Click on emednation located just to right of the date to navigate the site You will see what appear at times like photographs. Most are, in fact, the paintings of Dwight D Collman MD. It will be stated on most of the images because he does have a few photographs on the site because he uses photography at time as resource material for his art.
Patients acquire meningitis from a variety of mechanisms: direct exposure of the secretions of someone with active meningococcal meningitis, acquisition from extension, i.e., advancing infections that may be acute, subacute, or chronic and have now had specific pathogens cross into the brain via the circulatory system, or even via extension through the meninges. The concept I want to emphasize is you can sometimes find the source of meningitis and better focus your antibiotic therapy when a source is found. You can make a clinical diagnosis of sinusitis much of the time by simple palpation. The younger physician will always order a CT scan (almost). Like many diagnoses in medicine, this one can be made in simple cases with no radiologic study. It is important to know that many diseases I will cover require that a physician make the diagnosis with no test of any kind: key example…tetanus. It also has a long list of imitators (what we call the differential diagnosis). There is no test for tetanus and it has 4 presentations: neonatal, localized, generalized and cephalic…enough on that for now…I am sure most of you can imagine what you would see in a patient with obvious bilateral chronic maxilary sinusitis; thickening of the sinuses so the space of aeration appears too small; if there is an acute component you should see a meniscus…an air fluid interface: dark on top, the fluid a shade of white inferior to the meniscus. If the patient has an acute exacerbation of their sinusitis-related symptoms and this is established in the initial history, this is a site that should be considered as “the source” if symptoms progressed and they are acutely ill as with meningitis. Treatment, therefore may not only include antibiotics, but at some point may need to involve improved drainage of the sinuses. This is also true of meningitis caused by otitis media. If you do not drain the source it is like leaving an abscess (antibiotics have no ability to enter an abscess) any infection involving a closed space with organisms like an abscess or urinary retention which has become complicated with the onset of a UTI (that is an abscess with hydrostatic pressure forcing bacteria into the circulation) often seen in men with benign prostatic hypertrophy, MUST BE DRAINED. If you don’t address the source, the problem will persist. It can cause the demise of the patient. I was taught this by my favorite radiologist in medical school and it is worth sharing: “piss, puss, pancreatic juice, and problems (psychiatry works best when you talk the problems out of your body) all must be drained from the body or the patient can die!” reference “my wise now older radiologist mentor” I would say not a shift goes by that I don’t deal with this list. BTW the largest bladder I drained with a foley contained over 3500 mL of urine! This was a male patient with schizophrenia who was wide awake, not septic but waving his arms wildy and not saying much but awake and alert. He was brought to the ED from a shelter with no chief complaint other than the agitation he expressed with his arms. He looked pregnant! Make sure you undress your patients completely. There is no reason to ever clamp a foley catheter, something I have seen in texts and it is wrong! You may see some temporary bladder wall bleeding as a huge bladder rapidly is decompressed and this is of no consequence; the hypotension from draining a bladder is also a myth, usually the patient is in so much pain you often see tachycardia and hypertension. If there is more than 500 mL of urine and the patient is not able to drink, you should place an IV and replace the output…if you don’t you will likely discharge the patient with some degree of hypovolemia. You also need to always evaluate the serum potassium (actually all the electrolytes, BUN, Cr and glucose. Your goal is to save renal function and to relieve his pain from the severe outflow obstruction. Meds for this condition can be contributory.
If you are wondering about why pancreatic juice is on the list, my mentor was referring to obstruction of the common pancreatic duct: these secretions are so alkaline they can dissolve tissue, just like stomach acid is so acidic it can dissolve tissue (like the lungs when you aspirate).
BACK TO MENINGITIS:
It is important not to simply administer antibiotics without including a thorough physical examination after the antibiotics have been started intravenously. One of the problems in our specialty is attacking a problem with tunnel vision. Encephalitis is a similar problem. The cause (etiology) may need to be addressed for a very serious reason. Vectors such as mosquitos may harbor viruses that cause encephalitis. Think of it as a meningitis equivalent…an infection involving the brain tissue. Both can be lethal. If mosquito vectors play a role in a new case of encephalitis, without treating the mosquito population with insecticides could put large numbers of the local and ultimately distant populations at risk. The history of encephalitis has show that this is a very important issue. Reporting by emergency physicians and other critical care health care workers cannot be overstated for this reason. An epidemic can kill, thousands even millions. This is a general concept and I will discuss it in detail further. Back to meningitis.
Some antibiotics penetrate the blood brain barrier better than others. In the past three decades many of the antibiotics used to treat meningitis have not changed. However, with the increase in methicillin-resistant strains of Staph aureus (MRSA), is playing a much more significant role in treatment of such serious infections. The antibiotic that is clearly indicated if staph is suspected is Vancomycin. Studies have shown physicians should consult with their pharmacies to confirm an adequate initial dose is being administered because this is a life-threatenting infection. Even if the patient recovers, permanent neurologic disabilities remain a significant consequence. Here is a list of antibiotics and I will discuss the specific indications for each at a later time: (again other than vancomycin, this list is essentially the list I learned in medical school with the exception of the drug chloramphenicol (due to it’s potential toxicity). Some drugs are chosen and others eliminated for such a reason; it does not always mean the drug no longer a primary use agent, is not effective, it may be eliminated from a list because new agents that were developed. So physicians should know the treatment for meningitis even if they are well into their practice of three decades like me. This is considered common, required, and essential knowledge. Such knowledge always becomes a test item [TI] on all of the certifiction examinations (the original part I certification examination, the oral examination, and the recertification (ConCert ™) examination. All board certified emergency physicians are required to take mini exams that include approximately 30 hours of study to read the material and to complete the examination on such critical topics EVERY YEAR so that in a 10 year period no less than 8 of these examinations have been completed. THIS IS REQUIRED TO REMAIN ELIGIBLE TO SIT FOR THE RECERTIFICATION EXAMINATION. ONLY THE ABEM (AMERICAN BOARD OF EMERGENCY MEDICINE [ABEM]) HAS SUCH STRICT REQUIREMENTS TO MAINTAIN BOARD CERTIFICATION. THREE ARE OCCASIONALLY EXAMINATIONS THAT ARE ALSO MADE AVAILABLE TO US TO IMPROVE OUR KNOWLEDGE OF A CONTENT AREA SUCH AS TOXICOLOGY. ALL OF THESE TESTS HAVE READING MATERIALS AND AN EXAMINATION WHICH IS SCORED AND REPORTED TO THE ABEM. EMERGENCY MEDICINE NEEDS TO BETTER INFORM THE PUBLIC THAT THE EMERGENCY PHYSICIANS OF TODAY ARE HIGHLY EDUCATED SPECIALISTS AND THEY ARE DUE THE SAME RESPECT AS ANY OTHER ABMS/AMA SPECIALITY.
I mention this because you can still hear the public refer to such physicians as low level healthcare providers. The ACEP (American College of Emergency Physicians) needs to further the reputation of board certified physicians. The physicians who are working so hard to maintain their certification and to practice with only best practice standards need better confirmation and recognition. Physicians are just people and they have the same emotions. Thousands have told me in private they feel like they are the “second class physicians” of every hospital. They are saying that even colleagues and the hospitals who hire them do not adequately respect them. I would say I agree with this in my own experience and I am a physician who goes far beyond the minimum requirements and I just don’t think that way. I was trained to maximize medical management as well as simultaneouly bring the patient to disposition.
One final note about encephalitis with repeating. If you look at the face of the patient and see a cold sore (you may call it a fever blister), that is an active infection with either type I or type II herpes virus. The virus is now potentially travelling upwards (cephalad) into the brain in any patient who is aggressive, agitated or lethargic. Assume they have herpes encephalitis and treat for it empirically (without waiting for any tests) as this is a life-saving maneuver. Confirmation (like a test that is too delayed to be of use and won’t change your management) may end up with a dead patient and a post mortem examination of the brain. This is a behavior emergency physicians must learn and relearn. That is to “work” the patient’s medical issues from the standpoint of worst case scenario first! Why? Herpes encephalitis is a lethal infection and it literally “melts” both temporal lobes. It has a predisposition to this pattern that is essentially pathognomonic. Patients with agitation and a cold sore should be rapidly treated wihout delay (intravenous “vir” drug: acyclovir, valcyclovir, famvir). The medication is “harmless,” the involvement of the brain matter can be highly lethal. Acyclovir is used in peds so it is also safe in adults without any tests. Always elevate the head of the bed if you suspect brain involvement to increase venous outflow to as part of the treatment of potentially elevated intracranial pressure (ICP).
Crossing the Blood Brain Barrier the featured image above © 2017 Dwight Collman MD. Created on iPad Pro for a presentation on the treatment of meningitis which will appear in a series of presentations.
Painted with Procreate on the IPad Pro using IPencil. I enjoy inverting or altering color more now than ever. I love to make clouds of every type. This is another creation just using a common theme in art how space is divided: the sky, the water, the land. There is an corollary I will talk about in Emergency Medicine in the use of ultrasound and how we make a particular diagnosis.
If you know this topic and want to present that particular Ultrasound topic or any topic in Emergency medicine send it to me at EMednation.comEMBoardPrep@gmail.com.
I will organize the posts by subjects/subheading. Over the years thousands of doctors have submitted case images, skin findings and when I get one I know is a key part of the core content I add it. It enhances everyone’s experience.
I enjoy your input and realize that still today in 2017 many physicians still underutilize or do not even perform ultrasound studies in clinical practice. I have worked in many EDs where the ED physician has no access to an ultrasound machine to even perform a FAST study, EFAST or other protocol.
I hope you will let me share ultrasound images or other images with all of emergency medicine. I hope everyone will come to this site to learn more detailed emergency medicine that is explained in terms you can understand! I will also have presentations only in Density Format which saves time in reading. You will read all about that on one page when it posts called Density. I created this format decades ago to write, to memorize my own reading. I have three libraries at home now. It is a lot of reading.
Density has to do with a lot of why I have good recall. I am not special. I am a regular person who spent a lifetime studying just how to study. I think my greatest mentors for this were grammar school teachers. That is why I make myself the only speaker at my programs. It cuts down on wasted time, it keeps continuity of thought for an entire week and I build each day on what I taught the prior day and keep repetition and reinforcement going for the entire week. I used this image here because water does move in waves that appear to be repetitions. I use what some my consider “stretched association” as memory devices. They are much better than mnemonics. A mnemonic is almost useless unless you create it or take one and modify it FOR YOU.
You will see repetition in all of my presentations. Repetition and reinforcement of it are two critical factors for long term memory for keeping the facts you need so you are not dependent on a device like a phone. When you are at the head of the bed with a tube in your right hand and a laryngoscope in your left. You are also speaking the names and dosages of medicines. You may even make a mental calculation.
Sure some calculations you should not due in your head. My mom was a great example to me. She was a “human calculator” and she could do math in her head that I see no one today do without a device. This is from unhealthy over-dependence on modern technology. It is in large part, why most people say they have some sort of brain fog.
It does not have to be like that for the majority with aging. All have a brain that has lifelong plasticity which means it can learn and store new information and even rewire to relearn a behavior after an injury. It takes time to use that mechanism to restore function.
There are some calculations better left to computers;that is definitely true. Emergency medicine would be better served by physicians being less dependent on apps on a phone type device in actual real-time practice. It is illogical for someone to think any procedure will be performed better except by rehearsing the real procedure. That is the best type of training and education. That is why I repeat myself about education. I have travelled the past decade to work clinically, in part, to feel more safe and now you know why.
Working in so many diverse locations and types and sizes of hospitals, however, has shown me medicine has not advanced when it comes to the basic knowledge every provider must know. This is a huge failure for our system of education. America is not close to being number one in education so there is plenty of room for me to keep doing this for a good reason. I really believe this.
If you attended my programs before you know how intense they were. You can likely remember facts from 1989 that you learned then or in the 1990s or later because I made sure you heard the same thing over and over in different ways. This does cause you to think in different ways…that means you must be creating new axonal connections. This requires new chemical synthesis in the brain that ultimately does help wire your new memories to be more permanent.
I teach how important it is to activate your limbic system. The proof is having mine activated when I did not want it to be…when I was followed and finally hit by a truck by a stalker. We don’t choose to memorize those events in our lives. The limbic system, fight or flight, is all hard wired into the hippocampus bilaterally for long term memory. When you activate any part of the system (emotion or memory) you activate the other. That is why when you have an emotional event it usually stays with you for life w/o trying to remember it.
A positive way to improve recall is to use humor. Any emotion will work but I prefer humor. I don’t tell jokes; I am not good at that. It is funny, however, how much people laugh during long days of presentations because their minds begin to make “funny” associations.
I use numbers on pages; I use almost anything visual, kinetic or otherwise to help promote memory. I state my birthday not for gifts but so that every time you see 23 you know you can pull up some fact in your head: you likely remember a six year old weighs 23kg if you attended. Knowing that you can then open this next huge file of data and recall all of it: HERE WE GO: A few simple key points in life: one year is triple the birth wt. Normal birth weight is 3.5kg/7 mos is 7 kg (double the birth wt) and one year is 10 kg (triple the birth weight). A four year old is ¼ of a “standard” 70 kg adult which means a 4 year old is 17 kg (¼ of 70).
So what is in the middle of 4 and 6 years? 5 years. So then a 5 year old is 20 kg and that is correct for the non-obese. So now all the weights but the two and three year-old are stated easily. There is a “2” when you are two-years old and there is a “2” in twelve kg and that is the weight of a typical 2-year-old. Mathematically 3 is exactly the middle between 1 and 5 years. Hence a 3 year old is 15 kg, exactly the center of the range between a 10 kg one-year old and 20 kg 5 year old. Remember infants double their birth weight between newborn and 7 months and again between 1 and 5 years of life. A six year old = 23 kg. We started with that…that was the beginning of this construct.
Moving past that point it is real simple. For each year of life you just add 3 kg. 7 yr-old = 26 kg, 8 yr-old = 29 kg, 9 yr old = 32 kg, 10 yr old 35 kg.
Yes a 10 year-old is ½ of a “standard” 70 kg adult.
So now you can extrapolate and pull out all the weights up to 70 kg and yes we started with a painting and the idea it is constructed sky ocean beach, waves repeat…if you rehearse something like this for a few minutes a day for three days. Repeat that once a month for 3 months, tt is impossible to ever forget it.
Sounds like a lot of work? Not really. You spend so much of your life waiting in lines, waiting for a flight. Stop playing so many games you can’t use and study the information you will use in daily life. It makes you much more functional and rapid and your confidence soars.
I had so many doctors say it is impossible, for two years I called in two “pediatricians” (my youngest children) and they were very young teaching: pediatric weights, resuscitation fluids, burn fluids, dehydration fluids and maintenance fluids to doctors.
They had the doctors rolling on the floor laughing because of their ability to do this “stuff” which so many of us say we cannot do without a device. The device is connected to your body. It is so important also for your personal health and lifespan. You use your brain like this and you will keep a healthier brain. We have barely scratched the surface of what I have presented hundreds and hundreds of times.
Hopefully you will find use and gain confidence. Doctors tend to inadequately resuscitate patients. Patients can survive day to day with electrolyte imbalances and dehydration but they don’t feel well. Your job is to make them feel better…if I can say the oath in those simple words.
In emergency medicine the diagnosis is a tiny part of the job. In the live scoring of an oral simulation it is 1/8th of 8 performance ratings…so it doesn’t count for much. Our job is to gather data in a way patients are comfortable/we should not put the patient in danger to get the data (ordering a CT scan without a proper resucitation). With our approach, we anticipate and solve problems, maximally manage the patient medically/(includes procedures and suturing), order (ideally) “decision-altering tests” that lead us to as rapid a disposition as possible.
A mouthful again I know but you did not read diagnosis because it is inherent in this action-oriented approach to medicine. EM is unique. It is unlike any other “style” of medical practice. You can’t or won’t deliver as much action for your patient if you constantly have to use a device and an app. I am not against their use. It should be limited.
You are also scored for your true confidence on oral exams. A patient does not feel confident when a physician leaves and even states, “I need to go read about how to care for you.” If you have to do that it is not really wise to state it. Just like the word “stable”. I have a video that took years to make. I was in it for a tiny portion at the end of the production but still 2 years prior to its release by WGBH in Boston. The video series is about what I will say is “raising doctors”. You will see a physician crying in a hallway when she has to give a family bad news. This did not happen in that video but could have: “Doctor you are telling me my husband died?” 20 minutes ago you told me he was “stable.” If you never learn anything nor desire to learn anything from me learn just that. There is no place in emergency medicine for this word. It will only put you at risk. It will lull you too. No one is stable when they are so sick you did something like put in a chest tube after intubating them with a bunch of medications which can alter cardiovascular and even endocrine function to mention a few. Three organ systems injured…the patient will likely die in the next 30 days. That is a multiple trauma fact. So we just don’t say that. We don’t even say we stabilized the vital signs, we just say the numbers and we know what they mean.
Patients perceive this issue about confidence so just take away some confidence, add a dose of “your husband died.” after the “stabilized” or the “stable” word conversation…and this is why people want to see you later in court.
It is very clear to patients and family when someone with experience takes charge and manages them from a state in which they feel so sick they believe they might even die. All of you know when a patient says that to be mindful of such a statement because the patient is “sick”. They know it.
They might not be able to localize their problem for many reaons. Maybe they have a GCS of 8. So you need to act and intubate. Emergency medicine has been written in another text as a whole 2-page algorithm for each of the major 100 or more conditions most commonly seen. WE all need those algorithms, a little calculator, procedural skills and key judgement to keep the patient safe.
How did I pull all of that out of a painting of the beach? I am not manic. I am not weird. I just know what has worked for thousands and it is what I actually use in my practice. I always discuss the same stuff with the same stuff. I don’t have much opinion about what is best for the patient because I have read the pros and cons of the major topics and the basics have never really changed. When I say the basics it is a lot of information. There is nothing basic about it.
This is why to create a great physician takes many years. It is why also many APPs struggle and have unanswered questions but in live practice I disagree with this format. The rate of iatrogenic injury has increased. Well-meaning (no pun intended) APPs, physicians, and nurses make medical errors at a greater rate now more than ever.
If you disagree with me I would love to hear from you. Thanks.
Now enjoy this image if it pleases you:
I also just received this painting from my mom’s collection. Yellowstone Falls. © 1973 Dwight Collman. I love water, waterfall, waves. I painted this in my junior year of high school. Oil on cotton canvas. This is a digital file of the original painting which is in a frame. The mat is also digital so it is not real. That was a very productive year. I was in the middle of developing ECMO: from start to finish that was a 2 year project (age 15-17). You know what ECMO is right? If not, no worries. I also went on dates 🙂
Please note all of the art is available in high quality printed format or as a digital file. I will sign any of the art you print if you purchase and send to me if you want. Some even ask me to do something special to personalize it. It does increase the intrinsic value. People have been collecting my art for almost 5 decades. I am not special there are thousands of artists like this worldwide. It does help me to keep everything I do going.
I appreciate it just like I too appreciate services like Wikipedia. So today they asked me for a donation and I gave what I could. I am offering you art for the same reason. I hope it will brighten your days.