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Published by Chris Nickson
The October 2013 edition of Yosef Leibman's Emergnecy Medicine Update
The October 2013 edition of Yosef Leibman's Emergnecy Medicine Update

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Published by: Chris Nickson on Nov 24, 2013
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OCT 2013 1) Well you got to start somewhere, and the rectum is as good of a place as any. Ah yes, the delicate pleasure of a digital rectal e am. !es the e citement, the challenge. The deep philosophical meaning of melena. "ut why do we need that cosmic message in the #$% Well, $r. &essler has what to say on this. This test has is rarely useful o'erall. (t does not help in detecting urethral tears in trauma )ha'e you e'er felt a high riding prostate% Or *etter yet+ do you ,now what this is

supposed to feel li,e%.or years we ,now it won/t help for appendicitis and it isn/t relia*le
45 ‫ מתוך‬1 ‫עמוד‬

compared to manometry for anal sphincter tone. ) A#0 11)2-213- TA&# 3O0# 0#44A5#6 7ectal e ams ha'e little diagnostic *enefit in the #$+ unless you are loo,ing for a proctologic pro*lem Actually, ( 8ust saw this study also which points out how much we hate doing this e am and that the art of rectal e ams is in danger of *eing lost )A95astro 10: );-11<:- ( say+ you want art+ go to the museum. 2- 7eally not a 'ery useful study, *ut ( am using it as a sounding *oard. O'ercrowding leads to more *lood culture contamination. 4o let/s get these patients upstairs already and they will do *etter on other parameters as well. )A&#0 30)2-;31- Well, may*e. This study didn/t ha'e particularly great p 'alues o'erall, *ut among the dangerously o'ercrowded contamination was more e'ident, *ut then again the num*ers are not that high. The odds ratio is more con'incing *ut we really should *e using the relati'e ris, which shows us what the danger is in the patients that do ha'e positi'e cultures and not in all the patients in the study. .urthermore, C( were not reported which we touted as *eing more relia*le in the Aug #0=. )you did read it+ didn/t you%"ut ( *elie'e that *lood cultures should ne'er *e ta,en in the #$ in patients who are not in need for immediate anti*iotics. We are not the technicians for the internal medicine ward. TA&# 3O0# 0#44A5#6 o'ercrowding can affect contamination rates in *lood cultures. 3) This article dealt with heart pumps and the failure of the >ational 3ealth 4er'ice to pay for them, *ut ( wanted to 8ust
45 ‫ מתוך‬2 ‫עמוד‬

mention what we use now+ the (A"? )the *alloon pump- does not significantly impro'e cardiac out put )less than <00 ml@min- and it does not impro'e sur'i'al nor infarct siAe. There is something to myocardial stunning and with *ridging therapy to gi'e the heart a chance to reco'er we may impro'e sur'i'al, ( will not get in'ol'ed with the health care dollar )or "ritish 4terling in this case- )3eart 1;)1<-111:TA&# 3O0# 0#44A5#6 (A"? is not a great idea for sa'ing failing hearts. While we are mentioning the >34, let us introduce our Buotes of the month+ we are featuring funny "ritish Buotes+ yes, the "rits are not a staid, droll group+ they can actually *e somewhat humorous+ *ut then again+ may*e not. Well, letCs let you decide. Here is Stewart Francis:We

have a beautiful little girl who we named after my mother in law; in fact Passive Aggressive Psycho turns five tomorrow.
D- This article says that #$ physicians were good at detecting $ET *y their ultrasounds )Throm* 3aem 101)1-13:- 0ay*e, *ut this is a meta analysis and a small one to *oot. 4o this article also says that #$ physicians were good at detecting $ET *y their ultrasounds )A9#02;)3-3<D-. This one was done *y =ltrasound guru $r. "lai'as, and compared us to CTE. "ut it was a tiny study. And was done in patients with a suspicion of ?# so they may ha'e *igger clots and may *e easier to see. 4o another article says that #$ physicians were good at detecting $ET *y their ultrasounds. )A#0 1D)3-212-. "ut they
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e pressed the results in ??E and >?E which doesn/t tell us much and they didn/t mention &appa 'alues at all. TA&# 3O0# 0#44A5#6 #$ physicians were good at detecting $ET *y their ultrasounds. (f only some one would do a study to pro'e it. Tim Eine I'll tell you what I love doing more than anything trying to !a"# my$el% in a $mall $uit"a$e& I "an hardly "ontain my$el% <- (f you are a da*igitran lo'er you *elie'e that it causes less cere*ral *leeds. (f you are a warfarin lo'er, you are encouraged that at least it has an antidote. 3owe'er, if your coumadin patient *leeds in the head, the mortality is high, there is significant hematoma e pansion F e'en after ?CC )not sure that is a patient oriented outcome- and high 7an,in scale. ( am a da*igtran hater. "ut ( 8ust wanted to point out that 3 patients who got ?CC had throm*otic complications so no pro coagulant+not ?CC not factor se'en is completely free form throm*otic complications- )4tro,e D3):-1;12- TA&# 3O0#0#44A5#6 *leeding due to warfarin does *adly e'en with re'ersal. More Tim 'ine Now( mo$t denti$t'$ "hair$ go u! and down( don't they) The one I wa$ in went *a"# and %orward$& I thought 'Thi$ i$ unu$ual'& And the denti$t $aid to me 'Mr 'ine( get out o% the %iling "a*inet 2- 4till loo,ing for that magic neuroprotecti'e *ullet+ statins didnCt/ pro'e to *e it. They may help in pre'enting stro,e, which ma,es sense )i*id D3):-1112.45 ‫ מתוך‬4 ‫עמוד‬


You #now( $ome*ody a"tually "om!limented me on my driving today& They le%t a little note on the wind$"reen( it $aid 'Par#ing +ine&' ,o that wa$ ni"e& Tim 'ine again 7) >eurologists lo'e to classify headaches *ut almost e'eryone ( ,now has a headache which doesn/t really fit anyone category. 4o when they re'iew cluster headaches in this article F really all these inter'entions can help for other headaches+ so we ha'e presented in the past in #0=. 4o let/s cut to the chase, do not forget that steroids and o ygen may help and remem*er the occipital ner'e *loc,+ easy to do, and surprisingly wor,s for most headaches )C>4 $rugs 22):- <:1&eep this in your tool *o the ne t time youCre told Gnot tonight, dear, ( ha'e a headacheG TA&# 3O0# 0#44A5#6 remem*er steroids and ner'e *loc,s for headaches. 3ere is
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If I re eatedly stab my cornfla!es does that ma!e me a cereal !iller"
4tewart .rancis
8) Anticoagulants and renal failure+ in moderate renal failure you

can ad8ust the dose and gi'e da*igatran, or gi'e the fi ed doses of ri'aro a*an or api a*an. (n se'ere renal failure, you *asically ha'e to *e careful with all anticoagulants. Api a*an may *e the safest )9 Clin ?harm <2):-12D- #y girlfriend

thin!s I$m very mature. She also thin!s I$m inca able of being faithful. #y wife% on the other hand& 'Stewart Fracis(

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9) A really neato *urrito article.

?ro*iotics can reduce the amount of trauma complications+ the infectious ones that is. )Crit Care 1<)2- 1022- This is an article from China. Well, there are plenty of Chinese out there and pro*a*ly plenty of trauma *ut they only came up with 22 patients in each group. .urthermore the study was single *linded and the surrogate mar,ers were a ma8or part of the study *ut not the only outcome measure. What ( mean is F the more parameters you study the more pro*a*ility of confounders. "ut hey, if $annon wants to study this and are willing to gi'e me all the straw*erry yogurt ( can eat for a year, (/ll do the study )*ut only the 0H yogurt-. TA&# 3O0# 0#44A5#6 ?ro*iotics may
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ha'e a role in reducing trauma related infections. Tim Eine6 A!!arently( one in %ive !eo!le in the world are Chine$e& And there are %ive !eo!le in my %amily( $o it mu$t *e one o% them& It'$ either my mum or my dad& -r my older *rother( Colin& -r my younger *rother( .o/Chan/Chu& 0ut I thin# it'$ Colin& 10) !ea well, statins in this study reduced the amount of days in the (C= and time of mechanical 'entilation )#9#0 11)D-222-. We are really loo,ing for the statins to *e the sa'ior, and we ,now they are fairly good anti inflammatories *ut where they fit in isn/t clear yet. Are they neuro protecti'e% ( don/t *elie'e any thing is neuroprotecti'e. "ut let/s lea'e that )unless our (C= gurus ha'e what to say on this- This study was small, retrospecti'e and the p 'alues were pretty suc,y. Another Buestion you really must as, when reading a study Fnot that it is 100H negati'e F *ut you should still as, yourself why a paper li,e this from anesthesiologists in 4t Iouis is doing in an #0 8ournal form #urope. TA&# 3O0# 0#44A5#6 $o statins reduce (C= stay% When should we start them% I don$t thin! I

got the )ob at #icrosoft*& they didn$t res ond to my telegram. )4tewart .rancis11) We gotta tal, a*out a sensiti'e su*8ect+ catheters. This

pro*lem is *allooning, and due the pull ( ha'e with this su*8ect, we ha'e got some wi,ilea,s to pass on to you. ( really ha'e *agged some good articles on the su*8ect. ( don/t want to lea'e you guys dangling so let me 8ust remind you what
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they said to the =4A in 1::2+urinationJ The goal F is to reduce =T(s+ a *ad pro*lem that comes form catheters. These tips will help. >ot e'eryone with urinary o*trusions from a prostate will re o*struct+ consider draining them and letting them go home with out a catheter F 8ust e plain to them the possi*ilities. )( tried this recently and it wor,ed+ the patient came *ac, ; hours later and he peed 'ery nicely+ ( did an ultrasound and he left nothing inside ( saw him two wee,s later and all is fineJ-. Other ideas+ well anti*iotic@sil'er impregnated catheters are *eing used *ut they are e pensi'e and there will always *e resistance concerns. .or many issues, condom )?enrose- or Te as catheters are enough. 4uperpu*ic aspiration may cause fewer infections. (ntermittent catheteriAation is safer as well. 5et all catheters out *y day four This paper came from 4ingapore, so let/s welcome the 0alay peninsula su*scri*ers who 8ust 8oined up to the #0= family with three new su*scri*ers )3 from 0alaysia, one 4ingapore- ) Curr Opin (nfect $is 2<)D-32<Another article had some more protocols which wor,ed *ut it isn/t easy to tell which are really necessary and which weren/t/. They used sil'er coated catheters, )see a*o'e-.They also remo'ed them within two days, "ut in addition they minimiAed mo'ement of the catheter and if there was any part of the catheter circuit )*ag, tu*ing- touching the floor+ they repositioned ) ( don/t ,now why they did not 8ust replace it-)(nt 9 Kul 3ealth Care 2<)1-D3- The p 'alures here too were not that impressi'e. Another neato *urrito+
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they now ha'e a fi*er optic catheter system so that you can a'oid false passages and *leeding from lacerated prostates. )9#> 31)1-2:- TA&# 3O0# 0#44A5# Catheters are on the way out. &eep it that way. On a related su*8ect F#4"I F that is e tended spectrum *etalactamase which is ma,ing cephalosporins and Buinolones no longer effecti'e in =T(4 s in the community and we ha'e discussed it *efore. .osfomycin still wor,s, *ut it can de'elop mutational resistance during treatment. ( still use it for garden 'ariety =T(s )"9= intl 110)3-300- #y fairy

+odmother once as!ed me if I$d rather be well endowed or have a long memory% and I forget what my answer was% butL. )4tewart .rancis-.
12) This article is all a*out cu*oid fractures which is really

e citing to people with ad'anced dementia, *ut to few others. >e'ertheless+ 8ust remem*er+ if you are going to *rea, your cu*oid, you pro*a*ly ha'e other fractures in the foot as well or a Iisfranc/s fracture@dislocation )9AA Orth 4urg 20):-D:2- .They need a CT and casting is usua y en!ugh. T"#$ %&'$ '$((")$* Cu+!id ,-actu-es a-e -a-e .ith!ut ass!ciated
45 ‫ מתוך‬1/ ‫עמוד‬

#y wife and I decided we don$t want children; if someone wants them% we$ll dro them off tomorrow
,-actu-es. 4tewart .rancis again6
13) There is a direct association *etween statistics, sleep apnea,

and *ilious 'omiting. 4o in order to attenuate this unfortunate response, ( throw statistics at you in small doses and sugarcoat them. ( ,now most )actually all- of you do not care and those who do would *etter understand how isotonic solutions such as normal saline can cause acidosis )4cott, are you still reading%- *ut this is a straight forward one. We ha'e spo,en a*out the inadeBuacies of the p 'alue and here is another. 7ecall that the p 'alue 8ust tells us with how much certainty you can nullify the null hypothesis. That is F a p 'alue of 0.001 says that you can say with 11.1H certainty that the null hypothesis is *ull. 3owe'er, if your sample siAe is really large then small insignificant differences in effect get magnified and the p 'alues start to loo, great. )?0M 7 D)2-DD2-. >ow we three months ago mentioned that small sample siAe lead to wide confidence inter'als which ma,e the results unrelia*le and large sample sets as we see here also ma,e the p 'alues less 'alua*le so the solution is not to use p 'alues. Or 8ust forget all this and gi'e Iactated 7ingers in dia*etes and ma,e 4cott happy. TA&# 3O0# 0#44A5#6

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Clinical significance and statistical significance widen when

sample siAes are *ig 14) Cortisporin otic drops )de otic in (srael F neomycin, polymy in and a steroid- are not oto to ic. )#>T 9 11)3-10;- Well, ( donCt hear it. They made this determination on $?AO# testing which is not a patient oriented outcome. There were only 32 children and they were all healthy *ut were undergoing tu*e placement in the T0s. We do not ,now if infected ears will do worse. The control group also underwent this testing *ut it is not clear why especially since this study was retrospecti'e.
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>ow ( *elie'e it is pro*a*ly true *ecause there is not that much a*sorption of this med into the T0 although the Buestion could *e as,ed+ why not 8ust use a drug that isn/t ototo ic when gi'en 'ia other routes )neomycin is- F li,e a Buinolone for e ample+ *ut they are e pensi'e. 9ust for interest sa,e, the same e act author did a similar study with <00 ,ids and found the same results )oto 3ead >ec, 4urg 13< )2- 111 2002- TA&# 3O0# 0#44A5#6 The neomycin in ear drops is pro*a*ly not ototo ic. 3ere is 0onty ?ython6 01 d!n2t .anna ta 3 t! y!u n! 4!-e5 y!u e46ty headed ani4a ,!!d t-!ugh .i6e-7 1 ,a-t in y!u- gene-a di-ecti!n7 8!u 4!the- .as a ha4ste- and y!u- ,athe- s4e t !, e de-+e--ies79 15) $e metdetomidine is here and is trying to replace good old propofol. This article loo,s at the down side F no analgesia+ 8ust li,e propofol. (t is not as effecti'e or relia*le as propofol. (t has a longer onset and it can cause *radycardia and hypotension. =sing it with &etamine seems to attenuate all these negati'es. )?ed Crit Care 0ed 13)D-D23- The dose of $e is 1 micro gram per ,ilo. Other articles are more optimistic. They say it causes no reparatory depression and patients are easy to arouse. The hypotension and *radycardia are transient. )Clin $rug (n'est 32);-<21-.(t causes less delirium upon awa,ening )$rugs :1)11-1D<1-. ( ha'e no e perience *ut do not see a real ad'antage o'er propofol at this moment on time. Any one ha'e anything to say% TA&# 3O0# 0#44A5#6 $e medetomidine gi'es you another sedation option. Well tolerated, no resp depression, *ut may
45 ‫ מתוך‬13 ‫עמוד‬

*e less effecti'e. 4tewart .rancis is really Canadian+ *ut so what+ that is close enough to "ritish Is my wife dissatisfied

with my body"& a small art of me says yes
16) !ou got impetigo% 4o ru* on the mucipirocin. !ou got an otitis

e terna so 8ust put in the drops. 4o why change to flora of the *ody when you can gi'e the anti*iotics 8ust where you need them+ li,e with pneumonia F send them down with inhalations% )$rugs Today D;)<-331- The authors say this wor,s well in C. patientsN ( would li,e to point out pneumonia in the elderly may *e different+ so we 8ust raised the possi*ility F ,eep it in mind TA&# 3O0# 0#44A5#6 inhaled anti*iotics may *e good for pneumonia. "ut them again, the air in .lint 0ichigan may ,ill e'erything in your lungs as well. 8!u- highness5 .hen 1 said that y!u a-e i3e a st-ea4 !, +at2s 6iss5 1 !n y 4ean that y!u shine !ut i3e a sha,t !, g! d .hen a a-!und it is da-3+ 0ore 0onty ?ython 17) ( saw this study in A#0 and it isn/t rele'ant to us *ut it mentioned ?#CA7> which is ta,ing the pediatric community *y storm. This was first mentioned in Iancet 3:D)1212-1120way *ac, in 2001 in an effort to reduce the num*er of CTs we do in ,iddies. Of course you can 8ust fry their little *rains guarantying a new generation of mutant de'iants with low (Ks or you could try this rule.

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( li,ed the fact that it was di'ided into a*o'e age 2 and *elow *ut this is still not enough in my eyes as a 3 month old is not eBual to a 2 year old and a 3 year old is not eBual to a 1: year old. "ut here is the rule. Iess than two6 n!-4a 4enta status5 n! sca 6 he4at!4a e:ce6t ,-!nta 5 n! !ss !, c!nsci!usness !- !ss !, c!nsci!usness ,!- ess than 5 s5 n!n;se<e-e in=u-y 4echanis45 n! 6a 6a+ e s3u ,-actu-e5 and acting n!-4a y acc!-ding t! the 6a-ents . A*o'e age two6 n!-4a 4enta status5 n! !ss !, c!nsci!usness5 n! <!4iting5 n!n;se<e-e in=u-y 4echanis45 n! signs !, +asi a- s3u ,-actu-e5 and n! se<e-e headache. The 6-!+ e4 is that the nu4+e-s
45 ‫ מתוך‬15 ‫עמוד‬

.e-e s4a and the-e,!-e the <a idati!n set in the ! de- g-!u6 sh!.ed a 1//> sensiti<ity .hich is i46!ssi+ e. TA&# 3O0# 0#445#6 7educe the CTs you do in ,ids+ this -u e 4ay he 6 ?&@&A8 e:6ects the (6anish 1nBuisiti!n7 &u- chie, .ea6!n is su-6-ise...su-6-ise and ,ea-...,ea- and su-6-ise.... &u- t.! .ea6!ns a-e ,ea- and su-6-ise...and -uth ess e,,iciency.... &u- Cth-eeC .ea6!ns a-e ,ea-5 su-6-ise5 and -uth ess e,,iciency...and an a 4!st ,anatica de<!ti!n t! the D!6e.... &u- C,!u-C...n!... C"4!ngstC !u- .ea6!ns.... "4!ngst !u.ea6!n-y...a-e such e e4ents as ,ea-5 su-6-ise.... 12 c!4e in again.9 Anyone remem*er this s,etch% 18) Two things ( really li,ed in this study. They claim that magnesium has anesthesic, analgesic and muscle rela ant properties, which Buite honestly ( didn/t ,now. They ga'e them a D< mg *olus F which is not much F o'er 10 minutes. Then they intu*ated them anyhow under fentanyl and propofol. (ntu*ating condition were *etter. "ut the p 'alues were terri*le and the num*ers were tiny. ) e=r 9 Anest 21)1311- What ( did li,e a*out this study was that it was done in 0orocco+ a pretty country and that they used a *linded anesthesiologist who ne'ertheless intu*ated fine. TA&# 3O0# 0#44A5#6 Will someone+ may *e e'en 7ic, "u,ata Ftell me if magnesium really is a good pain relie'er and muscle rela ant and if so, why aren/t we using it% Su erintendant Praline: Now, this item,
"Crunchy Fro "! "m # to un$erst%n$ there&s % real 'ro in here( Whi,,o -hocolate -om any owner: )es, % *itt*e one! Su erintendant Praline: +h%t sort o' 'ro ( Whi,,o -hocolate -om any owner: " $e%$ 'ro ! Su erintendant Praline: #s it coo,e$(
45 ‫ מתוך‬16 ‫עמוד‬

Whi,,o -hocolate -om any owner: No! Su erintendant Praline: +h%t, % raw frog?! Whi,,o -hocolate -om any owner: +e use on*y the 'inest -%-y 'ro s, $ew .ic,e$ %n$ '*own 'rom #r%/, c*e%nse$ in 'inest /u%*ity s.rin w%ter, *i ht*y ,i**e$, %n$ then se%*e$ in % succu*ent 0wiss /uintu.*e smooth tre-*e cre%m mi*, choco*%te en1e*o.e %n$ *o1in *y 'roste$ with *ucose! Su erintendant Praline: 2h%t&s %s m%y -e 3 it&s sti** % 'ro 4 5o you e1en t%,e the -ones out( Whi,,o -hocolate -om any owner: #' we too, the -ones out, it wou*$n&t -e crunchy, wou*$ it 19) 4o you as, what *lood test is there that can tell us a*out

serious infections in ,ids that may not *e apparent. Well you ,now the answer to this already F you/re not an idiot. Well may*e you are, *ut at least you read #0=. 4o let/s ma,e it clear. The pre'alence of serous *acterial infections that aren/t o*'ious is so low that no test can *e trusted+ the low pre'alence means the tests will *e often falsely positi'e. Chance or *est guess may do 8ust as well )ann #merg #0d 20)1-12- The only ca'eat in this re'iew is that the Americans 'accinate against 4. ?neumo, so the results may not *e the same where you practice if you are not a !an,. 4o that does it. 5o put your procalcitonin where the sun don/t shine

45 ‫ מתוך‬17 ‫עמוד‬


TA&# 3O0# 0#44A5#6 >o *lood test in fe'erish ,ids unless it is clear they are sic,. 3ow do you decide% Ioo, at themJ .evis: 6sun 7 # cut $own
trees, # e%t my *unch, # o to the *%1%tory! 8n +e$nes$%ys #&** o sho..in , %n$ h%1e -uttere$ scones 'or te%! #ounties -hoir: 6sun 7 9e cuts $own trees, he e%ts his *unch, he oes to the *%1%tory! 8n +e$nes$%ys, he oes sho..in , %n$ h%s -uttere$ scones 'or te%! 9e&s % *um-er:%c, %n$ he&s 8;, he s*ee.s %** ni ht %n$ he wor,s %** $%y! .evis: 6sun 7 # cut $own trees, # s,i. %n$ :um., # *i,e to .ress wi*$'*owers! # .ut own womens& c*othin , %n$ h%n %roun$ in -%rs! #ounties -hoir: 6sun 7 9e cuts $own trees, he s,i.s %n$ :um.s, he *i,es to .ress wi*$'*owers! 9e .uts on womens& c*othin , %n$ h%n s %roun$< [starts to show signs of disgust] <in -%rs( [perk back up] 9e&s % *um-er:%c,, %n$ he&s 8;, he s*ee.s %** ni ht %n$ he wor,s %** $%y! .evis: 6sun 7 # cut $own trees, # we%r hi h hee*s, sus.en$ers, %n$ % -r%! # wish #&$ -een % ir*ie, :ust *i,e my $e%r =%m%4 #ountie -hoir: 6sun 7 9e cuts $own trees, he we%rs< hi h hee*s( [choir storms out in revulsion, as Bevis continues singing, to his Best Girlie's dismay]
45 ‫ מתוך‬18 ‫עמוד‬

.evis/s .est +irlie: 8h, >e1is! "n$ # thou ht you were so ru e$4 [runs off crying]

20!ou should ha'e ,nown this. "ut ( will *e nice+ you can ha'e appendicitis after an appendectomy+ it is called stump appendicitis.)K90 10<);-;0<21) ?atellar dislocations do 8ust as well with taping. )Arch Ortho Trauma 4urg 132);-1111- 0a,es sense *ut they compared it with cylindrical casting. We use ,nee immo*iliAers *ut that shouldn/t ma,e that much of a difference compared to cylindrical casting. .unction was done *y a ,nee scale F not sure how good it was, and there were only 1 patients in each group. 4till, to their credit+ they followed them for < years. TA&# 3O0# 0#44A5#+ Taping for patellar dislocations may do as well as casting All that was 0onty ?ython+ now for Tommy Cooper # went to the $octors! 9e s%i$ &#&$ *i,e you to *ie on the couch&!
# s%i$ &+h%t 'or(& 9e s%i$ &#&$ *i,e to swee. the '*oor& 22) Well >4A($4 do impair healing and *one formation.. *ut they

also cause angiogensis which is necessary for *one healing (s it a wash% )i*id p120<- Well, it is if you *elie'e this study. And it was done on mouse legs so who ,nows. Are >4A($4 e'il% ( thin, they are, *ut it isn/t clear if they may also *e *eneficial. TA&# 3O0# 0#4445#6 >4A($4 impair healing *ut do cause angiogneisis which is good ?o*ice %rreste$ two ,i$s yester$%y, one w%s
$rin,in -%ttery %ci$, the other w%s e%tin 'irewor,s! 2hey ch%r e$ one %n$ *et the other one o'' 23) We Buote legal *riefs of 4te'e 4el*st often and two points

that need to *e enforced )other than there are a lot of dum* physicians out there- are that do a good neuro 'ascular e am
45 ‫ מתוך‬19 ‫עמוד‬

on all orthopedics )here was a missed partial popliteal transaction-. Also do not forget that fol,s with sic,le cell trait can get dehydration that results in rha*do and compartment syndrome TA&# 3O0#0#44A5#6 7ead 4te'e 4el*sts Iegal "riefs+ they are worth it. " m%n c%me roun$ in hos.it%* %'ter % serious %cci$ent!
9e shoute$, "5octor, $octor, # c%n&t 'ee* my *e s4" 2he $octor re.*ie$, "# ,now you c%n&t, # h%$ to %m.ut%te your %rms 24) Iet/s get into really small people that all of us who ha'e had

children must deal with )>o ( am not spea,ing a*out6 $ad, ( need money-. What is doing in that diaper% Who doesn/t ,now what diaper rash is% We all tell our patients F let them run amo, without their diaper on *ut this can lead to less than pleasant results. (nterestingly enough, the Chinese ha'e a traditional cloth diaper and they pu*lished a study showing that they get more diaper rash than these new supera*sor*ent ones. This paper says the *est way to pre'ent diaper rash is to change new*orns e'ery hour and older ,iddies e'ery three to four hours )( thin, that is a little unrealistic as well-. Anything that minimiAes waste from touching the s,in will reduce diaper rash and this is how those pastes+Ainc o ide, starches, etc+ wor,. Co'ering them with Easeline will help as well. They recommend adding hydrocortisone if there is a *ad case. ( will point out that there is no mention of using anti*iotic creams. They claim you can tell when it is Candida *ecause they ha'e *eefy red plaBues, pustules and satellite lesions ,*ut ( 8ust add some clotrimaAole to my mi )Curr Opion ?eds 2D6D:2- There are mimics li,e
45 ‫ מתוך‬2/ ‫עמוד‬

Ainc deficiency, lichen slcerosis )which is really grody- *ut if this su*8ect really interests you+ 8ust press on the lin,. ( will point out that this article was written *y three pediatricians+ all females *ecause us men F well, we aren/t so good at diaper changing. "ut we are good at ,illing *ugsJ ( did change diapers, *ut ( will always remem*er the first one F ( didn/t ,now how to change a ,id )( was *a*ysitting- so ( called a friend. 3e told me li,e this G lay out the cloth diaper li,e a *ase*all diamondG )Ah this ( could understand- put the *a*y on the pitcherCs mound, and pull up and pin first *ase to home plate and third *ase to second *ase and pin. 3owe'er, if it rains, you got to start all o'erG TA&# 3O0# 0#44A5#6 #'er thin, a*out using cortisone cream for diaper rash% 1 t! d the a4+u ance 4en the .-!ng + !!d ty6e ,!- 4y e:5 s! he 3n!.s .hat -e=ecti!n ,ee s i3e Di66a $<ans 25) >ow on to cra**y *a*ies. !ou may *e using sucrose )in adults the eBui'alent is chocolate- . 3owe'er, as the years go *y, our a*ility to gauge pain in little fol,s impro'es+ it is no longer *ased 8ust on facial e pression. Actually ,ids could *e feeling pain without any facial e pression at all. This is *ased somehow on ##5s. The article is an editorial on a pessimistic study, *ut really, we ha'e little else to offer that is more effecti'e and while they can disagree on how effecti'e it is F it is an eBual option to anything else. Adding *reast feeding, ,angaroo care, and tuc,ing )is that hugging%- you will pro*a*ly get the *est results you can. ) Arch ?ed Adol 0ed
45 ‫ מתוך‬21 ‫עמוד‬

122):-22:-. ( thin, you should try to minimiAe pain li,e a'oiding heel stic,s and using #0IA TA&# 3O0# 0#44A5# 4ucrose is the *est we ha'e for the little ones 5e:% =oo: 2he 'ee*in
th%t you&1e he%r$ this -u**@@@@ -e'ore 2ommy Coo.er 26) This is going to micturate a lot of you off, so ( purposely

*uried in the middle. ( dou*t anyone will *e reading at this point this point. The clinical chest e am is useless. The studies supporting clinical e am are poorly done and are ancient coming from epochs that technology was minimal and we had nothing else to offer. 3e gi'es an e ample F we detect only 20H of murmurs correctly )"09 201263D<eD<21-. ( guess with practice the num*ers may *e *etter, *ut why search for creptations when you can easily ray them% ( thin, physical e am is the least important of my chart+ history and clinical decision ma,ing are way more important. >ot to say you don/t need it sometimes, *ut the lawyers who claim that you didn/t chec, *rachialradialis refle es so you are a *ad doctor is inane. !our thoughts% TA&# 3O0# 0#44A5#6 no need for chest e ams anymore. G!our mother is a TwitG 7oald $ahlI 1 d!n2t need y!u t! -e4ind 4e !, 4y age. 1 ha<e a + adde- t! d! that ,!- 4e. (te<en E-y 27) This article was way to Aussie for me+ the statistics were 8ust for $own =nder, and the phone num*ers for ?oison Control were all 'ery e pensi'e calls from where ( li'e. They also F despite *eing #?s+ recommend too often that an Ge pertG to icologist decideG *efore gi'ing certain treatments.
45 ‫ מתוך‬22 ‫עמוד‬

>e'ertheless, it seems to *e popular among young fol,s to use 'arious interesting su*stances for achie'ing &arma and you need to ,now them. Amphetamines are 'ery common and allow the user to dance all night, &nown as speed, *ennies and uppers, they are 'ery addicti'e. (n the se'enties, a synthetic super amphetamine has come out F parametho yamphetamine which can cause death. (n any case, ,eep in mind the sympathomimetic syndrome+ psychosis, agitation, tachycardia, and hyperthermia. 0( can occur. They can *e 'ery aggressi'e and they easily can de'elop rha*do. 3ere they recommend *icar*, the also say powerful anti hypertensi'es may *e necessary including phentolamine or clonidine. A'oid *eta *loc,ers, phenytoin and anticholinergics. $o not throm*olyse these patients. A deri'ati'e of amphetamines is 0$0A ,nown as ecstasy, #, OTC, adam or eccies. #cstasy li*erates serotonin and ma,es these ,ids loBuacious )that is what we really need F a teenager who ta,es a drug to tal, *ac, e'en more-, and increase empathy and intimacy. 0ild into ication can cause *ru ism, palpitations, and hypertension, while more serious o'erdoses result in the sympathomimetic syndrome. O*'iously it can cause serotonin time to icity as well. 4eiAures and hypernatremia are not uncommon. A *ig pro*lem here is adulterants+ for reasons un*e,nownst to me, the .$A does not regulate the contents and often foreign su*stances such as dishwashing powder can find their way into these. CocainePwhat can we tell you a*out co,e% (t does
45 ‫ מתוך‬23 ‫עמוד‬

ha'e a propensity for wide comple tachycardias, seiAures and CEA e'ents+ all can result in death. They treat again with "icar*)is there any e'idence for this%- and *enAos. &etamine is ,nown as cat 'alium, special & and 'itamin & and can *e snorted, howe'er the authors correctly point out that there is a wide margin of safety. >itrite+ gosh ( ne'er ,new a*out this+ *ut amyl and *utyl nitrites are inhaled for euphoria and if the first su*stance sounds familiar it is a component of the Iily cyanide antidote ,it. These are called poppers, *lue *ottles, 8ungle 8uice or liBuid incense. "asically these 8ust cause a 'asodilatation and a feeling of e hilaration. Eiagra can *e similarly a*used, *ut ( am of the opinion that Eiagra can ne'er *e a*used+ *ut most women ( ,now disagree. Occasionally these ampoules of nitrites are swallowed *y mista,e and the result is syncope, hypotension F *oth transient F *oth more seriously+ methemoglo*inemia. 5reater than a le'el of 20H is significant and the antidote is methylene *lue. 53" is .antasy, IiBuid 5, and 5rie'ous "odily 3arm. (t is colorless and practically fla'orless so it can *e used to spi,e drin,s. (t causes amnesia, li*ido and can *e used as a date rape drug. 4ince its a*sorption is unpredicta*le it can cause late crashing. Coma is really 8ust the tripN most of these reco'er without any pro*lem. "enAos F are on their way out, *ut recall alpraAolam is more to ic than other *enAos and more li,ely to cause addiction. .lunitraAepam is 10 times more potent than 'alium and is a date rape drug. (t is illegal to possess in the =4A *ut not in my country )now, don/t *e so
45 ‫ מתוך‬24 ‫עמוד‬

fast to *uy the plane tic,et- F so if you tra'el to the states with it F you will *e arrested e'en if you ha'e a prescription. >ewer sleep drugs such as Aolipidem and Aoplicone are also now *eing a*used *ut not to the same e tent. Anticholinergics are commonly a*used, *ut teenagers do not usually get these from meds as the side effects are not pleasant )you will find anticholinergic actions in antihistamines, TCAs, neuroleptics and cough and cold remedies-. 3owe'er, you can find these in weeds and mushrooms. They cause the anticholinergic to idrome which you *etter ,now for your *oards *ut they also hallucinate F pic, at things in the air and *eha'e aggressi'ely. They may ha'e formication )not fornication-. $on/t ,now what formication is% .irst scru* those arms of yours clean and we will tal, )9 ?Aed Child 3ealth D;6<20- TA&# 3O0# 0#44A5#6 (f you read the whole paragraph, you will learn a*out popular agents used to get high that your patients or yourself may *e ta,ing. De!6 e a-e 4!-e <i! ent y !66!sed t! ,u- than eathe- +ecause it2s sa,e- t! ha-ass -ich .!4en than 4!t!-cyc e gangs " e:ei (ay e 28) This is an e plosi'e loo, at diarrhea. 0ost of these points in'ol'e wor,ing up this pro*lem when it is a chronic issue which doesn/t interest me so much )if it does interest you, 8ust go into the lin,+ it is a free paper- *ut here are some *ullets that may help. 4ometimes diarrhea is constipation. !es you heard me right+ fecal impaction can allow liBuid stool and secretions out *ut lea'e the impacted stool. 9ust do a rectal
45 ‫ מתוך‬25 ‫עמוד‬

e am )see Q1 a*o'e- and that should answer this issue )although ( feel the impaction may *e *eyond the e amining finger so ( usually do an a*dominal film- Of course recall C diff, *ut thin, a*out meds+magnesium containing meds, anti*otics, ??(s, 447(s and >4A($ can all cause the runs. Caffeine and chemo can also do this. And do recall that there is la ati'e a*use+ although it is not as fun as ta,ing the stuff in the pre'ious paragraph. $o not confuse diarrhea with incontinence. 4teatorhea+ it is not floating stools, *ut rather oily stin,y ones+ that can *e from gas production from intestinal *acteria too and not 8ust from pancreatic failures. Ta,e a tra'el history as well for those weird *ugs. )0ayo Clinic ;:)2-<12- TA&# 3O0#0#445#6 $iarrhea F don/t forget meds and that o'erflow diarrhea is common. %ea th ,!!d sh!6s can 4a3e 6e!6 e ,ee <e-y i46!-tantF it2s i3e a +-and ne. -e igi!n .ith 6e!6 e t-ying t! c!n<e-t y!u t! Buin!a Di66a e<ans 29G Ti4e ,!- ette-s. A-!6 us a ine s!4eti4e t!!7 H!u d +e g-eat t! hea- ,-!4 y!u. Ei-st y5 &en (serson F ( couldn/t pull AriAona history past this fellow, and he fills us in more on the Camels Corp . Thanks for this month’s EMU. Since you mentioned Arizona, I thought I should set the record straight: While we have lots of wild and dangerous critters in Arizona, a farmer shot the last wild camel in 1893 when it tried to graze in his garden. Introduced in 1850 as the Army’s Camel Military Corps, they seemed to be
45 ‫ מתוך‬26 ‫עמוד‬

more successful than horses in traversing our great Southwest. Part of the success came when Hadji Ali (generally known as Hi Jolly of folklore and then Philip Tedro) arrived from the Middle East to teach soldiers how to deal with camels. The episode of U.S. history is remembered in the quaint town of Quartzite, Arizona, where a pyramidal monument in the cemetery is topped with a camel statue. As for camel bites, a larger series from the J Ind Med Assn (1982(Sept)79;5 & 6:65-8) showed that these can often be devastating injuries. That is due to the camel’s large mandible with very anterior canines and incisors that point backward. They found that the upper and lower teeth oppose during the bite, severely injuring the deeper tissues. The injury is compounded when the camel shakes its head on the long neck while holding its victim. Moral? Stay away from camels, if you can. Best wishes, Ken . Hish 1 had ta3en y!u- ad<ice; 1 =ust .ent ca4e -iding .ith 4y daughte-s. The ta3e !,, and anding .ith these c-eatu-es is I u6 i,ting. 5reg 3enry also weighs in. >ow 5reg is really a great guy and ( will gi'e a plug again for his 7is, 0anagement 0onthly which will teach you how to ,eep your nether parts out of the courtroom. Jsee

45 ‫ מתוך‬27 ‫עמוד‬


nu4+e- K1 a+!<eG 3ere are 5reg/s comments. ( ha'e again *een misBuoted *ut *etter to *e misBuoted than not
Buoted at all. On #0+7A? ( said we need nurses for critical patients only. !ou should ha'e techs doing the ma8ority) 10H - of the *asic wor,. Iet nurse do real nurse wor, and not *e tied up pushing patients to the floors. We need total wor, redesign *ut are afraid to as, real Buestions. !osef, ( thin, a de*ate on this topic would *e an ideal running de*ate topic for your e ceptional readership. #ither that or the meaning of life which is eating a pastrami sandwich at &atACs $eli on 3ouston 4treet in >!C. !our choice for topics. Io'ed the issue.. 5reg With all

due respect to .ather 5reg+ ( thin, the Americans ha'e shot themsel'es in the foot. !ou ha'e a doctor shortage. 4o you train physician assistants, nurse practitioners and #$ techs. Then you see that they are all much cheaper than a doctor. 4oon you/ll need one doctor for the the whole #$ and the rest of the #$ will wor, with these other indi'iduals. >ow ( will point out that these
45 ‫ מתוך‬28 ‫עמוד‬

physician e tenders do not e ist in many countries including my own, and ( am not critciAing the a*ilities of these pro'iders, *ut indeed F there is no longer any need for doctors. Truth *e told with internet F there indeed may *e no need for doctors. 5reg+ why don/t you do the pastrami sandwich of the month on 700% "nd n!. ,-!4 Lisa "4i- 'A DhA .h! is the assistant $A di-ect!- at (chneideh!s6ita and ,!-4e- y a 6-!,ess!- at $4!-y. Good issue and loved the pictures!
Sorry for the delay in answering but only got around to catching up on emails now. A few comments (what's new….) Colic – I would put child abuse much higher on my DD. Colic is very stereotypical in its presentation: several hours of crying, usually relieved by holding or walking beginning at the end of the first month/beginning of second month of life and usually resolving after a month or two. Most commonly late afternoon hours. Usually these kids are fine at night. Anything that deviates from this pattern should be considered pathologic and investigated. Parental reassurance is key: to avoid unnecessary tests and treatments and to have them understand that it does go away. I frequently recommend that the father or another family member take the child for these 2-3 hours (not a chauvinist, just the mom is still home on maternity leave) and let the mother sleep for a few hours (with ear plugs if necessary). From personal experience, I found that a kangaroo – one of those baby holders which hangs the baby off your front – was sanity saving. Pelvic exam – if you have to do one in an anxious or virginal adolescent, consider a bit of oral midazolam. It relaxes them enough that they can cooperate but they still stay awake (very important that she knows what is going on). Explain every step of the process before and during. Always have another staff member in the room, even if you are a female physician. These kids can misinterpret the exam as inappropriate touching. Nonconvulsive SE in kids: rare but even more rarely diagnosed early. Most commonly in kids with epilepsy who come in with behavioural changes. Most of the kids I've seen are developmentally disabled so it's the parents' insistence that something was wrong that made us get the EEG. There may be subtle signs on the PE like nystagmyus or tachycardia.
45 ‫ מתוך‬29 ‫עמוד‬

Iron poisoning: iron levels are useless. Many kids have iron deficiency anemia and if you do your job correctly, the iron levels will never rise. Clinical picture + metabolic acidosis, leukocytosis, hyperglycemia. By the way, I haven't seen a really serious case of iron poisoning here in about a decade since they changed the size and color of the prenatal vitamins. 1 ha<en2t seen 6ediat-ic

i-!n 6!is!ning eithe-5 +ut the a-tic e a66ea-ed in the 6ediat-ic ite-atu-e5 s! 1 had n! ch!ice. Than3s ,!- the c!44ents; they .e-e g-eat .

307onit Ie' from =C4$ is organiAing a tour to coincide with the (sraeli Association of #0/ s scientific assem*ly in 0arch. ( was una*le to reproduce her *rochure, *ut if you are interested, please get in touch with me and ( will *ut you all together.

EMU LOOKS AT: Give me $ome $#in( man
1nte-esting stu,, this 4!nth. Ei-st a itt e u6date !n ce u itis JM""A 67J2G 163 and i+id 185G and <en!4!us +ites; n!t use,u +ut <e-y inte-esting. J1n, Ais C inics ?" 26J2G2/7G 1n 1s-ae .e ca it (h!shana5 in $u-!6e $-ysi6e as and in the N("; it is ce u itis 1G Let2s s6ea3 a+!ut the disease and the 4i4ics. A! n!t t-y t! use di,,e-ent na4es ,!- (ta6h !- st-e6 !- +ased !n the de6th !, in,ecti!n !e:a4 ,indings; 4any 6e!6 e use the na4es e-ysi6e as and ce u itis inte-changea+ y. 2G They need an ent-y 6!int ,!- +acte-ia. This can +e s!4ething 4in!- i3e a +ite5 a sc-atch5 inte-t-ig! !- a ,unga in,ecti!n. @et.een the t!es is a g!!d -ese-<!i- !, (t-e6. C!u d a s! +e ,-!4 a 4a-ine en!<e4nati!n I +ut 4!-e !n that ate-. Ois3s inc ude A'5 a c!h! is45 D&PA5 d-ug use I +ut 4any 6atients .e-e 6-e<i!us y hea thy.
45 ‫ מתוך‬3/ ‫עמוד‬

3G $de4a is a s! a cause; actua y a 6-edis6!siti!n +ecause the s3in is st-etched taut and s4a +-ea3s can +e 6-esent. The y46hatics in y46hade4a a-e n!t .!-3ing .e 5 and s! in y46hed4a the-e is s!4e 4!-e -eas!ns ,!- in,ecti!n. (ince in,ecti!n in<! <es the y46h syste4 in any case5 6e-4anent da4age t! this syste4 is c!44!n and as a -esu t; the-e is usua y -ecu--ent ce u itis. 4G (t-e6 dies Buic3 y .ith the-a6y +ut the t!:ins cause a !t !, the sy46t!4s. C! !niQati!n !, st-e6 in !the- 6 aces I i3e (t-e6 ) in the ana cana can +e a s!u-ce !, ce u itis J<ia the y46athaticsG. 5G Li3e a+ testsR H@C is u6 !n y in 5/> !, the 6atients5 $(O I +et.een 6/;92>. COD is a itt e +ette- 75>;95. @ !!d cu tu-es a-e -ea y use ess; ess than 5> a-e 6!siti<e +ut (t-e6 is +y ,a- the 4!st c!44!n !-ganis4 and eads (ta6h +y 5*1 -ati!. ?eed e as6i-ati!ns a-e a itt e +ette- I n!t 4uch and 6unch +i!6sy e<en +ette- I+ut again I n!t 4uch. (.a+ cu tu-es !,ten sh!. c!nta4inants. (!4eh!. they a-e a+ e t! c!nc ude that st-e6 causes +et.een 75;9/> !, cases. 'O(" is Bui-e unc!44!n. 6G T-eat4ents; DC? is <e-y e,,ecti<e +ut .i 4iss th!se ,e. (ta6h cases. &-a t-eat4ent is <e-y e,,ecti<e and h!s6ita iQati!n is n!t needed in 4!st cases. T-eating the 6-eci6itants I es6ecia y ,ungi is c-ucia . Au-ati!n !, the-a6y is n!t c ea-; s!4eti4es this can c ea- u6 -ea Buic3 I it de6ends !n the e:tent !, 6-esent and 6-e<i!us da4age. $ e<ati!n is -ec!44ended; n!t su-e this -ea y he 6s. 7G L!sing .eight .i he 6 6-e<ent -ecu--ences. T-eating ecQe4a and Tinea .i as .e . '!nth y 1n=ecti!ns !, DC? 4ay 6-ec ude -ecu--ences as .e . 8G 1 guess y!u sh!u d c!nside- !dd +ugs I i3e in 6atients .ith i<e- disease5 (L$5 and the i44un!su66-essed. "ni4a +ites a-e ,a4!us ,!- Dastu-e a
45 ‫ מתוך‬31 ‫עמוד‬

and Pi+-i! Pu cni,uicus can +e seen in i<e- disease in th!se .h! eat she ,ish. Eungi can 4a3e a ce u itis as .e . 9G C!44!n 4i4ics a-e ecQe4a5 y46hede4a and i6!de4at!sc e-!sis J-ea yRG 1 .!u d add APT 5 insect +ites and DPA 1/G 1t is i46!-tant n!t t! 4iss the se-i!us cases. These hints .i he 6 y!u identi,y nec-!tiQing in,ecti!ns* 6ain !ut !, 6-!6!-ti!n t! 6hysica ,indings5 ede4a !- tende-ness e:tending +ey!nd the +!-de- !, the e-ythe4a5 <esic es !- he4!--haghic +u a J+ut these can a s! +e in unc!46 icated ce u itisG5 ecchy4!sis5 gang-ene5 c-e6tius5 cutane!us anesthesia5 , uctuance5 .!!dy indu-ati!n5 -a6id e:6ansi!n !, the e-ythe4a5 and dish.ate- d-ainage. &+<i!us y high ,e<e- and i a66ea-ance 4a3e se-i!us in,ecti!ns 4!-e i3e y. " ,inge- test is s!4eti4es used I .he-e a 2 c4 incisi!n is 4ade and i, the su+cutane!us tissue s ides !,, the ,ascia; it is 6-!+a+ y nec-!tiQing ,asciitis. %!.e<e-5 1 thin3 u t-as!und and CT 4ay +e !, 4!-e he 6. 11G %e-e is a itt e 6ea- . 1n s!4e ische4ic and DPA c!nditi!ns5 the eg can +e ,ie-y -ed +ut it disa66ea-s .hen the eg is e e<ated. This is a ,!-4 !, c audicati!n I Must i,t u6 the eg i, y!u a-en2t su-e y!u a-e dea ing .ith ce u itis 12G (tatis Ae-4atitis can !!3 i3e this5 +ut has sca es and is n!t as h!t !-ed. $de4a !, c!u-se is 6-esent 13G APT is dee65 s! usua y d!esn2t cause e-ythe4a. %!.e<e- the ,e4!-a <ein is c !se- t! the su-,ace at the inguina ,! d s! that can +e -ed. (PT is su6e-,icia and -ed and h!t +ut it !!3s i3e I a <ein that is in,ected. 14G "steat!tic ecQe4a acc!-ding t! the4 !!3s i3e ce u itis +ut it is 4!-e i3e a nett ed 6atte-n I 1 d!n2t thin3 y!u .i c!n,use this. The-e a-e sca es and itching. 1--itant and a e-gic ce u itis ; a s! d!n2t thin3 y!u .i 4iss
45 ‫ מתוך‬32 ‫עמוד‬

these. )!ut d!esn2t usua y ead t! an e:tensi<e e-ythe4a and ca-cin!4a e-ysi6e ati!des is n!du a- and 6 aBue i3e . 1t is ind! ent and <e-y indu-ated. 15G E'E can !!3 i3e this I .e see a !t !, that he-e; 4!st y ha<e a+d!4ina 6ain and a-th-itis5 +ut 3e 6 it in 4ind. $-yth!4e a gia is a -a-e disease. 1t d!es a,,ect the egs and is seen in 'A( and C'L. The -edness and +u-ning 6ains c!4e and g!es5 +ut it gets +ette- .ith c!! ing !, the i4+ 16G Hhat a+!ut (.eets synd-!4eR He ta 3ed a+!ut this 9 4!nths ag!. Pen!4!us @ites and (tings 1G ?! .ay 1 can d! =ustice t! this su+=ect I this is su6e-,icia ,!-ay int! the su+=ect. Hhy n!t =ust t-ead Tinntina iR @ecause the .-ite- is $ng ish and .e usa y see the a-tic es !, the "4e-icans .h! a-e n!t as c!nce-ned .ith 6ests that a-e !utside thei- +!-de-s. 8es5 .e .i n!t 4enti!n the c!-a sna3e; +ecause .he-e 1 i<e and 4!st !, -eade-s i<e; .e d! n!t see -ed !n + ac3 sna3es J!- ye !. !n + ac3G 2G S1 hate sna3esS .as the ,a4!us .!-ds !, 1ndiana M!nes in Oaide-s !,

the L!st "-3
45 ‫ מתוך‬33 ‫עמוד‬

The t.! ,a4i ies that +!the- us 4!st a-e <i6e-s and e a6idae. J he-e a-e !the-s +ut they inc ude i3e !ne sna3e in each ,a4i yG A! n!t disc!unt this; !,ten 6e!6 e .h! a-e +it a-e n!t =ust th!se teasing sna3es5 +ut hi3e-s -eaching int! da-3 6 aces5 ag-icu tu-a .!-3e-s5 sna3e ,ancie-s5 and in the case !, #-iats and (6itting C!+-as; e<en s ee6ing 6e!6 e. They 6!int !ut Ssna3es sh!u d +e a<!idedS .hich .as a -e<e ati!n t! 4e. 8!u !, c!u-se 3n!. .h! 6 ayed 1ndiana M!nes; he is in his se<enties a -eady7 J 1 .!n2t 3ee6 y!u in sus6ense I it .as %a--is!n E!-dG 3G $ a6ids usua y cause itt e in the .ay !, !ca e,,ects Je:ce6t c!+-asG +ut they e:hi+it neu-! e,,ects such as 6t!sis +i ate-a y and ,acia 6a-a ysis .hich 6-!g-ess d!.n t! the =a.s and nec3 !<e- the ne:t h!u-s. "ust-a ian e a6ids can cease -ha+d! and sea sna3es can causes gene-a iQed , accid 6a-a ysis. (6itting c!+-as can cause 6ain in the eyes and 6a 6-e+-a ede4a. Pi6e-s cause !ca e,,ects inc uding nec-!sis5 +ut hy6!tensi!n sh!c3 and + eeding a+n!-4a ities a s! !ccu-. #idney ,ai u-e can !ccu- t!!. The auth!-s i3e the c !tting test; =ust ea<ing .h! e + !!d in the test tu+e and chec3ing !<e- 2/ 4inutes t! see i, it has c !tted. 4G ?! suc3ing !ut the 6!is!n5 n! !ca incisi!ns5 n! e ect-ic sh!c3s !<acuu4 e:t-acti!n. They d! say as ,i-st aid t! use !ca 6-essu-e and !ne study has sh!.n the ?T) !int4ent 4ay he 6. "nti<en!4* %e-e is .hat y!u need t! 3n!.. 1nt-ade-4a tests d! n!t 6-edict hy6e-sensiti<ity -eacti!ns. D-et-eat4ent .ith e6i 4ay he 6 6-e<ent i44ediate -eacti!ns. L!ca nec-!sis -eacti!ns a-e !n y 6-e<ented i, the anit<en!4 is gi<en i44ediate y. Chi d-en 4ust +e gi<en the sa4e d!se as adu ts. &ccasi!na y y!u need t! gi<e -e6eat d!sages in t.!
45 ‫ מתוך‬34 ‫עמוד‬

h!u-s i, the CPTneu-!T !- c !tting e,,ects 6e-sist. The anti<enin has a sh!-t ha , i,e; e,,ects !, the sna3e +ite 4ay -ecu- a,te- a ,e. h!u-s !days .$a- y -eacti!ns a-e ana6h yact!id and a-e t-eated .ith e6i. (e-u4 sic3ness -eacti!ns sh!. ,e<e-5 itching5 u-tica-ia5 and a-th-a gia; they .i need %1 + !c3e-s and 6-ednis!ne. 5G &the- sna3e +ite t-eat4ents inc ude anti ch! ineste-ases i, the 6atient -es6!nds t! ed-!6h!niu4 !- at-!6ine as a test d!se. "nti+i!tics a-e n!t indicated un ess the-e c ea- y in,ecti!n. Lea<e + iste-s a !ne. 1, nec-!sis !ccu-s; then y!u need anti+i!tics and de+-ide4ent. (na3e +itten egs 4ay s.e 5 and +ec!4e tense5 c! d s.! en5 6u se ess and cyan!tic5 +ut this 1( ?&T C&'D"OT'$?T (8?AO&'$; i, y!u 4easu-e the c!46a-t4ent 6-essu-es I they a-e ,ine; d! n!t s ice this guy !6en. @e es6ecia y ca-e,u i, the 6atient has a c!agu ati!n de,ect ,-!4 the +ite +e,!-e y!u s ice anything. 1, the 6atient has +een s6it in the eye5 i--igati!n5 and 6ain -e ie, is indicated. 1n 1s-ae .e ha<e the Da estinian Pi6e- and @u-t!n2s Ca-6et Pi6e-; the inst-ucti!ns -ega-ding <i6e-s a66 y; anti<en!4 is a<ai a+ e. 1 ha<e had 6atients +-ing the sna3e t! the $A ,!- identi,icati!n and it did esca6e. E!-tunate y it .as n!t <en!4!us. 6G LiQa-ds; d! n!t inte-est 4e and sh!u dn2t inte-est 4!st !, the .!- d as the-e a-e !n y t.! that a-e 6!is!n!us; the gi a 4!nste- and the 'e:ican +eaded iQa-d. They d! n!t ha<e sha-6 teeth s! they +it and c ing tenaci!us y the 6atient unti thei- teeth can in=ect en!ugh 6!is!n. Dain5 hy6!tensi!n5 <!4iting5 angi!ede4a5 and 4i d c!agu !6athy can !ccu-. T-eat4ent is su66!-ti<e +ut 6 ease -e4!<e the iQa-d ,i-st +y 6-ying !6en the =a.s .ith a sc-e.d-i<e- and 4a3ing su-e it d!esnUt +ite s!4e!ne e se. C! d .ate- a s! !!sens thei- g-i6 2%e-ey!uU-e y!u45 ‫ מתוך‬35 ‫עמוד‬

neigh+!-h!!d gi a 4!nste- and +eaded iQa-d

45 ‫ מתוך‬36 ‫עמוד‬

7G ?!. .e g! ,-!4 a46hi+ians t! ,ish

E!!t.ea- is the +est 6-e<enti!n techniBue a th!ugh it .i n!t he 6 against sting-ays. Nse a shu,, ing gait .hen .ading. The !nes y!u .ish t! a<!id 4eeting inc ude -ays and sc!-6i!n,ish in the N("5 .ee<e-,ish in the N#5 st!ne,ish in (!utheast "sia and Li!n,ish in

aBua-iu4s and the t-!6ics. Hee<e-,ish*
45 ‫ מתוך‬37 ‫עמוד‬




8G The-e is i44ediate 6ain and s.e ing. Pi+-i! c!nta4inati!n can !ccuand in ,-esh .ate- I.atch !ut ,!- ae-!6hi us. Lea<ing s6ines in inc-ease in,ecti!n -ates. Oays ands sc!-6i!n ,ish can cause s.eating5 dia--hea5 hy6e-sa i<ati!n5 hy6!tensi!n5 and c!n<u si!ns. T-eat4ent is h!t .ate-. "nti<e-n!4 is a<ai a+ e in "ust-a ia .he-e a the g-eat
45 ‫ מתוך‬38 ‫עמוד‬

sna3es5 =e y,ish and a igat!-s i<e. A!:y !- T'V('W .i c!<e- the .ei-d +acte-ia in,ecti!ns. 9) $ating ,ish is a s! a dange-!us ente-6-ise. %!.e<e-5 y!u a 3n!. I !+ette- 3n!. a+!ut these ,!- y!u- +!a-ds. Ciguate-a is ,-!4 neu-!t!:ins ,-!4 ,ish that eat din!, agge ates. The-e a-e )1 signs t!!5 +ut the neu-! sy46t!4s Iand they a-e st-ange i3e 6a-astesias; 4ay ast ,!4!nths. 8!u can see this in g-!u6e-5 sna66e-5 4ac3e-e 5 =ac35 and +a--acuda i, y!u eat that J!- i, it eats y!uG. %e-e is a Ain! .ith a

, age ate. Tet-!t!:in is ,!und in sun,ish5 t!ad,ish and the ,a4!us 6u,,e- ,ish; 3n!.n as ,ugu in Ma6an. 1t can 3i y!u ,-!4 -e6a-at!-y 6a-a ysis .ithin thi-ty 4inutes. Che,s .h! -e4!<e the 6!is!n ,!-4 Eugu 4ust eat thei- !.n c-eati!ns as thei- ,ina e:a4 +e,!-e ce-ti,icati!n. Du,,e-,ish*

45 ‫ מתוך‬39 ‫עמוד‬




45 ‫ מתוך‬4/ ‫עמוד‬


(he ,ish can a s! 6!is!n <ia din!, agge ates. The th-ee ty6es a-e 6a-a ytic5 neu-!t!:ic and a4nestic. The ,!-4e- is the !n y !ne that can +e dange-!us5 a th!ugh a th-ee a-e usua y su-<i<a+ e; a th!ugh n!t ,!- the 4! us3. Last y5 tuna and 4ac3e-e can a s! cause sc-!4+!id 6!is!ning. This is a hista4ine -eacti!n. This !ne is t-eated .ith the usua anti hista4ine -egi4ensF the !the-s a-e su66!-ti<e a th!ugh acti<ated cha-c!a 4ay he 6 i, y!u use it -a6id y. D-e<enti!n* the t!:ins a-e a heat sta+ e5 s! c!!3ing .i n!t he 6. (c-!4+!id 6!is!ning is a<!ided +y eating ,-esh ,ish. ?!n sca e ,ish that a-e a-ge a-e a dange- ,!- ciguate-a. ?!t in issue ,!- 4e; these ,ish a-e n!t #!she-; e<en i, Eathe- )-eg + esses the4. 1/G #8 Me y,ish a-e n! ,un eithe-. @!: Me y5 Chinese Me y5 the D!-tuguese 'an !, .a- and 1-u3and=u a sting5 and cause death5 a th!ugh 4!st d! s! -a-e y Je:ce6t ,!- the @!:G Ch-ysa!-a a-e c!44!n in ?!-ht "4e-ica5 and De agia in the "d-iatic. Het suits5 yc-a suits5 and ny !n st!c3ings a 6-!tect against 4!st =e y signs. @!:es can cause death .ithin 4inutes ,-!4 6u 4!na-y ede4a5 c!n<u si!ns and CP c! a6se. 1-u3and=i synd-!4e is se<e-e 4ya gia5 6a 6itati!ns and s.eating. 1t can 6-!ceed t! "D$ and %T?. 'an !, Ha-s can
45 ‫ מתוך‬41 ‫עמוד‬

cause he4! ysis and gang-ene +ut this is a se<e-e en<en!n4ati!n and 4!st a-e n!t. 1 3n!.. 1 4et !ne !, these +ugge-s in E !-ida 4any yea-s ag! and g!t a nice 3iss !n the +utt. T-eat4ent I <inega- .i inacti<ate 4!st Me y ne4!cysts %!t .ate- .i he 6 6ain. (ha<e !,, the -e4aining ne4!cysts. The-e is an anti<en!4 ,!- @!:5 +ut it 4ay n!t .!-35 and +esides; .h! .!u d get itR They die s! ,ast. 11G He g!t sea u-chins he-e. '!st a-e in the g!<e-n4ent. 1n,ecti!n is c!44!n. Ta3e !ut the s6ines i44ediate y. %!t .ate- .i -e ie<e 6ainF y!u 4ay need t! s!,ten u6 the ,!!t .ith acet!ne t! ta3e !ut the s6ines. (yste4ic e,,ects can !ccu- such as 6a-a ysis !- CP c! a6se5 +ut this is unc!44!n. 12G Last y .e ha<e insects. %y4en!6te-a I that is5 +ees5 .as6s5 ye !.=ac3ets and h!-nets. He2 inc ude ,i-e ants as .e . '!st !, the hy4en!6te-a -a-e y sting 4!-e than !nce un ess they a-e ",-icaniQed in .hich case 4u ti6 e stings a-e the case I a th!ugh the <en!4 isn2t any dei,,e-net 5 it is =ust a !t 4!-e !, it.

45 ‫ מתוך‬42 ‫עמוד‬


"na6hy a:is is a 6-!+ e4 he-e5 as it is t! the =ac3 =u46e- ant .hich +ite in I y!u guessed it; "ust-a ia. @eta + !c3e-s can 4a3e the -eacti!ns .!-se. N-tica-ia and !ca -eacti!ns I e<en i, 4assi<e d! n!t ,!-ete ana6hy a:is ne:t ti4e the-e is a +ite. Has6 stings can get in,ected +ecause they s!4eti4es ,eed !n -!tting 4eat Jyuc3G. Ta3e !ut the stinge- i, y!u see it. 13G (c!-6i!ns a-e 6-esent in "-iQ!na; J.aiting ,!- y!u- ette-5 #enG +ut deaths a-e -a-e the-e. (c!-6i!ns a-e actua y Buite c!44!n in !uc!unt-y. 1n 1ndia5 they ha<e a -ed sc!-6i!n .hich can +e etha 5 1-an has th-ee dange-!us s6ecies. 1n 1s-ae the + ac3 sc!-6i!n is 6-etty ha-4 ess5 +ut the ye !. !ne can cause a--hyth4ias and c!n<u si!ns5 a th!ugh 1 ha<en2t seen these I +ut 1 sti !+se-<e the4 ,!- 6 h!u-s. Dain is c!44!n6 ace t! a sc!-6i!n +ites. #ids a-e !+<i!us y 4!-e
45 ‫ מתוך‬43 ‫עמוד‬

sensiti<e t! the e,,ects. The t!:ic e,,ects de6end !n the ty6e !, sc!-6i!n +ut sy46t!4s de<e !6 Buic3 y and a-e usua y )1; 6ain5 dia--hea5 and <!4iting5 ,! !.ed +y %T?5 sh!c3 and neu-! e,,ects. These neu-! e,,ects 4ay inc ude c!n<u si!ns5 ,asicu ati!ns5 6-ia6is4 and e--actic eye 4!<e4ents. (!4e can cause 6anc-eatitis5 s!4e can cause st-!3e5 and s!4e can cause !ca nec-!sis. Dain c!nt-! is c-ucia F anti<en!4 e:ists and .!-3s I at east in 1ndia and "-iQ!na.

14G Last y a-e s6ide-s

. Aeaths a-e -a-e +ut +e.a-e !, the Eunne He+ s6ide- .hich is ,!und !, c!u-se in X "ust-a ia. ?ec-!tic s6ide- +ites a-e usua y L!:!sce es s6ecies and a-e 6ain ess5 +ut .ithin h!u-s +u-ning sensati!ns de<e !6s and the .!und +ec!4es -ed .hite and + ue. " ch-!nic u ce- ensues c!<e-ed +y an escha-. ?eu-!t!:ic s6ide- +ites a-e i44ediate y 6ain,u .ith g!!se, esh and s.eating in the a-ea and then +egins the 6a-ty; ,e<e-5 %T?5 6sych!sis5 -ha+d!5 t-e4!- and 4usc e s6as4s5 -igidity !, ,ace and =a.s5 <!4iting; y!u get the 6ictu-e. E!-tunate y5 anti<en!4 is
45 ‫ מתוך‬44 ‫עמוד‬

a<ai a+ e ,!- the neu-!t!:ic s6ide-s. They sti -ec!44end 6-essu-e i44!+i iQati!n ,!- ,unne .e+ s6ide- +ites. Oe4e4+e- .hy + ac3 .id!. s6ide-s a-e ca ed .id!.s; they 4ate5 then +ite !,, the heads !, the 4a es and suc3 !ut thei- inna-ds. Hhat a i,e5 %uhR

45 ‫ מתוך‬45 ‫עמוד‬

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