An 7-year-old girl presents to your Emergency Department (ED) with an ankle inversion injury from while performing gymnastics. Plain films of her ankle show no fracture. It has been a long-held presumption that skeletally immature children with fracture-negative radiographs should be immobilized with a cast given the concern for an occult Salter-Harris 1 fracture. “Children do not get sprains” is a common teaching point. But a recent 2016 JAMA Pediatrics article challenges that premise in a prospective cohort study of 135 pediatric patients.1 Can these injuries be managed more like a sprain, utilizing a removable ankle brace?
“That is part of the beauty of all literature. You discover that your longing are universal longings, the you’re not lonely and isolated from anyone. You belong. ”
– F. Scott Fitzgerald
Knowing him, you are struck not by his gravitas but by his gentleness and depth of thought. We are excited by the opportunity to have him share his recommendations in this Book Club: Beyond the ED post and to give you a sliver of the Ed Newton that has touched so many of us.
Often in the prehospital setting, naloxone is administered by EMS (or possibly a bystander) to reverse respiratory and CNS depression from presumed opioid overdose. The patient then wakes up, and not uncommonly, refuses transport to the hospital. The question is: Is it safe to ‘treat and release?’ Or, rather, what is the risk of death associated with this practice. A hot-off-the-press article, just published in Prehospital Emergency Care, addresses this question.
Paraphimosis occurs when a retracted foreskin can’t be reduced back over the glans of the penis. Risk factors for paraphimosis include scarring, vigorous sexual activity, chronic balanoposthitis, and forgetting to replace the foreskin after catheterization or manipulation.
Paraphimosis can be a urological emergency as the tight ring formed by the foreskin can cause ischemia to the tip of the penis and eventually gangrene. Timely reduction is of high importance. Treatment involves gentle compression of the glans and gradual manual foreskin retraction.1 Unfortunately, as time goes on, more swelling occurs making traditional reduction techniques more difficult.
“Words can be like X-rays if you use them properly — they’ll go through anything. You read and you’re pierced.”
― Aldous Huxley,
Beyond his accomplishments, to talk to him is to talk to person who not only has the experience but both the willingness and ability to continue to think deeply. He continues to inspire many of us, not by his accomplishments but by his continued enthusiasm that he brings to the whatever he is working on. ALiEM is excited to have Dr. Louis Ling share his book recommendations in this edition of ALiEM Bookclub: Beyond the ED.
Ear irrigation is an important tool for adult and pediatric patients in the Emergency Department (ED) with ENT complaints. Irrigation can be used to clear ear cerumen, visualize tough-to-see tympanic membranes, and remove foreign bodies. This may reduce the need for subspecialist care and improve the patient’s hearing and quality of life.1 Commercial electronic and mechanical devices are available for irrigation and have been studied. Moulton and Jones presented the improved efficacy of foreign body removal using an electric ear syringe in an (ED) population.2 In this trick of the trade, we present a low cost and effective way of “ear-rigation” taught to us by one of our veteran nurses using easily available tools in the ED.