Sketchy EBM – Great Evidence Based Medicine Site

sketchy header

This really slick new site came onto my radar when listening to my friend, Ken Milne’s (@TheSGEM) podcast ‘The Skeptics Guide to Emergency Medicine. Ken’s podcast has surreptitiously taught me a great deal in how to interrogate research, as well as some great clinical topics. Having listened to a number of episodes in which Dr Anthony Crocco was a Guest Skeptic, I was thrilled to here that Antony had launched his own website focusing on Evidence Based Medicine and research appraisal.



Sketchy EBM has a growing gallery of videos that will undoubtedly enhance your thought processes around critically appraising medical research publications. As well as the EBM videos, Anthony’s (in)famous Ranthony videos are hosted – these are soapbox style rants in which Anthony tackles dogma and bugbears in Paediatric Medicine.

By way of introduction, I would strongly recommend spending the four minutes viewing ‘How I Read a Paper’. Jump in and get Sketchy and as the tagline says:

Always draw your own Conclusions

Lose the Egg – Take Off on Twitter

Recently I have been getting asked at increasing frequency, ‘How does Twitter work?’. I invariably give them these resources. Quite frankly, this post is simply curating the links I always end up Googling and giving to colleagues interested in losing their Twitter virginity.

The first, in my go-to series from Prof Rob Rogers @EM_Educator (University of Kentucky EM, iTeachEM and The Teaching Institute and The Teaching Course) is:

Getting Started With Twitter

Once feeling orientated and over the initial shock of another social media account, delve into a bit more of the anatomy of a Tweet:

Twitter Video Series #2

Now you are getting pretty good at this whole Twitter game, check out a bit of the buttonology of the basic Twitter App:

Twitter Video Series #3: The Twitter App

Ok, you are either getting hooked on the “Blue Bird”, ore have ditched it by now. Let’s get piggy and start hashtagging and composing some crowd pleasing Tweets:

Twitter Video Series #4: Tweeting and Hastagging 

Check out the rest of Rob’s Vimeo Channel for more tasty FOAM –


In addition to Rob’s great Video Tutorials, please do yourself a favour and check out this amazing (and visually stunning) blog post, penned by Paul McNamara @meta4RN, for the Ausmed  Education website:


Picard’s FOANed Skills – Testicular Emergencies


Follow Chris on Twitter @CtPicard

Injectable Orange Editorial: In the second installment of Chris Picard’s series of Nurse-oriented, evidence-based assessment skills, he dives into the assessment of cremasteric reflex for testicular injury. While it is not the role of the nurse to diagnose, understanding of assessment techniques and rationale add to the ability to communicate within the multi-disciplinary team. Chris continues to explore the disconnect in nursing when it comes to owning physical assesment skills. Check out Chris’ site

Editorial Addition, 31st July: Ross Fisher, Consultant Paediatric Surgeon from Sheffield in the UK, thoughtfully commented on this post and provided a definite reminder as to the context of all assessment being vital. Thanks Ross for contributing tacit experience into the discussion:

I’d be cautious about using the cremasteric reflex, particularly in children, as an assessment tool. In little ones, the reflex can be so sensitive as to pull the testis very high on simple contact of the examining hand, suggesting “loss” of the reflex to the unexperienced. In acute idiopathic scrotal oedema the scrotum can already be thickened and obscure visualisation. A testis may torse and then detorse and still have the reflex intact.

Our teaching is that INFERIOR pole tenderness of a testis is exceptionally unlikely to be torsion of the appendix testis or epididymitis ie very highly likely to be testicular torsion.


The cremasteric reflex is a superficial reflex that can be exceptionally useful in assessing testicular emergencies.

The cremasteric reflex is a contraction of the cremaster muscle, in response to the stroking of the thigh, which results in retraction of the testicle. Absence of the reflex is an ominous sign when assessing an acute scrotum.

When assessing an acute scrotum, the most important condition to rule out is testicular torsion (Ringdahl & Teague 2006). Testicular torsion occurs when the testicle rotates within the scrotum, the twisting out the epididymis results in impaired blood flow, ischemia can ensue rapidly, and can eventually result in loss of the testicle (Ringdahl & Teague 2006).

Testicular torsion usually occurs in the absence of trauma, and without precipitating factors; although an abnormal attachment of the testicle to the scrotum “bell clapper” deformity, present in approximately 10% of males, puts an individual at increased risk. The overall incidence of testicular torsion is estimated at 1 per 4000 in males under age 25, with the highest incidence occurring during the first few days of life, and from age 12-18yrs. (EBMedicineRingdahl & Teague 2006). Testicular torsion requires emergency urology referral, as ischemia begins within 4 hours (Ringdahl & Teague 2006). It is precisely for this reason that knowing how to assess for a cremasteric reflex is essential.


When assessing an acute scrotum for testicular torsion one testicle may appear to be shortened due to the twisting of the epididymis, cremasteric reflex may be absent on this side, but the test should be performed bilaterally. To assess cremasteric reflex the thigh should be stroked with a finger, the handle of a reflex hammer, or most commonly with the blade of a tongue depressor. A normal finding is a retraction of at least 0.5 cm; an abnormal, or absent reflex needs immediate referral.

Torsion second

The cremasteric reflex, in the presence of scrotal pain has been estimated at 96-99% sensitive (Ringdahl & Teague 2006Schmitz & Safranek, 2009); which is to say that the probability of having a false negative is approaching zero percent. Absent reflex is 66-88% specific for torsion, yielding a negative predictive value of 96% (EBMedicine). The caveat to these probabilities is that an absent cremasteric reflex can be considered normal in approximately 50% of infants under the age of 30 months (Ringdahl & Teague 2006). The importance of the high sensitivity from the nursing perspective is that we can be relatively certain that the odds of a false negative are low, and that there will likely be need for urgent referral of these patients.

Correction, or de-torsion of a testicle, can be performed manually with local or procedural sedation; however it is generally addressed through emergent surgical exploration and intervention. Salvage rates are time dependent: surgery within six hours is 90% successful in salvaging the testicle, successful salvage drops to 50% by hour 12, and less than 10% after 24 hours (Ringdahl & Teague 2006). For this reason there is a low threshold for referral and diagnostic studies.

As a nurse knowing how to assess cremasteric reflexes can be exceptionally useful because, in the presence of scrotal pain, an absent creamasteric reflex approaches 100% sensitivity for testicular torsion. Given the short window for surgical intervention, the risks of over-triage, or over treatment due to a false positives are far outweighed by the potential benefit that patients with testicular torsion will experience from rapid referral and intervention.

The cremasteric reflex is a low barrier, easily performed physical assessment. It is a highly sensitive screening tool for patients who need immediate physician attention and surgical referral.




Ringdahl, E., & Teague, L. (2006). Testicular Torsion. American Family Physician74(10).

Schmitz, D., & Safranek, S. (2009). How useful is a physical exam in diagnosing testicular torsion?. Clinical Inquiries, 2009 (MU).

EB Medicine Topics (EB Medicine Topics).,







Respiratory Review – Principles of Mechanical Ventilation

resp reviewRespiratory Review and the Principles of Mechanical Ventilation Videos

Complex areas of clinical practice, such as developing an understanding of Mechanical Ventilation are challenging to grasp for those new to critical care. Be you a Doctor, a Nurse, or a Respiratory Therapist, skill, knowledge, and mastery of Mechanical Ventilation are developed and acquired over time. We grasp the principles, revisit theory in clinical practice and develop tacit experience, all on our own learning trajectory. I know I have often had to revisit the foundation principles of Mechanical Ventilation throughout my career, re-integrating the core theory and have often found I’ve been left to leaf through textbooks and search broadly for unfiltered content online.

Enteoli pooler Oli Poole @RespReview, Respiratory Therapist practicing in Canada and provider of some of the best FOAMed, FOANed and FOAMcc content around on mechanical ventilation and associated clinical topics. If you like what you see below, please go and visit the Respiratory Review YouTube Channel This channel is a repository to an expanding library of top notch, Khan Academy style videos on Ventilation and related topics.

On this Injectable Orange page, with Oli’s permission, I am providing a second home/portal and a mini curriculum of sorts, around the foundational content. These videos run sequentially alongside the common induction knowledge pathways for those new to Intensive Care, and Critical Care in the ED or Respiratory Wards. This Page has a permanent home on the site at


Principles of Mechanical Ventilation 1: Goals and Indications for MV

Content: This video provides an introduction into the goals of mechanical ventilation, as well as categorising the indications for mechanical ventilation into 3 major categories.

Learning Outcomes: At the end of this video the learner should be able to:
1) Describe the goals of mechanical ventilation
2) Understand the major indications for mechanical ventilation
3) Describe the primary ABG disturbance for Type I and Type II respiratory failure


Principles of Mechanical Ventilation 2: Phases of a breath

Content: This video briefly outlines the 4 major phases of a mechanically ventilated breath:

  1. Start of Inspiration;
  2. Inspiration;
  3. End-Inspiration;
  4. Baseline.

Learning Outcomes: At the end of this video learners should be able to demonstrate knowledge of the 4 phases of a mechanically ventilated breath.


Principles of Mechanical Ventilation 3: Total Cycle Time and I:E ratio

Content: This video builds upon the video on phases of a breath, introducing the topics of total cycle time, and I:E ratio.
Learning Outcomes: By the end of this video learners should be able to:
1) Define Total Cycle Time and I:E ratio.
2) Calculate the I:E ratio using varying respiratory rates and inspiratory times.


Principlies of Mechanical Ventilation 4: Modes – Assist Control (AC)

Content: This video introduces the topic of modes of ventilation. Identifying the different breath types that can be delivered by a ventilator the video explores the ‘Assist/Control’ mode.

Learning Outcomes: After watching this video the learner should be able to:
1) Identify the 3 types of ventilator breath
2) Differentiate between a control breath and an assisted breath
3) Explain what happens when the patient triggers an additional breath in an assist control mode.


Principle of Mechanical Ventilation 5: Assist Control Volume Control

Content: This video specifically explores the features of Volume targeted breath delivery, including ventilator waveforms in Assist Control Mode.


Principles of Mechanical Ventilation 6: Phase variables

Content: A video on the 3 key phase variables: Trigger Variable, Limit Variable, and Cycle Variable.


Principles of Mechanical Ventilation 7: Calculating I:E ratio in Volume Control (VC)

Content: This video demonstrates how to calculate IE ratio, Ti, Te, and TCT in volume control.
It should be noted that some modern Ventilators allow Ti to be selected in “Volume Control”. Such modes are not truly volume control, but Pressure Regulated Volume Control (PRVC), or a version of it. We will cover PRVC in later videos.


Principles of Mechanical Ventilation 8: I:E ratio example 2 in VC constant flow

Content: This video builds, with another case upon Video 7. Second example of how to calculate I:E ratio in volume control with constant flow.


Principles of Mechanical Ventilation 9: Pressure Volume relationship in VC

Content: A video on the relationship between pressure and volume in volume control ventilation. A really important concept!
Key points:
1) Pressure is variable in volume control, the pressure generated will depend on the lung mechanics of the patient, the size of the breathing tube etc.. think of anything that changes COMPLIANCE or RESISTANCE
2) A high pressure alarm can be set to cycle high pressure breaths, this protects the lungs from the deleterious effects of high pressures
Compliance is key! Watch the video on compliance, up next.


Principles of Mechanical Ventilation 10: Compliance

Content: A video on lung compliance. Hopefully this will give you a good intuitive idea of what compliance is, and how it relates to mechanical ventilation.


Principles of Mechanical Ventilation 11: Modes – Pressure control

Content: This videos aims to provide and intuitive look at pressure control. This is simple an introduction to the pressure controlled breath delivery. We will be delving much deeper into the details later on.

Related homework: Inspiratory Time in Pressure Control: How to use the Flow Waveform!

resp review

I hope this serves as a gateway to Oli’s brilliant work. Please check out his other videos covering physiology topics related to ventilation. Oli has a talent for distilling the complex, into simplicity.

Hat Tip: I was first directed to Respiratory Review via the Critical Care Practitioner Podcast. Check out Jonathan Downham’s two interviews with Oli:

Picard’s FOANed Skills – Physical Assessment


Follow Chris on Twitter @CtPicard

Injectable Orange Editorial: So the call went out on Twitter for eager bloggers to share their words via Little did I expect to get a response from someone whose work I am already a devoted (if not somewhat new) fan of. Chris has been putting in some brilliant review articles over at his site FOANed ReviewsI genuinely believe that the work Chris is doing is what has been missing from the nursing space online – scientific knowledge translation for nurses. Chris has come on board, beginning with some cross-posts and hopefully to be a regular future contributor. His posts on this site will focus on exploring the evidence around clinical skills within the domain of nursing. So without further preface we kick of exploring the lost art (and science) in nursing physical assessment.


Physical assessment techniques have been a core component of undergraduate nursing curricula for the last 20 years; yet new research in the International Journal of Nursing Studies is adding to a growing body of evidence that suggests Registered Nurses aren’t using the skills taught to them in university.

Osborne et al surveyed nurses across 40 acute care units in Australia to determine the frequency with which they used different physical assessment skills. The physical assessment inventory used in this study is a 133 modified skill inventory used by Giddens (2007), Birks et al., (2012), and Secrest, Norwood and DuMont (2005). Of the 133 skills on the inventory an average of only 10 skills (7.5%) were performed regularly (daily), the majority of which were required to take a complete set of vitals; an additional 18 skills (14%) are described as being used frequently; with a surprising total of 93 skills (70%) reported as never being used (Osborne,S et al., 2015).

Frequency Description Skill n=133 (%)
5- Regularly Daily 10 (7.5)
4- Frequently Every 2-5 shifts 8 (6)
3- Occasionally A few times a year 10 (7.5)
2- Rarely A few time in career 12 (9)
1- Never Know how but have never performed 69 (51.9)
0- Never learned Do not know how to perform 24 (18)

Several factors were identified that predicted rates of physical assessments performed by nurses. Medical/surgical nurses tended to perform more physical assessments than psychiatric/mental health nurses of similar age and experience level; Specialty areas tended to use more specific skills ex: maternity floors performing more abdominal assessment techniques. Physical assessment skill usage was also found to be inversely correlated with: time worked in the profession and years of education, this however; could be due to nurses having less patient contact as they move into supervisor/manager or educator positions.

The researchers used a “Regression coefficient” to determine the degree to which a barrier decreases the utilization of physical assessment skills by nurses. An increase of reliance on others, not performing nursing assessments that overlapped with physician roles, by one unit resulted in a core skill decrease of 36.5%. As confidence decrease of one unit resulted in a core skill use decrease of 11.9% (Osborne,S et al., 2015). This study unfortunately didn’t offer any insight into other physical assessment techniques nurses were using; nor did the offer any suggestions on how nurses can increase their use of physical assessment techniques.

Of the six barriers to nurses performing physical assessment skills identified I believe reliance on others, and lack of confidence can be directly addressed by using online education services. This, as well as other studies of a similar design have identified a disconnect between education and practice. They have suggested that the reason nurses are performing so few of the skills in the assessment, is that few of the skills are relevant to nursing practice (Birks et al., 2013, Giddens, 2007, Osborne et al., 2015, Secrest, Norwood & Dumont, 2005), this too I believe can be addressed through online education.

Associations between barriers and use of core physical assessment skills adjusted for clinical role and work area (Osborne,S et al.,2015) .

Barrier subscale Regression coefficient (b) 95% CI F p value
Lower Upper
Reliance on others and technology −.411 −.483 −.328 62.9 <.001
Lack of time and interruptions −.176 −.254 −.090 14.6 <.001
Ward culture −.265 −.348 −.172 25.7 <.001
Lack of confidence −.234 −.305 −.157 29.6 <.001
Lack of nursing role models −.126 −.208 −.035 7.1 .008
Lack of influence on patient care −.317 −.414 −.204 23.9 <.001
Specialty area −.149 −.245 −.041 7.0 .008
Total barriers score −.430 −.516 −.329 46.2 <.001

A role for Free Open Access education

Free Open Access Medical Education (FOAMed) is a movement with the goal of sharing information, connecting practitioners, and decreasing knowledge translation times using social media (Life In The Fast Lane). FOAMed has also started to cross into the traditional academic forums of peer reviewed journals, with an “impact” rating system now being championed (Thoma et al, 2015)The fledgling nursing equivalent Free Open Access Nursing education (FOANed) is a continuation of the FOAM concept, with social media hosting of content applicable to Nursing

FOANed could be used to address some of the issues identified by Osborne et al. it can be used as a forum to share the education and resources necessary for nurses to learn new skills, and to connect nurses with mentors to role model positive behaviors. FOANed creates an opportunity for clinicians practicing at the bedside to engage in the education process, to elucidate the roles, responsibilities, and skills used in nursing. As this knowledge becomes more accessible, hopefully it will be translated back to academia, so adjustments to nursing curricula can be made.


Birks, M., Cant, R., James, A., Chung, C., & Davis, J. (2013). The use of physical assessment skills by registered nurses in Australia: Issues for nursing education. Collegian20(1), 27-33.
Giddens, J. F. (2007). A survey of physical assessment techniques performed by RNs: lessons for nursing education. The Journal of nursing education46(2), 83-87.
Osborne, S., Douglas, C., Reid, C., Jones, L., & Gardner, G. (2015). The primacy of vital signs–Acute care nurses’ and midwives’ use of physical assessment skills: A cross sectional study. International journal of nursing studies.
Secrest, J. A., Norwood, B. R., & Dumont, P. M. (2005). Physical assessment skills: a descriptive study of what is taught and what is practiced. Journal of Professional Nursing, 21(2), 114-118.
Thoma, B., Sanders, J., Lin, M., Paterson, Q., Steeg, J., & Chan, T. (2015). The Social Media Index: Measuring the Impact of Emergency Medicine and Critical Care Websites. Western Journal of Emergency Medicine.

Key to The Future: MNHHS Nursing & Midwifery Conference



                Simulation Education Workshop: Technique, Not Technology: Nursing CPD 2.0

This post is to curate a selection of materials linked to the the Simulation Education Workshop I delivered on May 12th (International Nurses Day) at the inaugural Metro North Hospital and Health Service Nursing and Midwifery Conference.

The central theme of this workshop was scenario based simulation through the progress of a nursing career. There is increasing adoption of simulation as a teaching technique for many technical and team based skills in the health professions. The aim of this workshop was to outline practical tools that can facilitate the utility of simulation at pivotal points in the progress from undergraduate nurse, to new graduate, to team leader, educator, executive and beyond. Nursing has many divergent career pathways, but using the correct framework, I believe scenario based simulation can facilitate a smooth transition, expanding scope of practice, leadership and communication skills and understanding the risks our environments hold.


Australian Healthcare Simulation Community

This Health Workforce Australia (HWA) project aims to connect simulation educators and provide standardised resources that can smooth out the bumps and workload involved in introducing a simulation program into your institution.



Simulation Glossary of Terms

A very useful glossary of the vocabulary of health simulation. Development of a common language is important to take simulation from being an ad hoc event such as the “Mock Arrest” to a more educationally sound and crucially integrated teaching technique. Terminology sets expectation.

HWA Data Dictionary



These documents are pro-formas that may assist with planning and evaluating scenarios.

Scenario template (pdf)

Scenario Template (doc)

Post Scenario Report (pdf)

Post Scenario Report (doc)


Podcasts & Blogs

There are some posts in the back catalogue of Injectable Orange that can be found here SIMULATION Posts

Top ten tips for In Situ Sim at St.Emlyns – A great blog and podcast post giving ten solid tips about integrating simulation into your workplace education program.

Injectable Orange Simulation Basics: Back to the Future – A casual walkthrough of the phases of simulation.

Simulating Healthcare Blog  – A brilliant blog by Dr Paul E. Phrampus, a guru in the world of healthcare simulation.

Mobile Medical Simulation – A brilliant website curating a whole host of resources from scenarios, templates and debrief guide.



Thanks again to my awesome co-conspirators Sean Lannan and Thea-Grace Collier.