Lions and Tigers and Bears

Dr. Loice Swisher’s daughter had five episodes of unexplained vomiting without a fever in just one month during 1999. Thinking through the files in her mind, she was unable to shake the memory of a young child 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 was a posterior fossa tumor.

“How did this happen?” she asked. The attending shrugged, offering up various possibilities. It was a difficult diagnosis because the symptoms at first are nonspecific. 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, "To an ER doc, unexplained vomiting is a brain tumor until proven otherwise."

That single phrase altered the course of her life. A "reassurance MRI" showed a 5 cm brain cancer, a 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 of us 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.

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.

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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.​

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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.

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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.

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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

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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).

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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.


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.


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.​

Wednesday, January 31, 2018

​The high-pressure alarm continued to ring. Endotracheal tube (ET) in place? Check. ET tube suctioned without problems? Check. Tubing not kinked and ventilator OK? Check. Chest x-ray? Ordered.​

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This is probably not something you ever want to see: a complete pneumothorax in a patient with an endotracheal tube. Breath entering the lungs under pressure has a high likelihood of making the collapse worse, eventually progressing to a tension pneumothorax. When the vent is screeching that high-pressure alarm, think DOPES and DOTTS.

DOPES stands for the causes:

D          Dislodged ET tube

O-        Obstructed ET tube

P          Pneumothorax

E          Equipment failure

S          Stacked breaths (​

DOTTS refers to the fix:

D          Disconnect the patient from the ventilator and assess for stacked breathing and equipment failure.

O         Oxygen through a bag-valve mask. If it is difficult to bag, think pneumothorax or tube obstruction. If it is easy to bag, think a dislodged tube or deflated cuff.

T          Tube position: Think about passing a bougie to see if the tube is obstructed.

T          Tweak the vent for breath stacking (decrease inspiratory time, decrease rate, and decrease tidal volume).

S          Sonography to check for pneumothorax

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The chest tube was placed, and all became right with the world. at least for this ventilator and patient.

Tip to Remember: Remember DOPES and DOTTS (especially ultrasound) when the high-pressure alarm is going off on the vent.​

Tuesday, January 2, 2018

A middle-aged woman was started on a direct oral anticoagulant (DOAC) for an upper-extremity deep venous thrombosis two weeks before presenting to the emergency department. She reported that she had coughed up some blood. She had never had blood clots before and had no other testing.

The whole thing was strange and concerning.

Only about 10 percent of DVTs are in the upper extremity. (Circulation 2012;126[6]:768.) One can divide them into primary (or provoked), secondary, or idiopathic. Primary ones are usually related to effort, particularly those who are performing repetitive overhead movement or have thoracic outlet syndrome. Secondary upper extremity DVTs are usually associated with intravascular catheters/wires or malignancy. Those with no known cause usually have a less revealing workup than patients with lower-extremity DVTs, but one has a better chance of finding an abnormality in patients without vascular catheters or known exertional risks.

On the other hand, studies have shown that extensive screening for cancer in patients with idiopathic or unprovoked DVTs do not necessarily detect more occult cancers and do not change overall survival.​

Still, she was coughing up blood. She was going to need a chest x-ray. In addition, some experts have commented that bleeding on a DOAC might be a red flag for cancer.

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One study showed that the subset of cancer patients with upper-extremity DVTs and no vascular catheters was 28 percent at three months. (Vasc Med 2011;16[3]:191.) Perhaps it is true that screening doesn't change the mortality statistics, but it almost certainly will change how that patient spends her time.

Tip to Remember: Consider the possibility that an underlying cancer is the cause if a patient on a DOAC has bleeding.​