April 2012

1)   Hope you had a great March (considering this is still February when I started this issue, this makes me a bit an optimist –if you are a reader of EMU then you must think I lost it) (I did). I avoid articles from the Annals of EM, but there is some extension that can be made. This RCT showed that IV erythromycin cleared the stomach as well as an NGT tube (Zonde).  While I do not believe that you really need an NGT for UGI bleed but this can be useful perhaps elsewhere. If erythromycin can cause rapid emptying of the stomach- then can we use this for emptying the stomach inpatients with swallowed foreign bodies? As an adjunct to whole bowel irrigation? To move up surgeries where the anesthesiologists want an empty stomach? (Ann Emerg Med 57(6)582) TAKE HOME MESSAGE; IV erythro can speed up gastric emptying that may help us in a number of clinical situations

2)   Another article I liked that we should mention for those who do not get the Annals is the concept that for iliofemoral DVT- the treatment was always just heparin or LMWH and hope there would be no PE.  A number of coalitions are now pushing for the use of thrombolysis- not only because it would prevent PE but also that it would prevent post thrombotic syndrome.  This syndrome is characterized by chronic pain, itching, cramps, and at the worse- chronic ulcerations which could lead to amputation. Obviously this is only for those who can have TPA safely. (ibid 590).  I would like to also point out a common error- be careful about sciatica- this can be an iliofemoral DVT.TAKE HOME MESSAGE: DVT may need thrombolysis if only to lower the prevalence of post thrombotic syndrome. This may be given locally.

3)   Bronichiolitis- yea, I know that nothing really works and so do you.  There is some evidence that dexamethasone and inhaled epinephrine when used together works, even though either alone is not that effective.  Hypertonic saline inhalations may work.  Still no good evidence for both of these but it is more promising then previous treatments (AJRCCM 183(10)1284) TAKE HOME MESSAGE: Hypertonic saline inhalations and a dexamethasone IV/epinephrine inhalation may help in bronchiolitis.

4)   Another in the "when nothing else helps" department-hydrocarbon aspiration causes a lipoid pneumonitis and patients do poorly.  In this case report they used surfactant.  It worked wonders.  Just a thought- we can't really say much more (Peds 127(6)e100). TAKE HOME MESSAGE: Surfactant may help in hydrocarbon aspiration pneumonitis.

5)   I can not bring my self to mention this article.  This is truly painful.  I know you know this, I'm sure of it- but could I be wrong? Asthma does not need antibiotics. Even if you start steroids- they do not need antibiotics.  Bacterial superinfection is very rare. (Same goes for most sinusitis and otitis media which are overwhelmingly viral diseases). Yet one out of six kids seeing their docs for asthma gets antibiotics. That comes out to 1 million useless prescriptions for antibiotics a year in the USA.(Peds  127 (6)1174) You better not be one of those docs or I will never ever let you read EMU again. TAKE HOME MESSAGE: Asthma does not need antibiotics.  And if you use them, I will need you to meet my friend Arnold.

6)   In this Turkish study they identified 75 esophageal intubations and 75 tracheal intubations with ultrasound at the suprasternal notch. It was 100% accurate, ( J Ultrasound Med 30(5)671) Could be true but 100 sensitivity and specificity makes me wonder- how good was this ultrasound guy and can I be as good as he was? Also, these cases were on elective surgical patients- is it harder to know in the patients we see? TAKE HOME MESSAGE: Ultrasound may be helpful in intubation to establish where the ET tube is.

7)   We have said this before but there is a little extra point here that needs to be emphasized.  Your success in defibrillating a patient goes up with higher levels of energy and fears of causing myocardial damage are unproven and unfounded.  Seems especially true in biphasic defibrillation and so they recommend starting at a high energy (their recommendation is the highest energy the defibrillator can give- a little more testosterone than I have) and staying there for further shocks. (Resusc 82(6)647). Actually Elliot Antman many years ago – before we had biphasic- recommended defibrillation at 720 J- using two machines together. This just in- the San Diego Football team has now changed its name to the Biphasics. TAKE HOME MESSAGE: Use high energies for defibrillation and use a biphasic machine please.

8)   It is hard enough to predict who is going to do poorly after cardiac arrest and now that we are cooling patients- it is even harder.  Yes the AAN has tried to give guidelines but they are mostly based on the pre freezing era.  They are ridden with poor studies and wide confidence intervals. What is clear is that you can not saying anything from the ED and even more- nothing can be said until day three when lack of corneal and papillary response and motor response may mean something- maybe. (Resuc 82(6)653).  I – without getting into ethical or religious questions here –feel that you just can not tell in the ED- and the evidence seems to be that way.  Put them in the fridge and let someone figure it out in another three days. TAKE HOME MESSAGE: Patients who arrive in cardiac arrest and survive- cool them –we can not at this point make decisions about survival prospects.

9)   I liked this review of the evidence that said what we all knew- do you know which of the anti arrthymics we use in resuscitations has been proven to work (i.e. - discharge alive)?  Answer: None (ibid 82(6)665). Now does your ACLS card feel better? TAKE HOME MESSAGE: Meds have never been proven to help in cardiac arrest.

10)               I have seen this- I think we all have but do you know how to treat it?  I am speaking about impalement injuries of the mouth- soft palate ones are especially scary looking.  However, my oral maxillo surgeon states that most of these heal spontaneously well with out any treatment, and this study says the same. (J Oral Max Surg 69(6)e147)  However I have no idea how they made their conclusions based on the cohort set they studied. They still did surgery in 32% of the patients – and it isn't clear if they were even necessary interventions. TAKE HOME MESSAGE: Most soft palate impalement injuries probably can be managed conservatively.

11)               This article looked at sources for strokes in young adults.  The cohort was small of course, and young adults was defined as 16- 54- which makes me at least a young adult. A cause was found in less than 50% of the patients. Patent foramen ovale with an atrial septal aneurysm was the most common cause but my reason for bringing this article is that cervical or cerebral artery dissection was fairly common as well. This age group is the ones that you want to give TPA and in dissection it may kill them.(Neuop 76(23)1983)  So what to do next, Sherlock?? TAKE HOME MESSAGE: Should you give TPA for stroke in a young person???? Not if there is a dissection- and how will you know if the CT of the head is normal and you leave it as that?

12)               Ah yes, the PE paper of the month. Actually, since we have beaten this subject to a pulp it is understood that there can not be that much new on the subject and indeed there is not.  But the results of this study highlight things we should be familiar with. They did a sequential study using the following- clinical suspicion, D dimer, ultrasound of the lower limb, V/Q scanning and then CTA only when a result was not conclusive in all previous studies.  Ultrasound established diagnosis in 13% of the patients and V/Q in 76%.  CT was only needed in the remaining 11% patients. (Chest 139(6)1294) Here are the points I want you to take home with you – or let us just summarize as usual TAKE HOME MESSAGE: Clinical suspicion is the first filter in PE. Ultrasound suggested PE in one in 10 patients and saved the patients a radiation load. V/Q scan did very well and the complaint that most are intermediate risk did not occur in this study. (However if you had a clinical suspicion I do not think D dimer helps much. I would take the clinical suspicion to the end- but that is just me). While we are on this subject we got a letter last month from Cobi Metzger who reminded us that the article on non thrombotic emboli did say that V/Q can be useful test were CT fails. I am not sure how this works, but thanks for the reminder.

13)               I think we sometimes think that oxygen is a benign medication and it really isn't.  In this study of ICU patients- those with post resuscitation increases in PO2 had increased incidences of mortality. Now it is true that patients that were sicker got more oxygen but I believe many of us do not realize the need to lower the oxygen level as soon as possible in intubated patients. (Circ  123(23)2717). This article comes from Cooper's ED which is Al Sachetti's home town- so we'll just say hello. TAKE HOME MESSAGE: Strive to lower oxygen in intubated patients as soon as feasible. 

14)               With proper cutoffs CRP and Pro calcitonin can be used to rule out serious infections in kids. My response is "bovine droppings!" They even admit the studies were methodologically poor.  However I will bring at least their conclusion that WBC neither could rule in or rule out serious infection with any certainty (BMJ 342:Jun 8). TAKE HOME MESSAGE: Ruling out of serious infections by blood tests is – as Greg Henry says- the refuge of the intellectually destitute.

15)               This really affects all of us – after checking a five year period in the national practitioner data bank they found more than half of the malpractice events were in the outpatient setting. This is contra to what we would intuit- surgical mishaps, OB mistakes were always the high risk areas. No, the office/clinic is a dangerous place. (JAMA 305(23)2464), Reasons for this are unknown but this usually reflects not dumber docs in the outpatient setting but a systems problem.- are patients that used to be admitted now being discharged earlier or denied admission when they really need it? Are insurance concerns a problem? In any case malpractice usually- as the article points out-reveals safety issues not being dealt with.  Is this worse with socialized medicine- this article cannot tell us but EMU goes worldwide and I would like to here from other systems what you experience. TAKE HOME MESSAGE: Malpractice in the primary care setting is increasing perhaps from unrecognized safety issues. Now on a similar topic, we have mandatory triage at our hospital and this takes up a nurse who is usually not so happy with the job.  In this study they found that even with triage, they rarely identified the sicker patients when using recognized guidelines. This is another example of a systems problem, in all probably they didn't succeed here because of a manpower problem- a flood of patients makes triage very hard. (Ann Emerg Med 58(2)137) TAKE HOME MESSAGE: Triage of sick patients rarely occurs within the ten minutes that standards dictate, and this can be a dangerous precedent.

16)               ED technicians can be taught to use ultrasound to get IVs in patients with poor access. What is particularly important to point out here is that the complications were minimal and of no consequence. (AJEM 29(5)496) Now we in Israel and probably many other places do not have ED technicians but we do have nurses and I am sure if they put in IV s they would be happy to have this tool.  Why stop there? Do you know how to use ultrasound to gain vascular access? TAKE HOME MESSAGE: ultrasound can be used by most anyone to find vascular access for peripheral IV.

17)               This article asked is it safe to sedate elderly patients? The answer is yes. Of course you are more careful, but they do well. (AJEM 29(5)541) This study was not done retrospectively which makes it especially attractive. TAKE HOME MESSAGE: Sedation for elderly patients is safe.

18)               There have been several reports of MRSA in household pets. (Vector Borne Zoonotic Dis 11(6)617). Actually this is neither the first article nor the most descriptive, but I truly could not resist taking an article from this journal that I am sure none of my readers (other than Rick Bukata) gets. We are not sure that this is truly transmitted from animals to humans since the clinical pictures are different in animals and people and also there may a difference in subtype although there are ones emerging that can transmit to people in the lab. (Epid Infect 138(5)195). Will this stop you from kissing your dog on the lips? I am not sure.

You are about to witness a murder. The victim- this article (Cerebro Vasc Dis 31(2)170). Cerebral bleeds on warfarin do better with PCC.  Well this is what we are now taught based on the premise that PCC has more of the clotting factors than FFP. This article went to prove that. Here is the reason for Murder one- they used hematoma expansion as one of the measures- but noted that hematoma size was similar in the group that got PCC and those who did not, although it was more often seen in those who did not get it. In all fairness they also measured who had bad Rankin scores but here is the kicker- who got the PCC? The patients that did better- but maybe they were better in the first place- the study was not randomized.  Even worse, the ones that did not get PCC- may have not have gotten anything- it isn't clear from the study so of course they didn't do as well.  And in addition there were some in the PCC group that got it even though they had an INR of 1.0. Why? So let's finish this off with a mercy killing of this article.  (the names have been changed to protect the innocent) 

(Extra points- Tell me who this is, who played him, what show was introduced with the line "the names have been changed to protect the innocent"  and who was the star of that show)
20)    I wanted to mention this article again for Dina, a faithful reader for many years. Nurses and pharmacists in the UK now have limited rights to prescribe.  This is an age old controversy which has gotten more acute and perhaps relevant with the advent of physician's assistants in many countries and also shortages of physicians in many areas.  Many pharmacies in the USA even provide medical care on the spot and this begs the question whether diagnostic decision making is similar or requires the same training as prescribing decision making.  And if it is more difficult, can nurses and pharmacists be trained to do it? The article thinks so and goes into the mechanics although of course they can provide no data. My comments are that FPs should not see this as a threat. Secondly the article points out that experience is probably the best teacher, and I think we all knew this from our own training that we often used the nursing staff to guide us. This is truly a gray zone as to where a physician is needed instead of an allied health professional, and of course where responsibility lies. (Soc Scie Med 73(3)375). Oh yes, I am sure again that Rick gets this journal.
21)    Here is a proposal that will reduce your malpractice rates significantly and will reduce frivolous suits.  The only problem is I couldn't make any sense out of this proposal and how relevant it is to all systems. I guess that is alright being that it originated from Harvard Law School (J Law Med Ethics 39(3)539). Now I have one malpractice lawyer who reads EMU, and some MD legal experts- can I put out a call for some help? If they answer, I will print their response in the next EMU.
22)    The landmark article on hiccups appeared way back in the late nineties in the pharmacy literature, but I am pretty sure little research has been done on the subject since.  This updated article states we still do not know the exact science behind hiccups.  We do however have a good list of causes.  CNS disorders, metabolic disorders, meds, low potassium, low calcium, hyperventilation and uremia. Now what can you do about it is a more difficult issue. Brainstem lesions will respond well to steroids or radiation, Chlorpromazine is the medication most often used (Thorazine, Taroctyl). However, this is a treacherous drug that has killed people when given too fast and can cause urinary retention, glaucoma exacerbations and hypotension. Haloperidol (Haldol, Halidol) seems better tolerated but less studied. Gabapentin may increase the release of GABA which would lower diaphragmatic excitability. It has no serious side effects and is well tolerated.  But the studies that it works are almost non existent. PPIs may reduce GERD and could theoretically work.  Baclofen is now the drug of choice.  It can cause dizziness, and ataxia.   How it became the drug of choice –I am not sure- could be this is for chronic hiccups in an office setting.. Dexamethasone will help in AIDS related leukoencephalopathy.  (Can Fam Phys 57(6)672). If your hospital administrator has this, try sneaking up behind him and screaming "boo".  Then let me know if you need a new job.
23)    Honey –which we mentioned last month as being a possibly good therapy for cough- is actually been used extensively in the treatment of wounds and burns. This review showed that honey has many attractive properties but it isn't clear how it works for wounds. It does inhibit inflammation (not sure that is a good thing) it also has anti bacterial effects against such bad boys like E Coli, Pseudomonas   S Aureaus and Acinetobacter.  While the evidence is very promising for all sorts of wounds, the actual evidence has not been so robust.  Surrogate markers, different formulations, animal studies, all plague definitive answers, although burns show the best results.  Lower extremity ulcers have good studies but mixed results, and the big one- diabetic ulcers have very little evidence. Wound botulism does not seem to be a problem, although most studies use sterile honey. (Am J Clin Derm 12(3)181).  Honey may also work by keeping wounds moist which helps wound healing.  It is also cheap, and your dog with MRSA, might enjoy licking your leg.
24)   
We got letters. Yoav Aronson, a cardiologist at my hospital has this to say on vitamin D Although I usually don't reply to authors and editors, I have a Pavlovian reflex whenever I see vitamin D discussed.
There is a study done in our hospital, with more-or-less the same results as the ones discussed in your last EMU
http://www.ncbi.nlm.nih.gov/pubmed/22331959 (QJM  Feb 2012)
In this study we checked the outcome for intubated and ventilated patients in the internal wards and the ICU.
Guess what – surprise – vitamin D deficiency was correlated with shorter overall survival.
I think the message is vit D should be given to the entire population, together with statins and maybe Prozac.
I am believer Yoav and started taking those pills again.  The Vitamin D ones, no the Prozac! Dr Shapiro comments on honey as a cough remedy: Point about honey for coughs. Good evidence for its use, but it is not the honey you buy in the store. Unpasteurized honey (you can get it in the health food store) works well. The pasteurization process (standard practice to prevent the crystallization of the honey in the jar), destroys and medicinal properties of the honey. So grandma was on to something, but you need to make sure you're using the same thin she did!
I would like to know just what that stuff is in honey that does help cough and then is destroyed by sterilization. Dr Shapiro was kind enough to give me a reference on honey from the International Journal of Clinical Practice (61(10)1705).  This study quotes very few articles from this century and does not evaluate the evidence nor is the criteria for the review mentioned other than they used search engines on Pub med and Google.  They also only provide 17 references and take a tangent to speak about maggots. I think our reference is a little more objective with the evidence.  Furthermore there is no mention on the use of honey for cough in this study.
 One of our subscribers is Scott Weingardt, the ICU/EM guru (Gosh, Scott, I saw a picture of you and you guys are so young.  I am old enough to be your brother!) We had a nice chat on some relevant subjects. Here is the correspondence. (The red is Scott, the Blue is Chris Nickson). Chris forwarded Yosef's excellent comments below:


Scott did not like sedation without
 paralysis for intubation, but many of us do not have the video laryngoscopes he has.  I use sedation with sux once I am close to the cords and then shoot it in.

That is an interesting twist, Paul Mayo (My debate partner on the EMCrit paralytic debate) sheepishly admitted that he does similar when he can't get through adducted cords.
It is essentially the same as a gas induction if the tube won't sink - increase the sedation, or give sux/ parayltic (good view, but cords clashing like the Cyanean Rocks - watch Jason and the Argonauts for the reference), or use everyone's favourite weapon in the airway arsenal - the bougie.


He also likes propofol instead of etomidate for sedation only intubations but doesn't say why ( adrenals?)
Reason is simply the intubating conditions. the NEAR database results for etomidate vs. propofol or thipental show a lower success rate, only explanation is less muscle relaxation. The studies that looked at etomidate-alone intubation showed much lower percentage success compared to the propofol studies. Most of these studies are in the debate video. This is not even mentioning the misery of trying to intubate the 30% of the folks who get a myoclonic response. Can you intubate with etomidate alone?--Absolutely!, just at a lower success rate than with propofol/fentanyl
I've been meaning to do a literature search on this for ages, but my feeling is that thiopentone seems to have a more reliable dose-response relationship in the real world than propofol. With propofol some people are asleep with 60mg, others it takes 160mg... We don't have etomidate in Australia so I can't comment.

He also said that we should try awake intubation with ketamine, but patients who are breathing fast  and are given ketamine- you never get the tube through- since they are breathing so fast.  I have tried it many times and end up with the tube just sitting on the cords.


Yep, you need to use a bougie for these folks, very hard to pass a tube in the tachypneic patients. Once the bougie is in, if you are having trouble passing the tube, give a squirt of propofol or sux.

I'm still yet to do an awake fibreoptic intubation with a video laryngoscope, but using a flexible bronchoscope the technique is much the same - scope through the cords, sedate/ paralyse, then advance the tube.

On a side note - who invented the bougie? The greatest thing ever!
Actually Chris, the bougie's official name is the Eschmann Bougie, so I imagine he was the inventor
Scott corrected me that Eschmann was the company that produced the product by MacIntosh- the curved blade guy actually invented it. See http://en.wikipedia.org/wiki/History_of_tracheal_intubation


25)    Lastly was great seeing our roundtable discussant Zach Kassuto at the IAEM Scientific Assembly from Drexel University of Medicine (he is not a Dragon fan) and Anna Coban from Poland.
26)    And yes, that is Sylvester Stallone playing Rambo, and Efram Zimbalist Junior said that line every week on the TV series FBI. (see #19 above)



EMU LOOKS AT: Jiggling and Giggling
 The first essay is really just the second part of last's month's essay – this time hyperkinetic disorders which are really not usually emergencies but they are seen and FPs need to know this. The source for this essay is the  Arch Neuro 68(6) 719).
1)    Chorea is "involuntary irregular purposeless movements that flow one into another." This is not that clear to me.  Here is an image,   which may help- a video link would be http://www.youtube.com/watch?v=OveGZdZ_sVs or search on youtube for chorea.
2)    The onset is usually acute and perhaps the most common childhood chorea is Sydenham chorea.  This is a manifestation of rheumatic fever and is actually pathognomic for the disease.  Associated symptoms include obsessions, emotional lability, and hand weakness.  Symptoms usually start 1-6 months after strep throat, so you have to ask that question.  There is no good research on the optimal treatment if any is necessary, but carbamazine and dopamine blockers may be helpful.  There is also a chorea in pregnancy.  Often it is accompanied by dysarthria.  It needs no treatment and usually resolves after birth or in the third trimester.  APLA can also be a cause and is actually the most common cause in the industrialized world.
3)    Hemiballism.  This is larger amplitude flinging movements however the difference between this and chorea are pretty arbitrary.  The most common cause remains stroke but non ketotic hyperglycemic state is the second most common cause.  This will get better over time, but again dopamine receptor blockers should be used to treat here.
4)     Myoclonus. This is sudden brief shock like movements. Causes are very varied and include toxic metabolic, cerebral anoxia and of course NMS and Serotonin syndrome which we discussed last month.  Other less commonly known causes includes coke, amphetamines, LSD and ecstasy.  Hepatic and uremic encephalopathies also are causes. There is a concept of myclonus status epilecticus with a very poor prognosis.  Treatments for myclonus include clonezpam, primidone and valproate.
5)    Tics are well known to us all.  They are brief and paroxysmal but can sometimes be vocalizations.  They tend to wax and wane, but are exacerbated by fatigue, stress, infection and of course medications,  Neuroleptics and clonidine work well.
6)    Dystonia.  There is dystonic storm or status dystonicus.  Most commonly this is caused by medication changes, infection or trauma.  They also need dopamine receptor blockers. In addition you can use anticholinergics, benzos and extreme cases may need general anesthesia or paralysis.  Oral agents rarely work here so IV agents given under ICU observation are the way to go here. Acute dystonia is often seen after exposure to dopamine receptor blockers usually as you know to neuroleptics or anti emetics.  Actually, dystonia is less common than Tardive or drug induced Parkinsonism, but this differentiation should be obvious in the ED.  Acute dystonias are acute, the others less so. Dystonia is more common in young men, the others in elderly.  In the USA they use Benadryl and Cogentin for this problem; in Israel we do not have these medications. While beperiden and trihexyphenidyl work well, they are oral agents that take time to work, so we usually give Phenergan (promethazine) in the ED.
7)    Torticollis – I am not sure why this is consider a  movement disorder, but this can be caused by posterior fossa tumors or infections like neck abscesses, mastoiditis and pharyngitis and is termed Grisel syndrome.  They say to do a CT but let me expand on this a little.  Bad causes to also consider  as well are epidural hematoma (spinal), spinal abscess, epiglottis. But also- URI, tonsillitis, sinusitis and otitis media.
 
Purim is the Jewish holiday of inanity.  We use this seasonal opportunity to take a break from seriousness to look at the looniest articles of the past year.  If you are old enough to remember Dr. Demento with his weird musical collection - I also have weirdness collection- i.e. articles going back to 1987 that question why people go to such extents to publish. Those who want to go back in history- let me know will give you some of my old issues.
1)    Reproduction is common enough and responsible for most of the pregnancies worldwide. However it is a delicate subject and I want to keep this a family periodical so we will just say that if your wife has been forgetting your close times together (and whose wife doesn't?) then see: (Brit Journ Hosp Med 72(5)292).  If she is still using the old line "Not tonight I have a headache" there might be some good reason she is saying that. See (Cephalagia 30(11)1329). Is your hearing going? See (Laryngoscope 121(5)1049).
2)    Recently there was uproar in Israel about the separation of males and females on buses.  However this is not an Israeli problem only.  Indeed there is a nursery in a large teaching hospital that placed a placard saying that despite the law in Great Britain that requires gender separation in the hospital, in the nursery they will have boys and girls next to each other in adjacent cots. Unless of course one of them complains.  Excuse me for saying this, but a country that gave us Prince Charles is concerned about separation of the sexes??? (BMJ 2011:343:d7451)
3)    Gosh those orthopedists- they come up with such solid research ideas.  Let us immobilize your arm and than see if it effects your driving.  I do not want to shock you with the results, but yes, it did.   J Bone Joint Surg Am 92(13)2263.  Had they done this study in Israel or in Italy – how would they have known that people drove worse when their arm was immobilized?  When are the ophthalmologists going to do a similar study?
4)     And then there those Gastro people who I would never suspect as being the most anal of physicians, but indeed they are doing colonscopies more often than they should, and according to this article the reason these elderly folks are getting more colonscopies is because they go to high volume colonscopists. (Arch Int Med 171(15)1335). To put it in other words- your hindquarters are putting some GI's kid though college.
5)    Rick Bukata's Emergency Medicine Abstracts is one of my favorite EM publications and it is what got me started on casing the literature. He writes an essay every month and he brought a wonderful case of bureaucracy. There was this ophthalmologist who was blind – legally speaking but he could operate on eyes with a special microscope.  (I am not sure who would go for an operation by a blind ophthalmologist). He had a Seeing Eye dog that brought him to the OR. He then filed suit against the hospital under the Disabilities Act because the hospital would not allow his Seeing Eye dog into the operating room.  He won and the hospital not only had to allow the dog in, but had to provide the dog with little booties and a sterile cape.  The hospital was then fined by the department of health for allowing a dog into the operating room. Now, can the dog do radial keratotomy? 
6)    Many of you have heard about this article but it has got to be one of the oddest ones of the year.  They had two tox cases in Iran where patients took Aluminum Phosphide. This material when combined with the HCl in the stomach can cause the patients to spontaneously ignite. (JEM 40(2)181) Now my question –when the patients arrest, do you shock them? BOOM
7)    OK Let us take a time out for the titles of the year:
a)    What's Shaking in the ICU? The Differential Diagnosis of Seizure in the ICU (Epilepsia 51(11)2338)
b)    Getting Urine to the Lab-Thinking outside of the Specimen Cup (Kidney Int'l 79(3)145)
c)    Dysfunctional Women Remain Unsexed (BJUI 106:431)
d)    Medicalisation of Ageing: Plastic People (BMJ 340:c3494)
e)    Shift Work, Jet Lag and Female Reproduction(Int J Endo 210:813764
f)    Sexually Transmitted Infections: A Consumer's Guide (MJA Dec 2011)
8)    Now for other departments: Why didn't I think of this? Alcohol hand gel can be a potential fire hazard regardless if you had Aluminum Phosphide for lunch. (J Plastic Recont and Anesth Surg 64:131)
9)    That's yucky department:  Transorbital endotracheal intubation in a case of severe facial trauma. This poor fellow had his face in many pieces after an MVA. He did not live long enough to show this off at cocktail parties (Resuscitaion 82(3)243).
10)    Research that changed my life.  An analysis of how two win the sport of Wife Carrying was studied by the folks that brought you Jeremy Lin-Harvard.  Indeed this Finnish sport is won most often by those who build muscle mass and people from Estonia where carrying your wife is a popular sport, probably more so than the sports mentioned in section 1) above. (MJA 195(11)723) Look what you missed out on by not going to Harvard. Or being Estonian
11)    I got so many more but I am running out of time- let's present them as bullets:
a)    Nonketotic Hyperglycemia related reflex epilectic seizures induced by Mah Jong playing (Epilepsy Behav 19(3)533)
b)    Management of Sword Swallower Injuries (J Laryn Otol 125(2)217)
c)    Sitcom Syncope (Postgrad Med 12296)137)
d)    Pneumoscrotum after blunt chest trauma (Urology 77(1)75)
e)    Fatal Hypernatremia (187) after drinking a large quantity of Japanese Soyu Sauce (J Forensic Legal Med 1892)91)
f)    Electricity and Fishing- a Dangerous Mix (Burns 37:495)
12)    ICD codes can be fun- you think those poor secretaries who doing coding all day are suffering- no siree bob. Code w6162xa- that is getting struck by a duck. However be careful because w6161xa is being bitten by duck (do ducks bite?).  But there are other bite codes like sea lion (w56.11) and macaw (w61.11xa) but this is only on the first encounter- subsequent encounters need different code (w61.11xd).W22.02 is walking into the a lamppost.  Add in XD to that code and that is walking into a lamppost more than one time. Careful- if it was a piece of furniture- that is W01.190D.  Got crushed by furniture? T71.153A. But if you were crushed by a sailboat- that is V91.34XD. Do not forget getting burnt due to water skis – that is V9107XA.  (Medscape Nov 11).
There is no substitute to intoxication for truly appreciating the world's medical literature.