Secret Diary of an Emergency Registrar

Age: Start or end of shift?
Status: Caffeinated.
Likes: Chest tubes. Wearing runners to work.
Dislikes: Describing CT brains to neurosurgical registrars over the phone.

An evening shift at St Anywheres…

14:00h: Start shift. Feeling refreshed and energetic after 3 days off. Will efficiently plough through the list, yet give each patient the personal attention they deserve. Will be pleasant and professional in referrals while remaining a firm advocate for my patients and the department. Will write succinct, clinically relevant, legally ass-covering notes at the time I see the patient. Today is a fresh start. Anything could happen. A trauma! A subarach! A low back pain!.

Asked how I spent my days off. Murmur non committal utterances giving impression of rock climbing, surfing, leisurely brunches with cool friends and live music. Omit to mention 11am sleep ins, laundering scrubs and binge watching Game of Thrones.

Check roster. My nemesis, Allan the Super Reg, is on and has already picked up 3 patients. Make myself a coffee while waiting for computer to open.

15:00h: make another coffee.

16:00h: Hit caffeine sweet spot. Churning through patients. Department is humming. That’s what I’m talking about!

17:00h: See a 55 year old man with back pain. Body habitus suggests my chance of a decent AAA view will be moderate to low, nonetheless wade in optimistically, probe in hand. Am too heavy handed on the gel and the probe slides out of my hand, bouncing off his abundant abdomen onto the floor. Fx%k! No obvious witnesses. Do brief mental calculation of cost of replacement probe divided by my hourly wage. Put machine back in cupboard and begin to spread rumour I think I saw Allan drop the probe.

18:14h: Checking wait list. Next to be seen is 57 year old lady, dizzy. Multiple other symptoms relating to at least 3 different organ systems and a list of proper co-morbidities meaning serious pathology will need exclusion. She is wearing sunglasses. Indoors. Decide to check some blood results and write a set of notes and come back in a few minutes.

18:19h: Entire doctor population circling the wait list in multi-player Mexican standoff, assiduously avoiding eye contact. Wait list building. See in-charge consultant move to check computer and panic, picking up dizzy lady.

18:21h: Multi-trauma patient arrives. Allan has his name next to him before the triage nurse finishes the notification. Bastard! Should have held my nerve. Allan calls a trauma call. I am on procedures. Blow the drip. Try to do FAST. Probe not working properly. Hmmmm.

18:40h: See my dizzy lady. She is very pleasant. I have absolutely no idea what is wrong with her, or how I can help her. She definitely can’t go home.

19:00h: Put my dinner, leftover Bolognese, in the microwave, quick toilet break. Write a set of notes while waiting for it to heat up.

20:00h: In the trauma cubicle Allan has masterfully enlocated an ankle, diagnosed a pneumothorax on ultrasound and inserted a chest tube. He is now engaged in backslapping, jocular banter with the orthopaedic registrar. Get a room guys!

20:30h: It’s actually under control and quite pleasant. Make another coffee, then 5 minutes very entertaining gossip session with the resus nurses about ‘who pashed who’ at last year’s Christmas party.

21:00h: 14 walk-ins and 3 ambulances arrive in the space of 43 minutes. Oh dear.

21:30h: Delirious 84 year old lady refers to male nurse, PSA, volunteer, radiographer and the husband of the patient next door as “doctor”. Calls me “sister” and asks for a bedpan.

21:33h: On seeing me arrive bearing a bedpan all the patients in adjacent cubicles also request a pan. Holy f*&k, is that Allan doing a surgical airway? With his non dominant hand???

22:00h: Nurse informs me that dizzy lady has developed pelvic pain.

22:12h: Just remembered my dinner coagulating in the microwave. Make serious inroads into pack of tim tams out for communal consumption. Scold self firmly. Must not eat any more tim tams or the nurses won’t like you anymore for eating more than your fair share.

22:14h: A consequence I am willing to live with.

22:22h: Allan is fetching a sweet little old lady a cup of weak, milky tea and a warm blanket. Man I hate that guy, But god damn is he a good registrar!

22:45h: Right. Have all available information on DL (dizzy lady) No more procrastinating. Time to sort out disposition. Oh wait, no urine sample yet.

23:00h: Have abandoned all pretences of contemporaneous documentation in efforts to wrestle the wait list into some semblance of control for the night staff. I’ll just do my notes at the end. No worries, I’ll knock them off in 15 minutes, tops!

23:12h: Waiting room out of control. Triage nurse looks like she wants to throw 3 packs of paracetamol through the window and hide under the desk. Patient have banded together with the good humour that emerges in crisis situations like bush fires or terror attacks or Monday evening. They cheer boisterously whenever anyone is called through the door to The Other Side. Someone has started a Facebook group, We’re Waiting To Be Seen In St As ED! There seems to be a a romance brewing near the vending machine between two patients who both really should be fasting.

23:15h: Have spoken to med, surg, gynae and neuro about dizzy lady. No acceptances, only vague promises to come and review. But none of them can possibly make any sort of assessment whatsoever until they have the full ward test. If only I hadn’t eaten all the tim tams I could have used them as a bribe.

23:30h: my dizzy lady finally wees. Score! If you squint and hold the full ward test strip up to the light at the right direction there is definitely, absolutely, without a doubt a trace of leuks. And that is SOLD to med with a UTI thank you very much ladies and gentleman, over and out.

00:47h: Sit, zombified, staring at screen desperately trying to recall details of patient I saw 6 hours ago. Only 5 sets of notes to go…

…Merry Christmas to all and thank you for reading this year.

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Research and Reviews in the Fastlane 062

Research and Reviews in the Fastlane

Welcome to the 62nd 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 10 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, Critical Care, CommunicationR&R Hall of Famer - You simply MUST READ this!
Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care. 2011;26(2):155-9. PMID: 21482347.

  • I saw a tweet from the recent Intensive Care society meeting with a quote from Peter Brindley: “communication is the most dangerous procedure in the hospital”. Following the strategies outlined in this review will go a long way to making it safe.
  • Recommended by: Chris Nickson
  • Read More: Communication in a Crisis (LITFL)

The Best of the Rest

Medical EducationR&R Hot Stuff - Everyone’s going to be talking about this
Pitts SR et al. Emergency Department Resource Use by Supervised Residents vs Attending Physicians Alone. JAMA 2014; 312(22):2394-2400. PMID: 25490330

  • This was a cross-sectional study looking at the resource utilization in patients seen by residents versus those seen by attendings alone. The study finds that resident supervised cases were more likely to be admitted to the hospital, had a greater use of imaging and longer ED length of stay. No causality can be shown here and there are numerous explanations to these findings including that residents are more likely to see sicker patients. Increased use of imaging and LOS should be expected as trainees are developing their clinical skills and acumen but better (not necessarily more) faculty supervision may be helpful in reducing admissions.
  • Recommended by: Anand Swaminathan

Emergency Medicine, NeurologyR&R Game Changer? Might change your clinical practice
Mantokoudis G et al. VOR Gain by Head Impulse Video-Oculography Differentiates Acute Vestibular Neuritis From Stroke. Otol Neurotol. 2014. PMID: 25321888

  • Should we reconsider HINTS and HIT as the gold standard for posterior circulation stroke diagnosis? This paper from an otoneurology group (including Newamn-Toker, the lead author of the HINTS paper) shows a diagnostic accuracy of 90% (sens 88% and spec 92%). The other corollary from this paper is that assessing HIT correctly probably requires a video HIT device instead of just plain physical exam. Apparently doing HIT in our patients is not as easy and not as good as we thought it was.
  • Recommended by: Daniel Cabrera

Trauma, ResuscitationR&R Hot Stuff - Everyone’s going to be talking about thisR&R Mona Lisa -Brilliant writing or explanation” width=
Spahn DR et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Critical Care 2013, 17:R76. PMID: 23601765

  • These are a well written evidence-based recommendations to guide the acute management of the bleeding trauma patient by the multidisciplinary Task Force for Advanced Bleeding Care in Trauma.
    The paper represents an updated version of the guideline published by the group in 2007 and updated in 2010.
  • Recommended by: Soren Rudolph

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

 

Malo C et al. Tamsulosin for treatment of unilateral distal ureterolithiasis: a systematic review and metaanalysis. CJEM 2013; 15(0):1-14. PMID: 23870675

  • This study is a meta-analysis looking at whether tamsulosin increases the rate of spontaneous stone passage in patients with renal colic. The authors report a benefit to the drug with a RR for passage of 1.50. However, this meta-analysis is significantly flawed as the studies entered into it had significant bias mainly due to issues with randomization as well as a high level of heterogeneity. This meta-analysis typifies the issue of garbage in equals garbage out and does not change the fact that tamsulosin has little good evidence to defend its use in these patients.
  • Recommended by: Anand Swaminathan

Emergency Medicine, Resuscitation, PulmonaryR&R Landmark paper that will make a difference

Oddo M et al. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med. 2006 Apr;32(4):501-10. PMID: 16552615

  • Look, obviously the goal is to not intubate the patient presenting with a severe asthma exacerbation… but our jobs often place us between the rock and the hard place. This article describes how best to deal with the uncomfortable position and benefit the patient the most.
  • Recommended by: Sean Fox
  • Read More: Mechanical Ventilation for Severe Asthma (Pediatric EM Morsels)

Emergency Medicine, PediatricsR&R Game Changer? Might change your clinical practice
Poonai N et al. Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ 2014. PMID: 25349008

  • This parallel-group, randomized, blinded superiority trial compared oral ibuprofen with oral morphine in pediatric patients (n=134) discharged from a pediatric ED after a non-operative extremity fracture. They found no statistically significant difference in analgesia between the two. Oral morphine isn’t the go-to analgesia in many pediatric patients and, even with the fight against pediatric oligoanalgesia, it doesn’t appear that it should be. Treat pain; proper splinting and ibuprofen should be sufficient in cases like those in this study.
  • Recommended by: Lauren Westafer

Pediatrics, AirwayR&R Eureka - Revolutionary idea or concept

Tessaro MO et al. Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children. Resuscitation 2014. PMID: 25238740

  • Inadvertent bronchial intubation can occur in up to 30% of paeds emergency intubations often with disastrous consequences if unrecognised. In this study, the authors evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube
    (ETT) cuff for confirming correct ETT insertion depth. There are numerous advantages to this approach including not waiting for the xray and no interruptions to chest compressions.The authors look at point of care tracheal ultrasound at the suprasternal notch to confirm tube placement. They found a sensitivity of 98.8% and specificity of 96.4% giving a (+) LR = 32 for confirming tube placement. Although the study wasn’t done in an ED population, this technique may be employed to prevent delays in recognition of mainstem intubation and cut time to initiation of management.
  • Recommended by: Sa’ad Lahri, Anand Swaminathan
  • Read More: Quit Mainstemming Kids 30% of the Time! (The Ultrasound Podcast)

Emergency MedicineR&R Game Changer? Might change your clinical practice

Zahir H et al. Edoxaban Effects on Bleeding Following Punch Biopsy and Reversal by a 4-Factor Prothrombin Complex Concentrate. Circulation. 2014. PMID: 25403645

  • Healthy volunteers taking edoxaban (an oral Factor Xa inhibitor) had their bleeding time after punch biopsy effectively attenuated by 4-factor prothrombin concentrate complex. Probably your go-to agent in the setting of life-threatening bleeding for these agents: edoxaban, apixaban, and rivaroxiban.
  • Recommended by: Ryan Radecki
  • Read More: 4-Factor Works for Factor Xa Inhibitors (Emergency Medicine Literature of Note)

ResuscitationR&R Mona Lisa -Brilliant writing or explanation” width=Johansson PI et al. How I treat patients with massive hemorrhage. Blood. 2014. PMID: 25293771

  • The optimal way to resuscitate the massive bleeding patient remains elusive. In this paper two of the most prominent concepts are presented. The Copenhagen concept uses transfusion packs, TXA and viscoelastic assays (VHA) to guide resuscitation in a goal directed fashion along the resuscitation phase. Activation of a massive bleeding protocol is based on clinical evaluation. In the Houston concept VHA is obtained early and activation of MTP is based on the ABC scoring system.
  • Recommended by: Soren Rudolph

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!

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LITFL Review 160

LITFL review

Welcome to the 160th 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

resizerThe London Trauma Conference was held this week. If you didn’t get a chance to go, and even if you did, there are some great summaries from Louise Chan on Resus.me and Iain Beardsell and Co. at St. Emlyns. [SL]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

  • Should we start using TEE in cardiac arrest management instead of TTE? emDocs.net reviews some of the advantages and disadvantages of this modality. [AS]
  • The UK Intensive Care Society held its yearly State of the Art Conference on the 8th till the 10th of December. The ICS blog has a recap of all the activities. Crit-iq also blogged about it. Enjoy the pearls! [SO]
  • Microwave technology, ketamine in agitated psych patients requiring aeromed transfer and more review of the cutting edge discussions from the London Trauma Conference via Resus.me. [AS]

The Best of #FOAMus Ultrasound

  • Are you ready for ultrasound guided CPR? Matt + Mike discuss how we’re doing CPR wrong and what we can do to improve. [AS]

#The Best of #FOAMped Pediatrics

  • Excellent induction podcast and blog post from St. Emlyn’s on the care of the child with shortness of breath. Contains a nice link to PED EM Morsels (Sean Fox) on bronchiolitis treatment as well. [AS]

The Best of Medical Education and Social Media

  • iTeachEM discusses Stress Inoculation Training with Mike Lauria and it’s role in medical student and resident education. [AS]
  • Great post on developing the EM Mindset for medical students and junior trainees from Bob Stuntz and emDocs.net. [AS]
  • The Road Ahead for FOAM from Aidan Baron on LITFL. [AS]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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CCC Update 009

Here is a quick overview of the major updates and revisions to the LITFL Critical Care Compendium since CCC Update 008.

Check these out:

Airway and cervical spine injuries

People can get pretty twitchy about intubating patients with suspected cervical spine injuries. Apply MILS, use a bougie and perform rapid sequence intubation. What’s so hard about that?… ;-)

Airway management in Major Trauma

An overview of the issues affecting airway management in major trauma, including the indications for intubation the possible causes of airway compromise in this setting.

Antimicrobial stewardship

Updated with a recent systematic review, CDC recommendations and the very useful ‘Antimicrobial Creed’.

Antibiotic timing

Updated in light of the Ferrer et al, 2014 study that reiterates the importance of early antibiotic adminstration in not only septic shock, but also severe sepsis.

Dexmedetomidine

This one has been totally revamped, not just the key clinical pharmacology but an evidence overview as well.

Intra-arrest therapeutic hypothermia (IATH)

In the wake of the TTM trial, some argue that intra-arrest cooling may still be of benefit. I’m not getting too carried away just yet…

Statins in Critical Care

Though the ink was barely dry on this one, the page has already been updated in light of HARP-2 looking at Statins in ARDS and STASH for aneurysmal subarachnoid haemorrhage. Relax, management hasn’t changed.

Vitamin D in Critical Illness

This page has already had a second lick of paint too – it has already been updated in light of the VITdAL-ICU study.

The post CCC Update 009 appeared first on LITFL.

smaccGOLD Education Q&A

Casey Parker (who you’ll know from BroomeDocs) and I were lucky enough to moderate a panel discussion on education at smaccGOLD.

Here is the audio:

The fantastic participants were:

  • Jonathan Gatward, Intensivist, Australia
  • Rob Rogers, Emergency Physician, USA
  • Victoria Brazil, Emergency Physician, USA
  • Damian Roland, Paediatric Emergency Physician, UK
  • Irma Bilgrami, Intensivist, Australia
  • Lauren Westafer, Emergency Medicine Trainee, USA

Questions discussed include:

  • Teaching in the context of a busy ED or ICU, including within the limits of the 4 hour rule: sniper teaching, flipping the classroom, in situ simulation and 5 minute teaching
  • How do we know if a FOAM resource is valid? Does FOAM lead to ‘Swiss Cheese’ learning? FOAM versus curricula?
  • What is the role of Wikipedia as a learning resource? Should FOAM creators be working on Wikipedia?
  • How to promote inter-professional and inter-specialty education?
  • What about resources for subspecialties like PICU?
  • How can junior doctors engage senior doctors in teaching on the job?
  • What advice should we give to trainees who want to get involved in education?
  • What is the best way to use 2-3 hours of protected teaching time each week?

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The road ahead for #FOAMed

This is a guest post written by Aidan Baron, aka @ALittleMedic, student-prehospitalist, one of the youngest FOAMers around and author of The Little Medic’s Blog

Explosive growth. Ever increasing content. Trailblazing innovations. FOAM is undoubtedly going places: the question is, where?

What does the future hold for the FOAM movement?

Only time will tell

And that’s the most exciting part.

Our FOAM world has come a very long way, though there are still challenges ahead.

There is an inherent risk of information overload, the ongoing process of developing a distinct identity and a steady stream of critiques; ranging from reflective self-evaluation to fear-mongering by the often technophobic.

One thing is for sure; the way we access medical education will continue to evolve over time.

Will #FOAMed endure as a distinctive force? Or will it simply dissipate into generic online learning?

What is it that distinguishes #FOAMed from soft copy e-textbooks and narcolepsy-inducing online lectures? Is it simply the free access? I would hope that our online evolution represents something greater.

Will the pain of information overload and substance heterogeneity outweigh the pleasure of instantaneous collaboration, inspiration and innovative learning?

We have witnessed how FOAM translated from a niche group of primarily critical care physicians, to a mainstream paradigm embraced by a range of diverse clinicians. It could be said that in the process it has lost some, though not all, of its loveable quirkiness in exchange for wider-spread recognition and uptake.

So, Where to from here?

Contribution vs Consolidation:

One of the biggest challenges facing FOAM is the management of information overload – a problem common to many aspects of the online world. Likely you too have recognised how near impossible a task it is to keep abreast of the horde of enthusiastic contributors who have taken a seat at the FOAM table. Luckily, a trend of content consolidation has gained momentum and many blog writers and clinicians have begun synchronising and summarising the information out there. The creation of these reviews and bite-sized tasters has allowed readers to benefit from maximal exposure with minimal exertion.
Even so, this process is relatively inconsistent and many times is duplicated by multiple authors. (Personally, I’m of the opinion that this is actually a strength, though that might just be the Darwinian in me)
Could a large part of the future of FOAM lie in consolidation and organisation rather than the explosive content-driven growth of the past half-decade?

Could Social media become a ‘Source Engine’?

A paradigm shift might be in order.
Why are we using Search Engines such as Google to find educational content?
Quality, usefulness and impact are easily distinguishable. The ‘better’ a resource, the more likely one is to remember and then recommend it when asked. This is a truly underappreciated strength of FOAM that sails beneath the radar – we are a collaborative network who aid each other in sourcing content! We are not discussing peer reviewed evidence here, rather the impact of educational content on people – who better to adjudicate this than other people!?
Let’s stop using search engines to find content that drives humans, and instead start using humans who’ve already experienced that content, and been driven by it, to recommend it to us!
Could Social media become a ‘Source Engine’?
Should we be ‘Sourcing’ quality content rather than ‘Searching’ for it?

A Question of Quality:

“But what about quality control?” is the cry sounded again and again by the rightfully sceptical.
First, let’s consider that #FOAMed is a movement built on the sharing of knowledge for the mutual benefit of our practice and thus ultimately our patients. Stringent critical analysis is applied by FOAMed readers in the form of post-publication comments and critiques, and more importantly, by content creators themselves. The best content is thoroughly researched, meticulously referenced and openly discloses the strengths and weaknesses of its arguments
Fortunately, good quality, high impact, clinically useful content stands out from the crowd.
The best FOAM bubbles to the surface.
SoMe (Social Media) is how we interact and share – we are all our own independent review process – highly shared content is thus far more likely (even though not guaranteed) to be of superior quality. The Internet is a ‘quality democracy’.
As with any new information, the onus is on the learner to evaluate the quality and trustworthiness of the source. In this, reputation is just as important in the online world as in any other teaching environment. After all, when was the last time you recall seeing poorly evidenced, low quality educational content from a well-regarded FOAM contributor? With this in mind, there is the potential for quality content from newer sources to go under appreciated, though FOAMed’s welcoming and egalitarian ethic makes this far less likely than in almost any other field!
There is no question in my mind that the benefits to our education and, most importantly; to patient care, outweigh the thus far theoretical risks.

Diversity in Delivery:

It has become apparent that trying to create an online one-stop-shop for all interests is both unrealistic and undesirable, and that a diversity of both contributors and consumers is healthy.
As learners, we have different needs.
Students are in search of entirely different content to residents, and in turn, to faculty.
Content creators and online educators shouldn’t attempt to be ‘all things to all people’ but rather pitch to a target within the FOAM spectrum of users.
There is a noticeable trend of increasing content relevance (e.g. Foamcast, CCH journal, LITFL R&R)  with resources that target different audiences. Perhaps this will become even more apparent in the future as more individuals from different career stages turn to FOAM for their learning needs.

As the FOAMed spreads:

Social Media can be intimidating and FOAM shouldn’t necessarily be synonymous with it.
Does FOAM exist without mainstream social media platforms?
In my opinion: Yes!
I prefer to view FOAM as a Tao. A way. An ethos.
As much as it pains me to admit, one does not need twitter to support or use FOAM.
Part-and-parcel of our global expansion is accepting that many find social media confronting or confusing. You wouldn’t throw a medical student into a resus room and shout “intubate!”
Let’s not apply a similar pressure to the more technologically conservative amongst us. In order to assist our colleagues, we can encourage them to start gradually, perhaps with an email subscription to a few high output blogs relevant to their area of interest.

Having said that, I truly believe that the connectedness that occurs through social media is one of the greatest strengths of FOAM.

What began as a small and tight knit circle of content creators in the critical care arena – the original pioneers of FOAM, has become a diverse and vibrant community – branching off into; paediatrics, general practice, family medicine, toxicology, wilderness medicine, ultrasound, ICU and many more: each with their own focus, leaders, memes, subcultures and hashtag !

The essential component remains that through Social Media, these offshoots and diverse threads of #FOAMed are able to constantly interact. With this comes a cross-pollination. We are maintaining a refreshing and innovative culture which encourages interdisciplinary collaboration and the breaking down of silos, rather than the tribal mentality of many modern medical institutions.

Information Overload
Content Consolidation
Sourcing Quality
Delivering Diversity

Just a few of the many tribulations and triumphs we have to look forwards to.

I see a bright future reflected in the glimmering surface of #FOAMed

Watch this space.

With Special thanks and gratitude to Dr Michelle Johnston (@Eleytherius) and Dr Penny Wilson (@NomadicGP) for their advice, input and editing.

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