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​Lions and Tigers and Bears​ by Loice Swisher, MD

Dr. Swisher’s daughter had five episodes of unexplained vomiting without a fever in just one month during 1999. Thinking about those, she said she was unable to shake the memory of a young child she saw in the ED with the same complaint 12 years before. The well-looking child had been bounced out of the ED four times with "viral syndrome" and "gastroenteritis." The diagnosis? A posterior fossa tumor.

“How did this happen?” she asked the attending, who shrugged and offered up various possibilities. It was a difficult diagnosis because the symptoms at first are nonspecific and it is uncommon. "The prior docs probably didn't get her up to walk or look in her eyes. They probably didn't think of it," he concluded. "But to an EP, unexplained vomiting is a brain tumor until proven otherwise."

That single phrase altered the course of Dr. Swisher's life—​and her daughter's. A "reassurance MRI" showed her daughter had a 5 cm medulloblastoma. Her daughter navigated a course of radiation, chemotherapy, and multiple complications, and Dr. Swisher started an entirely new medical education in the art of diagnosis.

Amal Mattu, MD, reminds those in emergency medicine to be on the lookout for lions and tigers and bears, not horses and zebras, Dr. Swisher explained. As an emergency physician and mother, she knows the profound impact this approach has on a patient's life. Using real cases, this blog aims to expose the lions and tigers and bears out there ready to bite.

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

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Thursday, June 1, 2023

June 2023: Preventing a Clean Kill

EMS in 5. V-tach on the monitor. The patient is awake. Vital signs are stable.

Gathering at the resuscitation bay, it was time to go over the pharmacologic options for stable V-tach with the resident. There was enough time to go over the dosages for amiodarone, lidocaine, and procainamide. Do we even have procainamide?

The patient arrived. We got down to business. The complexes were wide at about 115 on the monitor. He was talking while the ECG was taken.

Would you give amiodarone?

June LTB.jpg

If you did, this would be a clean kill, as Amal Mattu, MD, has said. The patient may end up dead with the administration of a sodium channel blocker if you follow the ACLS protocol of amiodarone or lidocaine or procainamide. His sodium channels are already essentially poisoned.

This is a regular really wide complex tachycardia. You know because it is more than one big box wide. When it is wider than a complete big box, reach for calcium and bicarb. The patient likely will have a toxicologic (tricyclic overdose) or metabolic (hyperkalemia) etiology for the ECG appearance.

The QRS complexes were already narrowing after calcium and bicarb by the time the potassium came back at 8.5.

Tip to Remember: Think toxicology or metabolic causes when there is a regular really wide complex tachycardia (RRWCT). Use bicarb and calcium. Otherwise, you may cause a clean kill.

Resources: How do you avoid a clean kill with wide complex tachycardias? Watch this Essentials of Emergency Medicine video with Dr. Mattu: https://bit.ly/44nZxgw.

Monday, May 1, 2023

May 2023: SVT in a Real-Life ED

I hate when it looks like TV.

It is a phrase that has run through my mind in the past. It is rarely a good thing and usually stressful. After three decades in emergency medicine, I can see it unfold.

Scene 1: A man in a wheelchair is being pushed rapidly by a nurse with his harried wife talking and going through her purse. A young man in scrubs is practically running in front of them with a piece of paper.

Loudspeaker: SVT coming from triage to the resus bay.

ED Tech: Here is his ECG. (She shoves the piece of paper in front of the pod's attending and intern.)

 LTB May 1.jpg

Scene 2: An entire medical team is assembled in the resuscitation bay. Two people in scrubs are helping the man out of the wheelchair. A third person is getting leads from the monitor and placing stickers on his chest. A fourth person is placing a blood pressure cuff on his arm. The resident makes his way to the patient's side. The ED attending is at the curtain of the room. The ED pharmacist arrives.

ED pharmacist (looking at the monitor): Are we doing diltiazem?

ED attending: Just got him in bed. We don't even have an IV yet. The QRS is wide but not concordant. I don't think its V-tach. I think there is aberrancy.

ED intern (her voice is heard over all the noise in the room): I want you to take a deep breath and blow out on this syringe for as long as you can. (Pan to the ED intern.) Harder. … Go longer. As long as you can. … Keep going. … OK. Lift his legs.

Suddenly, she puts the back of the bed down, and the nurse lifts the patient's legs in the air. The heart rate increases at first to 200 and then it breaks to 100.

ED intern: Let's get another ECG.

 LTB May 2.jpg

It reminded me of a scene from the TV show “ER." There was a man in SVT, and everything was going wrong. The intern put ice water in a basin, thrusting the patient's face forward. When he came up sputtering, he said, "What the hell are you doing to me?"

Scene 3: (All in my mind.)

Patient: What the hell? What type of medicine do you practice here?

(Camera pans around the room showing astonished faces.)

ED nurse: I've never seen that really work.

(Camera stops on the intern's face.)

ED intern: We reverted you. It's called a modified Valsalva maneuver, and it uses your body's nerves to slow down the heart. It has been studied, and it worked well in the REVERT trial. Keep the syringe in case it ever happens again. You could do it at home.

And cut.

Sometimes this job is really great when it looks like TV.

Tip to Remember: The modified Valsalva maneuver and the ice stimulated diving reflex can convert SVT. These can be particularly useful if you don't have an IV. (Watch a video demonstrating the modified Valsalva maneuver at http://bit.ly/3UauDDt.)


Friday, March 31, 2023

April 2023: A Textbook Presentation?

Atraumatic left hip and knee pain. An 11-year-old girl. Overweight. In word association, this was a textbook presentation until seeing the sex. It's more common in boys than girls. Still, girls do get slipped capital femoral epiphysis (SCFE).

She questioned me when I asked her to lie prone. Doctors don't usually examine patients on their belly. She was even more bewildered when I asked her to bend her knees so her legs were sticking up in the air. I had been taught by the legendary Jim Roberts that this was by far the best way to examine the range of internal and external rotation of the hips.

As the legs swing in and out like a pendulum, one can easily see a limitation of the swing, especially when compared with the other side. With SCFE, the head falls posteriorly, limiting the medial swing. Her swing was limited. She must have a SCFE.

LTB Textbook 1.jpg

The AP pelvis elevated the concern. A line (the line of Klein) drawn superiorly along the femoral neck should intersect the femoral head. There is a slip when it doesn't. Radiographically, the femoral head could look like ice cream falling off a cone. The line of Klein should also be checked bilaterally because an asymptomatic SCFE could be on the other side.

LTB Textbook 2.jpg

The frog-leg view clinched the diagnosis. It is usually the most sensitive view, and it was in this case. Clearly, she had bilateral slips.

LTB Textbook 3.jpg

Tip to Remember: Examining hip range of motion is easier when the patient is prone.


Wednesday, March 1, 2023

March 2023: The Aminlari Shoulder Reduction Technique

"What are you going to do?"

I am in a new shop, and I asked the resident what is typically done because there are so many options for shoulder reduction.

LTB Aminlari.jpg

We discussed several techniques. Some can be attempted without medication. The Cunningham technique uses massage of the superior trapezius and biceps, relaxing the muscles enough to slide back into place. Scapular manipulation manually displaces the glenoid and also can accomplish reduction without drugs. The use of a wide variety of pharmacologic agents, especially propofol, has now made reduction easier.

The resident first wanted to do the Milch technique—external rotation with abduction. Plan B would be traction-countertraction. Another long-known option is the Stimson maneuver, which tends to have relatively good success, but you need a weight (or a person) to pull on the patient's arm for perhaps 20 minutes to fatigue the muscles. This also requires the patient to be prone.

I had another idea, one that my former medical director said she used: moving the elbow toward the belly button. She said it worked without fail. After the Milch technique failed but the resident was still holding the patient's wrist with the elbow at 90 degrees, I just moved the elbow toward the umbilicus. The clunk felt palpable.

Then came the question: "What is that called?"

I didn't know. I searched the internet and couldn't find a name. I texted my friend. She has always called it the Aminlari technique after the emergency physicians who taught it to her, the husband-wife team of Amir Aminlari, MD, and Amy Aminlari, MD. It has been my go-to option ever since, and I've never had to use force.

Tip To Remember: Another option for shoulder reduction is to rotate the elbow to the belly button.

Friday, February 3, 2023

February 2023: An Unusual Distal Radius Fracture

The vast majority of distal radius fractures are directed horizontally—Colles, Smith, Barton. This vertical fracture line went from the radiocarpal joint to the lateral radial cortex, essentially avulsing the radial styloid.

LTB 1.png

It was a chauffeur fracture!

This eponym came from the days when cars were hand-cranked by the chauffeur, an occupational hazard caused by a direct blow to the back of the wrist when the car backfired. An alternative mechanism occurs from forced dorsiflexion of an abducted wrist.

This causes the proximal scaphoid pole to strike the articular surface of the radius, avulsing the radial styloid process. The force can be transmitted through the scapholunate ligament, disrupting the carpal connection. The force continues around the lunate and then tears across the triangular cartilage complex, often avulsing the ulnar styloid as well.

LTB 2.png


The increased likelihood of a scapholunate dissociation is the reason to request a scaphoid view with ulnar deviation or a clenched fist. The scaphoid view in this case suggested a widening of the scapholunate distance, but the patient did not have a scaphoid fracture but an ulnar styloid fracture.

Either way, follow-up with orthopedics is important because the fragment may require screw fixation to prevent the piece from migrating proximally.​