M2E Too! Mellick's Multimedia EduBlog

The M2E Too! Blog by Larry Mellick, MD, 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.

Monday, April 30, 2018

The hair or thread tourniquet syndrome is a relatively rare condition that has evaded me in the emergency department for several decades, until past year when three cases showed up over six months. This condition has been around for as long as there has been hair or thread and body appendages. In fact, this condition may have first been described in the 1600s. (J Pediatr Adolesc Gynecol 2005;18[3]:155.)

The etiology of this condition seems almost unbelievable. How in the world does a hair get wrapped repeatedly and tightly around an appendage of the body? Some authors expressed the need to consider nonaccidental etiologies more frequently. Stranger things, however, have happened in emergency medicine (e.g., the urinary catheter tying itself in a knot in the bladder of a patient). (APSP J Case Rep 2011;2[3]:21; J Clin Ultrasound 2009;37[6]:360.)

The risks of strangulation and autoamputation of the involved appendage are very real. This condition does not respect age, gender, or appendage. Hair tourniquets of the penis, clitoris, labia minora, teeth, uvula, fingers, toes, and even the larger extremities have been reported in the young and the elderly. They are, however, much more common in infants and young children than they are in adolescents or adults. In fact, a fascinating temporal association has been made between hair tourniquets and the mother's postnatal telogen effluvium, which causes significant maternal hair loss months after the infant's delivery. Consequently, we include hair tourniquets in that long checklist of potential issues afflicting the inconsolable infant. Corneal abrasions and colic may be much more common, but it makes perfect sense to examine all of the infant's appendages for a hair tourniquet.

I have been shocked by how rapidly these hair tourniquets burrow into the chubby subcutaneous tissues, making examination and quick removal nearly impossible. Hair has significant tensile strength, stretches when it's wet, and can be inadvertently tightened when an unsuspecting parent starts tugging on the exposed end of the hair. Furthermore, it can act like a garrote and cut through the soft skin of the infant while becoming increasingly inaccessible. When the health care provider begins to tease out the hair with a needle or forceps, bleeding quickly begins, making visualization even more difficult. Timely removal of the tourniquets is critical to preventing complications. The removal technique can be manual, chemical, or surgical.

Manual removal entails simply finding the free end of the hair or thread and unwinding it. This is often easier said than done. It can also involve using a blunt object such as forceps or an ear wax speculum, pushing it underneath the constricting material, lifting the tourniquet, and then cutting it and removing it. Chemical removal involves the use of depilatory agents that chemically break down hair protein. I have never used this technique, and some have reported that it can be a slow process. The failure rate will be high if the hair is already deeply buried. Most emergency departments don't plan ahead for hair tourniquets by stockpiling depilatory agents.

Surgical removal is sometimes necessary when presentation is late or the hair has rapidly burrowed deep into the subcutaneous tissue, preventing easy access for manual removal or lessening the potential effectiveness of depilatory agents. The surgical technique often requires anesthesia of the appendage, followed by a limited but relatively deep incision to ensure that the hair or thread has been released. In fact, the phrase "cut to the bone" is used on fingers and toes. A no. 11 scalpel blade is inserted at locations that avoid neurovascular bundles, and one goes all the way to the bone before withdrawing the blade. The incision on the penis or clitoris is made to the underlying fascia while being careful not to lacerate the three penile corpora bodies, the urethra, or the dorsal penile nerves. Incisions at the four and eight o'clock positions are recommended.​

Potential complications of the procedure can be trauma to the skin, bleeding, and infection, as well as injury of underlying neurovascular bundles. Contact dermatitis or skin irritation may occur if a depilatory cream is used. Assessment of tetanus immunization status is also recommended. Finally, close follow-up the next day is recommended to assess for continued improvement and absence of ischemia signs or infection.

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This child had a hair tourniquet deeply embedded in his pinkie.mellick photo 2 with video.JPG

Watch the removal of a hair tourniquet from a child's toe.

Monday, April 2, 2018

Many types and etiologies of headache and facial pain afflict our patients, and sorting through them can be a challenge. Craniofacial experts themselves, in fact, do not attempt to remember the subtle differences between the various conditions causing craniofacial pain, but instead refer to the third edition of the International Classification of Headache Disorders (ICHD-3). (https://www.ichd-3.org/.)

The ICHD-3 can help the clinician manage patients presenting with headache as their chief complaint. An international panel of headache experts oversee the classification, which is currently published in a beta format so mistakes can be identified and corrected.

Therapeutic management varies significantly depending on the actual type of headache, and a more precise diagnosis makes a difference in treatment success. Gaining maximal diagnostic competence improves our therapeutic accuracy and affects the lives of our patients.

This important classification currently has three main sections: primary headaches, secondary headaches, and painful cranial neuropathies, other facial pains, and other headaches. A primary headache has no other etiology, and includes migraines, tension headaches, and the lesser-known headaches such as the paroxysmal hemicrania, hemicrania continua, cluster headache, short-lasting unilateral neuralgiform headaches, and primary stabbing, primary thunderclap, nummular, hypnic, and new daily persistent headaches.

A secondary headache comes from another underlying condition or emergency. The differentiation between primary and secondary headaches is critical. Primary headaches are classified as migraines, tension headaches, trigeminal autonomic cephalalgias, and other primary headache disorders. Each of these taxonomies are subclassified. Secondary headaches are the head and face pain etiologies that cause emergency physicians the most angst. Headaches caused by life-threatening conditions such as ruptured aneurysms and subarachnoid hemorrhages, subdural hematomas, cerebrovascular accidents, venous sinus thrombosis, and brain tumors are just a few of the secondary headache etiologies that can masquerade as primary headaches and trip up even seasoned EPs.

A 9-year-old boy crashed his motor bike and had a concussion, forehead contusion, and broken nose. A month later, he was still experiencing pain in his forehead, but rather than go right to CT or MRI, Dr. Mellick injected some bupivacaine for suspected post-traumatic supratrochlear neuralgia. The child's mother reported that his pain never returned.​

Another major challenge is the complexity of the subclassifications of primary and secondary headaches as well as the painful cranial neuropathies and other facial pains and headaches. Without a reference tool such as the ICHD-3, the average clinician will rarely be able to make the diagnosis of the less common causes of craniofacial pain.

Secondary Headaches

-Headache attributed to trauma or head or neck injury

-Headache attributed to cranial or cervical vascular disorder

-Headache attributed to nonvascular intracranial disorder

-Headache attributed to a substance or its withdrawal

-Headache attributed to infection

-Headache attributed to disorder of homeostasis

-Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure

-Headache attributed to psychiatric disorder

The third section of the ICHD-3 provides the diagnostic criteria for cranial neuropathies, other facial pains, and other headaches. This section outlines conditions such as trigeminal neuralgia, occipital neuralgia, optic neuritis, nine other lesser-known neuropathies and headaches without a clear-cut etiology or not fitting specific diagnostic criteria for any other headache diagnosis. Having access to the current diagnostic criteria for these uncommon and diagnostically challenging conditions is a huge potential help to the average clinician.

Painful Cranial Neuropathies and Other Facial Pains

-Trigeminal neuralgia

-Glossopharyngeal neuralgia

-Nervus intermedius (facial nerve) neuralgia

-Occipital neuralgia

-Optic neuritis

-Headache attributed to ischemic ocular motor nerve palsy

-Tolosa-Hunt syndrome

-Paratrigeminal oculosympathetic (Raeder's) syndrome

-Recurrent painful ophthalmoplegic neuropathy

-Burning mouth syndrome

-Persistent idiopathic facial pain

-Central neuropathic pain

Headaches can be caused by life-threatening conditions such as aneurysms, like this patient who experienced a posterior communicating artery aneurysm and was taken for emergent aneurysm coiling.​

Wednesday, February 28, 2018

I was a practicing pediatrician before I did a residency in emergency medicine. One of the most common and sometimes most stressful decisions parents had to make in the neonatal nursery was whether to circumcise their newborn son. I have to admit that the hullabaloo about the foreskin has always intrigued me. The American Academy of Pediatrics has gone back and forth over the years on the topic of circumcision and its benefits, but the current evidence clearly establishes a benefit from this procedure (Pediatrics 2012;130[3]:e756) that is performed approximately 1.4 million times each year in the United States. (Mayo Clin Proc 2014;89[5]:677.)

The morning chore of the pediatric interns rotating through the nursery was to line up male infants and perform circumcisions. We became quite proficient and could have the foreskin fixed up with a device called the Plastibell in minutes. In fact, I vaguely remember several procedural speed competitions (by others, of course) called "Circ-Offs."​

It's almost unbelievable, but the removal or non-removal of a small piece of skin from the head of the penis has actually been the focus of medical and social attention for hundreds of years. A Google search for "circumcision" produces about 11 million results in 0.58 seconds, and a PubMed search for "male circumcision" shows 6,155 published articles. Circumcision has been around for a long time. A sixth dynasty (2345-2181 BCE) Egyptian tomb has artwork showing the practice of circumcision. (See image.)

Sixth dynasty Egyptian tomb artwork showing the practice of circumcision.​ Credit: GoShows/Flickr.

The removal of the foreskin also has strong religious implications. God reportedly told Moses that this was to be done on all Israeli newborn baby boys as a sign that they were to be a nation set apart by God. And the Apostle Paul, a former rabbi who followed Jesus, debated at length that circumcision was no longer mandatory for salvation because the law had been fulfilled. I remember my father, a small-town preacher, teaching the biblical perspective of circumcision. As a preadolescent man, I was highly embarrassed when first learning about this surgical procedure. During a church service, I leaned over and whispered to my mother the innocent question, "What is circumcision, Mom?" Her answer mortified and perplexed me. Why in the world would we be talking about this in church? Honestly, I still don't completely get it.

Clearly there are medical benefits to the procedure. Circumcision has been clearly demonstrated to reduce male urinary tract infections, decrease transmission of the human immunodeficiency virus, and significantly reduce penile cancer and human papilloma virus infections. There is also an associated reduction in the risk of cervical cancer among women with circumcised partners. Foreskin inflammation is also reduced following male infant circumcision. (Saudi Med J 2016;37[9]:941.)​

Uncircumcised boys and men are at increased risk of balanitis, posthitis, and balanoposthitis. Phimosis and paraphimosis are unique problems to the uncircumcised man. Phimosis is an inability to retract the prepuce or foreskin. It is actually divided into physiologic and pathologic forms because the foreskin normally cannot be retracted in the newborn. Only after a period of nocturnal erections does the foreskin stretch sufficiently to be retracted. Premature retraction during cleaning can result in penile injury and strangulation due to paraphimosis. Pathologic phimosis also occurs in adults, and is a truly nonretractable foreskin secondary to scarring of the distal prepuce, infection, and inflammation. (See video of a patient with balanoposthitis and phimosis.)


Watch a video of a patient with phimosis.

Circumcision has its own issues and associated complications. (JAMA Pediatr 2014;168[7]:625.) Accidental traumatic amputation of the glans, infections, hemorrhagic shock due to hereditary bleeding disorders, and excessive skin removal have been just a few of the adverse events reported in the literature. Meatal stenosis caused by diaper irritation and penile glans inflammation is also a known risk for circumcised males. (See video of a patient with meatal stenosis.)​

Watch a video of a young patient with meatal stenosis.

Iatrogenic complications have also occurred in ritual circumcisions performed by rabbis. During a ceremony known as a bris, a circumcision practitioner or mohel excises the foreskin from the infant's penis, and cleanses the wound by using his mouth to suck the blood from the incision. Unfortunately, this technique has occasionally and not unexpectedly resulted in transferring the herpes virus to the baby, and fatal infectious outcomes have occurred. (http://abcn.ws/1QRjm52.) A literature review published in 2015 found 30 cases of ritual circumcision-associated HSV infections between 1988 and 2012. (J Pediatric Infect Dis Soc 2015;4[2]:126.)​

Wednesday, January 31, 2018

Recently, I acquired a little Yorkshire terrier puppy for my 15-year-old daughter who had been requesting a puppy for many months. On the way home, she silently wept with joy over the puppy sleeping in her lap. The two girls immediately fell in love, and it has been fascinating watching my daughter's maternal instincts unfold. She now gushes over babies in strollers, every dog or puppy she sees, and every other small animal that runs across the road. It has also brought out the mama bear protective instincts in her. I mean, if I turn in front of a car a quarter mile away, she admonishes me for putting the "the baby" in danger.

We have laughed so much over the past few months watching this puppy's shenanigans. She brightens up a room just with her presence. Even our older and grumpier dog, Buckeye, seems to be undergoing a transformation because of Missy. The puppy seems to love this older dog passionately, like a big brother or a surrogate parent. When they are out together, she can't keep her paws off him and she repeatedly attempts to stand bracing her paws on his chest to lick his face. Like a grumpy old man, Buckeye, acts unappreciative of the puppy's attention, yet his growing affection toward his new little sister is obvious by his increasing willingness to play with her.

Watch a video of Dr. Mellick's daughter Dakota with her new puppy video Missy.​

I have to confess that my iPhone is packed with pictures and videos of the new pooch. This puppy has brought about some positive changes in me. The bottom line is that that pets can be "love catalysts." Our expressions of love and affection for our pets can create empathy habits that naturally spill over to those around you. In fact, this puppy has reawakened my appreciation for infants and children. It's not like I didn't like other people's children; it's just that I now find myself appreciating babies' smiles and natural cuteness like I haven't for years. The truth is that babies and puppies have a lot in common. Besides the obvious aspects that they can't directly communicate, they both are capable of clearly letting you know when they are hungry, in pain, or want to play.

The reality is that babies and puppies are cuteness personified. Consequently, they have the ability to bring out the best of our human instincts. In fact, the similarities are such that after several weeks of doting over our new puppy, I inadvertently told a mother that her baby was a cute little puppy. She laughed and was not offended because she knew what I meant. While the controversy over fake service dogs swirls, I've become convinced that pets are emotionally therapeutic for their owners. In some respects, every pet is a therapy or service dog or cat.

But there is more. Several days after arriving in our home, the puppy choked on a chewy dog treat and then vomited for the rest of the evening. I worried and hovered over her like an anxious new father. In fact, after hours of vomiting and not eating or drinking and as she became more listless, I told my wife that I was worried that she might even die. After driving my daughter to school early the next morning, I hurried the ill puppy to our veterinarian. As I listed off for the veterinarian a puppy version of the Yale Observation Score, I realized that other than being dehydrated, she still had a pretty social response, reacted to me, and wasn't whimpering in pain. The veterinarian provided some guidance, reassured me that the puppy would be fine, and generously didn't even charge me for the visit. Sure enough, later that morning, the puppy lapped up a bowl of warm milk and shortly afterwards ate soft puppy food for the first time in 24 hours. Out of this experience, I gained a renewed understanding and a little more patience for young, inexperienced parents who bring their infants with minor illnesses to the emergency department.​

Other pets have presented to emergency departments where I have worked, and watching them and their interactions has confirmed for me that pets can play a huge therapeutic role for our patients. Several months ago while working a shift in the VA emergency department, an elderly and ill veteran brought his Jack Russell Terrier to be in bed with him. It was obvious that that this loyal pet loved his owner, and the patient depended on this dog for comfort. More recently, while on shift in the pediatric emergency department, a woman surreptitiously brought her baby sugar glider with her into the patient care room.

Watch a video of Ajax, the Jack Russell Terrier that a patient brought to the ED with him.

She was concerned that she would be asked to leave with her contraband marsupial, but instead we welcomed her and joked about her little squirrel-like marsupial being which in reality was her therapy pet. Watching these patients with their cherished pets and my experiences with our new puppy has given me a renewed understanding that animals often serve as therapy or service pets to their owners, and maybe we should do a better job of acknowledging the importance of these roles.​

mellick sugar glider.jpg

Watch a video of a patient's sugar glider in the ED.​

Tuesday, January 2, 2018

Four different tourniquets can be used to manage uncontrolled extremity hemorrhage—the SWAT-Tourniquet, the Combat Application Tourniquet (C-A-T), the SOF Tactical Tourniquet, and the Rapid Application Tourniquet System (R.A.T.S.). All four include a tightening strap that wraps around an extremity.

R.A.T.S. uses a thick bungee-like elastic cord. Both the C-A-T and SOF use an adjusting strap, but only the C-A-T uses Velcro to secure the strap and prevent loosening. The SOF has a tightening buckle that can be unsnapped to open the tourniquet and allow the strap to be wrapped around the limb rather than pulling it over the extremity. The Velcro strap of the C-A-T tourniquet can also be slid over the extremity before tightening or can be opened and routed through the attached single-opening buckle.

The C-A-T and SOF tourniquets have a windlass that can be spun two to three times to do the final tightening of the strap. The straps for both must be maximally tightened before the windlass is tightened. Some recommend that the straps be tightened to the point that one cannot pass three fingers under it, and all slack must be completely removed before the windlass is tightened.

The C-A-T and SOF have a latching mechanism for the windlass. The SOF has a triangular-shaped ring, and the C-A-T has a C-shaped latching cradle. The C-A-T tourniquet keeps the windlass from popping out by using a nylon/Velcro cover that is secured on top of the cradle once tightening is completed. Both tourniquets have an option for recording and reporting the time that the tourniquet was first placed.

The SWAT-T has a neat name that describes its application: the Stretch-Wrap-And-Tuck Tourniquet. It is probably the easiest to store and transport, and can be rapidly deployed by twisting and popping open the plastic wrap. The SWAT-T is applied about two to three inches above the bleeding site with the goal of the first encircling wrap to be secure the tourniquet, and then obtaining tight overlap on subsequent wraps, until the ovals and diamonds printed on the wrap are stretched into circles and squares. This novel indicator system allows the operator to gauge the adequacy of tourniquet stretching and tightening. After the last tight wrap, the tourniquet end is tucked under a previous wrap.

R.A.T.S. consists of a half-inch flat bungee cord attached to a metal cleat used as the locking device. A slot on the opposite corner of the metal cleat is used to form a small tightening loop with the bungee. On first pass, the free running end of the bungee is passed under and around the bleeding limb and then through this loop. With each subsequent pass, the bungee is stretched and tightened to stop arterial blood flow. Three tight loops are made unless the thigh is too large for the third sequential loop. It is recommended not to stack the wrapped loops on top of each other but to spread them over several inches. Once the three loops are tightened, the free end of the bungee is secured by pulling it through the locking cleat.

Placement over skin is ideal for all four tourniquets, but they can be placed over clothing if necessary. The manufacturers of all four sought to create tourniquets that allow easy self-application or buddy application depending on the situation.​

The duration of application of these tourniquets is until the patient reaches a higher level of care or the bleeding has stopped. Clearly the shortest duration possible is the therapeutic goal, but tourniquets can remain in place for hours if necessary to stop life-threatening hemorrhage.


Watch a video demonstrating tourniquets that can stop extremity bleeding.

Watch a video showing how different tourniquets are applied.​

Watch this video to see a simulated SWAT operation where medics place an extremity tourniquet and a junctional tourniquet.​​