Funtabulously Frivolous Friday Five 104

Funtabulously Frivolous Friday Five 104

Question 1

As you pull back the curtain, your next patient bursts into a bout of uncontrollable laughter. Because it surely can’t be due to your appearance, you decide this patient must suffer from…?

  • Gelastic seizures
  • Gelastic seizures are epileptic events characterized by bouts of laughter.
  • Laughter-like vocalization is usually combined with facial contraction in the form of a smile.
  • Autonomic features such as flushing, tachycardia, and altered respiration are widely recognized. [PMC 2646637 ]

Question 2

What is the meaning of this phrase “j’ai des papillons noir”? How did Dr Freeman (the lobotomist) use this imagery on the cover of his publication “Psychosurgery“?

  • “I have black butterflies” – a euphemism for depression
  • Walter Freeman’s 1950 publication “Psychosurgery” featured a picture of a skull with a crack in it, out from this circled black butterflies.

Question 3

J.S. Bach underwent a procedure called “couching” in his later life. What is this procedure and what was the outcome for the great composer?

  • Couching is the earliest documented form of cataract surgery
  • A sharp instrument is used to push the opaque lens to the bottom of the eye
  • The ancient Indian surgeon Maharshi Sushruta first described the procedure in “Sushruta Samhita, Uttar Tantra” in 800 B.C
  • Outcomes are often little better than the initial visual impairment and complications rates are high. Despite this – the procedure is still commonplace today in countries such as Burkina Faso and Mali [PMID 11262674]
  • J.S Bach became totally blind after bilateral couching and died four months later. Intractable glaucoma secondary to phacoanaphylactic endophthalmitis the significant complication leading to his permanent blindness [PMID 22339937]

Question 4

What forms Schamroth’s Window?

  • Schamroth’s window – the diamond-shaped gap formed when two opposing fingers are placed back to back
  • Schamroth’s sign occurs in finger clubbing, when this window is obliterated and the distal angle formed by the two nails becomes wider
  • Schamroth described this sign in himself – following 3 episodes of infective endocarditis.[PMID 1265563]
Schamroth sign

Schamroth sign JAMA. 2010;304(2):159-161.

Question 5

What is Iatrophobia?

  • An abnormal or irrational fear of doctors or going to the doctor.

 

…and always remember – homeopathy CAN cure Ebola

Dr Medha Durge and other homeopathic physicians attack ‘armchair intellectuals’ at WHO who refuse to let them treat Ebola with snake venom remedy

Homeopathy and ebola

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Research and Reviews in the Fastlane 058

Research and Reviews in the Fastlane

Welcome to the 58th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Education
R&R Hall of Famer - You simply MUST READ this!
Starmer AJ, et al. Changes in Medical Errors after Implementation of a Handoff Program. NEJM 2014; 371(19): 1803–12. 25372088

  • Despite a significant impetus about its use in healthcare, there was no good evidence that a standard handoff tool at the moment of patient transfer or care improved outcomes. This is a multicenter study (9 sites) where they used the I-PASS mnemonic for transitions of care. The use of the tool decrease errors in a 23% and adverse events in a 30%. The participants in this study did not experience increase workload.
  • In the best study to date examining patient safety consequences with standardized handoffs, these authors found a reduction of 1.4 preventable adverse patient events per 100 patient admissions (4.7 vs. 3.3 events per 100 admissions). Nine different pediatric training sites were included in the study. Also of note, direct observation by research assistants found no change in resident workflow or amount of time with patients and family with the institution of the standardized handoff.
  • Recommended by: Daniel Cabrera, Jeremy Fried
  • Further reading: It’s a Patient Hand-Off Miracle (Emergency Medicine Literature of Note)

The Best of the Rest

Emergency medicine, Ultrasound
R&R Landmark paper that will make a difference
R&R Game Changer? Might change your clinical practice

Rubano E et al. Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing Suspected Abdominal Aortic Aneurysm. Acad Emerg Med 2013;20(2): 128-38. PMID: 23406071

  • You better think ultrasound if you are thinking acute abdominal aneurysm (Triple A).
    The prevalence of triple A is 1.3-15% in emergency department adults and increases with age. It’s greatest in males over 65 with a history of smoking and hypertension.
    These are patients that are the absolute definition of “can’t miss”. The mortality with rupture approximately 90 percent. There is no combination of history or physical findings that can reliably exclude acute abdominal aneurysm. Adult emergency department patients with any presentation consistent with potential triple A should be scanned.
    This paper is part of evidence based diagnostic series in Academic Emergency Medicine. The decision editor for this is the same guy who wrote the book on Evidence Based Emergency Care, Dr. Chris Carpenter.
    The positive likelihood ratio (+LR) was 10.8-infinity
    The negative likelihood ratio (-LR) was 0.00-0.025
    Bottom Line: Emergency department ultrasound, when applied by “trained” emergency physicians, is an excellent accurate diagnostic modality to detect triple A’s in symptomatic adult patients.
  • Recommended by: Ken Milne, Mike Mallin and Matt Dawson
  • Further reading: You better think ultrasound for acute abdominal aneurysm (Skeptic’s Guide to Emergency Medicine)

ResuscitationR&R Game Changer? Might change your clinical practice
Cheskes S et al. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation 2014; 18(3): 336-42. PMID: 24513129

  • The length of the pre-shock pause is strongly associated with the rate of good outcomes after cardiac arrest. This is the largest study investigating the topic. Reducing the pre-shock and post-shock pause is easy too: continue compressions while the defibrillator charges and immediately resume compressions after discharge. It’s small alterations in our methods that often lead to the biggest outcome changes.
  • Recommended by: Anand Swaminathan

Emergency medicine, CardiologyR&R Game Changer? Might change your clinical practice
R&R Landmark paper that will make a difference

Bangalore S, et al. Clinical Outcomes with β-Blockers for Myocardial Infarction: A Meta-analysis of Randomized Trials. Am J Med 2014; 127(10): 939-53. PMID: 24927909.

  • Outstanding meta analysis that looks at the effect of beta blockers in myocardial infarction before and after the modern reperfusion era. This paper is full of multiple data points that will significantly inform cardiology practice, to the point that the authors recommend that guidelines re-examine the recommendation for beta blockers in MI in patients undergoing contemporary treatment. Most significantly for emergency practitioners, no mortality or cardiovascular mortality benefit was found for the use of IV beta blockers in the acute phase. The COMMIT trial drives most of the findings, but no differences were found when that data was excluded in the analysis.
  • Recommended by:  Jeremy Fried

Emergency Medicine
R&R WTF Weird, transcendent or funtabulous!” width=Marquié JC, et al. Chronic effects of shift work on cognition: findings from the VISAT longitudinal study. Occup Environ Med. 2014. PMID: 25367246

  • This is french study using a large (3000+) cohort of workers from multiple areas of industry. The population was separated in shift workers (defined broadly as going to bed after midnight, waking up before 5am, alternating schedule or not able to sleep overnight). The applied cognitive tests to each patient in a yearly basis. The results showed chronic cognitive impairment in the shift-worked population compared to non-shift worked. There were small but statistically significant differences between the groups that were more marked if the shift-work was longer that 10 years. After 5 years of non-shift work, there was no difference suggesting recovery.
  • Recommended by: Daniel Cabrera

Emergency Medicine, AnaestheticsR&R Hot Stuff - Everyone’s going to be talking about this

Beaudoin FL, et al. Low-dose Ketamine Improves Pain Relief in Patients Receiving Intravenous Opioids for Acute Pain in the Emergency Department: Results of a Randomized, Double-blind, Clinical Trial. Acad Emerg Med. 2014;21(11):1193–1202. PMID: 25377395

  • This study (n=60) randomized patients in the ED getting IV opioids to morphine (0.1 mg/kg) + placebo or morphine (0.1 mg/kg) + ketamine (group 1 0.15 or group 2 0.30 mg/kg). Patients in the ketamine arm had significantly decreased pain without significant adverse effects, although the group with the higher dose of ketamine had a seeming increase in side effects without added analgesic benefit. The literature is mounting that low dose ketamine has utility in the acute analgesia armamentarium but selecting the right population will likely be key (and more is not better).
  • Recommended by: Lauren Westafer
  • Further Listening: Cliff Reid shares his experience on “sub-dissociative” ketamine for analgesia -NeuroRAGE Special Edition (RAGE podcast)

Emergency Medicine, Cardiology, Neurology
R&R Game Changer? Might change your clinical practiceGe Coll-Vinent B et al. Stroke Prophylaxis in Atrial Fibrillation: Searching for Management Improvement Opportunities in the Emergency Department: The HERMES-AF Study. Ann Emerg Med 2014. PMID: 25182543

  • While it’s clear that atrial fibrillation raises the risk of stroke in patients, selecting the right prophylaxis regimen continues to be challenging. In this observational study performed in Spain, the authors found that many patients that were moderate to high-risk for stroke were not discharged on the appropriate prophylaxis. Whether this is the Emergency Providers role or not is debatable but it is vital for us to consider starting the right medications upon discharge or ensuring close follow up where this can be done.
  • Recommended by: Anand Swaminathan

Pediatrics
R&R Hot Stuff - Everyone’s going to be talking about thisRalston SL, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014. PMID: 25349312.

  • Can we stop doing the wrong things for bronchiolitis, and start doing the right things? Don’t test for virus, order bloodwork, or get X rays. This also means don’t give steroids, albuterol, epinephrine, antibiotics, or CPT. Hypertonic saline is recommended against in ED, but maybe you can use in hospitalized patients.
    You should hydrate all patients with bronchiolitis. Start at their mouth if possible.
  • Recommended by: Justin Hensley

Resuscitation
R&R Hot Stuff - Everyone’s going to be talking about this
R&R Game Changer? Might change your clinical practice
Leidel BA et al. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation 2012; 83(1):40-5. PMID: 21893125

  • There continues to be an ongoing debate on the vascular access method of choice in patients in whom peripheral access has failed. This article demonstrates that IO access is more likely to have 1st pass success (85 vs. 60%) than central line insertion and is faster (2 vs. 8 min). A difference of 6 minutes is critical for interventions like airway management but may be negated by rapidity of infusion for procedures like blood transfusion or fluid administration.
  • Recommended by: Anand Swaminathan

Emergency Medicine, Infectious DiseaseR&R Game Changer? Might change your clinical practice
Singer AJ, Thode HC Jr. Systemic antibiotics after incision and drainage of simple abscesses: a meta-analysis. Emerg Med J. 2013. PMID: 23686731

  • Treatment for an uncomplicated cutaneous abscess is usually just incision and drainage. However, patients still routinely get prescribed oral antibiotics?
    An earlier 2007 systematic review in Annals of Emergency Medicine by Hanki and Everett looked at this issue. Their closing line was “A conclusive, multicenter, double-blind, randomized, placebo-controlled clinical trial is lacking and sorely needed.”
    This new SR identified only 4 studies (2 from 2010) and included almost 600 patients. The conclusion was adding antibiotics after I&D did not significantly improve early cure or recurrence rates for uncomplicated cutaneous abscesses.
  • Recommended by: Ken Milne

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

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Take Heart Australia

Guest Post by Professor Paul Middleton, emergency physician and founder of Take Heart Australia

I have spent the last 20 years practicing emergency medicine on the ground and in the air. I have attended countless cardiac arrests both in hospital and the pre-hospital setting; performed compressions on hundreds of chests; sent countless joules of energy through wobbling hearts, and squirted buckets of adrenaline into cannulae, IO needles and ET tubes…but I still have an empty feeling inside – I know we can do better.

We hear about cardiac arrest all the time, and as clinicians working in emergency medicine and critical care we spend a larger part of our time dealing with the prevention, treatment, and outcomes of cardiac arrest than any other group.

For the in-hospital cardiac arrest we are often incredibly well informed about the diagnostic synergies of gestalt and troponin, we may know about the predictive power of a lactate above 4 even in the presence of normal physiology, we can see the dysfunctional ventricle and the valvular regurgitation on our bedside echo, and we can avoid complications of intubation by our practiced use of NODESAT and bimanual laryngoscopy….

…but, the simple fact remains, that we are just not going to be there for the 30,000 Australians and 350,000 Americans who suffer cardiac arrest outside of the hospital setting.

Communities in the US, such as Seattle and King County, WA, have a cardiac arrest survival rate of over 60% for patients with shockable rhythms such as ventricular fibrillation or ventricular tachycardia. This is in sharp contrast to Australia, which has VF/VT survival rate of between 10 and 20%. This level of mortality would be unacceptable in any other pathology, so what makes it OK to just accept it here; and what can be so different about Seattle, King County, Arizona, Minnesota and Tokyo, that gives them survival rates 2-3 times that which we have in Australia?

What’s the secret?

Unfortunately, if we’ve learned anything from the last 60 years of resuscitation research…it’s that there is no secret. The venerable model of a “cardiac chain of survival” keeps proving to be true, and good outcomes for any cardiac arrest patient depend on an interlocking series of events occurring rapidly and effectively. When even one link is weak or missing, it can’t be compensated for elsewhere.

Chain of survival

Although the establishment of cardiac arrest centres, helicopter cardiac arrest retrieval, ECMO on arrival and even during transport are significant and valuable additions to care, none of them are any use if they are applied to a patient who has been in cardiac arrest without basic life support for more than ten minutes or so. We already know that for every one minute without BLS before defibrillation means almost 10% decrease in survival, and intense focus on technological and infrastructure-heavy additions to the far end of the chain or survival often miss the point that much more bang for our buck is achieved, much more cheaply, with focus on the first two or three links in the chain.

In most cases of cardiac arrest the weak, or more often non-existent, link is layperson intervention. Most cardiac arrests do not get bystander chest compressions; either they are afraid of doing it wrongly, afraid of causing harm, afraid of being found liable for some later problem, worried about catching some disease, or just not being confident that they could recognise the need. If high-quality bystander CPR is started, however, the decrease in survival slows to 3-4% each minute to defibrillation.

Similarly, the success of Automated External Defibrillators used by bystanders has been shown to be hugely beneficial, with twice the number of victims surviving in one trial where AEDs were added to standardised CPR training, compared to CPR alone. If you insist on having a cardiac arrest, have it at the Melbourne Cricket Ground, where bystander CPR rates are over 90%, 85% of victims are resuscitated at scene, and 70% leave hospital. OHCA survival can be between 40 -70% in airports, casinos and aircraft, but most success is seen where there are AED placement programs, or PAD programs, with lay rescuers trained as first responders and the AEDs linked to the ambulance service.

The first five minutes holds the key to survival. We need more people of all ages who are trained and willing to provide immediate CPR, more and easily accessible defibrillators and we need a coordinated healthcare system.

Thus, the challenges of cardiac arrest resuscitation have shifted from the clinical, such as finding the ideal antiarrhythmic medication, and toward the psychological – determining how to market CPR so people will learn it, teach it so they’ll remember it, and contextualise it so they’ll be willing to do it. It is no coincidence that the ILCOR and ARC guidelines have become exponentially simple and straightforward over the last few years; what we now realise very clearly is that we need to perform the most basic of interventions, but do them really, really well.

What are the possible models?

To illustrate what is possible, we should think about what happens in Seattle. Emergency physicians and senior emergency medicine technicians from Medic One, the venerable and highly effective ambulance service in Seattle City and King County, run the Resuscitation Academy. This teaches the core message that communities need to work as single systems to ensure the best survival from cardiac arrest, and that this system starts with the bystander. Not content with just making CPR training available, there are impassioned and active campaigns to inform, persuade and educate the entire community of the necessity of immediate recognition of the problem, instant CPR and AED use as quickly as possible. As a result, the population as a whole is responsive and primed to take responsibility to save the life of the victim who was standing next to them only a few moments previously. They joke that you can’t fall asleep in a Seattle park in the summer sun, as someone will immediately start pushing on your chest!

AEDs are positioned in multiple public locations and the Seattle AED Register not only plots the position of the majority on a mapping tool, but also allows immediate identification location by 911 operators to allow them to direct rescuers to devices. Seattle EMTs respond with at least three vehicles to each arrest, giving a minimum of seven EMTs at each scene, allowing a highly organised ‘pit crew’ model, where the role of each and every provider is explicitly planned, assigned and choreographed. This means that the fundamentals of performing deep and fast compressions with full recoil, minimal interruptions, no hyperventilation and seamless integration with defibrillation are comprehensively drilled well ahead of time.

Destination hospitals are well organised and clearly defined in terms of their capabilities and capacity, meaning that patients are rapidly transported to hospitals that are set up to provide immediate access to angiography and angioplasty, ECMO, targeted temperature control and intensive care.

To construct a system like this, which actually works to provide the desired result, numerous parties must be involved, including government, ambulance, hospitals and healthcare agencies, as well as, crucially, clinicians and the public themselves. This disparate and inertia-ridden bunch won’t come together without active efforts to recruit, enthuse, motivate and coordinate them, so champions are needed to advocate for a new system. Since most victims of cardiac arrest don’t survive, the problem remains one of low visibility and poor public awareness, but emergency and critical care clinicians, including paramedics, nurses and doctors, are well positioned to shoulder this burden, and utilise their motivation and energy to drive the changes needed. We even need the benefit of hearing the stories of survivors, as these are some of the most powerful motivators to do the job well, bringing the issue to life, particularly when knowledge of the problem is limited.

Everyone believes in the ideas and wants survival to improve, but we know we need to put in real work to make real changes, and although it’s often difficult to gain traction when most people don’t realise the problem even exists, transformation can snowball once momentum is developed. One of the great achievements in Seattle wasn’t just developing the tools for resuscitation, but was creating a culture of survival. Not only is the community proud of what they have, and believe in it strongly, but so also are the clinicians of all backgrounds. When someone collapses in the street there is an expectation that someone will intervene and that if they do so, the patient is likely to survive!

What can we do in Australia?

Take Heart Australia launched on 28th May 2014. This is a public advocacy organisation and a charity, and its aims are to increase survival from cardiac arrest in Australia. It is modelled after some great templates that already exist, such as the HeartRescue program, HEARTSafe communities, Take Heart America and, of course, the Resuscitation Academy.

Take Heart Australia plans to drive system change to construct a real chain of survival, where if someone collapses outside hospital, rescuers will be trained and willing to immediately intervene, call for help and start high-quality CPR; where there is a Public Access Defibrillation program in place that allows a bystander to quickly appear with an AED and use it, because the PAD program is coordinated with the 000 dispatchers who instruct the bystanders; where there are widely used smartphone programs that alert potential trained rescuers to the collapse; where the ambulance services arrive quickly and perform seamless and coordinated pit-crew BLS and ALS; and where the destination hospitals have the capacity and the training to implement recognised evidence-based solutions in peri- and post-arrest care to improve outcomes.

Supporting organisations include Surf Life Saving Australia, the Royal Life Saving Society, St John’s Ambulance, Careflight, the Royal Flying Doctor Service, Ambulance NSW, Fire and Rescue NSW, Police Rescue, the Royal Australian Navy Submarine and Underwater Medicine Unit, Laerdal, Zoll and Physio Control.

We are developing a THA badged HQ-CPR course, producing a documentary and talking to schools, RSLs, sports clubs and others about AED placement and training, and trying to come up with innovative schemes to allow areas to band together to provide AED coverage. We are talking to our colleagues in the ambulance, fire and police services to try to move forward an agenda of actually working together to actually make this all work, as well as lobbying politicians not only to bring it to their attention, but to keep it there!

What we need, though, is two more things to give Take Heart Australia the credibility, drive and energy it needs to start to take cardiac arrest survival towards Seattle levels. It needs data, and it needs you!

If we don’t know what we are doing then we can’t improve it, and if we don’t collect good data we cannot know whether all these interventions will incrementally improve survival. Take Heart Australia is working with our embryonic emergency medicine epidemiology and research network, the DREAM Collaboration, to put emergency medicine clinician researchers together across NSW and Australia, entering small amounts of granular clinical data into linked, routinely collected administrative data sets. We plan to actively work with ambulance services and other researchers to build up a clear picture of the outcomes of cardiac arrest and related problems. We are also working with some hospital colleagues to plan trials of in-hospital cardiac arrest registries and analysis.

We also need advocates, champions and campaigners across Australia, willing to drive change in their communities, nag bureaucrats and politicians, speak at meetings, assist with training, and a host of other tasks. Join us on Twitter (@TakeHeartAust), Facebook and the website and together we can make a difference…

 

Take Heart Australia we need you

 

 

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LITFL Review 156

LITFL review

Welcome to the 156th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

resizerIs clot retrieval in ischemic stroke the next development? Caution in allowing one marginally positive study to change practice. Rory Spiegel implores us to study our past mistakes (NINDS-2) so as to avoid repeating them. [AS]

Master your management of status epilepticus with help from this podcast from Oli Flower When the Seizure Doesn’t stop from SMACC. [SL]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

  • Jonathan Downham of criticalcarepractitioner.com has a great review of Paul Marik’s paper on iatrogenic salt water drowning- complete with well-researched references. Have a gander. [SO]
  • Do we need to correct the anion gap for albumin concentration?  No, according to this excellent post by Josh Farkas. Dogma successfully lysed. [SO]
  • Phillipe Rola discusses two trials of ECMO-CPR in this thoughtful post- the Australian CHEER trial, and a Canadian study by Bernardczyk et al. Both showed remarkably similar outcomes (about 50% survival with CPC 1-2 status). Is this really the future? [SO]
  • Don’t give up on patients with epidural hematomas and bilateral fixed and dilated pupils. Cliff discusses a recent article showing that a significant portion of these patients have good outcomes. [AS]
  • Master anaphylaxis with an excellent session from SMACC Gold by Rose. [SO]
  • Simon Carley, Minh Le Cong, Anthony Delaney, Oli Flower, Jonathan Downham, James Day and LITFL’s own Segun Olusanya sat down to discuss the recent ARISE trial of early goal-directed therapy in sepsis. See the study dissected from EM, PHEM, and ICM points of view. Have a listen!  [SO]

The Best of #FOAMus Ultrasound

The Best of Medical Education and Social Media

  • The KeyLIME podcast discusses the importance of trust in medical education and specifically in Emergency Department trainee education. Great topic for all medical educators. [AS]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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Let There be Light

I have been an emergency registrar approximately forever. Some people’s training years form a crisp, well defined, early-adult life phase. Mine are evolving into a meandering opus.

In early 2013, awake with a newborn in the wee hours of the morning, (a highly recommended setting for major life decision making) I concocted an audacious plan to Finish My Training. Rotations, exam sittings and an interstate move all slotted in with tetris-like precision, it was brilliant in theory but too fragile for in vivo conditions. Such was the interdependency of the various elements that an unexpected delay in the completion of one component wreaked havoc upon my carefully crafted path to fellowship, in the manner of my toddler son in a newly tidied room.

Left slightly flailing, I faced the reality of further years in my prolonged medical adolescence without a clear end point upon which to anchor. If I wished to continue with emergency training, (and considering I’ve caught myself lying in bed reminiscing about putting a chest tube, I probably did) it was time to stop dreaming of the lush pastures on the other side of Mt FACEM, and focus on making life work just a little bit better in the here and now.

There are numerous challenges associated with trainee life; exams, forced relocations and explaining to well meaning relatives exactly why you are still studying to name a few. I will assume, however, I am with the majority when I cite the decidedly unsexy roster as the main culprit in my struggle to maintain a reasonable sense of wellbeing. It goes without saying that night shift is a hugely disruptive work pattern, but a large proportion of late finishes and the constantly rotating shifts also contribute to the difficulty in maintaining a good sleep habit. The relationship between myself and restful slumber further strained by two small people and the resulting zero-sum game of inter-spousal sleep politics, it was clear that if I could better manage my sleep around shift work, I might just rule the world.

Working out the next step in this challenge (better sleep that is, not world domination) was a little trickier. As this subject falls somewhere on the spectrum between passion and obsession for me, there was no low hanging fruit left to tackle. Morning exercise and light exposure as natural as breathing. Blackout blinds installed. No caffeine at least eight hours before planned bedtime. No screen time the hour before bedtime (unless there’s something really, really important on the internet). A nice, wind down bedtime routine. Noise cancelling headphones for sleeping. A valiant, decade long attempt to cultivate the habit of daily meditation.

This was clearly a situation best addressed by some internet shopping and a little N=1 trial. Wallet loosened by the same post night shift disinhibition that is a mixed blessing on morning handover rounds, I jumped online and made two purchases; a relatively cheap pair of blue-light blocking shades, and a long coveted item, re-timer sleep glasses.

Background

It was the light which had attracted my attention on this occasion. The role of sunlight exposure as the master puppeteer of our circadian rhythm, via the pulsed release of melatonin from the pineal gland, to be precise. Rising melatonin levels increase sleep propensity. In a “typical” sleep pattern of falling asleep at 11pm and rising at 7am (I think I did this once around 2009) melatonin release will begin around 9pm and peak approximately seven hours later, at 4am, the witching hour of the night shift worker. By 9am, our melatonin levels have fallen significantly, release further inhibited by early morning light exposure, and levels are negligible throughout the daylight hours. This makes it increasingly difficult to fall into restful sleep, our artificial sleep pattern misaligned with our internal clock.

The whole process gets even more interesting when you consider that under normal circumstances, preparation for the next night sleep actually begins upon morning waking. The reason why every article ever written on sleep quality opens with “Go to bed and get up at the same time every day” is not purely to provoke irrational stabby rage towards the authors within shift workers everywhere, but because early morning light exposure plays a crucial role in sleep physiology by pre-setting the timing for evening melatonin release.

To summarise the relationship in 2 simple tenets:

  1. Light exposure early in the main waking period brings forward the sleep cycle
  2. Light exposure late in the main waking period delays the sleep cycle.

While there was enough basic science evidence to satisfy my inner skeptic, whether artificial manipulation of this process would be practical or beneficial was not so clear.

Blue light blocking shades

  • Financial Outlay: A large variety available online from $10 upwards.
  • Rationale: The amber lenses completely block the blue light wavelength to which the photoreceptors affecting melatonin release are most sensitive. This creates what one paper referred to poetically as a “physiological darkness”. Worn post night shift, the natural early morning inhibition of melatonin release is halted, making it easier to fall asleep in daylight hours. They can also be worn in the evening to shield artificial lights.
  • Evidence: Good. Multiple randomised control trials, at least one blinded and placebo controlled, reporting a significant benefit in sleep quality.
  • Use: As soon as handover finished at 8.30am I put them on to finish my notes and referrals (in the privacy of the reg office), and wore them for the drive home. They blocked glare effectively, and the tinted lenses made me feel just a little more Bono and a little less thirty something whose hobbies include wiping bench tops and folding washing. I also trialled wearing them at the tail end of a midnight finish and in the evening at home two hours before bedtime.

Re-timer sleep glasses

  • Financial outlay: Enough to result in a three year courtship prior to purchase.
  • Rationale: Developed by sleep psychologists at Flinders University, they are promoted for use for jet lag, seasonal affective disorder, shift work and sleep phase disorders. A light of the correct wavelength for maximal stimulation of the relevant photoreceptors is beamed directly onto the retina. The idea for shift workers is to promote a partial “circadian phase delay”, by delaying the usual melatonin peak by up to four hours. This shifts the highest fatigue period out of work hours, with a primary aim of improved workplace alertness rather than daytime sleep quality.
  • Evidence: While the science and background research appear sound, minimal clinical evidence related to this particular device was available.
  • Use: I emailed the support team to be given a personalised schedule, and was instructed to wear them for half an hour between 2 and 3am. I also went “off label” and tried wearing them directly upon waking at 2pm following the final nightshift with the intention of bringing the sleep phase forward. (Direct sunlight exposure is my default option here, but isn’t always practical.)
  • Surprisingly wearable, they fit easily and comfortably over glasses. I was able to eat and drink, move around and work on the computer without limitation. I eased into use by trialling them round the house, much to the delight of my children. I then bravely debuted them on the shop floor at 2am, much to the delight of the seventeen nurses who suddenly fell within my visual field, despite there NEVER being anyone there when I’m sterile, need to put in one last suture and run out of ethylon.
  • Re-timers aren’t really suitable for direct patient contact or face to face referrals, but I quarantined a section of time for note writing, phone referrals and a snack and was able to wear them for a relatively continuous half hour, even on one particularly busy night. If a patient required urgent attention I simply took them off and replaced them upon returning to the staff base. This planned desk time probably increased my overall shift productivity and certainly highlighted the non-urgent nature of the majority of our interruptions.

The Verdict

True benefit or an expensive case of self-justification bias leading to placebo effect? Not sure, but over a couple of trial weeks which included the full complement of shift hours, I fell into sleep easily, felt refreshed on waking, and in the night shift recovery phase noticed a distinct lack of the lethargy and anhedonia I have come to expect from this period. Re-timer use also appeared to lead to a significant curtailing of the 4-5am night shift slump. Given the tendency of human behaviour to regress to the mean, it’s too early to say whether the practical challenges of regular use in a hectic environment (not to mention relentless mirth from colleagues) will inhibit development of the habitual use required for meaningful, long-term outcomes.

It’s worth noting, however, that any effects occurred in an environment of careful attention to my sleep pattern. So while there may well be a role for such tools in the arsenal of the “lifestyle” shift worker, there is unlikely to be any benefit without continued effort in maintaining the fundamentals I glossed over earlier. A cool, dark, quiet environment for sleep. Regulation of caffeine intake. Going to bed early when possible. A full time, live-in night nanny. Fresh air, exercise and reasonable nutrition. The boring truth is that when practiced consistently, these things work.

The moral of the story? Sleep is a little bit like sepsis. Both start with S. Importance of proper management was underestimated for many years. Trying harder is good. There probably is no magic bullet, (I’m talking to you, Xigris) but meticulous attention to doing the basics well is likely to result in better outcomes. Get it right and you might just save a life. Or even rule the world.

Disclosures
The author paid for both products herself and has no affiliation with either company. She fully intends to disclose the true price of re-timer glasses to her husband, but is just waiting for the right moment.

References

  • Managing the health and safety of Shift workers, MJA Vol 199 Supplement: Sleep Disorders, a practical guide for Australian health care practitioners. [PDF]
  • Re-timer website

retimers
bluelightblockers

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TechTool Thursday 058 Presentain

TechTool review Presentain

Presentain aims to provide a fresh approach to delivering presentations. The idea is to make your presentations interactive and accessible. You can still create your own slides in the normal way (using PowerPoint, for example), and then use Presentain to show them to the audience. I tried it out recently for a conference presentation. It didn’t all go smoothly…

Website: – Presentain.com

How does it work?

Upload your slides to the Presentain website and then when delivering your presentation, your audience can view the actual slides on their own device. On each slide, there will be a website address at the top – your audience can look this url up on their own mobile/tablet to follow along.

What else can it do?

  • One of the great features is that your mobile phone can act as a slide clicker – simply press a button on your mobile to move to the next slide. You can view the current and upcoming slides on your phone.
  • There is also the option to record your voice along with the slides as you give the presentation. This can then be uploaded and published/shared.
  • And at the end of the talk it’s possible to view some stats about the number of people who accessed the slides.

What are the interactive features?

  • There is the opportunity to use polls in your presentation. These can be set up beforehand (i.e. question with a multiple choice answer) and they can be shown on screen at any point in the presentation. Audience members following along on their own devices will be able to select an answer on their screen, and the poll results are displayed in a pie chart.
  • Secondly, audience members can submit questions via the website. An alert appears when a question is submitted and these can be read on your phone during the presentation. If you want to display them on the big screen for the audience then you can do that too.

So, how does it work in practice?

I decided to try it at a conference presentation, even though I did feel slightly nervous about doing so. I had set up a few polls beforehand, but was worried about how many people would actually be accessing Presentain on their devices, so I bottled out of using the polls in the end. It was not a tech conference, and most people there would not have been particularly tech savvy.

Here’s a few things to bear in mind:

  1. Internet access. Using Presentain does rely on having internet access. To get the presentation started you need to connect the computer to your mobile and this requires an internet connection. And you need data on your phone to move the slides forward. As it turns out, being in a large conference centre does not guarantee decent internet access, so I ended up using my own phone data and used my phone as a wifi hotspot. It wasn’t ideal, but it did actually run well, and internet access didn’t hamper the presentation
  2. Audience engagement. It only works if your audience actually accesses the presentation on their own computers/tablets/phones. That’s how they vote in polls. I didn’t think people were doing it, which was why I didn’t attempt my polls. However, the stats at the end showed me that out of an audience of 70 people, 33 accessed the presentation. That’s pretty good for a first effort.
  3. Software. The audience needs to work out how to use the other features themselves e.g. voting, asking questions, sharing slides, requesting contact info. I didn’t explain how to use the app, other than to provide my presentation url. About 15 people requested a copy of the slides via Presentain and one person asked a question via Presentain (which I forgot that I could display on screen). Again, not a bad outcome.

Cost:

  • There is a free package which allows 5 presentations and 3 polls.
  • Other subscription options are $9.99/month or $29.99/month for higher or unlimited presentations and pool.

Will I use it again?

Overall, I think Presentain is great and I will be using it again. It’s good to try something different to engage your audience, and although some of the features are a bit gimmicky, as long as they don’t detract from your main message, then the interactivity and accessibility really can be an asset.

//www.youtube.com/watch?v=UN9a7XIvxW8

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