The top medical cases of May 2018

A migrating bullet, the results of the ice cube challenge, and “the magic of the Lewis lead” were among the most engaging cases shared in Figure 1’s medical community in May.

Every day, healthcare professionals in 190 countries use our free app to sharpen their clinical skills. Every month, we compile the cases they found most engaging. We calculate this based on:

Community Metrics: The number of times these cases were viewed, discussed, and shared by the more than 2M healthcare professionals on the platform.

Clinical Value: The quality, complexity, and educational merit of our top cases, as assessed by our medical and community teams.

May’s most engaging cases featured both unusual presentations and valuable discussions. Each offers a unique window on healthcare as it happens.

1.  The ice cube challenge.

An 11-year-old female with no previous medical history presents to her family doctor with two lesions on her arm. Her doctor shares the case on Figure 1, saying, “This lesion has been there for 3 days, new one popped up today. Blister formed spontaneously; negative Nikolsky’s sign. Both are mildly indurated and mildly tender. Any takers?”

A dermatologist offered up this suggestion:

Newest video trend… placing salt then ice cube on the arm. Result can be as significant as third degree burns! Looks like they tried it once, then on the second attempt left it on long enough to cause dermal burn.

The family doctor returned to say this was in fact correct, responding that:

Upon further interview, the patient admitted to the ice cube challenge. They are both on the non-dominant side, a solid piece of history for self-inflicted wounds. No reasonable suspicion of abuse or depression.

2. “The magic of the Lewis lead”

Changing the configuration of ECG leads on a patient can enhance the detection of atrial activity in arrhythmias. One such configuration is referred to as the Lewis lead, and in this pair of cases, a paramedic demonstrates how the different placement of electrodes offers more clinical insight.

The paramedic who shared this ECG explained it as follows:

The only thing you are getting out of a Lewis lead is either a hidden atrial activity that you never saw or a suspected atrial activity that is now more clear. Atrial rate in atrial flutter is usually 300 bpm but it’s possible for the rate to be 250 bpm to 350 bpm.

And a registered nurse added:

So Lewis leads are most beneficial for atrial flutters without clear F-waves. Essentially, it is a clearer view of the atria. In 2:1 conduction it is common to have only a QRS and a T-wave, with limited evidence of atrial activity. In these cases, Lewis leads are beneficial, but can be used to help to evaluate atrial activity whenever it is in question.

3. A neurosurgeon at the top of her game

4. Bullet embolism

“Last night my patient was shot in the leg and exploratory surgery was done to find the bullet,” a registered nurse reported in this text case.

“The trauma surgeon couldn’t find the bullet, so the patient was taken for a full body CT scan. The bullet was found up close to the right atrium. The bullet hitched a ride from the iliac vein up to the heart. Cardiothoracic surgery got involved and retrieved the bullet. Patient is still intubated but following simple commands and moving all extremities. Has anyone ever heard of this occurring? Has this ever happened in your hospital?”

Several healthcare professionals shared their experiences:

“I have - with buckshot, but not a single bullet,” said one dermatologist.“Yes it was a Kirschner wire [used to repair a] clavicular fracture 20 years before. Patient has MI [myocardial infarction] symptoms and during coronary angiography  the wire’s found in the right ventricle,” said a vascular surgeon, who shared this journal article on the phenomenon.“The most famous case in the US was former VP Dick Cheney’s friend, who he accidentally shot while they were hunting,” a registered nurse said. “Shotgun pellet traveled to one of his coronaries, causing a ‘mechanical’ MI! I’ve had two patients with serious bullet migrations.”

5. Lyme Disease season

This month, the Centers for Disease Control and Prevention (CDC) issued its most strongly worded warning yet about the dangers of Lyme disease. A recent case shared by an infectious disease specialist shows both the initial presentation and early results of antibiotic treatment. “A 53-year-old man presented to my office because of skin changes in the right part of the trunk. Everything started 4-5 days ago when he noticed a “pimple” on his  abdomen which was not painful, but he was feeling tingling,” the physician reported. “15 days previously he was on the mountain but he does not recall any insect bite or similar encounter.”

The physician prescribed a course of doxycycline, requested that the patient attend in 7 days for a follow-up, and  made a referral to a dermatologist. After the follow-up, the physician updated the case:

“The laboratory work-up showed normal CBC and CRP. I advised continuation of therapy for 21 days under suspicion of first stage of Lyme disease.”

The CDC shares advisories on Figure 1 from their account @CDCtravel. They remind healthcare professionals to “Always ask patients about upcoming travel plans, as well as recent travel.”