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 Thank you to our excellent speakers today — Dr. Colvin, Dr. Krauss, Dr. Amory, and our own Drs. Patrick and Fawaz. Dr. Krauss’ lecture and Q+A session is now available in MP3 format — check it out, and see all the other archived lectures under the ‘conference’ tab above.

I wanted to plug two excellent issues of EMPractice that had relevance to today’s conference — one on ED evaluation of vision change and one on musculoskeletal imaging. If you want to see more on knee arthocentesis, the NEJM has a nice video.

The following teaching points were adapted from Reueben’s M+M recap and subsequent emails:

Thanks to Dr. Fawaz for his expertly-presented case of the patient with multiple myeloma and anemia who complained of generalized and lower extremity weakness, back pain, and falls. This patient was seen a several times in the ED and admitted twice before the diagnosis of compressive spinal cord metastasis was made.

Key teaching points:

*New back pain in a cancer patient is cord compression until proven otherwise. The threshold to push forward with MRI on these patients should be low.

*Cord compression should also be considered in the cancer patient with new ataxia, lower extremity weakness, bowel/bladder dysfunction, and falls.

*Pain often precedes neurological symptoms, sometimes by months.

*The gait exam is often the most important part of the neurological exam.

*When imaging for cancer-related cord compression, consider including the entire spine, as metastasis at multiple sites is common.

*Negative plain films are not reassuring in the context of possible cord compression.

An excellent summary. I would only add some nuance to the first point — the threshold for MRI should be low, perhaps as low as your threshold for ordering a two sets and stress — both MI and SCC are disastrous if missed, yet we seem more reluctant to pull the trigger on MRI for SCC rule-out.

Peter also wanted to highlight a memorable article about ED evaluation of vertigo, in a neurology journal. The take home point, however, about ambulating your patients, is valuable.

Finally, Braden emphasized Dan’s point that cord compression isn’t always from the lumbar spine, and that 60% are due to the thoracic spine. “Patients may complain of upper arm weakness greater than leg weakness (check triceps extension strength!). These signs are sometimes subtle and patients have vague ‘weakness’ complaints but physical exam can sometimes lower your threshold for imaging (and make you look really smart in front of your consultants if you pick it up).”

Thanks to Dr. Close for her wonderful M+M presentation yesterday. The following M+M tips are adapted from Dr. Strayer’s followup email:

We recently saw a patient with active malignancy present with typical symptoms of hypercalcemia. Though the GEMM was resulted shortly after presentation and demonstrated a very high ionized calcium (more than twice the upper limit of normal and qualifies as hypercalcemic crisis), the diagnosis was not made for some time.

Consider the following diagnoses in patients with malignancies who present with unexplained symptoms.

1. Malignant pericardial effusion. Have a low threshold to perform point-of-care ultrasound to evaluate for an effusion.

2. Spinal cord compression. Back pain, lower extremity weakness, urinary retention, fecal incontinence.

3. Hypercalemia. Lethargy, confusion, generalized weakness.

4. Tumor lysis syndrome. Hematologic malignancy s/p chemotherapy with renal failure and electrolyte disturbances.

5. Neutropenic fever. Definition is a single temperature ? 101 (38.3) or fever of 100.4 (38.0) lasting longer than 1 hour in patient with ANC < 500. ANC = WBC * (%PMNs + %bands).

6.  SVC syndrome. Dyspnea, hoarseness, cough, facial and upper extremity swelling with distended neck and chest wall veins, facial edema and plethora.

7. Intracranial metastases. Seizure, altered mentation, neurologic symptoms or signs.

8. Hyperviscosity syndrome. Multiple myeloma / Waldenstrom’s / Leukemia blast crisis / Polycythemia patient with visual changes, mental status changes or neurologic symptoms, bleeding diathesis, or CHF.

This journal club was a look at four papers, four ways of treating pain in the ED — from mild to severe — using four approaches a little outside our comfort zone of NSAIDS and opiates.

I began the hour with a quick look at a fifth paper (Chang and Gallagher, Annals of EM 2006, Vol. 48 No 2), previously covered in this blog, about a RCT of patient’s reduction in pain after hydromorphone (dilaudid) vs. morphine. It served as a good introduction to pain assessment tools and I liked the author’s candid writing about factors in physician ordering beyond need — such as perceived price or just the psychological barrier to ordering 10mg of morphine over 1 mg or 2 mg of dilaudid. I also had to point out how great it was to see acknowledgment in print of our practice reality — the mode for initial pain score in this study was 10/10. A good read if you have the time.

I also recommended as background reading the section on Pain Assessment Tools, page 8-11 in the July 2006 edition of EMPractice by Curtis & Morrell.  The sections on pathophysiology of pain and ED pain epidemiology was also recommended.

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Joe has encapsulated his teaching points from his recent wide-complex tachycardia lecture into a convenient blog format. Thanks, Joe!

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We’ve heard a lot of wisdom in some great lectures about afib managmenet recently, so I wanted to recap some key points and links to resources.

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Our recent guest speaker Wyatt Decker challenged us to examine the usual afib ED treatment in the US, which as Alan noted is: 1) Cardiovert if unstable 2) achieve rate control 3) give heparin and 4) admit.

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To tackle one of the most controversial aspects to emergency medicine today, Shawn shook up the format of Journal Club and assigned reading to each class. The result? A raucous but informative session where much evidence was covered and many questions raised. Some of the highlights are below. Much of this is lifted from Shawn’s excellent handout at the end of the session — other participants’ opinions are marked as such.

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Dr. Zane’s wonderful lecture is now online, for those of you who missed it or want a refresher on surge capacity in disaster settings.

Thanks also to Dr. Constantine for his wonderful M+M presentation yesterday. The following M+M tips are adapted from Dr. Strayer’s followup email:

Key teaching points from this case of infective endocarditis:

* Do not convey undue diagnostic certainty to patients. In patients without definitive evidence of a specific diagnosis, consider that their symptoms, instead of reflecting a benign disease, could be the early symptoms of a more serious disease that hasn’t declared itself yet, and advise accordingly.

* Be careful about assigning specific diagnoses when lack of definitive evidence of these diagnoses exists. Gastritis, gastroenteritis, reflux, dyspepsia, heartburn, constipation, costochondritis, migraine, influenza, muscle spasm, sprain, strain, and anxiety are examples of diagnoses that should be assigned cautiously.  Symptom-based diagnoses such as chest pain, abdominal pain, headache, cough, and knee pain, while less satisfying to patients, usually better reflect the degree of diagnostic certainty we are able to generate in an emergency visit.

* Unless a patient is discharged without a period of observation or diagnostic studies, the chart should include a follow-up note, documenting the evolution of care and justifying discharge.

* Abnormal vital signs should either be normalized, explained, or a plan for addressing them included in the chart.

* Infective endocarditis may present with a variety of signs and symptoms. Consider the diagnosis in patients who have risk factors (intravenous drug use, abnormal heart valves) or suggestive findings (prolonged course of fevers and malaise, new murmur).

Thanks to all who spoke this past Wednesday — Jim, Kit, Shawn, Shefali, Seth, Dr. Paul, Dr. Weingart, and Dr. Kalb.

Jim has graciously agreed to let me load his first “Screen Sim” program online — you can download the whole zipped folder onto your computer here (see me if you need help). I just tried it and am thrilled to have my own little window with Jim speaking to me about stroke. Hopefully more simulators are on the way.

Also, thanks to Chris Strother for pointing me to some screen-simulators hosted at trauma.org. They’re called Moulages, a word that’s amazingly appropriate.

If you enjoyed the debate on dobutamine in sepsis, between our own Dr. Weingart and the MICU’s Dr. Kalb, you can relive the magic by downloading the audio (mp3 format).

Alternatively, Shawn has transcribed the key points, below (and thrown in some of his own thoughts, at the end):

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