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​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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Wednesday, June 1, 2022

“Wow! You don't see that that very often anymore. Why did you get a soft tissue lateral?"

My colleague had a preschool girl with a 101°F temperature and a palpable lump laterally in her neck. I understood instantly. Our community place does not admit children, so identifying sick children is of prime importance. Transfers take time. A soft tissue lateral neck may be reassuring or not.

Jun 22 Lions Tigers and Bears.png

I always evaluate the epiglottis and the retropharyngeal soft tissue when using soft tissue lateral neck x-rays to look for infection. Findings are nowhere near as common as during my training more than 30 years ago because of vaccines, but it is still almost immediate.

The vallecula visually pops out in this child, making the thin epiglottis easy to find. The retropharyngeal soft tissue, on the other hand, appears prominent. The width should be checked at C2 and C6 (from the anterior aspect of the vertebra to the posterior line of the airway). The distance should be less than 7 mm at C2, and the distance should be less than 14 mm at C6 in children under 15. To guestimate, the retropharyngeal tissue should be less than half of the corresponding vertebral body.

The child's neck in a more flexed position will make the tissue appear wider, and the image is better during inspiration. Still, assume this is abnormal until proven otherwise if the retropharyngeal space is widened. The risk in this area is high.

Tip to Remember: The inability or refusal to extend the neck, particularly when there is neck swelling or lymphadenopathy, should prompt one to consider a retropharyngeal abscess.


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Monday, May 2, 2022

Her fourth and fifth toes still hurt six weeks after getting her foot tangled in her backpack strap when getting up in the dark to go to the bathroom. It wasn't purple anymore, but she was still walking on the inside of her foot. The initial assumption was that it was a fracture, and it would heal. It was just a toe after all. It would heal.

But doubt crept in that maybe a dislocation had been there all along.

May 22 Lions Tigers and Bears 2.png

Nope. No dislocation. Just two healing toe fractures. It would just take more time, but they would heal. They were just toes after all.

Six months later, the pain was more severe than ever. The toes were intermittently on fire. Other times, it felt like a ribbon was being squeezed tight, pulling on the digits. Now and then, she felt pins and needles in the area. The pain seemed unrelated neuropathy. The podiatrist said maybe she had a neuroma. It was unbelievable. They were just toes and should have healed.

The MRI didn't show a neuroma. The fourth toe was still not healed. The podiatrist wanted to know if she was wrapping the toe. No, she said, the tape was too hard to use and hurt to pull off. But the podiatrist said she had a better idea. She cut a strip of self-adhesive bandage wrap and buddy-taped the toe. Maybe treating a broken toe like a broken bone would allow it to heal.

May 22 Lions Tigers and Bears 1.png

Tip to Remember: Self-adhesive bandage wrap is more comfortable, easier to place, and more likely for people to use to buddy-tape toes.

Friday, April 1, 2022

​Wait! What happened there? I had just taken signout, and my colleague was shutting down the x-rays on her computer. This image flashed across the screen.​

Apr 22 LTB 1.png

My passion for orthopedic radiographs took over. Fractures of both forearm bones are not something I see often in my non-trauma center community shop. These are most likely from motor vehicle crashes or falls from heights.

My mind jumped to the rule of the ring. It had already been fulfilled with the two fractures. Still, my eyes were drawn to the joint to look for a dislocation. My mind was sorting through the eponyms—Galeazzi, Monteggia, Essex-Lopresti—when my gaze landed on the ulna overlapping Gilula's first arc. Could this patient have one of those too?

Joints should not have overlapping bones. The usual gap (where the fibrocartilage complex sits) between the ulna and the triquetrum no longer existed. This clearly was not a usual both-bone fracture. I wanted to see the lateral for confirmation.

April 22 LTB 2.png

It was a variation of a Galeazzi fracture, a fracture of the radial shaft and a distal radioulnar dislocation. Dislocation is not common in both-bone forearm fractures, but it should be considered at the distal radioulnar joint and the elbow. Both have been reported before. (Am J Orthop [Belle Mead, NJ]. 2013;42[5]:E30; https://bit.ly/3JJBz4o.)

Tip to Remember:

Always check for joint dislocations (above and below) with both-bone fractures of the forearm.​


Tuesday, March 1, 2022

The EMS notification was that a 71-year-old man was going in and out of seizures. His vital signs were stable.

I followed the stretcher into the room when they arrived five minutes later. The EMS crew reported that he had previously had a stroke, but he wasn't on any medications for seizure. The family called 9-1-1 because he had been going in and out of seizures for 20 minutes. He suddenly became unresponsive during these episodes, but came back to himself immediately.

The patient had another episode while being placed on the monitor. He stopped talking and his limbs shook, and it seemed that his eyes deviated to the left. It looked like a seizure, and of course, the monitor alarm was going off.

But looking at the screen changed everything. My patient wasn't going in and out of seizures. He was going in and out of ventricular tachycardia.

Mar 22 LTB.png

Pads went on the chest; an amiodarone bolus and drip were started. No signs of ischemia were present on the ECG, and his electrolytes were normal. A COVID test was sent. (COVID has produced a wide variety of arrhythmias, most commonly atrial fibrillation, but bradycardias and ventricular dysrhythmias have been noted.) A discussion with the patient's cardiologist revealed that this patient had a known low ejection fraction. Wisdom from the expert: Sometimes bad hearts do bad things.

Once the patient's ventricular tachycardia was controlled, his “seizures" stopped. In fact, he never had seizures; he had convulsive syncope.

Tips to Remember: Seizure-like motor activity can occur in about 20 percent of patients with syncope. Consider a cardiovascular cause as the underlying etiology with loss of consciousness, even shaking, in a patient who seems to be seizing.

Reference: “InFocus: Clinically Differentiating Seizure from Syncope," EMN. 2017;39(6):8; https://bit.ly/3L6tMPu.


Tuesday, February 1, 2022

One must know what normal looks like to recognize abnormal.

I believe it was more difficult decades ago when I went through residency. The hard films were placed on an x-ray Rolodex that essentially forced us to look at many more images as they went rolling by until we stopped at the film we wanted. I had an hour of x-ray lecture every week during training. The spaced repetition and low-stakes quizzing imprinted the difference between normal and abnormal at a glance.

lunateAP.png

This is abnormal! Something is seriously out of place. If one knew normal, it would be obvious.

The most proximal of Gilula's arcs is completely disrupted. The lunate no longer has the normal rectangular shape. It looks more like a piece of pie. A normal articular surface is evenly spaced, often with a sclerotic line. This cannot be said of the way that the lunate articulates with the scaphoid, the trapezium, or the capitate.

Take a look at normal carpal bones to see if you can now spot the difference.

lunatenormal.png

 Knowing the normal orientation of the lunate can tip one off to an important (not to be missed) abnormality—a lunate dislocation.

lunatelat.png

LTB 4.png

Tip to Remember:

A normal lunate never looks like a piece of pie (or pizza) on an AP wrist.