“Do you know the four A’s of being a great emergency physician?” a colleague asks. He just overheard you giving your “It’s a virus” lecture to a twenty-something with a bad URI and no PMD to call her in a useless prescription for Fogmentin or Maxifloxicin.

“What are they?” you respond, certain that the response will be unsavory.

“In decreasing order of importance, they are Availability, Affability, Ability and Antibiotics,” he responds. “Though some would say that antibiotics trumps both ability and affability.” Fifteen minutes later, you break free of the fog surrounding you and go see your next patient, a 35-year-old man with an obviously red and swollen elbow. After asking the typical questions, you surmise that he has had about three days of gradually worsening redness, swelling, pain and “flu like symptoms.” Today he felt feverish, so he took his temperature and it was “109.”

“Do you mean a hundred point nine or a hundred and nine point zero,” you ask, hoping it will lead to some clarification.

“Yeah,” he answers. You suppress a groan and try again.     

“Was it one hundred point nine, like this?” you say, writing it down on the bed sheet so he can see it.

“I think so,” he answers. You decide that it really doesn’t matter that much and proceed to examine his elbow. The elbow looks red, swollen and angry. He has a lot of pain moving it even a little bit. It doesn’t appear to be the more common septic bursitis so you figure he probably has a septic elbow and needs his joint tapped. You explain the procedure and your additional concerns to him and then go off to order some labs, get consent for the procedure, and ask the nurse to give the fourth “A” of being a great emergency physician. Oh, and some analgesia – your colleague forgot the most important “A”! About 20 minutes later a nurse approaches you and says, “The guy with the elbow, won’t sign the consent. He says he’s afraid and just wants some antibiotics.”

When you re-enter the room, the patient says, “I don’t want to be a pain in the ass, Doc, but can’t you treat me without sticking a needle in there? I don’t think there’s any fluid there. I had a knee infection once and they didn’t have to drain anything; they just gave me the bug juice.”

“How about if we take a look with an ultrasound machine to see if I’m right or not?” you answer.

“OK,” he begrudgingly concedes.

About five minutes later you return with the machine, probe and KY jelly (someone lost the ultrasound gel again). You obtain the following images, plus some comparison images of the normal elbow.

What do you see? Is there a drainable fluid collection? Continue to next page for conclusion.




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