Archive | December, 2014

weather dependent nasal erythema in reindeer

23 Dec

repost of an old low-impact review for the holidays.  updates will be sporadic during this season, but until then, happy holidays and happy new year!


I love the fact that this review article exists:

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Weather dependent nasal erythema in reindeer (Rangifer tarandus).  Teece S, Foëx BA. Emerg Med J. 2007 Dec;24(12):848-50.



“There appears to be no evidence for a specific disease state in reindeer, therefore nasal erythema may be due to increased blood flow to the nose”

“The evidence suggests that in winter resting reindeer will not have a red nose, but that when frantically circumnavigating the globe their noses will glow as they try to lose heat.

A reindeer with a red nose at rest at the North Pole means either deranged temperature regulation, or the use of drugs. Neither of these conditions would inspire confidence for an arduous journey.”


Clinical bottom line

“A global positioning system is perhaps a more reliable navigational instrument than a reindeer with a brain at boiling point.”


References: the article; picture

practical wisdom: make a nice bandage

18 Dec

bit of wisdom from an October EP Monthly article by Dr. Silvermann, under the subheading of “Clean Up Your Own Mess” (another solid rule to live by):

“Because patients typically only see the bandage covering the lac repair, you want to make sure that it looks beautiful and everything else is cleaned up. They won’t judge your repair for a couple of days, but if the bandage looks good, they’ll think the whole thing looks good and they’ll leave happy.”


Sound advice.  I’ve been admittedly guilty of some haphazard rapid bandaging after taking time to do a meticulous lac repair (though oddly in retrospect, I do give particular effort in making a cosmetically pleasing splint, cast-padding, ACE wraps, and all), so a few extra seconds to make a nice-looking bandage/covering logically might do wonders for patient satisfaction.  


A brief PubMed search yielded little to nothing on this subject (if you find something, please forward it along), but it conceptually makes sense (our society is great at judging a book by its cover), and there’s little downside, so why not?


References: EP Monthly article; picture

visual aids: shoulder joint injection/aspiration

16 Dec

are you a visual learner?  need some quick-refresher visual aids for your next shoulder injection/aspiration?  take a gander at a few of these:


some nice Images in EM from the May ANNALS by Zala & Soskin, including:

(septic joint, so the effusion was not subtle)


INJECTION (normal shoulder) –via this SonoSite video:



INJECTION (dislocated shoulder) –via ALiEM video (neat tip: use a spinal needle–its deeper than you think):



Have at it.  The SonoSite video has some nice pictures, but a monotone narration.  The ALiEM video is a bit more dynamic, if you’ve got the extra few minutes.

References: annals images; SonoSite video; ALiEM video

Rash to Remember: Toxic Shock

11 Dec

A few pearls to help distinguish the badness of toxic shock syndrome from just any old rash

-involves skin and mucous membranes

-macular, resembles a sunburn

-involves the palms and soles

-more severe cases develop vesicles and bullae

-non-pitting edema due to increases in interstitial fluid

-late onset (1-3 weeks) develops into a pruritic maculopapular rash with desquamation of the palms and soles




Submitted by K. Estes

Management of Metacarpal Fractures

8 Dec
  • These fractures account for 40% of all hand injuries
  • treatment based on which metacarpal and the acceptable angulation of the fracture; general rules to remember:
    • index 10°
    • long 20°
    • ring  30°
    • little 40°
  • physical exam pearls:
    • fight wounds over MCP joint are open until proven otherwise
    • assess malrotation by examining “cascade” -> line up fingernails while fingers in full flexion



  • reduction and splinting if acceptable angulation and no immediate operative indications
    • “jahss” technique for reduction -> flex the patient’s MCP and PIP 90°, then apply dorsal force to proximal phalanx


    • intrinsic plus technique for splinting -> MCP flexed to 60-70°, IP fully extended, and wrist held in 10° less than maximal extension.


Submitted by Kelly Estes.


Sources: Content and Picture1 (, Picture 2 (

can’t find a Word catheter?

5 Dec

my current workplace has a decent stash of Word catheter’s, having worked in places where they are in short supply, it’s nice to have a few tricks up your sleeve if you need to improvise, such as this idea from an old ALiEM post:


basically, grab a rubber tube threaded with suture.


pull it through the bartholin abscess like a loop drainage (click through for a refresher + video)


Not rocket science.  Add it to the mental toolbox.


References: ALiEM post (& picture); loop abscess post; loop picture

word of the day: pneumorrhachis!

2 Dec

from a recent JEM article by Aiyappan et al.  

Case report of a 53 yo M complaining of facial and chest puffiness.  Had a hx of asthma.  X-ray/CT showed mediastinal air and subcutaneous emphysema, and also….



= intraspinal air

-> rare, can extend from posterior mediastinum into the dural space through the neural foramen.

-> can be asymptomatic, but watch out for cord compression symptoms


For some more depth, check out this 2006 review of this rare phenomenon.


References: case report, 2006 review; picture