Antibiotic Awareness Week: What’s your spiel?

Welcome back!  It is ANTIBIOTIC AWARENESS WEEK here in Australia.

The slogan I have been pushing with my trainees is: “Take time to have the chat, Don’t just write the script.”

Of course, that “chat” can turn nasty!  We have trained generations of families to expect, crave and depend upon the magical pills to cure every cough, sneeze and fever…. but we know that it is largely snake oil!  So my challenge to you all is to share your best spiel.  What do you say to the eager parent who really, really wants a bottle of Amoxil for that slight red ear?  How do you rationalise the need for a penicillin suspension for a runny nose with your next man-flu?

So I have a challenge for you all…


Send me your favourite lines.  The throw away comments and phrases you use to talk em outta the pills.

You can comment below if you like – or better still send me an audio recording of your favourite spiel – just talk it into your phone and send it over to

You might wing a prize.  But better still you might allow the rest of us to share your wisdom with our patients and keep the lid on the Antibiotic Armageddon that may be not too far away!

GO on!

Hit me with your best lines.


Clinical Case 121: Supracondylar Sono Subtlety

Another quick case from the Paeds files…

Simple story – 5 year old boy playing with his 6 year old sister on bunk beds.  Mum heard a thud then a scream and found him on the floor – he has fallen about 1 metre onto his outstretched arm.  No other injury seen.

On arrival to the ED he is holding his arm by his side in 90 degrees flexion, when asked – he points to his antecubital fossa to show where he is sore.

He has good pulses distally, there is some localised swelling but no deformity of the elbow.

So what is going on?  Well as usual it is 3 AM and there is no Xray available…  but as I said at SMACC Chicago: “No Xray, No Problem.”

So lets pull out the US machine and have a gander:

First view is a transverse of the posterior humeral condyles and fat pad.  The is abnormal – usually the fat pad lies beneath a line, convex down between the condyles – this pad is billowing up – this is a sonographic “sail sign” the tell tale for an elbow haemarthrosis.posterior fat pad

The second image is a long view of the posterior humerus with triceps tendon overlying.  There is  a subtle cortical break evident (can you see it?)  These can be tricky as they look a lot like normal growth plates in little kids – so luckily he has 2 arms and we can scan the other one to compare.  Asymmetry suggests a fracture – you can also use the probe to illicit tenderness to check fracture vs. growth plate.triceps

The third image is a long view of the proximal radius – checking for a fracture of the radial head – this was normal.  The other side looked the same and there was no tenderness over the radial neck.  The elbow was enlocated on further scanning.radial head

So we have a good story for a supracondylar fracture, a definite haemarthrosis, a subtle crack in the distal humerus and a normal looking radial head/neck.

So he got a long arm plaster and returned for review and an Xray to be sure…

Here are the plain film images:

So the subtle signs are seen – but I reckon they are more obvious on the US. What do you think?supra latsuprAP?

So a few controversial questions….

(1) Do we really need to Xray this kid?  It is a subtle undisplayed fracture which will always be managed conservatively.

(2) If the plain film had been reported as “Normal” or “non-diagnostic” what would you do given these US images?

Let me know your thoughts

And go check out the Sonowars podcast from Mike & Matt over at USPodcast for a more in depth look at how to do this scan. Fast forward tot he 20 minute mark for “fat pad sign”

And here is the 2012 paper by Rabiner et al [Crit US Journal ] that showed a 98% sensitivity for detecting elbow fractures.  The specificity was only 70%, against Xray as a god standard.  So beware of overcalling these?




Intubating the Critical Patient

Hi Team,

It has been a slow month on the blog and podcast as I have been working on a few other projects… one of which is very exciting and will hopefully be unleashed in 2016.

Can’t say too much about it but it is a collaboration with one of my favourite ED docs and is going to be something a bit special for my fellow Aussie bush docs.  Anyway – here is a bit of a taste of the sort of thing I have been working on.

Todays’s video is a simulated critical care airways case.  Mr Roger Flower is a 73 yo chap in type 1 respiratory failure who is starting to clap out.  He is going to be transferred 2000 km to the closest ICU via Flying Docs… but first we need to take control of his airway and ventilate him of the trip.

There are many ways to skin a cat and many tools with which to do it.  This is how our team functions in Broome.  Big thanks to my colleagues Drs Dave Hailes, Trent Little, Nick Gilbert and Rachel Cane (CN) for being the guinea pigs in this sim.

I hope you enjoy it and please feel free to offer your insights, preferences etc – only by sharing do we all learn.

On with the show (it’s about 15 minutes)….

This version has been compressed to make it easy to download.  If you would like a high-res copy, just let me know.

If you are keen to read / hear more about some of the techniques used – follow these links to the best Med Ed out there:

DSI from Dr Weingart

Apnoea Oxygenation  more from Drs Weingart and Levitan

RAMPing via LITFL critical care compendium

Own the Oxylog an oldie but a goodie!



PEMLit Review: Ultrasound for bronchiolitis?

Hi Broome Dockers

I started following and reading the PEMLit blog a while ago and have found it a really useful tool for staying abreast of all the latest from the Paeds ED and hospital literature.  You should definitely check it out.  Anyway, since I am always banging on about all things ultrasound and chests – I have been collared by the delightful Dr Natalie May to do a quick review for the site.  So you can read it here or check it out on the PEDLit blog.

So here is my review of:

Screen Shot 2015-10-15 at 10.08.34 pm


Where can I find this paper?  Here

What is this paper about (what is the research question)?

This paper aimed to correlate sonographic lung findings with clinically diagnosed bronchiolitis in infants.  The authors also attempted to provide some prognostic information [the need for oxygen support] based on sonographic lung features.

Summary of the Paper: 

The subjects were infants admitted for clinically suspected bronchiolitis.  There was also a cohort of “normal controls” used as a comparison.  The children underwent a clinical scoring by the treating Paediatrician and lung ultrasound by both a radiologist and Paediatrician sonographer.  The scans were all completed by two of the authors.

Design: This was a single-centre, observational cohort study conducted in an Italian Paediatric unit.

Objective: Aim of this study is to evaluate the accuracy of lung ultrasonography in the diagnosis and management of bronchiolitis in infants.

Outcome of interest:  To assess the correlation between clinical and sonographic lung findings in bronchiolitic infants.  Can LUS findings be used to predict the need for supplemental oxygen requirements?

Participants: One hundred six infants, aged from 9 to 239 days old were enrolled.

Inclusions: Clinically “suspected bronchiolitis” in infants.  Unclear as to whether these were consecutive cases – only 106 over a 3 year study period.

Exclusions: Radiological pneumonia, other “concomitant pathology” or the unavailability of the study sonographer.
Results: There was a high level [ ~90%] of agreement between the clinician’s severity rating and the predetermined sonographic severity scores.  There was also a high level of agreement between the two sonographers scoring of the LUS findings (K = 89.6%).  The lung US scoring predicted the need for oxygen supplementation with good accuracy [sensitivity: 96.6 %, specificity 98.7 % ] although there were wide confidence intervals as a result of the small numbers in this trial.

Authors’ Conclusions:

In summary, this pilot study demonstrates that the use of LUS in bronchiolitis can be considered as an extension of the clinical evaluation and could be incorporated into clinical algorithms to aid decision-making. Our promising data needs to be confirmed in larger cohort studies also involving critical patients.

On the study design:  This study design is typical of many pilot ultrasound papers.  Small numbers of patients in which sonography is compared to a gold-standard that may not be entirely accurate of itself.  Bronchiolitis is a clinical diagnosis, with no really objective diagnostic standard.  The use of just 2 experienced Paediatric sonographers in a single centre does raise questions about the external validity of the results and there is a high likelihood of bias here.  The clinicians were blinded to the sonographic findings – and therefore the risk of bias here was removed. The use of “normal cohort” and the “RSV swabs” in the study design was a little confusing and does’t really add to the results.

What were the results and what does this mean?  The results suggest that clinically diagnosed bronchiolitis looks like sonographic bronchiolitis as per the defined criteria used in this paper.  The protocol used did identify infants with more severe lung disease.  The need for supplemental oxygen was consistent with severe LUS changes.  However, given the “standard” was clinical examination it is unclear exactly what LUS would add to the prognostication by paediatricians.  The high degree of agreement between the two study sonographers is difficult to extrapolate given they are both highly skilled, ultrasound enthusiasts – a larger mix of observers would be needed to draw any conclusions about our ability to utilise LUS in small kids.

What can we take from this paper into clinical practice?

Lung ultrasound for the diagnosis and severity scoring of bronchiolitis is reasonably accurate.  Does it add anything?  Probably not, unless you are currently using CXR to ‘diagnose’ bronchiolitis.  This paper does provide some useful descriptions of the spectrum of disease and their sonographic appearance.

More questions to ask

Can ultrasound reliably differentiate bronchiolitis from important differential diagnoses in infants ? (e.g.. pneumonia, heart failure, upper airway obstruction… )

Are the sonographic findings in bronchiolitis consistent when obtained by sonographers of various experience?

Previous papers have compared LUS to conventional CXR for the diagnosis of bronchiolitis – and LUS was favourable.  It would be nice to see a paper looking at children with severe disease in which clinicians often turn to CXR to “reconfirm the working diagnosis” in order to ascertain it’s utility at that end of the spectrum.

Summary:  I think this paper is interesting in that it describes the sonographic spectrum of a common disease of infants.  The study is not really large enough, nor does it have the external validity to make it a “practice changer”.   This pilot can help inform us about the appearance of bronchiolitis – and in the future this may become a more commonplace part of our clinical assessment of children – but for now I am not sure it adds to our quiver.

Up for some SMACC craic?

Hello team,

Big week in critical care world with a whole bunch of new papers, research and great discussion taking place over the Twitter-sphere and on the blogs.

Of course, the major highlight of the week was the Aussie annihilation of the English rugby team and their eviction from their own home World Cup.  The Ashes are looking better already!

But the thing that got me most excited this week was the release of the new SMACC website and announcements of the line up, ticket releases and workshops.  The tech-angels in the SMACC machine have also started rolling out the first of the talks from SMACC CHICAGO – and you can access these on the website or through the App they have created. There is even a Youtube channel if you like the video versions.  And remember all the talks from the last few SMACCs are also there for free-honey-covered Edutainment.

The 4th SMACC will take place in Dublin, Ireland from 13 – 16th June 2016.  And I will be there (as always!).

The conference attendance is capped at 2000 people – and there is a huge international interest in snapping up all those tickets.  So if you are keen to get there, book you leave now, plan contraception and be aware of the registration process…

Registration will open on Wednesday, 28 October at 0900 Sydney EST (World clock release). This is open to the general public.
This will be the first of three ticket releases. Each release will have a limited amount of tickets available. These tickets will be split between full registrations (specialists) and discounted registrations (residents/nurses etc.). The release schedule is as follows:
First release: Wednesday, 28 October
Second release: Wednesday, 2 December
Third and final release: Wednesday, 3 February
We encourage you all to register as soon as possible but if you must wait until your rostered leave has been confirmed then you can chance your hand on Wednesday, 3 February.
All prior delegates will receive email reminder the week before sales open, but there is no other preference (first in best chance basis).
Due to registrations being limited there will be no one day only registrations available
Workshop registration also opens on Wednesday, 28 October. These are allocated on a first come first served basis only.
If you miss out on registration there will be a waiting list.
If you miss your preferred workshop there will also be a waiting list.

Now the day to remember: in 21 days the first tickets go up for grabs.  There may be a crush at the virtual ticket office, so put in your cyber elbow-pads and get ready.

So go on, don’t think too long… get that leave form in and get ready to join the community that learns the fun way.

See ya there, Casey.

Paediatric pneumonia? Lung Ultrasound.

If you are a regular reader then you will know that I have been spruiking lung ultrasound for a few years now.  In fact I wrote this post [ Ultrasound for pneumonia – sounds crazy? ]  way back in early 2012.  There continues to be a slow trickle of studies looking at US for pneumonia – and like a lot of US literature – the numbers are small in each paper.

In March 2015 Pediatrics published a systematic review titled:

Lung Ultrasound for the Diagnosis of Pneumonia in Children: A Meta-analysis by Perada et al.  This was a metanalysis of 8 smaller studies (2 in neonates) which showed that lung US performed well as a diagnostic tool compared to CXR.  The papers used a variety of “US users” from expert to novice sonographers.

The diagnostic characteristics have been reasonably variable across these small trials and they give the following as their overall analysis of lung US for pneumonia:

  • Sensitivity 96%,  Specificity  93%,
  • + Likelihood ratio = 15.3      -ve Likelihood ratio = 0.06
  • if you are into “area under the ROC” – it was 0.98 – which is pretty good!

These figures are our best estimate of the utility of LUS for pneumonia in kids.  They are significantly better than the characterisitics of traditional plain film.

So, are we there yet?  Is there enough evidence to change practice?

I think that there is.

Lung US is at least “non-inferior” to CXR.  US carries no risk of radiation and is a fast and technically easy scan to do in small people.  The cost is …  a few dollops of gel and the time to do the scan.

There will certainly be a risk of overdiagnosis given the relatively high sensitivity of US and the potential to misinterpret findings.  This is going to require education and training around image interpretation.  As with all point-of-care US – one needs to interpret the images in the clinical context and be prepared to do another test if the data doesn’t make sense.

So I would love to hear your thoughts –

  • is there enough here to change practice?
  • what barriers are there in your practice to change imaging preferences?

Let me know.