A patient presents with a deep muscle abscess. Is this necrotizing fasciitis? All too often I see the deliberation focus on things like the laboratory score or the imaging. The role of those things are being debated but what is beyond debate is to have the bedside skills for recognizing necrotizing infections.


Childers in 2001 and 2002 described the finger test as a diagnostic intervention at the bedside. It does not get enough attention. The instructions are to make a 2 cm incision down to fascia. “…if the tissues dissect with minimal resistance, the finger test is positive”


Other signs:

-lack of bleeding

-grey necrotic tissue

-dishwater purulence


There is no reason ED physicians should not know this and perform it. We are already making incisions to check for abscess. Know the 4 surgical signs of necrotizing fasciitis.



The 4 surgical signs of necrotizing fasciitis are:

-lack of resistant to finger spread

-lack of bleeding

-grey necrotic tissue

-dishwater purulence


Childers BJ Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68:109-16.


Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg. 2001;107:1025-35.



An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?


In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The population was strictly those less than 30 days of age, so it may not apply to older babies. The idea was inspired by bladder stimulation techniques used in adults with neurological diseases. There may be some element of a frontal lobe “release” reflex involved in the phenomenon.


The original study stacked the odds in their favor by feeding the babies, but follow-up studies all showed a greater than 50% success rate within 5 minutes. Thus, this technique is well worth trying in a low risk population.


Of note, the bladder tapping was 100 taps per minute. It is supposed to be gentle but the parents may quickly throw in the towel and ask for the catheter.


Take Home Points

-For the infant with a low suspicion of urinary tract infection, consider massage and bladder tapping to elicit a urination reflex


Herreros Fernández ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98:27-9.


You are seeing a patient with suspected pneumonia. Your attending hears crackles but you do not hear them. Later the radiograph shows pneumonia right where the attending heard crackles. What can you do to improve your pulmonary examination?


Sit up and take a deep breath might be bad advice?


Increase signal

Sensitivity for auscultation of crackles is increased in the supine position. Should you always listen supine? No. That is hard to do because anterior is less helpful and posterior requires you to squeeze the stethoscope behind their supine back. But be aware it is an option if you need to increase the sensitivity for the physical examination.


You can make crackles more easily discerned by varying your exam. If it sounded too quiet have them take a deeper breath.


Decrease noise

Should they always take a deep breath? No. That can increase other noise if they make upper respiratory noises. Have the patient take a “full and quiet” breath. That might be best for minimizing noise and maximizing signal.


Take Home Points:

-“Sit up and take a deep breath” is not the only way to do a lung examination

-Increase signal by auscultating the supine back

-Decrease noise by asking the patient to breathe deeply, but quietly


An elderly patient presents with cough and shortness of breath. The resident says the lung examination is normal and the chest x-ray is negative and wants to send the patient home. But you hear crackles posteriorly at the right base. And the oxygen saturation is 94%. And the patient looks ill. What do you do?


If your practice is to use chest radiograph as the gold standard for pneumonia (following IDSA guidelines – Mandell 2007) then you might be missing pneumonia. In medicine we tend (alas) to assume our reference standards are disease-defining until we compare them against something else.


Against CT scan, chest radiograph is probably about 75% sensitive and specific for pneumonia. Often the literature does not give exact numbers but false negatives and false positives are extensively documented. Where sensitivity is reported, it can be as low as 44%.(Self Am J Emergency Medicine 2013 – from a datebase of PE workups) A more representative finding for sensitivity is 77% (Ye PLoS One 2015). Good, but not perfect. Other studies show significant false positive rates (Clasessens Am J Resp Crit Care Med 2015). Specificity is probably also about 75% but we do not yet have a precise estimate of that. And of course there are significant differences between a supine 1 view chest radiograph in an altered patient and a 2 view standing radiograph with tidal volume inspiration.


Your overall accuracy is not doomed by limited tests. Your accuracy depends on how well you formulate Bayesian “prior probability” BEFORE applying results of tests. Of course, if you don’t want to do that there is always pulmonary ultrasound, with 95% sensitivity (Ye PLoS One 2015). But let’s talk bedside medicine.


The classical clinical signs of pneumonia are:




-asymmetric breath sounds


-progression of symptoms after 3-5 days


Steven McGee’s Evidence-Based Physical Diagnosis has an excellent chapter on this topic. It essentially supports the classical findings but reminds us of their limitations too.


Back to the case. You have a moderate clinical suspicion and you are aware that the gold standard is flawed. Do you order an ultrasound? CT? Do you start empiric antibiotics? Do you recommend next day follow-up? In this case you desire to admit the patient because she appears ill. But the utilization case manager and hospitalist argue that the admission does not meet Interqual criteria. They say it is impossible for a patient to have pneumonia without a positive chest x-ray and besides, the patient does not even have a fever (oral temperature).


You palpate the temperature at the neck with the back of your hand and leave it there for 5 seconds, and feel a tingle – this is a fever. The RN confirms the rectal temperature is 103. You perform a bedside ultrasound and find mild hepatization and a few air bronchograms in the area where you heard crackles. They do not accept the legitimacy of that test, despite the literature.


You order a CT scan and the radiologist confirms a moderate size consolidation, interpreted as pneumonia, at the exact area where you heard crackles hours before.



-Chest x-ray has limitations in sensitivity and specificity for pneumonia (probably about 75% for each)

-If you do a thorough physical examination with attention to heart rate, oxygenation, and auscultation then the CXR is probably adequate for most patients.

-When you need more information, consider pulmonary ultrasound, or CT scan of the chest.


You are intubating a critically ill patient. The first intubation attempt fails and the patient experiences rapid oxygen desaturation. The respiratory therapist tries to ventilate the patient but air leaks out around the mask with each breath. The chest does not rise and the saturation is dropping.


What is the problem?

Sometimes the problem is an insufficient seal around the mouth but more often the problem is soft tissue obstruction. We intubate supine. The tongue occludes the airway. The air follows the path of least resistance, which is out the face, leaking around the mask.


What are the choices of grip?

  1. One handed grip, aka C or CE grip (generally acknowledged to be less optimal).
  2. Classic two handed grip – taking the problematic one handed grip, and doing it with the other hand too. Similar to the grip you would have if holding a soda can.
  3. Jaw thrust grip – similar to the grip you would have if lifting a gurney or plank, thumbs on top, fingers below doing the work of lifting. Or if you will, taking your soda can and dumping it out forward.


Some studies say CE grip or jaw thrust grip are equally effective. So why do you say jaw thrust is better?

Most of the time airway resistance (A) is lower than mask resistance (M). Anything will work in that situation. What really matters is what happens when A is greater than M. That isn’t addressed in most of these studies.


What happens when A is higher than M?

When airway resistance is higher than mask resistance, the operator grips harder to raise mask pressure. The fingers often compress the submandibular space. This presses the tongue against the posterior airway, and raises airway pressure further. The harder you grip, the more you close off the airway.


What is a better way?


The best way to grip the mask is to press the mask to the face with the thumbs pointing forward. The fingers then fit over the angle of the jaw. If you want more pressure, you pull the fingers, which not only increases the seal pressure but also performs a jaw thrust maneuver. It pulls the tongue off of the palate.


Is there anything else that will help?


Place two nasal trumpets and an oral airway. Whether you have great technique or bad technique this will help. Don’t be afraid to “waste” some plastic here. I suspect that nasal trumpets also improve the effectiveness of apneic oxygenation via high flow rate nasal cannula.


Back to the case. You put the thumbs pointing forward on the mask and pull jaw thrust with digits 2-5. The leak is gone and the patient is re-oxygenated before your second attempt.



-Use the jaw thrust mask grip technique for ventilation

-Good mask ventilation is a crucial airway skill. Invest in it.

-If you are have ANY trouble, place nasal and oral airways


Suggested references:

Efficacy of facemask ventilation techniques in novice providers.

Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, Anderson MS.

J Clin Anesth. 2013;25:193-7


A patient presents to the emergency department on a 5150 hold. He is yelling and straining against police restraints. Of course you will use medications but also want to try calming him down through bedside interaction.


The human mind, unhinged by disease and drugs and high emotions, needs simple, calm communication that is easy to understand. Talk to the patient in a story format. Introduce the characters and organize it chronologically (past, present, future). Make it very clear that they are safe, and you are on their side.



Hi Mr. ____, I am Dr. ____. My job is to help people who are sick or hurt get better.”



“You are here because somebody called 911. They could tell something was wrong. When the police evaluated you they determined something was wrong also.”



“My job is to make you better. I am going to be talking to you and doing a physical examination.”



“When we are done we will determine the best treatments and the best place for you to continue to get better.”



You will be safe here and you will be treated with respect.”

” Everything we do will be in your ultimate best interest.



“Just as I promise to keep you safe and treat you with respect, I expect you to do the same for my staff.”



To get started I would like to calm you down with a medication. That can be through a shot or a pill. If you are willing to take the pill you can choose that. The medicine will calm you and make it easier for us to talk.”



“I know you will be safer if you get some medication. We are going to give you the shot and 4 people will hold you down. They will not hurt you. They are to keep you from hurting yourself and anyone else. When it is done I will talk to you some more.”



Go back to being therapeutic right away so the patient is reassured.

“Are you feeling better after the shot? I want to talk to you about what to expect going forward.”



“What are you most concerned about?”

“What would you most like to see accomplished today?”


How does your emergency department treat the patient with psychosis? This is a stress test for genuine patient-centeredness. If you can be sincerely non-judgmental with them, it reminds everyone that we are serious about our caring culture.



-Explain their care like a story. Introduce yourself and explain the past (how they got here), present (what you are doing now) and future.

-Everything you do is ultimately in their best interest (say that!)

-Reassure their safety first, and respect, and require them to abide by it also.

-Stay therapeutic before, during, and after conflict



Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. West J Emerg Med. 2012 Feb;13(1):17-25.


A patient presents with a recurrent anterior shoulder dislocation. Milch fails but Spaso works. The next month she is back and the procedure feels different, with more resistance. This time Spaso fails and Milch works. Same shoulder, so what is different? Why did the efficacy reverse?


Milch’s 1938 article started with a question: why do some reductions seem impossible and then under general anesthesia they become very easy, almost going in spontaneously? It was the muscle and tendon opposition, he concluded, so his technique focused on putting the patient in the muscle neutral position overhead (hanging from a limb position). The various shoulder muscles would share equal stress and equal angles.


Milch’s idea has probably not yet been fully fulfilled – it was the idea that shoulder reduction is not about overcoming force but about untangling the humeral head from the adjacent muscles, tendons, and soft-tissues. That was the same idea that inspired Kocher.


We have all had the tough shoulder that would not go in with technique A, but after trying technique B, a second attempt with A yielded an effortless reduction. There seems to be an unlocking of the soft structures that occurs.


Now as to the unlocking. I suspect there is advantage in the difficult shoulder to running through a variety of techniques. Ideally we would know which soft structures are causing the locking, but the literature lacks consensus and I do not know to resolve that. So I run though a variety of techniques.


This is reductionistic but you can think of all techniques as the application of external rotation in different positions.


Kocher is external rotation in the adducted humerus, as are all the derivative techniques.


Milch is external rotation in the abducted elevated humerus (technically he advocated doing the external rotation on the way up).


Spaso is external rotation in the forward flexed shoulder.


Back to the bedside. Its your next shoulder attempt. The shoulder is locked in internal rotation. Your goal is to get it into external rotation. You try Kocher but there is too much resistance to external rotation. You laterally abduct to Milch and you came close but did not fully reduce the shoulder. Finally, you perform forward flexion (Spaso) which also does not work. You then go back to Kocher, which this time was successful.


Take Home Points:

-The obstruction to shoulder reduction is not bone position but soft structures

-The obstruction can apparently be unlocked through applying external rotation in various positions through the range of motion

-If your favorite technique does not work, range the shoulder, externally rotate, and try it again.

Check out for more on Milch. If the link does not work, here is the location.



The Kocher technique, one of the oldest and most popular techniques, was developed for the subcoracoid anterior dislocation. Review Neil Cunningham’s resources at for insight on this, as well as his translation of the original Kocher article.


The goal of Kocher’s method, which was worked out on cadavers in 1870, is to roll the greater trochanter of the humeral head on the glenoid rim. It might have been named the “shoulder rim roll.” Here are the steps:


1) Adduct the elbow all the way to get the greater trochanter right next to the glenoid rim.

2) Externally rotate to roll the greater trochanter on the glenoid rim.

3) Forward flex the shoulder (sagittal plane) to tip the humeral head back toward the socket.

4) Internally rotate to complete the reduction.


Kocher’s words:

“Pressing the arm bent at the elbow towards the body, turning outward until resistance is felt, lifting of the outwardly rotated upper arm in the sagittal plane as far as possible, and finally slowly turning it inward” (translation by Cunningham)



The subglenoid dislocation will not be resolved with the Kocher technique because the external rotation phase will not latch onto anything. Kocher himself in his article specified that this was for subcoracoid dislocations, and said “the more therefore the head has departed from the coracoid process toward the interior … the less can be expected from the method.”



-Make sure you fully adduct the elbow first.

-Avoid traction, which is what creates the need for sedation(Chitgopar Injury 2005).

-Avoid sedation. This is the best way to avoid too much force. Kocher’s method excluded the use of force. Perpendicular forces of opposing muscles can lead to fracture. If you get resistance, use another technique.



-Kocher’s shoulder reduction was originally intended for subcoracoid dislocations, not for subglenoid.

-Do not use force with Kocher’s method.


References: (see the lectures and translation of the original Kocher article)

Chitgopkar SD, Khan M. Painless reduction of anterior shoulder dislocation by Kocher’s method. Injury. 2005;36:1182-4.


A patient presents with a scalp hematoma from a remote fall. When you press on it, it feels very soft but is not swollen. You are confused, and order a CT, which shows complete lysis of the bone,. Further workup suggests metastatic renal cell carcinoma. The patient is avoidant on history and keeps explaining away the findings and concerns. Hours later, while he is awaiting a bed upstairs, he reveals that a year ago his doctor suspected renal cell carcinoma but he refused a workup.


This patient suffers from denial. Whether that is a perfect term is debatable. In this case it is severe but so often denial seems to overlap with avoidance, perhaps even procrastination. It is at times the unwillingness to address an unpleasant reality. In medicine all too often we judge “denial” as a break with reality but we need to understand it as a human experience. Denial is the way some patients try to grasp onto hope. Go read Arthur Miller’s Death of a Salesman if you want a literary exploration of denial and hope.


We shouldn’t always oppose denial. Don’t argue over code status. If they want to be full code don’t gripe about them at the nurse’s station. They are dying. If knowing they will get 30 minutes of CPR in the end gives them comfort then let them have that consolation. If the patient-centered reasons aren’t enough, remember that practicing code situations only makes you better at it.


The literature is accumulating articles portraying denial as a positive thing. Denial mitigates terror and allows patients to continue to function. But in the emergency department we sometimes see patients at an earlier stage, where denial gets in the way of potentially curative treatment. So what should we do?


Accentuate the positive

Without distorting the truth, emphasize the safety and efficacy of your recommendations.


Build a relationship of trust by genuinely connecting as people

Spend some time getting to know them as people. Share anecdotes of those who have had good experiences, which not only illustrates safety but also displays your connection to patients. As emergency physicians we will not get long-term rapport, so build it for your consultants, whose expertise and caring we should commend to the patient (assuming we can do so truthfully).


Tools of persuasion – allowing an “out” lowers the cost of an “in”

Finally, point out that they can always choose to stop treatment later. That way they can say yes without feeling stuck. By giving them an “out” you are lowering the cost of going “in.”


Ultimately, denial is their choice. We will not be able to convince everyone to face the unpleasant reality but we should use the skills and techniques that best address their frame of feeling.


Take Home Points:

-Denial is often a way for the patient to have hope

-Give such patients hope through emphasizing the positives of treatment

-Connect on a genuine, human level

-Remind them they can change their minds later


Anecdote 1:Don’t call it a seizure, start CPR

Resident: Hey, remember that patient in room 7 with the heart attack? Now he’s having a seizure!

You: That is not a seizure, let’s start CPR!

(the patient survives, and receives emergent catheterization opening a blocked vessel)


Cardiac arrest is often accompanied by jerking movements. The cartoons of the 1940s understood this. Bugs Bunny would typically do a few good jerking leg kicks prior to faking death with Elmer Fudd, Yosemite Sam, etc. If the setting is more appropriate for cardiac arrest, check pulses first.


This is probably not substantially different from convulsive syncope but I will describe that separately:


Anecdote 2: Don’t call it a seizure, refer to cardiology

“we never figured out why the Brugada syndrome patient had a seizure” –someone who should know better


Blood bank studies show that about 10% of syncope events are accompanied by a convulsion. These can look like epileptic generalized tonic clonic seizures. The differences are:

Pre-ictal: what were the setting, the symptoms, and the signs, before the event. An aura suggests a seizure. Standing in church suggests syncope. Alcohol withdrawal suggests seizure, etc.

Ictal: convulsive syncope is less rhythmic, less symmetrical, and less sustained

Post-ictal: Convulsive syncope patients regain normal arousal within a minute, seizure patients take 10-15 minutes


It isn’t a seizure until you have a diagnosis. It is a convulsion. Apply an appropriate differential that includes convulsive syncope.


Ancedote 3: Don’t call it a seizure, check the temperature

A middle aged patient is waiting to be seen for generalized weakness. The triage RN rushes them out of the waiting room because of a “seizure.” He never lost consciousness and was awake the entire time. Temp is 103 oral. You ultimately diagnose sepsis from pyelonephritis.


Rigors can cause tremendous shaking and can make us worry about seizure. Obviously a seizure can raise the temperature so judgment is required. But don’t automatically assume that a convulsion from sepsis is a seizure. Rigors happen when the temperature is rising, so recheck the temperature.


Anecdote 4: Don’t call it a seizure, educate the family

A patient is here for opioids. The doctor said no. She has a history of developing “seizures” when she does not get narcotics. Now she is screaming loudly and, wait for it…. The RN runs to you announcing a seizure and asks if you will give Ativan. Okay, I admit it, I often give Ativan if I am not sure. One time I went to the patient and said “really, you are having a seizure? Can I see the tongue biting, show me the tongue” and she proceeded to show me her teeth, biting the tongue.


This is tough. Don’t expect the family to understand the difference between seizures and psychogenic convulsions (also known as pseudoseizure). Educate them on the potential for psychogenic causes (but don’t prematurely rule out epilepsy either, unless it is abundantly obvious)



-Our terminology can box us in. Don’t call it a seizure unless you are committing to an epileptic etiology.

-Ask about circumstances before, during, and after the event to identify possible convulsive syncope