Comments for The Medial Approach to Emergency Medicine

Comment on Diagnosing Hidden Atrial Flutter by 57 year old male: Chest Discomfort – Conclusion | EMS 12-Lead

57 year old male: Chest Discomfort – Conclusion | EMS 12-Lead — Fri, 21 Sep 2012 09:00:33 +0000

[...] more tips to becoming an Atrial Flutter Rock Star, check out our friend Vince DiGiulio's blog post "Diagnosing Hidden Atrial Flutter". Posted by Christopher Watford on September 21, 2012 • Filed under: ems-topics, [...]

Comment on The “Chest Pain and…” Syndrome by Brandon O

Brandon O — Thu, 13 Sep 2012 02:27:33 +0000

Best flags I’ve seen are pain that’s sudden, maximal at onset, and “worst ever.” Sharp or tearing/ripping pain is next, and the vast majority localize it to somewhere in the thorax (chest, back, in between) for TAD, but after that everything takes a bit of a dive. As you say, it’s almost the sister of a subarachnoid.

Very nice differentiating aneurysm from dissection; that confusion is very very common. The trouble, I think, is that even when you make the distinction, a lot of folks say “so who cares?” and that’s tricky to answer.

Comment on Forearm Rolling Test for Stroke by Christopher

Christopher — Wed, 29 Aug 2012 13:12:09 +0000

The Conga Line Test is an easy and fun test to administer at home, in a skilled nursing facility, or in the back of your ambulance! We recommend playing some Buena Vista Social Club to really set the mood.

In all seriousness this is wonderful and I think it is far easier to administer than the standard arm drift. At 3am nobody likes to remember palms up versus palms down…

Comment on Forearm Rolling Test for Stroke by Brandon O

Brandon O — Wed, 29 Aug 2012 02:17:26 +0000

If you’ve had good luck with it, then I believe it. I wonder how necessary it is to try both directions. Doesn’t seem like the neuromotor pattern would be all that different.

Comment on Forearm Rolling Test for Stroke by Vince D

Vince D — Wed, 29 Aug 2012 01:02:26 +0000

I had the same thoughts in regards to cerebellar testing, and I wonder if having the patient close their eyes would increase the yield by really testing the patient’s proprioception.

You second point is also a valid one. I’ve been using this for maybe two years now with most patients I test being able to perform it well enough, but my experience is very skewed because there’s been a good deal of selection bias. I’ve purposely skip it on less cooperative patients because I wasn’t that interested in forcing the issue, but I think from here on out everyone getting a CPSS will also attempt an arm roll.

I’ve been surprised in a few cases when some unexpected patients were able to follow this even though they had fairly progressive dementia, and I think it might have something to do with the active participation required of the test. Tell them to hold their hands out, and they drift off for a nap within two seconds, but get them actively involved in moving their arms and they tend to stick with you for a little bit. Changing direction can require a couple of tries, and there’s a whole lot of patients whose attention you cannot keep for long enough to even get them to lift up their arms in the first place, but a select few may surprise you.

Comment on Forearm Rolling Test for Stroke by Brandon O

Brandon O — Tue, 28 Aug 2012 14:56:23 +0000

I gusta this mucho. It seems like the rolling tests would also include some degree of cerebellar testing (e.g. for dysdiadochokinesia), due to the coordination and rapid cycling involved — which seems good for sensitivity although perhaps not for specificity. (But a positive cerebellar sign would perhaps present differently — rather than unilateral immobility, more of a general sluggishness or ataxia in the movement.) Things to ponder.

I do have some doubts as to ease of compliance… in the really elderly and comorbid patients, even the arm drift test can be a bit challenging to pull off. I suspect that getting them to do the cha-cha may require, let us say, a fairly low expectation of baseline performance.

Comment on Where to Put That Gravid Uterus by Brandon O

Brandon O — Sun, 29 Jul 2012 22:07:04 +0000

Excellent. You even hear it said sometimes that the standard “recovery position” for airway management should be left rather than right, but I’ve never heard any justification for that and always suspected it merely evolved from the desired to have the patient facing the tech in an ambulance. But the maternal version makes good sense at least.

Comment on Where to Put That Gravid Uterus by Vince D

Vince D — Sun, 29 Jul 2012 06:06:04 +0000

Most of my information was either straight-from, or already referenced in, the 2010 AHA guidelines or this (http://apps.who.int/rhl/reviews/CD007623.pdf) Cochrane Review on patient position during caesarean section. The right vs. left question is analysis 4.1 on page 27, which boils down to single study from 1978. I managed to find the actual study here (http://tinyurl.com/bsnb4u6), and it seems decent enough by 1978 standards.

The rail idea sounds like a good one, so I think I’ll actually measure the angle next time I’m at work. My guess would be in the 10-15 degree range

Comment on Where to Put That Gravid Uterus by Brandon O

Brandon O — Sun, 29 Jul 2012 05:18:16 +0000

Great stuff. What’ve you found on the left vs. right issue?

My general thought is that propping the backboard on the stretcher rail would be my first go-to solution. That’s probably 15-20 degrees.

Comment on Diagnosing Hidden Atrial Flutter by Ekgcasestudies

Ekgcasestudies — Thu, 15 Mar 2012 20:37:19 +0000

Great post and topic review– the most extensive summary of a-flutter diagnostic “tricks” I have yet seen in one place! I particularly appreciated your reference to the Bix Rule; I was unaware of this entity and I am very glad to have it on my radar. Keep up the good work!