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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, 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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Monday, June 01, 2015


We have the best stories. People are fascinated by what we see and do. Another great thing is that there is always something new to see in the ED. It's amazing that I am still seeing things I have never seen before, even after more than two decades in the emergency department.


Just the other night, this all came together when an elderly patient came in with a rectal prolapse. This had happened to the patient before, and the visiting nurse or another family member could usually get it back in. Not this night, however, and a call was placed to the surgical resident.


What was a typical night drastically changed when the resident arrived with a fistful of sugar packets. He was going to coat the prolapse in sugar!


A quick Internet search revealed this pearl was missing from my practice. Maybe I would have learned this is not an uncommon strategy with uterine prolapse in cows, sheep, and even cats giving birth if I had paid attention to my husband's childhood farm stories. In fact, there are even videos on the web! (


It was a relief to see literature on human patients as well. Granulated sugar has been used for rectal, ileostomy, and colostomy prolapses. In fact, the University of Michigan has a patient information sheet instructing patients how to reduce their own rectal prolapses. ( The granulated sugar absorbs fluid like a sponge. The prolapse may be easier to place back in once the mucosal edema decreases; that takes about 15 minutes.


It worked beautifully in our case.


Leaving work through the cafeteria in the morning, I smiled, wondering what they thought to see the stash of sugar packets decimated. I'm sure they had no idea how sweet it was to keep this patient from surgery.


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Friday, May 01, 2015

Scenario: It's 3 a.m. when a man arrives by EMS with a diffusely swollen, painful ankle, is unable to stand after a fall.


Question: What would the orthopedic consultant find helpful to know about this closed, neurovascularly intact fracture?





Discussion: Virtually every fracture has some kind of classification schema. Distal fibular fractures are no exception. If the orthopedists have gone to all the trouble to have a framework for these fractures, then there must be some important key finding to consider. The emergency physician should have some familiarity with these systems. The Weber classification is easiest to understand because it is based entirely on the anatomic relationship of the fibular fracture to the syndesmosis.


Weber A: Fibular fracture below the syndesmosis.

Weber B: Fibular fracture at the syndesmosis.

Weber C: Fibular fracture above the syndesmosis.


The fibular fracture is above the syndesmosis in this case, and is almost certainly a Weber C. The pronation-external rotation mechanism caused a medial malleolar fracture, a disruption of the anterior and posterior syndesmotic ligaments, and a tear through the interosseous membrane to the level of the fibular fracture. Often Weber C fractures will have widening of the syndesmosis. The more familiar Maisonneuve fracture also could be considered a Weber C.


Answer: This appears to be a Weber C fracture with a spiral fracture of the fibula several centimeters above the syndesmosis and associated with a significantly widened syndesmosis, medial malleolar fracture, and posterior subluxation of the talus.


Resolution: The patient was given pain medication, reduced, splinted, and kept NPO for the OR the next morning.


Tips to Remember:

n Evaluate the level of the distal fibular fractures.

n Assess for widening of the syndesmosis.



Ankle Fractures: Weber and Lauge-Hansen Classification;



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Tuesday, March 31, 2015

Not surprisingly, this x-ray belongs to a patient with severe wrist pain after an accident. A wrist series usually includes four views, but the PA film can be highly revealing with an ordered approach. What abnormalities can you see?



This is my standard approach to reviewing a wrist PA film:

  1. Count the carpals.
  2. Map the gap.
  3. Mark the arcs.
  4. Check the contours.

Here is a step-wise review of this image.

  1. It becomes obvious in counting the carpal bones that the scaphoid is in two pieces and that two fragments are punched off the radial styloid.
  2. A 2 mm or so gap should separate the sclerotic lines outlining the carpal bones. One could think of it like little roads that can be navigated around the carpals. Here, the scaphoid abnormally overlaps the capitate, and the distal fragment is much too close to the radius. In addition, the lunate has a funny tilt, which brings the radial side too close to the capitate.
  3. The proximal and distal carpal rows should be able to be outlined by three gentle arcs, which are called Gilula's arcs. An Internet search is in order if you have never heard of these. Only the third arc of the distal row is intact; the first and second arcs are disrupted.
  4. A careful review of the contours is also called for, and it reveals a step-off of the proximal triquetrum.

Abormalities include:

  • a scaphoid fracture.
  • a radial styloid with two fragments noted.
  • a likely perilunate dislocation given the abnormal positioning of the lunate; a lunate dislocation would give a more triangular appearance.
  • a triquetral fracture.

Tip to Remember:

As William Osler said, "The value of experience is not in seeing much but in seeing wisely." This can be applied to radiograph interpretation when a standard, ordered approach decreases the chances of missing important abnormalities.


Read more about wrist and hand conditions in our archive.


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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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