis above in number 6- of course you knew this- itwas Takayasu's Arteritis. And number 11- you clown- is calledHarlequin syndrome. If you got both of these then you are a genius orfrom Australia- or probably both.24) I inspired by new reader Steve Parrillo to consider some sportstrivia so I agreed. Do these pitchers ring a bell and what are they

known for ?

The first is Steve Carlton, the ace for the

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Phillies that in 1972 won 27 games for an absolutely dreadful Philliesteam that only one a total of 59 games for the season (which means hewon almost 50% of their games). The second is Denny McLain who in1968 was the last pitcher in Baseball to win 30 games in a season-nowadays 25 is virtually unheard of for most pitchers. The third wasMarc the Bird Fidyrch who was a phenom for Detroit and was rookiefor the year in 1976. He would speak to the ball; refuse to use ballsthat had been hit before and would manicure the mound. His nuttyantics got him much attention but due to a torn rotator cuff, he was outof baseball a mere four years later. Fritz Peterson was a great pitcher

for the Yankees 1966-1976. He however will best be remembered forhis swapping wives with fellow pitcher Mike Kekich. He got the betterdeal- he is still married to Kekich's wife and has four children from her.He also had a better career. The other pair did not work out. The lastguy is Sparky Lyle a star reliever for the Yanks in the 1969-1977whose book "The Bronx Zoo" on the feuding champion Yanks was abest seller. Now two questions- did you get them right? And do youreally care?

This month we look at three subjects that we will almost never see but you

need to know for the boards. They are drowning (NEJM 366(22)2102),Altitude Illness (BMJ 343) and Chemo emergencies (Lancet Onc 12:806) . Ifind that these subjects can be boring- the absolute last thing I want to be so let's pretend we are going back to those halcyon days of preparing foryour boards and ask simple questions to make sure you know your stuff-we'll soon see that even years later you are still the same genius I knew

you were when you started reading EMU.

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http://www.ncbi.nlm.nih.gov/pubmed?term=366%5Bvolume%5D+AND+22%5Bissue%5D+AND+2102%5Bpage%5D+AND+2012%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=343%5Bvolume%5D+AND+altitude+&TransSchema=title&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=12%5Bvolume%5D+AND+806%5Bpage%5D+AND+2011%5Bpdat%5D+AND+Morgan%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=366%5Bvolume%5D+AND+22%5Bissue%5D+AND+2102%5Bpage%5D+AND+2012%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=343%5Bvolume%5D+AND+altitude+&TransSchema=title&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=12%5Bvolume%5D+AND+806%5Bpage%5D+AND+2011%5Bpdat%5D+AND+Morgan%5Bauthor%5D&cmd=detailssearch

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ACUTE ALTITUDE ILLNESSThe percentage of oxygen in the air goes down as you ascentTrueFalseAnswer: The percentage of oxygen in inspired air remains always 20.94% inthe atmosphere. (If you are curious, the rest is nitrogen with a smattering ofargon) .The barometric pressure goes down so the oxygen is more spreadout- i.e. thinner- and so less is available, and so the answer is FALSE

Which of the following points can't help distinguish between a migraine and a

high altitude headache?a) resolves with descent

b) resolves with oxygenc) worse at night and with exertiond) resolves with ibuprofen

Migraines and high altitude headaches resolve with ibuprofen. Descentmakes high altitude headaches better and they are worse at night and withexertion. Many use oxygen for migraines but there is no evidence that it

works- it almost always works for high altitude headache. So the answer is d

A group of healthy hikers climb Mt Davis in Pennsylvania- the highestmountain in Pennsylvania (I am originally from Pennsylvania). 50% of thehikers developed dizziness, fatigue, nausea and vomiting and a severeheadache. What would you recommends in this situation?a) They should descend immediately 400 meters and they will began to seeimprovement in about two hoursb) They should have ascended more slowly or have taken acetazolamide

c) They should have been in better shape- athletes have a lower rate ofdeveloping acute mountain sickness.

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d) They should have not partied the night before.Acute mountain sickness is characterized by these symptoms and does getbetter with descent and slower ascent. Athletes do not have a lower rate ofAMS. But Mount Davis is only 1000 meters high and 1000 meters is not thatmuch. How were you supposed to know that? I guess you weren't. (Toobad, huh?) This is more likely to be due to alcohol intake the night before.HACE (High Altitude Cerebral Edema)

a) Altered mental status, stupor, ataxia, but death is rare.b) Treatment is dexamthasone, and gradual descent to avoid

worsening edema.c) This can easily be confused with hypothermia.d) Portable hypobaric chambers may help

Oh I am being devious here, and I know it. Coma and death are not rarein HACE although HACE in itself is and develops over 4000 meters.Immediate descent is the best treatment, but portable hyperbaricchambers have shown promise. It does look like hypothermia sotreatment for both is worthwhile.

Some nut comes to your office wanting to climb Mount Kilimanjaro (this isa lot higher than 1000 meters- actually 5895 meters high). What is yourbest advice to him to know if he will be susceptible to mountain illnesses?

a) check is CBC- if his hemoglobin is less than 11- risks are higherb) Send him to a chamber that can simulate hypoxia at 2000-4000meters and see how his saturation is after 30 minutes.c) obesity- not morbid but with a BMI under 30- is protectived) Past experiences do not correlate with the future

Actually the best predictor of the possibility of development of altitude illnessis past experiences- although if one had no problem in the past it doesn't

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mean they couldn't develop it in the future. Obesity is not protective at all.The chamber is a good idea. Anemia- suprisingly is not a risk factor.

HAPE- high altitude pulmonary edemaa) is non cardiogenic so do not give diuretics,

b) exercise is protectivec) Viagra is effective as treatment.d) Salmetrol and nifedipine are for prevention only

Too easy, right? A is the obvious answer, but the others are not far away.

Exercise increases risk- it is not protective. Viagra does work- to prevent,but not as treatment. Salmetrol is protective only but nifedipine can be usedfor treatment and prevention.Which of the following works to prevent acute mountain sickness?a)acetazolamideb)dexamethasonec) ginkod) hypoxic pre conditioningAcetazolamide can help reduce symptoms but does not prevent them when

ascent is too fast. Glucocorticoids may help but the side effects make thebenefit less than the danger. Both however can be used to treatment. Theformer works but takes 24 hours, the latter can improve symptoms enoughthat a safe evacuation can be done. Ginkgo head to head againstacetazolmide- the latter won hands down- as did placebo. Hypoxicpreconditioning is showing promise but hasn't been proven. Obviouslyoxygen will help as treatment and probably as prevention as well. Indeed,trains in the high plateaus of China are oxygenated. So the right answer wasnone of the above- that wasn't one of the choices? Well, too bad.

Which of the following does not exist?a) dry drowning

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b) Secondary drowning.c) Differences in damage between fresh and saltwater drowningd) Electrolyte abnormalities requiring correction in survivors ofdrowning

Right again- they all do not exist. Laryngospasm is very transient indrowning, and if there is no water in the lungs at autopsies it is due to waterbeing absorbed into the vascular system. Secondary drowning does notexist- later effects are usually evident early on and are due to surfactant loss.Saltwater drowning may cause more osmotic gradients but the damage to

the lung units and surfactant are similar. Electrolyte abnormalities are rareafter drowning and you have a good case not to have to take bloods at all.So the right answer is all of the above and that wasn't one of the choiceseither, but I felt if you fell once, you probably will fall again.Which is true?

a) A few breaths will bring pure respiratory arrests in drowningback, so start rescue breathing even in the water.

b) keep patients horizontal in the water face up until rescueequipment can be brought

c) get the water out of the lungs as part of rescue and ventilationwill be easierd) Most common rhythm is VF, but please wait until you are out ofthe water to deliver the shock.

The breathing should start in the water- they do come back fast- actually,94% of those who are rescued by lifeguards do not have to go to thehospital. Keep patients vertical who have no C spine damage as itlessens aspiration risk. They taught me maneuvers to get water out of thelungs when I was young but they are unnecessary and delay giving

adequate respiration. In addition they increase vomiting risk. Suctioningintubated patients also has the risk of delaying oxygenation and they

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advise to avoid it. Most common rhythm in PEA or asystole, but shockingVF is probably fun and I would definitely recommend you try it some time.(See idiot above)

With regards to pneumonia after drowning:a) hospitalized patients should receive antibiotics after drowning aslung units are damaged and more susceptible to infection

b) Chest films done in the ED are often positive for infiltrates.c) swimming pool drowning result in 56% risk of pneumoniad) Drowning in pools used by kids can be more dangerous as kids

use the pool for evacuation purposes.

Swimming pools actually rarely cause pneumonia. Kids do use pools asbathrooms and don't really use bathrooms as pools (thank Goodness forthat). (Dogs are another story). Prophylactic antibiotics are never indicatedand actually most chest films are positive because of the water in the lungs,but only 14% are actually pneumonia- use fever as a guide.CHEMO EMERGENICESNo questions here I am tired. Lets run through this in a way that will be

useful to EPs and FPs and we'll ignore the agents that cause this stuff- If youare an onc guy- look up the article

1) Syncope and palpitations in a patient getting chemo- many ofthese agents can cause arrhythmias that include fatal rhythms. Do anEKG and observe 24 hours. Many agents are cardiotoxic.2) Chemo treatment of lung tumors can cause a pneumothorax asthe nodule necroses the pleura as well.3) Acute pneumonitis can happen-a chest film will showabnormalities but your best bet is CT. As a continuum, ARDS can

occur as well from chemo.

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4) Acute hemolytic reactions which can manifest as back pain, feverand rigor, jaundice, tea colored urine and dyspnea. Thrombocytopeniacan also occur look for easy bruisablity.5) Yea this was a trick on the boards- neutropenic typhlitis. This isa strange condition where people get RLQ pain that is due to mucosaldamage to the cecum. Fever is typically present and CT is the imagingof choice but neutropenia can be the give away that this is notappendicitis. Give plenty of fluids, antibiotics and GSF. Some useTPN and full bowel rest. As a continuum, toxic megacolon can occurunder similar pathophysiology. Clostrideum difficle should be looked

for as well.6) Pancreatitis. Ho hum- you k new that this is caused by manyagents. Elevated liver function tests also occur but they can be causedby vaso occlusive disease- which has thirty percent mortality.7) These bad boys- especially platinums-can actually increase thestroke possibility. Abnormal mentation and headache -even seizurescan always be mets but can be the reversible posteriorleukoencephalopathy syndrome8) Steven Johnson- another you should've known

9) Vaso occlusive disease can also cause limb ischemia and bowelwall ischemia.10) HUS and TTP can occur but they are very rare. What is notableis that this form of TTP will not respond to plasmapheresis.

Enough for one month.

Title: "Carol's Theme"

Written By: "Joe Hamilton"

I'm so glad we had this time together,

Just to have a laugh, or sing a song.

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Seems we just get started and before you Know it

Comes the time we have to say, So long".

There's a time you wanna sigh for dreamin.

And a time for things you have to do.

The time I love the best is any evening

I can spend a moment here with you.

When the time comes and I'm feelin' lonely

And I'm feelin' oh so blue.

I just sit back and think of you only

And the happiness still comes through.

That's why I'm glad we had this time together.

Cause it makes me feel like I'm along.

Seems we just get started and before you know it

Comes the time we have to say, "So Long".

Good night everybody

Emu July 2012

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