Damian Baalmann, M.D. @dvb69339
Activity by Damian Baalmann, M.D. @dvb69339
Thank you for your comments Damian. As a relatively new user of SoME and FOAMed, “Top 10 ways to reconcile social media and ‘traditional’ education in emergency care” was a great paper to dive into the topic.
I was more generalizing about social media medical education. I think there are definitely examples such as St. Emlyns. Great point that traditional medical education may not teach critical analysis well. I did a quick literature search and could find nothing to really support traditional medical education in this regard. Would be interesting to investigate further. Again, thank you for the comments!
Written by Damian Baalmann, M.D. and reviewed by Dustin Leigh, M.D.
A 49 year-old, previously healthy female presents to your emergency department with chief complaint of a boil on her left thigh. Otherwise, the patient denies any fevers, chills, systemic symptoms. The patient first noted this boil 3 days ago and it has since grown in size and is painful to touch. Vitals reveal that she is normotensive, not tachycardic, afebrile and satting well on room air. Exam reveals 4-cm tender, fluctuant, erythematous nodule on the lateral aspect of the mid left thigh. No apparent overlying cellulitis or lymphadenopathy and the rest of the physical exam is within normal limits. Quick look with bedside ultrasound confirms your suspicion of a non-loculated, cutaneous, drainable abscess. Your nursing staff has kindly already brought lidocaine/epinephrine, a scalpel, 25-gaugle needle, syringe, normal saline, and for some reason, packing supplies to the bedside.
The Case of the Fiddleback Spider
Written by Damian Baalmann, M.D.
Reviewed by Fernanda Bellolio, M.D.
A 33 year-old, previously healthy male presents to your emergency department with chief complaint of a skin lesion on his left forearm. The patient is roomed, vitals recorded and you note he is normotensive, not tachycardic, afebrile and satting well on room air. The patient tells you that he has noticed this growing lesion on his left forearm for the past 3 days. Initially the lesion started as a “red dot” on his left forearm and now has become “blistery” and grown to about 2-cm in diameter. At first, the lesion was painless but once the “blisters” started, the pain became worse but has been fairly well controlled with extra-strength Tylenol. Otherwise no systemic symptoms and specifically no fever, chills, malaise.
Exam reveals with a healthy appearing male with a 2-cm lesion with central and surrounding vesiculation on the dorsum of his left mid-forearm. There is minimal erythema and some pain to palpation of the lesion. Remainder of the exam is normal.
You are just about to leave the room, considering your differential diagnosis, when, much to your surprise (and disdain), the patient whips out a mason jar with what else, but a brown spider in it! “Doc, I think this is the cause of my pain. You see, three days ago, I was putting on my flannel shirt that had been sitting on the floor of my bedroom. I thought I felt something in it as I was putting it on and then I saw this little guy crawling on the floor….like he just fell out of the shirt….I got some gloves and put him in this jar ‘cause I heard that brown ones can cause trouble.” You take the jar and note a motionless spider that is about 1-cm in length, brown, with some sort of pattern on the top of its back. You look at the patient, look at the jar, and then look back at the patient and think….what next?
Regarding Nitrofuratonin; I think that we can probably use it in patients with UTI with moderately impaired renal function. To my knowledge, the risk of subtherapeutic concentrations in the urine is more theoretical secondary to known poor tissue penetration by nitrofuratonin. In fact, previously, the nitrofuratonin product information said that the CrCl cut-off was 40; but somewhere along the way they changed this to 60.
A recent review by Oplinger and Andrews published in Annals of Pharmacotherapy suggests that maybe the evidence isn't that great that we should draw the line at CrCl of 60. They suggest that the limited data available would support considering using Nitrofuratonin in patients with a CrCl of 40 mL/min or higher rather than 60 mL/min.
And I think that this is a legitimate point that needs to be discussed and looked into further because a lot of our options don't work so well against common UTI bugs. But nitrofuratonin does and we maybe limiting ourselves a bit by not using it on a patients who may benefit from it.
M. Oplinger, and C.O. Andrews, "Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min: looking for the evidence.", The Annals of pharmacotherapy, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23341159
5 Simple Steps in the Ankle Block
A 33 year-old (60-kg) male is brought into your emergency department by EMS and appears to be in excruciating pain. As EMS is transferring the patient, they explain that the patient was mowing grass on a steep incline about 40 minutes ago when the lawnmower slid over his right foot causing amputation of his first through third toes. The toes were placed on ice and the patient notes no other injuries. No pain medicine has been given. Nursing obtains vitals which are normal aside from some mild tachycardia. IV access is obtained. 6-mg of morphine is immediately administered after the patient confirms no allergies. Head to toe assessment and review of systems reveals no other injuries aside from the toe amputation of the right first through third with all three amputations occurring through the proximal phalanxes with pieces of bone jutting out and bleeding well controlled. The patient denies any past medical history. You quickly identify that this is a Gustilo Class IIIB open fracture and you order IV cefazolin, gentamicin and you throw in some penicillin because of your concern of anaerobes as you find the amputation occurred on a farm. You have the toes, which appear fairly well preserved, wrapped in moist gauze, placed in a bag of normal saline and placed on ice; you take special care to not have the toes directly placed on ice. 20 minutes has passed and re-evaluation of the patient reveals that he is still in excruciating pain, so you repeat the morphine. You call your orthopedic doctor on call who commends you on the antibiotics, says that they typically will not reattach toes, but she does agree that the wound will need to be taken to the OR for a wash out. Unfortunately, she is stuck in another case in the OR and it will probably be 2-3 hours before she can take him because a pretty involved trauma case just rolled in several minutes ago. The orthopedic surgeon asks, “Can you keep the patient comfortable until then?” Meanwhile the patient’s nurse approaches you and states that the repeat morphine has barely touched the patient’s pain. You repeat the morphine, but you think: what are my next steps in pain management?
Damian Baalmann, 2nd year EM resident
A 67 year-old female (90-kg) is brought into your emergency department because of increasing confusion. As the nursing staff is hooking the patient up to the monitor, the patient’s daughter comes into the room explaining that the patient has a history of atrial fibrillation, CHF, renal failure, and lives at home with the patient’s husband. Over the past several days, the patient has had increasing confusion, weakness, malaise, and anorexia. The patient’s daughter also hands you a medication list that includes furosemide, digoxin, sublingual nitroglycerin, and baby aspirin. Vitals are bp 94/54, RR 16 breaths per minute. Exam reveals elderly appearing woman in moderate distress with clear lungs sounds and irregular tachycardic heart sounds with S3. Extremities have 1+ pitting edema. Electrocardiogram is obtained and is shown below. What are your next steps in management?
By Damian Baalmann, M.D.
Reviewed by Sara Hocker, M.D.
A 34 year-old male presents to your emergency department in moderate respiratory distress. He is conscious and as the nurses are hooking up monitors, you are able to obtain a history of recent sore throat, followed by increasing weakness in his extremities with progressive dyspnea on exertion. Several years ago, the patient underwent a thymectomy and has since been maintained on prednisone 30-mg/day and pyridostigmine 60-mg Q4H. Vitals: pulse 112, blood pressure 110/80 mmHg and respiratory rate of 26/min. His oxygen saturation is 87% on room air. What are your next steps in management?
PERC (Pulmonary Embolism Rule-Out Criteria) is a set of criteria established for patients with chest pain or dyspnea in outpatient settings (ie. primary care settings or emergency departments).