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.

Friday, September 1, 2017

Working in emergency medicine, I sometimes look through the retrospectoscope and think, "Next time I'm going to do that differently." There are cases where it's excruciatingly painful to look back and imagine what could have been. Others come with a sigh of relief knowing that I dodged a bullet but may not be so lucky in the future. This case was one of them.

It was the middle of the night. Walking into the room, the patient looked pretty good. It was a pleasant surprise, given the trepidation that came over me during the mid-shift sign-out, leaving me the only attending for the rest of the night.​

The handoff went something like this. A diabetic man in his 30s came in with a fever and groin swelling that had been going on for a couple of days. White blood cell count was elevated; lactate was normal. Antibiotics were given, and a CT scan was done. There's a collection of air in there. The surgery resident had seen the patient. The attending was notified, but the OR time hadn't been arranged yet. He looked really good.

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Looking at the images, my brain froze. This looked like Fournier gangrene. Guys like to keep their testicles. This looked close.

In our little community hospital, it takes an hour for the operating room to be opened after people are notified. Had we even begun this process? Contacting the surgical resident again, I learned a joint urology/general surgery procedure was planned. The urology specialist covers several hospitals, but was available immediately to come to our hospital. I immediately phoned my surgical attending colleagues to assure myself the correct message had been transmitted.

When the urologist arrived, I escorted him to the room. He said, "He looks pretty good." After peeking under the sheet at the left groin, he glanced my way. "You know, you could have stuck a knife in this."

A light bulb moment. I had been so busy working on definitive care with surgery that I missed the fact that I could assist with source control. I could have let out some pus and let some air in to irritate those anaerobes.

The patient went to the OR. He came out with all the important parts intact. Everything went well. We were lucky. Next time, I am going to stick a knife in there.

Tip to Remember: Always remember source control with infection!​


Tuesday, August 1, 2017

"I have tonsillitis," claimed the 20-something young woman who showed up at 2:30 a.m. because the pain was keeping her awake. She pointed dead midline between her chin and hyoid bone when asked the location of the pain. The back of her throat looks normal: uvula midline, no exudates, no vesicles, normal voice, and handling secretions. But the midline.... Should I be worried? The epiglottis sits right there. Before the Hib vaccine, it used to be almost all kids, but these days adults get epiglottitis. What to do? Soft tissue lateral neck? CT? Discharge?

I went with a soft tissue lateral neck, which was not at all reassuring.

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The epiglottis always bisects the hyoid bone in the anterior portion of the airway. It is usually somewhat parallel to base of the tongue with a strip of air into the vallecula. No such entity is distinctly visualized, so on to CT.​

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And the donut of truth made everything clear. The crisp, thin epiglottis can be seen pushed posteriorly by a rounded mass at the base of the tongue. The patient was right. She had tonsillitis! The radiologist concurred. It's always nice when the radiographs are in line with the anatomic drawing.​

LTB anatomy.png

Image by Bruce Blaus. http://blausen.com. WikiJournal of Medicine 1, 2014; DOI:10.15347/wjm/2014.010. ISSN 2002-4436.

Tip to Remember: It isn't only the palatine tonsils that can become infected and swollen. Lingular tonsillitis occurs at the base of the tongue and cannot be seen on routine visual inspection unless you are using a dental mirror.​


Monday, July 3, 2017

​An elderly woman arrived via ambulance at the emergency department after being knocked to the ground. Right hip pain prevented her from getting up. She had bilateral hip replacements, and was concerned that the right one could have come out of place. The area she indicated didn't seem dislocated. There was range or motion of the hip, and the leg was not shortened. Certainly, x-rays would confirm this.​

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The prostheses were intact. She had neither a hip fracture nor a dislocation. The patient still complained of pain, and was unable to ambulate. On closer inspection, the right superior pubic rami's inferior aspect had a cortical break. It certainly looked different from the other side.​

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CT actually confirmed two fractures of the superior rami.

These fractures are managed nonsurgically, but pubic ramus fractures do not bode well for patients. The reason for this is not clear and likely multifactorial. A study by Hill, et al., found that 13.3 percent of patients who had a fracture of a public ramus died within a year, and 54.4 percent died within five years. (J Bone Joint Surg Br 2001;83[8]:1141.) Certainly, the fracture causes few of these deaths directly. A pubic ramus facture, however, may indicate a frailty, putting the patient at risk. The study also found that simple falls were the most common cause and accounted for 87.4 percent of the fractures.

Tip to Remember: All that hurts in the hip are not proximal femur fractures. Always look at the pubic ring.​


Thursday, June 1, 2017

​A ballplayer had jumped and stretched for the ball but missed. Descending toward the ground, he put out his right hand to protect his face from hitting the pavement. The pain in the hypothenar eminence and lateral wrist was immediate, but he thought he could shake it off. A few hours later, though, he came in with pain in the lateral wrist, difficulty with full supination, inability to bear weight on the ulnar-deviated wrist when placing his hand on the bed and trying to push himself up, and a superficial abrasion on the hypothenar eminence.​

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Hypothenar eminence sports injuries are well known to be the cause of pisiform (blue circle) or hook of the hamate (red line) fractures. Two mechanisms are commonly reported — a direct blow or the impact when a loosely held bat (or racket) is kicked back into the palm. He didn't have point palmar tenderness, but I was compelled to look closely at the external oblique — the best view of these carpal bones. I then noticed the sclerotic circle in the hamate on the PA projection, further assuring myself that the base of the hook was intact.

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Showing the patient his images, I told him that there was no fracture — not of the pisiform, the hamate, the ulnar styloid, or any other bone. The ulna was snuggled in the radial sigmoid notch just as it should be at the distal radioulnar joint. He blurted out, "That big gap there (blue triangle). Is it supposed to look that way?"

"Yep, but that is exactly where I think the problem is!" I said. "It isn't really a gap." I explained that a cartilage cushion is there, similar to the meniscus of the knee. The cartilage can be crushed or torn, causing pain, swelling, and difficulty moving. That cushion, the triangular fibrocartilage complex (TFCC), makes it difficult to turn the wrist palm up and push up from when pressure is on that side of the wrist. He nodded his head in agreement, and said, "I think that's it."

As he was leaving with his splint and referral to orthopedics, he made a point to see me again. "Thanks, doc, for showing me my x-rays. That really makes sense." It felt like a win for patient care. I'll take that whenever I can.

Tips to Remember: No fracture does not mean no injury. Think TFCC injury if the FOOSH'ed patient has lateral wrist pain, difficulty supinating, and difficulty with weight-bearing on the ulnar-deviated hand.​


Monday, May 1, 2017

I have a passion for interesting x-rays. All of my colleagues know that by now. I'll have just arrived in the ED for my night shift and still be shoving my backpack under the counter when I'll hear a not-so-uncommon comment, "We had a great case today." These stories always energize me. The sharing, the learning, the awesome pickup, the right fight for the patient all remind me of why we do this job.

The signing out doc (knowing my absolute favorite thing is a wrist radiograph) recently popped open some radiographs on the computer, announcing, "You are going to love this."

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I scanned the AP and oblique hand films while he continued, "The patient fell last night and today came in because the hand and wrist were painful and scratched up." He pointed to the webspace between the ring and little finger, and cryptically added, "The odd thing is the patient felt like his knuckle was missing."

Finally I took a stand, "I don't like this little thing here [red arrow], and I don't like that sclerotic line there." Toggling back and forth from AP to oblique, I waffled, "I'm just not sure. It could be OK."

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Grinning while taking control of the mouse, he said, "That was the orthopedist's opinion until I told him to look at the wrist films." On the external oblique, the displaced fragment of the fifth metacarpal base stood out clear as day. He got me.

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Going back to the hand, I knew I had picked up some of the clues. There had to be more there. Something that I had missed or forgotten. And I had.

I had forgotten to look at the parallel M lines. One M line connects all the most proximal sclerotic lines of the carpal bones from the base of the thumb to the little finger. The other M line connects the sclerotic lines at the base of the metacarpals. These two lines are usually only 1-2 mm apart. When focused on these lines, the wide gap at the base of the fifth is glaringly obvious, and the double density increased sclerotic marking at the base of the fourth makes total sense.

I'd momentarily forgotten what normal looked like. The fifth metacarpal base always articulates completely across the top of the hamate. A quick refresher on a normal hand AP would have resolved the question of whether our patient had normal metacarpal-carpal articulation. He did not.

Fortunately, my astute friend had gotten additional views, the patient received appropriate care, and I relearned a valuable lesson.

Tips to Remember: Know normal to pick up the abnormal. Actually look at a normal film if you are unsure. Additional views can add significant perspective.