Funtabulously Frivolous Friday Five 109

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 109

Question 1

A friend casually remarks that she has an afternoon appointment with Doctor Fish, and asks you if you’ve heard anything about them. You caution her that…?

  • Doctor Fish
  • Otherwise known as Garra rufa, are used in ‘fish foot spas‘ (nibbling off dead skin)
  • Whilst they have not yet been reported to cause disease the fish have been found to carry a wide range of bacteria that could be pathogenic – including group B Streptococci, Aeromonas species, Vibrio species and Mycobacterium species [Reference]
  • Your friend thanks you and heads to a pedicure instead before you have time to tell her about Mycobacterium fortuitum

doctor_fish_blue

Question 2

The pest exterminator gives a wry smile as you explain why you are starting him on warfarin. “I’ve worked with that all my life!” he remarks, “One of the main reasons it’s effective is because rats can’t….”?
rat

  • …vomit
  • Apparently it relates to an absent brainstem reflex.
  • Also helpful that warfarin is reportedly odourless/tasteless. [Reference]

Question 3

You arrive home to find your flatmate in a state about “an alert” that the CDC had on their website. He’s only skim-read the article, but that’s ok because he’s seen a film that covers “the rules” – 1. cardio, 2. double tap, 3. beware of bathrooms, 4. wear seatbelts…. What was the topic of this 2011 article from the CDC and what film is your flatmate referring to?

  • Zombies
  • The CDC produced an article highlighting the importance of being prepared in an emergency, citing zombies as an example (complete with zombie awareness posters to download).
  • The rules mentioned are from the 2009 comedy-horror “Zombieland” [Reference]

Zombie

Question 4

Your ballpoint pen has run out of ink, you have a terrible memory for numbers, your phone is dead and you have just met the perfect woman (or man). What dermatological condition would come in handy about now?

  • Dermatographism
  • Dermatographism would allow you to write their number on your arm, and give you 15-30 minutes to find a working pen.
  • Dermatographism is an uncommon condition also known as physical urticaria. Physical pressure causes the skin to become raised and inflamed in the shape of the stimulus.

Question 5

Released in 1999, who does this stamp celebrate?
Vaccine

  • Vaccination
  • Edward Jenner’s development of the smallpox vaccine was commemorated in 1999 as part of The Patients Tale issue.
  • The image ‘on the cow’ is that of Edward Jenner, the father of vaccination, inoculating James Phipps, an eight-year-old boy with cowpox. [Reference]

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JellyBean 031 with Matt Eckersley

So you’ve heard of Christmas Island, right? It’s all bad, right? Well, it is bad but it’s not all bad and as often is said there’s two sides to every story. And as I often to say there’s more than two sides to every story.Matt Eckersley has been working out in the Indian Ocean Territories for a while. There is a lot of aspects to whats been happening out there that I knew nothing about. He has been there for a number of extreme events; self-harm events, riots, the 2010 boat sinking tragedy etc

Matt has also worked in the Christmas Island Hospital and soon is on the way to an even smaller more remote Cocos Island where the locals mostly speak Malay. Did you know that? There are a lot of new info in here. He gives a very measured and very informative insight into a largely misunderstood part of Australia.

He is impressively delicate and diplomatic about Christmas Island and good on him. I will not pretend; I am vehemently opposed to Australian Government policy on immigration, asylum seekers, mandatory detention etc. It’s evil. If karma exists some powerful white Australian people have some demonstrably awful times ahead.

Here is the link to the entire letter written by the Doctors from the Detention Centre, please, read it and be informed;

christmas island hospital
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Chest X-ray for the Part 1 exam

BSCC Anatomy 100

The following two videos will assist you in the part one exam. The points in the first video relate to the marks scheme provide to the present day. Be sure to point out obvious structures such as the ribs, clavicles, spine, lungs etc. The second video goes into further detail on the AP film and also the lateral chest x-ray which maybe helpful in the emergency department.

Question:

Please describe the main features on this chest x-ray in particular the mediastinum

Examiner explanation:

Examiner – additional points of reference including the lateral chest x-ray:

 

References:

 

Normal CXR Labelled

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Real ED Stories – Book Review

Emergency is an anatomy book. It is a collection of stories penned by Emergency Physicians across Australia, and through them the heart of the Emergency Department is meticulously dissected. The raw stories of individuals, of both patients and their clinicians, are laid wide open, for all to see. Emergency is a book that is by turns painful, occasionally gruesome, many times uplifting, but always, in its honesty, brilliantly authentic.

These are short stories, written not by masterful authors, but by the doctors working at the coalface of Australasian ED’s. And in that is its strength.

Some of the stories read like cathartic confessionals arising from a troubled experience, others as a manifestation of occupational grief, while others dispense a sort of education for the public – this is what goes on behind the scenes when you find yourself or your loved ones ferried, lights and sirens blaring, into an Australian Emergency Department. There are moments of bravado, joy, compassion, and humour. The dying patient, the human on the brink of life and death, is a common theme throughout the book. This is understandable. Cases of critical illness, cases of teetering mortality and the expectations and love of family members that shapes such presentations, are events that stick fast in the minds of the treating clinicians, and they irrevocably, continually, shape these doctors throughout their entire career.

And so these are their stories. They are all true, with just enough alchemical editing to preserve patient anonymity. At the heart of each of the stories is the fundamental unit of care – the interaction between a patient in need, and the team that cares for them, a team which includes paramedics, doctors, nurses, and other staff alike. Surprisingly, there is little mention of the scourge of the managerialism and bureaucracy that has crept insidiously into hospital care. Instead the vastly rich humanity of the individual patient interaction has been what has moved these doctors to write down their experiences and share them in this book. Yes, it is humanity, magnified and celebrated.

As a seasoned ED physician myself, I still found myself moved by each and every story. I finished most with a lump in my throat, and had to take a moment before starting the next one. It almost felt like a day at work, lurching from one critically ill patient to the next. Thus it might be advisable to dip into the book a little more sagely, one story at a time, not a gorge in one exhausting sitting (can’t have the experience too visceral, after all).

I must admit to a disclaimer. I have a (small, inconsequential) story of my own in this book. Is this a bit like getting your own mother to write a book review?
Perhaps. But I can guarantee one thing, this book has a power and a truth about it. Written, not by conventional writers, but those who really know a thing or two about treating the emergently ill and injured, with no greater desire than to share their story with the greater public.

Enjoy.

Resources

Real ED Stories

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Super Docs

Guest post by Tane Eunson – A student of the game (5th year M.B.B.S.)

As a typical kiwi bloke, I’m a dyed-in-the-wool rugby fanatic (pardon the sheep reference). So when opportunities with two Super Rugby franchises arose for me in the past year, I picked the ball up and sprinted for the posts.

As an ‘intern’ with the franchises, I was part of the ‘athletic performance’ teams. The hierarchical structures differed subtly within each team, but they both comprised the team doctor, two physiotherapists, two strength and conditioning coaches and a number of other interns in the varying disciplines. With regards to professionalism and teamwork, there was much for a student to learn in these environments.

The athletic performance team would typically meet before 7am to discuss the players’ training statuses; the sports equivalent of ward rounds.

“Andy has a Lisfranc fracture, remove cast and begin rehabilitation today”.
“Johnny has an infraorbital fracture from last night, maxillofacial review tomorrow”.
“Tom has a posterior malleolus fracture of his Tibia, arrange CT ?os trigonum fracture” etc.

Of course, not all medical complaints were hard tissue, there were an array of soft tissue injuries too; posterior cruciate rupture, intercostal haematoma, pectoralis major rupture, pre-patellar bursitis and everyone has ‘bumps and bruises’. These injuries are hardly surprising when you have 30 muscle-bound men launching themselves at each other for over an hour every week. What I did find surprising though was the majority of presentations to the team doc were for ailments more familiar to you and I; viral pharyngitis, shingles, folliculitis, sleep problems. Professional sportsmen are apparently human too and being a doc for a professional rugby team has more in common with general practice than one may expect.

The players would stroll in at 8am and log their ‘wellness’ scores. We want to know how they’ve been sleeping, how well they’re eating, how well they’re hydrating, how fatigued they feel; these are the professional sportsman’s vital signs. They’re screened with ‘adductor squeeze’ and ‘sit and reach’ tests and all the data is compiled to yield their ‘training-stress balance (TSB)’.

The players’ physical workloads are closely monitored and their training can be adjusted accordingly e.g. “Last week Joe had a season high for contacts and GPS metres run. His back has flared up and he has slept poorly. His sit and reach is down significantly and his TSB is high. We’ll rest him from full-contact today and treat his back with physiotherapy at 11am.” This structure gives the athletic performance team tangible markers to assess whether the player is “well or unwell” and gives the players the best opportunity to put a strong performance on the park, week in and week out.

And perform week in and week out they must.

In few other areas of medicine are our ‘patients’ so performance driven. Physical performance is what puts bread on the athlete’s table and without elite physical performance, their days as a professional athlete are numbered. Therefore, treatment and rehabilitation is ‘accelerated’ wherever possible. If the general public rehabilitates from PCL rupture with conservative management in 12 weeks, we’ll look for evidence to support 8 weeks. If the general public suffers an incomplete rib fracture that requires rest, we’ll consider the player getting an injection of local anaesthetic to mask the pain before a game.

This approach may sit uncomfortably with some medical professionals, but this is the reality of professional sport. We are dealing with grown men who have chosen to play a combative game for a living and it is the responsibility of the sports doctor to do everything, ethically and legally, in their professional capabilities to have these men prepared to perform. I concede it can be a delicate line to tread at times, but we must remember these are not your standard ‘patients’ in a hospital ward. These are fit men in a unique position where the currency of their livelihoods is athletic performance and we must do all we can to support them.

The position they find themselves in is truly unique, particularly in my homeland of New Zealand. These men are more than just rugby players, they are ambassadors for our country and they put our shaky isles on the world map. Most Kiwi boys grow up dreaming to be them and it is without hyperbole that their 80 minutes of work can affect the mood and economy of an entire nation.

With influence comes responsibility and some will cope better than others. At the end of the day, they are just young men and men are fallible. For instance in New Zealand, drinking culture is almost as firmly embedded as rugby culture and the two are intimately intertwined. You can even purchase t-shirts proclaiming, “My drinking club has a rugby problem”. Hence, it is with little surprise that we have rugby players making poor choices around alcohol. In a country like New Zealand, this means headline news and every season there is a very public incident involving a high-profile rugby player. Therefore, the team doctor must provide support for not only the physical demands of the athlete, but the psychosocial stressors too. Alcohol misuse is just one example, but depression and anxiety are possibly even more prevalent. The Lancet reported in November 2013 that a poll by the New Zealand Rugby Player’s Association found approximately a quarter of retired New Zealand rugby players have had alcohol or substance abuse problems. Moreover, approximately a third have had depression, feelings of despair, and/or experienced high levels of anxiety or stress. The team doctor must have the capabilities and resources to deal with mental health issues, as they will almost certainly be encountered in a rugby team environment.

Fortunately for the doctor though, he or she is not an island, and they are part of a team of health professionals. There are physiotherapists and strength & conditioning coaches that are integral parts of the team. However, the team doctor also needs to readily facilitate expert opinions and treatment from a number of other medical experts. In particular, strong relationships with orthopaedic surgeons and musculoskeletal radiologists are vital for timely and effective treatment of their players. This includes whether the team is at home, away domestically or playing internationally in any of the 3 competing unions; New Zealand, Australia and South Africa. On game day, there must be a neutral ‘game day doctor’, a ‘concussion doctor’, a ‘stitch doctor’ and can even be a ‘resuscitation doctor’ to manage the workload of the team doctor who acutely treats the players on the field. Therefore, to be an effective team doctor, one must not only be exceptional in their own field, but it is imperative they also have meaningful professional relationships with their peers in complementary disciplines. The maxim that ‘no person can make it on their own’ rings particularly true for the team sports doctor.

Therefore, to make it as a team doctor for a professional Super Rugby team , one must have the breadth of knowledge a GP possesses, yet the depth of knowledge for pathology common to the professional athlete. They must be able to accurately assess the wellbeing of their players to optimise consistent performance and be willing to ‘accelerate’ their management whenever appropriate. They must have the interpersonal skills to treat mental health issues and function well within a team, while having access to a strong network of health professionals. If one person can achieve all of these to a high standard, then they truly are ‘Super Docs’.

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JellyBean 030 with Jesse Spur

Injectable Orange. That’s an interesting one.Jesse Spurr is one of the FOAMed/FOANed talents that I have had the pleasure to meet through all this social Social Media stuff.

With an interesting past in sport, sports science, Jesse hit ICU nursing with a bang and became a simulation trainer really very quickly. (He must have been good at it.)

Jesse’s site www.injectableorange.com started out as a journal. On a WordPress blogging website. It’s more than that now. Jesse has an interest in cross germinating multi-disciplinary education. And an interest in the changing dynamics of interactions between different professions. And an interest in the curious nature of nursing training and career courses. And in the phenomenon of “N=1” as an influence of thinking in medical teams. He has a lot of interests.

We natter a bit about how the hell you get into this sort of thing and a few other nurse blog start-ups. If all that seems like a bit too much hassle you could be a guest contributor on Jesse’s site.

What a lovely bloke.

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