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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.

Monday, November 02, 2015

An elderly, "hyperventilating" man with no past medical history was brought by EMS to the emergency department because he had been feeling sick and weak for at least a week. A venous blood gas with critical care panel, an Accu-Chek, and an EKG were obtained.


Accu-Chek: 110

Venous blood gas: pH 7.23, bicarb 7, potassium 9.4




As expected, this patient was in renal failure, and impressive renal failure at that, with a BUN of 278 and a creatinine of 32.5. The kitchen sink of temporizing measures were thrown at him, and a procedure was performed.


Which procedure? Dialysis? No, he had a Foley catheter placed to relieve two liters of urine from his practically gravid bladder. He never had dialysis, in fact. The next morning, his creatinine was 23 with a potassium of 3.9. A week later, his creatinine was just a mere 1.9.


Tip to Remember:

Check for urinary retention in patients (especially men) with new onset renal failure. It may make a huge difference to the patient's treatment and make you look like a star.




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Thursday, October 01, 2015

It's Saturday night, and the next patient in the rack has hand pain. A young man watching the game at a local bar hit a wall when an argument broke out. One glance at the swelling of the lower lateral aspect of his dorsal hand, and the diagnosis is virtually certain. He has a boxer's fracture. Clearly, the force of the fist against an immovable object caused the proximal fifth metacarpal to break.


Shockingly, the expected fracture was missing on the first film. The metacarpals were completely intact! The lateral and oblique gave the answer, however.



This patient has a fracture of the body of the hamate and a fourth metacarpal dislocation with the metacarpal going with the displaced fracture fragment. In retrospect, a problem of the metacarpals or hamate should have been considered on the PA film because there was a loss of the usual zigzag clear space between the hamate and its associated metacarpals. These "parallel M lines" can help pick up a carpal metacarpal dislocation.


Hamate fractures rarely occur. Only an estimated two to four percent of all carpal fractures are classified as either type 1 (of the hook) or type 2 (of the body). The majority of hamate fractures are type 1, and tend to occur from a FOOSH injury (falling on an outstretched hypothenar eminence) or as a sports injury when a bat, racket, or club held loosely kicks back against the hook. When the hamate body is fractured, the mechanism is usually a direct blow with a clenched fist.


The dislocation was reduced, and the hand was splinted. Surgery is almost guaranteed for patients like this because these fractures are usually unstable.



Tips to Remember:

n Consider metacarpal dislocations and hamate body fractures when a proximal fifth metacarpal fracture doesn't materialize in your young boxer.

n Loss of the zigzag clear space between the metacarpals and the carpals can provide a clue to a metacarpal dislocation.

n The oblique view is the most likely plain film view to pick up a hamate body fracture.


Suggested Reading:

1. Borse VH, Hahnel J, Faraj A. Lessons to be learned from a missed case of hamate fracture: A Case report. J Orthop Surg Res 2010;5:64;

2. Cano Gala C, Pescador Hernández D, et al. Fracture of the body of hamate associated with a fracture of the base of fourth metacarpal: A case report and review of literature of the last 20 years. Int J Surg Case Rep. 2013;4(5):442;




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Tuesday, September 01, 2015

An elderly patient was brought in short of breath.



The x-ray finding was not seen on first glance. A colleague mentioned that his mentor recommended always rotating the film to the left and right as a better way to see a pneumothorax on plain radiographs. It seems human eyes are better at seeing horizontal lines than vertical ones. In fact, that simple maneuver seemed to make the pleural line pop. A dark viewing room makes the line stand out even more.






The patient was sent for CT to confirm the finding and to evaluate for adherence to the chest wall. Remember that ultrasound has been shown to have great sensitivity and specificity in diagnosing pneumothorax as well.


Tip to Remember: Rotate your chest films to see a pneumothorax more easily.



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Monday, August 03, 2015

This elderly patient fell after his right knee gave out while walking. Besides impressive calcification of the popliteal artery, what is wrong with his knee?








He has a comminuted tibial plateau fracture. The biggest radiographic clue is the meniscal line on the cross-table lateral. This is blood and fat in the joint. Fat droplets would be floating on top if you drained this effusion and placed the blood in a basin. You should always assume there is a fracture if you see this.


Another subtle clue includes an abnormal increase in density at the top of the tibia, which can come from an overlying fracture fragment or from compression of the bone. A lucent line also disrupts the trabecular pattern and an overlap of the medial cortex.






The CT confirms the diagnosis.




Tip to Remember: Look for a meniscal line on the cross-table lateral. The patient almost certainly has a fracture of the knee if you see one.



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Wednesday, July 01, 2015

A 27-year-old woman came into the ED in the middle of the night complaining of not being able to sleep. She was sure the continuous right-sided foreign body sensation under the angle of her jaw came from a fish bone stabbing her during a late-night dinner. A CT revealed an embedded fish bone. ENT removed the foreign body endoscopically, and she was discharged on oral antibiotics, and had an uneventful follow-up visit a few days later.



The question with my residents always seems to be, "Should we get an x-ray?" And my answer now is, "No."


It is certainly possible that careful inspection of the oral cavity (directly or indirectly) could identify a bone sticking out of a tonsil or base of the tongue. Looking and finding something can make a difference. Unfortunately, overlying mucous can easily hide a fish bone.


Plain x-rays, on the other hand, have quite a few problems. These objects can be easily missed depending on the angle of a tiny embedded fish bone. Normal calcifications also can be mistaken for foreign bodies. Plain radiography generally is confusing and adds little value for most patients with fish bones stuck in the throat.


When I am concerned about a fish bone stuck in the throat that I cannot see, my next step is uncontrasted CT.






The little bit of bone sticking out at the mucosal surface could be easily missed with inspection, especially for the inexperienced. In addition, it is shocking to see how deeply the bone can penetrate into the soft tissues. If not found and removed, retained fish bones have been most commonly implicated in neck abscesses. In fact, even with removal, the penetrating injury has resulted in infection.


Tip to Remember:

If you remove a fish bone from a patient's oropharynx, give her excellent instructions to return for any increasing symptoms with the throat because this could be a sign of a retropharyngeal infection.



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About the Author

Loice Swisher, MD
Loice Swisher, MD, is a clinical associate professor in the Drexel University Emergency Medicine Residency Program in Philadelphia and the first and only female board member of, the educational website. She was graduated from the Medical College of Pennsylvania emergency residency program after an educational fellowship in the early 1990s, and has been the nocturnist in the ED at Mercy Philadelphia Hospital since 1997.

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