Funtabulously Frivolous Friday Five 134

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…introducing Funtabulously Frivolous Friday Five 134

Question 1

You do a ketamine sedation and the patient develops laryngeal spasm. What physical manoeuvre can you preform to try and resolve the laryngeal spasm while the nursing staff draw up a paralytic?

  • Larson’s point or the ‘laryngospasm notch’ [Reference]According to Phil Larson its location is:

“This notch is behind the lobule of the pinna of each ear. It is bounded anteriorly by the ascending ramus of the mandible adjacent to the condyle, posteriorly by the mastoid process of the temporal bone, and cephalad by the base of the skull.”

laryngospasm notch

Question 2

What is Fox’s Sign?

  • Bruising over the inguinal ligament
  • It typically occurs in acute hemorrhagic pancreatitis.
  • Named after the the dermatologist George Henry Fox. [Reference]Fox's sign

Question 3

How did drug addicts in the 1970s and 80s help parkinson patients?

  • They discovered the effects of MPTP
  • Barry Kinston a 23yr old chemistry graduate was synthesising MPPP (an opiate compound) and injected himself with his concoction.
  • Unfortunately it had MPTP as an impurity which converts to MPP+ once across the blood brain barrier and selectively kills dopaminergic cells resulting in parkinsonism.
  • Barry was treated with levodopa but died 18 months later from a cocaine overdose
  • The use of MPTP is used in research to produce parkinsonism in different animal models, there was some delay in this as rats were initially modelled but they have some resistance to MPTP at lower doses, hence it was not until 6 people were poisoned in 1982 in California that further work was done on MPTP. Read the case book The Case of the Frozen Addicts by J. William Langston.

Question 4

When would you expect to hear Hammon’s Crunch?

  • Pneumomediastinum or pneumopericardium.
  • Hammon’s Crunch is commonly seen in Boerhaave syndrome and is typically a crunching, rasping sound, synchronous with the heartbeat. [Reference]

Question 5

Who drinks more coffee? Anaesthetists? Consultants or junior staff?

  • On average orthopaedic surgeons purchased the most coffee per person per year (177, SD 191) followed by radiologists and general surgeons.
  • Anaesthetists purchased the least coffee (39, SD 48 – we wondered if they had their own machine)
  • Hierarchical position was positively correlated with coffee purchasing. Senior consultants (>5 years’ experience) bought most coffees per person per year and junior doctors and registrars bought fewest. Propensity of buying rounds also increased with hierarchical position, with heads of departments buying more rounds than junior doctors.
  • Problems with the study include only using a single site and we believe that further multi-centre studies should be performed
  • For the full article please click on the link: Black Medicine.

…and in other news


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TechTool Thursday 067 MedShr

TechTool review – MedShr by MedShr Ltd on Android and iOS…and website

MedShr is a private social network for doctors. It aims to allow the sharing of interesting patients including photos/videos. Members can discuss their cases and ask for suggestions from others. It aims to help improve clinical practice and facilitate learning and the sharing of patient data in a secure environment.

The website gives no information about who runs MedShr (a bug bear of mine) but I know from speaking to them that it was created initially by a Cardiologist in the UK. I think they have brought in other UK clinicians to help edit/stimulate discussion on a range of specialties.

Website: – iTunesGoogle Play – Website


Once you verify that you are a healthcare professional, you can log into your account

  • Users can select their area of interest and view discussions/cases in their own specialty
  • Posts that interest you can be saved for later
  • You can follow/connect with specific users and be notified of their future posts
  • Patients can consent on the app to their images being used
  • Images can be de-identified in the app itself

I browsed the paediatric section. There was a good selection of images/cases across a range of specialty with some discussion underneath each photo.

User Interface

MedShr iphone1

MedShr iphone2

MedShr android 1

MedShr android 2

Clinical Content

The app contains general information about regional anaesthesia, including toxicity and troubleshooting.

Then you can select essentially any type of regional block and read about how to do it. Each block is split into a text-based section explaining the technique and describing the process in details; and then there is an images section, which shows fabulous photos of landmarks, and someone actually doing the procedure in practice.

How much does it cost?

  • FREE

Room for improvement

  • Add an About Us section to the website so it’s transparent who’s behind MedShr
  • The photos/cases are currently just posted in chronological order – this only works when there is a small number of cases, but as the site grows it will likely need some sub-categorisation
  • The search function doesn’t work too well at the moment – in the paediatric section there were many pictures of impetigo, but when I actually search ‘impetigo’, none of them came up

What’s the overall verdict?

  • It is clear that doctors benefit from sharing cases and photos and discussing them confidentially with their colleagues.
  • MedShr seems to facilitate that well.
  • Setting up a new social network is no easy task, so hopefully they can keep the momentum going by building up their community and having regular and active discussions


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Research and Reviews in the Fastlane 120

Research and Reviews in the Fastlane

Welcome to the 120th 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, 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

Emergency medicine
R&R Hall of Famer - You simply MUST READ this!


Swaminathan A et al. The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review. J Emerg Med. 2015. Nov;49(5):810-5. PMID 26281814

  • An amazing review by a few of our very own. Could our fear of topical anesthetics in simple corneal abrasions be based on a myth? This review found 6 RCTs that indicate topical anesthetics are effective for pain control. Although small RCTs are not enough to prove safety, there are plenty of reasons to think this might be a myth.
  • Recommended by Justin Morgenstern

The Best of the Rest

Emergency medicine
Stollman N et al. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology 2015;149(7):1944-9 PMID 26453777

  • New guidelines for treatment of uncomplicated diverticulitis reflect two randomized trials and one observational series suggesting antibiotics confer no routine benefit.
  • Recommended by Ryan Radecki

TraumaEdwards A. Top 10 TARN research publications. Emerg Med J 2015; 32(12):966-8. PMID 26598632

  • Celebrating 25 years of TARN (Trauma Audit and Research Network database) research. What have we learned from the vast amounts of data collected:
    – Patients with severe head injury should be treated at a neuro surgical center
    – Elderly patients do worse and at risk for Porum management, perhaps due to more complex presentation of injury.
    – Patients on warfarin do worse
    – The interrelationship between vital signs in hemorrhagic shock is not supported to extend suggested by the ATLS classification.
    – How data can be standardized to compared perfomance between institutions
    – That GCS scale as a clinical tool fir risk assessment, classification and prognosis plays an significant role in the improvement of head injury outcome.
  • Recommended by Soren Rudolph

ResuscitationHoller JG et al. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. PLoS One. 2015; 10(3): e0119331, PMID 25789927

  • This review aims at establishing epidemiological characteristics of nontraumatic hypotension (SBP ≤ 90 mmHg) and shock (any definition + and SBP ≤ 90 mmHg) in the ED and prehospital setting. Based on evaluation of 11880 papers 6 observationel studies (1000 patients) were identified all with a high risk of bias. Among these 1000 patients prehospital prevalence of hypotension was 2% and hypotensive shock was 1-2 % with an inhospital mortality of shock between 33 to 52%. ED prevalence of hypotension was 1% contacts with a mortality of 12%. There were insufficient data to perform a meta-analysis.
  • Recommended by Soren Rudolph

Systems and administrationR&R Eureka - Revolutionary idea or conceptRalston SL et al. A Multicenter Collaborative to Reduce Unnecessary Care in Inpatient Bronchiolitis. Pediatrics 2016; 137(1): 1-9. PMID 26628731

  • An intensive quality improvement intervention greatly diminished unnecessary resource utilization in the context of bronchiolitis care at most, but not all, hospitals involved.
  • Recommended by Ryan Radecki

Emergency medicineR&R Trash - Must read, because it is so wrong!

Jefferies S et al. Randomized controlled trial of the effect of regular paracetamol on influenza infection. Respirology 2015. PMID 26638130

  • In a grossly underpowered study, paracetamol had no observable effects on physiologic or viral parameters in influenza infection – which led these authors to somehow conclude acetaminophen has no value at all.
  • Recommended by Ryan Radecki

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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LITFL Review 217

LITFL review

Welcome to the 217th 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


How do we reach deep within to find empathy when we feel at our worst? By remembering the other side of the story, writes Phil Berry in his blog.“The trick at such times is to access the human in ourselves” [SO]


The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

The Best of #FOAMped Paediatrics

The Best of #FOAMim Internal Medicine

The Best of #FOANed Nursing

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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Funtabulously Frivolous Friday Five 133

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…introducing Funtabulously Frivolous Friday Five 133

Question 1

Why do onions make you cry?onion

  • Propanethiol S-oxide
  • When you cut an onion, separate enzymes start mixing and produce propanethiol S-oxide, which is a volatile sulphur compound. The gas that is emitted reacts with the water of your eyes and forms sulphuric acid. The sulphuric acid causes burning sensation in your eyes and in turn leads to the tears glands secreting tears. [Reference]

Question 2

Does a full moon correlate to extreme behavioural disturbances?

  • Yes, according to a study done here in Australia:
  • Of 91 patients with violent and acute behavioural disturbance, 21 (23%) presented during the full moon — double the number for other lunar phases (P = 0.002). Sixty (66%) had either alcohol intoxication or psychostimulant toxicity, and five attacked staff (biting [2], spitting [1], kicking [1] and scratching [1]). In contrast, 512 hospital security calls for patients with less severe behaviour were evenly distributed throughout the lunar cycle. [Reference]

Question 3

What does ‘hampton’s hump‘ represent on a CXR?

  • Refers to a dome-shaped, pleural-based opacification in the lung most commonly due to a pulmonary embolism and lung infarction (See image below – right middle zone on the lateral aspect) [Reference]
  • Other signs include Fleischner sign and Knuckle sign hamptons hump


Question 4

Protamine sulphate is used to reverse heparin but where was it originally isolated?


Question 5

What is St Anthony’s fire?

  • Erysipelas. 
  • It is an infection of the upper dermis and superficial lymphatics, usually caused by beta-haemolytic group A streptococcus. 
  • Erysipelas is more superficial than cellulitis, and is typically more raised and demarcated. 
  • Or occasionally herpes zoster if you are from Italy or Malta.  [Reference]erysipelas

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TechTool Thursday 066 MAP+EM

TechTool review – MAP+EM by Eola Holdings on iOS and Android

MAP+EM (Manage and Prescribe Emergency Medicine) aims to deliver your local hospital guidelines and prescribing policies in one easy-to-find place on your phone. It has been developed by three junior doctors in the UK.

Website: – iTunes – Google Play – Website


Their website is lovely for a start, and gives a really clear overview of their aims and what the app offers. I don’t normally comment on app names, but I’m not sure why they chose the name MAP+EM. Their guidelines are for the whole hospital, not just the Emergency Department, so the name seems to unnecessarily limit their market. And the plus in the middle of the name is confusing. They will find it very difficult to be searched on Google.

The app design is nice and clean. It has a good colour scheme and is easy to navigate. The guidelines can be downloaded on your mobile, so no internet connection will be needed to use it.

User Interface



mapem android 1

mapem android 2

Clinical Content

The content will be determined by your hospital but can include:

  • Treatment guidelines
  • Prescribing guidelines and doses
  • Pagers/hospital contact numbers
  • Calculators
  • Details about teaching/conferences.

How much does it cost?

  • FREE
  • The app is free for doctors to use.
  • Currently hospitals can use it for free, but clearly that’s not a sustainable business model, so I guess they may have to charge hospitals at some point

Room for improvement

  • The treatment guidelines have yellow highlighted sections for the drug dosing – it cheapens the look and is distracting. There is other bizarre highlighting going on throughout that should be removed
  • The giant red exclamation mark in the bottom right of every screen (disclaimer) is unnecessary – we should be able to accept the disclaimer and then get rid of it
  • A name change would help make their aims clearer and also improve online searchability

What’s the overall verdict?

  • This app solves two of the problems that most annoy me as a hospital worker – access to treatment guidelines and contact numbers.
  • The number of hours wasted trying to locate pager numbers and find guidelines must be costing the public health system a fortune.
  • There are other apps that do this, but MAP+EM is one of the best-looking and best-designed ones I’ve seen. I hope the developers can persuade hospitals to use this as it would benefit us all

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