Hey doc is it broken or fractured? To a physician this is a moot question. I have never understood the misconception that fractures and broken bones are two separate entities. All broken bones are fractures.
The complexity comes in the large number of qualifiers attached to the word "fracture". Simple, compound, comminuted, spiral, oblique, pathologic, torus, Salter-Harris, Hill-Sachs, monteggia, colles, bartons and many other eponymous sobriquets are used to describe specific fractures of various bones.
Simple vs complex. A simple fracture is enclosed by the body's tissues. A compound fracture is one that has penetrated the skin and is therefore contaminated with bacteria. Comminution connotes the fracture is in more than two pieces. A crush fracture means that bone is in many small pieces.
Fractures in the bones of children are unique because the bones are still growing. The Salter-Harris classification is related to the extend of the damage to these growth areas. The scale runs from 0-6 ( originally 1-5); from no visible disruption of the growth plate to complete crushing of the growth plate. The higher the degree of the damage, the more likely the growth plate will not heal and allow continued growth of the involved bone. It is imperative that these fractures be recognized by the ER doc and appropriate referral made for treatment by an orthopedic surgeon.
Pathologic fractures occur in bones that have been compromised by a disease process. Osteoporosis, the loss of bone density that occurs as we age, is a common cause of these fractures. Cancers, especially of the breast and prostate gland, metastasize to the bones. The tumor thins the bones and fractures may occur with minimal trauma. Metabolic diseases, such as parathyroid gland dysfunction, can also weaken the bones. The "dowager's hump" is a form of pathologic fractures of the vertebrae that leave the female (can occur in men as well) with a severely curved spine.
Bones are well supplied with nutrient blood vessels and some of the larger bones contain marrow (places where new blood cells are formed). Fractures can therefore cause a great deal of bleeding into the surrounding tissues. Arteries can lie along long bones, and a fracture may lacerate the artery causing even more bleeding.
The four limbs of the human body contain fairly rigid compartments. These structures have "walls" of dense connective tissue, skin and bones. If a fracture in a compartment occurs, the swelling may lead to increased pressure that can damage the nerves, veins, and arteries that course through the compartment. The muscles in the compartment are also effected and leaking of muscle proteins can block the tubular structures in the kidney and cause kidney failure.
The mechanism that caused the fracture gives valuable information to the ER doc. The type of fracture is determined by the specific trauma involved. Stubbing a toe, twisting an ankle, falling onto a hand; all contain clues as to the type of fracture the ER doc will be treating. Falls, MVC's, assaults are potential sources of fractures.
Bones are well supplied with nerves that transmit pain sensation. Fractures hurt. The caring ER doc will give pain medication and limit the motion of the fractured bone to make the patient more comfortable. Compound fractures require treatment for potential infection; tetanus shots and antibiotics are employed to avoid a limb or life threatening infection.
ER doctors, PA's and nurses are always alert to the possibility that a fracture may be caused by abuse. If the fracture type is not consistent with the history of how the fracture allegedly occured, abuse must be considered. Most states have mandatory reporting laws. These laws put the onus on the ER staff to notify the appropriate authorities of their suspicions. I once treated an infant for a swollen thigh. An x-ray showed a spiral fracture. This type of fracture is caused by a twisting stress on the bone. The parent told me that baby had fallen off the changing table. I initiated a child abuse investigation. A series of x-rays of the child revealed multiple fractures in all four limbs in various stages of healing.
Be active, take your calcium, wear protective equipment for the activities in which you participate. The ER will be ready to diagnose and treat that break/fracture.
Saturday, January 23, 2010
Friday, January 22, 2010
nunc est bibendum
Now is the time to drink, or more colloquially, I'll drink to that. Alcohol and the ER.
Alcoholic beverages are part of all human cultures and have been made and shared from the earliest recorded human history. Wine, beer, whisky, vodka, aquavit, mead, ouzo, grappa, cognac, scotch, rye, bourban, etc...
We drink to celebrate, mourn, relax or just get buzzed. Religious ritual often involve the use of wine. Some religions use abstinence as part of their belief system. Societies and governments have tried to regulate and even abolish the use of alcohol with little effect.
Alcohol use causes an enormous number of deaths each year from MVC's, acute alcohol poisonings, and liver disease from chronic use. It contributes to innumerable tragedies from sexual assaults to domestic violence and suicide.
The world's oldest ER doc is not a teatotaler. Later tonight, I will be enjoying three fingers of a 15 year old single malt scotch while my saintly wife has a glass of wine. Alcohol in the form of red wine seems to have a beneficial effect in decreasing the risk of heart attack and stroke. Moderate drinkers live longer than non-drinkers.
The key is moderation. Even small amounts of alcohol can impair one's ability to perform complex tasks, especially driving. Thousands of deaths occur every year in the USA from drunk driving, usually refered to as DWI or DUI. Anecdotally, I have observed that, more often then not, the drunk driver is less severely injured then his or her victims. The ER doc's formula for calculating how much the DUI perpetrator imbibed is to multiply by 2 or 3 the number of drinks they admit to having had.
Working in an ER near to a large urban university guarantees a certain number of cases of acute alcohol poisonings. This is most common early in the school year among freshman. Make no mistake about it, alcohol is a poison. It impairs the central nervous system. From a mild disinhibiting effect to coma and airway compromise, the effects of alcohol are related to the amount, and the speed of ingestion. Chugging, binging, jello shots, high proof beverages all can raise one's BAL (blood alcohol level) to lethal levels.
Simply passing out while drunk, especially if lying face up, can lead to aspiration (anything but air getting into your lungs) with often fatal consequences. People will commit criminal acts while drunk that have real penalties. Being drunk is not a very effective defense. I have examined and treated too many young women and men who were assaulted after becoming incapacitated by alcohol ingestion.
Alcoholism is a disease. There are genetic variations that predispose some people to become dependent on alcohol. An alcoholic will experience withdrawal symptoms after as little as a few hours from their last drink. Tremors, tachycardia (rapid heart rate), sweating, anxiety, elevated blood pressure are all symptoms of early alcohol withdrawal. Hallucinations (DT's), seizures and death may occur. Treating alcoholism requires medical intervention and counseling. The rate of relapse is high. 12 step groups such as Alcoholics Anonymous work well for motivated individuals. Alcohol abuse may be a form of self medication for people with underlying pyschiatric disease. There are hospitals that can treat these dual diagnoses.
The drunk tank no longer exists. Otis the drunk in Mayberry would not be allowed to let himself into the sheriff's cell today. He would be brought to the ER. I examine, test and hold alcoholics in the ER almost every night. Their nutritional status and central nervous system are evaluated. Frequent blood tests, head CAT scans, and banana bags (an IV solution with vitamins added that turn the IV solution yellow) are often employed. I know many of the chronic alcohol abusing patient by first and last name. They are the epitome of the ER frequent flyers. The number of beds in alcohol treatment facilities is woefully inadequate. Alcoholics rarely have insurance. ER docs are legally and morally obligated to treat these patients but I feel like the little Dutch boy with his finger plugging the hole in the dike.
No moral to this story. Drinking alcoholic beverages is part of the human condition. Be responsible. Drink slowly and in limited amounts. DON'T DRINK AND DRIVE. Take a cab, call a friend or family member, or have a designated driver. The life you save may not be your own.
Alcoholic beverages are part of all human cultures and have been made and shared from the earliest recorded human history. Wine, beer, whisky, vodka, aquavit, mead, ouzo, grappa, cognac, scotch, rye, bourban, etc...
We drink to celebrate, mourn, relax or just get buzzed. Religious ritual often involve the use of wine. Some religions use abstinence as part of their belief system. Societies and governments have tried to regulate and even abolish the use of alcohol with little effect.
Alcohol use causes an enormous number of deaths each year from MVC's, acute alcohol poisonings, and liver disease from chronic use. It contributes to innumerable tragedies from sexual assaults to domestic violence and suicide.
The world's oldest ER doc is not a teatotaler. Later tonight, I will be enjoying three fingers of a 15 year old single malt scotch while my saintly wife has a glass of wine. Alcohol in the form of red wine seems to have a beneficial effect in decreasing the risk of heart attack and stroke. Moderate drinkers live longer than non-drinkers.
The key is moderation. Even small amounts of alcohol can impair one's ability to perform complex tasks, especially driving. Thousands of deaths occur every year in the USA from drunk driving, usually refered to as DWI or DUI. Anecdotally, I have observed that, more often then not, the drunk driver is less severely injured then his or her victims. The ER doc's formula for calculating how much the DUI perpetrator imbibed is to multiply by 2 or 3 the number of drinks they admit to having had.
Working in an ER near to a large urban university guarantees a certain number of cases of acute alcohol poisonings. This is most common early in the school year among freshman. Make no mistake about it, alcohol is a poison. It impairs the central nervous system. From a mild disinhibiting effect to coma and airway compromise, the effects of alcohol are related to the amount, and the speed of ingestion. Chugging, binging, jello shots, high proof beverages all can raise one's BAL (blood alcohol level) to lethal levels.
Simply passing out while drunk, especially if lying face up, can lead to aspiration (anything but air getting into your lungs) with often fatal consequences. People will commit criminal acts while drunk that have real penalties. Being drunk is not a very effective defense. I have examined and treated too many young women and men who were assaulted after becoming incapacitated by alcohol ingestion.
Alcoholism is a disease. There are genetic variations that predispose some people to become dependent on alcohol. An alcoholic will experience withdrawal symptoms after as little as a few hours from their last drink. Tremors, tachycardia (rapid heart rate), sweating, anxiety, elevated blood pressure are all symptoms of early alcohol withdrawal. Hallucinations (DT's), seizures and death may occur. Treating alcoholism requires medical intervention and counseling. The rate of relapse is high. 12 step groups such as Alcoholics Anonymous work well for motivated individuals. Alcohol abuse may be a form of self medication for people with underlying pyschiatric disease. There are hospitals that can treat these dual diagnoses.
The drunk tank no longer exists. Otis the drunk in Mayberry would not be allowed to let himself into the sheriff's cell today. He would be brought to the ER. I examine, test and hold alcoholics in the ER almost every night. Their nutritional status and central nervous system are evaluated. Frequent blood tests, head CAT scans, and banana bags (an IV solution with vitamins added that turn the IV solution yellow) are often employed. I know many of the chronic alcohol abusing patient by first and last name. They are the epitome of the ER frequent flyers. The number of beds in alcohol treatment facilities is woefully inadequate. Alcoholics rarely have insurance. ER docs are legally and morally obligated to treat these patients but I feel like the little Dutch boy with his finger plugging the hole in the dike.
No moral to this story. Drinking alcoholic beverages is part of the human condition. Be responsible. Drink slowly and in limited amounts. DON'T DRINK AND DRIVE. Take a cab, call a friend or family member, or have a designated driver. The life you save may not be your own.
Monday, January 18, 2010
winter wonderland
Having shoveled 4-6 inches of heavy wet snow this morning, I felt that this is an appropriate time to write about the ER in winter. Snow, ice, freezing temperatures, and howling winds are the joys of a New England winter. Layers of warm clothes, insulated boots and a good heating system will get us through the rigors of this season.
The ER is open for the predictable and unexpected consequences of the challenges of winter. The sore back, aching muscles, frost nip and frost bite are quickly diagnosed and treated. Chest pains from angina or a heart attack require more diligence and effort by the ER staff but if you arrive alive, it is highly probable that you will survive the ER and your ischemic heart disease.
The back pain from shoveling or pushing one's vehicle may be more than sore muscles. The discs between our vertebrae are prone to rupture, herniation or degeneration especially as they age beyond their warranty. Nerve impingements from disc disease, arthritis, or shifting of the vetebrae can send lancinating pains into your buttocks, groin or legs. If the nerves that innervate the bladder or bowels are involved urinary retention and constipation may occur.
Time and pain medicine are the main components of treatment. A medical study was done that compared doctor prescribed physical therapy, chiropractic treatment, and simply giving the patient a pamphlet on how to treat their sore back. The results showed that the long term outcome was the same for all three approaches. An MRI is sometimes necessary to get an anatomical diagnosis of the source of the back pain.
Every snow storm, especially if the snow is wet and heavy, guarantees at least one snow blower hand injury. These occur when the snow blower is packed with snow and the operator sticks his ( I have personally never treated a woman for this injury) hand in, to clear the clog. When the obstruction is released, the blades immediately begin to turn and voila, hand salad. X-rays, antibiotics, pain medication, a tetanus shot and a referral to a hand surgeon are the ER docs treatment protocol.
Cold injures can be life threatening. Frost bite is tissue damage from cold exposure. It is often rated like thermal injures from first to third degree, depending on how deep the tissue damage extends. Lower temperatures, wind exposure, time of exposure and water contact all factor into how severe the frost bite will be. Hypothermia is a core (rectal or bladder thermometer) below normal. The factors listed for frost bite, also apply to the risks of hypothermia. Alcohol imbibing predisposes one to cold injuries. Alcohol dilates peripheral blood vessels and reduces shivering and one's awareness of the damage being done.
Hypothermia and cold water drownings are difficult to treat and give rise to prolonged resuscitative efforts. The ER docs' adage is that you're not dead til you are warm and dead. CPR and rewarming techniques are continued until the patient is no longer hypothermic. Brain function, especially in children, may be preserved in cold weather cardiac arrest as the cold itself slows metabolism and limits cellular death.
The ER docs and PA's treat an array of arm and leg injuries from skiing and snowboard mishaps, falls on icy walkways, and MVC's (motor vehicle collisions) on wet and slick roads. X-rays, CAT scans, splints, casts, crutches and pain medication will usually get the patient comfortable and back home.
A word about S.A.D. Seasonal Affective Disorder is a form of depression. It is defined as signs and symptoms of depression that occur during the winter in northern climes. The cause seems to be the lack of sunlight during the short winter days. The farther north one lives, increases the incidence of SAD. Specially tuned lights that mimic the full spectrum of sunlight help to treat this real disorder.
November to March. We who live in the Northeast, love the change of seasons. We relish the mild springs, warm summers, and colorful autumns. Some of us even love the snow and cold. My advice is to dress warmly, be prepared when outdoors, and remember that the Caribbean is only 4 hours by jet.
The ER is open for the predictable and unexpected consequences of the challenges of winter. The sore back, aching muscles, frost nip and frost bite are quickly diagnosed and treated. Chest pains from angina or a heart attack require more diligence and effort by the ER staff but if you arrive alive, it is highly probable that you will survive the ER and your ischemic heart disease.
The back pain from shoveling or pushing one's vehicle may be more than sore muscles. The discs between our vertebrae are prone to rupture, herniation or degeneration especially as they age beyond their warranty. Nerve impingements from disc disease, arthritis, or shifting of the vetebrae can send lancinating pains into your buttocks, groin or legs. If the nerves that innervate the bladder or bowels are involved urinary retention and constipation may occur.
Time and pain medicine are the main components of treatment. A medical study was done that compared doctor prescribed physical therapy, chiropractic treatment, and simply giving the patient a pamphlet on how to treat their sore back. The results showed that the long term outcome was the same for all three approaches. An MRI is sometimes necessary to get an anatomical diagnosis of the source of the back pain.
Every snow storm, especially if the snow is wet and heavy, guarantees at least one snow blower hand injury. These occur when the snow blower is packed with snow and the operator sticks his ( I have personally never treated a woman for this injury) hand in, to clear the clog. When the obstruction is released, the blades immediately begin to turn and voila, hand salad. X-rays, antibiotics, pain medication, a tetanus shot and a referral to a hand surgeon are the ER docs treatment protocol.
Cold injures can be life threatening. Frost bite is tissue damage from cold exposure. It is often rated like thermal injures from first to third degree, depending on how deep the tissue damage extends. Lower temperatures, wind exposure, time of exposure and water contact all factor into how severe the frost bite will be. Hypothermia is a core (rectal or bladder thermometer) below normal. The factors listed for frost bite, also apply to the risks of hypothermia. Alcohol imbibing predisposes one to cold injuries. Alcohol dilates peripheral blood vessels and reduces shivering and one's awareness of the damage being done.
Hypothermia and cold water drownings are difficult to treat and give rise to prolonged resuscitative efforts. The ER docs' adage is that you're not dead til you are warm and dead. CPR and rewarming techniques are continued until the patient is no longer hypothermic. Brain function, especially in children, may be preserved in cold weather cardiac arrest as the cold itself slows metabolism and limits cellular death.
The ER docs and PA's treat an array of arm and leg injuries from skiing and snowboard mishaps, falls on icy walkways, and MVC's (motor vehicle collisions) on wet and slick roads. X-rays, CAT scans, splints, casts, crutches and pain medication will usually get the patient comfortable and back home.
A word about S.A.D. Seasonal Affective Disorder is a form of depression. It is defined as signs and symptoms of depression that occur during the winter in northern climes. The cause seems to be the lack of sunlight during the short winter days. The farther north one lives, increases the incidence of SAD. Specially tuned lights that mimic the full spectrum of sunlight help to treat this real disorder.
November to March. We who live in the Northeast, love the change of seasons. We relish the mild springs, warm summers, and colorful autumns. Some of us even love the snow and cold. My advice is to dress warmly, be prepared when outdoors, and remember that the Caribbean is only 4 hours by jet.
Friday, January 15, 2010
cats and dogs
For baby boomers, the apex of academic achievement was an MD or JD. Doctors and Lawyers, professionals. Years of study; competition for admission; long apprenticeships leading to the prestige and financial success of a professional career. The reality of the realtionship between MD's and JD's is anything but collegial.
Doctors are trained to work cooperatively, sharing information and insights. From early in our education we are admonished to see one, do one, teach one. The teaching of our students and less experienced colleagues is enshrined in the Hippocratic Oath. One of the greatest joys in being the world's oldest ER doc is the opportunity to share my thirty years of ER experience with my young associates, physician assistants, nurses and EMS personnel.
Lawyers like to refer to each other as brother. They must mean like Cain and Abel. The legal system is adversarial in form. Two attorneys battle over a civil or criminal issue. Although the judiciary process seeks to arrive at "the truth", a good attorney can argue either side of any case.
ER docs interact with the two major branches of the legal profession civil and criminal. I have been a factual witness in many criminal hearings and trials. I have been asked to testify to the injuries suffered by my patients at the hands (feet, elbows, teeth or other parts) of their assailants. Occasionally I have been required to give testimony relevent to the medical condition of an alleged criminal who was treated or examined by me. My experience in emergency medicine has qualified me to give expert opinions as they relate to a criminal procedure. CSI ER DOC.
ER docs get sued for malpractice. This is a fact. Every ER doc gives his or her best efforts to relieve the suffering of our patients. We try to diagnosis and treat our patients competently and compassionately. "To err is human" and ER docs are all too human. We work long hours, manage many patients simultaneously and on occasion miss diagnoses and give inadequate or even harmful treatments.
When a patient is injured by our nonfeasance (missed something) or malfeasance (did something bad) we get served with a complaint. Thus begins the humbling, life altering, and painful journey through our civil court system.
The first step to is notify your insurer. Doctors pay large amounts of money for malpractice insurance premiums. The insurance company assigns a case manager and a defense attorney to guide and represent the doctor in defense of the malpractice action. The next step is the discovery process. Written questions, interrogatories, are submited by the patient's (plaintiff's) attorney. They are answered by the physician and his or her attorney.
The deposition is like the Spanish Inquisition without the religious overtones and no instruments of torture are employed. During the deposition the plaintiff's counsel asks questions of the defendant doctor. This sounds simple and straight forward. It is neither. The plaintiff's attorney asks leading questions, multipart questions and hypothetical questions, all in an attempt to have the doctor hang one's self. By our training, doctors are open, honest and prone to think out loud. Plaintiff's lawyers will use various tactics to exploit this vulnerability.
A good defense attorney is like a guardian angel. Their knowledge, experience and compassion can get even the most timorous doctor through this ordeal relatively unscathed. I have had the good fortune to be represented by remarkably gifted and empathetic defense attorneys in my long career.
Many medical malpractice suits are settled prior to trial. In my state, cases that go to trial are won by the defendant physician 80-90% of the time. There is an alternative to this anachronistic system, mediation or arbitration panels. If a patient feels that he or she was harmed by the care given by a physician, an action would be brought before a panel of experts from the legal, judiciary and medical fields. The evidence would be weighed without the emotional appeal to a jury of laypeople. Financials award, if given, would be determined by actual losses suffered by the patient and their family. Doctors would be more willing to acknowledge errors if such a system was in place.
Patients in the ER are often subjected to potentially dangerous tests and procedures in an attempt by the ER doc to cover his or her ass. Potentially cancerous causing radiation exposures from CAT scans, needle sticks, spinal taps are sometimes done in the name of "defensive medicine".
My saintly wife is a civil litigator, an attorney who represents one side of a civil court case. I sleep with the "enemy". Many of dearest friends are attorneys and even judges. I am priviledged to have many police officers as friends. I do understand the adversarial nature of our judicial system. It may not be perfect, but it is better than any other judicial system on this blue planet.
Doctors are trained to work cooperatively, sharing information and insights. From early in our education we are admonished to see one, do one, teach one. The teaching of our students and less experienced colleagues is enshrined in the Hippocratic Oath. One of the greatest joys in being the world's oldest ER doc is the opportunity to share my thirty years of ER experience with my young associates, physician assistants, nurses and EMS personnel.
Lawyers like to refer to each other as brother. They must mean like Cain and Abel. The legal system is adversarial in form. Two attorneys battle over a civil or criminal issue. Although the judiciary process seeks to arrive at "the truth", a good attorney can argue either side of any case.
ER docs interact with the two major branches of the legal profession civil and criminal. I have been a factual witness in many criminal hearings and trials. I have been asked to testify to the injuries suffered by my patients at the hands (feet, elbows, teeth or other parts) of their assailants. Occasionally I have been required to give testimony relevent to the medical condition of an alleged criminal who was treated or examined by me. My experience in emergency medicine has qualified me to give expert opinions as they relate to a criminal procedure. CSI ER DOC.
ER docs get sued for malpractice. This is a fact. Every ER doc gives his or her best efforts to relieve the suffering of our patients. We try to diagnosis and treat our patients competently and compassionately. "To err is human" and ER docs are all too human. We work long hours, manage many patients simultaneously and on occasion miss diagnoses and give inadequate or even harmful treatments.
When a patient is injured by our nonfeasance (missed something) or malfeasance (did something bad) we get served with a complaint. Thus begins the humbling, life altering, and painful journey through our civil court system.
The first step to is notify your insurer. Doctors pay large amounts of money for malpractice insurance premiums. The insurance company assigns a case manager and a defense attorney to guide and represent the doctor in defense of the malpractice action. The next step is the discovery process. Written questions, interrogatories, are submited by the patient's (plaintiff's) attorney. They are answered by the physician and his or her attorney.
The deposition is like the Spanish Inquisition without the religious overtones and no instruments of torture are employed. During the deposition the plaintiff's counsel asks questions of the defendant doctor. This sounds simple and straight forward. It is neither. The plaintiff's attorney asks leading questions, multipart questions and hypothetical questions, all in an attempt to have the doctor hang one's self. By our training, doctors are open, honest and prone to think out loud. Plaintiff's lawyers will use various tactics to exploit this vulnerability.
A good defense attorney is like a guardian angel. Their knowledge, experience and compassion can get even the most timorous doctor through this ordeal relatively unscathed. I have had the good fortune to be represented by remarkably gifted and empathetic defense attorneys in my long career.
Many medical malpractice suits are settled prior to trial. In my state, cases that go to trial are won by the defendant physician 80-90% of the time. There is an alternative to this anachronistic system, mediation or arbitration panels. If a patient feels that he or she was harmed by the care given by a physician, an action would be brought before a panel of experts from the legal, judiciary and medical fields. The evidence would be weighed without the emotional appeal to a jury of laypeople. Financials award, if given, would be determined by actual losses suffered by the patient and their family. Doctors would be more willing to acknowledge errors if such a system was in place.
Patients in the ER are often subjected to potentially dangerous tests and procedures in an attempt by the ER doc to cover his or her ass. Potentially cancerous causing radiation exposures from CAT scans, needle sticks, spinal taps are sometimes done in the name of "defensive medicine".
My saintly wife is a civil litigator, an attorney who represents one side of a civil court case. I sleep with the "enemy". Many of dearest friends are attorneys and even judges. I am priviledged to have many police officers as friends. I do understand the adversarial nature of our judicial system. It may not be perfect, but it is better than any other judicial system on this blue planet.
Thursday, January 14, 2010
head of the class
I have a headache. Simple, direct and yet those words fill an ER doc with dread. Tension, sinus, migraine, tumor, encephalitis, meningitis, vasculitis. The head is chock-a-block with things that can go from bad to dead very quickly.
Most headaches are benign. The muscles of the face, scalp and neck are prone to the stresses of our 24/7 life style. Too little sleep, too many deadlines, too much eye strain while working with computers: all can lead to tightening and spasms that cause tension headaches. Usually described as dull and aching, these cephalgias (head pains) are made better by rest and non- prescription pain medications. Reproducing or exacerbating the pain by palpation of the face or scalp are strong indicators that this benign headache is the culprit.
Sinuses are air filled cavities within the head. They function to warm and moisten the air we breath. They make the head lighter in weight. The problem arises from the fact that sinuses communicate with the nasal cavities by small holes, ostia. Infections, dry or polluted air, smoking, and allergies can all cause swelling that block the ostia. Fluid and air pressure build up and voila, a "sinus headache". Dull to sharp, worsened by bending forward, pain often is elicited by tapping over the forehead or cheeks. Decongestants, steroid nasal sprays and NSAID's are all helpful in treating sinus headaches. True bacterial sinusitis is much less common. The medical criteria include localized sinus pain, fever, tenderness, purulent drainage and even redness over the sinus for at least a week. All too often unnecessary antibiotics are prescribed for any sinus headache.
The word migraine is derived from the word hemicrania, half a head. These headaches are usually one sided, throbbing, and frequently associated with nausea, vomiting, and sensitivity to light and sound. There are several variations of migraine. Migraineurs (the French have been at the forefront of neurology for centuries) may have auras. These are sensations of smell, vision or hearing that warn the sufferer that a migraine is coming. Migraines can even mimic strokes, with abnormal sensations, visual changes or paralysis. The patient who has a known history of migraine should always be asked if this episode is worse than usual.
Cluster headaches are another variety of vascular headache. Unlike migraines, they are more common in men than women. One sided, often felt behind the eye, they are excruiatingly painful. They last seconds to hours. The "cluster" refers to the fact that pain comes and goes for hours to days, often followed by periods of weeks or months without any pain. Sweating, pupillary changes and even facial muscle weakness may accompany a cluster headache.
The elderly patient may present with a headache from inflammation of the arteries of the head. Temporal arteritis is often heralded by a dull to throbbing headache of the temple in someone older than 60 years. The ER doc must have a high degree of suspicion for this condition. If it goes untreated, it may progress to permanent vision loss.
Infections of the brain (encephalitis) or the meninges (the body tissues that cover the brain and spinal cord) can present initially with headache. Fever, neck stiffness, nausea and vomiting may help lead to the correct diagnosis. Unfortunately, early in the course of these infections it is easy to attribute these symptoms to the flu. CAT scans and lumbar puncture (LP or spinal tap) are required to make a definitive diagnosis. Delays in treatment may lead to severe disability or death.
Aneurysms are bulges that form in arteries. The brain receives a large share of the blood pumped out by the heart. The brain comsumes a great deal of the body's energy. Supplying the brain is a plumber's nightmare of arteries and veins. Berry aneurysms arise from the circle of Willis at the base of the brain. Arterial branches off this circle are the location of these timebombs. They produce no symptoms until they leak. Any headache that comes on abruptly and is described as severe, or the worst headache of the patient's life, is a subarachnoid hemorrhage(SAH) until proven otherwise. SAH is blood leaking out of an aneurysm or other weakened area of the vascular supply such as an arteriovenous malformation. A CAT scan will usually reveal the SAH. Even with a normal CAT scan, the ER doc may perform an LP as a small number of SAH's are not seen on CAT scan.
Tumors within the skull will eventually cause cephalgia. The cranium composed of the bones of skull is rigid. As a tumor grows it puts pressure on the surrounding structures and a dull but steadily worsening headache occurs. There may be some change in the intensity of the pain with changes in position.
It is ironic that the brain itself is insensitive to pain. We have seen on medical programs the brave neurosurgeon operating on the fully awake patient. Once the cranium and meninges have been anesthetised, the neurosurgeon can cut or cauterize brain tissue with the patient being awake and painfree.
From the benign to life threatening, "I have a headache" is a minefield that the ER doc must navigate. Head injuries will be "tackled" in a future blog. Take two tablets and call me in the morning.
Most headaches are benign. The muscles of the face, scalp and neck are prone to the stresses of our 24/7 life style. Too little sleep, too many deadlines, too much eye strain while working with computers: all can lead to tightening and spasms that cause tension headaches. Usually described as dull and aching, these cephalgias (head pains) are made better by rest and non- prescription pain medications. Reproducing or exacerbating the pain by palpation of the face or scalp are strong indicators that this benign headache is the culprit.
Sinuses are air filled cavities within the head. They function to warm and moisten the air we breath. They make the head lighter in weight. The problem arises from the fact that sinuses communicate with the nasal cavities by small holes, ostia. Infections, dry or polluted air, smoking, and allergies can all cause swelling that block the ostia. Fluid and air pressure build up and voila, a "sinus headache". Dull to sharp, worsened by bending forward, pain often is elicited by tapping over the forehead or cheeks. Decongestants, steroid nasal sprays and NSAID's are all helpful in treating sinus headaches. True bacterial sinusitis is much less common. The medical criteria include localized sinus pain, fever, tenderness, purulent drainage and even redness over the sinus for at least a week. All too often unnecessary antibiotics are prescribed for any sinus headache.
The word migraine is derived from the word hemicrania, half a head. These headaches are usually one sided, throbbing, and frequently associated with nausea, vomiting, and sensitivity to light and sound. There are several variations of migraine. Migraineurs (the French have been at the forefront of neurology for centuries) may have auras. These are sensations of smell, vision or hearing that warn the sufferer that a migraine is coming. Migraines can even mimic strokes, with abnormal sensations, visual changes or paralysis. The patient who has a known history of migraine should always be asked if this episode is worse than usual.
Cluster headaches are another variety of vascular headache. Unlike migraines, they are more common in men than women. One sided, often felt behind the eye, they are excruiatingly painful. They last seconds to hours. The "cluster" refers to the fact that pain comes and goes for hours to days, often followed by periods of weeks or months without any pain. Sweating, pupillary changes and even facial muscle weakness may accompany a cluster headache.
The elderly patient may present with a headache from inflammation of the arteries of the head. Temporal arteritis is often heralded by a dull to throbbing headache of the temple in someone older than 60 years. The ER doc must have a high degree of suspicion for this condition. If it goes untreated, it may progress to permanent vision loss.
Infections of the brain (encephalitis) or the meninges (the body tissues that cover the brain and spinal cord) can present initially with headache. Fever, neck stiffness, nausea and vomiting may help lead to the correct diagnosis. Unfortunately, early in the course of these infections it is easy to attribute these symptoms to the flu. CAT scans and lumbar puncture (LP or spinal tap) are required to make a definitive diagnosis. Delays in treatment may lead to severe disability or death.
Aneurysms are bulges that form in arteries. The brain receives a large share of the blood pumped out by the heart. The brain comsumes a great deal of the body's energy. Supplying the brain is a plumber's nightmare of arteries and veins. Berry aneurysms arise from the circle of Willis at the base of the brain. Arterial branches off this circle are the location of these timebombs. They produce no symptoms until they leak. Any headache that comes on abruptly and is described as severe, or the worst headache of the patient's life, is a subarachnoid hemorrhage(SAH) until proven otherwise. SAH is blood leaking out of an aneurysm or other weakened area of the vascular supply such as an arteriovenous malformation. A CAT scan will usually reveal the SAH. Even with a normal CAT scan, the ER doc may perform an LP as a small number of SAH's are not seen on CAT scan.
Tumors within the skull will eventually cause cephalgia. The cranium composed of the bones of skull is rigid. As a tumor grows it puts pressure on the surrounding structures and a dull but steadily worsening headache occurs. There may be some change in the intensity of the pain with changes in position.
It is ironic that the brain itself is insensitive to pain. We have seen on medical programs the brave neurosurgeon operating on the fully awake patient. Once the cranium and meninges have been anesthetised, the neurosurgeon can cut or cauterize brain tissue with the patient being awake and painfree.
From the benign to life threatening, "I have a headache" is a minefield that the ER doc must navigate. Head injuries will be "tackled" in a future blog. Take two tablets and call me in the morning.
Saturday, January 9, 2010
sex in the ER, the sequel
Shortly after posting "sex in the ER", my saintly wife and I were watching a sporting event on the TV. The inevitable ad for a medication to treat ED (erectile dysfunction or failure to launch) appeared. The warning that if you developed an erection that lasted more than 4 hours you should not celebrate, but should seek immediate medical attention. If you are naive enough to call the prescribing physician, you would be told to go to the ER. Thus we have sex in the ER, the sequel, or sex, the final frontier.
Priapism is a painful and persistent erection. If untreated, priapism can cause permanent damage to the erectile mechanism. The treatment of priapism involves needles being stuck into the penis; enough said.
Other misadventures can occur to the penis by intentional or unintenional acts. Penis rings are used to maintain or augment the male erection. Unfortunately, the swelling they cause may preclude their removal.
A pleasant, schizophrenic patient of mine had polydipsia. Whether he drank large amounts of water because of the dry mouth that antipsychotic medication can cause, or just because he was a little off, his polydipsia led to polyuria. He had to urinate frequently. Being an outdoor type of guy, finding places to urinate was a problem. His unique solution was to place a steel key ring around the base of his penis. When the swelling became too painful to bear he showed up in the ER with a rather large problem. Ring cutters are designed to cut through relatively soft gold, not hardened steel. I was eventually able to remove the offending ring, much to my patient's relief.
The penis is also susceptible to being fractured while in the erect state. The three compartments of the shaft of the penis have fairly strong walls. When enough force is exerted during certain sexual positions, these walls can break causing a penile fracture.
Rashes and burns from lotions, potions and candle wax are also conditions that can effect the poor penis. I would be remiss if I didn't mention the infamous Amazonian catfish. This tiny fish is attracted to urea. If voiding urine while standing waist deep in the Amazon is on your travel itinerary, be forewarned. This unique catfish will propel itself through the penile meatus and using the spines in its fins, will become lodged in the urethra. OUCH!
Women are not immune to problems with their sexual apparatus. Lost objects (most commonly a condom), injuries from overzealous partners or sex toys, and the same lotions potions and candle wax, may lead to a visit to the ER's pelvic pavilion. Every ER has at least one room or bed designated for examination of a woman's pelvic organs. Specula, swabs, ring forceps, fiberoptic lights are used to diagnose and treat those problems unique to the female anatomy.
The take home lessons are be smart, be careful, be prepared, have fun but don't urinate while swimming in the Amazon.
Priapism is a painful and persistent erection. If untreated, priapism can cause permanent damage to the erectile mechanism. The treatment of priapism involves needles being stuck into the penis; enough said.
Other misadventures can occur to the penis by intentional or unintenional acts. Penis rings are used to maintain or augment the male erection. Unfortunately, the swelling they cause may preclude their removal.
A pleasant, schizophrenic patient of mine had polydipsia. Whether he drank large amounts of water because of the dry mouth that antipsychotic medication can cause, or just because he was a little off, his polydipsia led to polyuria. He had to urinate frequently. Being an outdoor type of guy, finding places to urinate was a problem. His unique solution was to place a steel key ring around the base of his penis. When the swelling became too painful to bear he showed up in the ER with a rather large problem. Ring cutters are designed to cut through relatively soft gold, not hardened steel. I was eventually able to remove the offending ring, much to my patient's relief.
The penis is also susceptible to being fractured while in the erect state. The three compartments of the shaft of the penis have fairly strong walls. When enough force is exerted during certain sexual positions, these walls can break causing a penile fracture.
Rashes and burns from lotions, potions and candle wax are also conditions that can effect the poor penis. I would be remiss if I didn't mention the infamous Amazonian catfish. This tiny fish is attracted to urea. If voiding urine while standing waist deep in the Amazon is on your travel itinerary, be forewarned. This unique catfish will propel itself through the penile meatus and using the spines in its fins, will become lodged in the urethra. OUCH!
Women are not immune to problems with their sexual apparatus. Lost objects (most commonly a condom), injuries from overzealous partners or sex toys, and the same lotions potions and candle wax, may lead to a visit to the ER's pelvic pavilion. Every ER has at least one room or bed designated for examination of a woman's pelvic organs. Specula, swabs, ring forceps, fiberoptic lights are used to diagnose and treat those problems unique to the female anatomy.
The take home lessons are be smart, be careful, be prepared, have fun but don't urinate while swimming in the Amazon.
Friday, January 1, 2010
sex in the ER
Get your mind out of the gutter. The world's oldest ER doc is happily married. I am aware of ER workers who "fraternize" with each other. I hear the rumors and see the verbal foreplay. Today's topic concerns conditions and diseases of human sexual organs that present to the ER.
Torsion. The word means twisting. For the ER doc torsion is a true emergency involving the gonads. Ovaries and testicles can tort or twist, so that the blood supply to these precious organs is compromised. Missing this diagnosis means a dead gonad and a likely malpractice suit. The male version is usually obvious. A painful testicle is self-evident. High suspicion, a quick exam and ultrasound while waiting for the urologist to arrive, is the ER doc's task. Ovarian torsion is a lot more difficult. Deep in the pelvis, the pain of ovarian torsion can mimic any number of gastrointestinal and gynecological diseases. As usual, the ER doc must always consider the vascular disaster for any presenting complaint. In any female who hasn't had a total hysterectomy, ovarian torsion must be in the differential diagnosis.
STD's, sexually transmitted diseases, include an alphabet soup of infectious agents. LGV, HPV, HIV, HSV, GC, Hep B, Hep C all may transmitted via sexual contact. The list also includes other bacterial infections such as chancroid, syphilis, chlamydia. Even single cell animals such as amoeba and trichomonads can cause STD's. Sores, drips, swellings, pain, fever; are you getting in the mood? The most common STD's are relatively easy to diagnose and treat. Gonorhea, chlamydia and syphilis can be disgnosed with swabs or blood tests, and are treated with highly effective antibiotic therapy. Untreated they can progress to cause infertility and serious systemic diseases.
The many viruses that are sexually transmitted are more insidious and can lead to long term illnesses and delayed consequences. Herpes is a prime example. As a young and naive ER doc, I believed that the 2 types of herpes, HSV 1 and 2 were separated by the waist line. HSV 1 is universal. Every human has had a primary infection as a child and recurrent outbreaks as "cold sores" or "fever blisters" throughout one's life. HSV 2 was the alleged STD; only found below the equator. Human sexual behavior has made this geographic distinction moot. Either virus can be found at any of the sexual portals. Pain, blisters, and a life of recurrences are the legacy of HSV infections.
HPV has been in the news lately because of a recently released vaccine for young women. HPV, human papilloma virus has been linked to both venereal warts (condylomata) and cervical cancer. I recently treated a patient who had a rare cancer of the mouth and throat that was definitively linked to HPV. Young people who don't consider oral sex as risky should be cautioned. All STD's can be transmitted via orogenital contact.
Sex, drugs and rock and roll; STD's to follow. The use of needles for heroin, cocaine and other drugs is often tied to the professional sex trade. Trading sex for drugs, or earning money to purchase drugs is well documented. HIV and hepatitis B and C are easily transmitted by shared needles and then by sexual contact. HIV is treatable but not curable. The treatment is difficult, requiring expensive drugs, that must taken for life. Hepatitis B can be prevented by a vaccine and usually is self-limited. Hepatitis C has a treatment that is expensive, unpleasant and has a high failure rate. Having hep C will often lead to cirrhosis, liver failure and liver cancer sometimes decades after initial exposure.
Sexual assault is the most difficult of the diseases and conditions of the sexual organs that the ER doc must treat. Trauma, infections, possible pregnancy, and the maiming of the patient's psyche, all must be managed. The cases must also be documented and specimens obtained for forensic assessments by law enforcement agencies. Compassion, a non-judgemental attitude, and simple human decency are a professional and moral obligation.
If you are a parent, I would encourage you to share this blog with your teen or even tween child. Knowledge is power. Abstinence is an unrealistic policy. Humans are designed to reproduce the species.
Torsion. The word means twisting. For the ER doc torsion is a true emergency involving the gonads. Ovaries and testicles can tort or twist, so that the blood supply to these precious organs is compromised. Missing this diagnosis means a dead gonad and a likely malpractice suit. The male version is usually obvious. A painful testicle is self-evident. High suspicion, a quick exam and ultrasound while waiting for the urologist to arrive, is the ER doc's task. Ovarian torsion is a lot more difficult. Deep in the pelvis, the pain of ovarian torsion can mimic any number of gastrointestinal and gynecological diseases. As usual, the ER doc must always consider the vascular disaster for any presenting complaint. In any female who hasn't had a total hysterectomy, ovarian torsion must be in the differential diagnosis.
STD's, sexually transmitted diseases, include an alphabet soup of infectious agents. LGV, HPV, HIV, HSV, GC, Hep B, Hep C all may transmitted via sexual contact. The list also includes other bacterial infections such as chancroid, syphilis, chlamydia. Even single cell animals such as amoeba and trichomonads can cause STD's. Sores, drips, swellings, pain, fever; are you getting in the mood? The most common STD's are relatively easy to diagnose and treat. Gonorhea, chlamydia and syphilis can be disgnosed with swabs or blood tests, and are treated with highly effective antibiotic therapy. Untreated they can progress to cause infertility and serious systemic diseases.
The many viruses that are sexually transmitted are more insidious and can lead to long term illnesses and delayed consequences. Herpes is a prime example. As a young and naive ER doc, I believed that the 2 types of herpes, HSV 1 and 2 were separated by the waist line. HSV 1 is universal. Every human has had a primary infection as a child and recurrent outbreaks as "cold sores" or "fever blisters" throughout one's life. HSV 2 was the alleged STD; only found below the equator. Human sexual behavior has made this geographic distinction moot. Either virus can be found at any of the sexual portals. Pain, blisters, and a life of recurrences are the legacy of HSV infections.
HPV has been in the news lately because of a recently released vaccine for young women. HPV, human papilloma virus has been linked to both venereal warts (condylomata) and cervical cancer. I recently treated a patient who had a rare cancer of the mouth and throat that was definitively linked to HPV. Young people who don't consider oral sex as risky should be cautioned. All STD's can be transmitted via orogenital contact.
Sex, drugs and rock and roll; STD's to follow. The use of needles for heroin, cocaine and other drugs is often tied to the professional sex trade. Trading sex for drugs, or earning money to purchase drugs is well documented. HIV and hepatitis B and C are easily transmitted by shared needles and then by sexual contact. HIV is treatable but not curable. The treatment is difficult, requiring expensive drugs, that must taken for life. Hepatitis B can be prevented by a vaccine and usually is self-limited. Hepatitis C has a treatment that is expensive, unpleasant and has a high failure rate. Having hep C will often lead to cirrhosis, liver failure and liver cancer sometimes decades after initial exposure.
Sexual assault is the most difficult of the diseases and conditions of the sexual organs that the ER doc must treat. Trauma, infections, possible pregnancy, and the maiming of the patient's psyche, all must be managed. The cases must also be documented and specimens obtained for forensic assessments by law enforcement agencies. Compassion, a non-judgemental attitude, and simple human decency are a professional and moral obligation.
If you are a parent, I would encourage you to share this blog with your teen or even tween child. Knowledge is power. Abstinence is an unrealistic policy. Humans are designed to reproduce the species.
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