Category: Emergency


Clinical Case 054: Just a sip

Filed Under: Clinical Cases, Emergency, General Practice, Paediatrics by Casey Parker — 2 Comments
May 27, 2012

Mother of a 15 month old boy (weighs 11 kg) presents to the clinic with a bottle of massage liniment.

 

A quick glance at the label tells you the active ingredients are;

 

Per 50 milliliter:

 

 

Mum says she just popped out to hang the washing and left him playing on the floor.  She was not aware that her teenage son had left the bottle on the couch after going to footy practice.

 

When she came back inside she immediately smelled the menthol and found the little guy on the floor, playing with the bottle, it was dripping down his chin and he was making a disgusted face – like he had a bad taste in his mouth.  She picked him up and could smell the scent on his breath.  But he was fine, happy and she gave hi a bottle of milk to settle him and get the taste out of his mouth.
Ok, now you are seeing him 45 minutes later – he still looks fine, he is playing happily, smells like a gymnasium.  His obs are all normal and Mum says:
“I am sure it is fine – but I just thought I should bring him in for a quick once over…”
After examining him you agree that he is normal, no signs of respiratory distress, no chest or abdo signs.  Now here are the questions:
Q1:  What is likelihood that a toddler would have swallowed more than a few mils?
Q2: Which of the ingredients are potentially toxic? And how much would be required for potential serious badness?
Q3:  What signs, symptoms and timeframe will you want to keep an eye on this little boy?
Q4:  What resources can you use to help make this assessment and formulate a management plan?


Twitt
Comment

Clinical Case 053: thoracic tortuosity

Filed Under: Clinical Cases, Emergency, General Practice, Internal Medicine by Casey Parker — 6 Comments
May 17, 2012

OK.  This is just plain out there.  We see some unusual stuff in the remote areas – things you only read about in the books!  I am going to put this in the category of medical voyeurism.  This is not how we should go about our business, but I had to share these pics!

20 yo with pleuritic chest pain, not much else, but hypertensive BP =  160/90 [not that unusual up here in the tropics]

He managed to get a D-dimer… and then the inevitable CT angiogram  (probably PERC negative)

Here is a slice from the CT -

OK – spot diagnosis, what is going on?

Twitt
Comment

Clinical Case 052: Belly, bum and balls…

Filed Under: Clinical Cases, Emergency, General Practice, Paediatrics, Surgery by Casey Parker — 7 Comments
May 14, 2012

Today’s case is not in the ED.  This one unfolds on the ward – the morning after the admission.  So imagine yourself there – on the Paeds surgical ward.

6 year old boy was admitted last evening after referral from the local GP to the on-call Surg team.

He has a 24 hour history of increasing central abdominal pain.  The pain wa initially periumbilical, but overnight it has localized to the lower abdomen – maybe a bit more on the right. Urinalysis was normal

The surgical team have been on their super-early orning rounds and seen the child – they have written in the notes:

“ tender lower abdo, no rebound, guarding, otherwise soft, afebrile.  Bloods all normal.  PLAN:  Med team consult please.? epurients”

OK, now that is Surg -speak for – we aren’t operating on this kid – not a likely appendix.  Turf to med, maybe its constipation?

Half way though your ward round the nurse- coordinator calls you to say:  “You had better come see this kid – he has just had a bout of melena”

Hmmmm… not sounding like your average “un-appendix”.  So you pop in and see him.  Mum is looking worried.  His obs are normal, his belly is ‘as described’ by the Surg team.  When you pull down his jocks for a gander at his bottom you notice his scrotum is a bit red, and on examination his left testis is tender and there is a definite hydrocoele.  Hmmmmm…

OK – can you solve this Paediatric puzzle?

What is going on?  Well here is the clincher.

Rash

What are you going to do next?

Congrats to Dr Bek – who as it turns out practices about 500m down the road from me at the local Aboriginal Medical Service.  Bek gave the right and most insightful answer.  Good call from Maj and Patrick also – honorable commendations.  I happen to know Bek was at a recent talk I gave which covered HSP – so technically she did cheat? But I think she already knew before I got to her!

HSP (Henoch-Shonlein purpura) is an IgA-mediated leukocyoclastic vasculitis which produces a syndrome in children as described by the eponymous gents (and Heberden 30 years earlier). They described the quadrad of: purpura, arthralgia, abdominal pain and melena. Of course, they missed the meat – the renal disease. The disease involves a vasculitis of small vessels in the skin, gut, joints, glomeruli etc. It is pretty much the same disease as IgA nephropahy (Berger’s disease) in adults. HSP ends to occur in young children 4 – 10

I love HSP as a diagnosis as it is one of those end-of-the-bed diagnoses which can present in a number of ways – a rash, joint pain, belly aches etc. You have to keep it in you thoughts or you might miss it. The diagnosis is basically clinical – unless it is unclear as to the cause of the rash – so you might check for other causes of purpura. As opposed to ITP etc the platelets will be normal or elevated.

Treatment is mainly symptomatic – analgesia and “surgical” management of complications such as intussusception or torsion. GI bleeding, abdo pain and joint pain are usually treated with oral steroids. Does it work?  Well – maybe.  There are papers in both direction but they are all small and lack the power to say yes or no.  A rough summary is that they might make you belly pain get better sooner,  make the likelihood of an operation or CT scan lower and just might improve joint symptoms.  Now onto the million dollar question… the beans.

The reason HSP is an important problem in the long term is that there is an incidence of chronic renal disease. Usually a nephritic syndrome (though some mixed or nephrotic). And some of these kids will progress to renal failure. Here is the problem – there are studies that show that early steroids, and even cyclophosphamide do not reduce this progression. So we cannot treat the serious complication.

Monitoring includes urinalysis testing, BP monitoring – as there is about a 7% recurrence rate and the risk of renal disease goes up with recurrence and older-age of the kid.

 

Twitt
Tags: , , ,
Comment

Clinical Case 051: Cardiac conundrum

Filed Under: Emergency, Internal Medicine by Casey Parker — 11 Comments
May 6, 2012

This week’s case is “chest pain” in a relatively young man.

I am going to make it tricky by giving you info bit by bit – see if you smart buggers can work it out.

Step 1 – here is the initial ECG.  2 hours of central chest pain.  What is happening?  what are you going to do?

Does he meet criteria for thrombolysis?

OK – so you all seem to agree he has pericarditis on the ECG.  And the history was convincing – 23 yo, pleuritic left chest pain, radiating to the left arm.  He had a story of an acute “strept throat” and was just finished a week of oral penicillin.  BUT – the initial tropT was 0.88, and in the morning it was up to 16!  So he clearly has more than a simple pericarditis.

Just to be sure, late at night I did a bedside ECHO to check if he had anything suspicious.  This showed a small pericardial effusion and no “eyeball” evidence of regional (inferior) wall motion abnormality (for what it is worth with me – an ECHO gumby looking with my eyeballs!)

So lets say he has a myopericarditis.  Let us now look at the treatment.  How do you manage this?  And if you are super-smart – are there any other causes to consider other than “viral”?

If you are unaware of Dr Smith’s ECG blog then check out the section on pericarditis here - lots of pearls for telling MI from pericaritis.

Let me know on he comments.

Twitt
Comment

Medical Myths: Fever = blood cultures now!

Filed Under: Emergency, Internal Medicine, Useful Evidence by Casey Parker — 6 Comments
May 1, 2012

When I was an intern in a big old hospital one of the tasks we did was taking blood cultures off of patients who spiked fevers on the wards.  In fact thinking back on it, I think I was taking cultures to appease the senior ward nurses and not really stopping to think about the why?  Probably stabbed any number of patients with early sepsis and happily continued onto the next job without even worrying about the BP, lactate, line sepsis etc etc…  It was an annoying task as it was “time critical” – you had to get the cultures ASAP as the fever spiked – or else the boss would be grumpy, we might “miss the sepsis”.

Were we right to worry about getting the cultures done in a timely fashion?  Did it have to be “during the rigors?”

My colleague pointed out this paper by Riedel et al, Journ Clinical MIcro (April 2008).  This case-review looked at 1436 patients and their fever – culture timing profile and found that it really didn’t matter when you took the cultures in realtion to the spike of a fever – the majority of positive came from cultures taken hours after a fever.  This study cannot comment on the numbers of “missed” bacteremias as a result of wrong / delayed timing.

So what does it all mean for you, next time the nurse calls to tell you Mr Jones has spiked a temp….

  1. Walk, don’t run – it really doesn’t matter if you do it now or in an hour.
  2. Go there, look at the patient and think “what is going on here?”  Does he have a reason to be febrile already documented, on appropriate therapy?  Or, is he someone who needs to be reassessed for sepsis – does he have a line infection?  Does he have a wound infection?  Is he in SIRS or worse?  Do you need other sites cultured – urine, chest etc?
  3. Take cultures as clean as possible – aseptic approach – try and avoid those frustrating false positive BCs
  4. Contemplate changing the plan – look at the AB cover – is is sensible? Do you need to yank a line or call a surgeon to drain some pus?

Thanks Ben for the article.  Interns – relax, but do a more thorough job!    Casey

Twitt
Tags: ,
Comment

Clinical Case 050: Think Better, Do Better

Filed Under: Clinical Cases, Emergency, General Practice, Pearls and Pitfalls by Casey Parker — 5 Comments
April 30, 2012

Last week I received the following comment from a reader in a country nearby.  This was a great story for me to hear as it made all my long hours of reading and writing seem worthwhile.  There are plenty of podcasts and blogs that will teach you how to do life-saving stuff – but this story is about how a reader took something from Broome Docs and ‘saved a life’ in a very different way.  It is not about a single trick or a procedure – but about how to approach the daily practice of medicine in a better, patient-oriented and effective manner.  For me this is the essence of why I do what I do at Broome Docs.  Here is the story from Dr Tom:

Hi Casey,

Straight after I read your first article on Consult Skills, I clipped and saved it using Evernote so that I could access it on my iPhone whenever needed.

Lo and behold, last week I had my first opportunity to use it when a middle–aged lady presented with a two year history of severe low back pain, bilateral hip pain and right leg pain. She had had multiple visits to her GP, several locums and 3 different orthopedic specialists over that time. Even though she was on a benefit, she had paid to see a couple of specialists privately because she was so desperate.

When she arrived in our ED, one of our relatively new Resident Medical Officer’s went to see her. The RMO came back very frustrated and said that both the patient and accompanying relatives were very angry and demanding, and that she wasn’t really able to get anywhere with her.

At that stage I said to the RMO that we had two important functions to fulfill:

1.      To make sure that the patient didn’t have any emergent orthopedic conditions e.g. cauda equina syndrome, spinal abscess etc.

2.      To try to understand the patient’s point of view.

The latter was met with a slightly quizzical expression so I pulled out my iPhone, opened my Evernote application and showed her the section I had clipped a few weeks ago:

1.      They want to know the doctor is listening to them

2.      They want to know that the doctor cares

3.      They want to make sure the doctor understands what is going on

4.      They want the Doc to “get it right” – that is make the right call / decision / do the right test  etc…

5.      They want to know what to do next “what will happen to me now?”

At that stage I went into the patient’s room and said:

‘Hi, my name is Tom – I am the senior ED doctor on duty today. I understand you have been going through a really rough patch lately. The first thing I am going to do is to take your pain way with some morphine. Once you are comfortable, I would like you to tell me everything that has happened to you over the last couple of years; then I will have a good look at you, review your results, talk to the orthopedic specialist on call today and together, we will try and come up with a plan to get things sorted for you.

After 10mg of morphine she said – ‘Doctor, you know this is the 1st time in over two years that I have not been in pain’.

She then proceeded to tell me:

•       Her marriage had broken up and she was looking after 6 children on her own.

•       She was in so much pain that she was unable to dress herself (mainly because she could not bend down or stand on one leg), was unable to walk more than a few steps, had hardly been out of her house in the past few weeks and was largely confined to her bed or a chair.

•       She had a history of multiple severe drug reactions and was not currently taking any analgesics.

•       She suffered from stress incontinence and wet herself at least 2-3 times every day.

•       When she fell over, she was physically unable to get off the floor unaided.

•       Her teenage son had to take time off school to help dress and wash her, clean the house and do the cooking – this was now starting to adversely affect both his education and their relationship.

•       She was not eligible for any government subsidies (e.g. home help).

•       She was often tearful due to a combination of pain and frustration.

After listening to her history, I briefly re-capped to make sure that I had not missed any important points.  I then examined her and reviewed her recent imaging.

Next I rang the on-call Orthopedic Specialist and said –  ‘I’ve got a lady with chronic severe lower back, hip and leg pain; a plain film of her pelvis and hips shows severe bilateral hip OA; she doesn’t appear to have any new emergent orthopedic conditions but I would like to admit her so that we can sort out her analgesia, home help, mobility and definitive treatment’.

I returned to the patient and told her: ‘Great news, the Orthopaedic Surgeon has agreed to bring you into hospital, sort out your pain, get you a bit more mobile and most importantly, try and fast track some surgery on your hips.’

At that point she started crying and said:

‘You know, of all the doctors I have seen over the last few years, you are the only one who has ever sat down and really listened to what has been going on. Thank you so much’.

PROGRESS REPORT

After initially being admitted to hospital for a week, she has gone on to have her 1st hip replacement done and is due for her 2nd operation in 3 months time.

Great work Dr Tom.  I really appreciate your sharing this story with me and knowing that we can do better by changing the way we think and talk to patients.

Twitt
Comment

Clinical Case 049: the Unseen ECG

Filed Under: Clinical Cases, Emergency, Internal Medicine by Casey Parker — 15 Comments
April 15, 2012

I was sitting at the desk writing up some notes when the triage nurse stuck the following ECG strip under my nose.

The story was that this chap was a hypertensive, obese, diabetic vasculopath with impaired renal function who had presented with a fever of 39 deg and nasty looking diabetic feet (see Clinical case 047 for example…).  He was looking unwell so she did an ECG on the off chance he might be having a silent infarction.

So here we are – sick looking, high-risk sounding patient.

No chest pain; No previous IHD documented; Previous ECGs? – he had a normal exercise stress test 2 years ago with a normal baseline ECG in the chart

OK, all you smart ED types.  Can you make the diagnosis?  What is going on here?  There might be a trick or two …..

Ok a few observant comentators noted the machine was running at 50mm/sec – and the V leads were missing. The patient was running at 126 bpm clinically and on the monitor. Unfortunately our new nurse who was not familiar with the machine pushed the wrong buttons and gave me a terrifying minute or two as I made my way to the bedside! The penny eventually dropped and I could breathe a big sigh of relief!. The true ECG showed a tachy @ 126 with a RBBB pattern and no convincing P waves. So channeling Chris Watford (Emcrit) I did a Lewis lead config – and the P-waves popped up like they should! Sweet – we were back to boring old sinus tachy in a septic patient and all was well!

1. Always look at the patient before the ECG, or at least shortly thereafter!

2. If something doesn’t add up, check the basics, repeat the test and ask, ask, ask

3. Septic patients can develop nasty arrythmias – SVT, AF, transient heart blocks (RBBB), VT etc – so beware the sepsis with tachy, find those P-waves – as all the other options are not good for their cardiac output.

4. Lewis leads (S5) actually works, it is cheap, easy and makes you look smarter!

 

Twitt
Tags: , , ,
Comment

Consult Skills 3: Being Good at Bad News

Filed Under: Emergency, General Practice, Internal Medicine, Medicolegal / Ethical by Casey Parker — 2 Comments
April 10, 2012

We have a great job, but sometimes it sucks!  Forget the annoyance of shift work, the heirarchy and long hours – for me the worst part of the job is when we find something nasty, or have a poor outcome – giving bad  news to nice people is never easy.  Why?  well it goes back to the type of people we medicos are ‘on average’.  We are usually pleasant, we like to make others happy, ease suffering and get good results – this is one scenario where none of these is likely to occur.  So how do I think about “giving bad news”?

There are a lot of teachings out there, and anyone who has done any GP training will have had this drilled into them throughout their training.  In Australia you can be guaranteed that you will get a “bad news” case on your fellowship clinical exams. So here is a case and my “rules” for being good at bad news.

You are in your office checking your emails when the radiographer calls you to say she needs help….She has been doing a 19/40 anatomy US on a nice young lady with her husband watching to catch a glimpse of a face or a gender.  All seemed well, until the radiographer realised that this baby had no brain – it is anencephalic.  It is a small town – the radiographer plays netball with the expecting mother and cannot hold her poker face.  She stops scanning and tells her she is going to find a doctor to get a second opinion.  This is when she called you.

If you are like me – you know what this means, but the exact logistics of dealing with anencephaly are well beyond my scope of practice.  I need help and will be calling my local ObGyn for advice.  However, the young couple are aware that something is wrong.  You need to talk to them and provide counsel – so how to do this in real terms…

Here are my rules:

This will depend on your own knowledge and the scenario in question – but before you walk in the room you need to have a clear understanding of the problem, the management and prognosis.

This might mean doing some research or asking for specific specialist advice – but you have to know. If you are unsure – you know that will be the first question they ask – and you need to be able to provide clear and concise counselling. This is not the time for ummm or errs – the patient needs clarity and a direction. Any vague responses will likely provoke anxiety and confusion in a person who is already having the worst day of their life.

You do not need to have encyclopedic knowlege – but you should be able to provide clear and accurate information now, today!  So take a few minutes – call someone who does know and get the facts straight in your noggin

This conversation is going to take time – and it is the most important thing you will do today (this year?) so create plenty of time. Hand your phone or pager to a colleague.  There is nothing worse than feeling time-pressured or being interrupted for trivial problems in the middle of this crucial dialogue.  This conversation will be stamped into your patient’s memory for years to come so make sure you do all you can to make it quality.  If you cannot make time in the day – then plan to see the patient at the end of your day / shift – that way you are free to take as long as required without the pressure of the waiting room etc.

You need uninterrupted privacy. It is really hard to predict how any individual will react to the news you are giving them – so do it in a priavte room, away from traffic or onlookers. The curtained bay of an ED cubicle is not the place to do this! I once saw a doctor give a trisomy 21 result through the bullet-proof glass of the triage window – that is just wrong.

Beware that some folks will have a dramatic response – crying is normal, butI have seen a few people have syncope and prolonged, almost catatonic responses – so it is helpful to have a bed or somwhere the patient can lay down if the need arises.

It would seem obvious, but not always done. You want to ensure that the patient brings along all the people who they need – spouse, parent, children etc. If you get this wrong there are a few possible problems.   You need to ensure the patient is happy for those people to be there from a confidentiality POV.

- Talking to somebody alone is not advised – they need a support person to help them through and share the experience.  Sometimes even to get them home safely.

- If an important family member or person is not there – they will likely get the message indirectly and inaccurately – this will lead to tension, misinformation and sometimes anger

You need to decide the words you will use up front. You need to get the message across in clear, simple, unambiguous language.   It is human nature to want to hear things in a positive light – so you need to use clear language to avoid any misunderstanding.

The use of subtlety or pleasant euphemism is not allowed – that is about you wanting to avoid the unpleasant nature of the conversation. In order to do this right you will probably feel uncomfortable – that is your problem – not the patient’s!

Once you have given the patient / family the information you need to be quiet. Usually you are delivering life-changing news and it takes at least a few minutes for people to process and begin to comprehend what is happening.  Talking at this point is unhelpful at best! Let them process and just wait – when they are ready they will ask you what they need.  You may feel uncomfortable with a prolonged silence, but wait, resist to urge to add info or interpret their response.

It is well studied that patients recall very little of the data received in these scenarios. They remember the demeanour of the doctor, but often not the simple things – like what happens next. So before you start this consultation – have a clear plan / referral  /investigation or next appointment prepared. The patient will walk out in a haze often – so giving them a firm “next step” is vital – avoid open-ended time frames and the “I’ll get back to you” strategy.  I usually plan to see them the next day – they usually have a lot of questions.  In reality this is not a ‘one stop’ consult – it is the start of an important therapeutic relationship.

OK – that is my simple approach to the delivering of bad news.  Do you have any pearls or strategies that you have found useful in your practice?  Let me know

Twitt
Comment

Course Review: Advanced Paediatric Life Support (APLS)

Filed Under: Anaesthetics, Critical care / ICU, Emergency, Paediatrics, Uncategorized by Casey Parker — 7 Comments
April 9, 2012

Last week I completed the APLS course over 3 days.  I am an impartial educator and thought I would give my review – so what did I think?

APLS is a well organised and run course.  It covers a lot of material over 3 days.  The level is pitched at the post-graduate trainee – ideally PGY 2 -4 I think.  The days were long – 11 hours of material in a day… this is probably counterproductive.  The course could be streamlined I think without losing too much.

At ~$1900 – it is a reasonably expensive course.  For that money you get a lot of theory, manikin-based scenario training, but no animal / cadaveric models to improve your clinical skills.

The learning is largely based around lectures – not everybody’s preferred format!  I found the lectures a bit long and repetitive, especially if you had done the required pre-course reading of the manual.  The teachers were friendly and well-informed, and an effort to remain entertaining was evident.

The scenarios and skills stations were OK.  As a more experienced participant I found being put on the spot in simulation to be a strong learning tool and allowed me to identify my weaknesses and cognitive errors.  I was aware that some of the more junior participants found the live simulation a bit confronting.

The material presented is largely up-to-date, though there are some areas where there is a lack of evidence base.  For a ‘resus course’ the absence of ultrasound strategy was striking.  The preference for ETT over LMAs in resus seemed odd given recent changes in most major guidelines

The testing and scenarios were OK, but did lack some flexibility to allow more experienced clinicians to make judgement calls rather than blindly follow protocol – ie. there is some ‘lowest common denominator’ effect – I guess this is a function of running such a broad ranging course.  Good for jnior staff, but a bit frustrating if you are 10+ years into your career.

Summary:

APLS is a well run course that covers an ambitious amount of material in 3 days.  The educators are entertaining and well-versed.  I recommend it to junior doctors, and staff who are unfamiliar with Paeds patients and wanting to extend their knowledge from adult care.  For the office GP who wants to brush up their resus skills – it is OK.

If you already do a lot of Paeds, especially in ED or anaesthesia environments than this course might e aiming a bit below your educational needs.

Any one out there got experinces of the APLS to share?    Casey

Twitt
Tags: , ,
Comment

Clinical Case 047: Not so sweet feet

Filed Under: Clinical Cases, Emergency, General Practice, Internal Medicine, Surgery, Tropical disease by Casey Parker — 8 Comments
April 1, 2012

This week a classic Australian remote area case.  There is so much to discuss on this case!  But I have isolated a few key points to put under the microscope, and get your input / expertise.

47 yo. Aboriginal woman has returned to the ED complaining of painless purulent lesions on her left foot.  She was seen a week ago by the nice city locum who diagnosed cellulitis and commenced her on a week of oral flucloxacillin.  She has been taking this for 6 days, but it aint working!

Not so good.  She reports increasing ooze, and the occasional maggot escaping from her improvised dressing.

Here is the background info:

PMHx:  Diabetic (type 2 – is there any other kind?)

  • Hypertensive
  • Nephropathy with significant proteinuria, Cr 100 last visit
  • Retinopathy requiring laser last year
  • No documented ischemic heart disease, CVA or PVD

Meds:  metformin 2 g/day SR, Gliclazide 120 mg MR,  Quinapril 20 mg, aspirin 150 mg/d.  No Allergies

She is overweight with a BMI of 39.  Central adiposity.  Malodourous slough coming off the foot.  She has a good dorsalis pedis and posterior tibial pulse to feel

Obs: T = 38.4,  pulse = 98 SR, BP = 166/102,  RR 14, Sats 97% RA.  Her BSL is 29 mmol (~ 520 in USA)

This is bread and butter for the remote area docs, so i am going to ask 3 questions for you to ponder and comment upon…

Q1:  Antibiotics in this scenario – what are you going to use? Any particular pathogens to keep in mind?

Q2:  Imaging – what do you do?  Are plain films worthwhile?

Q3:  Management of her hyperglycemia (assume she is admitted) – what targets and what to use to achieve this?

….. OK, bonus question… #4 :  Maggots…. good, bad or indifferent?

Get your thinking caps on.  Especially you Dr Dorr – I am gonna quiz you on this this week!

Casey

 

Twitt
Tags: , , , ,
Comment