LITFL Review 264

LITFL review

Welcome to the 264th 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 chunk of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick Cummins

Another great set of talks from SMACCDub released this week: John Greenwood discussing assault on the RV and Haney Mallemat on the PEA Paradox. [AS]


The Best of #FOAMed Emergency Medicine

  • Rob Orman talks to a number of EPs about the practice changers in Emergency Medicine from 2016. [AS]
  • Edd Carlton discusses the latest update to the NICE Chest pain guidance, a new dictat or the case of the missed opportunity? [CC]
  • Bryan Hayes and the ALiEM team review the standout EM-Pharmacotherapy papers for 2016. [AS]
  • Excellent review of labs to order and how to interpret those labs after fluid drainage in patients with ascites and pleural effusions from the Taming the SRU site. [AS]

The Best of #FOAMcc Critical Care

The Best of #FOAMed Resuscitation

The Best of #FOAMtox Toxicology

  • A case report discussed by TPR team.  Do you know your U-47700?  No?  Neither did I, until now. [CC]

The Best of #FOAMus Ultrasound

  • How do we integrate our POCUS skills into actual problem solving? Philippe Rola discusses a 39 year old lady presents to his department with undifferentiated shock…and POCUS helps save the day [SO]

The Best of #FOAMped Paediatrics

  • Does the length of antibiotic therapy make a difference in otitis media resolution? EM Nerd and Don’t Forget the Bubbles both delve into the recent NEJM study investigating this question and point out that it’s all about how you define treatment success. [AS]

The Best of #FOAMim Internal Medicine

News from the Fast Lane

Reference Sources and Reading List

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Last update: Jan 9, 2017 @ 7:50 am

The post LITFL Review 264 appeared first on LITFL: Life in the Fast Lane Medical Blog.

WINning in ICU

This post is coauthored by Sarah Yong (@drsarahyong) and Lucy Modra from the Women in Intensive Care Medicine Network (WIN)

The Women in Intensive Care Medicine Network (WIN) was formed in 2015, with the aim of improving the gender balance in Australasian intensive care medicine through research, advocacy and networking.

WIN logo

But why was WIN established? How many female doctors actually work in intensive care medicine in Australia?

The Medical Training Review Panel reports data directly from Australasian specialty colleges regarding their fellows and trainees. In 2015, 17.1% of CICM fellows and 32.1% of CICM advanced trainees were female. In comparison, 51% of medical school graduates were women in 2015. Intensive care medicine is included in a list of “…specialties that consistently had a lower proportion of female trainees…”. There are even fewer women in leadership positions within intensive care medicine. Women make up only 10.5% of Clinical Directors of ICUs accredited by the CICM in 2016. There are only 4 women out of 18 members of the CICM board and just one woman sitting on the ANZICS board (15 members).

So, what’s the big deal – why does this matter?

The bottom line is that gender diversity is essential to ensure we can achieve the best outcomes for our patients and is imperative for the sustainability of our specialty. Sure, it is promising that the proportion of female trainees is higher than the proportion of female CICM fellows. However we need to work to ensure this translates to more female intensivists in the future, and importantly, improved female representation in leadership positions within our specialty. We cannot produce the best intensivists by drawing upon only half the cohort of medical students, and we cannot attract the highest quality leaders by recruiting from half the pool of clinicians. There’s good reason to think that our patients could benefit from an improved gender balance in the ICU workforce. In the business world, improving gender diversity on company leadership teams leads to increased profit margins. New evidence even suggests that the patients of female doctors have better outcomes than patients of male doctors.

So what’s WIN doing about it?

  1. Research (“In God we trust. For all others, bring data”)
  2. Advocacy and representation
    • Advocating to CICM regarding part time positions and parental leave provisions for trainees.
    • Encouraging female trainees and intensivists to nominate for leadership roles in intensive care medicine.
    • Engaging in conferences, e.g. debating ‘That the Part Time Intensivist will be the death of intensive care medicine.’ at the ANZICS/ACCCN ASM 2016
  3. Networking
    • Regular educational dinners
    • Networking events at critical care conferences

If you’d like to get involved, send us an email (, attend one of our committee meetings (Melbourne) or attend one of our dinner events (Melbourne or Sydney).

The post WINning in ICU appeared first on LITFL: Life in the Fast Lane Medical Blog.

Funtabulously Frivolous Friday Five 171

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 171

Question 1

Which famous fictional character suffered from Erethism?

  • The Mad Hatter due to mercury exposure.
  • Common symptoms include irritability, low self-confidence, depression, apathy, shyness, personality changes, memory loss and delirium.
  • The connection between the Mad Hatter in Lewis Carroll’s Alice and Wonderland and erethism is unclear, and a mere speculation however, the character was almost certainly based on Theophilus Carter, an eccentric furniture dealer who was well known to Carroll. [Reference]

Question 2

Leonard Thompson received the first what?

  • Insulin injection
  • On January 11, 1922, at 14 years of age in Toronto he received his first injection but due to impurities he had an allergic reaction. James Collip worked for a further 12 days to refine the canine insulin and successfully delivered a second injection.
  • Thompson showed signs of improved health and went on to live 13 more years taking doses of insulin, eventually dying of pneumonia at age 27 [Reference]

Question 3

Contaminants from this pub led to the discovery of what?

  • Penicillin
  • The Fountains Abbey in Paddington was frequented by Alexander Flemming and was across the road from his laboratory. The pub claims spores from the ale house drifted through the window onto Flemming’s culture dishes. [Reference]
  • Nee-sayers claim Flemming rarely opened the window and it was probably a contaminant from someones lab coat. I think a personal visit might be in order to discover the truth.


Question 4

Which psychiatric hospital in the UK gave rise to the word ‘Bedlam’?

  • Bethlem Royal Hospital
  • Europes oldest extant psychiatric hospital and the source of many horror stories, TV shows and films. [Reference]

Question 5

What is the mortality associated with selfies?

  • Research found selfie deaths are on the rise:
  • 15 selfie-takers died in 2014
  • 39 in 2015
  • 73 died in the first eight months of 2016
  • Fortunately a US team is developing an app to warn people they are taking too high a risk during their selfie attempt. It’s good to know as I come to the end of my training I still have job security. [Reference]


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Simulation Instructor Training Course

Simulation as a Teaching Tool
Feb 14-17 2017
Sunshine Hospital, Melbourne

What is it?

This is a four day immersive simulation course delivered by the Harvard Course Faculty (Centre for Medical Simulation). The CMS was one of the world’s first healthcare simulation centres and continues to be a leader in its field both at Harvard but also globally.

This is your opportunity to join us on this high level course. Through scenarios, lectures and group discussions you will be taught clinical, behavioural and cognitive skills through simulation.

How much is it?

  • Early Bird Rate $6750 (inc GST) until Thursday 22nd December 2016
  • Late Registration $6900 (inc GST) from 23rd December 2016

Where is it?

Sunshine Hospital, Melbourne, Australia

How do I apply?

Apply here
Or Contact:
Janet Beer, simulation manager at Western Health:
Mobile: +61 (0) 401 695 040

Should I ignore this post?

Probably not, spaces are limited to 22 and only 5 left.

Can I have more information?

Download (PDF, 1.19MB)

The post Simulation Instructor Training Course appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 167

Research and Reviews in the Fastlane

Welcome to the 167th 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, Soren Rudolph, 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

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


Myles PS et al. ATACAS study. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. N Engl J Med 2016. PMID: 27774838.

  • The ATACAS study was a large, multi-centre, double blind study with a 2 by 2 factorial design. Patients undergoing coronary artery surgery that were considered “at risk for peri-operative complications” were assigned to either receiving aspirin or placebo and tranexamic acid or placebo. The group that received tranexamic acid had a lower risk of bleeding compared to placebo. Even though there wasn’t a higher risk of death or thrombotic complications, there was a higher risk of post-operative seizures observed within the tranexamic acid group.
  • Recommended by: Nudrat Rashid

The Best of the Rest

R&R Hot Stuff - Everyone’s going to be talking about thisWillman MW, et al. Do heroin overdose patients require observation after receiving naloxone? Clin Toxicol 2016. PMID: 27849133

  • There has been recent interest in a policy of decreased or no observation time for patients receiving naloxone after heroin overdose. This article summarizes several retrospective reviews, concluding that patients with heroin overdose typically do well after EMS treat-and-release naloxone administration, and that they can be safely discharged from the ED after a period of one-hour observation. Considerable limitations in the retrospective nature of such reviews and significant impact of new adulterants such as fentanyl and U-47700 on current “heroin” overdoses seriously limit interpretation and applicability of these studies to today’s clinical practice. Strong caution should be taken in making practice changes based on retrospective and potentially outdated data.
  • Recommended by: Meghan Spyres
  • Further reading: Treating “heroin” overdose: The past is no guide (The Poison Review)

Emergency Medicine
R&R Game Changer? Might change your clinical practiceTaylor DM, et al. Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial. Ann Emerg Med 2016. PMID: 27745766

  • This was a well executed RCT that found midazolam 5 mg/droperidol 5 mg IV was superior to droperidol 10mg IV or olanzapine 10 mg IV for agitated patients. The 2-drug combo worked in 75% of patients at ten minutes vs ~50% in the other two groups. Also, fewer repeat sedative doses were needed when the drugs were combined. Median time to sedation was only 5 minutes for the combo vs. 11 minutes for the other two individual drugs. Adverse events were statistically similar in all groups, but the midazolam/droperidol group had a higher percentage temporarily needing jaw thrust or supplemental oxygen. For agitation, the combination of midazolam 5 mg/droperidol 5 mg IV was better and faster onset than droperidol 10 mg IV or olanzapine 10 mg IV. 
  • Recommended by: Clay Smith

R&R Eureka - Revolutionary idea or conceptPengel KB. Common overuse injuries in the young athlete. Pediatr Ann 2014. PMID: 25486038

  •  We constantly want kids to be more active… but that can lead to some injuries. The knee is very susceptible to overuse injuries, but before you simply label it a “Sprain” consider a few other ominous entities.
  • Recommended by: Sean Fox

Pediatrics                                                                                                                                                               R&R Eureka - Revolutionary idea or concept
R&R Hot Stuff - Everyone’s going to be talking about thisHoreczko T, et al. The Pediatric Assessment Triangle: Accuracy of its application by nurses in the triage of children. J Emerg Nurs 2013. PMID: 22831826

  •  This prospective observational trial looked at the outcomes of 528 children for whom the triage nurse had performed an assessment using the pediatric assessment triangle (PAT) at a large academic pediatric emergency department. Two pediatricians, blinded to that triage assessment, retrospectively reviewed the chart to determine the final diagnosis (of stable versus unstable). The biggest weakness of this data is that although 1002 charts were selected for review, only 528 contained adequate data for inclusion. The PAT did a good job screening for instability (97.3% sensitive 95%CI 64.6-98.8%), although like most screening tools it does over call (specificity of 22.9% with 95%CI 17.0-30.0%). The triangle was reasonable for identifying respiratory distress (LR+ 4, 95% CI 3.1-4.8), respiratory failure (LR+ 12, 95% CI 4.0-37), shock (LR+ 4.2, 95% CI 3.1-5.6), central nervous system/metabolic disorder (LR+ 7, 95% CI 4.3-11), and cardiopulmonary failure (LR+ 49, 95% CI 20-120). Perfect identification of the final assessment is not the role of a triage tool, like the PAT. The PAT tool performed well here, but perhaps a more appropriate measure would have been something like the number of children who become unstable within the first hour who were missed by the PAT? Bottom line: The pediatric assessment triangle is an excellent triage tool, but you still have to follow it with a complete medical assessment.
  • 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: Jan 5, 2017 @ 9:57 am

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