MVC

I am sitting in a car dealership having a headlight replaced. Being a fine piece of German engineering, the bulb will cost $209 plus labor. I have been told that the bumper assembly must be entered to replace this Xenon bulb. The car I drive is 10 years old. It is a squat, unsexy wagon. It's appeal is safety. "Bruno" weighs in at 4000 + pounds, is all wheel drive, has front and side airbags and has a manual transmission. Driving to and from the ER earlier this week during a blizzard, reinforced one of the reasons I drive this vehicle. The main purpose of owning 2 tons of car is to allow me to survive an MVC (motor vehicle collision).



My ER is a level 3 trauma center. Weather permitting, an MVC patient having life threatening injuries, may be sent to one of the level 1 trauma center 30 miles from my area by helicopter. Most occupants of a car crash are brought to the regional level 3 hospital. The patients arrive on a board with a cervical collar in place. ALS (advanced life support) is rarely needed for victims of motor vehicle trauma. New evidence has supported the concept of scoop and run versus the ALS, stay and play. Thankfully automotive design has made cars, trucks, and vans safer for their occupants in a MVC.



When a patient from an MVC arrives in the ER, the nurses, doctors, techs and PA's do a primary assessment. Vital signs, airway, breathing and cardiovascular are rapidly performed. Pertinent information as to the patients medications, allergies, past medical and surgical history and last food and drink ingestion. An examination of the patient from head to toes will guide the ER staff in determining what labs, radiographic and other diagnostic tests need to be necessary. FAST examination (an ultrasound of the abdomen) may be done quickly and without moving the patient. A trauma surgeon may be called in or the patient may be stabilized for urgent transport to a higher level trauma center.

The most seriously injured patients from an MVC are those that are ejected from the vehicle. The single most important tool for survival is to wear a seat and shoulder belt. The details of the accident such as speed, area of impact, and rollover may give clues as to the type of injuries that the patients will have. Prolonged extrication times are also important as internal injuries with ongoing blood loss must be addressed as soon as possible.

There are strong guidelines as to the type of seat and its position for protecting babies and children in motor vehicles. Parents must use the correct seat type for the age and weight of their child. Belts and straps must be applied as recommended by the device and car manufacturer.

Winter is here. Snow, ice, wind make driving a challenge. Take your time. Appropriate speed is determined by the weather and road conditions, not the speed limit. Wear your seat belt. Protect your children. Maintain your car with winter tires, lots of window washer fluid and proper air pressure in your tires. If there is a storm advisory, stay home. Don't drive unless you have to. Bruno, my trusty tank, will get me to the ER. I will be there with my coworkers, ready to care for the victims of MVC's

SAD

S.A.D is an acronym for seasonal affective disorder. This used to be referred to as the winter blues. Short days, long nights, cold, windy and snowy conditions make some feel blue. My beautiful wife will inevitably tell me that we must go somewhere warm and sunny during the long winters of the Northeast.

The holidays are also a source of winter depression. The joy and festive mood of the Christmas season reminds us of the loved ones who are not with us. Military personnel serving in war zones or on distant bases, family in far off cities, towns and foreign countries, and family and friends who have passed leave us bereft and aching.

The economy has idled millions of our fellow citizens. The number of Americans who have had their homes foreclosed is staggering. What parent wouldn't feel depressed when faced with a Christmas among strangers and no presents for their children.

I want to cure the winter blues. Isn't that what a physician is trained and sworn to do? SAD is treatable. Special whole spectrum lights can affect the parts of the brain that cause the sadness and lack of energy associated with SAD. In severe cases antidepressant medications may be prescribed and are usually effective.

In the ER, the number of psychiatric patients often increases around Christmas and New Year's. The staff provides a warm bed, food, a TV for entertainment and medications for our depressed, schizophrenic, bipolar, substance abusing patients. Their stay in the ER is prolonged because of the dearth of beds in the psychiatric hospitals.

To my gentle readers, I would make a request. Spread the joy of the holiday. Be kind to all you encounter. Donate food, clothes, toys and money. Volunteering costs you only some time and yet yields great rewards for the recipients and the givers. Be sensitive to those who are feeling the void of a missing loved one. Kind words, a hug if appropriate, and prayers if one is so motivated.

My wife and I will spend Christmas eve with family. Tomorrow we will visit my nonagenarian mother in the nursing home. "It's a wonderful life" is on TV tomorrow night. We will sit together, speak the dialogue along with Jimmy Steward and Donna Reed, and cry at the ending.

Merry Chistmas. Feliz Navidad. Chung Mung Giang Sinh. Boas Festose Feliz Ano Novo. Kala Christouyenna. Joyeux Noel. Soursdey Noel. Buone Feste Natalizie.

Peace on Earth!

Seven days til Christmas

Tis the week before Christmas and all through my mind,
Visions of moms with their kids; complaints of all kind:
Sniffles and coughs, fever and chills,
Spitting up, pooping, bumps and spills,
Swallowing toys, batteries, and herbage,
Infants and toddlers will eat any garbage.

The plants of the season give me concerns,
Mistletoe, poinsettias and even house ferns,
All can injure if chewed or ingested.

Holly especially is one to be detested:
20 berries to a child is a dose that may kill,
Vomiting, gasping, seizing; this is not a drill.

Take care with toys that have been painted,
With lead and cadmium, they could be tainted.

Sleds, skate, skis and snow boards make great presents,
Add a helmet for the young and even the parents.

Safety for my patients keeps me awake,
Thin ice may cause drowning for wee ones who skate.

Low temperature, wet and wind: frost bite is a real peril,
Layers of clothes, hats, scarves, mittens; warm winter apparel.

Hot toddies, egg nog and drinks for the season,
None for children and with good reason,

Alcohol is a poison even in small doses,
Take care of the partiers with curious noses.

But you'll hear me proclaim ere my words fade from sight,
Have a safe Christmas and to all a good night.

Fit to be Tied

Fit, spell, seizure, epilepsy, ictus are all terms that denote a seizure. Let's start with a definition. A seizure is a sudden neurological event caused by an abnormal excessive discharge of a group of neurons in the brain. The disease, epilepsy is recurrent seizures due to a chronic underlying process. Seizures are grossly divided into generalized and partial (focal).

Simple partial seizures do not lead to alterations in consciousness. The patient may have motor, sensory, automatic or psychic symptoms. Complex partial seizures include alteration in consciousness in addition to automatisms such as lip smacking, chewing, aimless walking or other complex motor activities.

Generalized seizures are either grand mal (tonic-clonic) or petit mal (absence). Have I ever mentioned that the French were the pioneers in neurology?

Grand mal seizures always present with a loss of consciousness and posture control. During the tonic phase there are marked contraction of muscles. Teeth clenching may lead to oral trauma and bleeding. The clonic phase of the seizure demonstrates rhythmic jerking of the body. There is usually a loss of control of the bladder and sometimes the bowels. A person having a grand mal seizure is not swallowing his tongue. One should not try and force anything into the patient's mouth. First aid is to remove any objects around the victim that they might cause injury and if possible to turn them onto their side.

Absence seizures are best described as a sudden brief impairment of consciousness without a loss of posture control. The typical petit mal seizure is 5-10 seconds of staring with minor motor twitching. The danger is that a petit mal seizure occurring while driving or performing any dangerous task could be disastrous.

Focal seizures involve only part on the body. Sometimes a single limb or side of the face, or more commonly a half of the body. Focal seizures are caused by anatomical abnormalities on the side of the brain opposite the side where the seizure activity is noted.

Some clonic movements may also be seen with many forms of syncope. Cardiac arrhythmias, vasovagal syncope, hyperventilation syncope may all show brief muscle twitching. In the ER psychogenic or pseudoseizures are part of the differential diagnosis in the seizure work up. Often patients with a true seizure disorder will have pseudoseizures. The lack of respiratory muscle involvement, the stylized movements and the lack of a postictal period of confusion and lethargy help to separate the psychogenic from the true seizure.

Seizures are often idiopathic, that is that there is no known cause. Genetics do play some role in idiopathic seizures. Tumors of the brain or metastatic tumors from other cancers, vascular anomalies such as AVM's (arteriovenous malformations), strokes and trauma to the brain are all anatomical causes of seizures. Many medications and abusable substances lower the seizure threshold and may lead to seizures. Isoniazid for tuberculosis, alkylating agents for chemotherapy, antimalarials (chloroquine and mefloquine), antipsychotics, antidepressants, alcohol, speed, cocaine, PCP, and methylphenidate are just some of drugs that may cause seizures.

In the patient with known epilepsy, a recurrent seizure work up will include an examination for any evidence of brain injury, infections, electrolyte abnormalities, and blood levels of the anticonvulsants that are prescribed for the patient. A drug and alcohol panel may also be done. Missed doses or simply stopping their medications are most often the cause of the recurrent seizure.

A first time seizure in an afebrile child or adult will lead to a more comprehensive work up. Besides blood and urine tests and a detailed history and physical exam, some type of imaging study will be performed. A CT or MRI of the head is part of the initial examination. An EEG will be done as soon as possible. Neurologists prefer that the patient not be started on an anticonvulsant until the EEG has been done. The ER doc must strongly admonish the patient that he or she is not to drive, operate machinery or engage in dangerous activities (scuba diving, climbing ladders, skiing, etc) until cleared by the neurologist. Seizures with fever especially in an adult may indicate a CNS infection such as meningitis or encephalitis and an LP will need to be performed.

Simple febrile seizures are a fairly common ER occurrence. In children from 3 months to 5 years, a seizure that is generalized, lasts less than 5 minutes and is accompanied by a fever is the usual presentation. The work up will depend on the individual patient's history and physical examination and height of the fever. About 80% of children who have a simple febrile seizure will not have any additional seizures. The EEG and use of anticonvulsants is rarely needed except for the 20% who return in the future with second or third febrile seizures. First aid as mentioned earlier is to protect the child from injury and to turn him on his side.

A newborn having a seizure, with or without fever, will be more aggressively evaluated with CT and LP almost always being part on the examination. Birth trauma and neonatal infection are the most common etiology of seizures in this patient population.

Status epilepticus is a life or death emergency in the patient with seizures. Status is the term used to describe a patient who has multiple seizure without a return to full consciousness or a patient who has continuous seizure activity. Untreated, status epilepticus will cause permanent injury to the brain or death. A recent patient of mine illustrates the difficulty in management of this condition.

The patient was man in his 60's who had had a hemorrhagic stroke in the past. He had a craniotomy to remove accumulated blood and was taking anticonvulsants. The injury to his brain had been on the left side. He presented to the ER with the paramedics and had been given IV lorazepam. This medication is a benzodiazepine and is a rapidly effective anticonvulsant. The patient was still having seizure activity involving the right side of his face and his right arm and leg. Blood tests and a CT did not show any obvious cause of his continued seizure activity. The patient was endotracheally entubated to protect his airway and multiple doses of ativan were given. He was given a loading dose of phenytoin, an additional anticonvulsant and paralytics to stop the motor activity. I arranged for urgent transfer to a tertiary care hospital as even when paralyzed the seizure activity of the brain could still be occurring. He needed continuous EEG monitoring. As he was about to be transferred I noticed a subtle twitching of his right eyelids. My parting shot was a loading dose on phenobarbital, a potent anticonvulsant.

Seizures are a frightening experience for the patient, their family and friends and even the bystanders who witness the ictus (from the Latin, meaning to strike). Historically, people with epilepsy were considered possessed. Exorcisms, trephinations (holes drilled into the skull) were perpetrated against these unfortunate patients. The psychic pronouncements of individuals with simple partial seizures may have been the basis for the oracles of mythology. As enlightened humans we should recognize that epilepsy in all its manifestations is diagnosable and treatable. There is no room in the 21st century for stigmatizing patients with epilepsy.

Knowledge leads to understanding.

Due Date

This epistle is dedicated to a dear friend. She is a great ER nurse who recently "caught" a baby.



Docs, nurses, cops, and EMT's don't deliver babies. Women deliver babies. Everyone else involved just helps. The hospital where I "live" has a busy OB service. More than 3,000 babies a year enter this troubled world from within our doors. Highly trained labor and delivery nurses and special care nursery staff along with obstetricians, anesthesiologists and pediatricians all work hard to ensure a safe and healthy outcome for mother and child.



Occasionally the delivery occurs in the ER. ER docs and nurses are trained, have the appropriate equipment and are ably backed up by the L&D and nursery pros. Deliveries in the community are the responsibility of police, firemen, and EMS personnel. The mother and child arrive in the ER and stop only if not stable enough for transport upstairs.



A recent episode highlights an unusual OB and neonatal case. The call was for a precipitous delivery in an apartment. The mother was OK but the baby was reported to be blue. The night ER staff was ready with a warming stand, and all the equipment for entubation and resuscitation of the newborn. The baby arrived crying lustily. His face was blue but the rest of his body was pink. He had good muscle tone and good respiratory efforts. His oxygen saturation was 100%. The blue face was caused by bruising from his too rapid descend through the birth canal. His mother's use of cocaine was probably a factor in his hasty entrance.



The twilight zone of deliveries resides in the cars that drive up to the ER entrance with a usually male driver yelling that his wife/girlfriend is having the baby in the car. In my 30+ years of ER experience, I have done 2 "auto" deliveries.



The first was in a small car. It was February and the ambient temperature of 20 degrees (F). The delivery was easy. The cold was the problem. Being a much younger "world's oldest ER doc", I placed the baby on the mother's stomach, wrapped both in a blanket and lifted them up in my arms and rushed into the ER. All went well for mother and baby.



My second drive-up delivery was very different. My "old" friend (the nurse to whom this blog is dedicated) ran out to the minivan in response to the husband's cries for help. A rather large woman of about 110 Kg was lying on the passenger's seat that was in the reclined position. The mother's feet were up on the dash and between her legs the nurse saw two tiny feet dangling from the vagina. The nurse's calls for help were clearly heard in the ER core as she yelled my name. I grabbed some gloves and went through the ER waiting room to the minivan. An obstetrician (who no longer works at our hospital) arrived almost at the same time.



A breech delivery is when any part of the lower half of the baby leads the way down the birth canal. This unfortunate mother was scheduled to have an elective Cesarean section at 8:00 AM that day for an ultrasound proven breech presentation. I was faced with a double footling breech delivery. Most emergency medicine residencies give little training in the management of abnormal deliveries. Ultrasound has decreased the unexpected brow, breech, or shoulder presentations. The OB doc who met me at the minivan offered only the advice that I should get the mother upstairs and then turned and reentered the hospital.



There was no way to safely lift and transport this woman from the van to the ER. My mind and hands recalled a single leg and full breech delivery that I had done while on my obstetrical rotation, during my EM residency back in the seventies. I probed and brought out the upper arm and then the lower arm and finally the baby's head. I clamped and cut the umbilical cord and rushed the baby into the ER. The mother followed soon there after. The baby had a broken clavicle but was otherwise perfectly healthy.



My nurse-friend and I were shaken by this close call. My partners all commented that they had never seen any type of breech delivery and were relieved that I (not they) had been working that night. The nurse shared with me that she had nightmares about this case. The what ifs were hard to digest. I slept well that morning, after my shift ended and I arrived home. Being OCD, I brushed up on all less than normal deliveries with a very old textbook from my medical school collection.



There is nothing more satisfying to anyone who works in health care than being part of a delivery. The birth of another human being is awe inspiring. It was a privilege to have had the opportunity to assist these 2 women. My dear friend currently works in the ER of a tertiary care hospital that handles most complicated OB cases in our region. Her occasional per diem shift in my ER and our friendship keep us connected. The case of the double footling breech is our special bond.

GGB redux

One of my earliest blogs was about falls in the elderly and the subsequent ER visits from the injuries suffered. I bloviated about the neurological, cardiac and pharmacological issues that led to these all too frequent events.

A recent ER patient and my elderly mother reinforced for me, the extent of this increasingly common health care problem. My patient was 101 years old and lived in an assisted living facility. She had some mild dementia but was amazingly intact mentally, considering her age. She arrived on a back board in a cervical collar and was crying out in pain. She complained of right hip pain and had an obvious deformity with her right leg being shorter than the left and externally rotated. A review of her medical record showed a fall had fractured her left hip a few years ago and she had a repair and successful rehab of this injury.

Two days later I awoke from my AM nap, after working my usual three night stretch, to find a text from my sister. My 91 year old mother had fallen at her assisted living facility and broken her right hip. Two years ago my mother had fallen and fractured her left hip. The repair and rehab required only one month before she was able to return to her "home".

After a lengthy stay in the ER, my mother was finally transferred to an in-patient bed and put in traction. The next day I drove 75 minutes to spend the day with my mother. I met the surgeon and anesthesiologist and signed the consent forms for her surgery. My mother also has some mild dementia. All her memories are present and accounted for, but the filing system is not very accurate. I had an interesting conversation with her anesthesiologist. I stressed that my mother did not wish any resuscitative efforts if she had cardiac or respiratory failure. He told me that in the OR they might need to do CPR temporarily if her heart rate dropped. My mother has severe kyphoscoliosis of her back. She is shaped like a question mark. One CPR compression would shatter her rib cage. I persuaded him that no CPR should be given under any circumstances. I kissed Ma and told her I would see her after the surgery and went to wait for her return to her room.

The surgery was successful. My mother's right hip was repaired. She has been oxygen dependent since the surgery because of persistently low O2 saturation. She is depressed and says she cannot understand why God won't answer her prayers and let her die in her sleep. She is frightened and dreading the rehab process. My siblings, our spouses, her grandchildren and their spouses and partners have all been to see grandma. Her nieces and nephews have been in touch. She is the last of her generation in her family that included more than 40 first cousins.

I spent some time with Ma yesterday at the nursing home/rehab center. The place is clean, well staffed and cheerful. She is no longer actively suicidal but still says she would welcome death. The challenge is whether she can be ambulatory enough to return to her "home". She and I talked about her marriage of 50 plus years to my father. She told me she had a wonderful life. She had a loving husband, and friends from her childhood that have survived and maintained contact. She has 4 grandchildren and three great grandchildren. She is loved and cherished by all her nieces and nephews.

One week post-op, she was lucid and on the mend. She still required supplemental oxygen and the pace of her rehab is much slower than it was 2 years ago. Thanksgiving is in less than 2 weeks. My wife and I play host to our extended families on this, our favorite holiday. I set turkey day as a goal for Ma. If she can walk even 10 steps with her walker by Thanksgiving, she can celebrate with those who love her. I'll keep you posted as her recovery continues.

There are two ER relevant issues from my patient's and my mother's cases. The first is the diagnosis of dementia. Not all confusion and memory problems in the elderly are Alzheimer's disease. The loss of neurons from aging and "ministrokes" cause much of the late onset dementia in the elderly. The diagnosis of Alzheimer's disease is anatomically based. Only a brain biopsy or a post-mortum examination of brain tissue can definitively make the diagnosis. Early onset dementia is presumed to be Alzheimer's unless some other cause is found. The level of confusion and even agitation in patients with dementia fluctuate from day to day and even during the day. Sundowning, increasing confusion beginning in the late afternoon or evening, is a well established phenomenon in patients with dementia.

The other problem, highlighted by my 101 year old patient, is the back board. These are used in some form to stabilize patients who might have an injury to the spine. Their design hasn't changed for decades. They are flat. The human spine is not straight. The normal spine arches forward in the neck, posteriorly in the thoracic area and forward again in the lumbar region. New designs have incorporated this natural curvature. They would be much more comfortable for the patient and give greater stability to the spine during transport. The newer models are also more expensive and the cost of replacing all the boards used by EMS services would be prohibitive. I understand the reality of cost containment but both my patient and my mother said that the board was more painful than their fractured hip. Food for thought.

Resquiescat in pace

RIP. As a new member of the medical staff of my hospital in the early 80's, I needed advise and guidance. A smiling pediatrician welcomed me to Local General Hospital. Dr M worked in a large multispecialty group practice. He later started his own office with his wife who managed the practice. Children from his practice would arrive in the ER after a phone call from M. The information would often include insights into the dynamics of the family. Having M's friendship and confidence was greatly appreciated by a naive ER doc.

I was privileged to be Dr M's personal ER doc. He and his beloved wife honored me by their confidence in my abilities. When my nephews needed a new pediatrician, Dr M welcomed them into his "family" of patients. Eight days ago M made his last visit to the ER. He had suffered a cardiac arrest at home. Despite CPR by his wife and the best efforts of EMS, ER and intensivists at our hospital, Dr M died on Halloween morning.

A memorial service was held this morning. I had worked the past three nights and grabbed two hours of sleep. A shower and my best dark suit made me presentable to say goodbye to my friend. The church was packed with colleagues, family, friends and patients. The receiving line at the wake last night began forming an hour before the viewing began. A reading from "Winnie the Pooh" was given by one of M's son. His other son who joined his office 5 years ago, read a pertinent passage from the New Testament. The CEO of our hospital gave a deeply felt and moving eulogy. A life long friend added a eulogy that gave insight into M's personal life.

What is the measure of a man? Dr M was a loving husband and father. Friend, mentor, care giver, teacher. He served as president of the medical staff, member of the board of trustees, and tirelessly raised the profile and brought in donations for the hospital. The loss of this extraordinary man will be felt by everyone who was embraced by his warmth and humanity.

The epitaph for Dr M is what he told my sister-in-law and the parents of all his kids, "take him home and love him".

All Hallow's Eve

Tomorrow is Halloween. I will be working my usual night shift. I fear that my fellow B.O.N.E.R. doc, Zorba, will have the scarier time tonight. Young adults and older teens use the occasion for excessive drinking, drugging and hormonally fueled shenanigans. Costumes, alcohol, parties, and hell raising are guaranteed to bump up the ER census.

My wife loves to hand out the packaged candy to the local kids. Our neighborhood contains many families with young children. Frightening tales of tampered goodies with poisons, needles and medications require that treats must be commercially produced and dispensed in their original wrappings. Earlier in my career, the ER offered to x-rays treat-bags to ensure that no metallic foreign bodies had been secreted into the candy.

The tricks of Halloween usually are benign and stale; egging, "TP ing", and flaming dog poop bags are common pranks. More innovative tricks such as hallucinogens in the cider, can swamp the ER with spaced out patients dressed as witches, devils, and assorted celebrities.

The application and adornment of the physiognomy of the Halloween party goer may lead to visits to the ER. Superglue is often used to attach horns and other embellishments. The problem arises when the glue gets into the eyes or near the nether regions. Removing the glued-on bits may cause avulsion of the underlying skin. OUCH!

In the Northeast, where I reside, hypothermia is also a risk during Halloween revelries. Costumes are often skimpy in their coverage and wearing a coat would ruin the ensemble. The effects of alcohol contribute to the hypothermia potential. Alcohol irritates the esophagous and stomach giving the imbiber a sense of inner heat. The vasodilating effects of alcohol cause increased heat loss from the skin and more rapid lowering of the core body temperature.

The truly tragic aspect of Halloween is the four fold increase, in auto-pedestrian accidents involving children, compared to the other 364 days of the year. Parents be advised, make your child visible and keep their own vision unencumbered. Glow sticks and necklaces, flashing LED lights, and reflective material are all excellent measures to make your child visible to drivers. Avoid masks and hoods that can limit the child's visual field. Drivers need to be extra cautious. The aftermath of injuring or killing a child are devastating for the victim's family and for the driver.

I do not wish to spoil the joy of Halloween. The world's oldest ER doc has fond memories of "trick or treat" ing with my friends back in the 1950's and 1960's. As a avid mimic, I would couple my costume with an appropriate accent. My mother's jodhpurs, and riding boots (she was a volunteer in the Women's Army Aircorp during WW 2) were paired with a puffy white shirt, monocle and my best British accent. A dhoti (Indian garment), begging bowl and an accent I learned from the movie, "Gunga Din" transformed me into Gandhi.

Today, October 30, is my twin sister's birthday. Yes, our birthdates are 28 days and almost 2 years apart. Think Danny Devito and the Arnold in the movie "Twins". No one embraces the joy and exuberance of the holiday more than my friend and spiritual twin, Joanne. Happy Birthday sis!

Algia

Almost every ER patient complains of some type of pain. Cephalgia, neuralgia, arthralgia refer to head, nerve and joint pain respectively. The root algia is from Latin. Angina from the Latin for choking also is used for several painful conditions. Angina pectoris is the term for pain in the chest from narrowing or blockages of the coronary arteries. Intestinal angina is used to describe pain from narrowing or blockages in the arteries that supply the GI tract. Ludwig's angina is severe throat pain from an infection in the mouth or throat that spreads towards the chest through the fascial plains of the neck. Colic is another medical term for pain that were thought to occur from intestinal sources. It's three types are infant (general crankiness without another source), renal (from the passage of a kidney stone) and biliary (from gall stones or bile sludge).

Pain is a protective mechanism. If one touches something hot, a reflex arc in the central nervous system causes withdrawal from the source of the heat even before we become fully aware of the pain. Noniceptors in the peripheral nervous system respond to heat, cold, pressure and sharp stimuli. These pain signals are carried to the brain by tracts in the spinal cord. The brain processes the information that one consciously perceives as pain.

Pain from an injury is from an obvious source and will resolve as the injury heals. A broken ankle will cause severe pain. Elevating and immobilizing the injured part with give some relief. As the fracture heals the pain will lessen and eventually resolve with complete healing. Similarly pain from an intrabdominal infection or from colic will resolve after appropriate treatment.

Treating acute pain is an important part of ER care. Unfortunately many physicians under treat acute pain. I have become much more "generous" in treating acute pain after my experiences as a patient with four major abdominal surgeries. PCA or patient controlled analgesia gives the pain sufferer, usually post-operative, the means to obtain IV pain meds by pushing a button. The amount and time interval between doses are set and locked. My only use of PCA was a failure. When I told the anesthesiologist (PCA may also be ordered by the surgeon) that the dose was too low and that I was getting little if any relief, he assured me that the dose was adequate.

Conscious sedation is used in the ER for patient comfort during painful procedures such as reducing fractures or dislocations, incising and draining an abscess or for a lumbar puncture. The drugs used for this sedation may include short acting pain medications such as fentanyl. A short acting benzodiazepine sedative such as midazolam is often combined with fentanyl to provide sedation with pain control. I prefer propofol. This drug causes a dissociation between the painful procedure and the perception of the pain. It's short duration and lack of long term side effects make it a valuable asset for the ER doc.

There are three main types of pain medications. NSAID's include ibuprofen, naprosyn, ketorolac and others. Acetaminophen is also a mild analgesic that may be taken solely or combined with an opiate. NSAID's are very effective for most mild to moderate short term painful conditions. Toothaches, menstrual cramps, minor orthopedic injuries and most headaches respond well to NSAID's. Moderate to severe pain usually require the third class of pain meds, opiates.

Opiates work by binding to the mu receptors in the nervous system. These receptors are widespread and are the target for our intrinsically made pain suppressors, endorphins. Anyone who has hit the "runner's high" during a prolonged workout has felt the effects of endorphins. The placebo effect is relief from the pain and other symptoms of disease or injury by an inert "sugar" pill. The belief that one is receiving treatment may cause the release of endorphins and explain the placebo effect.

Heroin, opium, morphine, codeine, hydromorphone, methadone, hydrocodone and oxycodone are all derived from the alkaloids obtained from the opium poppy. Other medications in the opiate group include meperidine, propoxyphene and fentanyl. Pills, liquids, patches, suppositories and injections are all ways of introducing these medications into the body. When given in adequate amounts for a limited time, opiates are both effective and safe.

The problems arise with pain that is never ending and psychological issues that effect pain perception. Neuralgia or nerve pain can last a lifetime and be debilitating. Damage to nerves from injury, infections (shingles), or metabolic diseases (diabetic neuropathy) may lead to constant pain. Pain from arthritis or disc disease may not resolve with treatment of the underlying condition. Phantom pain from amputated limbs is common and may be permanent. Pain from cancer is another example of the need for chronic pain management.


Patients with depression have an altered perception of pain. The flip side to this is that chronic pain may lead to depression. Antidepressants are often used with other medications to treat some forms of chronic pain. Anticonvulsants such as gabapentin have been used to treat neuropathic pain. Psychological counseling, physical therapy and exercise are also tools in the holistic approach to chronic pain management. It is important that patients with chronic pain be given long acting pain medications such as methadone, prolonged released morphine or fentanyl patches. A short acting medication such as hydrocodone or oxycodone should be available for acute exacerbations of the underlying chronic pain. The physician must take tolerance into account, and be willing to gradually increase the dose of the long acting medication as needed.

Physicians must accept some of the blame for the abuse of opiate pain medications by patients. Giving too little medication, for less time than is required for healing, will force the patient to try and find relief somewhere else. Some physicians give too strong an analgesic and this may lead to tolerance. Tolerance and addiction are the downside of opiate medications. There is evidence that the number of mu receptors increases in patients taking opiate medication for a prolonged period of time. The need for greater doses of pain meds to achieve the same level of relief (tolerance) may be the result of the increased number of mu receptors. The symptoms of withdrawal from opiates are all too real. The "screaming" of the mu receptors "feed me" is what makes withdrawal a living hell.

Drug seekers are the bane of an ER doc's existence. The causes of the pain may be genuine but their drug addiction makes them a drain on the time and patience of the ER staff. It is sometimes difficult to separate the patients with pain and the addicts looking to score. I have received letters, from various regulatory agencies, telling me that a patient who I prescribed opiate pain meds had received multiple prescriptions from multiple doctors. Multiple ER visits for minor problems, "allergies" to every drug except the one they want, and reported pain out of proportion to the injury, all may be indicative of the drug seeker. Threats to "call my lawyer" and verbal and physical assaults also are the signs of drug seeking behavior.

When I graduated from medical school in 1977, I didn't take the Hippocratic oath. My classmates and I took the Oath of Maimonides instead. "In the sufferer, let me see the human being."

Plus ca change

The more things change, the more they stay the same. It sounds classier in the original French. I was somewhat blocked as to a subject for today's blog. While waiting in line at Starbucks, I ran into an old friend. This gentleman is 11 years older than me. He went into medicine in his 40's after a career of writing. He and I worked together in the ER where I still practice. He was forced out and went to work in a small town in Vermont with an ER that sees 1/5 the volume of my hospital. He is approaching seventy and still going strong. I am only hoping to get to 67 before retiring.

There are quirks of ER practice that occur repeatedly. New generations of patients still have the same odd behaviors. The numbers keep going up and the mix of patients varies but somethings stay the same.

"I have this pain in my back for a month." After sliently groaning, I try not to roll my eyes and ready my questions. Bladder function, bowel habits, fever, chills, numbness, weakness... "I have an appointment with my primary care at 11:00 but I couldn't wait any longer." This is said to me at 2:00 AM. Why? The patient waited weeks to get an appointment but was unable to wait an additional 8 hours.

I approach a lovely woman in her eighties. The chief complaint is abdominal pain. "What is the problem tonight?" I ask with some trepidation. She begins her story in 1936. She regales me with issues from the Great Depression, WW2, her marriage and children. An older gentleman responds to the same question by taking out a notebook that details everything he has eaten in the past 6 month and how his body reacted to each and every meal.

A mother and infant on the stretcher resembling a renaissance painting of the Madonna and child. The chief complaint is fever and a runny nose. I ask what she gave for the baby's fever and she says "nothing, I brought him to the ER". In loco parentis. ER's have become substitute parents. This is especially true of first-time teen mothers. My dear friend Elizabeth, was an ER nurse who trained at Children's Hospital. She cared for the baby and gently educated the mother.

Vomiting and eating is a recurrent issue in the ER. The toddler who is in the ER for vomiting is being fed cheese puffs by his mother while seated on the stretcher. The first thing a patient who is retching in the barf bag asks is, "can I have something to drink?".

0600 on a Tuesday morning, after a three day weekend. The bus has arrived. Five patients in triage for mild complaints. The hidden agenda is the doctor issued work note. Mr Jones skipped work on Friday and now needs a note to justify his absence. Citizens who have scheduled court appearances also seem to develop vague symptoms early in the morning of their court date.

The patient generated diagnosis is usually from a visit to WebMD prior to arriving in the ER. When a young man tells me that he has Lupus, when I see a contact dermatitis on his face from his new cologne, I know that the internet is to blame. The appropriate cliche is "a little knowledge is dangerous". The herd of zebras that thunder through the ER is driven by various web pages devoted to empowering the patient. I am told what tests and scans that the patient feels he or she needs. I gaze over my reading glasses and try and explain a more rational approach to finding a cause of their listed symptoms.

My colleagues in primary care and other fields of medicine contribute to the cavalcade of self diagnosing and self ordering by my patients. "My pediatrician says Susie needs a CAT scan because her stomach ache could be appendicitis." "Jimmy has a headache and my doctor said it could be meningitis, so I want him to have a spinal tap." Susie is playing her video game while scarfing down an ice cream sandwich, and Jimmy was seen running around the waiting room and yelling at the other patients.

As my good friend Clyde pointed out to me over a cup of good coffee, plus ca change, plus c'est la meme chose.

ITIS

A beautiful fall day and I have an aching left shoulder. Tendinitis or bursitis. Popping aspirin helps. I know exactly how this injury occurred. A poorly done weight training session, one day after turning 58, caused this "itis".

Arthralgias, joint pains, are divided medically into inflammatory and non-inflammatory subsets. Rheumatoid arthritis is the poster child for inflammatory joint disease. The body's immune system attacks the components of the joints with pain, swelling and ultimately destruction of the joint. Anti-inflammatory medications such as aspirin and NSAID's have always been part of the treatment. Immune modulators are the newest and most beneficial treatment modalities. The side effects of this immunotherapy are an increased risk of infections and cancer.

Osteoarthritis is the most common form of joint disease. There is a familial risk of the more severe form of the condition. Wear and tear of the joints from work and recreational stresses make all of us susceptible to OA. Our bones may get thicker as we gain weight but our joints don't get larger or more robust from added body weight. Arthritis, leading to joint replacement, is increasing because of the epidemic of obesity in our nation.

Joint pains may also be caused by injury and inflammation of tendons, ligaments and bursas near joints. My shoulder pain is most likely tendinitis of the biceps tendon. Bursitis is a possibility. Bursas are sacs that help lubricate the tendons and bones around the large joints. A plain x-ray of an aching shoulder may reveal calcification in the bursa from chronic inflammation. Those calcium crystals are like microscopic knifes, stabbing at the tender lining of the bursa.

NSAID's are the first line of treatment for all the "itises" in or around the joints. Rest, ice, creams such as Icy Hot may give additional relief from pain. A well placed shot of a corticosteroid by a physician is the best long term treatment. I am contemplating a visit to my favorite orthopedic surgeon, "the Czar", even as I write this blog.

Another condition that causes joint pains is nerve impingement. Carpal tunnel syndrome is pain in the wrist with numbness, and pain in the fingers from injury to the median nerve, as it courses through the wrist bones (carpal tunnel). Repetitive motions such as typing, assembly work and carpentry may lead to swelling in the carpal tunnel and pressure on the median nerve. Nerve impingement can also occur at the elbow, knee and ankle. Temporary relief with splints, anti-inflammatory medications and avoidance of the mechanical cause is possible. Surgery is often necessary and curative.

As we age, our joints simply wear out. Our bones thin, our muscles become weaker, and our connective tissue becomes less flexible. Arthritis is part of the natural aging process. There is no cure, despite the many "snake oil" sellers in newspapers, magazines and especially on the internet. There is no scientific evidence that glucosamine and/or condroitin alleviate or arrest the progression of arthritis. Ditto for shark cartilage, "super fruits", and assorted creams and lotions. Maintaining an "ideal" body weight, regular low impact exercise, and a good night's sleep are your best weapons in the fight against degenerative joint disease.

I feel obliged to mention a disease that makes ER docs cringe when listed on a patient's medical history, Fibromyalgia. Back in the mid 70's, as a medical student I had an instructor named John J Calabro, MD. Dr Calabro was a rheumatologist. He was a dedicated teacher and a compassionate physician. He also wrote one of the earliest treatises on a condition known as fibromyalgia. I remember him telling me that the woman he married had been one of his patients, who he diagnosed with fibromyalgia.

Muscle fiber pain is a loose English translation for fibromyalgia. As with Chronic Fatigue Syndrome and Chronic Lyme disease, two other conditions associated with severe and long term muscle and joint pains, there exists no specific lab test to confirm the diagnosis. Tests for lupus, rheumatoid arthritis and general inflammatory markers are all negative/normal in fibromyalgias. The disease is diagnosed by objective criteria. Harrison's textbook of medicine describes fibromyalgia as a "common disorder characterized by chronic widespread musculoskeletal pain, aching, stiffness, paresthesias, disturbed sleep and easy fatigability along with multiple tender points". The tender points are usually symmetric and number more than three. The upper back, shoulders and neck are common sites. This heightened (exaggerated?) and painful response to applied pressure is the hallmark of fibromyalgia. The ratio or women to men with fibromyalgia is 9:1. Certain anti-convulsants and anti-depressants, anti-inflammatories, "trigger point" steroid injections and long term opiate pain medications are used to treat fibromyalgia.

Improved sleep, exercise, weight loss and stress reduction have all proven helpful in treating fibromyalgia. In patients under fifty, fibromyalgia is the most common diagnosis for musculoskeletal pain. Despite my respect for Dr Calabro, I remain an agnostic concerning fibromyalgia. research into the levels of neurotransmitters in the pain-sensing portions of the brain may ultimately confirm the cause of this condition. Stay tuned!

Germs Chapter 3, The Deadly Viruses

There exist many viruses that are lethal or at best controllable. HIV, rabies, and hemorrhagic fevers all are included in the "deadly viruses".

Rabies is caused by a rhabdovirus. There is a large reservoir of rabies in the animal kingdom. In the US, bats, raccoons, skunks, coyotes and foxes are common sources. Any predator animal and even some large prey animals may harbor rabies. Bites, scratches and even saliva may transmit the virus. Animals who are infected die. The viral inoculation occurs at the site of penetration. The virus travels up the local peripheral nerves and eventually makes its way into the central nervous system ultimately causing encephalitis and death. Infected animal often display abnormal behavior. Aggression and unprovoked attacks may be evident. During the late stages, the infected animal or human has difficulty swallowing. The drooling saliva from this dysphagia gave rise to the term hydrophobia (fear of water) to describe rabies.

Rabies is not universally fatal. There have been a few victims who survived. The Milwaukee protocol arose from the survival of a young woman after she became infected with rabies. The treatment involved a drug induced coma. Ketamine, midazolam and phenobarbital were used to place the patient in a coma. Antiviral medication (ribavirin and amantadine) were given intravenously. The patient has made a remarkable recovery. Other factors may have aided her survival. The bite was in her finger. The strain of the virus may have been weak.

The treatment of rabies involves giving passive immunity by injecting RIG (rabies immune globulin) into the area of the bite and into the large muscles of the buttocks. The amount of RIG is based on the patient's weight. Stimulating active immunity is done by giving rabies vaccine in several doses over the course of a month. This treatment can have painful and even serious medical side effects. If the source animal can be tested and found to not have rabies, the human victim may be spared those many injections.

Don't feed or even approach feral animals. Dogs in the US rarely harbor rabies. Feral cats are a potential source. Be careful and notify animal control as soon as possible.

Viral hemorrhagic fevers include Crimean-Congo, Rift Valley and South American strains. The filoviruses that cause Ebola and Marburg also cause hemorrhagic illnesses. The symptoms include fever, petechiae, mucosal and gastrointestinal bleeding. Severe headaches, hypotension and vomiting and diarrhea occur. The only treatment is supportive care with hydration, blood products and careful monitoring. The mortality rate is high.

Yellow fever, and Dengue are caused by flaviviruses. They cause liver damage, with jaundice being evident (yellowing of the skin and conjuctiva). Black vomitous is often seen in Yellow fever. There is a vaccine available for these diseases and if you are traveling to areas that are endemic for them, you should get the vaccination. Mosquitoes are the carrier for all the hemorrhagic fevers. Use of bed netting and avoidance of mosquitoes are good practices in endemic regions.

As an emergency medicine resident back in the late 70's, I saw a few young men with purple colored skin lesions. The had fevers, weight loss, unusual infections such as pneumocystis pneumonia. The skin lesions were shown by biopsy to be Karposi sarcoma. I had read in my pathology text that this cancer was usually seen in elderly men from the Mediterranean area.

AIDS was the name given to the constellation of diseases caused by HIV. The virus was subsequently identified as a lentivirus. This retrovirus uses RNA as its genetic material. After thirty years of research, no effective vaccine to prevent HIV infection exists. HIV binds to and kills a type of lymphocyte that is involved with human cellular immunity. The infections and cancers that make up AIDS, arise because of the damage to the patient's immune system.

The early history of HIV/AIDS was of horrible, wasting death. Although not curable, HIV/AIDS has become a chronic manageable disease. HAART is highly active antiretroviral therapy. This treatment uses medication that attack the virus in several ways. Nucleoside Reverse Transcriptase and non-Nucleoside Reverse Transcriptase inhibitors interfere with the virus's ability to copy its RNA. Protease, entry, and integrase inhibitors work by other mechanisms to hinder the HIV. The patients are followed with blood tests to monitor their viral load and CD4 lymphocyte counts. These potent medications have significant side effects. They must be taken faithfully. Unfortunately, the incidence of HIV is increasing because of continued unsafe sex practices and IV drug abuse.

HIV exposure from occupational needle sticks or unprotected sexual contact can be treated with PEP (post-exposure prophylaxis). This involves taking anti-retrovirus medication for several weeks. It is effective but the side effects of the medications make it difficult to complete the treatment.

Hepatitis C is caused by a single strand RNA virus. It is spread by contaminated needles or blood exposure. There is a treatment involving pegylated interferon and ribavirin. The treatment doesn't work for all patients and the side effects of the medications may prevent completion of the treatment course. Hepatitis C often leads to cirrhosis and hepatocellular carcinoma many years after the initial infection. The blood supply is no longer a source of this disease. IV drug abuse and occupational exposure to infected blood are the main sources.

I find it humbling that the simplest living organisms (viruses) cause so much human illness. Our overpopulation and encroachment into all environments on this small planet have exposed us to many of these scourges. Knowledge and research are the best chance for our overcoming these diseases. Stay informed, practice safe sex, if you use IV drugs, avail yourself of clean needle exchange programs. When traveling, check with the CDC for advisories concerning diseases in the areas you are visiting.

Germs Chapter 2, The common viruses

Last week I was first in line at my hospital to receive this year's influenza vaccine. Flu shots must be given every year as influenza virus strains change frequently. Influenza virus is capable of antigenic drift and antigenic shift. Think of people who alter their appearance by dying their hair or wearing disguises. This would represent antigenic drift. Now imagine if a criminal could change his or her DNA. That would be similar to antigenic shift. Human and animal influenza strains can swap genetic material and recombine to form novel strains against which, we poor humans, have no immunity. Remember last year's H1N1, the swine flu. Strains that appear in the southern hemisphere and in Asia are used to make the new vaccine for any given year. All health care workers, teachers, first responders, transportation workers, people with chronic medical conditions and those who believe in an ounce of prevention, should get yearly flu shots.

Most upper and lower respiratory tract infections are caused by viruses. These life forms are little more than a piece of DNA or RNA inside an envelope. They require the cellular mechanisms of another higher life form to replicate. The list of respiratory viruses includes influenza and parainfluenza viruses. Parainfluenza is the leading cause of croup. Is there anything more frightening to a parent than waking in the night to the sounds of your child having a cough like a seal's bark and the stridor (loud audible inspiratory and sometimes expiratory sound) that is croup?

Adenovirus, coronavirus and rhinovirus are among the hundreds of viral strains that cause colds. The symptoms of the common cold are familiar: sneezing, coughing, congestion, disturbed sleep and general misery. Differentiating between colds and the flu can be tricky. In general influenza has all the symptoms of a cold but is accompanied by high fever, severe body aches (even your hair seems to hurt), severe sore throat and lasts greater than a week.

RSV is a particularly nasty respiratory virus. The S stands for syncytial. RSV spreads cell to cell down the respiratory tract along intracytoplasmic bridges, e.g. syncytia. RSV cause bronchiolitis and viral pneumonia in infants and toddlers. Their small airways can become plugged by the RSV infection and lead to low oxygen levels. A somewhat effective anti-viral medication is administered to those children with RSV and low oxygen levels. Endotracheal intubation and respiratory support may become necessary.

The gastrointestinal tract is the other target of common human viral infections. Enteroviruses include coxsackie virus, echovirus and poliovirus. Thankfully poliovirus, which lead to paralysis is not seen except in a few countries in the world, because of nearly universal immunization with oral polio vaccine. In addition to the vomiting and diarrhea of gastroenteritis, enteroviruses can cause "hand, foot and mouth" disease. They are also the cause of many cases of viral myocarditis. I recently treated a young man, 16 years of age, for fever, body aches and headaches. His blood work was unremarkable. I suspected Lyme disease and sent off the blood test. Two days later he returned with his mother because he developed a dry cough and had become very short of breath. A chest x-ray revealed an enlarged heart and congested lungs. My partner, who is very adept at ultrasound, showed me that the patient's heart chambers were dilated and hypokinetic and that there was a small amount of fluid in the pericardial sac. We transfered this young man to a pediatric hospital and the offending agent was an enterovirus.

Most patients with viral gastroenteritis do well with sips of clear fluids and a slow progression of their diet. High fevers, weakness, lethargy, dry mucous membranes, decreased urine output and a sunken appearance (in infants) of the fontanel (soft spot on the top of the head) should alert the patient or the parent that dehydration is occuring and an ER visit is necessary.

Rotavirus, norovirus and Norwalk-like virus are all capable of causing localized and severe out breaks of gastroenteritis. Their have been episodes of hundreds of people on a cruise ship coming down with norovirus gastroenteritis. How would you like to be the ship's doctor and nurse on that cruise? An effective and relatively safe vaccine is now available to prevent rotavirus.

Herpes viruses deserve a section of their own. Cold sores, chicken pox, shingles, genital herpes, mononucleosis, and roseola are all diseases caused by members of the family of herpes viruses. Although most cases of herpes infection are self limited, this group of viruses can last a lifetime. Shingles is a recurrence of herpes zoster. The chicken pox infection one had as a child may cause you to harbor the virus in a dormant state in the nervous system. When this dormant virus awakens, it causes a rash and severe pain along a nerve in the body. This can occur anywhere from the face to the toes. Herpes simplex 1 and 2 can cause recurrent painful sores in the mouth and/or genitals. The practice of orogenital sex has blurred the distinction between these 2 strains and the regions they afflict.

Vaccination is our best weapon against viral infections. Mumps, measles, "German measles", chicken pox, hepatitis B, influenza, polio and rotavirus vaccines have saved countless lives and made childhood much less dangerous. There is no evidence that vaccinations cause autism. I would urge all parents to follow the recommendations of the American Academy of Pediatrics with regards to immunizations for their children. To my fellow older folk, there is a vaccine for herper zoster, that is recommended at age 60 to decrease the incidence and intensity of shingles. I highly recommend that you receive this vaccine.

The next chapter of Germs will deal with the deadlier viruses that bedevil humans.

Germs, Chapter 1

Germs! Viruses, bacteria, fungi. Never mind the parasites. Bacteria are very much in the news lately. The headlines scream: "Flesh eating, superbugs, resistant to all antibiotic". The problem is real and getting worse all the time. As the great philosopher Walt Kelly (writer of the comic strip Pogo) phrased it, "we have met the enemy and he is us".

Bacteria live in us and on us. The human gastrointestinal tract harbors up to a trillion bacteria. A newborn ingests bacteria along with mother's milk. The bacteria in our gut are beneficial. They help us digest and absorb nutrients. They even produce nutrients that we need to survive. They deter the growth of pathogenic bugs. Our skin, including the the sweat and oil glands and hair follicles, swarm with bacteria. the respiratory system including the nostrils, sinuses, air ways and lungs are also home to innumerable bacteria.

Companies that sell cleaning products have made us all germophobes. Hand soap, shower products, kitchen and bathroom cleaners and now even clothing contain antibacterial chemicals. Yes, you can buy socks that have silver impregnated fibers to kill the bacteria that make your feet stink. Children's toys are touted to have antibacterial compounds in the plastic. My kitchen cleaner will kill 99.9% of germs. The problem is that 0.1%.

Bacteria reproduce rapidly, if conditions are right. The bugs not killed by the cleaner are resistant to the antibacterial chemical. Random mutations or environmentally induced mutations will allow a few bacteria to survive. The offspring of these resilient bugs are all resistant.

Antibiotics have saved millions of lives. Before penicillin and sulfa, any wound often led to a lethal infection. Today few bacteria are susceptible to these antibiotics. At first the answer was to increase the dose of the antibiotic. Higher doses of penicillin could overcome early resistance in strep and staph bacteria. Bacteria evolved. A mutation led to the bacteria producing an enzyme that deactivated the penicillin molecule.

Humans are also resilient. Chemical manipulation of the penicillin molecule by adding a B-lactam ring produced methcillin. Mankind gave the bugs a new challenge. B-lactamase was the bugs response. MRSA is methcillin resistant Staphylococcus Aureus. One of the superbugs is now resistant to the antibiotics that was designed to kill this menace. A recent patient in the ER was noted on his nursing home records to have MRSA and VRE (vancomycin resistant enterococcus). The nurses gowned up and followed the infectious disease recommendation to try and minimize the chances of this bug spreading to our other patients.

In this war between bacteria and humans, the bugs are winning. NDM-1 (New Delhi metallo-beta-lactamase-1) is the latest and greatest superbug. Be afraid, be very afraid. The bacteria are developing resistance faster than the drug companies can modify old antibiotics or formulate new drugs.

Tuberculosis is as old as mankind. Human remains from our earliest ancestors show evidence of Tb infections. Public health initiatives in the late 19th and early 20th centuries along with effective antibiotics and forced quarantine, made Tb rare in the USA. Laws still exist that allow the confinement of Tb patients, if necessary, to force completion of their treatment.

Enter MRDTb and XDRTb. Multi-drug resistant and extreme-drug resistant Tb have become a scourge in many countries. Tb was once curable with one or two antibiotics. As resistance developed, additions drugs were added to the treatment regimen. MDR and XDR have rendered standard treatment ineffective.

Resistance develops as the few survivors of our antibiotic bombardments reproduce new generations of resistant bugs. Resistance based on a enzyme defense may be encoded on a plasmid. This piece of genetic material can be swapped between bacteria of different species. The bugs can pass on their defenses leading to superbugs. Bacteria also like to hang together. In our bodies pathogenic bacteria produce biofilms. This material screens the bugs from the physician's assault weapons. The antibiotics can't even get at the bugs.

What went wrong? Physicians and patients are to blame. Doctors prescribe antibiotics for conditions that are caused by viruses, or that will resolve without antibiotics. 80% of ear infections resolve without antibiotics. When I try and explain this to the mother of a 2 year crying because of his or her booboo ear, I am met with hostility. The mother insists that she must be given a prescription for amoxicillin or azithromycin. Her child's pediatrician always gives her a script.

Sinusitis, ear infections, colds influenza and gastroenteritis are all treated with often unnecessary antibiotics. Patients given prescriptions for antibiotics, whether needed or not, rarely take the medication as prescribed. If the patient feels better in a few days, he or she will stop taking the antibiotic despite the doctor's admonition to finish the entire treatment course. The unused pills are kept in the medicine cabinet, only to be taken later when the next cold hits.

Physicians must take the lead in preventing the development and spread of antibiotic resistant bacteria. Educate your patients. Patients must become informed consumers. Read about antibiotic resistance. Don't demand antibiotics unless the healthcare provider says that they are truly necessary. If you are prescribed antibiotics, take them on time and until you complete the treatment.

In many countries, antibiotics may be purchased without a prescription either legally or on the black market. I treated a young Cambodian woman in the ER for weakness. Her blood tests revealed aplastic anemia. Her bone marrow had stopped producing red and white blood cells and platelets. She had treated a cold with an antibiotic she purchased in her local ethnic market. Chloramphenicol is an antibiotic that may cause aplastic anemia. This past week, a patient from Brazil was taking tetracycline bought at the local bodega.

Are we doomed? Have the bacteria won? New antibiotics will be created. Better infectious disease protocols will be formulated and applied. The ultimate weapon may be bacteriophages (bacteria eaters). These are viruses that kill bacteria. A patient with a life-threatening bacterial infection may be inoculated with a bacteriophage instead of being given an antibiotic. This treatment is being used in Russia and may be coming to your local hospital.

Delirious

It has been 2 weeks since my last blog. My wife and I spent Labor Day weekend in Newport,RI having the joy of watching our youngest niece get married. We were deliriously proud and happy!

Delirium is an acute condition of confusion. The causes of delirium include medications, infections, vascular problems, metabolic disorders, endocrine diseases, and toxins. When an elderly patient arrives in the ER with a "change in mental status", the hunt for the cause of their delirium begins.

My beloved wife has had to deal with my own episodes of delirium. General anesthesia caused me to have paranoid delusions as I awoke in post-op. I told her that people were after me and had injured my abdomen. I had visual hallucinations induced by Dilaudid, a narcotic pain medication. I saw bunnies and giraffes in the patterns of the ceiling tiles. Another Dilaudid fueled delirium had me speaking French and not being aware of why my wife couldn't understand what I was saying.

Many prescription and non-prescription medication can lead to delirium. Benadryl, if taken in excess can cause confusional states. A mnemonic for diphenhydramine overdose is "red as a beet, dry as a bone, hot as a hen and mad as a hatter". As mentioned in a previous blog, mercury was used by hat makers to work the felt. The mercury, a neurotoxin, was absorbed through the skin and caused injury to the brain, thus "mad as a hatter". Drugs that have anticholinergic properties, narcotics (morphine, etc), benzodiazepines (valium, ativan, etc.) and many other medications can lead to delirium.

Alcohol can cause delirium when ingested and for habitual users as a symptom of withdrawal. Delirium tremens is the shaking and confusion seen in alcoholics as they withdraw. Street drugs such as ecstacy, LSD, GHB, PCP, ketamine and cocaine can all cause acute delirium.

Hyper and hypo: glycemia (blood sugar), natremia (sodium), calcemia (calcium), magnesemia, hypoxia (low oxygen), and hypercarbia (high carbon dioxide) are all potential causes of delirium. Liver failure, leading to elevated ammonia level,s and kidney failure, with resulting high urea levels, may both cause delirium as these toxic products of normal body functioning affect the brain.

Both overactive and underactive thyroid hormone levels may cause an altered mental state. Addison's disease (low levels of cortisol) and patients taking corticosteroids chronically, who cease taking these medication abruptly, may present as acute delirium. Malnutrition from anorexia, wasting diseases (such as cancer), and in chronic alcoholism often have deficiencies if vitamin B12, thiamine, folic acid, and niacin. These deficiencies may all lead to delirium.

Dehydration from lack of water intake in nursing home patients, heat exposed patients, and patients with water loss from vomiting and diarrhea may develop a change in mental functioning, i.e. delirium.

A very wise, part time ER doctor told me that when an elderly woman presented with a change in mental status, I should always check for a urinary tract infection. Any systemic infection from UTI's to pneumonia to skin and other soft tissues, may lead to delirium. Infections of the central nervous system (CNS) such as meningitis and encephalitis almost always cause alterations in consciousness.

Sensory and sleep deprivation and stress, as with a patient in a hospital ICU, may develop psychosis. Severe hypertension may cause hypertensive encephalopathy. Auto-immune diseases such as Lupus and vasculitis are potential causes of delirium. Certain forms on nonconvulsive seizures may present as acute delirium.

Whew! Do you get the picture. The work up of a patient with acute delirium is challenging. The medical description of delirium includes hyperactivity and hypoactivity. The patient may be agitated, even assaultive or lethargic. They often have altered wake and sleepy cycles. They may have perceptual deficits involving their hearing, vision, touch, etc. Symptoms of psychosis such as visual, auditory and olfactory hallucinations and delusions (false beliefs) are often present. Impaired memory is common.

Let's consider a few patients that I have recently treated in the ER. Joe is an alcoholic. He is in his 50's and is a life long abuser of alcohol. Food is eaten infrequently and of low nutritional value. He falls frequently. It is summer and he is often outdoors during the heat of the day. He presents with a temp of 103, pulse of 130, BP 160/90, shaky and very confused. He babbles about the aliens who are monitoring his thoughts. Infection, alcohol withdrawal, liver disease, malnutrition, hyperthermia, dehydration, electrolyte abnormalities, CNS injury ...

Mary arrives from the NH. The report says she is more confused than usual. Mary is a diabetic, has had a stroke that prevents her from walking, and has mild dementia. She has a low grade fever, is "picking the bugs" off of her clothes. She kicks and scratches the nurses as they try to take her vital signs and obtain blood and urine for testing. Infection, dehydration, CVA (stroke), low or high blood sugar, medication reaction ...

Jim is an obese diabetic with chronic bronchitis on prednisone. He has sleep apnea. He has been known to have a few drinks every day. His daughter found his medication bottles empty and a month out of date. His CPAP machine for his sleep apnea has cobwebs. Glucose abnormal, hypoxic, elevated CO2, low cortisol from not taking his prednisone, infection, alcohol elevated or withdrawal...

Susan is a 20 year old college student brought in by ambulance for acute psychosis. She is clearly having auditory and visual hallucinations. She responds to my questions with paranoid delusions. Is this schizophrenia or bipolar disorder with mania and psychosis? Before calling the psychiatrist, I have to medically clear her. Infection, metabolic disorder, drug use ...

A patient presenting with delirium is challenging for the ER staff. Information from family, EMS, friends, caretakers and prior records is invaluable. A thorough examination of the patient is crucial. Labs, imaging studies, and diagnostic procedures may all be utilized to arrive at the cause of the delirium. The treatment of delirium is to treat the underlying cause. Simple. NOT.

Back to school

Yes, it's time to send our children back to school. Eager minds have pined all summer, thirsting for knowledge. My younger nephews and godson are all heading to their classrooms. I spent more than $600 yesterday on my nephews for clothes, shoes, and supplies. My nephew in college, who will be turning 21 this semester, got some free advise as to dangers of excessive drinking. I think he was listening.



A recent tragedy spurred me to blogify about the perils and ER related aspects of the return to school next week. A high school star athlete was killed in a single car crash. He probably would have survived, if he had been wearing his seatbelt. Inexperienced drivers, feelings of invincibility, cell phones and friends in the vehicle are the ingredients for the all too frequent MVC's involving young drivers as they head back to school.



A word about neuroanatomy may be illuminating. The frontal lobes of the brain are important in both complex motor function and in judgement. The frontal cortex is slow to develop, and isn't fully mature until the mid to late twenties. Combine lack of judgment, excess testosterone/estrogen, and distractions from MP3 players, and cell phones and you have a recipe for an ER trauma patient.



The city where I practice the art of EM is home to a large state university. Every year, as the freshmen arrive, the first case of alcohol poisoning appears. I dread that call to the parents, telling them that Johnny or Susie is entubated and on a ventilator with acute ethanol poisoning. Deaths from alcohol and drugs such as Ecstasy, methamphetamines occur in college and high school students. Prescription drugs are also frequently abused. Ritalin, Provigil and other stimulants are used to help cram for exams and just to get buzzed. These medications can cause potentially dangerous heart rhythm problems.



Sedatives such as Rohypnol and alcohol may be used to commit sexual assaults. Both women and men have been raped while under the influence of sedatives. The assailants may be law abiding citizens, who commit their crimes while they too are impaired by alcohol and/or drugs. Lives are permanently damaged.



I would encourage my younger readers to review "Sex in the ER" parts 1 and 2. Freshmen in college are often experiencing independence from their parents for the first time. The intimacy of dormitory living and the excitement of college life get the hormones churning. An 18 year old coed who finds out from Robin, my PA, that she has Herpes, realizes too late that she should have practiced safe sex. Herpes and HIV are treatable but not curable. A single unprotected encounter may last a lifetime.

Parents, other family members and friends of all students, please do your best to prepare your children. School is not a punishment. Children must grow and develop to eventually become independent adults. Helicoptering is not a good solution to the anxiety of being a parent. SAT prep courses, e-mailing teachers to protest grades, and doing your children's assignment will fail in the long run. Grade inflation and trophies for trying frustrate the value of learning from one's mistakes.

Talk to your children openly and honestly about the joy of learning. Don't neglect to discuss drugs, alcohol and sex. A parent is still the most important teacher that a child will have in their life. Fell free to invite your children to read and comment on this blog.

Spare parts

The bionic man is still just a bad TV series, but more patients than ever have pieces of metal and plastic and even sophisticated electronics inside their bodies. Joints, stents, ports, lines, pacers, defibrillators, shunts and implants are all "foreign bodies". If bacteria get into the blood stream, these foreign bodies can become infected and the resulting fever and chills will send the patient to the ER.

Bacteremia can occur from dental procedures, catheterizations, and from on-going infections of the skin that get into the deeper tissue. Using needles to inject drugs is an obvious source of infective organisms entering the blood stream. Many dangerous bacterial species produce a biofilm on the surface of the spare parts. This film protects the microorganism from the antibiotics used to treat the infections.

PICC lines and Portacaths are ways of having intermittent and prolonged access to the venous system. Cancer patients, and patients needing prolonged nutritional or antibiotic treatment have these devices.

Hips, knees, elbows, shoulders and other joints can all be replaced when they become damaged from injury or disease. The artificial joints are made from non-ferrous metal and plastic. They can become infected as mentioned earlier. These joints, especially prosthetic hips are prone to dislocation. ER docs are often asked to reduce a dislocated hip after a fall or movement that "pops" the joint out. Conscious sedation is used to get adequate relaxation of the muscles during an attempt at reducing the dislocation.

Vascular, biliary, and ureteral stents are used to prop open channels. The current best treatment for most myocardial infarctions (heart attacks) is immediate cardiac catheterization and placement of a stent to open a blocked coronary artery. Vascular stents are also used in the carotid arteries in the neck and throughout the arterial circulation. Stents may be placed by a gastroenterologist into the bile duct if scarring or tumors are blocking this structure. Pancreatic cancer may invade or compress the flow of bile which would cause the patient to become jaundiced.

Renal stones cause horrific pain as they pass from the kidney to the bladder, by way of the ureter. Small stones may pass spontaneously. Larger stones may require procedures to break the stone into small pieces, that can be passed. A ureteral stent may be passed up from the bladder, using a cystoscope, to allow urine to flow around the stone until a lithotripsy or other procedure is performed.

Shunts are used by neurosurgeons to remove cerebrospinal fluid from the ventricles of the brain and empty into the abdominal cavity. These VP (ventricle-peritoneal) shunts are palpable as a button-like reservoir on the surface of the skull and a tube tunneled under the skin to the abdomen. The one-way valve of the shunt can malfunction causing increased intracranial pressure. The patient may present to the ER with headache, nausea and vomiting. A VP shunt may also get infected.

Pacemakers and implantable defibrillators are complex electronic devices used to keep a heart beating or to shock a fibrillating heart back to a stable rhythm. They are programmable and give information of their activities to the cardiologist. Mechanical problems include twisting in the "pocket" of skin in which the devise resides. Wires and leads may fracture. The battery will eventually need replacing but can fail unexpectedly. A defibrillator may oversense and send shocks to the patient when there is no fibrillation. A run-away pacer may accelerate the heart rate to dangerous levels. As with all spare parts, they may become infected.

A form of pacemaker is being used in patients with certain types of seizures and even in patients with intractable pain. These devices give electrical impulses to nerves or the spinal cord. These pacers are prone to all the problems associated with cardiac pacemakers. A cochlear implant is a device used to give hearing to patients with the most common form of deafness. The ER doc must be able to recognize and begin treatment if these devises become infected.

I would be remiss if I didn't mention the use of implants in cosmetic surgery. Breast implants are plastic bags filled with saline, oil or silicone. Similar implants are also being used to enhance a man's pectoral muscles and to augment the buttocks of both men and women. The face may be a repository of material in the cheeks and chin during cosmetic procedures. Rupturing of the implant, shifting of its position and the ever present risk of infection may bring the patient to the ER doors. Dentist implants are usually dealt with by our colleagues in the dental sciences.

The transplantation of organs is a future topic for your scribe.

Young at heart

Recently I examined a teenaged boy with fever, muscles aches, headaches and intermittent vomiting. There were no signs of meningitis, no respiratory complaints but persistent high fevers despite acetaminophen and ibuprofen. The labs tests were not helpful. I sent a sample of blood for testing for Lyme disease and started amoxicillin for presumed Lyme disease. In much of the New England, Lyme disease has become prevalent.

Fast forward 2 days, and this polite and well spoken young man is back in the ER with his mother. A non-productive cough and significant shortness of breath have developed. One of my partners has examined the patient and we meet at the x-ray screen. The chest x-ray shows an enlarged heart and signs of congestive heart failure. My partner performs an ultrasound of the heart showing poor motion of the heart muscle and fluid around the heart in the pericardial sac.

The patient was tranferred to a pediatric CCU in a major teaching hospital. The presumptive diagnosis was myocarditis. Inflammation of the myocardium can be caused by infection, toxins and immunological disorders. Viruses especially coxsackie B and echovirus are the most common infectious agents. Parasites, protozoans, bacteria and fungi may also cause myocarditis.

Toxins that cause myocarditis include clozapine, an atypical antipsychotic used to treat schizophrenia. Cocaine is a direct myocardial toxin as well as a vasoconstrictor that can precipitate an MI (heart attack). A number of immunological disease such as sardcoidosis, rheumatoid arthritis and lupus cause myocarditis.

Chest pain in young patients rarely occurs from coronary artery disease. Kawasaki disease is a complex condition that may include injury to the coronary arteries in children. Pericarditis, inflammation of the membranes that cover the and enclose the heart, also presents with chest pain in young people. The etiology of pericarditis includes infections, medications, immunological and metabolic disorders.

The title of this blog relates to the fact that this patient was, is and will remain in my "heart". Doctors enjoy discussing unusual and challenging patients and diseases. This patient definitely falls into the category of a "great case". I try to connect with all of patients. Having been at the same hospital for most of my career, it is common for me to see patients and/or their family members more than once. Each shift I seek out "the one". A patient who breaks through the 30 years of EM cases and touches my cynical soul. This was the first time that I met this patient and his mother. He and I spoke about entering high school in September. We reside in the same town. He was "the one".

Emergency medicine is all about the moment. ER staff rarely gets follow up information concerning patients who are tranferred to other hospitals. The immediacy of EM has always been a great part of my career choice. The lack of follow up is a source of frustration. I will hope for a good outcome for this young man.

Another week begins. Another 20-30 patients to be examined and treated per shift. Another search for "the one".

Proust

The title refers to "Remembrance of Things Past". I got a phone message this morning from a woman who I first met in nursery school in 1956. The 40th reunion of the high school that I attended during 10th grade is coming up this fall. I left this school and graduated from a private school. There were 2 reasons for my choice. I wanted a more academically challenging education and I was a nerd/geek. My interests included history, mathematics and science. Being tall and skinny, and very average in the looks department sealed my status. My few friends were the other brains and dweebs at the public high school. The private school I attended was a male only bastion of the WASP elite. My interests were nurtured and I received a first rate education.

Reunions of any kind hold little appeal for me. I have attended my wife's 25th college reunion and the 25th high school reunion of the school that drove me out. A dear friend who graduated from Hometown High wanted to experience reunion(ing) with the very people who ostracized us. My friend's husband had zero desire to attend, so I went as her date.

The same "girls" who barely acknowledged my existence as a teen, now seemed enamored to be reacquainted. Being an MD, driving a $40,000 car, wearing an Italian made suit, and sporting a Rolex watch (a gift from my beautiful wife) made me attractive.

The experience of this reunion strengthened my philosophy of never going backwards. Trying to maintain the ties of one's youth will not keep you young. Embracing the present and anticipating the challenges of the future are the key to a vibrant life. Study the past, but don't live in the past.

Medical knowledge is ever expanding. To remain effective as a physician requires a great deal of time and effort. The history of medicine is a particular interest of mine. The pioneers of modern medicine laid the foundation that is still relevant today. The eponymous diseases such as Crohn's, Parkinson's, and Huntington's are windows into our heritage as physicians.

Being the senior attending in my ER group is a never ending source of stimulation. Bright, eager ER docs, fresh from their residencies join our practice. The ways of the force are mysterious. Much to learn, do they have. Yoda am I. These young ER docs encourage me to keep up with the latest information and tools of Emergency Medicine.

This year we welcomed a new doctor. He completed his Emergency Medicine residency just weeks before joining our group. He is smart, articulate, compassionate and hard working. He also is so young, that he had not been born when I was the new ER doc, fresh from my residency, 30 years ago. I was excited to learn that he is a second generation ER doc as his mother is also a member of our guild.

No reunion for the world's oldest ER doc. I would rather hang with my current posse, than reminisce with the spectres of my past.

OD

Sobering statistics about suicide rates were reported in an EM journal yesterday. Unless the victim is found dead, suicide attempts end up in the ER. The biochemistry of depression has been established. Levels of neurotransmitters in sections of the brain are the biological basis of depression. We all get the blues. I am listening to "the Blues" as I write this blog. Clinical depression is unremitting sadness. The depressed patient feels no joy. Sleep, appetite, energy levels are all affected. Hopelessness leads to suicidal thoughts and suicide attempts. The young and the elderly are most likely to attempt suicide. The elderly and all males are most likely to succeed. Violent means of suicide (guns, hanging, jumping from height, car crashes) are more often the choice of men. Pills and non-medication ingestions are the preferred means for women.

Almost any medication in the family medicine cabinet can be lethal in high enough doses. Acetaminophen (Tylenol and others), ibuprofen (Advil etc.) and aspirin are all lethal in high doses. Sleep aides, cold pills and allergy meds can kill. Household cleaners and plumbing supplies are especially dangerous. Rubbing alcohol and antifreeze will do the trick. Prescription medications of all types may kill if taken in excessive quantities.

The Hemlock Society offers suicide "how-to" information. The internet has a wealth of insight into the most lethal medications and toxins. Fortunately, the ER staff has the same access to the treatments and antidotes for ingestions used in suicide attempts. The key is the history: what was taken, how much was swallowed, and when did the ingestion occur. Toxidromes are the signs and symptoms in the patient who has ingested certain medications or plants. The ER doc can make educated assumptions as to the type of drug ingested by the appearance, vital signs, and physical examination of the patient.

Lots of mnemonics have been created to aid the ER staff in remembering these toxidromes. Antihistamines such as Benadryl, if taken in large amounts, may present as a patient who is "red as a beet, dry as a bone, hot as a hen, and mad as a hatter". A little historical aside: the phrase, "mad as a hatter" refers to the fact that hat makers, in the past, used chemicals containing mercury to work the felt. The exposure to mercury caused damage to their brains; they became "mad".

I read a new mnemonic recently, METAL ACID GAP. This is to help in recalling the causes of high anion gap metabolic acidosis (HAGMA). Earlier this week an ambulance arrived with a 60ish patient. The call said he was having a stroke. The patient was comatose but moved both arms when I rubbed my knuckles over his sternum. Scraping a tongue depressor on the soles of his feet showed a normal Babinski response. He was breathing at more than 30 respirations per minute. This was not a stroke. Labs tests showed a profound metabolic acidosis. His pH was 7.07 (normal 7.4), his bicarb was 8 and his carbon dioxide level was 11. His anion gap was greater than 100. The anion gap is the difference between the calculated osmoles in the serum of the blood such as sodium, glucose, BUN, etc and the direct measurement of the osmolality of the serum. The gap leads to a search for the "missing osmole". The patient's family was most helpful. When I described the types of medications and household products that could cause his condition, they found what I had suspected. The patient had ingested antifreeze which contains ethylene glycol. This chemical is fatal in even small ingestions. A treatment does exist for this toxin. If begun soon after the ingestion, the patient should survive.

Acetaminophen, ibuprofen, aspirin and diphenhydramine (Benadryl) are the most frequently used non-prescriptions medications in suicide attempts. Acetaminophen is particularly nasty. As few as 30 regular strength tablets are enough to cause liver injury and possibly death from liver failure, in a small teen or adult. A very effective antidote exists, but if the treatment is started too long after the ingestion, the liver damage may be irreversible. The kidneys are frequently injured by toxic ingestions of OTC (over the counter/ non-prescription) pain medications. Hemodialyis is used to both treat the renal failure caused by the ingestion and to remove the toxin from the blood.

Vitamins, mineral supplements, and herbal medication may also cause injury and death in large ingestions. Iron compounds are a cause of HAGMA. The tendency of iron tablets and certain other pills to form concretions makes the ER doc's job more difficult. One of the most important parts of treating OD's is to prevent further absorption of the toxin from the GI tract. A concretion is a hard lump of tablets. Activated charcoal is given orally to overdose victims in an effort to bind the offending drug and carry it out the rectum. Minerals do not bind to charcoal and concretions of meds such as aspirin, prevent the charcoal from fully binding the drug. The resourceful ER staff, after entubating the patient to protect the airway, will use whole bowel irrigation to try and flush the pills out of the gut. A large tube is passed down the esophagous to the stomach, and liters of solution are infused until the results from the rectum are running clear.

A word about physician assisted suicide is in order. Patients with chronic medical conditions, that will lead to incapacitation, or those patients having intractable pain, may wish to end their lives. Some countries allow the physicians caring for these patients to prescribe medications to aide the patient in ending his or her life. The medications prescribed are usually potent sedatives. In high enough doses, these drugs will depress respirations, leading to fatal hypoxia and a rather peaceful death. Having witnessed my father's death I am strong supporter of physician assisted suicide. Terminal cancer patients in hospice care are given lorazepam, morphine, fentanyl, etc. While the doses are not directly lethal, they ease the patient's death. If I was faced with a painful or undignified demise, I would want to have the option of dying at a time of my choice. A bottle of 30 year old single malt scotch and a sufficient quantity of tricyclic antidepressants would be my personal formula.

Overdoses are frequent, unpredictable and always challenge the ER staff. The patient often does not wish to be treated. After all, they took the overdose to get high or to die. Having to use physical restraints, and placing tubes in every body orifice, would be considered assault and battery in any other locale. The ER staff makes every effort to preserve life. It was a good week for me, none of my patients died.

This is Spinal Tap

Lumbar puncture (LP) , what lay people call a spinal tap, is a diagnostic test performed by ER docs rather frequently. The procedure is done to determine two potentially life threatening medical conditions: infections of the brain or the coverings of the brain which are called encephalitis and meningitis respectively, and subarachnoid hemorrhage (SAH), blood leaking from blood vessels on the surface on the brain. Headaches, fever, vomiting, confusion and lethargy may all be symptoms on these diseases.

Meningitis is an inflammation of the three membranes that cover the brain and spinal cord. Viruses, bacteria and occasional fungi and parasites may cause these infections. Non-infectious causes of meningitis include certain cancers. Encephalitis is an infection of the brain most commonly caused by viruses. West Nile, Eastern Equine and Herpes Simplex viruses are the most likely etiological agents.

Subarachnoid bleeding usually arises from arteriovenous malformation (AVM) or aneurysms in the circle of Willis. A SAH is suspected in any patient who presents to the ER with the "worst headache of their life". Thunderclap headaches come on suddenly, with severe pain at the onset of the headache. Even people with chronic headaches, such as migraines, who report that their presenting headache is different and more severe than usual, may have a SAH.

CT scans of the brain are done on any patient suspected of having a SAH. A scan may also be carried out on a patient who may have meningitis or encephalitis, if the physician thinks there may be a mass and/or increased pressure in the brain. Blood from a SAH shows up well on a CT. About 1% of SAH will not be visible on an initial CT. If the patient comes in days after their thunderclap headache, the CT may be normal as the density of the SAH may make it invisible on the CT. An LP will be done to insure that no case of SAH is missed.

This past month I did three LP's. The three patients ranged in age from 10 days to 30 years. The infant presented with a significant fever. All neonates (less than a month old) who have fever above a certain threshold must have an LP to check for meningitis. The other two LP's were on an adolescent with fever, headache, vomiting and neck stiffness (the classic symptoms of meningitis), and a patient with sudden onset of the worst headache of one's life with a CT that was negative for blood.

An LP may be performed with the patient sitting up and bending forward. More commonly the patient lies on his or her side, and curls into the fetal position. The skin is carefully cleansed with an antibiotic solution. The area is draped with sterile barriers and the ER doc wears sterile gloves and a mask. In my early days as an ER doc, the only way to ameliorate this painful test was with local anesthesia to numb the area. Luckily for my patients and for me, conscious sedation is now readily available. During the LP, a spinal needle enters the skin in the midline of the lower back. The target is between the 4th and 5th or 3rd and 4th lumbar vertebrae. The location of the LP is to prevent damage to the spinal cord. Having the patient bending forward or curled forward makes it easier to pass the spinal needle between the vertebrae. The needle is advanced until a faint "pop" is felt. The needle has now pierced the dura, the tough outermost covering of the central nervous system. The stylet in the spinal needle is removed and cerebral spinal fluid (CSF) begins to flow.

A manometer is sometimes attached to the spinal needle to measure the pressure of the CSF. 3-4 tubes of fluid are obtained, each containing about 1 milliliter of CSF. The pressure, color, and clarity of the CSF may all give clues as to the diagnosis. The CSF is sent to the lab to be analyzed for the presence and number of both red (RBC) and white (WBC) blood cells. The number of WBC's are further divided into the type of WBC. If a SAH is suspected, the RBC count is performed on the 1st and 4th tubes to see if the number is the same or changing. The CSF is cultured for microorganisms, and examined under a microscope after being stained with dyes. The glucose and protein of the CSF is measured. Additional tests may be ordered if unusual infections are suspected.

I now offer all my patients the option of having their LP done with conscious sedation (CS). The agreeable patient (written informed consent) is placed on continuous monitoring of their heart rate, oxygen saturation and blood pressure. The drugs used vary, but all sedate the patient while maintaining spontaneous respirations. The ideal agent would have no effect of heart and lung function and wear off rapidly after the procedure is complete. CS is used in the ER for reduction of fractures and dislocation as well as LP. My personal preferred drug is Propofol. Despite the fact that this drug contributed to the death of Michael Jackson, it is safe and effective when used appropriately. In infants and young children, Ketamine may be used as an alternative to propofol.

Obese patients present a challenge in performing an LP and having conscious sedation. Ultrasound may aid the ER doc to find the anatomic guideposts that are hidden under adipose tissue. Severely obese patients are more likely to have respiratory compromise from CS because of the restriction of their body weight on their chest muscles and diaphragm.

In the northeast, where I work, summer is encephalitis season. Meningitis and SAH can occur at any time. The ER staff is ready and able to properly diagnose and treat patients with the headache that may be the BIG ONE.