Subarachnoid Hemorrhage (SAH) is one of the more angst-inducing pathologies an Emergency Physician faces on a daily basis. A disease for which we have a well established diagnostic pathway. The strategy of non-contrast CT followed by a lumbar puncture (LP) has been showed to effectively eliminate the risk of SAH (1). And yet there is […]
EMNerd
The Nihilistic Ramblings of Rory Spiegel, MD
The Adventure of the Resident Patient
In a properly automated and educated world, then, machines may prove to be the true humanizing influence. It may be that machines will do the work that makes life possible and that human beings will do all the other things that make life pleasant and worthwhile. -ISAAC ASIMOV The term Cyborg, short for […]
The Adventure of the Speckled Band
Blood pressure is one of the least understood and yet most intervened on metrics in modern medicine. Though we have found meager success in controlling blood pressure over the long-term (1,2) our attempts to translate these benefits to the acute setting of the emergency room have not been met with improved short-term outcomes. Traditionally acutely […]
“The Adventure of the Empty House”
Well before Han Solo was frozen in carbonite, before Sigourney Weaver crossed galaxies in cryostasis, or Walt Disney was cryopreserved, we have been fascinated by the stasis-like powers of hypothermia. Given this enthusiasm, we most likely would have reacted with just as much vigor even if the initial trials of hypothermia for out of hospital […]
A Study in Scarlet
A recent article published in the NEJM by Steg et al demonstrates that it is not the efficacy of an intervention that determines the success or failure of a trial, but rather the definition of its endpoints (1). In contrast to the majority of trials examining novel anticoagulants for ACS, Steg et al chose […]
“The Adventure of the Veiled Lodger”
The HINTS exam is a 3-part test designed by Dr. Newman-Toker to clinically exclude a central cause of acute vertigo in patients who present with vertiginous symptoms. HINTS involves most famously, the head impulse test(see diagram below), a maneuver which involves torquing your patients head from midline to 20 degrees of rotation(or Vice Versa) and […]
“The Adventure of the Missing Three-Quarter”
Since Hector Pope published his now infamous study in the April 2000 NEJM, Emergency Physicians ability to clinically differentiate ACS has been called into question(10). Despite the fact the study’s findings that ED physicians missed an almost flawless 0.18% of chest pain patients who went on to be diagnosed with a MI, we have been […]
The Man with the Twisted Lip
As an Emergency Medicine doctor we are trained to function in varying degrees of uncertainty. We work in a world of risk of benefits vs harms. When the benefit to harm ratio reaches a threshold for action we are taught to do so swiftly and decisively. Given this, […]
The Adventure of the Three Students
There are few things that make emergency medicine nerds more excited than decision rules. So when the Canadian gods of decision instruments, Jeff Perry and Ian Stiell, published the results from the validation cohort of their recently derived SAH decision rules they of course had our full attention. On September 25th 2013 JAMA published this […]
The Sign of Four Part 2
On September 9th 2013 the article we have all been eagerly awaiting (or perhaps just myself!), was published in Circulation by Sarode et al (1). What was formerly known as Trial 3002 was officially named “Efficacy and Safety of a 4-factor Prothrombin Complex Concentrate in Patients on Vitamin K Antagonists Presenting with Major Bleeding”. Surprisingly […]
The Case of the Thirteen Watches
Door-to-balloon time is probably the most overstated, but least understood surrogate outcome measured in Emergency Medicine today. No sooner does the patient with midsternal chest pressure and ST elevations set foot in the emergency department, when they are packaged up and swept away to the cath lab by a gang of cardiology fellows and attendings. Now with […]
A Case of Identity
On August 17th 2013 The Lancet published what appears to be Eli Lilly’s face saving article on its derailed quest to replace its predecessor, clopidogrel (1).In its attempt to emulate Bristol Meyer with its triple C (CURE, CREDO, CLARITY) trials, pull the wool over the healthcare industry’s global eyes and become the second leading sold drug […]
The Adventure of the Crooked Man
A recent study entitled, “Outcomes at 12 Months After Early Magnetic Resonance Imaging in Acute Trauma Patients With Persistent Midline Cervical Tenderness and Negative Computed Tomography” published in the June 2013 issue of Spine has attempted to shine a small amount of light on a topic that has cast a large shadow of doubt on […]
The Adventure of the Red Circle
When it comes to non-traumatic intracranial hemorrhage (ICH) the onus of the emergency physician is diagnosis, while location and severity are of far less importance. Once the diagnosis is made and the initial stabilization complete, there is very little for us to do other then notify the ICU team and contact the neurosurgeon, who, in […]
The Adventure of the Greek Interpreter
In Greek mythology Peitho was the Goddess of persuasion and seduction. Please feel free to find irony where you see fit… I am a sucker for catchy trial names. I swoon in anticipation when reading of the recent publication of a large multi-centered randomized control trial on a topic that is relevant to emergency medicine. […]
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