Clinical Case 140: Rapid POCUS Diagnosis

A quick case from the Broome vault…

This case really shows how we can use bedside POCUS to make really important diagnoses in rapid time.  Sometimes the fact that “traditional tests” are not available forces me to use POCUS as a “Substitute” which works out really well!

If you are a POCUS junky or want to get involved in a really cool free-POCUS project then please check out thepocusatlas.com  – online atlas launching soon!! Thanks to Dr Michael Macias for making this happen

Our patient today is a 45 yo chap who has presented to ED with 2 days of non-productive cough and some vague posterior chest pain which seems to be worse when he tries to lay down at night.  He has no significant previous medical history.  He denies any fever, recent URTI or prodromal symptoms.  On specific questioning he has noticed some exertional dyspnoea in the last few weeks which he had attributed to being “outta shape”.  He does recall that his older brother has had a heart problem and had to have a “pacemaker” at age 48 for some “heart issues”.

Obs:  HR = 85 SR,   BP 160/100,  SpO2 = 96% RA,  RR = 20,  Afebrile

Our trusty local medical student has had a listen and think that there may be some bibasal crackles, maybe some decreased air entry.  He isn’t sure if he heard a murmur or not…

So that is pretty much where the clinical data stops.  It is Saturday, there are no labs or radiology available for at least 48 hours…. so let’s look at the chest and see what is going on.

Here are the posterior lung views looking at the bases:

RIGHT LUNG BASE                     LEFT LUNG  BASE

We see symmetrical bibasal, anechoic pleural effusions.  As we scanned up above these effusions we saw symmetrical, dependent B-lines which continued all the way up to the upper lungs.  So the most likely diagnosis here is pulmonary oedema with bilateral effusions.

So, now we must look at the heart – that is where the problem is most likely to be.

Here is a rough and ready subcostal view (long axis):  SUBCOSTAL LONG AXIS   {click for vid clip}

If you would like a little colour Doppler to help: SUBCOSTAL LONG + COLOUR {click for clip}

Tech tip: Some patients just do not have good windows, so you need to be creative and use any window that gives you the data that you need to make a call.  Generally you can get either parasternal OR subcostal views on most patients, so keep looking, don’t quit if your first window is tough.

A few still images to help bring it all together…

Apical 4 chamber

Subcostal – LV Ed diameter 5 cm

M Mode EPSS – dilated LV makes this huge! 3 cm

So this is how I put it all together. We have a man who was “well” until recently.

He has dilated cardiomyopathy with pretty poor global LV function (guessing his EF is 20 – 30 %).

He also probably has some degree of mitral regurgitation, which is probably functional due to the dilated LV, rather than a primary valve lesion.

Put together with the family history – we may be looking at a genetic lesion? Maybe something environmental?

The power of POCUS in this case was that it allowed us to diagnose all of that within a few minutes of triage.  Without POCUS and with no conventional tests available on the weekend this chap would have lingered, undiagnosed.

POCUS makes our jobs much more satisfying and can really accelerate the delivery of excellent care in “resource poor” hospitals.

I have been talking at the EMUGs sessions in Australia recently about POCUS in Under Resourced Environments (PURE).  However, I think this is the wrong way around.  For me, POCUS, is about getting the most out of the resources that are available.  Moving the care forward,  doing smarter care with the resources that we have at our dispopsal.

So if you have a great POCUS case to share – go over to thePOCUSatlas.com and share your images with the world.  We can learn together to deliver great care.

Casey

 

First10EM Journal Club: March 2017

Hello EBM listeners

After a month of radio silence we are back with the March episode of the Justin & Casey Journal club.

This month we have 11 papers in 3-quarters of an hour. We cover the good, bad and ugly of migraine sprays.  How Facebook stats can determine your longevity, Marik’s Magic Sepsis Sauce and how to “toughen up” in the face of rudeness mid-Resus!

As always – the papers discussed are available on the links below in full-text, PDF glory.  So don’t rely on our simple minds – have a read and make up your own mind!  You can read Justin’s in depth, written analysis over at First10EM (great blog!)


Most misunderstood and misinterpreted paper of the month
Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use.   The New England journal of medicine. 376(7):663-673. 2017. PMID: 28199807

Bottom line: Opioids are a problem. Prescribe responsibly. Don’t use combination pills. Avoid euphorics like percocet and stick to plain oral morphine. Prescribe only short courses for acute pain. But ignore this paper – it doesn’t tell you anything.


Why we need resuscitation sequenced Intubation
Perbet S, De Jong A, Delmas J. Incidence of and risk factors for severe cardiovascular collapse after endotracheal intubation in the ICU: a multicenter observational study.   Critical care (London, England). 19:257. 2015. PMID: 26084896

Bottom line: In critically ill patients, post-intubation cardiovascular collapse is common. We need to resuscitate these patients prior to intubation, and be prepare for deterioration.


Intranasal Ketorolac?
Rao AS et al. A Randomized Trial of Ketorolac vs. Sumatripan vs. Placebo Nasal Spray (KSPN) for Acute Migraine. Headache.   Headache 56(2):331-40. 2016. PMID: 26840902

Bottom line: I don’t use any of these options in the emergency department for migrain right now. This paper won’t change my practice.


Intranasal lidocaine? Adding insult to injury?

Avcu N, Doğan NÖ, Pekdemir M. Intranasal Lidocaine in Acute Treatment of Migraine: A Randomized Controlled Trial.    Annals of emergency medicine. 2016. PMID: 27889366

Bottom line: Just in case you were wondering, intranasal lidocaine is unlikely to help your migraine patients.


Forget the sepsis bundles, these patients just need vitamins
Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study.   Chest. 2016. PMID: 27940189

Bottom line: Definitely not a game changer, but I think it is interesting, and you will here about it, whether in a medical venue or on NPR.


A couple papers on rudeness…
Riskin A, Erez A, Foulk TA. The Impact of Rudeness on Medical Team Performance: A Randomized Trial.      Pediatrics. 136(3):487-95. 2015. PMID: 26260718

Riskin A, Erez A, Foulk TA. Rudeness and Medical Team Performance. Pediatrics. 139(2):. 2017. PMID: 28073958
Bottom Line: Our performance is not directly influenced by outside stimuli – it is our interpretation of those stimuli that matters. That is good news, because you can train yourself to alter your interpretations and therefore maintain the excellent performance you are accustom to. (JM: You can read more about this in my recent post Performance Under Pressure.)


The easy IJ…
Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access.   The Journal of emergency medicine. 51(6):636-642. 2016. PMID: 27658558

Bottom line: I will definitely keep this procedure in mind in patients with difficult vascular access


Treatment for first time seizures?
Leone MA et al. Immediate antiepileptic drug treatment, versus placebo, deferred, or no treatment for first unprovoked seizure. The Cochrane database of systematic reviews. 2016. PMID: 27150433

Bottom line: This is all about shared decision making to me. There isn’t a clear answer, so I will probably still leave this decision to the neurologists in follow up.


They might bend, but they won’t break
Jiang N, Cao ZH, Ma YF, Lin Z, Yu B. Management of Pediatric Forearm Torus Fractures: A Systematic Review and Meta-Analysis.    Pediatric emergency care. 32(11):773-778. 2016. PMID: 26555307

Bottom line: There is no reason to be casting torus fractures. We should probably stock velcro splints in the ED instead.


Could facebook extend your life?
Hobbs WR, Burke M, Christakis NA, Fowler JH. Online social integration is associated with reduced mortality risk. Proceedings of the National Academy of Sciences of the United States of America. 113(46):12980-12984. 2016. PMID: 27799553
Bottom line: I wish I had more friends

Bronchiolitis 2017: Winter is Coming

The bronchiolitis season is here! Well it is in Broome anyway.  Winter in the southern hemisphere is on the way and we are all ready for the coughing, coryzal, crackly chickens that will crowd into our cubicles soon.  Bronchiolitis is the bread ‘n butter of Paeds Emergency care – this is something we need to do well and know backwards to deliver great care.  Recent years have seen quite a bit of flux in the state of the evidence for managing our little wheezers.  If you live below the equator then you may be aware of the PREDICT crew [Paediatric Research in Emergency Department International Collaborative network].  This is an Aussie / NZ research group who put out evidence-based clinical guidelines and carry out research in kids ED practice.

Their 2016 AUSTRALASIAN BRONCHIOLITIS GUIDELINES were put out recently, just in time for the silly season.  [PDF version is here].  You can read either the long version, or the shorter practical version if you like your EBM spoonfed!

I thought it might be interseting to run throught he recommendations and see what is new, what is controversial and what we may need to change. So please do NOT consider this a cook book for the management of bronchiolitis – it is really just what I found interesting and may influence my practice.


CLINICAL EXAM & DIAGNOSIS: Bronchiolitis remains a clinical diagnosis.  It starts with upper respiratory symptoms and progresses to the lower tract on day 2-3.  These include cough, tachypnoea, increased work of breathing, recessions and the presence of crackles and wheezing.

Hot tip: I have developed a new test to clinically confirm bronchiolitis: THE TBA (Triple Blind Auscultation) All you need is 3 medical students / JMOs or other eager young Paeds learners.  You send them one at a time, at 5 minute intervals into the bay to listen to the babe’s chest.  You then sit them all down and ask them what they heard… if a heated debate breaks out about where the crackles were eg : left upper lung, right lower, both bases…. then it MUST be bronchiolitis!  This is how mucus behaves.  However, if they all agree the creps were only in the left base… think again.  [If you only have one student available – you can just send them back in 3 times, it is amusing to watch them debate their own findings with themself.!! ]  Sorry, cruel – but crucial to learn.


RISK FACTORS FOR SEVERE DISEASE:

  • Preterm (gestational age < 37 weeks) – though some folk like to measure “age since conception < 48 weeks”. So if you were born at 36 weeks and are now 11 weeks old you are 36 + 11  = 47 weeks “post conception”.
  • Age less than 10 weeks (which is similar to Post-conception age < 48 weeks.
  • Failure to thrive
  • Known congenital heart disease
  • Chronic lung disease ( eg. bronchopulmonry dyplasia, lung disease of prematurity..)
  • Congenital neurological disease ( I would include genetic disease such as Down’s etc)
  • Cigarette exposure
  • Being Aboriginal – though this is a crude risk factor in my opinion..

In Broome we tend to see quite a lot of kids with prematurity, FTT, cigarette exposure and being Aboriginal, so our threshold for admission may need to be set low.  Though I think we are best to do this assessment on an individual basis.


CHEST X-RAY:  Just DON’T DO IT!  If youthink the diagnosis is bronchiolitis after taking a history and examining the kid.  You do not think that the kid is overtly septic, and in need of source localisation. The please do not Xray them.  Sure – its just one Xray, hardly any radiation right?  Well there are 2 arguments against that logic.

  1. As a policy, for the whole population we need to limit radiation exposure – and this is prime territory for achieving that goal without a loss in safety.
  2. Several studies have shown that doing a chest Xray, leads to the domino effect of:  CXR = subtle consolidation = “maybe this is pneumonia?” = IV ABs = harm and unnecessary AB use.

So when is a CXR useful? Well pretty much never in the ED.  Sure some kids will ahve something else going on, but that is usually detected when they fail to follow the expected course on day 4 – 6.  This is best left to the inpatient team.  CXR up front is low yield and confuses the picture.


LUNG ULTRASOUND

No, you guessed right! It was not mentioned in the guidelines.  So this is my opinion! I love lung US in kids – it was what I spoke on at SMACC Mini last year.  However, the first rule of POCUS is this: have a clear question you can answer.  Ruling out pneumonia – LUS is pretty darn good.  Ruling in bronchiolitis, not so good.  There is a bit of data out there to show it is accurate [Basile et al BMC Paeds 2015].  However, it doesn’t add too much to our clinical exam and history. Remember LUS is very sensitive – you will see tiny subpleural consolidations in bronch – it would be easy to interpret these as “pneumonic consolidation” if your brain wanted to see that!  Same as CXR, there is a slippery slope into overtreatent here.  So you question should be one of “ruling out a proper pneumonia” if you feel the need to scan.


OTHER INVESTIGATIONS:

  • Bloods: FBP, Blood cultures and EVEN the much hallowed CRP have NO role in bronchiolitis.
  • Viral tessting: PNA, NPA, PCR…. these are not useful. However, we are often asked to do them to allow our wards to group inmates by species.  The new guidelines state clearly that we should not be “cohorting” kids based on PNAs [Grade C rec] so I think we can stop doing this unless the teaam really want it for other reasons / research.
  • URINE MICRO:  this is a tricky one.  An oft asked, but rarely answered question.  The guidelines say we MAY consider it in infants < 2 months with a fever  > 38 degress. This is the same group I am stil doing a septic work up for anyway, so do it for that reason.  Be aware that there is a reasonably high rate of “false positive” urine cultures in kids with clear URTI and bronchiolitis.  Catching that golden fluid may be simply confusing the picture in kids with clinical bronchiolitis over 2 months of age.

OXYGEN… 92%.

92% oxygen sats is the magic number.  This is lower than I see a lot of our team accepting before we commence oxygen.  The 92% is qualified as “persistently below 92%” – given how often these kids plug & unplug airways.  They are saying that we should wait n see, rather than react to momentary desaturations.  They also recommend stopping oxygen if SpO2 is higher than 92% – this would require frequent attempts to wean the O2.  IN short I think there is a growing acknowledgement in Medicine that OXYGEN is not benign.  We should use it sparingly.

Now how should we deliver this oxygen?  well the old standard is simple “nasal prong O2” … but there is a new kid on the block.  I will dive a little deeper into HFNCs [heated, humidified, high flow nasal cannulae.. HHHFNC]


HHHFNC OXYGEN

I have noticed a trend over the years with bronchiolitis… nothing works.  Every now and then a new hero is put forward, we want it to work, we expect it to work, we hate to see thse poor little tikes suffering away as we stand by the bedside with not an arrow in our quiver other than the passage of time…. this last season’s hero was HHHFNC.  Quite an acromyn!  Recently I haev seen this started in the ED for kids with increased work of breating despite normal oxygenation on traditional NCs.  Is this the right thing to do?

The guidelines are clear, sorta… “HFNC CAN be CONSIDERED in INPATIENTS with HYPOXIA (SpO2 < 92%).  Do not use it in kids with higher sats.”  That sentence contains a few qualifiers!  Basically there is very little good quality data to support the routine use of HFNCs for any clinically / patient-centred outcome.  BEWARE – there is also little safety data on these devices.  So we just don’t have the evidence either way.

Here is how I think we should practice (pure opinion): give oxygen via traditional NC – these are cheap and easy, can be used in a wide range of settings, training is not too onerous. I don’t think we should be using HFNC in the ED ever really, unless we are en route to ICU otherwise.  If a kid has clearly failed on traditional NC after a decent duration (hours, not minutes) on the ward -then it may be worth a go on the HFNC.  If they are clinically deteriorating to the point where invasive ventilation is being considered – then HFNC may save a few, but don’t relax just yet!

I think each department needs clear parameters to trigger the use of HFNC – I really don’t enjoy debating each case at the end of the bed.  This is simply not good medicine when we are dealing with such a common problem.


HYDRATION:  NG vs. IV

Hydration is one of the key principles of successful management in bronchiolitis.  We are dealing with little people, breathing fast, working hard and with limited capacity to increase oral fluids. The best hydration strategy is the one which works!  In mild cases – smaller, frequent feeds are fine. However, in the kids who need our help should we go with the NGT or IV as first line?

When we think about acute gastroenteritis we tend to go with NGT.  There is good data around its safety and efficacy.  However, for bronchiolitis IV seems to be more entrenched in practice.. at least it is where I work.  The evidence suggests that they are equally good. But… remember that these are often chubby tots, IV access is tricky at times.  Oakley et al [Lancet 2012] found “first pass success” was 85% for NGT  vs. 56% for IV. So I reckon that unless there is another indication to place an IV, NGT seems like a good opening gambit for kids with clear bronchiolitis.

There is a specific recommendation to AVOID any hypotonic fluids if you are using an IV hydration strategy.  And the goal is somewhere between 60 – 100% of maintenence rate.


JUST SAY “NO” TO DRUGS

I will run through this list in quick time, as the data and recommendations are pretty clear.

  • Steroids – NOT indicated
  • Adrenaline – IV, IM or nebulised… no, no, no
  • Hypertonic saline – probably not. This remains an open question. Watch this space. Not for prime time.
  • Antibiotics (any kind) – no. Resist the urge to treat the perihilar consolidation that turned up on the CXR that you should not have ordered!
  • Antivirals – not helpful, expensive and not available where I work.

Beta2 AGONISTS

This is a bit more murky for me.  The guidelines are very clear that salbutamol / albuterol offer no benefit and possible harms to children under 12 months of age.  That is fair, makes sense and is consistent with current practice.

But what about the older kids?  The second year, particularly kids aged > 18 months are starting to get into the territory of asthma, viral-wheeze and the benefit starts to potentially increase.  There is a real dearth of good data in this age group.  Studies are underpowered, heterogenous and conflicting.

My practice has been to try them, at a decent dose, as a “trial” in the ED and watch them closely for any signs of improvement.  This IS NOT supported by the literature it would seem.  I sense a change coming!


SUCTIONING

A lot of the Paeds ED folk that I have learned from swear by nasal suctioning!  The drainage of boogers seems to provide good relief, facilitate feeding and decrease work of breathing. However, the trial data is not so clear.  Superficial suctioing seemed benign, however there was evidence of harms from deep nasopharyngeal suctioning.   So if you are a “sucker” – be a superficial one!


NORMAL SALINE NOSE DROPS

I have been writing this up as a routine since I was a PAeds RMO around the turn of the millenium.  NEver really questioned it.  I tell parents to do it to “clear a passage” prior to feeding in the obligate nose breathers full of crusty boogers.  The data is essentially non-existen in either direction.  So should we do it?  Well, it does give us something to do & amuse us whilst Nature takes care of the cure.. [Candide] Or to put it another way: “suck it and see” – if it helps, carry on.


WASH YOUR BLOODY HANDS – this is how we spread this disease… and others. You do not need evidence, just soap!


That is a wrap.  All the guidelines are of course – guidelines.  These are a prescription for how to run an ED or ward.  The patient and family in front of you all come with specific quirks and questions. We are clinicians – we need to treat them as individuals.

This disease is one where the social background is crucial to the management.  The single mum with 3 kids and a sick infant needs more help than the professional primip with grandparents on autodial.

Be prepared to do the best we can in the face of the winter tide of mucous.

If you prefer your Bronchiolitis education in an audio format and have yet to check out the excellent PEM Playbook podcast by Dr Tim Horeczko then do yourself a favour – pop over to the blog and listen.

Comments, queries and concerns are always welcome

Casey

Lessons Hard Learned: Dr Resa Lewiss

Welcome back.  A brand new Lesson Hard Learned episode from one of my favourite POCUS pals.

Dr Resa Lewiss is a Colorado-based ED Physician and international teacher of POCUS.  Specifically she has done a lot of work in the developing world to bring the power of POCUS to the coal face of care in some really remote places.  She is also a wonderful advocate for the role of women in medicine.  Check out her SMACCDUB talk for more on that.  She has spoken at TEDMED on the transformative role of US in the ED.

DISCLAIMER: Despite our shared passion for POCUS in the ED, bush or anywhere… there is no mention of ultrasound in this podcast!

This is a horrific case that Resa heard over a sterile drape many years ago.  It is a time capsule of how ‘medicine was then’, and contains some important lessons that we should heed today so that we don’t have to learn them again.
DIRECT DOWNLOAD

Medicine has changed for the better in the last 30 years.  Often we buck against the endless bureaucracy – however, there is a reason for all that safety, QI and legalise stuff.
Share your thoughts on the comments below.

Casey

Time to Pause, Reflect & Pay It Forward

Gday

So it has been a month since my last post, which I think is a Broomedocs record!  I decided to take a litle time to pause and reflect, do a bit of reading and work on a few of my other projects.  Don’t worry – all the clinical stuff will return soon.  Justin and I have taken a month off from the Journal club to chillax, I have been working on a few new guest podcasts and spending time enjoying the monsoon season in wet and wonderful Broome. So I just thought I should touch base to let you know what is happening and give a shout out to a few excellent things happening in the FOAMed world.

First up:

The Emergency Medicine Ultrasound Groups are a gang of Point of Care US gurus from all over Australia who are running a great new organisation.  Started by Drs Brian O’Connell & Chris Partyka [ @chrispartyka  www.thebluntdissection.org ] this motley crew of passionate POCUS providers has been cobbled together to spread the word about bedside US.  They are running face-to-face meetings in all the major cities of Australia which involve presentations, organisational events and social meetings. The next EMUG event is on in Perth on Thursday 23rd March (check out their blog for details).  I will be virtually attending to give my second EMUG talk on “applying the telejelly” or “Remote POCUS: the longest probe”.  There is a great line up of guest speakers from Australia, Nepal all talking about how we can do better care through POCUS.  So if you are in Perth, check it out… or see the website to find out when the circus is visiting your town.

Next:

I recently “discovered the IMReasoning podcast – this is a show out of New Zealand, run by Drs Art Nahill and their brand new Twitter handle is @IMReasoning .  The podcast includes clinical cases dissected in great detail by these very funny Internal Med Physicians.  If you are a trainee and want to understand how the “old guys” think – this is a window into the minds of a couple of very smart chaps.  There are also a lot of great interviews with experts in cognitive theory in medical practice, diagnsotic error and some cool futuristic projects around diagnostics.  I recently got in touch with Art and Nic and hope to learn more from them soon.  So do me a favour – pop onto iTunes and have a listen to the podcast, follow them on Twitter and get these guys into #FOAMed.

Next:

More POCUS excellence.  THE POCUS ATLAS is a cool project dreamed up by Dr Michael Macias in Chicago.  The team involves a few familiar US devotees and a few up and coming POCUS lovers.  This project is designed to share clinical images and create a virtual library of cases, images and education to consolidate your POCUS learning.  What we need you to do is to send in your images and clips , just read the “contribute” page for instructions.  We hope to build a free online resource that can be used the world over to teach POCUS.  This is the essence of FOAMed, sharing to enhance caring.  So dust off your USB, open your hard drives and share the love.

Not quite free:

A few years ago I started doing some work for the Hippo group on the Primary Care RAP, the same team that bring you EM:RAP and Paeds RAP to name a few.  Although tis is not free (costs about $350 bucks a year) I believe it is a really useful podcast for anyone working in GP / Primary Care.  The gang at PC RAP are a really fun and smart group of Docs lead by the inimitable Heidi James.  The team love listener engagement, questions and insights from you out there.  So if you haev an idea for the show, a clinical question you want answered or just a chance to bounce ideas off like-minded docs please send them through.  Tweet, email or mail me.

Free, but not OPEN:

I am not a big Facebook fan, it drives me insane with all the ads and complexity of timelines… but there is one Group I do love – the GPDU gang (GPs Down Under).  This started out with a small group of Aussie / Kiwi GPs sharig thoughts over a closed forum and has ballooned into a massive community of 4000 doctors from all over Australasia.  You need to be a GP or GP trainee to join.  Although not “open access”, this community embraces the values of FOAMed and shares widely resources, ideas and support for one another.  So do yourself a favour, get on there and join the conversation.

SMACC un Berlin:

I am really looking forward to dasSMACC in Berlin in a few months.  This year will be alittle different (isn’t it always!) with a giant arena and some huge international guest speakers.  But as always, SMACC is really about the people. The coming together of the FOAM community to share stories and get to know those faces behind the Tweets.  This year I will be doing a bit of teaching on the Bedside US workshops and will be relaxing through the rest.  Should be a great week.  Hope to see you there, please come say “Hi” or “Guten dag”, and if you cannot attend, just join the Twitter storm and follow the frenzy that is SMACC.

Son of SMACC:

If the SMACC conference got pregnant and had a kid, then it would be born in Brisbane this August.  Yes, the child of SMACC – the inaugural DON’T FORGET THE BUBBLES conference is on : 28 – 30th August this year.  Hosted by the awesome team behind DFTB website (Andy Tagg, Tessa Davis, Henry Goldstein, Ben Lawton and friends) – it will be BIG in a LITTLE way.  This is all about Paediatrics – acute, chronic, the big picture and the very small. Speakers from every continent… and a few from Broome too.  So if you are looking for a great way to spend your CME – get in before it is too late. See you there.

Thankyou:  Dr Mike Cadogan is a founder of the FOAMed movement and one of the tech-geniuses behind all that stuff you see out there on the web.  Mike has been fighting tirelessly in the background to keep the hackers at bay and make this blog and many other function.  So a huge thanks to Mike and his elves – what you do really matters to us all!

OK, that’s a bit of what is happening in the backroom, behind the scene here in the Broome Docs lab.  I will be back on the airwaves soon and looking forward to hearing from you.

Catchya

Casey