Browsed by
Author: James Nelson

HOW TO DIAGNOSE SEPTIC ARTHRITIS

HOW TO DIAGNOSE SEPTIC ARTHRITIS

The biggest challenge in diagnosing septic arthritis is to think of it. Once you think of it, there is a diagnostic process that you activate. The second biggest challenge is that that diagnostic process we learn in training is flawed. We have no alternatives right now, so I will share with you my thoughts on how we should use our judgment as clinicians.   Triggers to consider septic arthritis essentially are the same triggers as infection anywhere. Celsus’ cardinal signs…

Read More Read More

SOFT TISSUE FOREIGN BODY: PAIN WITH MANIPULATION

SOFT TISSUE FOREIGN BODY: PAIN WITH MANIPULATION

A patient presents with redness and swelling. There had been a wound there 2 weeks before and the patient is worried about retained foreign body. Xrays are negative for foreign body. The student tells the patient “Good news! The xrays show there is no foreign body there!”   You wince a bit. Every mature clinician must know the limitations of the tools they use. I want to take a divining rod to the beach and see if it knows which…

Read More Read More

REAPPROXIMATING MID FOREARM FRACTURES THROUGH ANGULATION

REAPPROXIMATING MID FOREARM FRACTURES THROUGH ANGULATION

A patient presents with a mid forearm fracture. Reduction is tough because it is 100% displaced. Unlike distal fractures, you can not grab the bone as it is surrounded by muscle. It is hard to pull enough traction to reapproximate. Now what?   Try angling more during your reduction, exaggerating the angulation. Now it is slack enough you can put the distal piece on the proximal piece. Use your other hand to guide it on manually. Once the two pieces…

Read More Read More

DIAGNOSIS AND TREATMENT OF ATOPIC DERMATITIS RELIES ON UNDERSTANDING THE SKIN BARRIER

DIAGNOSIS AND TREATMENT OF ATOPIC DERMATITIS RELIES ON UNDERSTANDING THE SKIN BARRIER

A patient presents with a rash. In emergency medicine we often recognize certain rashes at a glance, like urticaria or a viral exanthem. This does not fit any of those. The patient is scratching vigorously. Is this atopic dermatitis, commonly known as eczema?   Eczema might be the most common rash we see in the emergency department but its presentations are diverse so it is not always a “know it at a glance” diagnosis. We can get tricked. The etymology…

Read More Read More

HOW TO ACCESS THE HUMAN SIDE OF MEDICINE

HOW TO ACCESS THE HUMAN SIDE OF MEDICINE

A patient presents with respiratory distress and COPD. She is very dramatic in her gestures, very upset and emotional. The first time you saw her you had given her lorazepam and sent her home. It turns out she frequently gets that. You and your colleagues eventually set boundaries on that but she continues to present daily for respiratory distress. This case turns out to involve the deeper human side of medicine. How do you access that?   How do we…

Read More Read More

HOW TO GET PATIENTS TO TELL THE TRUTH ABOUT DRUGS

HOW TO GET PATIENTS TO TELL THE TRUTH ABOUT DRUGS

Patients often lie about drug use and that can interfere with care. Part of practicing emergency medicine is using skill in communication to get through those communication pitfalls.   To get patients to tell the truth on drug use, start with asking about past use. Then ask current.   Furthermore, sometimes it helps to ask the question specifically In my area, I tend not to ask “do you use drugs?” I ask “did you try amphetamines when you were younger?”…

Read More Read More

A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

Templates do not just facilitate documentation but also can guide bedside observations. The person taking a history who uses OLD-CARTS might be reminded to ask a dimension of a symptom that otherwise would not have been elicited.   What does it mean to say a child is “well-appearing” or “ill-appearing?” I find the GCS (Glasgow Coma Scale) categories to be helpful:   Eyes – is the child attentive with the eyes Motor – is the child appropriately active/reactive Verbal –…

Read More Read More

NONCONVULSIVE STATUS EPILEPTICUS

NONCONVULSIVE STATUS EPILEPTICUS

There are two scenarios where you might see non-convulsive status epilepticus (NCSE): -Presentation of coma -Failure to rouse after seemingly successful treatment of a seizure (one article said up to 20% of status epilepticus generates NCSE after resolution of the convulsion)   The gold standard is 48 hours of continuous EEG monitoring. Unfortunately at many EDs we rarely can get EEG monitoring at all. Thus we need to be mindful of some subtle clinical signs.   Clinical signs or triggers…

Read More Read More

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

Here is a potential airway technique that may help with visualization: hold the laryngoscope in the left hand (the usual) but the right hand, instead of being at your side, is behind the patient’s head. You then move it around until you get the best view. Then you have an assistant hold the head in that spot.   A hospital in Southern California started doing that. The technique deserves some exploration. The work of Richard Levitan reminds us that the…

Read More Read More

INDIRECT LARYNGOSCOPY

INDIRECT LARYNGOSCOPY

A patient presents with severe sore throat. You wonder about epiglottitis. You know that using a mirror to look at the epiglottis is a great way to check this but are not confident in your skills. What do you need?   Dental mirror – they are cheap, have your ED stock them   Light – can use a headlamp, the kind that are sold in outdoor stores. Get one with a spot beam rather than a flood light. Nice to…

Read More Read More