This is the post I created for the guys who attended the “Social Media and EMS” workshop at the Irish EMS Gathering in May 2013. Hopefully something from the 2.5 hrs stuck in your brains so that you’re not seeing all this as entirely new material.

Twitter

Firstly we got everyone to join Twitter. You can do this via the website or via an app on your computer or phone. For interest sake I use TweetDeck through Chrome on my computer and use Twittelator Pro on my iPhone.

I suggested that when you join twitter you should put a little of biographical information about yourself. People are more likely to interact with you if they know something about you. There are a lot of fake, spam Twitter accounts and having some info on someone helps people to trust you.

I suggest having a profile picture as well rather than the default, anonymous egg.

For example here’s mine:

Follow People 

When you get started I suggest you follow a few key people to start with. Here’s 5 to get you started:

@sandnsurf

@precordialthump

@cliffreid

@broomedocs

@M_Lin

The more interact, post and reply to people, the better your twitter experience will be. We don’t bite honestly, we loved being asked questions on Twitter.

Follow Lists

You can also follow lists, either other peoples or your own that you create. This is a good way to ensure that you’re spending your time well on Twitter. If you make a list of people who consistently tweet high value info then you’ll not be bored by dross about people’s dinner…

Here’s a list I have of “medical tweeters”

Follow Hashtags

Hashtags [words beginning with the '#' symbol] are good ways to join conversations together. My favourite hashtag is #FOAMed, this is a consistent conversation about FOAM resources. You can type #FOAMed into the twitter website or onto your twitter app to find it.

NB, on a mac the # symbol is produced by pressing the ‘option/alt’ key and ’3′ together.

If you want more twitter basics then check out momthisishowtwitterworks.com

Podcasts

I think the key is to get your podcasts on your smartphone. That way wherever you are yo can listen to them. It’s much more important to have them on your phone your computer in that sense.

The basic ‘podcasts‘ app from apple on the iphone is a reasonable place to start.

Once downloaded, start the app and click the ‘store’ button.

Once you’re in the store, search for whatever it is you’re interested in.

Once you find a podcast you want to subscribe too, just click on the subscribe button. Every time a new podcast is released it should download automatically to your phone.

LITFL have a great list of podcasts and a searchable database too, if you need to find more.

Feed Reader

Most of the FOAM websites produce new material on a regular basis. To save you having to visit the site to check if new amterial has been released, you can use something called a feed reader that will collect all the new material from all your favourite websites in one place. I used to recommend Google Reader but it’s shutting down in July 2013 and I’m now suggesting feedly as a good alternative.

Once you’ve added feedly to your internet browser or downloaded the app to your phone or tablet then you can add the websites you’re interested by either clicking on the RSS symbol on the website

or copying and pasting the website URL into the search box

The mobile app is kept in sync with your computer and is set out in a similar easy to use way.

If you’re looking for one place to look for all the best in FOAM then check out Kane Guthrie’s LITFL review.

Blogs

So say you’re keen to start putting out your own FOAM material, then starting a blog is a good way to start. Here’s the website we set up at the workshop in 15 minutes.

This is what the ‘dashboard’; the construction site of the website looks like.

This is all free and easy to do via wordpress.

Google Plus

We only mentioned this briefly but I said I thought it was a brilliant platform for FOAMed but unfortunately under utilised. Its best features are probable communities [check out ECG+ and the EMCrit community] and the google hangouts. Here’s a nice example of google hangouts being used to stream a conference live.

Or here as a conversation between experts discussing some medical papers. Saves all the hassle (but not quite as much fun) of actually meeting up.

Screencasts

Due to technical issues we couldn’t quite pull this off live at the workshop but a screencast is typically a recording of what’s on your screen with a voice over. It’s a great way to share a lecture you’ve prepared with lots of other people. Once the video file is made you can upload it to YouTube, Vimeo or even better GMEP for other people to see.

Screenr.com let you record screencasts without having to download a separate app but I do a fair bit of this so I use one called screenflow.

As an example here’s a screencast of the talk I gave at the conference.

Lastly the app I used for displaying my iPhone screen was one called Reflector which is $12 but a really, really well put together app that lots of people recommended but I first found via Haney Mallemat and my brother the software developer.

The post Workshop for EMS Gathering appeared first on Emergency Medicine Ireland.

Just a little shout out to a conference I’m speaking at next week.

The Irish EMS gathering is a conference aimed at pre-hospital specialists being held in Co Kerry, way over there in the south west of Ireland. The program (see morning sessions, afternoon sessions and evening sessions) is a good mix of academic and leisure activities so it’s definitely worth checking out.

They were foolish enough to let me talk on social media and the auld Twitter malarkey which is a real honour for me. I’m speaking on Wednesday morning and hopefully running a workshop on the wednesday afternoon as an introduction/development session on how to use the old interwebs to learn and share effectively.

If anyone is going please stop by and say hello, it’d be lovely to meet you.

As far as I’m aware they’re still open to registrations and I’d highly encourage you to come along.

I’ll endeavour, as usual to do a screencast of my presentation for the rest of you all to enjoy/criticise/abuse…

The post EMS Gathering – Killarney, Ireland. May 15th-16th 2013 appeared first on Emergency Medicine Ireland.

This was all brand new to me. I was reviewing a syncope patient left over from the night shift before. The hand over was: recent change in anti-hypertensives, now feeling weak and dizzy about 1 week. Syncopal episode at dinner table last night.

She’d been in the department overnight, got some fluids, bloods and an ECG. The ECG was said to be normal.

I went and chatted to the patient and yes indeed it did sound all very like postural hypotension. I went back and looked at the ECG and did my usual syncope ECG review looking for the following:

• Brugada
• HOCM
• WPW
• intervals – QT and PR

And there it was – a nice big QTc of 550ms staring at me.

I still suspect that postural hypotension was the main cause of her symptoms but it would be a tad on the risky side to call it that in the context of a long QT. K+ and Mg++ were on the low side (3.5 and 0.6) so she got a bit of both and admitted for ECG monitoring.

The interesting bit came in the discussio with admitting doctor who was (for once) interested, enthusiastic and asked about the standing test for Long QT. This was all news to me but effcetively people with a long QT syndrome (LQTS) have an abnormal response in QTc with standing.

In healthy people on standing the heart rate goes up with corresponing shortening of the QT interval. Due to the fact that heart rate goes up more than the QT comes down, the QTc actually goes up slightly,

In LQTS the QTc often goes up substantially.

This paper addresses this concept and while it’s in now waty perfect (ie it examined it in people known to have LQTS which undermines its use as a diagnostic test in undiagnosed QT problems) it suggests that in healthy people an increase in QTc on standing of about 10-15ms is allowed but in LTQS is likely to be in the range of 90-100 ms.

Viskin, Sami, Pieter G Postema, Zahurul A Bhuiyan, Raphael Rosso, Jonathan M Kalman, Jitendra K Vohra, Milton E Guevara-Valdivia, et al. “The Response of the QT Interval to the Brief Tachycardia Provoked by Standing: a Bedside Test for Diagnosing Long QT Syndrome..” Journal of the American College of Cardiology 55, no. 18: 1955–1961. doi:10.1016/j.jacc.2009.12.015. PMID 20116193

METHODS

• the normal response to standing after lying is an increase in HR. This would normally be accompanied by a shortedned QT. In LQTS this apparently isn’t the case
• The intervention was standing and recording QT changes.
• they did this on high risk LQTS (lots of features but no diagnosis as yet) and those who actually had it genetically documented. The controls were healthy relatives of those pts or volunteers (the vast majority)
• took them off Beta blockers for a day then lay them flat 10 mins and stood them up for 5 mins with telemetry.
• blinded investigator performed the measurement had a set part of the trace. Bazzett’s  formula was the main one used.
• excluded the obviously normal and obviously prolonged

RESULTS

• 68 LQTS; 82 controls
• the baseline QTs were 380 v 450 – not diagnositcially different but borderline
• the QT went down in all the normals but less than the RR interval therefore the QTc goes up slightly.
• the QT of those with LQTS didn’t change at all. In some it went up. Or put another way the QTc of the control group went up 13ms while the LQTS patients the QTc went up 89ms

Not something I’m going to be doing every day, but it’s a fairly nice, bedside test that we can apply in the ED.

The post Standing Test for Long-QT syndrome appeared first on Emergency Medicine Ireland.

This is the second part of a recent lecture I gave to some first year med students to get across how important their anatomy is to understanding trauma.

First part lives here

You may have to click through to the GMEP site to see the full HD version

PDF of slides

The post Anatomy for Emergency Medicine 027: Basic Anatomy of Abdomen and Pelvic Trauma appeared first on Emergency Medicine Ireland.

This isn’t so much an AFEM post but more of a brief review of a paper and a video.

Everyone finds neuroanatomy tough, you’re not alone. Most of it doesn’t really concern us in the ED that much. However we will have people attend or be referred with isolated III, IV and VI palsies.

If you understand the basics you can  know when to get worried and scan and admit and to relax and explain to the patient that this will likely improve with time.

First I suggest watching this video from the single best eye teaching source I’ve found [Chris Nickson found it for me of course ]

I also found this paper [via the only neuro blog I read] which covers the anatomy but also some advice on when to image and when not to. This is my basic summary.

In general

• a lot of isolated palsies can be observed as most are vasculopathic and will resolve
• isolated palsies in young people should cause consideration for mass. Non-vasculopathic sixth palsies are relatively high risk here
• the key point is identifying isolated. If they have headache or other signs then it’s not isolated
• temporal arteritis can be involved in all of them, as can myasthenia but there should be other signs/symptoms

III

• if motor only can usually be observed as most will be vasculopathic if the risk factors exist
• if mixed motor and pupil should be imaged
• if pupil only then think about compression

IV

• even traumatic IVs don’t need imaging for ICH (though maybe for fracture)
• head tilt is common along with pupils not at the same level
• some are congenital that have decompensated
• again the vasculopathic ones do quite well
• sub-arach space rarely involved
• isolated non-vasculopathic ones may (with caveats) be observed (unlike VI and III)

VI

• traumatic VI needs a scan
• vasculopathic can be observed
• non-vasculopathic should get scanned (they quote a 25% malignancy rate which seems awful high)
• they oddly don’t mention benign raised ICP as a cause

In the ED it’s not always as straightforward as this as the key is follow up. Depending on your access to neurology/ophthalmology will dictate how you manage them.

The post Cranial Nerve Palsies -III, IV and VI appeared first on Emergency Medicine Ireland.

This is a screencast of a recent lecture I gave to some first year med students. It’s mainly to give the students some clinical info to keep their regular anatomy teaching relevant. It’s not designed to be a comprehensive intro to trauma in any way.

It’s longer than the usual podcasts so I’ve split into two parts.

Feedback, is as always, welcome.

You may have to click through to the GMEP site to see the full HD version

PDF of slides. 

The post Anatomy for Emergency Medicine 026: Basic Anatomy of Chest Trauma appeared first on Emergency Medicine Ireland.

I mentioned these on Twitter a while back but I thought they deserved a little plug.

All hospitals have pretty good policies and procedures about what to do when a staff member gets a needlestick injury. A lot of these patients in the systems I’ve worked in come to the ED out of hours. It’s our responsibility to do a risk assessment and  ensure the appropriate bloods and paperwork are done and in the rare occasion consider PEP.

Where I’m currently working in Dublin has a substantial population of IV drug users and we also receive patients from large prison across the road. It makes for an interesting population of patients. It also results in lots of blood born virus (BBV) exposures in the community setting.

These guidelines [free PDF here] give clear and specific guidance about what to do in each situation. They were put together by a whole bunch of people but there a few emergency physicians involved in the process too so it’s relevant to what we do.

There’s lots of useful info in it but here’s some highlights

• Hep B vaccine is highly effective at preventing infection if given ear;y (preferably within 48hrs) and they suggest a low threshold for giving it in any significant exposure. This is of course good news considering how tremendously infective Hep B is. There is a role for passive immunity from Hep B immunoglobulin but they confine it to “limited circumstances”
• There is no prophylaxis for Hep C (which is a shame considering how easily transmissible it is), however it’s still important to get them tested and followed up as early treatment is highly effective at clearing the virus.
• HIV PEP should only be considered within 72 hours of the injury (hence the importance of the role of the ED when the ID guys are off for the weekend). To know when to give it requires a little sociology. Given the local population where I work, the majority of needlestick injuries are going to be sourced from IVDU and are fairly high risk so we use a reasonable amount of HIV PEP in these cases. Of note the number of people from occupational exposures (ie healthcare workers) who have seroconverted since the introduction of PEP is almost zero.
• Don’t forget tetanus
• Bites: “A recipient of a bite that breaches the skin but with no visible source blood does not require any follow-up from the point of view of HIV and HCV.” They do suggest Hep B
• Sexual exposure: In the case of sexual assault, Ireland has Sexual Assault Treatment Units (SATU) available but they may occasionally end up in your ED and the guidelines have a good algorithm for management.

There are lots of useful numbers to give you and your patient an idea of what the risk actually is.

And finally the tail end of the document has patient information leaflets, so that you can give the patient something home with them so they don’t have to remember all the information you just threw at them.

I’ve used the guidelines about once a week since I found them and I keep them as a PDF file on my phone so I can access them in work.

As a final plug there’s a one day conference launching the guidelines in Dublin on 19th April 2013 [Details below]

PEP Conference

I’d be interested in how the guidelines match up to practice elsewhere in the world. If you’ve any thoughts leave them in the comments.

Conflicts of interest:

I have no financial or academic ties to these guidelines and I had no part in the development of them, however I do know some of the people who were. This post simply reflects the fact that I think they’re pretty useful for clinical practice.

UPDATE:

Graham Walker points out that there’s a nice risk estimator on the MD Calc site that’s worth checking out too.

The post Post-Exposure Prophylaxis Guidelines for Ireland appeared first on Emergency Medicine Ireland.

I mentioned these on Twitter a while back but I thought they deserved a little plug.

All hospitals have pretty good policies and procedures about what to do when a staff member gets a needlestick injury. A lot of these patients in the systems I’ve worked in come to the ED out of hours. It’s our responsibility to do a risk assessment and  ensure the appropriate bloods and paperwork are done and in the rare occasion consider PEP.

Where I’m currently working in Dublin has a substantial population of IV drug users and we also receive patients from large prison across the road. It makes for an interesting population of patients. It also results in lots of blood born virus (BBV) exposures in the community setting.

These guidelines [free PDF here] give clear and specific guidance about what to do in each situation. They were put together by a whole bunch of people but there a few emergency physicians involved in the process too so it’s relevant to what we do.

There’s lots of useful info in it but here’s some highlights

• Hep B vaccine is highly effective at preventing infection if given ear;y (preferably within 48hrs) and they suggest a low threshold for giving it in any significant exposure. This is of course good news considering how tremendously infective Hep B is. There is a role for passive immunity from Hep B immunoglobulin but they confine it to “limited circumstances”
• There is no prophylaxis for Hep C (which is a shame considering how easily transmissible it is), however it’s still important to get them tested and followed up as early treatment is highly effective at clearing the virus.
• HIV PEP should only be considered within 72 hours of the injury (hence the importance of the role of the ED when the ID guys are off for the weekend). To know when to give it requires a little sociology. Given the local population where I work, the majority of needlestick injuries are going to be sourced from IVDU and are fairly high risk so we use a reasonable amount of HIV PEP in these cases. Of note the number of people from occupational exposures (ie healthcare workers) who have seroconverted since the introduction of PEP is almost zero.
• Don’t forget tetanus
• Bites: “A recipient of a bite that breaches the skin but with no visible source blood does not require any follow-up from the point of view of HIV and HCV.” They do suggest Hep B
• Sexual exposure: In the case of sexual assault, Ireland has Sexual Assault Treatment Units (SATU) available but they may occasionally end up in your ED and the guidelines have a good algorithm for management.

There are lots of useful numbers to give you and your patient an idea of what the risk actually is.

And finally the tail end of the document has patient information leaflets, so that you can give the patient something home with them so they don’t have to remember all the information you just threw at them.

I’ve used the guidelines about once a week since I found them and I keep them as a PDF file on my phone so I can access them in work.

As a final plug there’s a one day conference launching the guidelines in Dublin on 19th April 2013 [Details below]

PEP Conference

I’d be interested in how the guidelines match up to practice elsewhere in the world. If you’ve any thoughts leave them in the comments.

Conflicts of interest:

I have no financial or academic ties to these guidelines and I had no part in the development of them, however I do know some of the people who were. This post simply reflects the fact that I think they’re pretty useful for clinical practice.

UPDATE:

Graham Walker points out that there’s a nice risk estimator on the MD Calc site that’s worth checking out too.

The post Post-Exposure Prophylaxis Guidelines for Ireland appeared first on Emergency Medicine Ireland.

[image via NetDance on Flickr. CC License]

Hospitals are busy places. We have no space, no beds, no staff and inevitably less money to make this all happen. This is the situation we have.

We’re fairly pragmatic folks so we find ways to manage the work more efficiently and try and do more as an out patient or involve things like ADPs (accelerated diagnostic protocols)

But when we get slammed and have more admitted patients than you have trolleys to put them on then the system grinds to a halt and you can’t assess treat and admit/discharge anyone new.

In Stony Brook in New York, the hospital (and that’s the important bit, not just the ED) decided that when the ED was choked that they could put some of the stable patients as extras in the hallways of the wards. You can imagine what the ward staff thought of that.

This is a brief paper reviewing their experience.

Viccellio, Asa, Carolyn Santora, Adam J Singer, Henry C Thode, and Mark C Henry. “The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: a 4-Year Experience..” Annals of Emergency Medicine 54, no. 4 (October 2009): 487–491. doi:10.1016/j.annemergmed.2009.03.005. PMID 19345442

This is a review of patient flow effectively and not a trial in any prospective sense. All they wanted to show was that this was happening and what the effects were.

It is not the highest quality science and does not claim to be.

RESULTS

• 25% of those assigned to a hallway bed actually got a proper bed immediately
• another 25% got a proper bed within an hour
• the rest got a proper bed within 8 hrs.

THOUGHTS

Your hospital probably has more beds than they say they do. Spreading the crowding from one place to the whole hospital spreads the moral and professional responsibility to a hospital wide problem. It’s remarkable how that motivates resources.

Importantly it must be realised that this is no panacea for a poorly run hospital. In fact every time a hospital implements something like this it’s a sign that something is deeply wrong. However it can alleviate a crisis.

The Irish Association has a nice statement on FCPs. And indeed a nice EMJ paper on the same too.

The post Full Capacity Protocols appeared first on Emergency Medicine Ireland.

The night shift insomnia that leaves me with about 4 hrs sleep a day has given me the chance to catch up with a bit of reading so here’s a paper for you.

This got a very amount of Twitter attention when it came out as it was a bit of a headline grabber:

Shanafelt, Tait D, Sonja Boone, Litjen Tan, Lotte N Dyrbye, Wayne Sotile, Daniel Satele, Colin P West, Jeff Sloan, and Michael R Oreskovich. “Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population..” Archives of Internal Medicine (August 19, 2012): 1–9. doi:10.1001/archinternmed.2012.3199. PMID 22911330

First a quick run through of the study and then some thoughts

METHODS

• this was a massive survey of the AMA register of doctors compared with the general population. It was done effectively by mass emailing
• the survey used the “gold standard” of burnout: the Maslach Burnout Inventory
  • the only problem here is that it’s a bit of a cumbersome tool so they let the docs fill in the whole survey whereas Joe Bloggs only filled in what the authors state are the predictive bits of the survey. They say that doing this has been studied before and is kosher but there you go…

RESULTS

• only a 26% (7000/27000) response rate in the docs. A response rate of somewhere closer to 70% is considered important as it’s giving a much more representative of the people you’re surveying. If you think about it could be only the pissed off, grumpy docs answering the survey. Or maybe even the opposite and only the calm and cool docs with lots of free time filled it out
• bottom line was that a lot of docs feel overworked and burnt out. And this is higher than the general population
• the people with the highest symptoms of burn out were the EM docs. By a clear country mile it seemed. We were much better than the surgeons in terms of work-life balance but despite this we were still burnt out.

THOUGHTS

I think this is vitally important stuff.

Emergency Medicine is like a puppy – it’s for life not just for Christmas but it seems increasingly both from my own anecdotal experience and now represented in study form in various settings that we’re going to have real difficulty keeping docs in the specialty.

In the US there are comparatively huge numbers of trained Emergency Physicians compared with the UK/Irish model. These guys work shift patterns often for their entire career. They are well paid and work reasonable hours (I was quoted that 30 hrs a week was an average for an EP in the US – can anyone corroborate this?) Despite their resonable work life balance these guys are really burnt out.

Now the UK/Irish model is a service delivered by trainees and non-board certified EPs, (the “sickest looked after by the thickest” as some have joked) these guys are paid less and work more hours than fully trained EPs, of whom we have vanishingly few. Just imagine how much more burn out might apply to those docs who deliver hands on emergency care day in, day out (or night in, night out)…

As I enter my ninth year since graduation from med school with no clear end in sight to my training (largely my own fault I’ll admit) the importance of work-life balance and the threat of burn out becomes more and more apparent. Workforce planning is one of the biggest problems (along with overcrowding) that EM has to face in this part of the world, but if we are to address it in any way we must address sustainability and burn out.

The post EM docs are more burnt out than most but none of us are great… appeared first on Emergency Medicine Ireland.

ICEM 2012 was a big deal for me. Great craic, the coining of the term FOAM, meeting lots of great EPs and learning a whole ton of good stuff.

Twitter was a big thing at the conference and a few of us, (myself, Cadogan and John Cronin) had the idea of documenting the use of new media at the conference. We got a few other folk involved, set up some databases and this publication was the result.

It’s not the highest science in the world, but it’s a useful piece to document the rise of online platforms for teaching and involving other people

I’m aware of the irony of a paper on FOAMed being neither free nor open access but as per the EMJ publishing license I’m allowed to share the pdf file with up to 100 of you, so if you can’t get access to the file send me an email and I can get you a copy. I’m also allowed to publish the text of the manuscript which I’ve embedded below as a google doc (if it doesn’t load just refresh the page)

Thanks again to Audun at Symplur.com who provided the awesome “network centrality analysis” as a way of visualising how the conversation at ICEM 2012 happened.

If anyone is keen to do similar studies on some of the upcoming or more recent EM conferences then I’d love to hear from you.

Feedback is as ever welcome.

Figure 1: Social media accounts of ICEM 2012 speakers

Figure 2: Content analysis of ICEM 2012 tweets

Figure 3: Network Centrality Analysis

The post EMJ Publication: Impact of Social Media at ICEM2012 appeared first on Emergency Medicine Ireland.

Today I think I’m finally giving up on my old system.

The old system was email subscriptions to the table of contents (TOC) of about 30 different journals that i filed under a gmail label and reviewed roughly monthly. If I saw a title or abstract that interested me then I’d pull the pdf and read it at my leisure. I now have over 1500 pdfs that I’ve read over the past 4 or 5 years.

This was an incredibly time-sucking task that often didn’t help me that much in finding the stuff I want to read.

So I think, given the proliferation of alternative sources of literature review out there I’m going to ease off on tracking the journals a bit. Let me outline my new alternatives.

Emergency Medical Abstracts

• 40 papers a month by two of the sharpest minds in Emergency Medicine  These guys taught me how to read a paper. After listening to the “tape” I comb through the 40 papers in the abstracts and pull the pdfs of the ones that really catch my eye
• NB this is a subscription service that I get for free through my EMRA membership [Ed. this is the best $50 you will ever spend in emergency medicine...]. Can be pricy if you’re a non-trainee

Emergency Medicine Update [#FOAMed]

• Yosef Leibman does a stellar review of the non-mainline journals and pulls out some real crackers. I pull the pdfs on only the ones I really want to get the detail of. 

R&R in the Fast Lane [#FOAMed]

• Somewhat infrequent but a great place to find out what your peers have been reading

Journal Watch

• Another subscription service – I  just use the free version to get the titles of the papers

Keeping up with Emergency Medicine [#FOAMed]

• another great podcast of journal reviews. 

EM Literature of Note [#FOAMed]

• Ryan started his site around the time I started mine and after a while I did less and less of the critical review stuff because… well… he’s just so much better at it than I am. He also finds lots of papers that you won’t find in the main EM journals

St Emlyns Twitter Journal Club [#FOAMed]

• there’s been a twitter journal club for a while ran mainly by @silv24 but this one comes from the Virchester crew and is EM specific

Resus.me [#FOAMed]

• Cliff is doing the hard work at 4am to find the papers we should be reading. Cheers Cliff!

Twitter [#FOAMed]

• rarely a day goes by that I’m not following a link on Twitter to pub med and downloading a pdf to read later. This is a truly invaluable source

These are just a selection of the resources I’ve been using over the past couple of years but which I’ll be relying on from now on.

The problem with this is that you have to trust your filter. It’s almost like a pseudo-publication bias. If people only read papers that have been tweeted then lots of important stuff (that may be contradictory to your position) will not get read.

Of course this problem exists already in that all of us have a tendency to read (and remember) stuff that interests us.

Feel free to chime in with comments and suggestions in the comments.

The post Keeping up with the literature appeared first on Emergency Medicine Ireland.

This one’s a little bit different. You’ve all heard of SMACC I’m sure. If not which rock where you hiding under?

It’s the the most exciting conference happening this year. All the your favourited FOAMites in one place giving it dixie on all things EM and Critical Care. There is still time to get booked in for it.

I, alas, will be holding fort on the Emerald Isle supporting the dog, wife and her ever enlarging bump and saving the spondoolies for next years SMACC (that’s happening lads isn’t it?)

They’ve put out the challenge for short, high impact teaching videos for the EM/CC community in the form of PK talks. Below is my offering. It’s a rehash of some old material but hope you like it.

The post Anatomy for Emergency Medicine 025: PK SMACC talk appeared first on Emergency Medicine Ireland.

This is a great, short and high value talk on elbow effusions from @DrAndrewDixon of radiopaedia.org.

http://www.youtube.com/watch?v=k1UYfi9zdOg

If you’ve not been following some of the great stuff coming out from radiopaedia then you’re missing out.

The post Elbow effusions from Radiopaedia.org appeared first on Emergency Medicine Ireland.

Migraine Barbie from Migraine Chick on Flickr (CC License)

Shameless self-promotion here but a Best Bet written by myself and @dreapadoirtas of underneathEM just got published in the EMJ this month.

If you’re a FOAM follower then you’ll probably already heard that a dose of dex can reduced the rate of recurrence of migraine in ED patients. There’s an NNT of about 10.

The short paper can be found on the EMJ website [access required]. It’ll be on Pub Med soon.

The post Steroids for migraine Best Bet appeared first on Emergency Medicine Ireland.

Pollack, Charles V, Donald Schreiber, Samuel Z Goldhaber, David Slattery, John Fanikos, Brian J O’Neil, James R Thompson, et al. “Clinical Characteristics, Management, and Outcomes of Patients Diagnosed with Acute Pulmonary Embolism in the Emergency Department: Initial Report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry)..” Journal of the American College of Cardiology 57, no. 6: 700–706. doi:10.1016/j.jacc.2010.05.071. PMID 21292129

METHODS

• this was a large ED based registry study from multiple US EDs to see how PE patients present and what happened to them
• it included both people who ended up having a confirmed PE and those empirically treated for PE awaiting tests and ultimately ruled out for PE
• PE diagnosis could be based on lots of different tests (all appropriate I think)

RESULTS

• 2400 pts, 1800 who had PE
• vast majority (90%) diagnosed by CT
• 3% were hypotensive on presentation
• SOB, pain, and symptoms suggesting DVT were commonest presenting complaints
• 5% presented with syncope: it happens but it’s not common
• of those who got echoes (only a quarter) there was RV dyskinesia in half
• 85% of those with PE got anti-coagulated in the ED – this is lower than I expected, though presumably because they had contra-indications.
• mortality rate attributable to PE was 1.1% (though all cause mortality was 5.4% meaning that lots of sick people get PEs and die of something else)

COMMENTARY

I know I’ve ranted on this before but I do find it fascinating.

I grew up with the notion that PE killed roughly 1 in 5 of those with the disease. That’s kind of scary. That’s similar to STEMI mortality. There is no doubt that there was a time when the PEs we diagnosed carried that type of mortality. Big feck-off PEs that is.

As the technology has changed we have created a new disease – let’s call them pulmonary fluff instead of pulmonary emboli. Emboli are terrifying, fluff not so much.

We have presumed that pulmonary fluff is the same disease as the big bad pulmonary emboli.

We are left with, i think, with two possible conclusions

1. we seem to have discovered a treatment (in heparin) that reduces mortality from 20% to 1%. An absolute risk reduction (ARR) of 19%. Considering that lytics for STEMI probably by you a 2% ARR we should be absolutely stunned.
2. The alternative is that we are now diagnosing lots of pulmonary fluff and the mortality rate from pulmonary fluff is 1% at a baseline and giving all this people heparin to treat their fluff does nothing; an ARR of 0%.

It may be somewhere in between those 2 answers but we have yet to make up our mind which.

The post Is pulmonary embolism really all that bad?… Again… appeared first on Emergency Medicine Ireland.

Levy, Jason A, Richard G Bachur, Michael C Monuteaux, and Mark Waltzman. “Intravenous Dextrose for Children with Gastroenteritis and Dehydration: a Double-Blind Randomized Controlled Trial..” Annals of Emergency Medicine. PMID 22959318

METHODS

• RCT of kids with relatively severe gastro (nearly half got admitted)
• randomised to either initial 20ml/kg saline or D5NS
• fluid use beyond that was up to the doc
• everyone got blinded ketone and sugars taken by the researchers; though they don’t mention how often they got unblinded BSLs as part of usual care which may confuse things
• outcomes were rate of admission (which is a surrogate for what the kid looked like as that’s what usually determines admission)

RESULTS

• n = 188
• 44% admitted in saline group, 35% in D5NS group (non-sig)
• half of kids got glucose at some point of their care
• it improved the ketones

THOUGHTS

• i imagine they’re a fairly glucose heavy institution given that they were studying this which might not be immediately comparable to most places
• 20% of kids were hypoglycemic at initial BSL suggesting that any benefit here might be down to simply treating hypos – if the kids hypo he’s gonna look a bit shitty – it doesn’t mean much beyond symptomatic care but still nice to know.

Just as a reminder – we know that ORS needs glucose to allow the gut to absorb fluid and electrolytes though when you’re giving fluids IV you should be able to avoid this.

The post IV dextrose for kids with gastro appeared first on Emergency Medicine Ireland.

The last one – wa hey!

There are a few zebras in here but worth putting in your differential.

Video of supracapular nerve release.

http://www.youtube.com/watch?v=xk1wM5CANUI

Video of scapular winging

http://www.youtube.com/watch?v=dfTe0nPclDE

The post Anatomy for Emergency Medicine 024 – Shoulder: Nerve compressions appeared first on Emergency Medicine Ireland.

OK, so I admit PCI for stroke is something I made up, but I think it’s a reasonable analogy. Given that treatment for STEMI moved from tPA to PCI then it’s hardly surprising to see a similar trend in the stroke world.

The idea is to remove (or sometimes lyse intrarterially) the cerebral arterial occlusion using interventional radiology. Whatever you make it’s certainly pretty cool and ambitious technology. There are a number of trials and devices out there for this type of thing, perhaps the most famous being the MERCI device.

Below is a review of two recent studies that compared new devices against the MERCI device.

Nogueira, Raul G, Helmi L Lutsep, Rishi Gupta, Tudor G Jovin, Gregory W Albers, Gary A Walker, David S Liebeskind, Wade S Smith, TREVO 2 Trialists. “Trevo Versus Merci Retrievers for Thrombectomy Revascularisation of Large Vessel Occlusions in Acute Ischaemic Stroke (TREVO 2): a Randomised Trial..” Lancet 380, no. 9849: 1231–1240. doi:10.1016/S0140-6736(12)61299-9.

METHODS

• big sponsored trial to prove that the TREVO is better than MERCI device. Stryker makes both interestingly…
• both are retrieval devices where the coil goes distal and the clot is withdrawn (there are others called micro aspiration)
• all had to have failed tPA or be ineligible for it. (ALERT – lots of cherry picking can be done here)
• lots of exclusion criteria (excluded 80% of those screened)
• end point was revascualrisation NOT clinical outcome; hardly unsurprising though

RESULTS

• 180 pts
• The TREVO (the new device) did better in both the reperfusion and the clinical outcomes.
• more died in the TREVO group at 90 days (24% v 34%) they somehow neglect to mention this…

———

Saver, Jeffrey L, Reza Jahan, Elad I Levy, Tudor G Jovin, Blaise Baxter, Raul G Nogueira, Wayne Clark, Ronald Budzik, Osama O Zaidat, SWIFT Trialists. “Solitaire Flow Restoration Device Versus the Merci Retriever in Patients with Acute Ischaemic Stroke (SWIFT): a Randomised, Parallel-Group, Non-Inferiority Trial..” Lancet 380, no. 9849: 1241–1249. doi:10.1016/S0140-6736(12)61384-1.

METHODS

• a Dublin made device being trialled in the US against the only currently approved device
• similar criteria as the previous trial – either failed tPA or contraindications and within 8 hrs
• primary outcome was recanalisation NOT clinical outcome

RESULTS

• total 120 pts
• excluded 80% assessed
• stopped early for benefit (always a shame…)
• solitaire device was better on everything (even mortality in this tiny trial)
• of note mortality was 44% in the MERCI group and 18% in the Solitaire group. Think about that for a second – in the MERCI group almost half died – that seems a bit off to me – most strokes don’t die in numbers like this – at least not by 90 days. They certainly didn’t die in these rates in the lytic trials.

Some thoughts

These are all very selected patients – so this is the best possible picture of the results. This is NOT a treatment that will be available to all your stroke patients. Often it will be limited by anatomy but it’s also only gonna be done in the younger patients with a better chance of outcome. The key will be (as with most things) being able to work out who might actually benefit from this sort of thing.

This may over the next 20 years become like PCI for STEMIs. But i doubt it, for the same reasons I’m dubious about lytics in stroke.

1. diagnostically stroke is a much more difficult disease than STEMI
2. the brain and its circulation is a lot more complex and tenuous than the heart (we have a circle of willis for a reason  - a built in collateral circuit in case of failure of flow.)

For added value I’ve added a demonstration video for all 3 devices below. See if you can spot the differences.

http://www.youtube.com/watch?v=9BEH8xzLRSs

http://www.youtube.com/watch?v=uG9eDdOEC4U

http://www.youtube.com/watch?v=zlQ0E29rB3k

The post PCI for stroke trials appeared first on Emergency Medicine Ireland.

As per the rules and guidelines set out by by st-emlyns

I only went back to real work in July, so I’m only gonna choose 5 instead of 10 as I just haven’t had enough patients to try out a full 10!

In no particular order

ONE

Bougie Aided Cricothyroidotomy.

• I had the misfortune/pleasure/browntrouserinducingmoment of doing my first cric this year and there wasn’t even a hesitation as to which method I used. Lots of people have weighed in on this (in particular Scott) in the #FOAMed world but I wouldn’t have done it without them

http://www.youtube.com/watch?v=wVQFJR7qmrQ

TWO

NIV via the Oxylog.

• To be fair I had used this occasionally in the past but then on request Minh did a whole piece on it for me and now it’s routine. Now of course the Oxylog isn’t exactly an ICU quality ventilator but it’s a little bit more controllable and powerful than the creaky bipap machine in the corner that you have to pipe in an unknonwn FiO2 via a sideport…

THREE

ultrasound guided FIAB

• I’d been using ultrasound for simple femoral blocks for a while but Gareth Hardy and the Ultrasound podcast have persuaded to look a bit harder with the machine and go under the fascia.

FOUR

Cunningham shoulder technique

• while I’d tried this before, this was the first year I managed to pull it off

http://www.youtube.com/watch?v=AQfkf5DtRxM

FIVE

Paraspinal injections for headache

• Al Sachetti brought this to my attention and while it’s not perhaps the most EBM of procedures I’ve tried it a few times now with pretty good success.

http://www.youtube.com/watch?v=0jIqzJs5c2g

Happy Christmas to all the wonderful readers. Will be back in the New Year. Vive la FOAM.

The post FOAMtastic top 5 for 2012 appeared first on Emergency Medicine Ireland.

This is a fun one. We all love a good dislocation.

I cannot recommend shoulderdislocation.net enough. Spend some time there, get a room, enjoy the view. There’s some great stuff on there.

If you’re into papers then this one from Neil Cunningham from a few years ago has some great stuff in it.

Here’s a video of the technique in action

http://www.youtube.com/watch?v=jIVjVRXo79w

Image credits:

Radiopaedia.org: Shoulder dislocation with fracture greater tuberosity

Shoulderdoc.co.uk: Rupture long head biceps.

PS apologies for audio on this one. Levels were set wrong.

The post Anatomy for Emergency Medicine 023 – Shoulder: Dislocations appeared first on Emergency Medicine Ireland.

There are of course a number of papers looking at the same thing but I saw this one recently.

Yuen, Chi Kit, Ka Leung Mok, and Pui Gay Kan. “The Validity of 9 Physical Tests for Full-Thickness Rotator Cuff Tears After Primary Anterior Shoulder Dislocation in ED Patients..” The American Journal of Emergency Medicine 30, no. 8: 1522–1529. doi:10.1016/j.ajem.2011.12.022. PMID 22386341

Great study question  – in shoulder dislocation can we pick up full thickness tears at 10 day follow up using clinical exam?

METHODS

• ultrasound by the trained EPs as gold standard – this could easily be questioned both in terms of training and in terms of modality – is MRI better?
• the big problem was the EPs doing the ultrasound were the same guys who did the exam – there was no blinding here so you can effectively find what you want to.

RESULTS

• 50 pts over 4 years (another problem…)
• 40% had a tear
• they conclude that the empty can test was the best – which is nice because that’s what I’ve been doing.
• even at that sens was 90% and spec 55% for the empty can.

Desptite the obvious weaknesses of the paper tears are common and contribute to morbidity so they’re worth looking for

Here’s a video of the empty can test just as a refresher

http://www.youtube.com/watch?v=SCiOrkyGgqw

The post Which test for rotator cuff tear following shoulder dislocation? appeared first on Emergency Medicine Ireland.

click for source

H/T Rob Bryant for tweeting the paper.

Ketamine in known elev. ICP. J Neurosurg. Pediatr. 2009 Jul;4(1):40-6 #FOAMed #Iloveketamine http://t.co/jrn7noEk

November 21, 2012 5:04 am via Camera on iOSReplyRetweetFavorite

@RobJBryant13

Rob Bryant

We all love ketamine, or at least Minh does. But there has always been the bogey man stories, that if you use ketamine in someone with a head injury, there brain will explode and you’ll get covered in lots of brain goo which is never  a good luck. As a result, I rarely see people reach for ketamine as an induction agent for these people.

There is increasing evidence that the ICP rise attributed to ketamine is likely a bit of a myth based on faulty early data and even faultier interpretation (a bit like lignocaine/adrenaline is bad for fingers…)

This study provides a little bit more ammo that ketamine is safe for ICP. It’s not gold standard, bullet proof evidence but the case is building.

Bar-Joseph, Gad, Yoav Guilburd, Ada Tamir, and Joseph N Guilburd. “Effectiveness of Ketamine in Decreasing Intracranial Pressure in Children with Intracranial Hypertension..” Journal of Neurosurgery. Pediatrics 4, no. 1: 40–46. doi:10.3171/2009.1.PEDS08319. PMID 19569909

METHODS

• single centre in Israel in the PICU with kids with TBI
• two groups, 
  • one who got ketamine for a procedure
  • the other who got ketamine for the ICP specifically
• ketamine was 1-1.5mg/kg
• all were on midaz and morphine as sedation
• some had propofol as well
• a bunch got mannitol or hypertonic saline or thiopental and some even had decompressive craniectomy

RESULTS

• 30 patients, 82 episods of ketamine administration, most for treatment of raised ICP
• it worked, it lowered the ICP by about 5mmHg in both groups of patients

Their only concern is that some of the prior studies showed ICP rises in those who were probably inadequately anaesthetised. This bunch of kids were doped up to the max and they say maybe that’s why the ketamine is safer.

They were surprised that the ketmaine actually lowered the ICP not just didn’t increase it.

This is, of course, a tiny little study and with all the different interventions going on you could make the argument that we can’t tell if it was the ketamine that lowered the ICP. None the less it’s still encouraging that the bogey man of raised ICP is a little bit mythical.

The post Ketamine use in TBI – the ICP goes down not up. appeared first on Emergency Medicine Ireland.

This is fairly simple straightforward case but it reinforced something for me.

4am standby call for a STEMI. At 4am. Was he shovelling snow at 4am?

Anyhow.

Chest pain for 9 hours.

Diagnosis

The post ECG Case 003 appeared first on Emergency Medicine Ireland.

Concussion is a strange beast. We know what to do with extra-durals (we think) but what do we do with concussion. We don’t even know what it means or what is going on at a cellular level. Yeah the CT looks normal but that doesn’t mean the brain is normal. Certainly, patients with concussion type symptoms don’t feel or behave normally.

So what do we do with a condition like that? Study it lots and come up with consensus statements like this one.

It’s a good read and it’s freely available. Concussion is something we see A LOT of and we need to think a little beyond “is there blood in the brain or not”

The evidence behind all this isn’t wonderful (in terms of high level RCT) but the paper does provide some useful insight into what to tell patients. I’ve given some highlights with commentary below.

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include:

While wordy, it’s fairy accurate – “we haven’t much of a clue but there’s a lot going on.”

1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.

2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however it is important to note that in a small percentage of cases however, postconcussive symptoms may be prolonged.

5. No abnormality on standard structural neuroimaging studies is seen in concussion.

This is what I try to explain to patients – though obviously it needs translated into patient speak. Typically I will spend a good 5 minutes talking to patient and family following evaluation for a bump on the head like this. Time well spent for a disease which we have no other intervention for. Talking to patients – hard bloody work but worth it.

The panel however unanimously retained the concept that the majority (80–90%) of concussions resolve in a short (7–10 day) period

I don’t use the numbers in discussion (though I might now) and I say 10-14 rather than 7-10 days but they get the point that most people are better quickly

brain CT (or where available, MR brain scan) contributes little to concussion evaluation

DO NOT SCAN FOR CONCUSSION. Of course – it’s not always that easy to tell but a scan will not help in the slightest for concussion

It is worth noting that standard orientation questions (eg, time, place, person) have been shown to be unreliable in the sporting situation when compared with memory assessment.

I don’t currently do formal memory assessments – it usually becomes clear in the situation (when the patient asks for the 4th time what happened…) that memory is an issue

The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded programme of exertion prior to medical clearance and return to play

Generally each step should take 24 hours so that an athlete would take approximately one week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise.

In my current ED we see a lot of young sports players (mainly rugby) whose first question is when can they get back to play

Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment

This is something that seems to reinforce the significance of concussion for patients.

There is no good clinical evidence that currently available protective equipment will prevent concussion

While it seems there’s evidence for helmets reducing fractures, there seems to be none for reducing concussion.

Well worth the read.

McCrory, P, W Meeuwisse, K Johnston, J Dvorak, M Aubry, M Molloy, and R Cantu. “Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport Held in Zurich, November 2008..” 43:i76–90, 2009. PMID 19433429

The post Some thoughts on concussion appeared first on Emergency Medicine Ireland.

Continuing our (seemingly never ending) journey through the shoulder and beyond the plain film.

Cheers as always to radiopaedia.org for the cited images.

The post Anatomy for Emergency Medicine #22 – shoulder: AC and SC Joints appeared first on Emergency Medicine Ireland.

An older, but sprightly female is brought to the ED after developing multiple episodes of vomiting. Her husband had been vomiting as well but his symptoms had settled after a few hours.

She has minimal clinical history apart from hypertension for which she takes two separate agents.

The prompt to attend the ED came after the lady passed out for about 30 seconds following an episode of vomiting.

Her vitals are normal and her ECG is shown below.

I’m no Amal Mattu but that looks like pretty standard A Fib to me…

While you are enquiring about any further past medical history she becomes nauseated again and begins to retch. The retching quickly stops but she is no longer able to answer your questions. While you’re becoming increasingly frustrated with your patients reluctance to engage in conversation, the nurse shoves you out of the way and commences CPR.

Following about 30 secs of CPR and the patient pushes the nurse away. You review the telemetry reading from the monitor and it is shown below.

Whats the diagnosis

The post ECG Case 002 appeared first on Emergency Medicine Ireland.

yet more on the shoulder and the impingement syndrome.

Enjoy. Or not…

The post Anatomy for Emergency Medicine #21 – shoulder: subacromial space and labrum appeared first on Emergency Medicine Ireland.

No not that waiting room medicine.

We’re all resus jockeys aren’t we?

#idratherbeinresus

Most of us in FOAMed community love resuscitation. We love the critically ill. We love the drama, the excitement. We love all the mr EMCrit has taught us.

I’m one of these people. Give me a full day in resus any day – bring on the sickies.

Unfortunately, if your ED is in the real world, you’ll realise that the vast majority of our customers don’t need resus. Our world is a seething waiting room of ambulatory patients with a bewildering variety of symptomatology.

How do you manage the waiting room? Most places have triage  - there is clinical justice with the sickest seen quickest (listen to this talk by my current boss.) Unfortunately if you get a lot of sick people and don’t have a system in place the lower triage acuity patients wait so long that they eventually leave. In the US this means your hospital doesn’t get paid. In our systems, we all breathe a sign of relief when patients do not wait to be seen. Not so much when they re attend twice as sick the next day, or are found dead.

Our traditional approach is rule out serious pathology. And we’re not bad at that. You’ve hurt your ankle, the x-ray shows no fracture – therefore we have accomplished our job as EPs.

Hmmm…

Once you’re in resus as a patient, you get lots of attention. Our spidey sense is immediately higher – purely because of your physical location in the department. I am much more likely to order certain tests when I am in resus because my mind is in a certain place. This is obviously a bit of  a problem.

One of the hardest things to do as an EP is to pick out both the serious pathology and the important diagnosis (because some really important diagnoses won’t kill people or even bounce back on us but will cause a  lot of morbidity for the patient) from the teeming mass of NSN (non-specific nonsense) that fills the waiting room.

Be careful with a diagnosis of soft-tissue injury

Be careful with non-specific abdo pain

Be careful with all the non-specific nonsense – a lot of it is really quite specific for something you’ve not heard of.

It’s a jungle out there guys. Tread carefully and good luck.

The post Waiting room medicine appeared first on Emergency Medicine Ireland.

Now here’s something that didn’t exist when I was a lad. There is now an EM student society in Ireland. A few very motivated and enthusiastic med students got together and started this and I thought it was well worth a shout out. I’d thought vaguely about EM when I was a student but it was still fairly new and the pathways for training weren’t nearly as well developed as they are now.

Anyhow, check them out and if you’re a student in Ireland get in contact and find out why EM is the best specialty around.

This is what they have to say.

We are a student-run national society for any Health Science student interested in Emergency Medicine. Originally set up in Trinity College (Ed- where I used to teach), there is now an EMSSI branch in every University in Ireland with an UG or PG Medicine course. We sit on the IAEMTA Committee as student representatives, and the Chair of the IAEM Academic Committee Prof Ronan O’Sullivan is our Honourary President.

Our aims are

• To provide a forum for interested students to experience life in Emergency Medicine in Ireland
• To facilitate extracurricular up-skilling in clinical skills specific to Emergency Medicine; intubation, lines, resusc etc.
• To educate about pre-hospital emergency management
• To provide links to and information on EM sub-specialties, such as Expedition Medicine, Wilderness Medicine etc.

So, if you are a Health Science student with an interest in Emergency Medicine, we want to hear from you!

Getting in touch is easy: e-mail emssi.youruniveristy@gmail.com, e.g. emssi.tcd@gmail.com, emssi.ul@gmail.com, emssi.nuig@gmail.com etc.

Alternatively get in touch with us via Facebook  and we’ll put you in touch with your local EMSSI Chapter for details on how to join.

Looking forward to hearing from you!

They also got a nifty write up here

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