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 Contributors
Nicole A. Bonk, MD
Assistant Professor (CHS)
Department of Family Medicine and Community Health
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Gastrointestinal Bleeding

Shannon M. Burke, MD
Resident, Class of 2021
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Fever

Lauren J. Curato, DO, FACEP

Assistant Professor
Department of Emergency Medicine
Columbia University Vagelos College of Physicians and Surgeons
New York-Presbyterian Hospital
New York, New York
Chest Pain and Cardiac Dysrhythmias

Bram A. Dolcourt, MD
Associate Residency Program Director
Sinai-Grace Hospital, Detroit Medical Center
Assistant Professor
Department of Emergency Medicine
Medical Toxicology
Wayne State University
Detroit, Michigan
Poisoning and Overdose

Joshua Gauger, MD, MBA

Assistant Medical Director
Assistant Professor (CHS)
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Trauma, Shock, and Resuscitation

Jonah Gunalda, MD
Assistant Professor
Clerkship Director
Department of Emergency Medicine
University of Mississippi Medical Center
Jackson, Mississippi
Abdominal and Pelvic Pain
Altered Mental Status
Headache, Weakness, and Dizziness
Professionalism, Ethics, and Communication

Megan E. Gussick, MD
Assistant Professor
Assistant Medical Director, Division of Prehospital Medicine
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Wound Care
Corlin Jewell, MD
Education Fellow
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Environmental Exposures

Aaron Kraut, MD
Residency Program Director
Assistant Professor (CHS)
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Fever

Nicholas A. Kuehnel, MD
Medical Director, Pediatric Emergency Medicine
Assistant Professor (CHS)
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Pediatrics

Michael Mancera, MD, FAEMS

Associate EMS Medical Director
Assistant Professor (CHS)
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Prehospital, Disaster, and Administration

Benjamin R. Parva, MD
Resident, Class of 2022
Department of Emergency Medicine
University of Mississippi Medical Center
Jackson, Mississippi
Altered Mental Status

Kaitlin Ray, MD
Assistant Residency Program Director
Assistant Professor (CHS)
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Musculoskeletal Injuries

Dana Resop, MD
Assistant Director of Clinical Ultrasound
Assistant Professor
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Vaginal Bleeding
Ultrasound in Emergency Medicine

Adam J. Rosh, MD, MS, FACEP

Attending Physician
Department of Emergency Medicine
Southern Ohio Medical Center
Portsmouth, Ohio

Daniel Rutz, MD
Assistant Professor (CHS)
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Eye Pain and Visual Change
Endocrine Emergencies
Psychosocial Disorders
Emerging Infectious Diseases

Jessica Schmidt, MD, MPH

Assistant Ultrasound Director, Medical Student Education
Director of Global Health
Assistant Professor (CHS)
BerbeeWalsh Department of Emergency Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Ultrasound in Emergency Medicine

Lauren M. Titone, MD
Assistant Professor
Department of Emergency Medicine
Columbia University Irving Medical Center
Vagelos College of Physicians and Surgeons
New York, New York
Shortness of Breath
 Contents
Introduction
Acknowledgments

Chest Pain and Cardiac Dysrhythmias

Questions
Answers

Shortness of Breath
Questions
Answers

Abdominal and Pelvic Pain

Questions
Answers

Trauma, Shock, and Resuscitation

Questions
Answers

Fever
Questions
Answers

Poisoning and Overdose

Questions
Answers
 Altered Mental Status
Questions
Answers

Gastrointestinal Bleeding
Questions
Answers

Musculoskeletal Injuries
Questions
Answers

Headache, Weakness, and Dizziness

Questions
Answers

Pediatrics
Questions
Answers

Vaginal Bleeding
Questions
Answers

Ultrasound in Emergency Medicine

Questions
Answers

Environmental Exposures
Questions
Answers
 Eye Pain and Visual Change
Questions
Answers

Prehospital, Disaster, and Administration

Questions
Answers

Wound Care
Questions
Answers

Endocrine Emergencies
Questions
Answers

Psychosocial Disorders
Questions
Answers

Emerging Infectious Diseases

Questions
Answers

Professionalism, Ethics, and Communication

Questions
Answers

Index
 Introduction
Emergency Medicine: PreTest® Self-Assessment and Review, Fifth
Edition, is intended to provide medical students, as well as house
officers and physicians, with a convenient tool for assessing and
improving their knowledge of emergency medicine. The 570
questions in this book are similar in format and complexity to those
included in step 2 of the United States Medical Licensing
Examination (USMLE). They may also be a useful study tool for step
3, the National Board of Medical Examiners (NBME) Emergency
Medicine and other clerkship examinations.
Each question in this book has a corresponding answer and a
short discussion of various issues raised by the question and its
answer. For multiple-choice questions, the one best response to
each question should be selected. A listing of subject-based
recommended readings follows each chapter.
To simulate the time constraints imposed by the qualifying
examinations for which this book is intended as a practice guide, the
student or physician should allot approximately 1 minute for each
question. After answering all questions in a chapter, as much time as
necessary should be spent reviewing the explanations for each
question at the end of the chapter. Attention should be given to all
explanations, even if the examinee answered the question correctly.
Those seeking more information on a subject should refer to the
recommended reading lists or to other standard texts in emergency
medicine.
 Acknowledgments
A hearty thanks goes out to my family for their love and support,
Danielle, Ruby, Rhys, and especially my parents, Karl and Marcia; the
dedicated medical professionals of the emergency departments at
New York University/Bellevue Hospital, and Wayne State
University/Detroit Receiving Hospital; Catherine Johnson for giving
me this opportunity, and my patients, who put their trust in me, and
teach me something new each day.

Adam J. Rosh

I am forever grateful for the incredible women who shaped my path

in academic medicine: Drs. Gloria Kuhn, Melissa Barton, Michelle
Lall, and Azita Hamedani; the many talented emergency medicine
residents and medical students of both Wayne State University/Sinai-
Grace Hospital and University of Wisconsin for allowing me to be a
part of your education; Adam Rosh and McGraw Hill for this amazing
opportunity; and most of all, my family for loving and supporting me
along the way: especially my husband, Steve, our boys CJ and
Owen, my mom, and my dad.

Ciara J. Barclay-Buchanan
 Chest Pain and Cardiac
Dysrhythmias
Lauren J. Curato, DO, FACEP

Questions
The following scenario applies to questions 1-3.

A 38-year-old woman presents to the emergency department (ED)

with chest pain and mild shortness of breath that began the night
before. She was able to sleep without difficulty, but awoke in the
morning with persistent pain that worsens with a deep breath. Upon
walking up a flight of stairs, she became very short of breath,
prompting her ED visit. On physical exam, she was noted to be
tachycardic and have left calf pain. She has no past medical history
(PMH), but has smoked half pack per day for 15 years and is on an
oral contraceptive.

1. What is the most common electrocardiogram (ECG) finding for

this patient’s diagnosis?
a. S1Q3T3 pattern
b. Atrial fibrillation (AF)
c. Right-axis deviation
d. Right bundle-branch block (RBBB)
e. Sinus tachycardia

2. Which of the following tests is best to confirm the suspected

diagnosis?
a. Brain natriuretic peptide (BNP)
b. Cardiac troponin
c. Chest X-ray (CXR)
d. Computed tomography angiography (CTA) chest
e. D-dimer

3. Which of the following is an indication for the administration of

thrombolytics for this diagnosis?
a. Bilateral proximal clot
b. Hypotension
c. Persistent tachycardia
d. Right atrial dilation
e. Elevated BNP

4. A 70-year-old man with a long history of hypertension presents

to the ED complaining of intermittent palpitations for 1 week. He
denies chest pain, shortness of breath, nausea, and vomiting. He
recalls feeling similar episodes of palpitations a few months ago but
they resolved spontaneously. His blood pressure (BP) is 130/75 mm
Hg, heart rate (HR) is 140 beats/minute, respiratory rate (RR) is 16
breaths/minute, and oxygen saturation is 99% on room air. An ECG
is seen in the figure. Which of the following is the most appropriate
next step in management?

a. Sedate the patient for immediate synchronized cardioversion

with 100 J
b. Prepare patient for emergent cardiac catheterization
c. Administer oral warfarin
d. Administer intravenous (IV) amiodarone
e. Administer IV diltiazem
The following scenario applies to questions 5 and 6.

A 54-year-old woman presents to the ED because of increased

weakness. Her daughter states the patient has been increasingly
tired, occasionally confused, and has not been eating her usual diet
for the past 3 days. The patient has a history of end-stage renal
disease (ESRD) requiring dialysis for the past 5 years. On
examination, the patient is alert and oriented to person only. The
remainder of her examination is normal. An initial 12-lead ECG is
performed as seen in the figure.

5. Which of the following electrolyte abnormalities best explains

these findings?
a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypercalcemia
e. Hyponatremia

6. Which of the following medications is most important to

administer first?
a. Albuterol
b. Calcium gluconate
c. Dextrose
d. Insulin
e. Kayexalate

7. A 29-year-old tall, thin man presents to the ED for shortness of

breath for 2 days. In the ED, he is in no acute distress. His BP is
115/70 mm Hg, HR is 81 beats/minute, RR is 16 breaths/minute,
and oxygen saturation is 98% on room air. Cardiac, lung, and
abdominal examinations are normal. An ECG reveals sinus rhythm at
a rate of 79 beats/minute. A chest radiograph shows a small right-
sided (<10% of the hemithorax) pneumothorax. A repeat CXR 6
hours later reveals a decreased pneumothorax. Which of the
following is the most appropriate next step in management?
a. Discharge the patient with follow-up in 24 hours
b. Perform needle decompression in the second intercostal space,
midclavicular line
c. Insert a 20 F chest tube into right hemithorax
d. Observe for another 6 hours
e. Admit for pleurodesis

8. A 42-year-old man is brought to the ED by emergency medical

services (EMS). He has a history of alcohol use with multiple
presentations for intoxication. Today, the patient complains of acute
onset, persistent chest pain associated with dysphagia, and pain
upon flexing his neck. His BP is 115/70 mm Hg, HR is 101
beats/minute, RR is 18 breaths/minute, and oxygen saturation is
97% on room air. As you listen to his heart, you hear a crunching
sound. His abdomen is soft with mild epigastric tenderness. The ECG
is sinus tachycardia without ST-T–wave abnormalities. On chest
radiograph, you note lateral displacement of the left mediastinal
pleura. What is the most likely diagnosis?
a. Aspiration pneumonia
b. Acute pancreatitis
c. Pericarditis
d. Esophageal perforation
e. Aortic dissection

9. A 65-year-old man with a history of hypertension presents to the

ED with sudden-onset tearing chest pain that radiates to his jaw. His
BP is 205/110 mm Hg, HR is 90 beats/minute, RR is 20
breaths/minute, and oxygen saturation is 97% on room air. He
appears apprehensive. On cardiac examination, you hear a diastolic
murmur at the right sternal border. A CXR reveals a widened
mediastinum. You call for a stat bedside transesophageal
echocardiogram (TEE) which confirms your suspected diagnosis.
Which of the following medications should be administered first in
the treatment of this patient?
a. Amiodarone
b. Esmolol
c. Nicardipine
d. Nifedipine
e. Nitroprusside

10. A 32-year-old woman presents to the ED with a fever of 101°F

over the last 3 days associated with generalized fatigue, myalgias,
and mild shortness of breath that worsens with exertion. On cardiac
exam, you detect a murmur. Her abdomen is soft and nontender
with an enlarged spleen. Skin examination demonstrates track marks
to the antecubital fossa. Chest radiograph reveals multiple patchy
infiltrates in both lung fields. Laboratory results reveal white blood
cells (WBCs) 14,000/μL with 91% neutrophils, hematocrit 33%, and
platelets 250/μL. An ECG reveals sinus rhythm with first-degree
heart block. Which of the following is the most appropriate next step
in management?
a. Diagnose community-acquired pneumonia and discharge with
oral antibiotics and outpatient follow-up
b. Order liver function tests and a Monospot and advise her to
refrain from vigorous activities until cleared
c. Treat with IV antibiotics and admit to the hospital for
community-acquired pneumonia
d. Obtain four sets of blood cultures, order an echocardiogram,
start IV antibiotics, and admit to the hospital for suspected
endocarditis
e. Place the patient on isolation and order three sets of sputum
cultures for AFB, consult infectious disease, and admit to the
hospital for suspected tuberculosis

The following scenario applies to questions 11-13.

A 61-year-old woman was walking to the grocery store when she

started feeling chest pressure in the center of her chest. She became
diaphoretic and felt short of breath. On arrival to the ED by EMS, her
BP is 130/70 mm Hg, HR is 76 beats/minute, and oxygen saturation
is 98% on room air. An ECG is performed as seen in the figure.

11. Which of the following best describes the location of this

patient’s myocardial infarction (MI)?
a. Anteroseptal
b. Anterior
c. Lateral
d. Inferior
e. Posterior

12. Which of the following therapeutic agents has been shown to

independently reduce mortality in the setting of acute MI?
a. Nitroglycerin
b. Aspirin
c. Unfractionated heparin
d. Lidocaine
e. Diltiazem

13. This patient’s ECG demonstrates an ST-segment elevation

myocardial infarction (STEMI). You activate the STEMI team in
anticipation of the patient going to the cardiac catheterization
laboratory for percutaneous coronary intervention (PCI). Which of
the following time intervals is gold standard for “door to balloon”
time in acute STEMI?
a. 45 minutes
b. 60 minutes
c. 75 minutes
d. 90 minutes
e. 120 minutes

14. A 21-year-old woman presents to the ED complaining of light-

headedness. Her symptoms appeared 45 minutes ago. She has no
other symptoms and is not on any medications. She has a medical
history of mitral valve prolapse. Her BP is 105/55 mm Hg and HR is
170 beats/minute. Physical examination is unremarkable. After
administering the appropriate medication, her HR slows down and
her symptoms resolve. You repeat a 12-lead ECG that shows a rate
of 89 beats/minute with a regular rhythm. The PR interval measures
100 milliseconds and there is a slurred upstroke of the QRS complex.
Based on this information, which of the following is the most likely
diagnosis?
a. Ventricular tachycardia
b. Atrial flutter with 3:1 block
c. AF
d. Lown-Ganong-Levine (LGL) syndrome
e. Wolff-Parkinson-White (WPW) syndrome
15. A 65-year-old man presents complaining of chest pain. He was
out to a restaurant having a steak and drinking wine when he
suddenly felt a piece of steak “get stuck” in his chest. He coughed
and then vomited, but it did not resolve the sensation. He attempted
to drink water, but spit it back up. In the ED, he complains of
dysphagia and is occasionally retching. On examination, his BP is
130/80 mm Hg, HR is 75 beats/minute, RR is 16 breaths/minute,
and oxygen saturation is 99% on room air. He appears in no
respiratory distress. CXR is negative for air under the diaphragm.
Which of the following is the most appropriate next step in
management?
a. Administer 1 mg glucagon intravenously while arranging for
endoscopy
b. Administer a meat tenderizer, such as papain, to soften the food
bolus
c. Administer 10 mL syrup of ipecac to induce vomiting and
dislodge the food bolus
d. Perform the Heimlich maneuver until the food dislodges
e. Call surgery consult to prepare for laparotomy

16. A 59-year-old man presents to the ED with left-sided chest

pain and shortness of breath that began 2 hours prior to arrival. He
states the pain is pressure-like and radiates down his left arm. He is
diaphoretic. His BP is 160/80 mm Hg, HR is 86 beats/minute, and RR
is 15 breaths/minute. ECG reveals 2-mm ST-segment elevation in
leads I, aVL, and V3 to V6. Which of the following is an absolute
contraindication to receiving thrombolytic therapy?
a. Systolic blood pressure (SBP) greater than 180 mm Hg
b. Patient takes aspirin daily
c. Total hip replacement 3 months ago
d. Peptic ulcer disease
e. Previous hemorrhagic stroke

17. A 67-year-old woman is brought to the ED by paramedics

complaining of dyspnea, fatigue, and palpitations. Her BP is 80/50
mm Hg, HR is 139 beats/minute, and RR is 20 breaths/minute. Her
skin is cool and she is diaphoretic. Her lung examination reveals
bilateral crackles and she is beginning to have chest pain. Her ECG
shows a narrow complex irregular rhythm with a rate in the 140’s.
Which of the following is the most appropriate immediate treatment
for this patient?
a. Diltiazem
b. Metoprolol
c. Digoxin
d. Coumadin
e. Synchronized cardioversion

The following scenario applies to questions 18 and 19.

A 61-year-old woman with a history of congestive heart failure (CHF)

is at a family picnic when she starts complaining of shortness of
breath. Her daughter brings her to the ED where she is found to
have mild tachypnea, an oxygen saturation of 85% on room air, and
rales halfway up both of her lung fields. Her BP is 185/90 mm Hg
and pulse rate is 101 beats/minute. On examination, her jugular
venous pressure (JVP) is 6 cm above the sternal angle. There is
lower extremity pitting edema.

18. Which of the following is the most appropriate first-line

medication to lower cardiac preload?
a. Metoprolol
b. Morphine sulfate
c. Nitroprusside
d. Nitroglycerin
e. Oxygen

19. You have successfully lowered this patient’s preload; however,

her respiratory status worsens. She develops increased work of
breathing, accessory muscle usage, and is diaphoretic. Which of the
following is the most appropriate next action?
a. Noninvasive positive pressure ventilation
b. Rapid sequence endotracheal intubation
c. High-flow nasal cannula
d. Ketamine infusion
e. Morphine sulfate

20. A 27-year-old otherwise healthy man presents to the ED with a

laceration on his thumb that he sustained while cutting a bagel. You
irrigate and repair the wound and are about to discharge the patient
when he asks you if he can receive an ECG. It is not busy in the ED
so you perform the ECG, as seen in the figure. Which of the
following is the most appropriate next step in management?

(Reproduced, with permission, from Tintinalli J, Kelen G, Stapczynski

J. Emergency Medicine: A Comprehensive Study Guide. New York,
NY: McGraw Hill, 2004:193.)

a. Admit the patient for placement of a pacemaker

b. Admit the patient for a 24-hour observation period
c. Administer aspirin and send cardiac biomarkers
d. Repeat the ECG because of incorrect lead placement
e. Discharge the patient home

The following scenario applies to questions 21 and 22.

A 61-year-old woman with a history of diabetes and hypertension is

brought to the ED by her daughter. The patient started feeling short
of breath approximately 12 hours ago and then noticed a tingling
sensation in the middle of her chest and became diaphoretic. An
ECG reveals ST depression in leads II, III, and aVF. You believe that
the patient had a non–ST-elevation MI (NSTEMI).
21. Which of the following cardiac markers begins to rise within 3
to 6 hours of chest pain onset, peaks at 12 to 24 hours, and returns
to baseline in 7 to 10 days?
a. Myoglobin
b. Creatine kinase (CK)
c. Creatine kinase-MB (CK-MB)
d. Troponin I
e. Lactic dehydrogenase (LDH)

22. If the patient in this scenario is found to have an MI, which of

the following is considered a core measure in management?
a. Administration of anticoagulants
b. Aspirin on arrival
c. β-Blocker administration in the ED
d. Performance of baseline CXR
e. Serial ECGs

23. A 27-year-old man complains of chest palpitations and light-

headedness for the past hour. He has no past medical history and is
not taking any medications. He drinks beer occasionally on the
weekend and does not smoke cigarettes. His BP is 110/65 mm Hg,
HR is 180 beats/minute, and oxygen saturation is 99% on room air.
An ECG reveals a regular rhythm, rate of 180 beats/minute, and QRS
complex of 90 milliseconds. There are no discernable P waves.
Which of the following is the most appropriate medication to treat
this dysrhythmia?
a. Digoxin
b. Lidocaine
c. Amiodarone
d. Adenosine
e. Bretylium

The following scenario applies to questions 24 and 25.

A 70-year-old man presents to the ED with paramedics. The patient
collapsed in the street and bystanders performed cardiopulmonary
resuscitation (CPR). Paramedics found the patient to be in
ventricular fibrillation. They performed CPR and defibrillation
according to ACLS protocols after which they obtained return of
spontaneous circulation and proceeded to intubate the patient.
Initial ED vital signs are BP 85/45 mm Hg, HR 105 beats/minute, and
oxygen saturation 94%. An ECG is shown in the figure.

24. Which coronary artery is most likely occluded?

a. Acute marginal branch
b. Left anterior descending artery
c. Right coronary artery (RCA)
d. Posterior descending artery
e. There is no arterial occlusion; this is hyperkalemia

25. Which of the following is the most appropriate definitive

treatment?
a. IV heparin infusion
b. Electrical cardioversion
c. IV calcium gluconate
d. Thrombolytic therapy
e. Percutaneous angioplasty

26. A 55-year-old man presents to the ED at 2:00 AM with left-

sided chest pain that radiates down his left arm. He takes a β-
blocker for hypertension, a proton-pump inhibitor for
gastroesophageal reflux disease, and a statin for high cholesterol.
He also took sildenafil the previous night for erectile dysfunction. His
BP is 130/70 mm Hg and HR is 77 beats/minute. The patient’s chest
pain has been constant since starting after exertion and you are
concerned for unstable angina. Which of the following medications is
contraindicated in this patient?
a. Aspirin
b. Unfractionated heparin
c. Nitroglycerin
d. Metoprolol
e. Morphine sulfate

27. A 71-year-old man is playing cards with some friends when he

starts to feel a pain in the left side of his chest. The fingers in his left
hand become numb and he feels short of breath. His wife calls the
ambulance and he is brought to the hospital. In the ED, an ECG is
performed. Which of the following best describes the order of ECG
changes seen in an MI?
a. Hyperacute T wave, ST-segment elevation, Q wave
b. Q wave, ST-segment elevation, hyperacute T wave
c. Hyperacute T wave, Q wave, ST-segment elevation
d. ST-segment elevation, Q wave, hyperacute T wave
e. ST-segment elevation, hyperacute T wave, Q wave

The following scenario applies to questions 28 and 29.

A 22-year-old college student went to the health clinic complaining

of a fever over the last 5 days, fatigue, myalgias, and a bout of
vomiting and diarrhea. The clinic doctor diagnosed him with acute
gastroenteritis and told him to drink more fluids. Three days later,
the student presents to the ED complaining of constant substernal
chest pain. He also feels short of breath. His BP is 120/75 mm Hg,
HR is 122 beats/minute, RR is 18 breaths/minute, temperature is
100.9°F, and oxygen saturation is 96% on room air. An ECG is
performed revealing sinus tachycardia. A chest radiograph is
unremarkable. Laboratory tests are normal except for slightly
elevated WBC.

28. Which test will help make the diagnosis in this patient?
a. Erythrocyte sedimentation rate (ESR)
b. Procalcitonin
c. C-reactive protein (CRP)
d. Troponin
e. LDH

29. Which of the following is the most common cause of this

patient’s condition?
a. Streptococcus viridans
b. Influenza A
c. Coxsackie B virus
d. Atherosclerotic disease
e. Cocaine abuse

30. A 23-year-old elementary school teacher is brought to the ED

after collapsing in her classroom. She remembers feeling light-
headed and dizzy and the next thing she remembers is being in an
ambulance. There was no seizure activity. She has no medical
problems and does not take any medications. Her father died of a
“heart problem” at 32 years of age. She does not smoke or use
drugs. BP is 120/70 mm Hg, pulse rate is 71 beats/minute, RR is 14
breaths/minute, and oxygen saturation is 100% on room air. Her
physical examination and laboratory results are all normal. A rhythm
strip is seen in the figure. Which of the following is the most likely
diagnosis?

a. WPW syndrome
b. Long QT syndrome (LQTS)
c. LGL syndrome
d. Complete heart block
e. Atrial flutter

31. A 55-year-old man presents to the ED with chest pain and

shortness of breath. His BP is 76/40 mm Hg, HR is 89 beats/minute,
RR is 28 breaths/minute, and oxygen saturation is 90% on room air.
Physical examination reveals crackles midway up both lung fields
and a new holosystolic murmur that is loudest at the apex and
radiates to the left axilla. ECG reveals ST elevations in the inferior
leads. Chest radiograph shows pulmonary edema with a normal-
sized cardiac silhouette. Which of the following is the most likely
cause of the cardiac murmur?
a. Critical aortic stenosis
b. Papillary muscle rupture
c. Pericardial effusion
d. CHF
e. Aortic dissection

32. An 82-year-old woman is brought to the ED by her daughter

for worsening fatigue, dizziness, and light-headedness. The patient
denies chest pain or shortness of breath. She has not started any
new medications. Her BP is 140/70 mm Hg, HR is 37 beats/minute,
and RR is 15 breaths/minute. An IV is started and blood is drawn. An
ECG is seen in the figure. Which of the following is the most
appropriate next step in management?

(Reproduced, with permission, from Fuster V, et al. Hurst’s The

Heart. New York, NY: McGraw Hill, 2004: 904.)
a. Bed rest for the next 48 hours and follow-up with her primary-
care physician
b. Administer aspirin, order cardiac enzymes, and admit to the
cardiac care unit (CCU)
c. Place a magnet on her chest to turn off her pacemaker
d. Admit for cardiac monitoring and echocardiogram
e. Place on a cardiac monitor, place external pacing pads on the
patient, and admit to the CCU

33. A 19-year-old man is brought to the ED by EMS for an episode

of syncope that occurred during a basketball game. A friend states
that the patient dropped to the ground shortly after scoring a basket
on a fast break. On examination, you note a prominent systolic
ejection murmur along the left sternal border and at the apex. An
ECG reveals left ventricular (LV) hypertrophy, left atrial enlargement,
and septal Q waves. You suspect the diagnosis and ask the patient
to perform the Valsalva maneuver while you auscultate his heart.
Which of the following is most likely to occur to the intensity of the
murmur with this maneuver?
a. Decrease
b. Increase
c. Remain unchanged
d. Disappear
e. The intensity stays the same, but the heart skips a beat

34. A 55-year-old man with hypertension and a one-pack-per-day

smoking history presents to the ED complaining of three episodes of
severe heavy chest pain this morning that radiated to his left
shoulder. In the past, he experienced chest discomfort after walking
20 minutes that resolved with rest. The episodes of chest pain this
morning occurred while he was reading the newspaper. His BP is
155/80 mm Hg, HR is 76 beats/minute, and RR is 15
breaths/minute. He does not have chest pain in the ED. An ECG
reveals sinus rhythm with a rate of 72 beats/minute. Initial troponin
I is negative. Which of the following best describes this patient’s
diagnosis?
a. Variant angina
b. Stable angina
c. Unstable angina
d. NSTEMI
e. STEMI

The following scenario applies to questions 35 and 36.

A 58-year-old man is brought to the ED for an episode of syncope at

dinner. His wife found him suddenly slumping in the chair and losing
consciousness for a minute. The patient recalls having some chest
discomfort and shortness of breath prior to the episode. His rhythm
strip, obtained by EMS, is shown in the following figure.

35. Which of the following best describes these findings?

a. Mobitz type I
b. Mobitz type II
c. First-degree atrioventricular (AV) block
d. Atrial flutter with premature ventricular contractions (PVCs)
e. Sinus bradycardia

36. As you are examining the patient described in the previous

question, he starts to complain of chest discomfort and shortness of
breath and has another syncopal episode. His ECG is shown in the
figure. Which of the following is the most appropriate next step in
management?
a. Call cardiology consult
b. Cardiovert the patient
c. Administer metoprolol
d. Administer amiodarone
e. Apply transcutaneous pacemaker

The following scenario applies to questions 37 and 38.

A 31-year-old kindergarten teacher presents to the ED complaining

substernal chest pain that is sharp in nature. The pain is worse when
she is lying down on the stretcher and improves when she sits up.
She smokes cigarettes occasionally and was told she has borderline
diabetes. She denies any recent surgery or travel. Her BP is 145/85
mm Hg, HR is 99 beats/minute, RR is 18 breaths/minute, and
temperature is 100.6°F. Examination of her chest reveals clear lungs
and a cardiac friction rub. Her abdomen is soft and nontender to
palpation. Her legs are not swollen. Chest radiography and
echocardiography are unremarkable. Her ECG is shown in the figure.

(Reproduced, with permission, from Fuster V, et al. Hurst’s The

Heart. New York, NY: McGraw Hill, 2004: 304.)

37. Which of the following is the most appropriate next step in

management?
a. Order heparin and obtain a CTA to evaluate for a pulmonary
embolism (PE)
b. Prescribe ibuprofen and discharge the patient home
c. Administer aspirin, heparin, clopidogrel, and admit for acute
coronary syndrome (ACS)
d. Administer thrombolytics, if the pain persists
e. Prescribe oral antibiotics and discharge the patient home

38. The same patient returns to the ED 1-week later reporting

shortness of breath and worsening chest pain. She cannot catch her
breath and becomes light-headed with minimal activity. Her vitals
include BP 80/42 mm Hg, HR 124 beats/minute, and RR 24
breaths/minute. She is afebrile. On physical examination, you note
distended neck veins, distant muffled heart sounds, and cool
extremities. Her ECG demonstrates sinus tachycardia with low
voltage throughout all leads. What is the most likely diagnosis?
a. Acute myocarditis
b. Tension pneumothorax
c. Cardiac tamponade
d. Dressler’s syndrome
e. Pleural effusion

39. You are evaluating a 70-year-old man for an ankle sprain.

While in the ED, his automatic implantable cardioverter-defibrillator
(AICD) begins firing. When he is placed on the cardiac monitor, you
note that he is in a sinus rhythm with a rate of 80 beats/minute. You
also obtain a quick point of care metabolic panel and blood gas, both
of which are normal. The AICD continues to fire while the patient is
resting on the stretcher and in sinus rhythm. Which of the following
is the most appropriate next step in management?
a. Send the patient back to the radiology suite for another
radiograph to desensitize his AICD
b. Administer pain medication and wait until the device
representative arrives at the hospital to turn off the AICD
c. Admit the patient to the telemetry unit to monitor his rhythm
and find the cause of his AICD discharge
d. Place a magnet over the AICD generator to inactivate it
e. Make a small incision over his chest wall and remove the AICD
generator and leads
 Chest Pain and Cardiac
Dysrhythmias

Answers
1. The answer is e. The patient most likely has a PE originating
from a thrombus in her left calf. The diagnosis of PE is usually made
with a CTA or less commonly a ventilation-perfusion scan performed
in nuclear medicine. The most common ECG abnormalities in the
setting of PE are sinus tachycardia and nonspecific ST-T–wave
abnormalities. Other ECG abnormalities may be present and
suggestive of PE, but the absence of ECG abnormalities has no
significant predictive value. Moreover, 25% of patients with proven
PE have ECGs that are unchanged from their baseline state.
With a large PE, the right heart becomes strained. Classic ECG
findings of right heart strain and acute cor pulmonale are tall,
peaked P waves in lead II (P pulmonale), right-axis deviation (c),
incomplete or complete right bundle-branch block (d), a S1Q3T3
pattern (a), or AF (b). The finding of S1Q3T3 pattern is nonspecific
and insensitive in the absence of clinical suspicion for PE.
Unfortunately, only 20% of patients with proven PE have any of
these classic ECG abnormalities.

2. The answer is d. CTA is more than 90% sensitive and specific

for diagnosing PE. While all the other answer choices are important
in the work up of a patient with shortness of breath and chest pain,
they will not definitively diagnose PE. The blood tests, BNP (a) and
cardiac troponin (b), are important markers that can help to risk
stratify patients with known PE as these can be released when there
is right ventricular (RV) strain. Patients without RV Strain can be
treated with anticoagulants alone while patients with evidence of RV
strain need to be assessed for thrombolytic therapy. The main
purpose of a CXR (c) in the work up of this patient is to rule out
alternative causes of chest pain and dyspnea. The most common
finding on CXRs in patients with PE is a normal CXR. The D-dimer
(e) is a blood test that measures the presence of the breakdown of
fibrin in an intravascular thrombus. Its concentration varies with clot
burden. The D-dimer is helpful to rule out thrombosis when it is
negative in patients with low pre-test probability; however, a positive
D-dimer is nonspecific (specificity 50-60%) thus further imaging is
required.

3. The answer is b. The use of fibrinolytic therapy in PE is

reserved mostly for patients with massive PE and hemodynamic
collapse. Massive PE is defined as a proximal embolus with
sustained hypotension (SBP < 90 mm Hg for 15 minutes or a 40
mm Hg drop from baseline) or hypotension requiring inotropic
support or any RV strain. Other causes of hypotension must be
excluded. Additionally, patients who lose pulses or suffer from
persistent profound bradycardia also fall into this category.
The use of systemic fibrinolytic therapy in submassive PE is less
clear. Based on the MOPPET (Moderate Pulmonary Embolism Treated
With Thrombolysis) trial in 2013 (1), it appears that the use of
fibrinolytics in this population leads to a reduction in the
development of long-term pulmonary hypertension. Catheter-
directed thrombolytics (if available) may be safer and equally
effective. The definition of submassive PE includes those scenarios
where there is no persistent hypotension of requirement of inotropic
support, but there is evidence of either RV strain [RV dilation on
echocardiogram or CT, RV dysfunction on echocardiogram, elevated
BNP, electrocardiogram (EKG) changes such as new RBBB or
anteroseptal T-wave inversions or ST elevations or depressions] or
myocardial necrosis. The presence of bilateral proximal clot (a)
reflects significant clot burden, but does not guide therapy beyond
traditional anticoagulation. Persistent tachycardia (c) is common in
patients with pulmonary emboli given the additional work required of
the myocardium with increased pulmonary afterload. RV dilation (d)
is a surrogate marker for right heart strain when it is identified on
echocardiography. This also implies some degree of RV dysfunction
supporting the definition of a submassive PE. Elevation of BNP (e) is
seen as a result of myocardial stretch. It is frequently identified in
patients with pulmonary emboli and may be associated with worse
prognosis. Evidence of myocardial necrosis required for the definition
of submassive PE is reflected by a positive troponin.

4. The answer is e. AF is a rhythm disturbance of the atria that

results in irregular and chaotic ventricular conduction. This irregular
electrical activity can lead to reduced cardiac output from a loss of
coordinated atrial contractions and a rapid ventricular rate, both of
which may limit diastolic filling and stroke volume of the ventricles.
AF may be chronic or paroxysmal (sudden onset lasting minutes to
days). On the ECG, fibrillatory waves are accompanied by an
irregular QRS pattern. The main ED treatment for stable AF is rate
control. This can be accomplished by many agents, but the agent
most commonly used is diltiazem, a calcium channel blocker (CCB)
with excellent AV nodal blocking effects.
If a patient is unstable, he should be immediately cardioverted
(a). However, this patient is stable and asymptomatic; therefore, the
goal in the ED is rate control. Catheterization (b) would be correct if
the patient exhibited ST-segment elevations on the ECG. If the
patient is in AF for more than 48 hours, he needs to be
anticoagulated (c) prior to cardioversion because of the risk of atrial
thrombus. In general, a patient with stable AF undergoes an
echocardiogram to evaluate for thrombus. If there is a thrombus
present, patients are placed on warfarin for 2 to 3 weeks and
cardioversion takes place when their international normalized ratio
(INR) is therapeutic. If no clot is seen on echocardiogram, heparin is
administered and cardioversion can take place immediately. Long-
term anticoagulation is usually completed with warfarin or the new
anticoagulant agents. Amiodarone (d) is an antidysrhythmic agent
that sometimes achieves rate control in AF; however, it is not a first-
line agent and in the ED the primary goal is rate control, not rhythm
control.

5. The answer is b. Patients with ESRD, who require dialysis, are

prone to electrolyte disturbances. This patient’s clinical picture is
consistent with hyperkalemia (normal potassium is 3.5-5 mmol/L).
The ECG can provide valuable clues to the presence of hyperkalemia.
As potassium levels rise, peaked T waves are the first
characteristic manifestation. Further rises are associated with
progressive ECG changes, including loss of P waves and
widening of the QRS complex. Eventually, the QRS widens
further and assumes a sine-wave pattern, followed by ventricular
fibrillation or asystole. ECG findings of hyperkalemia are very
specific, but a screening ECG is not sensitive enough to rule out
hyperkalemia.
ECG manifestations of hypokalemia (a) include flattening of T
waves, ST-segment depression, and U waves. Hypocalcemia (c)
manifests as QT prolongation, whereas hypercalcemia (d) manifests
as shortening of the QT interval. There are no classic ECG findings
with hyponatremia (e).

6. The answer is b. Elevated potassium is cardiotoxic by a few

methods that lead to membrane excitability. It increases the resting
membrane potential of the myocyte, causes slow depolarization and
decreased length of time of depolarization. When potassium levels
are very high, the depolarization threshold increases leading to
decreased cardiac function. There are three ways to treat
hyperkalemia: antagonize the membrane action of potassium, drive
extracellular potassium into cells, and remove potassium from the
body. All of the answer choices are treatments used in hyperkalemia
but it is important to start with calcium gluconate (b) in this
patient with ECG abnormalities of hyperkalemia. Calcium works
rapidly to stabilize the cardiac membrane by increasing
depolarization threshold and increasing cardiac conduction speed
(thereby narrowing the QRS complex). It does not actually decrease
potassium levels, thus other treatments are required. Calcium
gluconate is more frequently used than calcium chloride, which
ideally is given via central access to prevent local tissue necrosis.
Albuterol (a) and insulin (d) both work by shifting potassium
intracellularly by stimulating the Na-K-ATPase pump. Dextrose (c)
does not affect potassium levels but works to counteract the
hypoglycemia that can result from administration of Insulin. Oral
kayexalate (e) is a cation exchange resin that works to remove
potassium from the body through the stool but it takes hours to
work and is thus not effective in the acute management of
hyperkalemia. In this patient who has ESRD, hemodialysis will be the
definitive treatment to reduce her potassium level.

7. The answer is a. The patient has a primary spontaneous

pneumothorax (PTX), which occurs in individuals without clinically
apparent lung disease. In contrast, secondary spontaneous
pneumothorax occurs in individuals with underlying lung disease,
especially chronic obstructive pulmonary disease (COPD). For
otherwise healthy, young patients with a small primary spontaneous
PTX (<20% of the hemithorax), observation alone may be
appropriate. The intrinsic reabsorption rate is approximately 1% to
2% a day and accelerated with the administration of 100% oxygen.
Many physicians treat with oxygen; observe these patients for 4
to 6 hours and then repeat the CXR. If the repeat CXR shows no
increase in the size of the PTX, the patient can be discharged with
follow-up in 24 hours. If outpatient follow-up cannot be
appropriately arranged, the patient can return to ED in 24 hours for
reevaluation or they can be admitted to the hospital for observation.
Air travel and underwater diving (changes in atmospheric pressure)
must be avoided until the PTX completely resolves.
Needle decompression (b) is a temporizing maneuver for
patients with suspected tension PTX. Tube thoracostomy (c) is used
in secondary spontaneous PTX, traumatic PTX, and PTX greater than
20% of the hemithorax. In some scenarios, a pigtail catheter may be
used in place of a full tube thoracostomy. Unless there is a change in
his status, the patient does not need to be observed for another 6
hours (d). A pleurodesis (e) is an operative intervention to prevent
recurrence of PTX. It is performed on patients with underlying lung
disease or recurrent pneumothorax.

8. The answer is d. Esophageal perforation (Boerhaave

syndrome) is a potentially life-threatening condition that can result
from any Valsalva-like maneuver, which rapidly increases esophageal
pressure (including childbirth, vomiting or retching, coughing, and
heavy lifting). The most common cause of esophageal perforation is
iatrogenic, such as a complication from upper endoscopy. The classic
physical examination finding is mediastinal or cervical
emphysema. This is noted by feeling air under the skin on
palpation of the chest wall or by a crunching sound heard on
auscultation, also known as Hamman sign. Radiographic signs of
pneumomediastinum can be subtle. Lateral displacement of the
mediastinal pleura by mediastinal air creates a linear density
paralleling the mediastinal contour. On the lateral projection,
mediastinal air can be seen in the retrocardiac space.
Aspiration pneumonia (a) is an inflammation of lung parenchyma
precipitated by foreign material entering the tracheobronchial tree.
Alcoholics are prone to aspiration pneumonia because of ethanol’s
sedating effect and subsequent decrease of the normal protective
airway reflexes. Chest radiograph findings are often delayed with
atelectasis typically being the first finding. The right lower lung is the
most common site of infiltrate because of the right mainstem
bronchus’ more vertical angle and larger size compared to the left.
Alcoholics have a high incidence of pancreatitis (b), which can
present with epigastric tenderness and vomiting; however,
mediastinal air is not present on radiography. The physical
examination hallmark of acute pericarditis (c) is the friction rub. The
rub may be caused by friction between inflamed or scarred visceral
and parietal pericardium or may result from friction between the
parietal pericardium and adjacent pleura. Additionally, this patient’s
ECG did not exhibit the ST elevations and PR depressions typically
seen in pericarditis. Aortic dissection (e) usually occurs in patients
with chronic hypertension or connective tissue disorders. While CXR
in aortic dissection is not specific, a widened mediastinum is
classically taught. They should not have Hamman sign.

9. The answer is b. The patient’s clinical picture of chronic

hypertension, acute-onset tearing chest pain, diastolic murmur of
aortic insufficiency, and CXR with a widened mediastinum is
consistent with an aortic dissection. The goal is to decrease the
blood pressure and the HR to decrease the shearing forces on the
vessel wall that could worsen the dissection. The goal SBP is 100 to
120 mm Hg and HR less than 60 beats/minute. Esmolol is a
titratable and short-acting β-blocker. It should be given first as it
decreases the blood pressure and shearing forces and reduces the
reflex tachycardia that occurs with vasodilatory agents.
Amiodarone (a) is an antidysrhythmic agent used to treat
ventricular arrhythmias which this patient does not have. Nicardipine
(c) and nifedipine (d) are both CCB that cause vasodilation and
decreased peripheral resistance. Nicardipine can be used as a
second-line agent in place of nitrates or when β-blockers are not
well tolerated (it seems to have little effect on HR). Nifedipine is only
available in oral form which is not acceptable in this acute situation,
and it can increase HR. Nitroprusside (e) is a vasodilator that relaxes
vascular smooth muscle to reduce afterload and preload by
producing NO. This may be added as an agent to further control
blood pressure after the β-blocker has already been initiated.

10. The answer is d. The incidence of endocarditis in an

intravenous drug user (IVDU) is estimated to be 40 times that of
the general population. Unlike the general population, endocarditis in
IVDUs is typically right sided with the majority of cases involving
the tricuspid valve. Patients with IVDU-related endocarditis usually
have no evidence of prior valve damage. The most common
organism in IVDU-related endocarditis is Staphylococcus aureus.
Patients may present with fever, cardiac murmur, cough, pleuritic
chest pain, and hemoptysis. Right-sided murmurs, which vary with
respiration, are typically pathologic, and more specific for the
diagnosis. In patients with right-sided endocarditis and septic
pulmonary emboli, pulmonary complaints, infiltrates on chest
radiographs, and moderate hypoxia have been described in greater
than 33% of patients. Without a good history and physical
examination, these symptoms and signs may mislead the physician
to identify the lung as the primary source of infection (a and c).
Blood cultures will be positive in more than 98% of IVDU-related
endocarditis patients if three to five sets are obtained. Diagnosis
generally requires microbial isolation from a blood culture or
demonstration of typical lesions on echocardiography. TEE is the
most sensitive imaging modality for demonstrating vegetations and
tricuspid valve involvement in IVDU-related endocarditis. Initial
antibiotic treatment should be directed against S. aureus and
Streptococcus species.
Mononucleosis (b) presents with fever, sore throat, and
lymphadenopathy. Patients may also have an enlarged spleen
putting them at high risk for traumatic injury. However,
mononucleosis does not cause a heart murmur or patchy infiltrates
on chest radiograph. Liver function tests (LFTs) are abnormal in
more than 90% of patients with infectious mononucleosis.
Tuberculosis (e) generally does not present with chest pain or
cardiac murmur; the most common symptom is cough and it is
usually hemoptysis that causes concern to prompt ED visit.

11. The answer is d. The standard 12-lead ECG identifies patients

having an acute STEMI upon presentation in the ED. It is important
to identify the anatomic location of an acute MI to estimate the
amount of endangered myocardium. The RCA supplies the AV node
and inferior wall of the left ventricle in 90% of patients. Inferior
wall MIs are characterized by ST elevation in at least two of
the inferior leads (II, III and, aVF). Reciprocal ST changes (ie,
ST depression) in the anterior precordial leads (V1-V4) in the setting
of an inferior wall acute MI. The RCA also provides perfusion to the
right ventricle and it is important to identify RV involvement with a
right-sided ECG. If there is RV involvement, patients are preload
dependent and therapy that decreases preload (eg, nitroglycerin and
morphine) should be avoided. In general, the more elevated the ST
segments and the more ST segments that are elevated, the more
extensive the injury.
The anteroseptal wall (a) of the heart is supplied by the left
anterior descending coronary artery (LAD). An acute MI is identified
by ST elevation in leads V1, V2, and V3. The LAD also supplies the
anterior wall (b) of the heart and LAD infarction exhibits ST
elevations in leads V2, V3, and V4. The lateral wall (c) of the heart is
supplied by the left circumflex coronary artery and an infarct exhibits
ST elevations in leads I, aVL, V5, and V6. A posterior MI (e) refers to
the posterior wall of the left ventricle. It occurs in 15% to 20% of all
MIs and usually in conjunction with inferior or lateral infarction. In a
posterior MI, deep ST depressions are seen in V1, V2, and V3, or ST
elevations on a posterior ECG. The following figure summarizes the
distribution.

12. The answer is b. Aspirin is an antiplatelet agent that should

be administered early to all patients suspected of having an ACS,
unless there is a contraindication. The ISIS-2 (Second International
Study of Infarct Survival trial (2)) provides the strongest evidence
that aspirin independently reduces the mortality (by 23%) of
patients with acute MI.
Nitroglycerin (a) provides benefit to patients with ACS by
reducing preload and dilating coronary arteries. However, there is no
mortality benefit with its use and is contraindicated in inferior wall
MI. Unfractionated heparin (c) acts indirectly to inhibit thrombin,
preventing the conversion of fibrinogen to fibrin and thus inhibiting
clot propagation. ASA and heparin are synergistic in their effects in
preventing death. Routine use of lidocaine (d) as prophylaxis for
ventricular arrhythmias in patients who have experienced an acute
MI has been shown to increase mortality rates. Use of CCBs like
diltiazem (e) in the acute setting has come into question, with some
trials showing increased adverse effects.

13. The answer is d. When a patient is diagnosed with an STEMI,

the standard of care for therapy is immediate reperfusion with PCI.
The Joint Commission evaluates the time from arrival (door) to
reperfusion (balloon). Hospitals accredited as STEMI centers are
held to this standard. Based on clinical trials evaluating outcomes in
MI, the time window for door to balloon is 90 minutes.
All other answer choices (a, b, c, and e) are incorrect.

14. The answer is e. WPW syndrome is caused by an

accessory electrical pathway (ie, bundle of Kent) between the
atria and ventricles. The primary significance of WPW syndrome is
that it predisposes the individual to the development of reentry
tachycardias. The classic ECG findings include a short PR interval
(<120 milliseconds), widened QRS interval (>100
milliseconds), and a delta wave (slurred upstroke at the
beginning of the QRS). When conduction occurs, anterograde down
the AV node and then retrograde up the accessory pathway
(orthodromic), the ECG will appear normal. When the impulse
occurs, anterograde down the accessory pathway and retrograde up
the AV node (antidromic), the QRS complex will be wide. In the
presence of antidromic conduction (conduction first through the
bypass tract), the normal slowing effect of the AV node is lost and
rapid ventricular response rates (>200 beats/minute) can occur. The
most dangerous circumstance is in AF where impulses occur at a
rate greater than 300 beats/minute. This can quickly lead to
ventricular fibrillation. Procainamide is the drug most commonly
associated with the acute treatment of WPW, and nodal agents like
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The Project Gutenberg eBook of The Strife of
the Sea
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Title: The Strife of the Sea

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W. J. Aylward

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*** START OF THE PROJECT GUTENBERG EBOOK THE STRIFE OF

THE SEA ***
IN THE WAKE OF THE WEATHER CLOTH.—See Pages 305–320.

THE STRIFE
OF THE SEA

T. J E N K I N S H A I N S
AUTHOR OF “THE WIND-JAMMERS,” ETC.
 NEW YORK

THE BAKER & TAYLOR CO.

33–37 East Seventeenth St., Union Sq., North

Copyright, 1903, by THE BAKER & TAYLOR CO.

Copyright, 1901 and 1902, by Harper & Bros.
Copyright, 1902 and 1903, by The Success Co.
Copyright, 1902 and 1903, by The Independent.
Copyright, 1903, by The Butterick Pub. Co. (Ltd.)

Published October, 1903.

 TO
ROBERT MACKAY
 CONTENTS

PAGE

The Old Man of Sand Key, 11

The Outcast, 37
The Sea Dog, 77
The Cape Horners, 101
The Loggerhead, 135
The White Follower, 165
King Albicore, 199
The Nibblers, 227
Johnny Shark, 251
A Tragedy of the South Atlantic, 277
In the Wake of the Weather-Cloth, 313
 ILLUSTRATIONS

Clawing off the Cape, Frontispiece

Facing Page
The Great Shape Sailed for the Top of the
Buoy, 44
Full into the Center King Albicore Tore
His Way, 214
The Line Was Whizzing Out, 300
THE STRIFE OF THE SEA
THE OLD MAN OF SAND KEY
 THE OLD MAN OF SAND
KEY

H
e was an old man when he first made his appearance on the
reef at the Sand Key Light. This was years ago, but one
could tell it even then by the way he drew in his chin, or
rather pouch, in a dignified manner as he soared in short circles over
the outlying coral ledges which shone vari-colored in the sunshine
beneath the blue waters of the Gulf Stream. He had fished alone for
many seasons without joining the smaller and more social birds, and
the keepers had grown to know him. He was a dignified and silent
bird, and his stately flight and ponderous waddle over the dry reef
had made it quite evident that he was a bird with a past. Sandy
Shackford, the head keeper, knew him well and relied implicitly upon
his judgment as to the location of certain denizens of the warm
Stream. He had come back again after a month’s absence, and was
circling majestically over the coral banks not a hundred fathoms
from the light.

The day was beautiful and the sunshine was hot. The warm
current of the Gulf flowed silently now with the gentle southwest
wind, and the white sails of the spongers from Havana and Key West
began to dot the horizon. Here and there a large barracouta or
albicore would dart like a streak of shimmering silver through the
liquid, and the old man would cast his glance in the direction of the
vanishing point with a ready pinion to sweep headlong at the mullet
or sailor’s-choice which were being pursued.
His gray head was streaked with penciled feathers which grew
longer as they reached his neck, and his breast was colored a dull,
mottled lead. His back and wings gave a general impression of gray
and black, the long pinions of the latter being furnished with stiff
quills which tapered with a lighter shade to the tips. His beak and
pouch were of more than ordinary proportions, for the former was
heavy and hooked at the end and the latter was large and elastic,
capable of holding a three-pound mullet.
He soared slowly over the reef for some time, and the keeper
watched him, sitting upon the rail of the lantern smoking his pipe,
while his assistant filled the body of the huge lamp and trimmed its
several wicks.
 To the westward a slight ripple showed upon the surface of the
quiet sea. The pelican sighted it and stood away toward it, for it
looked like a mackerel that had come to the surface to take in the
sunshine and general beauty of the day. In a moment the old man
had swung over the spot at a height of about a hundred feet; then
suddenly folding his wings, he straightened out his body, opened his
beak, and shot straight downwards upon the doomed fish. It was
literally a bolt from heaven from out of a clear sky. The lower beak
expanded as it hit the water and opened the pouch into a dipper
which scooped up the mackerel, while the weight of the heavy body
falling from the great height carried everything below the surface
with a resounding splash that could be heard distinctly upon the
light. Then up he came from the dive with the fish struggling
frantically in his tough leathern sack. He rested a moment to get his
breath and then stretched forth his pinions again and rose in a great
circle into the clear blue air.
“The old man’s fishin’ mackerel this mornin’,” said Sandy, “an’ I
reckon I’ll get the dory an’ try a squid over along the edge o’ the
Stream as soon as the breeze makes.”
“Well, take care you don’t lose nothin’,” said Bill with a grin.
“Whatcher mean?” snarled the older keeper.
“Nothin’,” answered the assistant.
“Then don’t say it,” said Sandy, and he walked down the steps of
the spider-like structure, muttering ominously, until he reached the
reef a hundred feet below, where, hauled high and dry, lay his boat.
Sandy was an old man, and had depended upon false teeth for some
years. The last time he had gone fishing he had lost them from his
boat, and as he could not leave the light he had nearly starved to
death. In desperation at last he had set the ensign union down and
signaled for assistance, the second keeper Bill being ashore on
leave, and after the U.S.S. Ohio had come all the way from Key West
to find out the cause of the trouble he had been forced to explain to
the officer his humiliating disaster. As the danger of landing in the
surf had been great and the services of the man-of-war had been
required for a whole day, he had been forced to listen to a lecture
upon the absurdity of his behavior that did little to encourage him,
and it was only his emaciated appearance and unfeigned weakness
from loss of food that saved him his position as keeper.
He shoved his small boat off and sprang into her. Then he
stepped the mast, and hauling aft the sheet swung her head around
and stood off the reef, riding easily over the low swell. High above
him was the lantern, and he looked up to see Bill gazing down at
him and pointing toward the southward, where a ripple showed the
breaching fish. His lines were in the after locker, and he soon had
them out, one of them with a wooden squid trolling over the stern
as the little craft gathered headway.
The memory of his former disaster now came upon him, and he
took out his teeth, which were new, and examined the plates upon
which they were fastened. A small hole in either side showed, and
through these he rove a piece of line. Then he placed the teeth back
in his mouth and fastened the ends of the line back of his ear.
“Let ’em drop an’ be danged to it, they’ll git back mighty quick
this time,” he muttered. “I wonder where that old pelican left the
school of fish?”
The old bird had satisfied his present needs and had flown away
to a distant part of the outlying bank, where he was now proceeding
to enjoy his catch at leisure. Far away to the northward, where Key
West showed above the horizon, a long line of black specks were
rapidly approaching through the air. They were the regular fishermen
of the reef, and they were bound out to sea this morning for their
daily meal. On they came in single file like a line of soldiers, their
distance apart remaining regular and the motions of their leader
followed with military precision. Every time he would strike the air
several sharp strokes with his wings, the motion would be instantly
taken up by the long line of followers flapping their own in unison.
 The “old man” heeded them very little indeed as he quietly ate
his fish, and they knew enough not to bother him. They sailed
majestically past and swung in huge circles over the blue Gulf to
locate the passing school.
The old man mused as he ate, and wondered at their stupidity.
Even the light-keeper knew as much as they. There was the
breaching school a mile away to windward, and the stupid birds
were still watching him.
He saw his wives go past in line. There was old Top-knot, a wise
and ugly companion of former days, her penciled feathers on her
neck rubbed the wrong way. Behind her came a young son, an
ingrate, who even now would try to steal the fish from him did he
but leave it for a moment to dive for another. He glanced at him and
ate steadily on. He would finish his fish first and look out for his
ungrateful son afterwards.
Further behind came his youngest companion, one who had
hatched forth twelve stout birds during the past few years and who
was still supple and vigorous, her smooth feathers still showing a
gloss very pretty to look at. But she gave him no notice, and he ate
in silence until they all passed far beyond and sighted at last the
breaching mackerel.
When he had finished he sat stately and dignified upon the sand
of the reef, all alone. Far away to the southward, where the high
mountains of the Cuban shore rose above the line of water when he
soared aloft, a thin smoke rose from some passing steamer. To the
northward the spars of the shipping at Key West stuck above the
calm sea. All about was peaceful, bright, and beautiful daylight, and
the ugly spider-like tower of the Sand Key Light stood like a huge
sentinel as though to guard the scene.
The day was so quiet that the sullen splashes of the fisher birds
sounded over the smooth surface of the sea, and the breeze scarcely
rippled the blue water. The deep Gulf rolled and heaved in the
sunshine, and the drone of the small breakers that fell upon the reef
sounded low and had a sleepy effect upon the old fellow who had
finished his fish.
He sat with his pouch drawn in and his long, heavy beak resting
upon his neck, which he bent well into the shape of a letter S. Now
and then he would close an eye as the glare from the white coral in
the sunshine became too bright. The man in the boat was trolling
back and forth through the school of fish with hardly enough way on
his craft to make them strike, but every now and then he saw him
haul aboard a shimmering object that struggled and fought for
freedom. Above, and at a little distance, soared the pelicans. Every
now and then one would suddenly fold its wings and make a straight
dive from the height of a hundred feet or more, striking the sea with
a splash that sent up a little jet of foam.
The sun rose higher and the scorching reef glared in the fierce
light. The old man shifted his feet on the burning sand and looked
about him for a spot where he might bring another fish and lie quiet
for the afternoon. He turned his head toward the westward, where
Mangrove Key rose like a dark green bush a few feet above the
water of the reef. Two small specks were in the blue void above it,
and his eyes instantly detected them and remained staring at them
with unwinking gaze.
The specks grew larger rapidly, but they were a long way off yet,
and he might be mistaken as to what they were. He had seen them
rise above the blue line before, and if they were what he took them
to be there would be trouble on the reef before long. Yes, he was
not mistaken. They rose steadily, coming on a straight line for him,
and now they were only a mile distant. Then he noticed one of the
objects swerve slightly to the eastward and he saw they were,
indeed, a pair of the great bald eagles from the Everglades of
Florida.
He was an old man, and he gazed steadily at them without much
concern, although he knew they meant death to all who opposed
their path. They were pirates. They were the cruelest of killers and
as implacable and certain in their purpose as the Grim Destroyer
himself. The pelicans fishing for their living over the reef were good
and easy prey. A sudden dash among them, with beak and talons
cutting and slashing right and left, and there would be some full
pouches of fish to empty. It was much better to let the stupid birds
fill up first and then sweep among them. Then, after despoiling them
of their hard-gotten catch, they would carry as much of the plunder
as they cared for to some sheltering key to devour at leisure.
The white head of the leading pirate shone in the sunshine and
his fierce eyes were fixed upon the fishermen. The old man was
apparently unnoticed, although there was little within the sweep of
that savage gaze that was left unmarked. Those eyes could see the
slightest object on land or sea far beyond the reach of ordinary
vision. They had even this morning, probably, been watching the
fishermen from some distant key miles away to the northward.
The old man was a huge, tough old fellow, and he dreaded
nothing. He gazed at the fishermen and a feeling of disdain for their
weakness came upon him. He thought of his old scolding mate, Top-
knot. What a scared old bird she would be in a moment with that
great eagle sailing straight as a bullet for her, his beak agape, and
his hoarse scream sounding in her wake. How she would make for
the open sea, only to be caught in a few moments and torn until she
disgorged her fish. His eldest son would make a show of fight,
perhaps, and in a very few minutes would be a badly used up
pelican. As for the rest, how they would wildly and silently strike for
the open ocean, going in single file as was their custom, only to be
overtaken one by one, until they were all ripped and torn by the
fierce fighters, who would follow leisurely along behind, striking and
clutching, screaming and calling to increase their fright and dismay.
He was almost amused at the prospect, for the pirate birds
seemed to know him instinctively for a barren prize and swept with
the speed of the wind past him and over the reef to the blue waters
of the Gulf beyond, where the fishermen were still unaware of their
approach. He would watch and see the skirmish, for no harm could
come to him even though all the rest were killed and wounded. He
swung himself around and gazed seaward again, and suddenly the
thought of his uselessness came upon him.
Why should he sit there and see this thing done—he, an old
man? He had led the flock for many years. Should he, the father of
many and the companion of all in former days, see them cut up by
two enemies? What if they no longer cared for him? What if the
younger birds were ungrateful and would steal his fish? Was he not
the old leader, the one they all had looked to in the years gone by?
Did not even the men in the tower treat his knowledge with respect?
And here a couple of fierce marauders from the forests of the land
had passed him to wreak their will upon the timid birds whose leader
had grown old. Memories of former days came to him, and
something made him raise his head very straight and draw his pouch
close in.
He sat gazing for a few moments longer. The eagles now had
closed up half the distance, for they were going with a rush. A
pelican saw them and headed straight out to sea, striking the air
wildly with outstretched pinions. Then in they dashed with hoarse
cries that caused the keeper in the boat to luff into the wind to
witness the struggle.
The old man launched his weight into the air, and with a few
sudden strokes rose to the height of a couple of fathoms above the
sea, bearing down toward the screaming birds with the rapidity of an
express train.
Above Sandy Shackford a very mixed affair was taking place.
The two eagles had dashed into the pelicans without warning and
were within striking distance before many of them could even turn
to flee. Old Top-knot had just caught a fine fish and was in the act of
rising with it when the leading eagle swooped down upon her with a
shrill scream. She was an old and nervous bird and a touch from any
other creature she dreaded at all times. Now, right behind her came
a giant shape, with glaring eyes and gaping beak, a very death’s-
head, white and grisly, while beneath were a pair of powerful feet,
armed with sharp talons, ready to seize her in a deadly grip. She
gave a desperate leap to clear the sea and stretch her wings, but the
sight was too much for her, and she sank back upon the surface.
The great eagle was too terrifying for her old nerves, and she sat
helpless.
In an instant the eagle was upon her. He seized her fiercely in
his talons and struck her savagely in the back, and the poor old bird
instantly disgorged her newly caught fish. Her savage assailant
hesitated a moment before striking her down for good and all, while
he watched the fish swim away into the depths below. Then he
turned to finish her.
At that instant there was a tremendous rush through the air, and
a huge body struck him full in the breast, knocking him floundering
upon the sea. The old man had come at him as straight as a bullet
from a gun, and, with the full force of his fifteen pounds sailing
through the air, had struck him with his tough old body, that had
been hardened by many a high dive from above.
The eagle was taken completely aback, and struggled quickly
into the air to get out of that vicinity, while the old man, carried
along by the impetus of his rush, soared around in a great circle and
came slowly back to renew the attack. In a moment the eagle had
recovered, and, with true game spirit, swung about to meet this new
defender of the fishermen. They met in mid-air, about two fathoms
above the sea, and Sandy Shackford cheered wildly for his old
acquaintance as he landed a heavy blow with his long, hooked bill.
“Go it, old man!” he cried. “Give it to him. Oh, if I had my gun,
wouldn’t I soak him for ye!”
The other birds had fled seaward, and were now almost out of
sight, being pursued by the second eagle. One limp form floated on
the sea to mark the course of the marauder. Old Top-knot had
recovered from the shock, and was now making a line for Cuba. The
old man was the only one left, and he was detaining the great bald
eagle for his last fight, the fight of his life.
 Around and around they soared. The eagle was wary and did not
wish to rush matters with the determined old man, who, with beak
drawn back, sailed about ready for a stroke. Then, disdaining the
clumsy old fellow, the bald eagle made a sudden rush as though he
would end the matter right there. The old man met him, and there
was a short scrimmage in the air which resulted in both dropping to
the sea. Here the old man had the advantage. The eagle could not
swim, his powerful talons not being made for propelling him over the
water. The old man managed to hold his own, although he received
a savage cut from the other’s strong beak. This round was a draw.
During this time the second eagle had seen that his companion was
not following the startled game, and he returned just in time to see
him disengage from a whirlwind of wings and beaks and wait a
moment to decide just how he would finish off the old fellow who
had the hardihood to dispute his way. Then he joined the fight, and
together they swooped down upon the old man for the finish.
He met them with his head well up and wings outstretched, and
gave them so much to do that they were entirely taken up with the
affair and failed to notice Sandy Shackford, who was creeping up,
paddling with all his strength with an oar-blade.
The encounter could not last long. The old fellow was rapidly
succumbing to the attacks of his powerful antagonists, and although
he still kept the mix-up in a whirl of foam with his desperate
struggles, he could not hope to last against two such pirates as were
now pitted against him. One of them struck him fiercely and tore his
throat open, ripping his pouch from end to end. He was weakening
fast and knew the struggle must end in another rush. Both eagles
came at him at once, uttering hoarse cries, and drawing back his
head he made one last, desperate stroke with his hooked beak.
Then something seemed to crash down upon his foes from above.
An oar-blade whirled in the sunshine and struck the leading eagle
upon the head, knocking him lifeless upon the sea. Then the other
rose quickly and started off to the northward as the form of the
keeper towered above in the bow of the approaching boat.
 Sandy Shackford picked the great white-headed bird from the
water and dropped him into the boat and the old man looked on
wondering. He had known the keeper for a long time, but had never
been at close quarters.
“Poor old man,” said Sandy. “Ye look mighty badly used up.” And
then he made a motion toward him.
But the old pelican wanted no sympathy. His was the soul of the
leader, and he scorned help. Stretching forth his wings with a mighty
effort, he arose from the sea. The reef lay but a short distance away,
and he would get ashore to rest. The pain in his throat was choking
him, but he would sit quiet a while and get well. He would not go
far, but he would be alone. The whole sea shimmered dizzily in the
sunshine, but a little rest and the old bones would be right again. He
would be quiet and alone.
“Poor old man,” said Sandy, as he watched him sail away. “He’s a
dead pelican, but he made a game fight.”
Then he hauled in his lines, and, squaring away before the wind,
ran down to the light with the eagle and a dozen fine fish in the
bottom of his dory.
The next day the old man was not fishing on the reef. The other
birds came back—all except one. But the old man failed to show up
during the whole day.
The next day and the next came and went, and Sandy, who
looked carefully every morning for the old fellow, began to give up
all hope of seeing him again. Then, in the late afternoon when the
other birds were away, the old man came sailing slowly over the
water and landed stiffly upon the coral of a point just awash at the
end of the key.
As the sun was setting, the old man swung himself slowly
around to face it. He drew his head well back and held himself
dignified and stately as he walked to the edge of the surf. There he
stopped, and as the flaming orb sank beneath the western sea, the
old man still stood watching it as it disappeared.
 Sandy Shackford lit the lantern, and the sudden tropic night fell
upon the quiet ocean.
In the morning the keeper looked out, and the old man was
sitting silent and stationary as before. When the day wore on and he
did not start out fishing Sandy took the dory and rowed to the
jutting reef. He walked slowly toward the old man, not wishing to
disturb him, but to help him if he could. He drew near, and the old
bird made no motion. He reached slowly down, and the head he
touched was cold.
Sitting there, with the setting sun shining over the southern sea,
the old man had died. He was now cold and stiff, but even in death
he sat straight and dignified. He had died as a leader should.
“Poor old man,” said Sandy. “His pouch was cut open an’ he jest
naterally starved to death—couldn’t hold no fish, an’ as fast as he’d
catch ’em they’d get away. It was a mean way to kill a fine old bird.
Ye have my sympathy, old man. I came nigh goin’ the same way
once myself.”
And then, as if not to disturb him, the keeper walked on his toes
to his boat and shoved off.
THE OUTCAST

THE OUTCAST
T
he day was bright and the sunshine glistened upon the
smooth water of Cumberland Sound. The sand beach glared
in the fierce rays and the heat was stifling. What little breeze
there was merely ruffled the surface of the water, streaking it out
into fantastic shapes upon the oily swell which heaved slowly in from
the sea. Far away the lighthouse stood out white and glinting, the
trees about the tall tower looking inviting with their shade. The swell
snored low and sullenly upon the bar, where it broke into a line of
whiteness, and the buoys rode the tide silently, making hardly a
ripple as it rushed past.

Riley, the keeper of the light, was fishing. His canoe was
anchored close to the shore in three fathoms of water, and he was
pulling up whiting in spite of the ebb, which now went so fast that it
was with difficulty he kept his line upon the bottom. When he landed
his fiftieth fish they suddenly stopped biting. He changed his bait,
but to no purpose. Then he pulled up his line and spat upon his
hook for luck.
Even this remedy for wooing the goddess of fortune failed him,
and he mopped his face and wondered. Then he looked over the
side.
For some minutes he could see nothing but the glint of the
current hurrying past. The sunshine dazzled him. Then he shaded
his eyes and tried to pierce the depths beneath the boat.
The water was as crystal, and gradually the outlines of the soft
bottom began to take form. He could follow the anchor rope clear
down until a cross showed where the hook took the ground.
Suddenly he gave a start. In spite of the heat he had a chill run
up his spine. Then he gazed fixedly down, straight down beneath
the small boat’s bottom.
A huge pair of eyes were looking up at him with a fixed stare. At
first they seemed to be in the mud of the bottom, two unwinking
glassy eyes about a foot apart, with slightly raised sockets. They
were almost perfectly round, and although he knew they must
belong to a creature lying either to or against the current, he could
not tell which side the body must lie. Gradually a movement forward
of the orbs attracted his attention, and he made out an irregular
outline surrounding a section of undulating mud. This showed the
expanse of the creature’s body, lying flat as it was, and covering an
area of several yards. It showed the proportions of the sea-devil, the
huge ray whose shark-like propensities made it the most dreaded of
the inhabitants of the Sound. There he lay looking serenely up at the
bottom of the boat with his glassy eyes fixed in that grisly stare, and
it was little wonder he was called the devil-fish.
Riley spat overboard in disgust, and drew in his line. There was
no use trying to fish with that horrible thing lying beneath. He got
out the oars and then took hold of the anchor line and began to haul
it in, determined to seek a fishing drop elsewhere or go home. As he
hauled the line, the great creature below noticed the boat move
ahead. He watched it for some seconds, and then slid along the
bottom, where the hook was buried in the mud.
It was easy to move his huge bulk. The side flukes had but to be
ruffled a little, and the great form would move along like a shadow.
He could see the man in the boat when he bent over the side, and
he wondered several times whether he should take the risk of a
jump aboard. He was a scavenger, and not hard to please in the
matter of diet. Anything that was alive was game to his maw. He
had watched for more than an hour before the light-keeper had
noticed it, and now the boat was drawing away. His brain was very
small, and he could not overcome a peculiar feeling that danger was
always near the little creature above. He kept his eyes fixed on the
boat’s bottom, and slid along under her until his head brought up
against the anchor line, now taut as Riley hove it short to break out
the hook. This was provoking, and he opened a wicked mouth
armed with rows of shark-like teeth. Then the anchor broke clear
and was started upward, and the boat began to drift away in the
current.
 The spirit of badness took possession of him. He was annoyed.
The boat would soon go away if the anchor was withdrawn, so he
made a grab for it and seized the hook, or fluke, in his mouth, and
started out to sea. Riley felt the sudden tug from below. He almost
guessed what it was, and quick as lightning took a turn with the line
about the forward seat. Then, as the boat’s headway increased
rapidly, he took the bight of the line aft and seated himself so as to
keep her head up and not bury in the rush. His knife was at hand
ready for a sudden slash at the line in case of emergency.
“If he’ll let go abreast o’ the p’int, all right,” said Riley. “I seen
lots harder ways o’ getting about than this.”
The tide was rushing out with great rapidity, and going along
with it the boat fairly flew. Riley watched the shore slip past, and
looked anxiously toward the lighthouse for the head keeper to see
him. It would give the old man a turn, he thought, to see a boat
flying through the water with the occupant sitting calmly aft taking it
easy. It made him laugh outright to imagine the head keeper’s look
of astonishment. Then he saw the figure of the old man standing
upon the platform of the tower gazing out to sea. He roared out at
the top of his voice, hoping to attract attention, but the distance was
too great.
Meanwhile the sea-devil was sliding along the bottom, heading
for the line of white where the surf fell over the bank of the outer
bar. The hook, or fluke, of the anchor was held securely in his
powerful jaws, and the force necessary to tow the following craft
was felt very little. The great side fins, or flukes, merely moved with
a motion which caused no exertion to such a frame, and the long
tail, armed with its deadly spear of poisoned barbs, slewed slightly
from right to left, steering the creature with accuracy. And while he
went his mind was working, trying to think how he could get the
man from the boat after he had taken him out to sea beyond any
help from the shore. A sea-devil he was, and rightly named. This he
very well knew, and the thought made him fearless. He had rushed
many schools of mullet and other small fish, who fled in frantic
terror at his approach. He had slid into a school of large porpoises,
the fishermen who seldom gave way for anything, and he sent them
plunging in fear for the deep water. Once he had, in sheer devilry,
leaped upon a huge logger-head turtle weighing half a ton, just to
see if he could take a nip of his neck before the frightened fellow
could draw in his head behind the safe shelter of his shell. He could
stand to the heaviest shark that had ever entered the Sound, and
had once driven his spear through the jaws of a monster who had
sneaked up behind him unawares and tried to get a grip upon his
flukes. All had shown a wholesale respect for his powers, and he had
grown more and more malignant as he grew in size and strength.
Even his own family had at last sought other waters on account of
his peculiarly ferocious temper.
Now he would try the new game in the craft above, and he felt
little doubt as to the outcome. A sudden dash and twist might
demoralize the floating tow, and as he neared the black can buoy
which marked the channel, he gave a tremendous rush ahead, then
a sudden sheer to the right, and with a quick slew he was heading
back again in the opposite direction.
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