Welcome to Talk EM, brought to you by the Emergency Medicine Institute, where our whole goal is promoting medical excellence. Our focus is on advanced practitioners of emergency medicine, nurse practitioners and physicians who work in the field of taking care of people who are truly sick. We discuss the issues that are pertinent to us in clinical practice. Welcome.
I feel like I’m back at my job. When I was going through college I was a karaoke DJ taking requests and I will never forget the lady who came up every single week; she traumatized me. She would sing the song Grandpa and she had kind of a hair lip, a speech impediment, and she would do it every single week. I’m traumatized to this day by that song.
I was messaged on Facebook and someone said, “John, could you help me understand meningitis, could you help me understand the work up of meningitis?” I’d be glad to do that.
A Story About Meningitis
Now, to tell you about meningitis, I will never forget this girl and she was 22 years old. I took care of her about five years ago, Niagara Falls Memorial Hospital. It was flu and cold season but I had a lady came in with a headache, neck pain, belly pain, malaise and a vaginal abscess. She had all this different stuff going on and initial triage note, I couldn’t make any sense of what was going on here.
So I did what any good instructor would do, I sent a student, “Go see this women will you?” Fine; they go in to see this patient and the student comes out and it was typically a pretty good student. Where normally, I know a good student because they make me feel like I know the patient. This student was pretty good but I still had no idea what was going on. When I walked in the room to see this patient, I remember she was facing away from me and she was kind of curled up in a fetal position, she had a gown on, no blanket and she was laying on the gurney and I remember kind of saying, “Hey, look, sit up so I can talk to you.” Kind of being a little firm with her because it was a really busy ER shift. She sits up but as she sat up, her gown fell off. Her breasts were exposed and she didn’t flinch to cover herself up and I’m like, “This is not normal; something’s wrong.” All of a sudden, I was drawn in, going, “My spidey senses are firing off.”
She gives me a story that doesn’t really make much sense. She doesn’t have meningismus, her belly’s soft, she has a vaginal abscess. It’s in the right inguinal area, it was about the size of a mothball, not quite a golf ball and she said she had it a month and an abscess for a month should make you go, “Could it be a lymph node?” But it was tender and I was really pretty sure it was indeed an abscess. So I know she’s sick but I don’t know primarily what it is yet. Her vital signs didn’t really scream at me that she was septic, so I started this work up. Let me just do a chest x-ray, urine, pregnancy, some abdominal labs and I’ll eventually ID this abscess.
I had a surgeon that came through and he and I are friends, he’s been a 40-year plastic surgeon and if I have abscesses I let him drain them. Not that I’m not capable and very qualified to do it, but he gets paid a lot of money to do it so if he’s there, I’ll throw them to him. He has done a lot of favors for me so I said, “Dr. Doldan do you want to come do this abscess?” He goes and does the abscess and he comes back to the nurses station 15 minutes later, “Where’s John at? Where’s John? John?” I’m like, “Dr. Doldan I’m right here.” He goes, “That girl’s sick.” I’m like, “I know she’s sick, I feel it too.”
Because all the labs were coming back normal, her radiograph was negative, urine was clean and I did a pelvic exam that was unremarkable, he said, “John, I’d scan her chest and her belly, something’s wrong with her.” I scanned her chest and her belly, still everything was okay, I couldn’t figure it out.
I finally went to my supervising doc at the time, his name was Jerry Gorman. He’s a physician’s physician, just a really good doc and a good leader. I went to him. And this is a mistake that a lot of advanced practitioners make, especially the PAs that I talk to in conferences. They will want to talk to a doc about a patient but really feel confused and they’ll start with a SOAP note. They’ll kind of go, “Hey I’ve got this patient here and da, da, da…” They’ll run it by the doc in hopes that the doc will say, “Hey let me come see the patient with you.” It’s an undercurrent but it’s not overtly said and then when the doc doesn’t immediately come and see the patient, at times PAs, probably nurse practitioners as well, feel like, “Come on, I kind of wanted you to see them with me.” They feel a little bit lost.
I cannot stress this to you enough and I’ve talked a lot about it on our podcasts in past episodes. If you’re an advanced practitioner, even if you’re a physician, I don’t care who you are, if you’re not comfortable you don’t give a SOAP note, you give them an APSOP note, AP, give the assessment and plan first. The assessment with is, “I’ve got a patient I’m uncomfortable with and the plan is you’re coming to see them with me.” That exactly what I did with Dr. Gorman. I said, “Dr. Gorman, I’ve got a patient I’m uncomfortable with, I need you to come see them with me.”
He came with me and I’m talking to him and giving him the scoop. This is how our mind works sometimes; when you talk something out without bias the answers become self-evident. In my experience, that’s the beauty of journaling. When you journal, it really puts your thoughts down on paper and the answers become self-evident. I go through five or six journals a year, it’s an incredibly important part of my business life, or how I run my life.
Well, as I’m telling Dr. Gorman what’s going on, the words don’t come out of my mouth before it finally hits me. He says it, “John she needs an LP.” But I didn’t even need him to say it because I talked it out; she needs to be tapped. So I did an LP and damn sure, she was meningitis. She was meningitis and we think probably she seeded her bloodstream and her cerebral spinal fluid from that abscess. She was put on 2 grams of ceftriaxone and 1 gram of vancomycin. I put some acyclovir on board because her chemistry was more suggestive of a non-bacterial infection but that’s neither here nor there. She was admitted.
The Work Up of Meningitis
First and foremost, you have to walk into a room and get a feel for the patient in correlation with vital signs. Now we just did a video on vital signs. Go back and revisit that if you haven’t because vital signs are a secret weapon. When someone is septic, there’ll be footprints of that. There’s normal footprints of that in almost everybody, whether it’s a child or an adult or geriatric, there’s almost always footprints of this infection. It could be febrile or hypothermic. Normally tachycardia, if they’re hypotensive, they’ve gone to a different level, they’re really sick.
I really look at that respiratory rate and, I cannot stress this enough, no respiratory rate is valid unless you take it yourself. Respiratory rates are the most unreliable vital sign, so you don’t count on a respiratory rate unless you check it yourself. Now why is the respiratory rate so important? It’s so important to me because if I have someone who is septic, they’re going to be breathing fast. They’re potentially going to be Kussmaling in their respirations. Now how is that relevant? If someone’s Kussmaling in their breathing, that’s a metabolic acidosis.
It really was a big passion of mine teaching lab medicine and helping people understand an acid base, my experience is that’s a real nebulous, confusing kind of thing for a lot of people. It sure was for me when I got into hospital medicine and I had to cover a respiratory wing. I would take care of super sick people but I felt really poorly trained on blood gases.
So I have a system, a system that goes into how to assess blood gases. Now when you’ve somebody who’s in a metabolic acidosis, they have some funky acid in their body and therefore that’s buffering bicarb and then they have too much carbon dioxide relative to the bicarb. So the bicarb drops, now they have too much carbon dioxide and carbon dioxide is an acid so they’re going to try to clear that acid so they’re going to be tachypneic. That’s why, when working up a septic patient, you have to look at that respiratory rate. I want to look at their respiratory rate; I want to look at their other vital signs.
One of the things about being an entrepreneur, I’ll openly admit that I am not great at financial statements. I’m just not good at how they correlate with each other but I’m working on it. It’s my goal to slay that in 2018. You almost have to look at vital signs that way in clinical correlation. How do they correlate with the patient that is in front of you? When I walk into a patient’s room and my concern is infectious disease, I’ve got to look for it.
Always, your history will guide you. If they’re coughing, you have an idea. If their belly hurts, you have an idea. If they’re peeing a lot and it burns when they urinate, that gives you an idea. What about the black swan, like the thing? I don’t know; it’s like veterinary medicine, they come in, “Hey the person’s not acting right.” When a geriatric mental patient comes in, you’ve got to be a really good clinician.
Wind and Water
Now there’s five body compartments that I look at, always first wind and water, wind and water, wind and water. That’s chest x-ray and a UA. Now caveats of the chest radiograph. Understand that too often, we get portable chest radiographs and I believe that’s only about 85% as good as if you get a two view. If the patient’s stable, send them over for a two view, PA and lateral, radiograph. Remember, you can’t falsely have a negative chest radiograph and still have pneumonia in two circumstances. One is if they’re dehydrated. If they’re dehydrated, you can have a pneumonia in their lung, yet not see it. Second thing is that a pneumonia can hide behind the heart, that’s called the lingula. If you don’t have a lateral radiograph, you cannot see that.
Urine analysis, cath them as often as you can, if you have a reliable patient that can pee for you, that’s beautiful. Make sure they clean themselves off well, because if you have a lot of epithelial cells it’ll really make that urine not valid. So you take wind and water.
Brain and Belly
Next, I’m going to do the two Bs, brain and belly, brain and belly, brain and belly. So brain is, do they have meningitis? Do they have meningusmus? Do they have a Brudzinski sign or Kerning sign or do they just have a really tender neck? I was in Madagascar just about 20 months ago and I had an interpreter, a lady came in she said she had a stiff neck and I said, “Oh, look out the window.” She shifted her whole shoulders. “Look at the ceiling.” She wasn’t moving her neck; I was very sure she had a viral meningitis. How do I know it wasn’t bacterial? Well she had it for five days and if she had bacterial meningitis she would have been dead by then. So I want document and I want you to, you have to, document supple neck and no headache. Those are absolute keys to the meningitis workup.
Belly, just know that if you’re going to examine the belly, make sure you know the three major physical exam findings. You have guarding, rigidity and rebound. You have to know what those are. Remember that guarding is a voluntary response to palpation. It could either be because they’re ticklish or pain response and it’s non specific. Ladies, if you want to know what guarding feels like, go up to a guy that you kind of know but don’t know really well and stand a little closer to him that you normally do and at a spontaneous time, reach up and grab his bicep and don’t let go. Just squeeze it. We guys cannot tolerate a woman grabbing our bicep, we will flex. You grab my bicep, I’m going to flex. I’ll show you what I got. That’s guarding, it’s a voluntary response. Rigidity of the peritoneum is tight and can’t relax, that’s a sign of peritonitis. Rebound kind of speaks for itself. It means the inflamed peritoneum is touching an inflamed organ and that suggests peritonitis as well.
Now last one is skin. Make sure you roll your patient, really look them over head to toe. Make sure it’s not a cellulitis. Now, “Are there any other places that you can have an infection John?” There are, but you need to start this way. You can’t have someone who’s got endocarditis, look for the features of endocarditis like the rough spots in the retina and look at their hands for splinter hemorrhages or Osler’s nodes, Janesway’s lesions. If you have someone with ascites, they can get spontaneous bacterial peritonitis so they have a big belly, typically from portal hypertension either from cirrhosis or hepatitis; you may need to do paracentesis to look at the fluid.
When it comes to meningitis, you can’t rule out meningitis until you tap them. You need an LP and to my advanced practitioner colleagues out there, I promise you something, LPs aren’t as hard as you think. They’re just not as difficult as you think. You just have to get into a situation where you practice them a few times and I promise, they’re not that hard. If you ever come to one of our emergency medicine conferences, we don’t do the procedures as much but grab me and I’ll show you how to do one in a break; it really isn’t that hard. I used to think it was this really mystic, scary technique. It’s not that bad. It’s a little more complicated than a blood draw but not by much. You just have to really focus on anatomy. The key thing I would show you is how to make sure the anatomy is right and then if you miss on your first attempt, how to get it on the second attempt.
Now what are you looking for? The optimal thing is going to be a culture and sensitivity but that takes a long time. I immediately want a gram stain back to show me what shape the germs are in there. Do I see bacteria and if so, what kind? Is it gram-positive diplococci suggesting strep pneumonia, gram-negative diplococci, that’s neisseria meningitis? That’s a really bad meningitis; it’s highly contagious. Or, could it be a viral meningitis? And that’s been the most common thing I’ve seen, where they don’t have a positive gram stain. They have more white blood cells than there should be there. Now the way I think about it is if you have a germ in the cerebral spinal fluid, it’s going to eat the sugar and then it’s going to poop out protein, so the chemisty of someone with meningitis is low glucose, high protein. You’ll correlate that clinically and you’ve always got to think it’s bacterial until proven otherwise. It’s 2 grams ceftriaxone and 1 gram of vancomycin. Immediately then you can consider acyclovir, remember that an HIV positive patient, that opens up a whole new ball of wax. You’ve got to think things like Indian ink, think cryptococcus and all sorts of other things.
Now, here’s a question that I’m asked many times at conferences. Should you do an LP without a CAT scan? Now, if they have no signs of increased intracranial pressure, I feel it’s safe to do. What kind of signs? If they don’t have altered mental status, papilledema, a normal focal neurological exam, I feel it’s pretty safe and I have done it before. For anybody out there who’s got a difference of opinion, please share that here; I’m all for that. I hope that I’m a kind of instructor teaching board review content or emergency medicine, urgent care that is never above challenge. I’m just a PA like you guys are, trying to get by in life and practice medicine and hopefully share a few points. So if you have any evidence based recommendations about when you shouldn’t do an LP without a CAT scan, I’d be very open to hearing about it.
In conclusion, there are three headaches that you absolutely cannot miss. If you miss a migraine headache, I don’t care, there’s not long-standing sequelae, if you’ve missed a cluster, sinusitis, these are the things you don’t want to, but they don’t have immediate really bad sequelae. You cannot miss subarachnoid, you can’t miss temporal arteritis and you can’t miss meningitis.
If you don’t know how to do LPs, it’s going to really limit you in your diagnostic ability. If you can do an LP, it is so reassuring to someone with bad headaches and someone with a potential infectious disease, you take meningitis and subarachnoid off the table. I think it’s an essential skill and the squeaky wheel gets the oil. If you work in a place that does do a number of work ups for headache, just tell somebody, “Hey, I want to learn LPs” and you could probably get them signed off pretty quickly. I had the privilege of working in a regional stroke center where we needed LPs all the time and I just started tapping people left and right and now I feel comfortable with it.
Meningitis is a high-risk, can’t miss disease with bad sequelae, so you can never miss it. With a pediatric exam, remember you always have to document supple neck, supple neck, supple neck, supple neck. “Neck is free moving,” that’s got to be in 100% of your charts with a kid that comes in with any infectious problem. It’s kind of like someone with back pain. You’d better document they’re ambulating well, unassisted, they have no saddle anesthesia and they have no bowel or bladder incontinence or retention. You’ve got to protect yourself on every single back pain chart for cauda equina and every single kid, you’d better protect yourself against meningitis. I’ve done my share of medical legal work, I do medical legal lecturing and we have a medical legal CME on a performance improvement basis, which I’m very proud of. So I like sharing with people how to stay out of trouble and that’s a big part of our emergency medicine curriculum.
Meningitis, think about it with headache, neck pain or fever of unknown origin. LP is going be your definitive way to diagnose it and from that, you’ll get your culture sensitivity.
I hope this is helpful to you. Can you do me a favor? If you find these podcasts and blog posts helpful, share them with other people because the more people that listen, the more we know we can make an impact and that drives me to keep putting out this content.
What other topics do you want? Please post comments, email me, or leave a message on Facebook. If I don’t know the topic well enough to speak on it, I’ll find somebody. I’ll do a podcast with somebody who knows, or I’ll help you research it, or I’ll research it myself because I’m a lifelong learner.