The child with possible appendicitis provides a diagnostic dilemma for the Emergency Department physician.  What was once a purely clinical diagnosis is now a diagnosis frequent augmented by a need for further imaging.  While the surgeon taking a child to the OR without imaging certainly does still exist, imaging with either ultrasound or CT is often utilized by ED physicians and general and pediatric surgeons alike.   In a recent publication in by Hryhorczuk et al in Radiology (click for abstract) it noted that CT scans were used in children with abdominal pain in 2% of cases in 1999 versus in 16% of patients in 2007.  Ultrasound, while useful is very much technologist dependent with respect to the adequacy of views that are obtained.

Should CT scans be used, the usage of low dosage CT scan provides a very reasonable option in reducing radiation exposure while obtaining adequate images as well.  In a recent New England Journal report by Kim et al. (N Engl J Med 2012; 366:1596-1605) (click for abstract) in 891 patients that received either regular (521 mGy-cM) versus low dose (116 mGy-cm) CT scans, the negative appendectomy rate was not significant at 3.2% versus 3.5% (CI -3.8 to 4.6).  While usage of CT scan is clearly not indicated in all cases, given pretest clinical suspicion and frequently in coordination with radiology and surgical specialists.

Block 12 has been up and running.  After a slow start volume wise the ED has picking up in volume.  Make sure to have your End-Of-Shift evaluation cards filled out on a regular basis.  For the most up to date schedule for all Resident shifts click here. Remember any changes that are made need to be through the site director at emsitedirector@gmail.com.  See you in the Department!!

The 1^st annual Lansing Marathon is just days away.  Among the many things that happens to a runner’s bodies in an event such as this is the possibility of hyperthermia.  Exactly what type of temperatures may we be looking at?

An interesting study from 1983 by Maughan, RJ, Leiper JB, and Thompons J. entitled “Rectal Temperature after Marathon Running” in the British Journal of Sports Medicine found some with rectal temperatures even over 40 degrees Celsius.  The mean temperatures at the finish line for these individuals who had a rectal temperature taken at 38.7 (±.9) Celsius. (just minutes after running 26 miles, amazing what people will do for science) Ambient temperatures on this day weren’t even that high, with temperatures not even over 55 degrees Farenheit.

Recongition of this possibility, and then cooling measures and adequate hydration represent the foundation of treatment.

Welcome to Block 11 to all our rotating resident and students!!  Hopefully it’s been a productive week

For the most updated schedules for the students click here, for those who are resident in the ED on block 11 please click here. This Thursday is the CityWide Research day, so we’ll see you all there.  Check the info under week 1 and week 3 as above for some links to interesting articles.

After a great city wide conference today, lecture will continue next Thursday at McClaren as previously.  Please click here for the most updated schedule of resident/student lectures.  This contains the reading schedule for our current students!  Don’t forget to pick up your copy of the Mahadven and Garmel book in the library.

As always, Please contact me with any scheduling conflicts and any concerns that you have on this rotation. See you in the Pit!!

The holidays are over, Flu and RSV are on the way, It’s a great time to be in the ED getting people better and providing top notch care to the people of Lansing.  The most updated schedules can be found by clicking here. For some interesting readings and some information on the ED conferences that are coming up, The World Famous Lansing EM residency sign-out can be found at the following link.

As alway, Contact me if there’s any questions thru the emsitedirector@gmail.com address.

The Signout Team is at it again.  Here’s our bi-monthly signout of all the activities and some interesting articles on frostbite, wicked cold EKGs, and what an interesting Peds Overdose case that we can learning something from.  Click HERE to check it out.

Also, be sure to check out the “Week #3 link” above with the passwords you’ve been provided.  This upcoming Saturday is the procedure lab so expect some emails on this as well.

Is much of what we do in medicine evidenced base?  While that would be the hope there’s clearly many things we do that are unfounded based upon what we find in the literature. Two such myths you’ll stumble across with some frequency in the ED concern avoid epinephrine in digital blocks for those finger lacerations as well as common recommendations following lumbar punctures in order to reduce the chance of spinal headaches.

Despite common practice to avoid any local anesthetics containing epinephrine for prevention of distal ischemia and gangrene in fingers, there’s little to no evidence supporting this practice.  Multiple reviews in the plastic surgeryliterature have found just this.  Onerecently published article in Plastic and Reconstructive Surgery by Chowdry et al¹ in 2010 from the University of Louisville looked at 1111 cases of individualswho received lidocaine with epinephrine digital blocks and found no complications.  In 2001, Wilhelmi et al²randomized 60 patients to either lidocaine with or without epinephrine and not only observed no complications in the “with epinephrine group” but also found that fewer patient’s required repeat blocks and there was better hemostatic controlled obtained so the need for finger tourniquets could be avoided.

How about that patient that forgets to lie flat after the lumbar puncture?  Should we book them an appointment
for anesthesia at the pain clinic for an inevitable spinal headache in a day or two?  A Cochrane Database Review³ attempted to clear this up and back in 2002 they found 11 studies that totaled 1723 patients for review.  They found a trend (yet not a significant one) towards an increased risk of spinal headaches in those individuals required to have prolonged ‘bedrest’ (31%) compared to those treat with immediateimmobilization (27%)[OR 1.21 (CI 0.94-1.55)].  That’s right, A
range of 1-70% obtain some degree of spinal headache!! A smaller needle, bevel’sbeing parallel to the dural fibers, caffeine infusions, and blood patchesappear to be options that are there with potential benefit that should likely be where more of an evidence based approach to preventing spinal headaches should lie.

1. Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Whilhelmi BJ. Do not sure epinehprine in digital blocks:myth or truth? Part II. A retrospectivereview of 1111 cases. Plast Reconstr Surg. 2010 126(6):2031-4.Plast Reconstr Surg. 2010 Dec;126(6):2031-4.

2. Wilhelmi BJ, Blackwell SJ, Miller JH, Mancoll JS, Cardano T, Tran A, Phillips LG, Do not use epinephrine in digital blocks:myth or truth?Platic Reconst Surg 2001 Feb;107(2):393-7.3.

3. Sudlow C, Warlow C. Posture and fluids for preventing post-dural puncture headache. Cochrane Databse Syst Rev. 2002;2:CD001790

Welcome to the ED.  Check your emails for the medical student schedules and rotating resident schedules or click on the links (students or residents)!!!  Any schedule changes that take place between you do need prior approval.  Remember to log into the Week #1 information at the top of this page with the provided password for some interesting articles to review.   Check your emails frequently for updates to the didactic schedules–> This upcoming week there will be no Thursday resident didactics due to the holidays. Feel free to contact me with any questions that may arise.

Due to problems getting subjects for the procedure lab that were not shipped to the Vet school in time the Procedure Lab for this Saturday has been cancelled.  Report to your clinical duties as previously planned.

The Newest Signout is here, The Newest Signout is here, The Newest Signout is here!!!  Thanks to the SignOut team (headed by Jamie C.) for their latest production.  Click here for information on upcoming conferences, an update on CA- MRSA, information on those nasty post-tonsillectomy bleeds, and other challenging cases.

This weekend is a very optional Procedure lab on MSU’s campus where we’ll be able to perform and practice some of the less frequently performed procedures encountered in the ED setting.  All current rotators and students are welcome to stop by, let me know if you’ll be attending.  Some of things we’ll be doing can be found by clicking here.

I will readily admit the number of changes to the schedule has overwhelmed me to a certain degree (Holy scheduling chaos, Batman).  Tonight I’ll be posting the schedules in the Peds and Adult ED (in Q hall) for the current resident rotators.  PLEASE MAKE CHANGES THAT HAVE ALREADY BEEN APPROVED BY MYSELF IN PEN ON THESE PRINTED COPIES AT THE TIME OF YOUR NEXT SHIFT.  What’s currently hanging up is the initial schedule found here. Pleas make those changes so I can make sure we’re all on the same page.  Thanks for your flexibility!!

Finally, for the Peds ED resident rotators and students (optional for students) we’ll be going over some topics (peds ortho, head injury, peds tox) on Monday in the Jerome Street basement beginning at 9 AM.  We’ll be discussing a landmark article on pediatric head trauma which we can find here.

As always, Contact me with any questions or concerns (at emsitedirector@gmail.com) and I hope your EM rotation is going great!!!