Funtabulously Frivolous Friday Five 178

LITFL: Life in the Fast Lane Medical Blog
LITFL: Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

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 178.

Question 1

You finally manage for the first time in the year to make it to the doctors lounge and find the surgical team playing computer games. You roll your eyes and mutter something derogatory under your breath. The surgical team state that they are training. Do video games actually help surgeons?

  • Surprisingly yes (when it comes to laparoscopic procedures in the sim lab)
  • When tested in a simulation environment those surgeons that played >3hrs per week of video games made 37% less errors and were 27% faster than their non-gaming peers. [Reference]

Question 2

Why is it called ‘Plaster of Paris’?

  • Plaster is the common name for calcium sulphate hemi hydrate made by heating the mineral gypsum. Plaster was first made about 9000 years ago, but it wasn’t used on a large scale until 1700s, when it was required to be used in on all buildings in Paris post the 1666 fire of London.
  • This resulted in large-scale mining of gypsum which was available around Paris in huge quantities (namely Montmartre). Thus, during the early 18th century, Paris became the centre of plaster production, and hence the name, Plaster of Paris. [Reference]

Question 3

After Valentine’s day you meet up with friends and discuss what you did. You claim you scaled a wall to sing to your sweetheart and subsequent sustained a ‘lover’s fracture’, what is this and what is the associated injury?

  • The name “lover’s fracture” is derived from the fact that a suitor may jump from great heights while trying to escape from the lover’s spouse and sustains a calcaneal fracture.
  • There is an important association between lover’s fractures and a burst fracture of the lumbar spine. [Reference]

Question 4

Who first described the phenomenon of clubbing?

Question 5

What was Devonshire colic?

  • Colic from lead poisoning as a result of drinking cider. Cider leached lead out of the vats and presses in England during the 17th and 18th centuries.
  • This discovery was made by Dr. George Baker in the 1760s and by the mid 1820s lead poisoning due to cider was nearly non existent due to a change in components. [Reference]

  • And if you didn’t grow up in the South West of England here is a little treat from the Wurzels + Tony Blackburn:

Last update: Feb 24, 2017 @ 8:28 am

Funtabulously Frivolous Friday Five 178
Neil Long

Research and Reviews in the Fastlane 173

LITFL: Life in the Fast Lane Medical Blog
LITFL: Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Research and Reviews in the Fastlane

Welcome to the 173rd 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 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid,  Justin Morgenstern 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

Emergency Medicine
R&R Hall of Famer - You simply MUST READ this!
Brison RJ et al. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ. 2016 Nov 16;355:i5650. PMID: 27852621

  • Easy summary: A very good RCT that demonstrates physiotherapy offers no benefit over routine emergency care for mild ankle sprains.
  • Recommended by: Justin Morgenstern

The Best of the Rest

R&R Game Changer? Might change your clinical practiceCampbell M, Buitrago SR. BET 2: Ice water immersion, other vagal manoeuvres or adenosine for SVT in children. Emergency medicine journal : EMJ. 34(1):58-60. 2017. PMID: 27974431

  • A short best evidence review examining which approach is most effective for managing SVT in pediatric population. The authors found that ice water and adenosine are both more effective than carotid sinus massage or Valsalva maneuvers.
  • Recommended by: Jeremy Fried

R&R Game Changer? Might change your clinical practiceLiu Bexkens R el at. Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis. The American journal of emergency medicine. 35(1):159-163. 2017. PMID: 27836316

  • Clay Smith: This meta-analysis found hyperpronation for nursemaid’s elbow was better than supination/flexion – a lot better. The aggregate failure rate for hyperpronation was 9%; for supination/flexion it was 27%. Authors calculated a NNT of 4. Hyperpronation beats supination/flexion for nursemaid’s elbow.
  • Justin Morgenstern: This is an interesting study, but I find it hard to believe the results. There was a 27% failure rate with the supination flexion technique? That doesn’t make any sense. I haven’t seen this technique (or any technique) fail in reducing a pulled elbow any time in the last 5 years. Hyperpronation might be better, but these numbers don’t make sense.
  • Recommended by: Clay Smith and Justin Morgenstern
  • Further reading: Hyperpronation romps supination-flexion (EM Topics); December Journal Club (BroomeDocs)

PediatricsR&R Game Changer? Might change your clinical practiceChapa-Rodriguez A1 et al. Severe anemia in an adolescent male with sickle cell trait: a case report. J Pediatr Hematol Oncol. 2015 Jan;37(1):e60-2. PMID: 25432648

  • Sickle Cell Trait is not as benign as we all may have thought! There are several issues that we should consider, but we need to particularly be aware of Renal Medullary Cancer that presents with flank pain and/or hematuria!
  • Recommended by: Sean M. Fox
  • Further reading:  Sickle Cell Trait (Pediatric EM Morsels)

Emergency Medicine
R&R Game Changer? Might change your clinical practiceOquist M et al. Comparative analysis of five methods of emergency zipper release by experienced versus novice clinicians. Am J Emerg Med. 2016 PMID: 27836312

  • “This is a prospective, randomized trial of different zipper release techniques using a simulated model (chicken skin stuck in the zipper instead of foreskin). A group of medical students and emergency medicine faculty all tried 5 techniques for releasing the zipper in random order: cutting the median bar, using a screwdriver to separate the face-plates, using mineral oil as lubricant, lateral compression of the zip fastener using pliers, and removal of teeth of the zip mechanism using trauma scissors. The most successful technique was simple manipulation after application of mineral oil, and it was also the quickest. Of course, I don’t care as much about the time it takes, unless the child is freaking out. I care most about pain, which this study can’t tell us about. The technique that resulted in the least damage to the skin was cutting the closed end of the zipper with trauma scissors and allowing it to unzip backwards. Lateral compression and rotating the screw driver were both unsuccessful and more damaging. Clearly this is a tiny study using chicken skin, but I think it is interesting, and with finicky procedures like this, it always good to have a few backup techniques. Bottom line: Scissors and mineral oil will be my first options when this comes up.”
  • Recommended by: Justin Morgenstern

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.

Last update: Feb 23, 2017 @ 2:38 pm

Research and Reviews in the Fastlane 173
Justin Morgenstern

JellyBean 055 with polymath Dr Mark Wilson

LITFL: Life in the Fast Lane Medical Blog
LITFL: Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Mark Wilson; Neurosurgeon, Retrieval Physician, App Designer, Volunteer, Sceptic and Gentleman. It is hard act to follow. It is hard not to like this chap.

Mark Wilson somehow found time to talk to Matt McPartlin at SMACC. He really had an awful lot to do in Dublin too. Mark was presenting, fighting, drinking, dancing, facing his PhDemons and listening to @Kangaroobeach, all of which are frankly exhausting. But then he was asking for trouble by being so good at everything and even better at certain sexy media friendly matters.

Mark knows concussion like very few people ever will. He is a neurosurgeon that gets down and dirty in the streets of London with the paramedics as a Retrieval Physician. He invents apps that go huge and actually save people lives. The App is called GoodSAM which may have been inspired by the bible or possibly by the legendary public house literally underneath the helipad at The Royal London Hospital. He has essentially created a way of real-time crowd-sourcing a medic when you really really want one.

I wish I could do that.

Mark is the main person behind the GoodSAM app which has been reviewed by Tessa Davis here on LITFL.

Lots of us have little moments of App inspiration but Mark has done it. It is free so it is genuine #FOAMed. It is also much more in that; it mobilises an entire community of volunteer responders which crosses the divide between clinician and non-clinician. The follow up is interesting too. Mark released this App back in 2014. Being one of the more successful Apps it really didn’t end there. The app is now in version 5. It has a life of its own and Mark still maintains it, updates it, promotes it, fixes it up when problems arise. It is an ongoing concern.

Have a listen to Mark and Matt, have a look at the GoodSAM App and have a think about getting involved.
The Good Samaritan

JellyBean Large

Last update: Feb 23, 2017 @ 8:25 am

JellyBean 055 with polymath Dr Mark Wilson
Doug Lynch

To BPT, or not to BPT, that is the junior doctor’s question…

LITFL: Life in the Fast Lane Medical Blog
LITFL: Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

As my graduating peers and I embark on our medical careers, it’s a fitting time to consider which medical careers we actually desire. I’ve always had a strong sense of direction for the specialty path I wish to pursue, but at times, like now, I flirt with the idea of pursuing other avenues. It is an important issue that deserves deliberate consideration as it’s what most of us will dedicate the lion’s share of our lives to.

  • Is being a “specialist in life” as a GP the way to go?
  • Or to heal with steel in surgical training?
  • What about the variety of skills and presentations in ED?
  • How about the doors that open via basic physician training (BPT)?

As I wondered how to systematically manage this internal psychological conflict, I did what any task-oriented and mildly-obsessive junior doctor would do and devised a psychiatric management plan for myself..

32yo male doctor presents with indecision concerning medical career path.


  1. Priorities/ Risks
    • There are already a surplus of junior doctors.
    • Over 200 graduates missed out on internships this year in Australia, yet Perth has a new medical school on it’s doorstep.
    • Competition will only get fiercer, the risk of missing a place on that desired specialty program has never been greater.
  2. Status
    • ?inpatient vs ?outpatient.
    • Do you want a hospital or community-based career? Public sector, private sector or both?
  3. Location
    • ?local vs ?rural/remote vs ?interstate vs ?international
    • Where do you desire to live, but also where’s the demand for your specialty?
    • It may be be tough working as an intensivist if you want plan to live in the bush.
  4. Collateral History
    • Gain as much knowledge as possible from multiple sources. Corroborate that information. Consider
    • Advanced trainees (a little satire from Gomerblog, find the trainees during their 1-hour reflection time)
    • Mentors – if you don’t have a mentor, get one. The best experiences I’ve had thus far in medicine have been directly attributable to mentors.
    • Training colleges – e.g. Australia’s approved medical colleges
  5. Investigations
    • Bedside – surf the web, social media groups, research college societies.
    • Bloods – get some skin in the game and attend conferences – e.g. the Australasian conference calendar
    • Imaging – get a first-hand look at the role with placements. Volunteer. Get your face out there. NB: there’s a great volunteering opportunity next year for all manner of Australasian-based doctors at the 2018 Gold Coast Commonwealth Games.
  6. Vitals
    • Supply & Demand – Is it feast or famine for your specialty in the next 5-10 years? e.g. I reviewed the latest workforce statistics and projections in Western Australia.
    • Remuneration – the top 12 most well-paid jobs for men in Australia are all medical specialties, and if you’re a woman, 19 of the top 22 most well-paid are accounted for by medicine.
    • Training Pathway/ Requirements – Compare pathways with this nifty career pathway tool from the AMA.
    • Competitiveness – EVERYTHING is competitive now. Gone are the days off falling into a specialty pathway, so how do you separate yourself from the pack?
    • Have a back-up plan! One of the best pieces of advice I took from a series of orientation lectures recently was to have a back-up plan. Life rarely goes exactly the way we want it, so just keep your options open.
  7. Consults
    • Philosophically speaking, what it is you want to do with your working life? Consider consulting some of history’s greatest minds. Warning: the rabbit-hole goes deep.
    • Alain de Botton (Swiss/British Writer)
      • “work is meaningful…whenever it allows us to generate delight or reduce suffering in others”.
    • Oliver Sacks (Neurologist/ Author)
      • “I have been given much and I have given something in return; I have read and traveled and thought and written…Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.”
    • Epicurus (Greek Philosopher)
      • “…work is satisfying when it’s meaningful, in very small groups or alone and when we sense we’re helping others. It isn’t through money or prestige”
    • Jean Paul Sartre (French Philosopher)
      • “…don’t live in bad faith” –  don’t believe you have to do a particular job, remember you’re a free human being.
  8. Biological
    • How will your specialty affect you physically?
    • Sedentary vs active role? Would you prefer to mostly sit a desk, or run around outside? (NB: yes, you can run around outside as a doctor and get paid for it).
    • Sleeping? Does the routine of a “9-5” or the variability of shift work suit your sleeping patterns?
    • Planning a family? Is that surgical program or part-time GP more likely to be sympathetic to those plans?
  9. Psychological
    • What is your passion? What’s your gut feeling?
    • How is it likely to affect your mental health? We need to be aware that as doctors we’re more likely to experience mental health issues than the general public.
  10. Social
    • How will your specialty affect you socially?
    • Work-life balance? Will you work weekends? Nights? On-call? Shift-work?
    • Team-based vs individual specialty? Do you like being part of a big team/clinic or being more of a lone operator?
    • Social support networks? Do you, or your specialty, have support structures in place?
    • Litigation risk? Doctors get sued. Some more than others
    • Culturally congruent? Does your culture frown upon you working purely in the private sector? Or performing abortions? Or conducting stem-cell research?
    • Is it spiritually fulfilling?
  11. Begin discharge planning on admission
    • Start planning to discharge yourself from your desired training pathway the second you step foot on the ward! Begin with the end in mind.

…or if you’re too under the pump for all of the above, you’re probably already familiar with this much simpler management plan..


  1. Continue current management plan

Best of luck!


  1. Royal Australian College of General Practitioners. Your Specialist in Life. 2016.
  2. Maria Hawthorne. More than 200 medical graduates miss out on jobs. Australian Medical Association,; 2017.
  3. Gomerblog. Week to Reflect on Their Poor Career Decision. 2017.
  4. AHPRA. Approved Programs of Study. 2017.
  5. MJA. Calendar of Conferences in Australia and New Zealand. 2017.
  6. Gold Coast 2018 Commonwealth Games Corporation. Help Shape Our Games. 2017.
  7. Australia GoW. Specialist Workforce Capacity Program (SWCP) 2015 summary sheets. 2015.
  8. Sarah Kimmorley. Australia’s Top 50 highest paying jobs.; 2016.
  9. Australian Medical Association. Career Pathways Guide. 2016.
  10. Alain De Botton. Pleasures and Sorrow of Work. Great Britain: Penguin Books; 2009.
  11. Oliver Sacks. Gratitude. Pan Macmillan UK; 2015.
  12. The School of Life. Great Thinkers. Latvia: Livonia Print; 2016.
  13. Tane Eunson. Super Docs 2.0. : 2016.
  14. Mukesh Haikerwal. Doctors’ mental health needs our help MJA InSight; 2016.
  15. Anupam B. Jena, Seth Seabury, Darius Lakdawalla, Amitabh Chandra. Malpractice Risk According to Physician Specialty. New England Journal of Medicine,. 2011;365(7):629-636.

To BPT, or not to BPT, that is the junior doctor’s question…
Tane Eunson

Like a bridge over troubled waters

aka Cardiovascular Curveball 014

A 38yo man presented to ED with a 2 hour history of central crushing chest pain. His past medical history included haemochromatosis and a negative stress echo done one year ago following an episode of chest pain which the patient describes as different to the pain that bought him to the emergency department today.

An ECG is done:

Q1. Describe this ECG.

The ECG demonstrates

  • underlying sinus rhythm with a rate of 75 bpm and normal axis.
  • antero-lateral ST elevation.
  • auto-analysis of the ECG states ‘ACUTE MI’.

The patient looks well. His observations are normal, and despite aspirin and GTN he is still complaining of 7/10 chest pain.

Q2. Is the auto-analysis interpretation correct? Is this an Acute MI?

Thankfully Prof. Steve Smith, an emergency physician and creator of Dr Smith’s ECG Blog thinks he can help…

Dr Smith has created a formula using logistical regression to aid in differentiating between subtle anterior STEMI and benign early repolarisation (BER). This formula is to be used when the diagnosis is in doubt i.e. not an obvious STEMI and no LVH, LBBB, or reciprocal ST depression. [Original Article] [Blog Reference]

The formula:

Subtle Anterior STEMI Calculation = (1.196 × [ST-segment elevation 60 ms after the J point in lead V3, in mm]) + (0.059 × [QTc in ms]) – (0.326 × [R-wave amplitude in lead V4 in mm]).

  • if result is > 23.4 then the sensitivity and specificity for subtle MI is around 90%, the higher the value the more likely the diagnosis is MI.

Q3. How does this apply to our patient?

  • QTc was calculated by the ECG machine at 410ms
  • The result from Dr Smith’s formula = 21.6
  • This makes the ECG findings suggestive of BER rather than subtle anterior STEMI.

Q4. What would you do now?

  • Cardiology were urgently consulted
  • On review they were convinced the ECG changes represented a STEMI
  • The patient was taken to the cardiac cath lab post haste.

Q5. The angiogram report


  • Left Main coronary artery – Normal
  • Left Anterior Descending coronary artery – Bridging with ?spasm mid-vessel
  • Left Circumflex coronary artery – smooth and angiographically normal
  • Right coronary artery – Dominant, smooth and angiographically normal
  • Left ventriculogram – mild hypokinesis anterior wall, overall normal ejection fraction
  • Impression – Nil occlusive coronary artery disease, Left anterior descending coronary artery bridging with ?spasm

After reading the angiogram report and subsequent findings of no obstructive lesion and with a lesson concerning the finer points of ECG interpretation on my lips I checked the patient’s blood tests which revealed a high sensitivity troponin of 3010 ng/L (<26ng/L).

Despite the Dr Smith’s formula predicting BER over Acute Coronary Syndrome the patient has a significantly raised troponin and a regional wall motion abnormality, however there is no occlusive coronary artery disease.

Q6. Would you have activated the cardiac cath lab?

  • I was fortunate enough to see this patient at 0900 on a Tuesday in a tertiary hospital with a well staffed cardiac cath lab. It would have been difficult to argue against going to the lab given the resources at hand.
  • I also happen to work in a state that is massive and the effort and cost of retrieving a patient from some of the locations in my state can be considerable. Having tools such as Steve Smith’s calculator at hand can be an amazing boon for those who don’t have the ease of access to a cath lab that I do, where they can present objective evidence to the fact that ‘this is not a STEMI’ when people come in with chest pain that you know is not suffering from ACS.
  • In this case the patient did not have a fixed obstruction in his coronaries to account for his regional wall motion abnormality and significantly raised troponin and so the formula was right. Wasn’t it?

Q6a. What is this ‘bridging’ they mention in the coronary cath report report?

  • Myocardial bridging is a congenital anomaly in which a segment of a coronary artery takes a “tunneled” intramuscular course under a “bridge” of overlying myocardium.
  • This causes vessel compression in systole, resulting in hemodynamic changes that may be associated with angina, myocardial ischaemia, acute coronary syndrome, left ventricular dysfunction, arrhythmias, and even sudden cardiac death.


  • Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med 2012;60(1):45-56. PMID: 22520989
  • MDCalc – Subtle Anterior STEMI Calculator
  • Lee MS, Chen C. Myocardial Bridging: An Up-to-Date Review. J Invasive Cardiol 2015 Nov;27(11): 521-528. PMCID: PMC4818117

Last update: Feb 20, 2017 @ 6:03 pm

The post Like a bridge over troubled waters appeared first on LITFL: Life in the Fast Lane Medical Blog.