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.

Wednesday, November 1, 2017

A middle-aged man was found on the highway. A concerned passerby called 911, and then EMS made him a patient of mine. Approaching the stretcher, the aroma of alcohol permeated the air. Such is my life as an inner-city nocturnist.

This patient was a little different, though. He said he had been short of breath before passing out. Peeking out from the bottom of the sheet was an ankle boot. The patient provided little assistance with his history. His exam was otherwise completely normal.

Just that week at the mortality and morbidity conference, a case bearing similarities struck terror in our hearts. A middle-aged man with a leg injury came back coding. His autopsy revealed a massive pulmonary embolism. I believe the fear generated from his death made me send a D-dimer on this patient.​

With the roll of the dice, we lost. The D-dimer was elevated.

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After an unrevealing portable chest x-ray, he went to CTA. I was going home. Signing out, my last words were send him home after his CTA is negative and he can walk.​

Arriving back for my next night shift, I saw this patient was admitted. I couldn't believe this patient with normal vitals and a normal pulse ox really had a PE. He didn't. He had a mediastinal mass. What had I missed on his x-ray?

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Clicking through the slices, I saw that the teaching from medical school was right. Really, one view is no view with x-rays. The very narrow, long mass hid right behind the sternum. My best chance of finding that on plain radiographs would have been an obliterated retrosternal clear space.

Tip to Remember: Lateral chest x-rays do show pathology not seen on the AP or PA view. If you can get two views, you might just find something you didn't expect.​

Monday, October 2, 2017

​An older man presented to the emergency department for respiratory complaints, and a routine series of studies—blood work, ECG, and a chest x-ray—almost automatically appeared in the orders.​

LTB chest xray dentures.jpg

Haziness on the left side—left hilar fullness probably isn't good. A CT scan would likely confirm the fears of cancer.​

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The large mass wasn't unexpected, but did you see the metallic foreign body in the stomach? There was something on the left side under the diaphragm on the upright chest radiograph. The same thing appeared on the coronal CT image. Did he swallow something?

Upon detailed questioning, the patient remembered that he had lost his "partial." He had no idea where it went, and hadn't yet followed up with his dentist. Well, now we know where his partial was.

Ingested foreign bodies are much more prevalent in the pediatric population, but adults are not immune. The mentally impaired, seizure-prone, or substance-addicted patients have long been known to arrive in the emergency department with a variety of objects in their gastrointestinal tract. Bones, particularly fish bones, are a commonly encountered GI foreign body in adult patients. These usually get hung up in the oropharynx, but wayward dental appliances from implants to full dentures have ended up in the esophagus, stomach, and beyond.

Fixed dental prosthetic devices may loosen. (Ann Med Surg [Lond] 2015;4[4]:407; J R Soc Med 2004;97[2]:72.) Often patients are not aware of the dangers, and do not seek rapid dental care. Eventually, loose fixtures may become unattached and swallowed, which may put the patient risk for obstruction, perforation, fistula formation, and bleeding or wall necrosis. This patient was lucky that the unexpected object was seen on his chest x-ray.

Retrieved crowns, partials, and full dentures can be sterilized and reused, which may be financially important to some patients.

Tip to Remember: When reading a radiograph, look beyond what you expect to see.​

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.



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.


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.​


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. 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.​