Winter Update Hello world...

Emergency Medicine is fantastic--I am posting here today because scheduling allowed me a three and a half day weekend this block! Much better than my colleagues in Medicine, Surgery, or OB-GYN--it would never happen on those rotations.



Let's do a case. A 42-day old infant girl presents at 8pm, upgraded from the pediatric urgent care center located at your ER (don't you wish you had one!), with bleeding from the rectum. The parents were concerned because of a 5 day history of worsening blood mixed with mucous (currant jelly) and a normal appearing green stool. Stooling frequency unchanged--4-5x per day. No apparent pain with passing stool or abdominal pain, no vomiting, no fever. Weight gain was appropiate, and baby did not seem overly fatigued, although mother thought she was a little pale. No recent antibiotic use or NSAID use reported for baby or mother. They had come to the our ER after it started and baby was started on a soy based formula and sent home. 1 day previously, baby was started on Neutramigen (last resort before hyperalimentation), but the bleeding had worsened--more obvious blood in the stools for the last day. Prior to starting the soy based formula, baby had been breast feeding. Mother had had cracked nipple previously about two weeks ago with a little bleeding, but it had resolved after 2 days. Baby had been born 2 days post dates by C-section for failure to progress. Normal primigravida prenatal course, no NICU time, no peri-natal infections reported. Parents report an iguana and two dogs in the house, are non-smokers, have no medical problems, and the baby has no siblings.

On exam, baby was well appearing, in no distress, and appeared well hydrated, with no pallor or jaundice. Mild baby acne over L lateral face and forehead seen. VSS, afeb. No bruises noted on skin. Oro-nasopharyngeal exam revealed pink mucosa without bleeding, hyperemia, or thrush. Normal cardiovascular and lung exam. Normal bowel sounds. No tenderness, distension, or masses on abdominal exam, no organomegaly. No caput medusa. No cracks, fissures, or hemmorhoids appreciated. During the (normal) digital rectal exam,I got an episode of forceful pooping for my trouble, getting baby shit on my pants, eliciting knowing smiles from the parents, and endearing me to them forever. Strongly guiac positive semisolid green stool mixed with red mucous.

CBC revealed a HB/Hct of 12/36, WBC of 14, plt of 640. Complete metabolic panel within normal limits except for slightly elevated AST/ALT, but normal bilirubin and alkaline phosphatase.

So what's the differential?
--Whenever you see currant jelly stools in a child less than 2, my spastic reflex is "intussusception," which is a good reflex, as this is a dangerous and often-missed diagnosis, it can lead to "the process progresses to transmural gangrene and perforation of the leading edge of the intussusceptum." . Other features of this diagnosis missing from this picture: altered mental status, intermittent abdominal pain, vomiting, intestinal obstruction, preceeding upper respiratory infection, wrong age--"intussusception occurs in infants aged 5-10 months," and palpable abdominal mass.

--Meckel's diverticulum--which often presents with painless rectal bleeding, and can be a lead point for intussusception. However, in this case: no signs of abdominal pain, the bleeding was relatively mild (Meckel's typically produces profuse rectal bleeding--because of ectopic gastric mucosa ulcerating), wrong time frame (remember 'rule of two's'--2% of population, 2% manifest clinical sx, 2 feet proximal to the terminal ileus, and 45% of symptomatic patients are less than two years old) and again, no sign of obstruction, and the patient did not appear acutely ill (which would prompt perhaps a search for a meckel's--typically via Meckel's scan, a nuclear test.).

--Necrotizing enterocolitis: Less common in normal birth weight babies, no peritoneal signs, and simply not ill.

-- swallowed maternal blood--excluded by history in this case--cracked nipple most common--not an issue here.

--Anal fissures, cracks, and fistulas--rectal exam is mandatory in case of rectal bleeding, fortunately negative in this case.

--Milk protein allergy--quiet, can last for days after last milk ingestion, can lead to GI bleeding. This ended up being our probable diagnosis.

The patient was discharged after a discussion with the PMD and referral for close GI followup.

--dex

*Picture from www.restaurantwidow.com  ¶ 9:24 PM 2 comments links to this post

  Good for a laugh Don't think he's going to make it...

Labels: Humor

  ¶ 1:06 PM 1 comments links to this post

  Is there Life Before Death? Yeah...the new place. Can't say where it is, 'course, y'unnerstan', but...it rocks. I think one of the most critical things is that people are happy here. I mean, the people who have been here for a while. And they keep people here. Not like my last place, where people would only stay a couple of years (as attendings, I mean.) But this place--when I asked how many from the graduating class they hired, they said, "None!". And I thought, well, that's not good--the new attendings want to get away, right? No, actually...as it turns out, there were just no positions open; that lots of the graduating class would stay if they could, but there was no positions because nobody leaves because they are happy here.

I'll have to admit, I really didn't want to move...so I didn't. Now I have an hour commute, but I'm never bored, and I never wait. I figure I'll listen to my Gold Standard stuff left over from studying step 3. The pharmacology at least will still not be old. And since it is such a chore for me to study when I'm home (I'd rather watch Battlestar or The Daily Show or clean or read novels like Lois McMaster Bujold, or (hopefully) get back into Aikido or back into Guitar or talk to my GF.)

As always, more later...

Labels: Hobbies, Interning, The Job

  ¶ 2:10 PM 1 comments links to this post

  I'M BACK!
Back in action, folks...was really overwhelmed in March, couldn't post.

Good news--Got a new job; as a new emergency medicine intern at a good sized hospital, that's an excellent program, old (by ER standards), and with a lot of institutional memory and experience. Bad news is I'll probably have to move, leaving my beloved apartment, but the program is that good, that I can leave the apartment behind with nary a tear.

Continue the progressive march to the glorious future, comrades!

And for some ER news, as many of you probably know, new guidelines for prophylaxis for infective endocarditis have been published by the AHA, and the good news is the number of people at risk for IE is much fewer than previously thought. The guidelines therefore are much more restrictive than previously, saving a lot of antibiotic prescriptions and preventing antibiotic-associated complications like C. dificile colitis, anaphylaxis, tachyphylaxis, and antibiotic resistance--here's a synopsis...

New guidelines regarding antibiotics to prevent infective endocarditis

The American Heart Association recently updated its guidelines regarding which patients should take a precautionary antibiotic to prevent infective endocarditis (IE) before a trip to the dentist.

The guidelines, published in Circulation: Journal of the American Heart Association, are based on a growing body of scientific evidence that shows that, for most people, the risks of taking prophylaxis antibiotics for certain procedures outweigh the benefits. These guidelines represent a major change in philosophy.

The new guidelines show taking preventive antibiotics is not necessary for most people and, in fact, might create more harm than good. Unnecessary use of antibiotics could cause allergic reactions and dangerous antibiotic resistance.

Only the people at greatest risk of bad outcomes from infective endocarditis — an infection of the heart's inner lining or the heart valves — should receive short-term preventive antibiotics before common, routine dental and medical procedures.

Patients at the greatest danger of bad outcomes from IE and for whom preventive antibiotics are worth the risks include those with:

artificial heart valves
a history of having had IE
certain specific, serious congenital (present from birth) heart conditions, including:
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits

- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter interventions, during the first six months after the procedure

-any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device

a cardiac transplant which develops a problem in a heart valve.

P.S. all photos and pictures will now be created by yours truly to avoid copyright infringement.

Labels: Guidelines

  ¶ 4:25 PM 0 comments links to this post

  WooHoo! 2006 Medical Weblog Awards are here!

Go here to vote.

I'm not nominated. Like, whatever, man. Who cares about your stupid contest anyway.

Next: My interview at North Shore-LIJ.  ¶ 12:50 PM 6 comments links to this post

  Sigh. I've enabled word-verification for comments after deleting dozens of spam comments.

I had a dream the other night about how to get back at them spam commenters. I thought about becoming a hacker, an uber-h4XX0R, dealing out DOS's attacks to the sites the spams link to. We would be locked in epic combat, me versus the spammers, using ever-more sophisticated tools to punish the wicked spam-commenters and protect the innocent bloggers.

Then I woke up.

Happy New Year!  ¶ 9:26 PM 2 comments links to this post

  Plugging a Useful Meme
Imagine this was your drug rep.

I was over at #1 Dinosaur's, and he said he'd just been over at DB's, guess what he said: Just say no to drug reps!

And I thought I was all alone. (US site down? WTF?)

TANSTAAFL, people.

As a doctor and prescription-writer, I consider myself a judge of what medications to give, or not. "And you shall take no gift; for a gift blinds those who have sight, and perverts the words of the righteous." -Exodus 23:8

And now I'll repost (they're that good) Robert Caldini's "Six Weapons of Influence".

"* Reciprocation - People tend to return a favor. Thus, the pervasiveness of free samples in marketing. In his conferences, he often uses the example of Ethiopia providing thousands of dollars in humanitarian aid to mexico just after the 1985 earthquake, in return to past gestures Mexico had with Ethiopia.

* Commitment and Consistency - If people agree to make a commitment toward a goal or idea, they are more likely to honor that commitment. However, if the incentive or motivation is removed after they have already agreed, they will continue to honor the agreement. For example, in car sales, suddenly raising the price at the last moment works because the buyer has already decided to buy. See cognitive dissonance.

* Social Proof - People will do things that they see other people are doing. For example, in one experiment, one or more accomplices would look up into the sky; the more accomplices the more likely people would look up into the sky to see what they were seeing. At one point this experiment aborted, as so many people were looking up, that they stopped traffic. See conformity, and the Asch conformity experiments.

* Authority - People will tend to obey authority figures, even if they are asked to perform objectionable acts. Cialdini cites incidents, such as the Milgram experiments in the early 1960s and the My Lai massacre.

* Liking - People are easily persuaded by other people that they like. Cialdini cites the marketing of Tupperware in what might now be called viral marketing. People were more likely to buy if they liked the person selling it to them. Some of the many biases favoring more attractive people are discussed. See physical attractiveness stereotype.

* Scarcity - Perceived scarcity will generate demand. For example, saying offers are available for a “limited time only” encourages sales."

Strewth!

--dex.

P.S. Wikipedia is having a pledge drive a la NPR. Reflecting on my heavy use of it, I gave $20 bucks. You should too. It's one of the best things about teh intarweb.  ¶ 7:32 PM 2 comments links to this post