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.

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.​​

Friday, December 1, 2017

There is a saying, "Complexity in the face of adversity breeds chaos." I'm not sure where this maxim originated, but it is definitely true in resuscitation settings. That's the crux of this post: Is the abdominal tourniquet simplicity in the face of adversity compared with the resuscitative endovascular balloon occlusion of the aorta (REBOA)?

We all know how futile it feels to do CPR on a traumatic cardiac arrest patient with suspected massive blood loss. Just what are we pumping, and if there is any remaining intravascular blood, where are we pumping it?

I will never forget the pain of trying to resuscitate an 11-year-old boy who was run over by a neighbor turning into her driveway. She never saw him as he rolled down the street lying flat on his skate board. He received everything we had, including an open thoracotomy and aortic cross-clamping. He ultimately died from severe liver lacerations and venous injuries.

This patient and thousands like him demonstrate that we need more tools in the fight against this type of traumatic cardiac arrest. Before someone else points it out, we need to be clear that traumatic arrests are not simply the proverbial internal injuries. The Centers for Disease Control and Prevention estimated that 30 percent of all injury-related deaths are due to brain injuries in the United States. (MMWR Surveill Summ 2017;66[9]:1.) Many of those patients will also have noncompressible torso hemorrhage.

Open thoracotomy can occasionally be life-saving, and cross-clamping the aorta may be helpful in stopping exsanguinating noncompressible torso hemorrhage. This procedure, however, is not very practical in rural and resource-limited settings. It can be performed by a trained operator, but it creates the "now what?" scenario. The rural emergency physician has to manage an unstable patient who has an open chest and cross-clamped aorta and who needs to be transferred emergently for ongoing resuscitation and critical care. Open thoracotomy can be dangerous to the operator. Lacerations from errant scalpels and jagged edges of broken ribs commonly occur. Exposure to body fluids and blood is almost unavoidable despite the best personal protective equipment.

Open thoracotomy, nevertheless, makes sense for treating penetrating wounds of the heart and life-threatening pericardial effusions, as does cross-clamping the aorta for noncompressible torso hemorrhage. But what if we could compress torso hemorrhage at the same time we cross-clamp the aorta? That leads us to a discussion of the abdominal aortic and junctional tourniquet (AAJT) and REBOA.

REBOA is touted by many, and some evidence suggests that it is effective. One meta-analysis of studies comparing REBOA to cross-clamping of the aorta showed that the odds of mortality did not differ between the compared groups. (World J Emerg Surg 2017;12:30.) But REBOA simply stops blood flow in the aorta. It does not actually compress sites of torso hemorrhage. Even if REBOA stops blood flow in the aorta, venous bleeding will continue until the injured veins are empty. It is also not an entirely practical solution because training, experience, and availability of REBOA remain primarily limited to trauma centers. It is even less available in the prehospital arena where it would be most effective.

On the other hand, the AAJT can cross-clamp the aorta and provide compression to torso hemorrhage, and it is available in prehospital and austere environments. For the record, feedback from field use suggests that training in the correct application of the AAJT is important, and the tourniquet will cause a degree of pain and discomfort in the awake patient.​

Several interesting abstracts on the AAJT and REBOA were presented at the Military Health System Research Symposium (MHSRS) 2017. The animal studies were far from conclusive, but they are an excellent start to answering some important questions. One abstract compared the AAJT and REBOA in a model of noncompressible pelvic hemorrhage using 20 Yorkshire swine. Those authors reported that the AAJT and zone 3 REBOA achieved hemostasis and that blood pressure was elevated with AAJT use proximal and distal to aortic occlusion. The AAJT application increased pulmonary pressure and inspiratory pressure but not the PaO2/FiO2 ratio or SpO2, and lactate and hemoglobin levels were elevated in AAJT-compared with the REBOA-treated animals. No differences were observed in inflammatory markers or microscopic examination of tissues between the two modalities. (See table.)​​​

Also helpful was a paper recently published in Military Medicine by Rall, et al. (Mil Med 2017;182[9]:e2001.) The paper admittedly suffered from the limitations inherent in animal models of trauma and hemorrhage, but it demonstrated that the application of the AAJT improved ROSC in a hemorrhagic cardiac arrest swine model. Twelve male Yorkshire swine weighing between 70 and 90 kg were used in the procedures. The animals underwent controlled hemorrhage until cardiac arrest defined as carotid systolic pressure below 10 mm Hg for 10 seconds occurred.

After three minutes, all animals underwent CPR, transfusion of five units of blood, and were randomized to treatment with or without an AAJT. The primary outcomes for the study were survival and time. Survival time was significantly different between the two groups, and five of the six animals in the CPR with AAJT group survived, while only one animal in the CPR alone (control) group survived to the end. We now have some evidence that applying the AAJT while aggressively transfusing blood might save lives.

Locally, I have been asking why we don't apply the AAJT to all traumatic arrests. Recognizing that time is a factor, ultrasound can fairly effectively rule out hemothorax, pneumothorax, and a life-threatening pericardial effusion. The presence of these findings may indicate that an open thoracotomy is needed. Additional questions exist that need to be answered before the AAJT is applied routinely to all traumatic arrests. If there is concern for a thoracic aorta injury, is application of the AAJT a contraindication? Or if there is a head or c-spine injury in a traumatic cardiac arrest patient, is the AAJT appropriate for these patients? In the end, these are probably judgment calls. But in the words of a colleague on this subject: "Most of these patients are going to die whether or not you apply the AAJT, so you have nothing to lose." I tend to share this opinion.​

The AAJT appears to be a simpler and less complex solution to the problem of noncompressible torso hemorrhage, and evidence is finally starting to trickle in that supports the use of the AAJT in traumatic cardiac arrest patients.​


Watch a video of Dr. Mellick explaining how to use the AAJT to save lives in the ED​.

Watch a demonstration by Richard Schwartz, MD, who along with John Croushorn, MD, invented an abdominal tourniquet.

Wednesday, November 1, 2017

The labor pains leading to the birth of the specialty of emergency medicine began in the mid-1960s. The public demand for emergency care was growing around the country, and physicians were leaving their private practices in greater numbers and working full-time in urban emergency departments. Nevertheless, the quality of care was at times problematic, and the need for training in emergency medicine was widely recognized.

The American College of Emergency Physicians was founded in 1968, and it became a driving force for the creation of the specialty. The first training institution was the University of Cincinnati, and this organization convinced the American Medical Association to allow a residency program to be developed under the family medicine specialty with a certificate of training in emergency medicine in 1970.

That is where the story of Bruce Janiak, MD, the first emergency medicine residency graduate in the world, began his career. He agreed to do his internship year at the University of Cincinnati in family medicine in return for the opportunity to train in emergency medicine. During that internship year (1969), he worked with several faculty members to develop an emergency medicine residency curriculum. After graduating from the residency in 1972, Bruce served two years in the Navy before moving to Toledo, OH, to become the medical director of the emergency department at Toledo Hospital. That is where we met.

As a first- or second-year medical student at the Medical College of Ohio at Toledo, I remember someone encouraging me to meet with a recent graduate of a new specialty, emergency medicine. I met Bruce just as he was getting on a hospital elevator. We talked briefly about his new specialty, and then our paths parted for several decades. Dr. Janiak would go on to spend the next 28 years at Toledo Hospital, and when that role ended, I played a role in recruiting him to the Medical College of Georgia.

I have had the pleasure of working with Dr. Janiak for several decades, and have come to appreciate his ability to think outside the box and his passion for teaching. Dr. Janiak, now 74, continues to work full-time in academic emergency medicine, and still has the excitement of a medical student starting his clinical rotations. When we work together, I can be guaranteed that Bruce will stop by my work station three or four times to discuss an interesting case or to share a teaching point. And knowing my passion for making educational videos, Dr. Janiak will frequently scout out patients with interesting conditions who might be willing to collaborate on a video. But Dr. Janiak recently volunteered to be the subject of my next video.

We were working parallel shifts, and Bruce mentioned in passing that he thought he might be throwing premature atrial contractions or his known atrial fibrillation dysrhythmia might have returned. Sure enough, near the end of our shifts, Bruce indicated that his atrial fibrillation had indeed returned and that he was planning to undergo a cardioversion in our department. "Let's make a video of my cardioversion," he said. What followed was a once-in-a-lifetime video opportunity. A patient undergoing cardioversion in the emergency department doesn't allow a video every day in which he is also the procedure's primary narrator. For me, personally, this video was an opportunity to highlight the emotional toughness, relentless passion for teaching, and self-effacing humor of my friend and colleague, Bruce Janiak, MD, who also happens to be the first emergency medicine resident in the world.

Watch a video of Dr. Janiak undergo cardioversion and describe the procedure.​