Archive for category Drugs and Treatments

PTSD in Children Following Dog Bites

A physician acquaintance of mine is on a mission to promote awareness, especially amongst emergency physicians, of the potential for post-traumatic stress disorder in children who have been attacked and/or bitten by dogs.  Thus this blog post.  As a practicing psychiatrist, he has treated a number of such children, and he believes that it is very important for physicians who are treating these children for their bite wounds to inform parents to actively watch for signs of PTSD and to obtain evaluation and treatment if indicated.  Dr. Schmitt has lectured and published on this topic (Larry Schmitt, MD, Dog bites in children: Focus on posttraumatic stress disorder, Contemporary Pediatrics, Jul 1, 2011).  He makes a good case for the need for parents and pediatricians to monitor these children closely after their injury, and for incorporating information about PTSD into post-treatment ED and inpatient discharge instructions.

One may not readily consider the diagnosis of PTSD in children, but after dog bites it appears that children pick up on the guilt and sadness in their parents’ faces, and tend to bury their feelings and avoid discussion of the attack.  This of course may precipitate PTSD, and make it more difficult to identify this pathology unless one recognizes the symptoms (excessive anxiety, irritability, decreased school performance, sleep disturbance, reduced creativity, withdrawal, altered appetite, depression, physical complaints, pronounced startle responses, and behavior problems), and relates them back to the attack.  Parents need to know not only how to recognize PTSD, but also what to do to mitigate the potential for their child to develop PTSD.  Preemptive psychological management is likely to be helpful, and parents need to participate in helping their children cope with this trauma and its psychological impact.

Dr. Stanley Goodman published a pdf on the web which provides an extensive outline of this issue; and he suggests that ‘children need to be helped to understand the following, in order to lessen their feelings of vulnerability and helplessness:

1. that many children become fearful whenever they have reminders of the incident, such as seeing other dogs or even watching movies/TV shows with dogs.

2. that they may feel more nervous when they leave their house, fearing they may be attacked and bitten again by a dog.

3. that they may experience depressive symptoms, such as feelings of helplessness, frustration, and diminished social and/or educational functioning; but these feelings are not a sign of weakness.  Rather, they are a foreseeable reaction to having been bitten.’

Emergency physicians treat a lot of children with dog bites, and they have an important role to play beyond caring for the injuries themselves.  Making parents aware of the potential for PTSD, providing information about the signs and symptoms of PTSD in written dog-bite discharge instructions, and suggesting referrals for preemptive psychological counseling can all make a significant contribution to the child’s successful recovery from this kind of trauma.

This post also appears in The Fickle Finger

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World AIDS Day 2010

Wow, it’s already been a year since my last post about World AIDS Day.

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What is Defensive Emergency Medicine?

So I read all the time that defensive medicine costs all this money (and depending who you talk to, it’s a lot of money or not that much), but I still don’t know when I’m practicing it or when I’m not. So I came up with a few scenarios and want you to vote on what you think. I’ll leave the poll open for the next week, and then post the results after that. Real cases we all see daily (I don’t necessarily practice this way, just giving examples!):

Scenario 1:

52 year-old woman with hypertension and dyslipidemia, got in an argument with her daughter, had 3 minutes of left-sided chest pain and “my left arm was numb,” with maybe some shortness of breath (“sometimes,” she says, which doesn’t really answer your question), self-resolved. Now in the ED feels fine, EKG unchanged and unremarkable from the last one. No prior stress test. You admit her for rule-out ACS. “This could be unstable and new angina!”

Scenario 2:

40 year-old male with a history of PE on coumadin, with three weeks of non-pleuritic 1/10 chest pain and shortness of breath. Gradual onset. EKG and chest x-ray are normal, and INR is therapeutic and perfect: 2.5! You CT angio the patient for pulmonary embolism. “If it’s a PE and he’s therapuetic on his coumadin, he needs an IVC filter!”

Scenario 3:

4 year-old male had a brief LOC after his brother opened a door quickly and hit him in the forehead. Healthy kid. Normal vitals, normal neuro exam, no signs of a basilar skull fracture. 2cm hematoma. PECARN suggests observation vs. CT. You CT the kid. “I would hate to miss a subdural in a 4 year-old, that’d be devastating!”

Scenario 4:

26 year-old healthy female with a day of vomiting, no diarrhea. Says she has abdominal pain, but belly’s not tender. Tachy 106, otherwise vitals are normal and she looks well. Plan is for fluids and reglan and re-assess. Your resident orders a CBC and BMP for some reason, and the WBC comes back 24.8. Patient feels a little better, is tolerating PO, and abdomen is still not tender. You order a CT scan of the belly anyway, “That’s a really high white count! I’d hate to send an appy home!”

Scenario 5:

36 year-old female with a history of anemia on iron with heavy vaginal bleeding, history of heavy periods. Not pregnant. 2 days of bleeding, says she’s going through 8 pads a day, this is heavier than her normal “heavy” vaginal bleeding. Well-appearing in the ED, BP is 130/66, HR in the 70s, no signs or symptoms of symptomatic anemia. Vaginal exam has some pooling of blood in the vault, no active bleeding from the os. Her prior hematocrit in the computer system from 6 months ago is 34.3. You order a CBC. “Maybe it will be really low and she’ll need a transfusion!”

Answer the survey.


What The Heck Is Your Private Blog Like?

A video introduction. Sorry for the mumbling.

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Would you like to know your Ranking?

As an emergency medicine resident, I remember taking tests and wondering where I stood compared to my peers. I would review different materials and focus on areas that I did not feel strong in. As a resident, I took the Ohio Acep review course and took their 700 question CD and reviewed all the explanations. I later was able to review the quiz questions and make suggestions.

Interesting enough, I was able to create the iPhone, Ipod Touch, * iPad edition of the quiz question for Ohio Acep. The app was just released and should show up on the app store in the next 48hrs. The app allows users to take the test and review each answer. It allows the user to focus on the questions or course materials they need to work on by creating custom test. The app also allows users to “know their ranking”, the app will ask users for an alias and will upload their test scores on each section of the test and will give an overall rank based on the users that have already taken the test. The ranking will update every time someone takes the test and clicks on ranking. To see the current ranking of beta testers and updated ranking please click here. To download the app or to see screen shots of the app click here.

* on iPad you will be able to double the size of the screen but the images might be slightly distorted.

Below I have included more information about the app.


Emergency Medicine Quiz Questions
On Sale for limited time, Price is 20% off.

Includes a new, 50-question pictorial review! Contains 700 review questions and referenced answers in an easy-to-use multiple choice format.

** “New Rankings feature, only users to see where they are ranked compared to their peers around the world. The app will rank each person based on subject and overall ranking depending on percent correct! Visit our website for more information.” **

The Emergency Medicine Review Course held annually by Ohio ACEP offers a comprehensive review for the physician preparing for the Qualifying examination, ConCert examination or continuous certification, or who simply desires an intensive review of emergency medicine. Attended by hundreds of physicians each year from across the country, this premier review course promotes high pass rates and receives high compliments.

Email us your feedback so we can make this app even better.

They have created this CD based on years of experience with preparing Emergency Medicine Physicians. The CD edition of this program retails for 100$ US Dollars.

The iPhone app is easy to use.

Topics include:
Endocrine, Metabolic & Nutritional Disorders
Infectious Disease
LifeLong Learning Self Assessment (LLSA)
Pictorial Review
Rheumatology/Soft Tissues

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The next Vaccine rush

Texas A&M was recently given a 40 million dollar grant from the U.S. Department of Defense to develop vaccines from tobacco.  What is amazing is that this 21 aces with 145,000-square-foot facility could produce a billion vaccines in a month. Clinical trials should begin late 2011. Dont worry about nicotine. The plants do not have any.


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Fear and Loathing in D-Dimer

Am I the only one who hates the d-dimer for pulmonary embolism? I can’t imagine that I am. It was supposed to reduce our number of CTs, but the data suggests that it has instead increased them. (Full disclaimer, I never practiced in the days of V/Q scans or the days without d-dimer, but this is what I’m told.)

I find my practice pattern typically using the PERC Rule and/or Well’s Criteria for PE to identify well-appearing people who are “very low risk,” who would likely be harmed more than benefitted by a d-dimer test. And then for low-risk, I’ll end up using a d-dimer.

But when the computer screen blips that the result is back, I get a similar little blip in my chest, hoping it’s going to be negative. Interesting that I feel this way, given that I have no other reaction like this, except occasionally while waiting for the altered patient’s rectal temperature.

On one hand, I wonder, if this is the reaction I’m feeling, hoping and trying to mentally will the number to be negative when I click the “View Results” button, should I have even ordered the test to begin with? And on the other is how atypical, nefarious, and sometimes-weird presentations of pulmonary embolism can be. And then on the third hand: is the pulmonary embolism in the otherwise healthy, young, well-appearing person actually cause for alarm? (Some experts would suggest that our bodies are in a constant state of coagulation/anticoagulation, and that we’re all walking around with occasional, small PEs that our lungs dissolve or filter.) Maybe this is different (“benign PE”) from the PE in the cancer patient, or the hypotensive patient, or the one with the saddle thrombus. And on the fourth hand: there’s not even any good data that anticoagulation is of any benefit in pulmonary embolism (even though it’s the standard of care, and we all still give it).

Maybe I just hate PEs, or ruling them out in seemingly low-risk patients: the time, the money, and most of all, the contrast load and radiation exposure. But for now, I guess we’re stuck with our imperfect tests, clinical gestalt, and bedside evaluations of risk and benefit.

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Trick of the Trade: Laryngoscope Lifting Strength

Intubation of mannequin

You are about to endotracheally intubate a patient. As you struggle to elevate the laryngoscope more anteriorly, has your left hand ever trembled while trying to see the vocal cords? Before you say, “I think the cords are too anterior, hand me the [insert your favorite backup airway adjunct]“, let’s focus on some basics.

How can you gain significantly more laryngoscope lift strength? You can do more left arm bicep/tricep exercises, or…

Trick of the Trade
Hold the laryngoscope handle as close to the blade as possible.

Grabbing part of the blade helps to stabilize against the “waggling” of the handle. Furthermore, it is easier to pull exactly along the long-axis of the handle at this grip point. I would avoid holding the laryngoscope handle as shown in the image above. Is the physician intubating or holding a fragile cup of tea?

Proper holding of larynoscope handleThe most stabilizing larngyoscope grip
which provides maximal lift strength.

For other airway Tricks of the Trade, take a look an older post.

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