What pearl could I possibly find worthy of continuing tweets and dissemination? The last two posts, one of which was retweeted by both @M_Lin and @precordialthump (thanks!), are a tough act to follow.
So first I thought about maybe high flow nasal cannula, the forgotten oxygenation method. I could highlight those magical nasal prongs that can deliver up to 60 Liters per minute of humidified O2 and up to 6 mmHg of PEEP while keeping patient comfortable (relatively), eating and likely swearing at you. But then a quick FOAM search showed that @emupdates had a great post from 2012 and that @cliffreid already blogged about it‘s application during RSI for apneic oxygenation.
Then a sick LVAD patient roles in and I became tempted to write a small review of the approach to the LVAD patient. Does anyone know how to measure their blood pressure? You can’t do it with an automatic BP cuff. But again, a great review by @FTeranmd was right there on the MayoEM blog.
So then, as I was standing around contemplating potential interesting subjects for this post, my chairman asks me to look at this Xray of an adult s/p elbow trauma:
Easy, there are fat pads. Enlarged anteriorly (sail sign) and seen posteriorly, so there is definitely an occult fracture. As I stood triumphantly, he followed up with a second questions. Where is the fracture? Supracondylar are the words that came to my mind and mouth as most of the elbow effusions I had seen were from supracondylar fractures. “Absolutely wrong” said Mr. Chairman. As it turns out, supracondylar fractures are the most common elbow fracture (60% of fractures) in children (1). In adults the most common cause is radial head fracture (~50% of elbow fractures). (1). All the while, the answer was just sitting in front of me. A close inspection of the radial head reveals what is very likely a fracture line. I should have spent more time with @ABargren‘s emin5 review of elbow Xrays.
Beaten down, I was walking away when a fellow resident asks: “Hey, do you remember the dose for Otic mineral oil?”. Me: “What? Humm…no, what are you prescribing it for?” Co-resident: “I just diagnosed a guy with dry ears”. Yes, I thought to myself, this is by far the best diagnosis of the day, and this will be the theme of my post. The diagnosis and management of dry ears. A small but bothersome affliction for which waiting to go see your PMD or a quick google search just doesn’t cut it.
So, turns out one can get dry ear canals from over cleaning, hearing aids, or a primary lack of production of ear wax. Risk factors include hx of dermatitis, psoriasis and eczema. Be careful to also consider otitis externa, as the two can be confused. Treatments include (ironically) keeping the ear dry from water. Patient can try a few drops of vegetable, olive or mineral oil as well. Beyond that they need to follow up with their PMDs or ENT doctors.
Behold FOAMed community, a subject that I bet has never been addressed, dry ear canals.
(1) Goswami, Gaurav K. “The Fat Pad Sign 1.” Radiology 222.2 (2002): 419-420.