I have heard of using tea bags under your eyes to reduce puffiness, but to combat odors in the ED?
In my growing list of “Tricks of the Trade” tips for protecting your olfactory nerves (Antacid booties for toxic sock syndrome, aerosolized orange juice, abscess drainage using suction), I got a clinical gem from Dr. James Juarez (Rogue Valley Medical Center in Ashland, OR) after my recent Tricks of the Trade talk at High Risk EM in San Francisco.
The classic prior teaching for the treatment of diverticulitis includes:
Do ALL patients need to be admitted? There is some early literature suggesting that there is a small sub-population who fare well with outpatient treatment.
This article from Annals of EM in the “Best Available Evidence” series summarizes the existing literature well.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
This paper only provides guidelines, based on the limited evidence out there. Still use your common sense. For instance, I’d still admit patients who are elderly (>80 years old) or have evidence of any perforation on CT. If on the fence, admit the patient.
Still it’s nice to see that the treatment of uncomplicated diverticulitis on an outpatient basis has some supporting literature.
A patient presents with a swollen finger after falling and fracturing it. The patient is more distraught by the fact that she can’t get the ring off her finger. She implores you not to cut the ring off.
There are textbook chapters written about tightly wrapping the digit with string from distal-to-proximal and sliding the string under the ring. Theoretically, the provider can pull and unwind the proximal end of the string to gradually coax the ring over the coils of string.
I have personally found little luck with this maneuver.
They all died from an aortic dissection. We commonly consider this diagnosis for Emergency Department patients presenting with severe chest pain. There is an International Registry on Aortic Dissection which published a retrospective, descriptive study of 464 patients with dissections.
I find this list helpful, because it illustrates the fact that the classic signs and symptoms aren’t actually very common. Here are some scary examples:
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
The finger-to-nose exam is typically used to detect a cerebellar lesion. In subtle cases though, this can be be difficult to detect.
How can you improve your sensitivity of this exam?
The ideal clinical decision tool has a sensitivity and specificity of 100%.
You need a high sensitivity to be sure that your negative result indeed predicts a true negative. That means if your clinical decision tool suggests that you don’t need to get a head CT, then your head CT would have been normal.
On the flip side, this realistically means there is a low-moderate specificity. That means a clinical decision tool with at least 1 positive criterion does not always mean that there will be an abnormal finding on head CT.
There are 3 major clinical decision rules that I’ve heard tossed around in the literature:
There is no perfect tool.
Take a look at these decision rules and their inclusion criteria.
Which do you use? I use a combination of all 3 and my clinical gestalt.
Go to ALiEM (PV) Cards for more resources.
Thanks to Dr. David Duong and Dr. Najm Haqu (UCSF) for letting me cross-post their amazing instructional video on the “EM Eye Exam”. These videos were made for the purpose of teaching senior medical students on their UCSF-SFGH EM clerkship. I thought it’d be great to share these tutorials, since the eye exam is typically a daunting task for many medical students (and residents).