Factoid: Hypercalcemia Clinical signs and symptoms

The memory aid ‘moans, stones, bones, groans and psychic overtones’ is often used to recall the signs and symptoms of hypercalcemia.

  • Nausea and vomiting
  • Altered mental status, lethargy, confusion
  • Abdominal pain, kidney stones
  • Constipation
  • Weakness
  • Headache
  • Depression
  • Polydipsia, polyuria, nocturia

Treating prescription opioid addiction – Lecture

Dealing with prescription drug addiction is a daily reality in many emergency departments. These patients can be frustrating and leave doctors feeling burned out. Part of the problem is that many physicians don’t have an organized approach to identify and treat this problem.

This lecture presents a philosophy and treatment strategy that allows physicians to identify and treat prescription medication addiction in a consistent and rational manner.

Enjoy! Feedback is appreciated, and if you would like to see more (or less) audio content please let me know.

Click here for the lecture, or use the inline media player below…

Linezolid – Considerations in the war on MRSA

A 45 year old man presents to your hospital with cellulitis of the leg with some small areas of ulceration. He’s had this before, and has always swabbed positive for MRSA (methacillin resistent Staphylococcus aureus). Sure enough his GP swabbed him 2 days ago and he is growing out MRSA again. His GP also started him on Doxycycline and Clindamycin, which had worked well for him before, but this time his swab results show resistance to all of the tested oral agents.

The patient looks clinically well, and is a good candidate for out patient IV therapy with vancomycin. But, just as you are considering placing an IV you remember an advertisement you saw in one of the throw away journals that grace doctor’s bathroom stalls everywhere. You remember a drug called linezolid (aka: Zyvox, Zyvoxid, Zyvoxam), is this another oral option?

Linezolid is currently the only antibiotic available in the class of drugs called oxazolidinones.

It inhibits bacterial protein synthesis through binding to the 50s ribosomal subunit. Linezolid is a bacteriostatic antibiotic.

  • Gram positive bacteria: Linezolid has broad clinical effect against most gram positive bacteria including Enterococcus (including VRE), Staphylococcus auerus (including MRSA), Streptococcus species, Nocardia, Listeria and Corynebacterium.
  • Gram negative bacteria: Linezolid is ineffective against most gram negative bacteria. It has no effect on Pseudomonas or Enterobacter sp. There may be some effect against Moraxella, Pasteurella, Fusobacterium, Legionella, Bordetella, Haemophilus influenza, and Capnocytophaga. It is not a primary drug for gram negative infections.
  • Mycobacterium: Linezolid is effective against mycobacteria and has been used as part of multi-drug treatment.

Linezolid resistance has been reported in a variety of gram positive bacteria, including linezolid resistant MRSA.

The most common side effects are GI upset, nausea and headache. Serious but rare side effects include thrombocytopenia, myelosupression, neuropathy, and GI bleeding.

Linezolid is also a weak monoamine oxidase inhibitor.

Linezolid is a monoamine oxidase inhibitor (MAOi). Contraindicated concurrent medications include tricyclic antidepressants, SSRI’s, SNRI’s, meperidine (Demerol), phenylephrine, and tyrosine rich foods.

Linezolid is not cheap! A 10 day course of 600mg BID (20 tablets) will run you about $2000.

Linezolid has a specific (and FDA approved) role in the treatment of VRE. Additionally it is active against most MRSA and may be useful for patients who cannot tolerate vancomycin or have contraindications to IV therapy. Linezolid is expensive, but may be cheaper than hospitalization or out patient IV antibiotic programs.

Oral medication therapies are certainly more convenient than intravenous medication. It is tempting to see linezolid as a convenience medication, but I personally think that this is a misguided approach. Linezolid resistance is possible, and indeed has been reported. In an era of limited new antibiotics and snowballing resistance patterns, linezolid should remain a protected antibiotic, used only when specifically clinically indicated.

The Size of the Bite; Managing Stress in Emergencies

‘You never seem to get too stressed out’, one of the nurses at my work recently told me, ‘why is that?’ It got me thinking, why don’t I seem stressed out, what am I doing when I do get stressed out at work? Certainly there are times when I feel stressed, but because I believe that an uncontrolled stress reaction can be detrimental to my ability to do my job I have found ways to turn down the gain when the stress is high.

In the emergency department stress is everywhere, from the critically ill patient in septic shock, to the patient with a sprained ankle. Every patient in the department is having a bad day, and every one of them is stressed out. Some doctors love the stress, the air around them glows as their very nature of being elevates surrounding electrons to higher energy states.

Stress itself can be a useful response, it can hone thinking and actions and when used appropriately can elevate your game. When stress degenerates into panic or frustration however it becomes just another obstacle to be overcome in an already difficult situation. As a physician in a busy emergency department often with single physician coverage I believe stress management is an important part of my job. It would be easy to become overwhelmed and over-focused on any of dozens of things in an individual shift. Emergency physicians working in an environment that is frequently stressful (probably 99% of us) should employ active strategies of stress reduction throughout our shifts. This increases our job satisfaction and it also increases patient care.

By now some of you are thinking ‘This guy lives n the west coast, he probably has a little yoga-meditation room at his hospital and sees 1 patient every 2 hours!’ Nothing could be further from the truth. The type of stress reduction I am talking about happens as you work, and it allows you to work better and faster.

Step 1: When the temperature in the room goes up, my temperature will go down. When the patient, the nurses or other physicians are getting increasingly overwhelmed, agitated, and stressed the situation becomes dangerous. The potential for medical error and misadventure is high at these moments. This group stress response can feel like a tornado and it can be tempting to allow yourself to be sucked into that vortex. Resist. When everyone else is stressed force yourself to speak calmly, slowly, with little intonation. Do not yell, but if you need to you may start out by saying in a firm voice ‘Everyone listen to me, this is how we will begin…’ Set (or reset) the tone of the room, the tone you want to project is calm confidence (even if you do not feel confident).

Step 2: Identify the person in the room who is the most stressed out and give them a task. If this person is a nurse, you need them to go draw up a med or start an IV or do some other useful task. You need to choose something that is simple and tangible and will redirect their focus away from the stress of the situation. If this person is a family member, give them a pen and paper and ask them to write down what they think is important so it will not be forgotten. If this person is the patient place your stethoscope on their chest and tell them you need them to give you 10 slow breaths while you listen to their lungs.

Step 3: When the whole situation is overwhelming break it down into smaller bites. An ambulance arrives unexpectedly and the paramedic runs into your resus room holding a child who has just been run over by a car. The situation is overwhelming, people are screaming, what do you do. This situation is emotionally charged and overwhelming, it would be easy to get caught up in the panic. Really we know nothing about the patient aside from the fact that there is a potentially devastating injury. The totality of the situation is overwhelming from both an emotional as well as a practical perspective. In a situation like this the best strategy is to step away from the totality of the situation for a moment, and take a small very manageable piece to start with. In situations of critical illness these initial first steps are the same regardless of the illness or injury. These initial first steps; put oxygen on the child, immobilize the C-spine, establish IV access, offer an opportunity to reset the tone of the room. Although these first steps take only moments if they are directed with calm confidence they will de-escalate the room and allow the remainder of the resuscitation to proceed calmly. When you personally feel stressed or overwhelmed it is useful to simply think of the next 1 or 2 things that need to be accomplished and then execute these very short term goals. Usually this will reset your internal stress level and allow you to again assert a calm confidence into the situation.

Stress is a useful response and it should not be ignored. Many of us in emergency medicine are here because we enjoy stress, and thrive in a world of high stakes decision making. Stress can be one of our most useful tools in emergency medicine, but for all of us there are moments that threaten to overwhelm our capacity to cope and degenerate into panic. Whether it is a failed airway, an injured child, or a difficult patient encounter using active techniques to manage stress will improve both your situational responses as well as your patient care.

Factoid: Pneumonia Mimics on CXR

You’ve just seen a previously well 50 year old man with a cough and fever. A chest x-ray shows what you think is a pneumonia. Finally, a straightforward case! You are finishing up his charting and about to write ‘pneumonia’ as your diagnosis when you pause, is there anything else you could be missing?

  • Pulmonary embolism
  • Neoplasm/Cancer
  • Congestive heart failure
  • ARDS
  • Atelectasis/Lobar collapse
  • Pleural effusion
  • Bronchiolitis obliterans organizing pneumonia (BOOP)
  • Tuberculosis
  • Granulomatous disease (Wegner’s granulomatosis, Churg Strauss syndrome)
  • Collegen vascular diseases (Systemic Lupus Erythematosus, Mixed connective tissue disease)
  • Drug induced pulmonary disease (eg Amiodarone lung)
  • Pulmonary fibrosis
  • Eosinophillic pneumonia
  • Allergic/Hypersensitivity pneumonitis
  • Radiation pneumonitis
  • Foreign body obstruction