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Friday, April 24, 2015
A stomach bug is spreading across the United States, with a majority of cases apparently in Massachusetts.
Shigella, a bacterial infection, is causing flu-like symptoms: fever, vomiting, stomach cramps, and diarrhea. Worse than that, however, is that 90 percent of samples tested resisted ciprofloxacin, which is the first line of defense for treating adults. The Centers for Disease Control and Prevention expressed concern that the strains are antibiotic-resistant, and are being carried by those traveling to the United States. Some strains, for example, arrived in people traveling from India and the Dominican Republic. The bacteria infection is spread through sharing foods and from hand-to-mouth contact. Physicians warn that those with Shigella should wash their hands frequently, should not cook for others, and use different bathrooms, if possible.
Read more: http://bit.ly/1aNNrSl.
Thursday, April 23, 2015
By David Beran, DO; Lauren Harrell, MD, & Christine Butts, MD
It is 4 o’clock in the morning. You are working an overnight shift in a busy emergency department when EMS calls in a stroke activation. They report the patient awoke moments earlier with extremity weakness.
They arrive several minutes later with a 69-year-old woman with a blood pressure of 147/62 mm Hg, a respiratory rate of 30 bpm, a heart rate of 47 bpm, an Sp02 of 100%, and afebrile. The neurology service is at the bedside when the patient arrives. She has a history of hypertension and breast cancer, and is six months status-post total left breast resection. EMS explains that on their arrival, the patient was being carried by her husband after a vagal episode and had a systolic pressure of 60 mm Hg, which improved en route with a normal saline bolus.
The patient is placed in a critical care bed in your emergency department. She has normal mentation, and states that she awoke feeling generally weak and needing to have a bowel movement. Too weak to move, her husband carried her to the restroom and back to the bed, and he then activated EMS. The EMTs found the patient was not generally weak, but had left arm and right leg weakness. She was unable to walk and had a syncopal episode when they tried to move her to the stretcher.
The patient is in no obvious distress in the ED. Her neurologic exam reveals total paresis, severe sensory loss, and absence of deep tendon reflexes of the left upper and right lower extremities. Her right upper and left lower extremities exhibit normal motor function, sensation, and reflexes. She has a normal cranial nerve exam, and auscultation of her heart reveals bradycardia and normal heart tones. She has unremarkable pulmonary and abdominal examinations. Within 10 minutes of her arrival to the ED and prior to the completion of your exam, she is taken to radiology for a noncontrast CT scan of the brain, which shows no acute abnormality. When she returns to the ED, a portable chest x-ray is performed.
You continue your physical examination, and find that her left arm is cool and pulseless, as is her right leg. The nurse repeats her vital signs, and finds her blood pressure to be 60/28 mm Hg in the right arm with a heart rate of 45 bpm. A blood pressure reading is not taken in her left arm because of her mastectomy, but readings are obtained in her lower extremities: 132/62 mm Hg in the left lower extremity and 66/33 mm Hg in the right. A review of the chest x-ray shows an abnormally widened mediastinum. (Image 1.) The ultrasound machine is brought to the bedside, and an intimal flap is seen extending throughout the abdominal aorta. (Image 2.)Radiology is called back, and an emergent CTA of the thorax is ordered. CT surgery is consulted, and asked to come to the ED immediately.
This case not only demonstrates the capability of bedside ultrasound to aid in decision-making, but also highlights the complex nature of the pathology that emergency physicians encounter during their day-to-day routines. Next month, we will discuss the many learning points revealed in this case.
Dr. Butts is the director of the division of emergency ultrasound and an assistant clinical professor of emergency medicine at Louisiana State University (LSU) at New Orleans. Follow her @EMNSpeedofSound, and read her past columns at http://bit.ly/ButtsSpeedofSound. Dr. Beran is an assistant clinical professor of emergency medicine at LSU New Orleans. Dr. Harrell is a first-year emergency medicine resident at LSU New Orleans.
Wednesday, April 22, 2015
Acetaminophen is ineffective for treating low back pain, and provides minimal short-term benefit for people with osteoarthritis, according to a study published in the BMJ. (http://bmj.co/1CtQVPE.)
The study included only randomized control trials comparing the efficacy of acetaminophen with placebo. Trials had to include participants with neck or low back pain or osteoarthritis of the hip or knee. The authors assessed 5,366 patients after searching through several databases and unpublished studies. They included 10 trials in people with hip or knee osteoarthritis and three investigating people with low back pain. The authors provided accurate estimates and clinically interpretable scores on 0-100 point scales of pain and disability to facilitate the interpretation of their results.
Read more about acetaminophen in our archive.
Tuesday, April 21, 2015
A 54-year-old man who drank 16 eight-ounce glasses of black iced tea per day went into renal failure, according to an article in the New England Journal of Medicine. (http://bit.ly/1NWVuID.)
The patient presented to an ED with weakness, fatigue, and body aches. A urine sample was remarkable for abundant calcium oxalate crystals – a hallmark of kidney stones – but no blood. The kidney ultrasound was normal, but the patient had an elevated serum creatinine level of 4.5 mg/dL, a marked increase over the 2.5 mg/dL he had a year earlier, and the 1.2 mg/dL he had six months before that.
A renal biopsy found, among the oxalate crystals, interstitial inflammation with eosinophils, and interstitial edema consistent with oxalate nephropathy. His urinary excretion levels of oxalate were two to 14 times the norm in 24 hours.
Black tea contains 50 to 100 mg per 100 ml of oxalate, which makes the patient’s estimated oxalate consumption well over the recommended limit of 1,500 mg per day.
Read about other kidney conditions in our archive.
Monday, April 20, 2015
Marshall T. Morgan, MD, died April 16 after being ill for several months. Dr. Morgan, 73, was a professor of clinical medicine and the chief of emergency medicine at UCLA. He was widely recognized by colleagues and students as an outstanding educator and a compassionate physician with a calming voice, inviting smile, and gentle touch, according to a statement released by the university. He came from humble beginnings, growing up in a small Ohio town without indoor plumbing, to graduate from Princeton and lead an illustrious career.
Dr. Morgan was the 2007 recipient of the Sherman M. Mellinkoff Faculty Award, considered by the faculty to be the highest honor awarded by the David Geffen School of Medicine at UCLA. He was appointed assistant professor of medicine in the UCLA School of Medicine and acting co-director of the UCLA Emergency Medicine Center in 1974. Two years later, he moved to Santa Monica Hospital, first serving as associate director and later as director of the emergency department. Dr. Morgan returned to the UCLA campus in 1982 as the medical director of the Emergency Medicine Center.
He was later appointed chief of the division of emergency medicine and served as chief of staff of the UCLA Medical Center from 2006 to 2008 after holding other leadership positions. Dr. Morgan was a member of the California Medical Association House of Delegates from 2008 to 2011, and served as president of the Los Angeles County Medical Association from 2013 to 2014.
“Despite working most of his career in tertiary medical centers, Dr. Morgan always had a bit of the country GP in him, putting patients first and technology second,” said Dr. John Mazziotta, the vice chancellor of UCLA Health Sciences and dean of the David Geffen School of Medicine. “His dedication to his patients and his commitment to the academic mission were exemplary.”
Dr. Morgan is survived by his wife Jean Marie; his children Marshall T. Morgan, Jr., Courtney Morgan-Greene, Shirl Monique Vanderplas, Terrence Watson, and John Watson; 10 grandchildren, and two great-grandchildren.