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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.​

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Monday, December 31, 2018

Some medical conditions have signs and symptoms that significantly overlap, making a diagnosis a little more difficult. Epididymitis, testicular torsion, and torsion of the testicular appendage are examples, but orbital and preseptal cellulitis are others that can cause significant diagnostic confusion.

Both conditions are more common in children than in adults, and preseptal or periorbital cellulitis is more common in children under 5. The preseptal and orbital spaces are separated by only a thin membranous septum that originates in the orbital periosteum and inserts into the tarsal plates. It is only this thin septum that stands as a barrier against progression of the preseptal infection into the orbit.

Both conditions may present with eye pain, eyelid swelling, and erythema. The occasional bee sting or mosquito bite near the eye, with its dramatic swelling of loose areolar connective tissue, can cause similar diagnostic confusion. Several years ago I had a patient with what appeared to be a localized reaction to an insect bite that subsequently turned out to an early preseptal cellulitis. On the other hand, allergic reactions that cause periorbital swelling and conjunctival chemosis are less difficult to differentiate because of the bilateral presentation.

Preseptal cellulitis once had implications that were more serious. Haemophilus influenzae type b was one of the most frequent etiologies of these infections, and it was common practice for all of these children to undergo spinal taps as part of their evaluation. The Hib vaccine dramatically reduced the frequency of infections.

The most common antibiotic recommendations for both infections still include treatment to cover Streptococcus pneumoniae and other sinusitis-associated bacteria as well as Staphylococcus aureus. Obviously, if the preseptal or periorbital cellulitis occurred after a break in the skin and the infecting organism seems most consistent with staph, then treatment with an antibiotic such as clindamycin alone may be appropriate.

Preseptal Cellulitis Pearls

  • Preseptal cellulitis is more common in younger children and is more common than orbital cellulitis.
  • Imaging is not generally indicated, but CT imaging with contrast is entirely appropriate when in doubt about the diagnosis.
  • Eye pain often occurs with periorbital cellulitis but not with eye movement. Imaging can be justified if you cannot adequately examine the eye.
  • Chemosis rarely occurs with preseptal cellulitis, but it is much more common with orbital cellulitis.
  • Direct inoculation is more common as a cause of the infection with preseptal than orbital cellulitis.
  • Treatment as an outpatient with oral antibiotics is entirely appropriate, but the most common recommendation is to treat both with an antistaphylococcal antibiotic that you would use to treat sinusitis, such as amoxicillin-clavulanate.
  • Haemophilus influenzae type b was once a formidable agent of infection that resulted in screening lumbar punctures. The Hib vaccine has dramatically reduced the incidence of this infection.
  • Outpatient treatment is usually successful.

Orbital Cellulitis Pearls

  • Orbital cellulitis is more common in children, but occurs more frequently in older children than preseptal cellulitis.
  • The ethmoid sinuses, the most common location of orbital infections, are separated from the orbit by only the paper-thin lamina papyracea.
  • The main three examination findings that confirm the diagnosis are ophthalmoplegia (and often diplopia), eye pain with movement, and proptosis.
  • Three percent to 11 percent of those with infections can have vision loss. One percent to two percent can be fatal.
  • If fever, chemosis, and leukocytosis are present, orbital cellulitis should be a strong consideration.
  • Most cases of orbital cellulitis can be treated with antibiotics alone, but surgical drainage of a subperiosteal abscess is occasionally needed.
  • CT imaging with contrast is the tool most commonly used to make the diagnosis.
  • Hospital admission for administration of parenteral antibiotics is required for this condition.
  • Use parenteral antibiotics targeting Staphylococcus and sinusitis-causing bacteria such as Streptococcus pneumoniae and Haemophilus influenzae, nontypable, such as vancomycin and ceftriaxone.
  • Treatment with metronidazole is recommended if intracranial infection is suspected.
  • The valveless superior and inferior orbital veins increase the risk of an intracranial spread of infection because they drain directly into the cavernous sinus.
  • Consider a cavernous sinus infection or other intracranial spread of infection if vision complaints and pain develop in both eyes.
  • Lateral canthotomy and cantholysis are emergently required on rare occasions.

CT imaging may at times be the only way to differentiate between preseptal and orbital cellulitis. Close follow-up is strongly recommended because of the risks associated with failure to diagnose orbital cellulitis.

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Watch this video to learn about treating orbital cellulitis.

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Watch this video to see the management of a patient with preseptal cellulitis.

Tuesday, December 4, 2018

I recently met with a group from our children's hospital to standardize the hospital management of bronchiolitis according to the latest American Academy of Pediatrics guidelines. (Pediatrics 2014;134[5]:e1474; Unfortunately, these guidelines seem to cause confusion for experienced and inexperienced emergency physicians alike.

This confusion comes from the guidelines raising unaddressed issues and new questions, most importantly not tackling important aspects of frontline clinical practice. These guidelines were developed with the best evidence currently available, and their application mostly causes confusion with our undifferentiated patients. In fact, the guidelines may potentially create unnecessary vulnerabilities in our clinical practice by minimalizing our approach to these wheezing infants. Clinical evaluations, workups, and treatments seem to be discouraged.

Diagnosis under the AAP Guidelines

  • 1a. Clinicians should diagnose bronchiolitis and assess disease severity based on history and physical examination. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 1b. Clinicians should assess risk factors for severe disease, such as age under 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency, when making decisions about the evaluation and management of children with bronchiolitis. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 1c. Radiographic or laboratory studies should not be obtained routinely when clinicians diagnose bronchiolitis based on history and physical examination. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)

Treatment under the AAP Guidelines

  • 2. Clinicians should not administer albuterol (or salbutamol) to infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 3. Clinicians should not administer epinephrine to infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 4a. Nebulized hypertonic saline should not be administered to infants with a bronchiolitis diagnosis in the emergency department. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 4b. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis. (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings].)
  • 5. Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting. (Evidence Quality: A; Recommendation Strength: Strong Recommendation.)
  • 6a. Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a bronchiolitis diagnosis. (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles].)
  • 6b. Clinicians may choose not to use continuous pulse oximetry for infants and children with a bronchiolitis diagnosis. (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles].)
  • 7. Clinicians should not use chest physiotherapy for infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 8. Clinicians should not administer antibacterial medications to infants and children with a bronchiolitis diagnosis unless there is a concomitant bacterial infection or a strong suspicion of one. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 9. Clinicians should administer nasogastric or intravenous fluids for infants with a bronchiolitis diagnosis who cannot maintain hydration orally. (Evidence Quality: X; Recommendation Strength: Strong Recommendation.)

The Undifferentiated Patient

Wheezing patients presenting to the ED and outpatient clinic will often be undifferentiated patients in contrast to the patients admitted and treated in the hospital. This is where there seems to be a disconnect between the guidelines and the clinical practice of emergency medicine. Unfortunately, the undifferentiated febrile or afebrile patient who presents with varying degrees of respiratory distress may not have bronchiolitis.

Bronchiolitis must be distinguished from a variety of acute and chronic conditions that affect the respiratory tract. The differential to consider includes a number of life-threatening conditions. Whether or not the guidelines acknowledge it, many patients may require further testing and treatment to differentiate better the etiology of the wheezing and adventitial sounds.

Bronchiolitis Lookalikes

  • Asthma
  • Recurrent viral-triggered wheezing
  • Pneumonia
  • Chronic pulmonary disease
  • Foreign body aspiration
  • Aspiration pneumonia
  • Congenital heart disease
  • Congestive heart failure
  • Myocarditis

The Differential Diagnosis

Bronchiolitis is at best a syndrome or collection of signs and symptoms. RSV predominates, but multiple other viruses and some atypical bacteria can present with the syndrome. In fact, at least four viruses are commonly associated with wheezing in children: the respiratory syncytial virus, the rhinovirus, the human metapneumovirus, and the influenza viruses. It helps to know that coinfection with viral and bacterial pathogens such as Haemophilus influenza type b or Streptococcus pneumoniae is uncommon because of the widespread use of conjugate polysaccharide vaccines, Bordetella pertussis, Chlamydia trachomatis, or Mycoplasma pneumoniae must be included in the differential diagnosis of a lower respiratory tract infection in a young child. In fact, one of the videos below shows an infant acutely ill and co-infected with both RSV and pertussis.

The Fallacy of 'Do Less, Not More'

It is possible for seasoned providers in pediatric care to make a bronchiolitis diagnosis without further testing, but it might not be realistic to expect everyone to do the same. And it might be unrealistic to expect learners to be able to confirm the diagnosis without additional steps to differentiate the patient. (Many of my undifferentiated wheezing patients respond to nebulized albuterol and epinephrine.) Furthermore, the overall message of "do less, not more" in the current guidelines may be the predominant message heard by learners or non-pediatricians, inadvertently resulting in sicker patients not being evaluated and treated aggressively when appropriate.

The 2014 AAP guidelines seem to personify therapeutic nihilism, but more optimistic and current evidence should be incorporated into the next revision of these guidelines in 2019. It is not possible to dive deeply into the evidence, but my analysis of the current literature suggests that the following treatment options have now sufficiently matured to allow their routine application in treating the bronchiolitis syndrome:

  • Hypertonic saline (3%) nebulization (Cochrane Database Syst Rev 2017;12:CD006458)
  • Nebulized epinephrine (Cochrane Database Syst Rev 2011;[2]:CD006619 and several other studies)
  • High-flow nasal cannula (multiple studies)
  • Heliox therapy (Cochrane Database Syst Rev 2015;[9]:CD006915)

The undifferentiated patient presenting with bronchiolitis syndrome and the health care provider's experience or comfort level pose challenges that are not sufficiently addressed in the guidelines. I am convinced that there is a mismatch between ivory tower recommendations and frontline care. In fact, it is common to hear clinicians sounding like guilty schoolchildren feeling obligated to justify why they are not following these clinical guidelines. Thankfully, there is less to feel guilty about because we now have growing evidence-based treatment options for our bronchiolitis syndrome patients.

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This video shows apnea in a child infected with RSV and swine flu.

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This video shows two infants with RSV presenting to the ED.

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.