Conference Notes 5-28-2014


Chan        Study Guide   Genitourinary

 In a female with recurrent uti’s you have to treat presumptively  for STD’s.   Treat with ceftriaxone and azithromycin and flagyl.    Elise and Harwood comment:  You should treat for GC/Chlamydia/Trich.    Also you should consider interstitial cystitis as a diagnosis.   Girzadas asked the question if other faculty are checking EKG’s for long QT interval prior to prescribing Zithromax.  Most faculty felt Girzadas was being overly compulsive.  Girzadas said he has picked up a couple of patients with QT intervals over 500 with  screening ekg’s.   Most faculty were not swayed. 

 Fournier’s gangrene:  polymicrobial etiology,  aggressive infection in genital/ perineal region.   Requires emergent surgical debridement.   Most commonly this occurs in poorly-controlled diabetic males.  Antibiotic coverage should include gram positives & negatives and anaerobes. 

There was a discussion among faculty about asymptomatic bacteriuria in pregnant patients.   Elise and Kelly get a formal urinalysis on pregnant patients in the ED to look for bacteriuria.  If they find it, they treat for a week.   Harwood does not look for bacteriuria with a formal urinalysis.  He just does a urine dip and makes a treatment decision based on that.   Resident reports about our OB clinics is that they don’t routinely screen for bacteriuria.  Faculty felt they have a different patient population than we do and we may need to look for this more aggressively.

Up to Date Reference: Bacteriuria has been associated with an increased risk of preterm birth, low birth weight, and perinatal mortality. In clinical practice,  only one screening voided urine specimen is typically obtained, and treatment is usually started in women with ≥105 cfu/mL without obtaining a confirmatory repeat culture. Multiple studies have been performed to assess whether rapid screening tests, such as dipstick, enzymatic screen, reagent strip, or interleukin-8, might have comparable sensitivity, specificity, and predictive value to urine culture for the detection of asymptomatic bacteriuria in pregnant women [20-22]. These methods do not come close to urine culture in terms of sensitivity and specificity and should not be used.

Girzadas comment: It looks to me like you probably need a urine culture to definitively diagnose asymptomatic bacteriuria.

 There was a discussion about the difference between the terms pathognomonic and sine qua non:   Pathognomonic is a very specific symptom or sign.   Sine qua non is a very sensitive symptom or sign. 

 Treatment of priapism: Aspirate corpora cavernosa.   If that doesn’t solve the problem,  and inject 1ml of diluted phenylephrine into the corpus cavernosum every 3-5 minutes until resolution.   Harwood comment: you don’t have to inject both sides.  There is a vascular communication between both corpora cavernosum.

Attempt at detorsion of testicular torsion should be the technique of “opening the book”    If you get partial relief with 180 degrees of detorsion it is ok to detorse further.  If your attempt worsens pain,  try using the “close the book” technique.  Pt’s still need surgery after successful manual detorsion because they are at risk for recurrent torsion.



*Open Book Detorsion Technique


Epididymitis: >35 yrs old is more likely due to ecoli.   <35 is more likely STD  #1 is chlamydia and #2 is GC.  If you get an U/S diagnosis of epidydimitis in a child, Cindy said she was told by Dr. Nold that the diagnosis is more likely torsed appendix testes.  Most faculty would manage this child with a urine culture, starting antibiotics to cover ecoli and give an NSAID for possible torsed appendix testes.  Kelly comment: There is literature supporting conservative management with no antibiotics in kids with an ultrasound diagnosis of epididymitis.  Treat only if pyuria is present or urine culture comes back positive.


3 anatomic locations where kidney stones get stuck in the ureter: ureteropelvic junction, pelvic brim/crossing over iliac vessels, ureterovesicular junction.   If a stone makes it to the disal third of the ureter, 70% will pass spontaneously.   


*Kidney stone anatomic areas of getting stuck


Balanitis= inflammation of the glans.   Balanoposthitis=inflammation of glans & foreskin.

 Paraphimosis reduction techniques include: compression with ace bandage,  osmotic agents, puncture technique, forceps retraction, and dorsal slit procedure.


Paraphimosis puntcure technique 


Avoid urinary catheterization in patients who can void spontaneously and can sit on a bed pan/commode or ambulate to bathroom.  You want to avoid catheter associated uti’s in these patients.


Intraperitoneal bladder rupture: gross hematuria in 98% of patients.  Usually it occurs in a patient with a full bladder who suffers a compressive force (MVC) causing bladder to rupture at dome.   Extraperitoneal bladder rupture usually is due to a pelvic bone fragment perforating the bladder. 

*Intraperitoneal bladder rupture (you can visualize bowel loops due to contrast)


*Extraperitoneal bladder rupture


Negro/Herron        Oral Boards


Case1.   50yo male exposed to unknown gas in a train station.  Multiple casualties at this incident.  Pt has diarrhea and vomiting.   HR=40.   SLUDGE (cholinergic) toxidrome.  Diagnosis: Nerve gas (organophosphate) poisoning.    Critical actions:  decontamination,  personal protective equipment Atropine hi dose,   2-PAM (Pralidoxime), , airway control if needed.    Avoid succinylcholine in these patients because there is competitive inhibition of the succinylcholine by the cholinergic agent.  Use rocuronium in higher than normal dose    Kelly , Harwood, and Elise comment: Step one in managing these patients is using personal protective equipment, decontamination of the patient, getting unnecessary personnel away from the resuscitation room.   EMS personnel know this but ED docs don’t do this naturally.  We need to address resuscitation safety for our team first before we start treating the patient.   Andrea comment: Your first call should be to a poison center.  They can mobilize atropine resources.  You frequently will use up your hospital resources of atropine.   Girzadas comment:  In a previous conference notes it was discussed that having a patient drink atropine eye drops actually can provide a very large dose of atropine for a patient in a mass casualty event if IV atropine is not available.


Case2.     23yo female with  lower abdominal pain and shuffling gait.   On exam, patient has CMT.   U/S is negative.  Diagnosis: PID with peritonitis.    Critical actions: IV antibiotics, admission.   Not all PID patients need to be admitted. Criteria for admission for PID : pregnancy, non-compliance with treatment,  not improving with oral meds, TOA, high fever, nausea and vomiting, severe abdominal pain/peritonitis, need for surgery, other possible diagnoses like appendicitis.


Case3.     15yo male presents pulseless after sustaining blunt trauma to chest in hockey game.   EKG shows V-fib.      Diagnosis: Commotio cordis    Critical actions:  Defibrillate,  IV Epi, CPR,   Intubate.  Therapuetic hypothermia. Elise comment: Don’t intubate this patient first.  The key thing is defibrillation.  Shock first and then do all the other stuff like intubation and meds second.


*Commotio cordis


Maletich    M & M


24 yo female with a CC of flank pain.  Patient was diagnosed with a kidney infection and started treatment with macrobid  the day prior.  The clinical setting in the ED was very busy, rife with distractions.    At this ED visit, the patient had bilateral flank tenderness and abdominal tenderness on exam.  Jim orders a CT of abdomen and pelvis with IV contrast.  Labs significant for HGB =8.9.  No UCG available yet.  The ED attending intervenes at this point and performs bedside U/S.  U/S shows fluid in Morrison’s pouch.  The attending asks the patient are you pregnant?  Patient states yes.   The management  of the case rapidly changes gears to resuscitation of a hypotensive ectopic pregnancy.  In OR patient  was found  to have a ruptured cornual pregnancy.


Jim questioned how this occurred.  Why was the patient bradycardic, and why was there no vaginal bleeding?

There are multiple papers describing that vital signs fail to correlate with hemoperitoneum in ruptured ectopic pregnancy.  This postulated to be due to increased parasympathetic tone from peritoneal stimulation.


*ectopic pregnancy location


Cornual ectopics are also known as interstitial ectopic pregnancies.  These are in the muscle where the fallopian tube originates.  These occur later in pregnancy.  When these rupture, they can bleed quite a bit.  Cornual pregnancies account for 2% of ectopics but unfortunately also 44% of the deaths.   Harwood comment: The artery in the cornual section of the uterus is large and if there is rupture  in that vicinity they bleed severely.

 Blood in the wrong place is painful.  Blood irritates the peritoneal cavity.  

Sola comment: The pregnancy test in a child-bearing age female is really equivalent to a vital sign.

You can  use the patient’s blood to run a urine pregnancy test if you are facing delays getting urine.   

Anna Sklar’s comment: This case is an example of framing bias.  The patient was triaged to a lower acuity area of the ED.

Andrea’s comments:  We are all pattern seekers and building your pattern on the report of an inexperienced student’s exam is fraught with hazard. You really need to see the patient yourself so that you don’t have premature closure based on an incomplete or inaccurate pattern.

Sola comment: If there is a long wait for a CT scan, get an U/S to the bedside.

Elise comment: Our own emotional baggage taints how we view the patient.

Girzadas comment: These are all great comments describing how different biases affect our thinking when we are at work.  Often when most needed our thinking is foggy when we are working in a busy ED environment. When we are working in the ED our thinking is not as clear as when we are sitting in the conference room discussing the case.

McKean comment: This patient is in shock and is not making much urine.  That is why it was tough to get urine.

Harwood comment:  Bile and gastric fluid are the most irritating fluids to the peritoneum.   You will see relative bradycardia due to blood in the belly multiple times the rest of your career.  It is not that uncommon.   You can send blood for a qualitative HCG in the lab which is pretty quick  or you can run the urine preg test with the patient’s blood.

Anna Sklar comment: Give the patient the benefit of the doubt.  Before you chalk up the patient’s behavior to dramatics give them all your thought and effort to rule out life threats.


Cash/Lovell      Resident as Clinical Teacher

 Elise showed a funny video of a pedantic surgeon teaching young surgeons at the bedside.  Pedantic teaching techniques don’t work very well: Aggressive yelling, not being respectful of learners, focusing on minutia, not giving learners time to think, ignoring the patient. 

 Characteristics of Great teachers:  Energy level, approachable, enthusiasm, engaging.  They take the time to ask you challenging questions.  Hold you accountable.  Give you usable feedback.    Elise comment: It is optimal to highlight feedback to the learner by saying explicitly, “I am going to give you some feedback now.”   

The literature says great teachers have very positive non-cognitive skills like positive relationships, communication, and enthusiasm.    Your medical knowledge and technical skills are important but are considered a baseline that all teachers must have.   The non-cognitive skills separate the adequate teachers from the great teachers.  

Excellent teachers state these are important behaviors: tailor your teaching to the learner.  Actively involve the learner.  Give the learner responsibility for their learning.  Actively seek opportunities to teach.   Agree on expectations.  Be a role model. Thinking out loud is a good way  to convey your thought process.

 Traditional teaching: Teacher-centered method .  Teacher functions as expert consultant. Learners are passive.  Learners don’t express clinical reasoning skills.

Newer teaching model: Learner-centered teaching.  Teachers focus time on finding knowledge gaps and teaching to that gap. Teachers act as facilitators.  Learners ask more questions and actively pursue knowledge.

One minute preceptor model:

  1. Get a commitment from the learner.  Have them say what they would do in the situation.
  2. Probe for supporting evidence.  Identify the learner’s knowledge gaps.
  3. Teach a principle.  Give a pearl to the learner.
  4. Reinforce what was done well.  Give positive feedback on what they knew or what they did well.
  5. Correct mistakes
  6. Identify next learning steps.  Encourage the learner to continue independent learning after the encounter.

These don’t all have to be done every time.

The residents then practiced using this model.

Unfortunately I missed the rest of this outstanding lecture due to a meeting.