LITFL Review 231

LITFL review

Welcome to the 231st LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

resizer Paul Marik, critical care legend, takes on lactate in this incredible podcast from the Intensive Care Network. My brain is still recovering. [SO]

 

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

  • Josh Farkas explains why fentanyl infusions could be dangerous in prolonged ICU sedation of patients on mechanical ventilation. [SR]
  • My new family at the Bottom Line review an old paper on supine position as a risk factor for VAP. Now we can understand one of the reasons why 30-45 degrees head up tilt is used in ICU… [SO]

The Best of #FOAMed Resuscitation

  • A brilliant new FOAM resource from Sheffield ED in the UK with FOAMshed! This first post on perimortem c-section gives a succinct overview on the topic. [SL]

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

The Best of #FOAMim Internal Medicine

  • In the Louisville Lecture series, Dr Rosenblum provides a breathlessly exciting talk on Pulmonary Cases for internists. [ML]

The Best of #FOANed Nursing

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

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Sitting on the Couch, Talking Evolution

I’m seated here, in upholstered comfort, with two questions. The couch is a dreadful, shameless pun, which I will explain in a moment. The questions though, are real.

Both questions relate to the relevance of evolution in emergency medicine. The first is how does our current understanding of evolution help us be better clinicians? The second question is what do we not yet know? Or, in other words, what is the depth of our ignorance? (Please don’t answer that. It is a rhetorical question*).

Evolution. To briefly recap the last three and a half billion years (give or take), it started when a few basic molecules chunked themselves together. Amino acids assembled into proteins – monomers to polymers, folding themselves into proteinaceous origami. DNA formed. Pretty quickly this had the remarkable idea to split and produce an heir. This was the real miracle of life. Twitches of biological advantage then produced, amongst other things, a wall to box in the carbon-based bits and bobs forming cells – units which then really got the hang of division. They did this over and over. For a while things bided their time. These bacterial grade debutantes swum round in a vicious, blistering stew for two billion years, at the end of which they realised it was time for an upgrade. By this point they had oxygenated the planet, and some serious evolution could occur. Then any hiccoughs that might produce a biological advantage were passed on, creating more and more complex organisms. Finally humans popped up with their hardly conceivable physiology; their countless internal interactions and stupendously complex responses occurring every single second. Go on, try it, just for a moment, think about what your body is doing, simply sitting and reading. Seriously. It is too cool for words (certainly far too cool for mine).

But what does this sublimely elegant sequence of events have to do with emergency medicine? Sepsis – 3. That’s what. We were discussing the new terminology in teaching. qSOFA. (SOFA, get it? I am sorry. I really am). Sepsis has to be one of the most complex disease processes around. It is a rampaging, blazing blizzard of swirling chemicals; a genomic, metabolomic monsoon. Distressed mitochondria signaling for help, agitated endoplasmic reticulum producing misfolded proteins in panic, redundant cascades sparking up and looping back on themselves. The entire organism in disarray. All of the responses interconnected and surprisingly unique to each individual. Here at the pointy end of evolution, human pathophysiology in full-flight is an event almost too wondrous to behold. And we reduce it down to a respiratory rate, some confusion, and a 3 digit number. I fully appreciate that qSOFA is designed as a descriptor of organ dysfunction in response to infection, and is neither meant to describe, nor diagnose (I am preparing myself for the reader backlash here). But, certainly in ED, it feels so far removed from this complex and individualised disease that it hardly seems to raise an eyebrow of interest.

Rafts of guidelines we use have similar problems. How does one grind down an almost infinite array of interactive cellular combinations and permutations into a simple guideline or diagnostic algorithm? Artificial Intelligence is on its way, we are told – Holmes and Watson machines that will replace most of a doctor’s diagnostic work. Well good luck to them, I say.

To return to the original question, how does an understanding of evolution make us better clinicians? Well we can start by respecting the complexity of the response humans have to disease, and how little of it we truly understand. This way we are less likely to be prone to dogmatic statements, more respectful of the individual presentation in front of us, and more considered in our therapeutic decisions. It also helps us to understand why much of current research, on single interventions, produces small, if not no, gains (and many results seem to be simply the outcome of number-exploitation, rather than true effect).

We are the privileged few. Sometimes one can only appreciate the terrifying complexity of something when it goes wrong. We get to see it, and we are thus are not condemned to a life of sleep-walking, never appreciating the magnificence of evolution and what it means to inhabit a human body with all of its labyrinthine convoluted function.

Our second question is what is it that we don’t know? The other 99%, I would hazard a guess. Like the fact that we have just discovered 1200 new exoplanets, nine of them potentially habitable, all of these possibly with carbon, hydrogen, nitrogen, maybe even oxygen, all dancing around and thinking about getting it on. There is so much more for humans to discover. It’s an incredibly exciting time to be open-minded about new discoveries, both without and within, and be prepared to drop rigidly held teachings when we learn more. For us, it’s glycocalyces, hidden chemical messengers, brand new communication cascades, and so much more. And we are here, in medicine, taking part. We are, surely, the lucky ones. More wonder, I say. More wonder.

*A rhetorical question may not be what you think. Although the standard teaching is a question for which one already knows the answer, this is not quite true. The Greeks and Romans, who bestowed upon the world the flamboyantly wonderful figures of rhetoric, had dozens and dozens of terms and classifications for rhetorical questions (none of which they could actually agree upon. Sadly, their empires crumbled before they had a chance to tidy up the definitions). Some of the examples of rhetorical questions are: apocrisis, antiphora, epiplexis, subjectio, and epitemesis, amongst many others. Mine was an example of hypophora. I did not want you to answer it (knowing full well the extent of my own ignorance). Instead I intended to answer it, however lamely, in the remainder of the text. Those Greeks were onto something.

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JellyBean 033 with Anne Creaton

Bula!
So Anne Creaton is knee deep in Fiji.
Knee deep in another culture.
Knee deep in Government Bureaucracy.
Knee deep in the most beautiful water in the world.
What a woman!
I worked with Anne a few years ago when she helped start up the Ambulance embedded aeromedical service called Adult Retrieval Victoria in Melbourne.
That wasn’t hard enough for her. So she headed off to Fiji to try to bring some of what she had learned to the Pacific.
Now I don’t know what you know about Fiji. It is an incredibly interesting place with an incredibly interesting mix of people.I know that I don’t know enough about the history of Fiji, the story of native Fijians and indo-fijians, “Indentured Labour” and the relatively recent political complexity/instability. I am willing to bet that out of the few of us that have visited Fiji 99% will have visited the 3 biggest islands or a resort island. There are 330 islands in Fiji and about 500 islets. It is the biggest and most developed of the remote independent pacific island nations. It has the biggest campus of the fascinating University of the South Pacific and a newer second University of Fiji.
There also exists something called Pacific Time or Fiji Time.
(“It’s Time, Jim, but not as we know it.”)
Anne is humble about what she is trying to do but I am less reserved. I looked at doing something like Anne is doing about 15 years ago. I wasn’t brave enough. She was.
Here are a few questions for you; What does the Australasian College of Emergency Medicine (ACEM) do outside Australia and New Zealand? Should they do more? Have you ever heard of their Special Interest Group called IEMN?
Have a listen and get in touch with Anne if you want to know more, you’ve got options. Anne gives a talk at SMACC Dublin Day 1 at 11:40 Caring for the Critically Ill in Fiji @AnneCreaton

Thanks again to @rollcagemedic for offering to do some #Jellybeans in #Chicago
I am resetting the Jellybean numbers to fit with @sandnsurf and @precordialthump at www.LifeintheFastLane.com so this is called Jellybean 33. I’ll rename the others later. Because now I’m going to sing my kids a song….”

JellyBean Large

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Funtabulously Frivolous Friday Five 145

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 145

Question 1

What is bendopnoea?

  • Dyspnoea while bending forward
  • Bendopnoea is a novel symptom that was found in 28% of subjects with NYHA class III and IV heart failure. The pathophysiology appears to be increased filling pressures on bending without reducing the cardiac index.
  • It also has a strong association with a raised JVP, so if you can not see the pesky JVP, just get the patient to tie up their shoes (mean time to SOB = 8 seconds). [Reference]

Question 2

What are Tardieu spots?

  • Originally described as subpleural spots of ecchymosis by French police doctor Auguste Ambroise Tardieu in 1859. He first described this phenomenon following the death of a newborn child by strangulation or suffocation. [Reference]
  • This description has spread in forensic science to indicate any violent asphyxiation except drowning. The petechiae/ecchymosis can be present on a number of visceral surfaces including lung and myocardium. Clinically you may see them on the subconjunctiva, conjunctiva or in the oropharynx or skin of a patient from an attempted hanging.

Tardieuru

Question 3

What is the Rubin manoeuvre?

  • Used for shoulder dystocia, it is now a combination of moves to dislodge the obstructing shoulder.
  • Rubin I = suprapubic pressure
  • Rubin II = applying posterior pressure on the anterior shoulder, which would bring the foetus in an oblique position with the head towards the vagina
  • The Woods’ scream manoeuvre is the Rubin II but in the opposite direction. [Reference]
  • See diagrams below for the HELPERR mnemonic for shoulder dystocia and how to do the manoeuvre’s – clean pair of scrubs post procedure is optional.

HELPERR

Rubin

 

Question 4

What is the acnestis?

  • The part of the body where one cannot reach to scratch. [Reference]

Question 5

If you are as cool as a cucumber how cool are you?
cucumber

  • It is generally written that high water content of the fruit keep them them ‘cool’ and moist inside. Core temperature measurements estimate that the inside of the cucumber is up to 20 degrees (F) cooler than the external environment. [Reference]

 

The post Funtabulously Frivolous Friday Five 145 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 134

Research and Reviews in the Fastlane

Welcome to the 134th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Critical Care, Nephrology, Cardiothoracic Surgery
R&R Hall of Famer - You simply MUST READ this!

 

Combes A, et al. Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study. Am J Respir Crit Care Med. 2015 Nov 15;192(10):1179-90. PMID: 26167637.

  • This French prospective, multi-centre randomized controlled trial looked at patients with severe shock receiving high dose catecholamines within 3-24 hours after cardiac surgery. Patients were randomised to either conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury OR early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous veno-venous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function. The results did not show any difference in mortality or other patient centred outcomes between groups. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia.
  • Recommended by: Nudrat Rashid

The Best of the Rest

Research and Critical Appraisal                           R&R Eureka - Revolutionary idea or conceptZipkin DA, et al. Evidence-based risk communication: a systematic review. Annals of internal medicine. 161(4):270-80. 2014. PMID: 25133362

  • Statistics are easily gamed and, are increasingly called upon as we engage patients in shared decision making, Communicating with patients – Think the number need to treat (NNT) is the best way? That’s not what this review found. They found that participants most accurately perceived risk when presented with absolute risk reduction but were most swayed by relative risk.
  • Recommended by: Lauren Westafer

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about this

Trac MH et al. Macrolide antibiotics and the risk of ventricular arrhythmia in older adults. CMAJ 2016; 188(7):E120-9. PMID: 26903359

  • Do macrolides increase the risk of lethal cardiac dysrhythmias? This article is a large, population-based, retrospective cohort of adults > 65 years of age. It compares those who were prescribed a macrolide with those prescribed a non-macrolide antibiotic looking at the primary outcome of a presentation for a ventricular dysrhythmia at 30 days and a secondary outcome of all-cause mortality at 30 days. They found no difference. While it’s a suboptimal study methodology, this is further evidence that we need not fear these complications. But, this shouldn’t stop us from restricting treatment to only those who need it (i.e. don’t prescribe a Z-pack for a URI).
  • Recommended by: Anand Swaminathan

Education                                                  R&R Hot Stuff - Everyone’s going to be talking about thisZwaan L, et al. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Quality & Safety. 2016. PMID: 26825476 

  • Cognitive biases are a fun and sexy topic in medicine – I talk about them all the time. However, there is really no empiric evidence that teaching these biases or learning cognitive forcing strategies improves patient outcomes. This survey, based on clinical vignettes, indicated that physicians do not agree whether biases are present, and the assessment of bias is itself heavily influenced by hindsight bias. This is another small piece of the growing evidence that clinical decision making is incredibly complex and that simply identifying cognitive biases is unlikely to be a quick fix for diagnostic error.
  • Recommended by: Justin Morgenstern

Toxicology
R&R Hot Stuff - Everyone’s going to be talking about thisLevine M et al. “Systematic review of the effect of intravenous lipid emulsion therapy for non-local anesthetic toxicity.” Clin Tox 2016. PMID: 26852931

  • Use of intravenous lipid emulsion (ILE) for non-local anesthetic drug toxicity is increasing, however evidence-based criteria for its use is still lacking. A workgroup was formed to review the effects of ILE in a systematic fashion. This is article provides a comprehensive summary of the literature in detailed tables broken down by substance, highlighting the log D for lipophilicity and clinical outcome. The workgroup underscores the overall low quality of evidence currently available, as well as heterogeneous outcomes reported after use of ILE in non-local anesthetic drug toxicity.
  • Recommended by: Meghan Spyres

Systems and Administration
R&R Hot Stuff - Everyone’s going to be talking about this
Studdert DM, et al. Prevalence and Characteristics of Physicians Prone to Malpractice Claims. N Engl J Med. 2016 Jan 28;374(4):354-362. PMID: 26816012.

  • An interesting paper that examines the characteristics of malpractice claims in the United States. The authors used the National Practitioner Data Bank (NPDB) to obtain data on all payments made against MDs and DOs in a ten year period. Every practitioner in the NPDB has a unique identifier, allowing the authors to identify multiple claims against the same prover. By combing over the data, the authors found approximately 1% of all physicians accounted for 32% of paid claims in the time period. While limited in the study design, this large data analysis demonstrates a link between claims being paid out once and future payouts. Thought provoking and perhaps reassuring to the majority of physicians practicing? It also provides some foundational knowledge as the first step towards building a better liability system.
  • Recommended by: Jeremy Fried

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

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