​Lions and Tigers and Bearsby 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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Monday, July 2, 2018

​An AP image of a shoulder flashed up on the screen. My colleagues often bring me interesting, rare, difficult, and classic cases because I write this blog. All are intellectually stimulating cases that remind me of the exciting parts of being an EP. It's a challenge to see how many clues I can find to make the diagnosis. These short interactions also help me form stronger bonds with my colleagues, a bonus for my interest in wellness.​

LTB posterior shoulder 1.jpg

First, my eyes were drawn to the wide glenohumeral interval. The space is huge (yellow lines in photo below). The glenoid appeared vacant. It also showed the rim sign where the glenoid rim can be seen without overlap. The normal half-moon appearance of the superimposed glenoid and humeral head was gone.

Next, the shape of the humeral head was wrong. It looked like a lightbulb when it should look like a club (blue circle).

And the normally smooth Moloney's arch formed by the medial scapular border and down the humeral shaft had a point (purple inverted V). It should be a Romanesque arch, not a peaked Gothic one. Moloney's arch is just like the gently curved, continuous, contoured Shelton line in the hip. It wasn't right either.​

Finally, there was a subtle "M" (red lines) made by the contours of the greater and lesser tuberosity in the internal rotation. This is a Mouzopoulus sign.

LTB posterior shoulder 2.jpg

This must be a posterior dislocation.​

The screen on the Y view confirmed that to be correct. The humeral head sat under the acromion (yellow circle) instead of in the glenoid fossa (red circle). In anterior dislocations, the humeral head sits near the anteriorly located coracoid process (blue circle).

LTB posterior shoulder 3.jpg

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Tips to Remember:

-Posterior dislocations are often missed. Remember to look for all the signs, including the vacant glenoid sign, the rim sign, the half-moon sign, the light bulb sign, the normal contour of Moloney's arch, and the Mouzopoulus sign to get the diagnosis.

-Share interesting cases with your colleagues. It makes our jobs more intriguing, and reminds us why we do what we do.

Reference:

  1. Weerakody Y, Radswiki et al. Posterior Shoulder Dislocations. https://radiopaedia.org/articles/posterior-shoulder-dislocation

Friday, June 1, 2018

My relief had arrived, and we were just starting sign-outs. The resident broke in, "This guy with the sore throat. I think he's sick!" Glancing up from the computer, she continued. "He's barely talking. He has inspiratory stridor. And he is sweaty."

The resident had me at inspiratory stridor. Diaphoresis on a chilly morning in our ED was just icing on the cake. Intrigued and concerned (we did not have ENT or an open OR at that time in our shop), I followed my oncoming colleague to the bedside. The experience was just as sphincter-tightening as the description. The 20ish-year-old man sitting bolt upright and holding on to the bed rails could not even count to one. The back of his throat was normal, and the bedside soft tissue lateral neck radiograph provided no reassurance.

LTB stridor 1.jpg

Decision: immediate intubation. This was going to be tough. Few airways get tougher than this. All hands on deck (anesthesia, surgery, respiratory, CCU). All resources readied, including a scalpel and bougie.

The first look down was disorientingly frightening. It looked like a cervix. The swollen epiglottis and aryepiglottic folds allowed only a tiny opening still available for plastic to pass. With amazing skill, luck, and perhaps some prayer, a 6.0 ET tube made it through that tiny passageway into the trachea.​

The patient was whisked away to the CCU, and we had time to debrief and review. The patient's lateral neck image was placed beside a normal one on the computer screen.

LTB stridor 2.jpg

LTB stridor 3.jpg

The epiglottis (red arrow on normal x-ray; cross our patient) had the telltale appearance of an epiglottitis thumbprint sign. Our patient also had a vallecula sign, a shallow vallecula seen with epiglottitis. The aryepiglottic folds (white cross) were more prominent than I had ever seen them. The extremely narrowed glottic opening (green line) explained the bizarrely ballooned hypopharynx; the patient had done everything he could to get air into his lungs. Staring at the images, we all knew that this would be one that would be imprinted on our brains for the rest of our careers. Adult epiglottis carries a mortality of seven to 20 percent. This patient was at the verge of meeting death that morning, and was pulled back from the edge.

Tips to Remember:

-Always respect inspiratory stridor and diaphoresis.

-The epiglottis always bisects the hyoid bone anteriorly. Follow the base of the tongue down into the vallecula, eventually reaching the hyoid. The usually narrow epiglottis (approximately 3 mm) should appear to spring up from the hyoid like a flower immediately posterior to the vallecula.

-Look for the thumbprint and vallecula sign when considering epiglottitis.

Suggested Reading:

1. Ames WA, Ward VMM, et al. Adult epiglottitis: An Under-Recognized, Life-Threatening Condition. Br J Anaesth 2000;85(5):795.​

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Monday, April 30, 2018

"Doc, I broke my foot about three months ago and was in a boot. Tonight I was in a fight. When I went to kick, I twisted my foot. I can walk, but wanted to come in to get it checked out."

Simple. Straight-forward. X-ray ordered.

LTB calcaneal 1.jpg

My eyes were rapidly drawn to the two gaping fracture lines—one posteriorly in the calcaneal tuberosity and the other extending from the posterior facet through the subtalar joint to the plantar surface. Böhler's angle confirmed what can be seen intuitively: This calcaneus was crushed.​

LTB calcaneal 2.jpg

Böhler's angle is formed from two intersecting lines coming together at the apex of the posterior facet. The first line is drawn parallel to the superior aspect of the tubercle from the highest part on the posterior tubercle to the highest point of the posterior facet. The second line is drawn from the highest point on the posterior facet to the highest point on the calcaneus at the calcaneocuboid joint. A normal angle is between 20 and 40 degrees. An angle less than 20 degrees indicates disruption and collapse of the subtalar joint at the posterior facet.​

How much is new? How much is old? How could he be walking on this? How badly is this calcaneus destroyed? The patient was sent to the donut of truth (the CT scanner), and his prior treating institution confirmed that he had been diagnosed with a calcaneal fracture three months before. Those records indicated that it had been in near anatomical alignment, that he had been sent home with a boot and told not to bear weight, and that he never followed up with orthopedics.

LTB calcaneal 3.jpg

Clearly, this was no longer in near anatomic alignment. The comminuted fracture fragments were now widely displaced. This is what happens when you walk on a calcaneal fracture involving the subtalar joint—it collapses.

Tip to Remember: Carefully consider weight-bearing in calcaneal fractures, especially those that involve the posterior facet joint.​

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Monday, April 2, 2018

The scapula is truly the Rodney Dangerfield of bones: It gets no respect. Every chest x-ray we see gives us two chances to embed in our minds what normal looks like. Few avail themselves of this opportunity. In fact, most do not have any systematic process to look at this bone at all. That will change today!

A 59-year-old man fell down some steps, landing on his left shoulder and upper back. He presented with pain in that area and difficulty lifting his left arm.

LTB scapula 1.jpg

The wrist has a well-known mnemonic—Some Lovers Try Positions That They Can't Handle—to remember the order of the carpal bones. I'm proposing a brand-new mnemonic for the scapula—Golfers Never Bitch Swinging A Club—to remember a methodical approach to assessing the scapula. Starting at the shoulder joint, one circles the bone to scrutinize each part.

Golfers         Glenoid

Never           Neck

Bitch            Body

Swinging      Spine

A                 Acromion

Club             Coracoid

LTB scapula 2.jpg

LTB scapula 3.jpg

The first problem in this patient's case is seen coming down from the glenoid to the neck: a small chip fragment and an angle in the normally smoothly-arched neck into the body (purple arrow). Something is definitely wrong there, but don't stop looking. Next, trace the entire triangular border of the body. As one rounds the corner of the tip and proceeds toward the superior border, the cortical edge is lost. A part seems to be missing: a divot in the bone causes concern (yellow arrow).

LTB scapula 4.jpg

Confusion often occurs when one reaches the top of the scapula. Where exactly is the superior border, and where is the spine? The key here is that the acromion is the end of the scapular spine (red arrow). To locate the superior border, begin at the superior angle and follow the sclerotic line down toward the coracoid (blue line).

The CT confirmed what we already know. The patient has a widely gaping scapular body fracture extending from slightly above the inferior angle on the medial border to the area of the scapular neck with a tiny bony fragment noted. The CT also showed some additional fracture lines.

Tip to Remember: Golfers Never Bitch Swinging A Club gives you a systematic way to evaluate the scapula. It is worth it to have an organized framework because it takes force to break this bone and one should look for underlying injuries. One also doesn't want to look like a fool for missing an obvious fracture.​

Wednesday, February 28, 2018

"I just put a young woman in her mid-30s back in room 9," the triage nurse said. I made a mental note that that was the GYN room. The nurse continued, "She feels bad, fatigued, and just not right in her stomach." The obvious question flew from my mouth. "Is she pregnant?"

"I have the urine, but the quality controls are being run now, so it will be a few minutes."

I glanced at the EMR before heading back to the room: normal vitals, no fever, no medications, a couple of kids, no surgeries, last period three weeks before. Not much there to go on, but I could see her while waiting for the urine.​

I found a fully dressed young woman sitting comfortably on the bed. She gave me the same story. I thought I knew where we were going. I asked if she thought she was pregnant. The noncommittal answer made me sure I had the reason she was in my ED in the middle of the night. The answer would be in the urine.

LTB-hepatitis1.jpg

Getting back to the computer, the urine results were back. Not pregnant!

OK, not the direction I thought we were going. Looking at the urine dip, which always seems to come in tandem with the urine pregnancy, showed she was not dehydrated and didn't have a UTI, but there was trace bilirubin and high urobilinogen. What to do with that?

She looked so good clinically. I could send LFTs to the lab. There goes the length of stay with an added hour at least to get the results back. Shared clinical decision-making! That would be the answer.​

She wanted the tests. She felt bad. She wanted to know why.

LTB-hepatitis2.jpg

I was shocked. She had hepatitis! I hadn't even truly considered that. She didn't look yellow, and I had been jaundiced that she looked too good to have anything seriously wrong. I was so sure of that that I wasn't swayed by the urine dip. How often do those abnormalities pan out?

Sometimes it is better to be lucky than good. She was diagnosed with acute hepatitis C. The HCV RNA PCR results were almost 2.5 million log IU/ml. Diagnosis on the first visit allowed for earlier evaluation, and likely prevented the spread of a communicable disease.

Looking back at this case, I am humbled. I anchored my diagnosis on pregnant or not. I even started to convince myself that the seen abnormalities were really red herrings leading me down a blind path. Yet these results are on a point-of-care dip because they can provide clues to a diagnosis. Bilirubin should not be in the urine. This patient's was only trace and may be a false-positive, but a high level of urobilinogen should also not be in the urine either. This combination should have significantly elevated the level of suspicion. Urobilinogen may be elevated with hemolytic anemias, hepatitis, and various toxicologic issues affecting the liver and causing cirrhosis.

Tip to Remember: High levels of urobilinogen are not normal, and should precipitate a work-up consideration of hemolytic anemia, abnormal liver issues, or both.​