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Lions and Tigers and Bears

Dr. Loice Swisher’s daughter had five episodes of unexplained vomiting without a fever in just one month during 1999. Thinking through the files in her mind, she was unable to shake the memory of a young child with the same complaint 12 years before. The well-looking child had been bounced out of the ED four times with "viral syndrome" and "gastroenteritis." The diagnosis was a posterior fossa tumor.

“How did this happen?” she asked. The attending shrugged, offering up various possibilities. It was a difficult diagnosis because the symptoms at first are nonspecific. It is uncommon. The prior docs probably didn't get her up to walk or look in her eyes. They probably didn't think of it. He concluded, "To an ER doc, unexplained vomiting is a brain tumor until proven otherwise."

That single phrase altered the course of her life. A "reassurance MRI" showed a 5 cm brain cancer, a medulloblastoma. Her daughter navigated a course of radiation, chemotherapy, and multiple complications, and Dr. Swisher started an entirely new medical education in the art of diagnosis.

Amal Mattu, MD, reminds those of us in emergency medicine to be on the lookout for lions and tigers and bears, not horses and zebras, Dr. Swisher explained. As an emergency physician and mother, she knows the profound impact this approach has on a patient's life. Using real cases, this blog aims to expose the lions and tigers and bears out there ready to bite.

Tuesday, December 16, 2014

A young woman was transported by EMS with excruciating ankle pain after slipping on the ice. A quick glance at the x-ray clearly shows the reason, but this should raise an additional red flag for EPs.


Always remember the "rule of the ring." The tibia and the fibula are held together by an interosseous ligament to form a ring in the lower leg. Undertake a search for a second abnormality if there is a fracture in the tibia or fibula above the ankle syndesmosis. This x-ray should beget another if you remember the rule of the ring.



This external rotation injury is a Maisonneuve fracture, in which there is:


  • A spiral fracture of the proximal third of the fibula.
  • A disruption of the interosseous ligament.
  • Another abnormality on the distal tibial side of the leg.

The distal tibial injury most commonly affects the ankle joint itself, widening the mortise or creating a medial malleolar fracture. The distal tibial fracture may occur about the level of the syndesmosis in a few cases, however. Regardless, the abnormality triad produces an unstable fracture usually requiring ORIF.


I have been shocked by quite a few patients in the past who had significant pain in the ankle but never complained of knee pain, even on re-evaluation after the images were reviewed. Maintain a high index of suspicion with documented injuries despite the clinical exam of the knee.


Tips to Remember:

  • Remember the rule of the ring. A distal tibia fracture or mortise widening should prompt strong consideration for ordering a knee film.
  • Always make a deliberate evaluation of the ankle mortise.


Radiology Case: Maisonneuve Fracture;


What tips do you have for treating patients with ankle pain?


Wednesday, December 03, 2014

A woman in her mid-30s returned in tears with excruciating pain in her chipmunk cheek. Earlier that day she was discharged on Tylenol and sour candy for cheek swelling. The initial recommendations seemed appropriate for the most likely diagnosis: a salivary stone. Now what?


Physicians have an algorithm for many situations, and different chief complaints have well-travelled paths. This isn't one of them. When faced with an unusual diagnosis, I decide which outcome would be best for the patient and work back from there.


Hospitalization might be the final emergency department disposition unless her pain is much better controlled. She required a definitive diagnosis. She will need imaging to get there. Ultrasound has been used for this in the past, but I elected to use CT because of greater institutional experience and evaluation for possible post-obstructive infection or abscess. The first thing she needed, however, was pain control and IV for contrast and labs.


The CT clearly showed the plumbing problem. She had a large obstructing stone in the distal aspect of the Stensen duct with associated sialadenitis and concern for early abscess formation and myositis.




She was admitted for IV antibiotics, pain control, and eventual stone removal.


Tip to Remember: If you are not sure what to do, consider your best and safest disposition and devise a plan to get there.


Has your desired outcome ever led you back to a diagnosis?

Wednesday, November 12, 2014

Coming out of a patient's room, my eyes immediately fell on a hallway bed on which a sobbing linebacker-sized 26-year old man rocked back and forth in a fetal position. He looked sort of like “a kidney stone,” but the tech handed me an EKG chirping "chest pain." The EMR indicated he had a past medical history of asthma, hypertension, and congestive heart failure, but he didn't take any medications. He smoked but denied drug use.


The EKG was not normal. There was no worrisome ST segment elevation, but left ventricular hypertrophy with diffuse T wave repolarization abnormalities suggested longstanding poorly controlled hypertension. He was worried the pain was cardiac because he had a "big heart." The left-sided chest pain traveled to his back, and he felt short of breath. His exam was normal except for his blood pressure: 158/98 mm Hg.


Within minutes of receiving IV morphine, he was lying on his back texting and joking with friends. Annoyance was palpable in the nursing station: “If you can text, there is nothing wrong with you.”


I wasn't going to be led down that path this time. I have taken that awful, shocking journey, pronouncing patients too young to have whatever. OK, maybe not 26, but it was the right story. My mantra to protect myself and my patient is "always maintain a high index of suspicion." He was going to have to prove to me he was well, not prove to me he was sick.


The chest x-ray provided no reassurance.



In addition to the widened mediastinum, the patient had a double density at the aortic knob. The CT angiogram confirmed the double density of a true and false lumen of this type A dissection.



Tip to remember: Doctors suspect aortic dissection in less than half of all cases. You must maintain a high index of suspicion and learn the subtle signs to save your imminently croakable patients.


Have you had a patient like this one whose complaint you were tempted to dismiss?



Al-Wahaibi K, Al-Dhuhli H, et al. “Acute Cardiovascular Emergencies: Missed Killers in the Emergency Department,” Oman Med J 2008;23(2):112;

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Monday, November 03, 2014

A patient in her early 20s came into the ED holding her right arm near her body with a complaint of right shoulder pain. She said she was punched in the shoulder during a fight the night before. Do you believe her story?



Checking the contour of the scapula reveals a cortical break in body. The undressed physical exam revealed ecchymosis and tenderness near the right scapula. The patient was told a fractured scapula requires more force than a punch, and she then added that she was thrown back against a metal pole during the fight. A CT scan confirmed the diagnosis.



Scapular fractures are uncommon, estimated to be only one percent of all fractures. Fractures of the body account for more than half of scapular fractures. Other fractures are those of the neck, glenoid, acromion, and the coracoid. A fractured scapula requires significant force, which demands the consideration of deeper injuries such as pulmonary contusions, pneumothorax, brachial plexus, and vascular injuries. It is also prudent to widen the physical evaluation to include head and abdominal trauma because the full mechanism of injury isn't usually isolated just to the scapula.


Most scapular fractures are treated conservatively with a sling and early mobilization, as in this case. Surgery tends to be reserved for those fractures that involve the joint or impinge on joint function. Examples of these include a large or displaced glenoid rim, displaced glenoid fossa fractures, and depressed acromimial fractures that impinge on the rotator cuff muscles.


Tips to Remember:

n Hallway exams can hide important physical exam clues.

n Some patients intentionally do not answer questions truthfully, but it is quite possible that they have a different understanding of words and importance from a physician. It is entirely possible this patient considered the affected area a part of her shoulder. After all, she had problems moving her shoulder. Don't assume that you and the patient have the same grasp of the situation.


Did you ever have a patient you disbelieved because you were using different ways of describing and understanding the problem? Share them in the comments section below.

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Tuesday, October 14, 2014

EMS ambles in with a "probably drunk" patient around 4 a.m. They report finding this 70ish homeless man with mental health issues sitting on the sidewalk. The patient complained of a group of men coming upon him and kicking him in the butt.


I went to check him after he was settled in a room. To my shock, the supine gentleman was trying to pee in a urinal without success. I've seen plenty of guys peeing in the ED. My concern was that he was lying down. Anyone who has been in the ED for a period of time knows that drunk guys who are barely able to speak will still try to stand up to go. Even male hemiparetic stroke patients will fight to be upright to relieve themselves.


My mind started to race that this guy might need an MRI. Maybe he really was injured, and now had a cord compression. Even though he was still lying there with a urinal between his legs, I commanded him to lift his legs. He lifted only the left one. I repeated the order, and again he lifted only the left. My concern grew as I slapped the bottom of his right foot and insisted he tried to lift that one off the bed. He did it, but he was a little shaky.


What the heck? Is he drunk? Is his cord compromised? Does he have a brain injury? I asked if he could have hit his head, and he responded, "I've been stumbling for the past few days. I could have."


To the Doughnut of Truth for head, abdomen, and pelvis scans, which provided the answer:



He had an impressive subacute on chronic subdural hematoma with a hematocrit not present on a prior CT in July. It was amazing. He had a GCS of 15, no headache, and no evidence of head trauma.


Tip to Remember: Beware of men lying down to pee.


Have you ever had a case where something unusual made you keep digging for a less-obvious answer? Share your story in the comments section below.

About the Author

Loice Swisher, MD
Loice Swisher, MD, graduated from the Medical College of Pennsylvania emergency residency program after an educational fellowship in the early 1990s. She has been the nocturnist in the ED at Mercy Philadelphia Hospital since 1997.

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