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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, 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.

Thursday, October 02, 2014

A man in his late 30s with no medical problems presented to the emergency department with three weeks of right upper quadrant abdominal pain. He was started on an H2 blocker and tramadol at a local clinic. An outpatient right upper quadrant ultrasound was performed three days before he came to the ED, and was read as normal. He was told to go to the ED if any new symptoms developed. He came in after he developed vomiting.


The patient’s vital signs were normal, including a temp of 97.5°F, in the ED. He said his pain was 8/10. He also had mild mid-epigastric tenderness. The only significant abnormality on the labs was a WBC of 15.4, which gave him an Alvarado score of 3. A CT was ordered because of his prolonged symptoms and increasing WBC.









The CT was read as a complex cystic mass in the RUQ arising from his appendix, likely a complicated, perforated appendix with adjacent abscess. Antibiotics were given, and the patient was referred to interventional radiology for drainage.


Tips to Remember:

n A patient can still have appendicitis without a fever.

n The location of pain is not always in the right lower quadrant. The appendix can be subhepatic, retrocecal, pelvic, or left-sided. Prior surgery with adhesions can bring an appendix into a less expected location.

n No scoring system picks up appendicitis in every case.



Pitfalls in appendicitis. Emerg Med Clin North Am 2010;28(1):103.

Wednesday, September 17, 2014

A middle-aged woman presented to the ED with right-sided neck pain that she had developed that day. She reported that she had spit out a lot of blood, but denied fevers, chills, chest pain, shortness of breath, nausea, and vomiting. She said she hadn't felt well for the past few days.


The CT gives the answer.




The patient had a thrombosed right internal jugular vein with a fistula extending into the peritonsillar abscess — Lemierre's syndrome. ENT took the patient to the OR.


n Lemierre’s syndrome was first described by Andre Lemierre in a 1936 article of 20 cases. This septic thrombophlebitis of the internal jugular vein occurring after an acute pharyngeal infection was often fatal in the pre-antibiotic area. He noted that infection could spread easily to multiple distant sites from the infected vessel, including the lung (most common), brain, liver, and other organs.


n Reports of Lemierre's syndrome have been increasing over the past 15 years or so.


n The infection is most commonly caused by a normally occurring mouth anaerobe called Fusobacterium necrophorum, which produces several toxins including a lipopolysaccharide endotoxin, leukocidin, hemolysin, and hemagglutinin products. Polymicrobial infections have been found in up to a third of patients. (Int J Emerg Med 2013;6[1]:40.)


n The CT shows a distended IJ with enhancing walls, an associated intraluminal filling defect, and soft tissue swelling.


n Treatment is prolonged parental antibiotics and perhaps ligation of the internal jugular vein. Anticoagulation is currently controversial.

Wednesday, September 03, 2014

A 21-year-old woman came in to the ED in the middle of the night after hitting her hand with a hammer. She had swelling and tenderness over the dorsal first metacarpal. Two linear hypodense lines disrupting the normal trabecular pattern were seen, but there was no cortical break noted. Fracture?



Here is another view that shows the same lines.




The radiology read: Two parallel curvilinear hypodensities in the distal and midshaft of the first metacarpal, which are new since the prior exam and most consistent with nondisplaced, possible trabecular microfractures, which do not appear to extend to the cortex.


She was placed in a thumb spica and given the number for orthopedics, so does it matter whether these were noted? Maybe not medically because this was likely a severe crush injury, but it can make a difference.

  • Missed fractures are one of the more common complaints with malpractice against emergency physicians.
  • We had the patient view the images on the computer so she could see the barely perceptible abnormality. That might help with the ever-elusive patient satisfaction.
  • The next morning there was no annoying, disruptive, time-stealing callback from radiology that had to be followed up by a colleague.

Tips to Remember:

1. Pay attention to the trabecular pattern because linear abnormalities can be subtle clues to a fracture.

2. Look for prior comparisons.

Wednesday, August 20, 2014

A man in his mid-50s with intermittent nosebleeds was sent in by his primary doctor for “abnormal labs.” The CBC sent from the office revealed a hemoglobin of 5.9 mg/dL. He had no past medical history and no sites of bleeding except for nosebleeds. Labs were sent to confirm the anemia as well as for potential admission.


His lab results were WBC 5.5; HGB 5.0; platelets 160; NA 124; K 3.4; Cl 99; CO2 23; BUN 16; Cr 1.8; glucose 71; anion gap 2; calcium 9.3; and albumin 2.1.


What is his diagnosis?


With the pressure on wait times and length of stay, I think much more often we put patients on the "admit train" to get them out of the ED. We put them in their "boxcar" with the hope that they will get off at the right stop. This patient was put on the severe anemia boxcar: Send appropriate labs, get consent for transfusion, admit, and move on. Seeing patients quickly is often given higher regard than taking the time to reflect critically on a patient's condition. A little more attention can make a difference in getting the patient on the best track.


Here is the biggest red flag. How often do you see a 50-year-old man with a hemoglobin of 5? How often do you see it in any man who doesn't have cancer, sickle cell, or a GI bleed? Um ... never. Sure, we see it all the time in women with heavy periods. A severely anemic male, however, is an anomaly worthy of deeper scrutiny.


The other unusual anomaly — an anion gap of 2. Recalling deeply buried bits of minutiae for the boards, a low anion gap goes along with multiple myeloma. From these two odd factors, the workup for multiple myeloma was started in the ED.


That was, in fact, his diagnosis. The very astute physician might have recognized the renal insufficiency as an additional concerning clue. The skeletal survey was more revealing, showing innumerable lytic lesions. The bone marrow biopsy confirmed the diagnosis: a hypercellular marrow with 62 percent monoclonal plasma cells consistent with multiple myeloma.

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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