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M2E Too! Mellick's Multimedia EduBlog by Larry Mellick, MD

​The M2E Too! blog presents important clinical pearls using multimedia. By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.​

Please share your thoughts about Dr. Mellick's posts.


Thursday, November 1, 2018

Pediatric patients frequently put foreign bodies into their mouths, noses, and ears. The spectrum of foreign bodies that children place into their facial orifices are impressive. Paper, vegetable matter (such as peanuts), toys, beads, metal screws, and Play-Doh are just a few examples.

The insertions are often done surreptitiously, only to be discovered days or sometimes weeks later. Occasionally, the retained foreign nasal bodies will ferment and present with a purulent, unilateral nasal drainage, accompanied by an unrelentingly repulsive odor. Sometimes an occasional cockroach wanders into the external auditory canal looking for a dark, moist cavity for sleeping or laying eggs. There appears to be a preference for the right nostrils or right external auditory canal, which correlates with a higher percentage of right-handed children.

Classic Techniques

The classic techniques for removing foreign bodies from the nose and ears include using the following:

  • Alligator forceps
  • Balloon-tipped catheters
  • Frazier suction tips
  • Ear curettes
  • Nose-blowing
  • Bulb syringe
  • Bag-valve-mask
  • Mother's breath

Tension with ENT Colleagues

An ongoing low-grade tension between otolaryngologists and emergency physicians always seems to be brewing about attempts to remove foreign bodies. It is understandable because our ENT colleagues only see our failures and our failures often slightly traumatize our patients and their orifices. If every patient with a foreign body required an otolaryngologist, however, the demand would probably outstrip the specialty's availability.

Thankfully, emergency physicians are increasingly experienced at managing these cases. And, in MacGyver fashion, we do a good job of developing our own tools for removing foreign bodies like the right-angled hook, improvised suction catheters, the application of topical skin adhesive, and the use of rare earth magnets.

Procedure Risks

Many of the classic techniques are not easily reproduced, and often fail in my hands. Besides failures, other risks include trauma-induced bleeding of the orifice's skin or mucosa, pain, perforated tympanic membranes, and unwanted displacement of the foreign body. Dislodgement may include pushing the foreign body deeper into the orifice, making access and removal even more difficult. It can also result in aspiration or ingestion of the foreign body.

My most memorable case was one where I had to remove two small screws from a child's nose with forceps. Just as I was transporting the screws across the open mouth of the crying child, I dropped both screws directly into his mouth. A subsequent x-ray demonstrated the two screws sitting safely in his stomach. Thankfully, our patient had no complications and passed the two screws uneventfully several days later.

Pain is another risk. The external auditory canal is a sensitive area containing multiple nerves that are notoriously difficult to anesthetize. Topical anesthesia has only a partial effect, and four quadrant injections for local anesthesia are difficult and painful. The nose, notorious for bleeding from the slightest trauma, can also hide foreign bodies behind and under the turbinates.

Procedure Adjuncts

Thankfully, a number of adjuncts can make removing a foreign body from the nose or ears go more smoothly, including:

  • Child life specialists
  • Atomized intranasal midazolam
  • Papoose boards or burrito sheets
  • Atomized intranasal lidocaine
  • Topical tetracaine to the external auditory canal
  • Oxymetazoline hydrochloride nasal spray
  • Ketamine procedural sedation
  • Nasal speculums
  • Otoscopes

Insects, most often cockroaches, are occasionally still moving. Besides being unnerving to the patient, insects desperately clawing during the extraction process can be uncomfortable, but several substances are reportedly excellent at humanely euthanizing cockroaches: microscope oil, 2% to 4% lidocaine, viscous lidocaine, mineral oil, EMLA cream, and ethanol.

Post-procedure Interventions

A number of interventions are often recommended following extraction. First, always check the orifice for additional foreign bodies. Many clinicians will use topical antibiotic drops for the external ear canals or a topical antibiotic ointment for the nostrils. Their reasoning is that trauma to the mucosa or skin is not uncommon after orifice instrumentation. Systemic antibiotics may be necessary to treat sinusitis from a chronically retained nasal foreign body. Pain control with ibuprofen or acetaminophen is also helpful. Post-procedure epistaxis can be treated with an oxymetazoline nasal spray. The emergency department visit may also be an appropriate time for counseling the parents on child safety.

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Watch a video of using a suction catheter to remove a bead stuck in child's nose.

Two medical students help Dr. Mellick experiment using suction to remove a hearing aid from the ear in this video.

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EPs first tried a bulb syringe, direct removal, and bag-valve-mask to remove a nasal foreign body, but sometimes you just have to call for ENT consult, as shown in this video.

Saturday, September 29, 2018

Delusional parasitosis is a rare condition, but it is more common where methamphetamine and cocaine abuse is high. It is a fascinating condition to witness; patients are convinced that their skin is infested with foreign organisms or materials despite incontrovertible evidence to the contrary.

This condition is known by numerous names—Ekbom syndrome, delusory parasitosis, psychogenic parasitosis, delusional parasitosis, delusional ectoparasitosis, formication, chronic tactile hallucinosis, dermatophobia, parasitophobia, and cocaine bugs—but delusional parasitosis and more recently delusional infestation are considered the correct nomenclature. Another term commonly used in association with this condition is Morgellons disease. Morgellons refers to cutaneous symptoms like biting, crawling, or stinging sensation, finding fibers on or under the skin, and persistent skin lesions. Formication, a medical term derived from the Latin word for ant, is the sensation that resembles small insects crawling on or under the skin.

Patients have reported infestations ranging from "bugs," parasites, worms, and mites to bacteria, fungus, living "threads," and other living organisms for the pruritus they experienced. It is not uncommon for these patients to present clothing lint, pieces of skin, or other debris contained in plastic wrap, on adhesive tape, or in matchboxes. Some authors call this the matchbox sign or the Saran wrap sign. The patients will confidently state that these containers house the parasites, but close inspection, possibly even under a microscope, consistently fails to demonstrate insects or parasites. Even entomologists and pest control professionals often find themselves consulted by these patients.

It is nearly impossible to convince these patients that they do not have infestations despite the most convincing health care provider arguments and clinical demonstrations. It is almost embarrassing as the health care provider to try to convince an obviously intact person without any obvious cognitive impairment that he is delusional.

Unfortunately, these patients can inflict significant harm to themselves from self-treatment or their insistence on medical intervention. The video below shows a patient who adamantly defended her mental health as normal, but her shaved head and skin injuries from topical cleaning solutions and picking at her skin were dramatic.

Delusional parasitosis is considered a monosymptomatic hypochondriacal psychosis, and have been associated with schizophrenia, obsessional states, bipolar disorder, depression, and anxiety disorders. Many patients with psychopathology may complain of delusional parasitosis, and its coexistence is generally considered coincidental. Secondary delusional infestation is a symptom caused by a medication or another medical illness rather than a disorder. This condition, like other isolated delusional disorders, occurs primarily in white middle-aged or older women, even though the condition has been reported in all age groups and in men.

Treatment is ideally a therapeutic alliance with the patient, discontinuing any medication or drug that may be causing the condition, and administering psychotropic medications. If stopping offending agents does not result in improvement, antipsychotic medications such as risperidone, aripiprazole, olanzapine, or quetiapine may be required. Convincing the patient to take the medication requires significant discussion and patient education. Antipsychotic drugs may be used for limited periods in secondary delusional infestation while the underlying medicine, medical, or psychiatric condition is being managed.

About five to 15 percent of reported cases represent folie à deux, where other family members adopt the delusional symptoms. I remember evaluating a 4-year-old for this condition; he presented with his entire family, including his grandmother. Even though the index patient was the child's mother who was using methamphetamines, the grandmother showed me scuff marks on the floor and described them as parasites that had fallen off their bodies.

Watch a video of a woman with delusional parasitosis whose shaved head and skin injuries were dramatic.

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Friday, August 31, 2018

Sometimes when it's time to remove a Foley catheter, the balloon won't deflate. This problem occurs more commonly in patients with long-term Foley catheters. Even though we have all seen nursing home patients present with penile bleeding after pulling out their Foley catheter with the balloon still inflated, that is obviously not an option for emergency physicians. The problem is that the recalcitrant balloon is sitting out of reach, deep in the urinary bladder.

The cause of the balloon malfunction can be anywhere along the catheter, but it's usually found in the balloon inflation port, the balloon drainage channel, or the balloon itself. A commonly reported cause of the problem is using saline to expand the balloon. With time, salt crystals from the saline precipitate in the various locations responsible for deflation failure.

A urologist named Frederic Foley, MD, developed his eponymous catheter in the late 1920s and early 1930s. It was originally an open system, but was turned into a closed system with a bag in the 1950s. I suspect that we are pretty much familiar with the catheter parts, which include the balloon inflation port, the urine drainage port, the inflatable balloon to anchor the catheter in the bladder, and the tip or bladder opening.

Catheters can be made of rubber, plastic, or silicone. The balloon volumes range between 5 mL and 30 mL. There are also straight single-use catheters, the curved or coudé catheter, and a three-way Foley catheter for administering medications or irrigation. Catheters come in multiple diameters, and is measured using the French scale or French gauge system. It is usually abbreviated as Fr, but other variations, including CH or Ch for the system's inventor Joseph-Frédéric-Benoît Charrière can be used. The higher the number, the larger the catheter diameter, and 3 Fr is equal to 1 mm. So a 24 Fr catheter measures 8 mm in external diameter. The range of sizes typically available are as follows: 5 Fr, 6 Fr, 8 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, and 26 Fr.

Managing the Failure to Deflate

Managing a Foley balloon's failure to deflate includes addressing the potential sites of obstruction in either the balloon inflation port, the balloon drainage channel, or the balloon. Consequently, the techniques used involve drainage port and channel management or balloon destruction. A number of different techniques have been reported in the literature, but I will focus on those most practical for emergency physicians. Having an ultrasound machine available to visualize the balloon would be extremely useful with most of the following techniques.

Consider and Manage Balloon Cuffing

The failure to remove a Foley catheter may not be caused by failure of the balloon to deflate. Instead, it can be caused by balloon cuffing, where the balloon deflates but fails to deflate flush with the catheter. Instead, a circumferential elevated cuff persists at the balloon equator and makes catheter removal nearly impossible. This is remedied by placing 0.5 to 1.0 mL of water into the balloon to smooth out the contour of the balloon, allowing subsequent removal.

Removal of the Balloon Inflation Port

The first step in attempting to deflate a Foley balloon is often cutting off the inflation port with a pair of scissors. The balloon will promptly deflate if the obstruction involves a defective inflation port. The water from the balloon will be observed dripping from the inflation port.

Guidewire Application

Once the inflation port has been removed, the channel is now available for inserting a lubricated guidewire. A guidewire from a central line kit or ureteric guidewire can be used with its floppy end first to try to clear the drainage channel of any debris. If this does not work, the guidewire can be used to puncture the balloon. After instilling 200 mL of water into the bladder, insert the firm end of the guidewire to puncture the balloon. Filling the bladder with water protects it against bladder injury in case the balloon bursts instead of draining slowly.

Balloon Overinflation and Rupture

This technique is generally discouraged because bladder injury can occur and balloon fragments can remain in the bladder requiring removal by cystoscopy. It involves placing an intravenous catheter into the drainage channel of the Foley catheter (after the inflation port removal) and instilling water under pressure. Again, injuries to the bladder have been reported, and unwanted balloon fragments are almost guaranteed.

Direct Puncture of the Balloon

Percutaneous suprapubic puncture of the balloon using ultrasound guidance is another option. The balloon is brought into close contact with the bladder wall, and an ultrasound-guided percutaneous suprapubic puncture is accomplished. Other techniques describe vaginal, transurethral, or transrectal approaches, but these are most likely outside the scope of emergency physicians. Again, any time a balloon puncture technique is accomplished, inspect the balloon after catheter removal to assess for missing fragments. If a portion of the balloon is missing, then a subsequent cystoscopy is recommended.

Chemical Deflation of the Balloon

The use of chemicals such as acetone has been reported, but mineral oil is probably the safest. The technique involves instilling 10 mL of mineral oil into the balloon inflation lumen. If balloon rupture does not occur in 15 minutes, the procedure is repeated. Acetone and mineral oil can take several hours to rupture the balloon. These chemicals can be irritating to the bladder, and a new Foley should be placed after the balloon is deflated to irrigate the bladder to remove them. It is recommended that the bladder be filled to capacity with normal saline before chemical deflation is attempted.​

Failure of the Foley balloon to deflate is a relatively rare event, but it can be quite disconcerting when it happens. After watching this month's video and reviewing the options discussed above, you can rest assured that you now have all the tools necessary to successfully resolve this emergency.

Watch a video of Dr. Mellick discussing all the tips and tricks you need to tackle a Foley ballon deflating failure. 

Monday, August 6, 2018

A bursa, a fluid-filled synovial sack, serves in the body as either a pulley or a cushion, and bursitis, of course, is an inflammatory response that can occur to a bursa. The causes of the inflammatory response can be trauma (direct or overuse), infection, or rheumatologic or crystal-induced disease.

Whether a bursa is deep or superficial ultimately determines the most likely pathophysiology and dictates the most appropriate treatment. Superficial bursae are those closest to the skin, and they are most vulnerable to direct trauma and infection—the prepatellar, infrapatellar, and olecranon bursae. Deep bursae include the subacromial, pes anserine, and trochanteric bursae. The superficial bursae generally serve as cushions, while the deep bursae more commonly function as pulleys.

mellick subacromial.jpg

Watch a video of Dr. Mellick treating a patient with subacromial bursitis.

Deep bursae are less likely to become infected because they are less vulnerable to the direct inoculation of bacteria that can occur with superficial bursae, but they are more vulnerable to diseases surrounding them. Osteoarthritis of the knee commonly causes pes anserine bursitis, for example, and a partial tear of the supraspinatus muscle or acromioclavicular arthritis can cause subacromial or subdeltoid bursitis. Unfortunately, it is almost impossible to differentiate between subacromial bursitis, rotator cuff tear, or rotator cuff tendonitis.

Because the etiologies of the inflammation of deep and superficial bursae are different, the diagnostic modalities and treatments are as well. Superficial bursitis most commonly caused by direct trauma, crystal-induced disease, or infections is treated by needle aspiration and testing the fluid for evidence of crystals or infection. Injecting corticosteroids and anesthetics is not typically performed for superficial bursitis because infections, chronic pain, and changes of the overlying skin can result.

mellick housemaid.jpg

Watch a video of treatment for a patient with housemaid’s knee.

Instead, NSAIDs, compression dressings, and antibiotics are common interventions used to treat the inflammation of superficial bursae. Staphylococcus aureus is the culprit approximately 80-90 percent of the time when a bursa is infected. Oral antibiotics appropriate for the most common infecting organism and aspiration of the bursa are the mainstays of therapy. Sometimes repeated aspirations of the septic bursa are necessary, and the infected bursa will occasionally need to be surgically drained or have a bursectomy is performed. Surgical interventions, however, are more commonly associated with complications. (Arch Orthop Trauma Surg 2014;134[11]:1517.)

mellick pes asernine.jpg

Watch a video of Dr. Mellick treating a patient with pes anserine bursitis.

The inflammatory responses of deep bursae are most frequently caused by disease of surrounding muscles, tendons, or joints. Infections are much less common, but injections with corticosteroid and anesthetic mixtures are commonly performed to manage these conditions. NSAIDs, physical therapy, and interventions directed at healing the surrounding injured muscles, tendons, and joints are the most common modalities. It is important to remember that one's interventions will be relatively futile when the cause of the bursitis is pathology in the surrounding anatomical structures. The response to subacromial injections of corticosteroids and anesthetics, for instance, will only be transient as long as the rotator cuff partial tear or AC joint arthritis is left untreated.

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Watch a needle aspiration of a patient with olecranon bursitis.​

The videos associated with this blog demonstrate therapeutic interventions for superficial and deep bursae. Needle aspiration of an infrapatellar and olecranon bursae as well as injections of corticosteroids and bupivacaine into an inflamed pes anserine and subacromial bursa are demonstrated.​

Monday, July 2, 2018

The fascial planes in the upper and lower extremities play an important role in function and form, but they also make the extremities vulnerable to compartment syndrome. Emergency physicians are quite comfortable evaluating and diagnosing compartment syndrome: severe unrelenting pain, pain with passive motion of the muscle groups involved, and possibly paresthesias and pallor. The first patient I saw with this condition was at the Tripler Army Medical Center in Hawaii. A sailor dangling his legs over the dock presented after his leg was crushed between the dock and a battleship that suddenly shifted its position. I still remember the patient in the trauma room screaming in severe pain.

During my two years as an FBI doctor in the training academy at Quantico, I became quite familiar with chronic and acute exertional compartment syndrome. Agents-in-training and older police officers in physical fitness training would often present with this condition. Severe pain would typically develop in the anterior compartment while they were running and could usually be relieved with rest. Some had this condition chronically, and worked around and through it. Surgical release of the compartment was eventually the outcome for most of these cases.​

Compartment syndrome of the hand is another rare condition that can have devastating consequences. Several decades ago, a colleague of mine in Columbus, OH, accidentally impaled her hand with a recently used large central line needle. The wound became infected, and she ended up receiving emergent fasciotomies of her hand. More recently, I saw a patient who presented late after a fall from a ladder that crushed his hand under his body. This patient presented with unrelenting pain despite the fasciotomies of the hand done a week or two earlier. He had run out of his pain medications several days prior to his presentation. Only healthy doses of parenteral opiates and intermittent infusions of low-dose ketamine seemed to bring him relief.

Watch a video showing a patient with late-presentation compartment syndrome. His hand was crushed after a fall from a ladder.​

A rarer presentation of lower extremity compartment syndrome, the spontaneous compartment syndrome, presented on at least two occasions recently. One patient was an older colleague. He colleague and the other patient shown in the video had spontaneous onset of severe pain in the distribution of the anterior leg compartment. Shortly following the onset of this pain, both developed a foot drop of the involved extremity. The inciting event for the compartment syndrome almost assuredly had to be a vascular event, but other cases of spontaneous compartment syndrome have been associated with diabetes mellitus, ruptured peroneus muscles, and exertional activity. These two cases of spontaneous anterior compartment syndrome did not require fasciotomy, and were followed up by the appropriate services.

Compartmental pressure measurements with the Stryker instrument has been the recommendation until recently. Remember the Stryker? Yes, that tool that always seemed to be missing when you or your consultant needed it. Now we have a much better and more disposable tool: the Compass device by Centurion. This disposable pressure gauge efficiently and effectively measures compartment pressure. A training video showing emergency medicine residents learning to use this device by measuring artificially elevated compartmental pressures of oranges demonstrates how easy this tool is to use. (Below.)

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Watch a video showing how to use the Compass device for compartment syndrome and how to practice using it on an orange.​

Compartment syndrome has classic causes and clinical presentations. Crush injuries, infections within the fascial space, and muscle damage during extreme overexertion can cause compartment syndrome. Intermittent exercise-induced compartment syndrome and spontaneous compartment syndrome of the lower extremity are less common presentations that are at risk of misdiagnosis.

Watch this video showing a man with compartment syndrome in his foot.​