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.

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

LTB PTX fixed.jpg

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.​

Friday, December 1, 2017

"It's been hurting for months, but now I'm really having pain and difficulty walking too."

The resident relayed those words said by a 60ish-year-old woman in our emergency department. Now the resident was waffling over whether to get an x-ray. On one hand, ordering radiographs will increase her length of stay, and will certainly not show a fracture. On the other hand, the patient's satisfaction might improve by taking some pictures. The resident decided to do the x-ray; adding it probably won't help much anyway.​

The AP film seemed to confirm his fear of wasted time and resources.


When the lateral popped up on the screen, however, those feelings vanished.​


The patella seemed almost adherent to the anterior femur. There was no joint space left, and there were huge osteophytes. It would seem that this lady could benefit from a patellofemoral replacement. The patient was shocked to learn that she wouldn't need the entire knee replaced. There were three compartments to the knee, and only one of hers was bad. Funny, both she and the resident were happy to have the x-rays. Even though there wasn't a fracture, there was a diagnosis.

Tip to Remember: Tricompartmental arthritis includes the articular surface of the medial tibial, lateral tibia, and the patella. It is possible to replace one, two, or all three.​

Wednesday, November 1, 2017

A middle-aged man was found on the highway. A concerned passerby called 911, and then EMS made him a patient of mine. Approaching the stretcher, the aroma of alcohol permeated the air. Such is my life as an inner-city nocturnist.

This patient was a little different, though. He said he had been short of breath before passing out. Peeking out from the bottom of the sheet was an ankle boot. The patient provided little assistance with his history. His exam was otherwise completely normal.

Just that week at the mortality and morbidity conference, a case bearing similarities struck terror in our hearts. A middle-aged man with a leg injury came back coding. His autopsy revealed a massive pulmonary embolism. I believe the fear generated from his death made me send a D-dimer on this patient.​

With the roll of the dice, we lost. The D-dimer was elevated.

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After an unrevealing portable chest x-ray, he went to CTA. I was going home. Signing out, my last words were send him home after his CTA is negative and he can walk.​

Arriving back for my next night shift, I saw this patient was admitted. I couldn't believe this patient with normal vitals and a normal pulse ox really had a PE. He didn't. He had a mediastinal mass. What had I missed on his x-ray?

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Clicking through the slices, I saw that the teaching from medical school was right. Really, one view is no view with x-rays. The very narrow, long mass hid right behind the sternum. My best chance of finding that on plain radiographs would have been an obliterated retrosternal clear space.

Tip to Remember: Lateral chest x-rays do show pathology not seen on the AP or PA view. If you can get two views, you might just find something you didn't expect.​

Monday, October 2, 2017

​An older man presented to the emergency department for respiratory complaints, and a routine series of studies—blood work, ECG, and a chest x-ray—almost automatically appeared in the orders.​

LTB chest xray dentures.jpg

Haziness on the left side—left hilar fullness probably isn't good. A CT scan would likely confirm the fears of cancer.​

LTB chest xray dentures2.jpg

LTB chest xray dentures3.jpg

The large mass wasn't unexpected, but did you see the metallic foreign body in the stomach? There was something on the left side under the diaphragm on the upright chest radiograph. The same thing appeared on the coronal CT image. Did he swallow something?

Upon detailed questioning, the patient remembered that he had lost his "partial." He had no idea where it went, and hadn't yet followed up with his dentist. Well, now we know where his partial was.

Ingested foreign bodies are much more prevalent in the pediatric population, but adults are not immune. The mentally impaired, seizure-prone, or substance-addicted patients have long been known to arrive in the emergency department with a variety of objects in their gastrointestinal tract. Bones, particularly fish bones, are a commonly encountered GI foreign body in adult patients. These usually get hung up in the oropharynx, but wayward dental appliances from implants to full dentures have ended up in the esophagus, stomach, and beyond.

Fixed dental prosthetic devices may loosen. (Ann Med Surg [Lond] 2015;4[4]:407; J R Soc Med 2004;97[2]:72.) Often patients are not aware of the dangers, and do not seek rapid dental care. Eventually, loose fixtures may become unattached and swallowed, which may put the patient risk for obstruction, perforation, fistula formation, and bleeding or wall necrosis. This patient was lucky that the unexpected object was seen on his chest x-ray.

Retrieved crowns, partials, and full dentures can be sterilized and reused, which may be financially important to some patients.

Tip to Remember: When reading a radiograph, look beyond what you expect to see.​