As part of TechTool Thursday, I thought it would be interesting to look at more than just app reviews.  This week I interview Adrian Bonsall

Adrian Bonsall is a Paediatric Emergency Fellow at Sydney Children’s Hospital.  Prior to studying medicine he worked as a computer programmer and systems analyst in the UK

When did you start becoming involved in health IT?

I’ve been programming since the first personal computers were available over 30 years ago.  Whilst a medical student I wrote programs that integrated a GP surgery’s software and developed revision aids.  Later I wrote a paediatric resuscitation scenario builder and a rostering software

What led to you start your rostering software? 

It began in 2001, when my then Emergency Department director was bemoaning the trials of devising a JMO roster which didn’t lead to a string of complaints about inequality, not meeting the current award or double-bookings.  I thought a simple 6-step process might be the way to lead even the least savvy computer user through to a better roster.  The Roster Wizard has been employed at about a dozen major hospitals, mainly in NSW, but also in Northern Territories, Queensland and the UK

Have you been involved in any other health IT projects?

A few.  I developed a Paediatric Resuscitation Calculator for drug doses & equipment sizes and it has been extensively used at Sydney Children’s Hospital and now further afield.  In 2011 I designed & built the Children’s Emergency Department website for the Mater Children’s Hospital in Brisbane and am now trying to revitalise the Sydney Children’s Emergency Department intranet site.  I have also ‘donated’ my revision notes (~350 topics) for the ACEM Part II exam, which I try to keep updated on my own embarrassingly under-constructed site (ambonsall.com).  I also write little web calculators for topics such as Burns fluids, Paediatric Growth centiles, and DKA fluids

Don’t you find implementing health IT in hospitals is a bureaucratic nightmare?

The three main issues I have encountered are: the meeting merrygoround that seems necessary to get anything approved; hospitals with their own IT departments can show some resentment and obstruction; and getting paid for professional work done whilst holding on to one’s intellectual property can be problematic

What do you enjoy most about health IT?

I really enjoy programming and breaking down the problem in a logical manner.  To me building my own software is a creative outlet, even if many other programmers have done it similarly in the past. 

What are you careers aims for the next 10 years?

I would like to have the time and resources to tackle another couple of large projects.  The current solutions to the Electronic Medical Record that I have used in emergency departments are slow, needlessly complicated, do not appear to save time for clinicians who have to input the data in real life practice, and have problems with integration with other hospital systems

What is the best piece of advice you’ve been given?

Don’t give interviews

The post TechTool Talk 004 appeared first on Life in the Fast Lane medical education blog.

The stage is set

In preparation for #IETMC13 the International Faculty Development teaching course – the #MeduBrawl has begun.

Traditional learning versus the flipped classroom, versus social media and FOAM. Gloves are off as we prepare to better understand the best teaching modality for medical education…

RIGHT...started a fight with @amalmattu after his statement.. "Those who CAN, teach. Those who CAN'T, tweet."

about 4 hours ago via webReplyRetweetFavorite

@sandnsurf

Mike Cadogan

@sandnsurf The battle of wits has begun. And it ends when you decide and we both drink, and find out who is right and who is out of characte

about 4 hours ago via webReplyRetweetFavorite

@amalmattu

Amal Mattu

@sandnsurf Definitely teaching=helping & vice versa. Will be fun debate, hi tech vs low tech, ipod vs 8-track, Wii vs. Atari... @IEMTC13

about 3 hours ago via webReplyRetweetFavorite

@amalmattu

Amal Mattu

@medicalgraffiti @M_Lin @IEMTC13 @amalmattu @sandnsurf @EM_Educator oh, oh. We love to teach, fight, and tweet! Can we play? #medubrawl

about 2 hours ago via TweetCaster for iOSReplyRetweetFavorite

@ultrasoundpod

Matt and Mike

@ultrasoundpod @M_Lin @IEMTC13 @amalmattu @sandnsurf @EM_Educator The #MeduBrawl is happening this Oct in Baltimore. Come on down!!

about 2 hours ago via Twitter for iPhoneReplyRetweetFavorite

@medicalgraffiti

John Greenwood

@ultrasoundpod @medicalgraffiti @m_lin @iemtc13 @amalmattu @sandnsurf @em_educator "teach,fight &tweet..." twitter's own "eat, pray love"...

about 1 hour ago via Twitter for iPhoneReplyRetweetFavorite

@bhanders

Neel Bhanderi

@IEMTC13 @amalmattu @sandnsurf I'm taking an initial duck&cover approach in this EduBrawl. Will strategically strike when u least expect it!

about 2 hours ago via Twitter for iPhoneReplyRetweetFavorite

@M_Lin

Michelle Lin

The post Teach, fight, tweet… appeared first on Life in the Fast Lane medical education blog.

Welcome to the 104th edition!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.

The Most Fair Dinkum Ripper Beaut of the Week

Emergency Physicians Monthly

• Top spot goes to Emergency Physicians Monthly with a thought provoking and awe inspiring post on  Dying, Naturally, in the Emergency Department. How to walk a dying patient and their family through an unimpeded natural death in the emergency department. 
  

The LITFL Review Top Picks

Resus.ME

• RSI haemodynamics in the field - interesting study…How much harm could we be causing during intubation? 
• Cliff takes us through on of the holy grails of critical care medicine in Predicting volume responsiveness.
• Difficult intubation on ICU - no wonder there having complicatiosn when capnography was only being used 46% of the time – doesn’t seem like the standard of care to me.
• Awake intubation - When one of the masters of EMCC education becomes a dummy! – Some tips on topicalise your awake intubation patient!

http://www.youtube.com/watch?v=SqkeRWwH760

The Poison Review

• Are vasopressors effective therapy in calcium channel blocker overdose? - When old school approach might be just as good the the new school approach, just not as cool- agree interesting read!
  
• Metformin overdose and hypoglycemia - Be aware: Metformin overdose can cause hypoglycemia in the absence of other glucose-lowering drugs, and blood glucose levels should be monitored closely.

StEmylns

• It’s Good to Talk – Debrief in the Emergency Department . Brilliant summary of what debriefing is, and how to get the most out of it in the emergency department setting. 
• Is the picture starting to get clearer around….Cullen on high sensitivity Troponin.

 boringem

• Handheld Ultrasound - this really is taking the probe to the bedside, anywhere in anyplace!

Emergency Medicine Tutorials

• Toxicology for PGY1+2 - Nice intro summary on the basics of toxicology for the junior staff.
  

PHARM

• The airway masters Jim Ducanto handles a tonsillar bleed airway and shares some pearls along the way.
  
• Emergency Surgical Airway with Dr Keith Greenland as he shares his research focusing on the not technical skills of the CICV scenario.

http://www.youtube.com/watch?v=5dRlApLVuDY

The Trauma Professional’s Blog

• Trauma Pearl: Unexpected Respiratory Failure After Blunt Trauma. Bottom line: Unexplained respiratory failure after blunt trauma, especially if no chest injury has occurred, is nearly always due to a missed abdominal injury.
  
• Don’t Ignore The Naughty Bits - Remember to take a look downstairs on your next trauma patient – you might be surprised by what injuries you can find.

thebluntdissection

• a test of metal… all wrapped up in a toxicology conundrum. Nice review on recognising and managing chronic lithium toxicity.

Pediatric EM Morsels

• Kids are becoming more and more like “little adults” Are you prepared to manage  Hypertensive Crisis in Kids?
  
• Diarrhea and Dehydration - Some great pearls here especially on how to communicate this issue to the family.

ETMCourse

• Life after death: the long term outcome of ED thoracotomy survivors - The results may surprise some of you!
  

Emergency Medicine News

• Emergentology: Your Emergency Family - or team. We all bring something to the family of the emergency department, and its generally something very special, and i love being part of that.
  

EM on the Edge

• Superb review on were we are at in the management of The Crush Syndrome…expect the unexpected….
  

EMCrit

• Janus General and Service Update - EMCrit creates his own virtual hospital to discuss and share cases, all in the process of maintaing confidentiality and providing some amazing FOAMed.
  
• Cyclic (Tricyclic) Antidepressant Overdose - There on there way back, and heading to an ED near you! Are you prepared to manage the dread TCA overdose?

empem.org

• Investigation of Pediatric Headaches - Not an easy task, but this podcast certainly does put you on the right track.
  

 Intensive Care Network

• Harris on Oxidative Stress- What is it? Why is it important? Roger Harris gives us the low down on it!
• Prevent trache deaths - Excellent podcast on dealing with issues and emergency in patients with tracheostomies! Worth a listen!

 Resus Review

• DKA presenting as Wide Complex Tachcyardia - Start the insulin and check the K!
  

Dr Smith’s ECG Blog

• Atypical Chest Pain: Suspicious ECG, and a Left Main ACS is found in a 30-something!
  

EKG Videos

• Rodney Dangerfield revealed! Here’s the scoop on STE in aVR.
  

http://www.youtube.com/watch?v=fMvi_MnUqt0

The LITFL Review Shout Out of the Week

The SMACC2013 opening videos have been released- and the are awesome. Check them out on YouTube SMACC Channel or listen to them on iTunes.

Check out:

Scott Weingarts opening talk on “The Essence of Critical Care”

http://www.youtube.com/watch?v=3QcGom3rslg

And the amazing Cliff Reid on: ‘Making things Happen”

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

The GMEP Cases of the week

GMEP Video of the week:

This weeks video is by Andy Neil from Emergency Medicine Ireland  with his video on social media he gave at the Workshop for EMS Gathering:

Twee Dee and Twitical Care

A motto to live by http://t.co/KJMr9AXufb

about 3 hours ago via EchofonReplyRetweetFavorite

@precordialthump

Chris Nickson

News from the Fastlane

• Want to search, find and look for everything FOAMed? Then check out - GoogleFOAM!
  
• Emergency Medicine Update May 2013 - Another awesome review of the literature.
• R&R In The FASTLANE 031 - with another great wrap up of the literature.

The Final Words

Stolen from CCM-L and modified. 3 things needed to be good ER doc. 1. Good sense of humor; 2. Poor sense of smell; 3. Mastery of ketamine

May 12, 2013 11:10 pm via webReplyRetweetFavorite

@JoeLex5

Joe Lex

LITFL Review EM/CC Educational Social Media Round Up

Show Reference list

The post The LITFL Review 104 appeared first on Life in the Fast Lane medical education blog.

The SMACCalanche has begun!

Cliff Reid (@CliffReid) was without a doubt one of the superstars of SMACC. His talk ‘Making Things Happen’ is a lucid, practical and often times hilarious guide to the inner workings of a leading a great resus. The good news is that if you missed it you can now check it out on the SMACC podcast or watch the video on Resus.ME. Cliff’s ‘Making Things happen’ page on Resus.ME is a gold mine of references and resources supporting the talk.

Go on, check it out, make it happen!

The post Making Things Happen appeared first on Life in the Fast Lane medical education blog.

We are all at risk of missing the giant man in the gorilla suit every day in ED.

The Invisible Gorilla study is a classic –  watch the video.

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

The viewer is asked to count the number of times the people in white shirts pass the ball to each other.   At some point in the video a man in a giant gorilla suit walks slowly into the middle of the screen, beats his chest and then wanders off.  50% of people didn’t even notice him because they were so focused on counting the passes (that’s not to mention the other deliberate mistakes in the video).

Harvard researchers have now shown that even medics suffer from ‘Invisible Gorilla Syndrome’.

Although you might not think it, radiologists are just human and not superheroes who sit in a darkened room all day picking up every minor deviation from the norm.

Trafton Drew, a researcher at Harvard Medical School’s Visual Attention Lab, showed radiologists images like the one below and asked them to identify cancerous nodules…

Click to enlarge

The Results

So what’s the issue?  It’s called inattentional blindness – your brain is focusing on one specific issue and so all the other side issues are just phased out.

This is a problem we face every day in ED: recurrent abdo pain; drunk and disorderly; wheezy child; back pain.   The information we are given before we see the patient focuses our minds on particular areas and this can lead to us simply muting and ignoring the other potential problems.

Don’t ignore the gorilla.

References

• The Invisible Gorilla
• Radiologists can miss a Gorilla hiding in plain sight
• Drew, T., Vo, M. L. H., Wolfe, J. M. (in press). The invisible gorilla strikes again: Sustained inattentional blindness in expert observers. Psychological Science.

The post Inattentional blindness, unintentional consequences appeared first on Life in the Fast Lane medical education blog.

Sir Peter Wyllie of Alice Springs was the inaugural winner of the F.UCEM PhD (Publicly Happy to Display) award

Now Sir Peter Wyllie goes one step further…heli jumping over Noonamah, NT

the quest for the ultimate LITFL photo continues….

The post LITFL Leap of Faith Noonamah NT appeared first on Life in the Fast Lane medical education blog.

If you’ve wanted to check out legendary EM speakers like Amal Mattu, Mel Herbert, and Billy Mallon in the flesh but couldn’t face going to Las Vegas for a big American conference here is a solution.

Go to Chile instead!

My Santiago-based emergency physician buddy Pablo Aguilera is part of the crew putting together Urgencia UC: Conceptos 2013, an emergency medicine conference featuring luminaries like those named above as well as local speakers. It will be great if you’ve got some Spanish to work with but all the talks will be simultaneously translated into English/ Spanish (depending on what language the talk is in of course). It runs from August 29th to 30th 2013 (with an ECG workshop on the 28th) and you can register here.

Check out the website for Pablo’s EM program in Chile, the conference website, the conference Facebook page. Oh, they’re on Twitter too (@urgenciauc).

The post Urgencia UC: Conceptos 2013 appeared first on Life in the Fast Lane medical education blog.

Here is the May 2013 edition of EMU.

You can subscribe to EMU directly via email by sending a message to:
jbleibmd AT yahoo.com

Also, remember to check out previous editions of EMU on LITFL here.

Emu May 2013

The post Emergency Medicine Update May 2013 appeared first on Life in the Fast Lane medical education blog.

The expansion of the FOAM world is a bit like blowing up a balloon. The early stages involved a lot of effort for a small increase in size, but as it gets bigger, the resistance is falling away and expansion is getting faster and faster.

Obviously this is a good thing.

But it can make it easier for us all to get lost and there is the danger of information overload — indeed, I’ve written a guide to (in)sanity in the age of FOAM that I continually update, the LITFL post on Information Overload. The FOAM world is now impossible to keep up with. We need to be able to find what we want when we need it, according to our knowledge needs.

One of the great developments for ‘just in time’ learning is the creation of GoogleFOAM by Vancouver-based EM Physician Todd Raine (@RaineDoc). It was known as emgoogle.com in it’s previous incarnation, but has now grown to be more inclusive.

This is what GoogleFOAM is all about:

• it is a search engine
• it allows a unified search of all the FOAM resources on the Web
• it is partly derived from the complete list of EM/CC Blogs is available at LITFL here, as well as the Podcasts available here.
• as GoogleFOAM develops it will allow search restrictions to separate realms, such as anaesthesia, general practice, ultrasound, etc.
• if you want to add a site to GoogleFOAM send Todd an email: taraine at hotmail dot com

GoogleFOAM is a work in progress, but is already a fabulous tool. It helps both learners and teachers find high quality free resources instantly.

GoogleFOAM is also particularly valuable for FOAM creators. Something that has been lost a little with the growth of FOAM has been the recognition that interconnectedness is everything to a blog. This how the first FOAM blogs and podcasts got their feet through the door in the first place — by building a network of relevant links that created a community. As more FOAM is created I liked to see more links to what has come before, so that users can see the incremental gain, so that connections are forged, relationships are created and conversations started. GoogleFOAM is ideal for this — search it before you blog or podcast and don’t be stingy when linking out

Vive la FOAM.

The post GoogleFOAM appeared first on Life in the Fast Lane medical education blog.

Barone Rocks presents Manik, M.D.M.C and the Medical Music project with the awesome Anti-Arrhythmic Sickness Video…

http://www.youtube.com/watch?v=KBTWIiGs30Q

As part of the Medical Music project – this song was one of the 5 songs on the M.D.M.C.’s demo album: “One Third Of One Percent… the EP” from 2010. After which this song was picked up by Kaplan Medical’s professor of pathology, John Barone, M.D. and is now featured in a collective work of 11 songs in the album “Barone Rocks: Volume 1: Medical Hip Hop” – with part proceeds donated to Pediatric Brain Tumors and ALS foundation.

The post Emergency Musical Interlude XLII appeared first on Life in the Fast Lane medical education blog.

Communication is the key.

When it fails competent individuals can form an incompetent team.

Communication researcher Lorelei Lingard has important lessons for all healthcare workers, and how the concept of individual competence drives medical education, in this TEDx Talk:

http://www.youtube.com/watch?v=vI-hifp4u40

We need to become collectively competent.

The post Collective (In)Competence appeared first on Life in the Fast Lane medical education blog.

aka Postcards from the Edge 011

Lee Fineberg and Mark Newcombe are Emergency Physicians and Helicopter-Retrieval specialists who are better know in international EM circles for putting together a very successful conference on developing Emergency Medicine globally in Sydney last year. Their conference is called DevelopingEM and on Twitter they are @developingem. This ‘postcard from the edge’ is an interview with them about the DevelopingEM project.

1. Firstly what was the vision behind the Developing EM conference and what inspired you to host the inaugural sessions last year?

Mark:

Thanks Bish for the interview. There were a number of inspirations for DevelopingEM.

First and foremost was the desire to provide a conference experience that was different and inspirational for everyday clinicians. I think both of us have always wanted to in some way continue a meaningful interaction with global health and DevelopingEM 2012 was a way for us to introduce this concept.

However, the DevelopingEM 2013 conference in Cuba will allow our ultimate aim to come to fruition, through providing a clinically relevant emergency and critical care educational experience in an interesting destination, at the same time as interacting with and supporting local systems. We plan to do this through sponsoring local delegate attendance, provide educational hardware to the region, sponsor regional workshops, and foster ongoing interactions between physicians in the region and our delegates and faculty.

Lee:

Mark pretty much summed it up, but I’d also add that a strong part of our goal is to expand the boundaries of EM by bringing it to regions where it’s not yet practiced as a specialty. EM is well positioned to provide initiatives for global health improvement and we hope that by bringing our specialist faculty and conference delegates to these regions they will have the opportunity to meet colleagues from these regions, maintain connections, and hopefully even work in these regions in the future.

With the explosion of FOAMed on the scene, I don’t think there could be a better time to include all the regions of the world in the charge towards the best available Med-Ed and training. As Mark mentioned we don’t see ourselves as just another conference organization as we like to be part of the solution for local problems. Given limitations to internet access that may exist, we hope to use our conferences as a means to set-up computer/e-work stations in medical centers within developing regions. We’ve partnered with some amazing educators to provide both a curriculum for EM training as well as hard drive access to literally thousands of video & audio lectures. We’ll also be using proceeds from registration, non-industry sponsorship and donations to fund and maintain these e-work stations as well as subscriptions to various online journals & websites. And of course we’ll be sure to include direct links to the best of FOAMed!

2. Can you share some of the highlights from the first conference in Sydney last year?

Lee:

Without a doubt it was the general buzz that folks had for what we’re trying to do. More than just your typical conference lectures, people were seriously enthusiastic about being there and about involvement in future events. Whereas delegates at most conferences cant wait to find the door, we had several people offer their heartfelt thanks to us not to mention their promises to assist us with future projects. In fact, on hearing of our mission statement at the conference commencement one of our delegates who had lived and worked in Havana, Dr. Jeannie Ellis, got on the phone straight away to the Australian ambassador for Cuba. By the end of the first day we were arranging to meet with the Cuban Ambassador, Mr. Pedro Monzon to discuss DevelopingEM – Havana. And before we knew it we were well on our way. And the honest pledge of help from everywhere just keeps coming. If you take a look at our faculty – all of whom are self-funding – you’ll get an idea of what I mean. We’ve got some fantastic people share our interests and who’ve joined us for Sydney, Havana and beyond.

Mark:

I think the most amazing thing for me was that everything actually worked out without a hitch. People registered, presenters showed up at the right time on the right day, there were no AV malfunctions and despite the access to an open bar no one fell in the harbour during our dinner cruise!

We also got some amazing feedback on some amazing presentations which was pretty incredible in itself, and in general people seemed to get our concept and appreciate our efforts. Having a week off afterwards was also a particular highlight.

The first Developing EM conference featured IEM legends like Peter Cameron

The Wilderness Rescue workshop at the first Developing EM conference in Sydney.

3. What is the reason behind Cuba as a venue for the upcoming conference and what have you got installed? Who is the event for, and why do you think they should put this one in their calendars now?

Mark:

Cuba was Lee’s idea but what an idea! Both being ‘pinko socialists’ we’d had an admiration for the Cuban health system for some time, and our more recent visits to Cuba solidified our interest in the country and it’s people.
Not only is it an amazing setting for a conference, but I think we can learn a great deal from the Cuban health system.

As far as the program goes it’s a mix of evidenced-based, clinically relevant presentations that were so popular last time, as well as presentations on IT, Simulation, Politics, and Global Health. We’ll also have workshops on Simulation and Ultrasound to be held in conjunction with the plenary in Havana, and let’s not forget a great social program and plenty of opportunities to meet our Cuban and Caribbean medico colleagues.

Lee:

As an American should I be “taking the fifth” on this? Or at least get some sort of legal advice??? Nah.

Many might say that given the quality and extent of Cuban health care – both domestically and internationally – that Cuba certainly doesn’t satisfy the area of need designation. In fact Cuba may very well serve as a model of health care delivery and global health outreach. For me the reason for bringing our conference to Havana was twofold;-

Firstly I wanted our delegates to see just how much can be done with limited resources. Cuba’s economy and GDP is a small fraction of ours and yet they have more government-sponsored doctors working abroad then all of G8 countries combined. At last count Cuba has 30,000 are health personnel workers in international collaborations in 103 different countries, 19,000 of whom are physicians! Mark and I recently returned from a meducational trip to Vanuatu and there were no fewer than 5 Cuban docs were working there on 2-4 year contracts arranged for them by the Cuban government. Profiling Cuba and their work was one of the main reasons for having the DevelopingEM conference in Havana, to show our delegates what can be done with limited resources if tried.

Another reason was the US embargo against Cuba. Politics aside, I think that the ongoing issue is a humanitarian disaster and an embarrassment to the developed nations of the world. I think that as docs we have an obligation to support the people of Cuba especially with respect to their health. I hope that by bringing our conference to Cuba that our delegates and faculty might learn a bit more about this issue, how it affects the health and lives of the Cuban people, and how we might in some way help to improve the situation even if just a little.

By the way I should point out that a legitimate professional conference such as ours is one of only a handful of ways that US citizens are legally allowed to travel to Cuba. For more information please see the US State Depts website.

Photo by Jorge Royan (used with permission under CC license)

4. Organizing a conference like this probably takes a lot of collaboration both locally and overseas. Do you have requests for help with this conference with regards to teaching and training or other resources?

Mark:

You’re right Bish, this sort of endeavour takes a lot of planning. As Lee mentioned we’ve been lucky enough to have the assistance of Dr. Jeannie Ellis, the Cuban ambassador to Australia Mr. Pedro Monzon, and Pedro Veliz, one of the preeminent emergency physicians in Cuba. Without the assistance of these three DevelopingEM 2013 would likely not have even gotten off the ground. We’ve also had ongoing assistance from our past faculty as well as an expanding faculty whom are equally enthusiastic about our project and program.

Lee:

I can’t agree more, but I’d also like to add that one of our goals with developingEM is to extend the conference beyond just the plenary. In addition to the main conference in Havana, we’re also planning for our specialist faculty and delegates to provide workshops and courses throughout the Caribbean.

At present we’re planning an Ultrasound course not only in Havana but also for St. Lucia. We’ve been working with Dr. Lisa Charles, the CMO for their main hospital in Castries to arrange the course. The faculty for the St. Lucia Ultrasound workshop will be headed by Mike Stone and Matt Dawson from the Ultrasound Podcast (a fantastic FOAMed site for Ultrasound skills training, so check it out). In addition our own Dr. Ricardo Hamilton, Director of Trauma at Liverpool Hospital & a native Bahamian, is working on an ATLS course for the Bahamas. We also have on offer the possibility for a PALS or APLS course as well as a Radiology workshop on Interpretation of EM Imaging for the region.

So if anyone out there is keen to help us find a Caribbean home for one these courses or perhaps would like to suggest another then by all means let us know– we’re always interested in fresh ideas! And should one of our esteemed delegate colleagues be keen to help out as faculty for a course then also let us know. You can contact us at: developingEM at gmail.com or to me directly at slfineberg at gmail.com

Photo by Jorge Royan (used with permission under CC license)

5. Finally do you have any tips or practical advice for anyone planning to attend the Developing EM (Cuba) conference later this year?

Lee:

For our US peeps I think the first step is having the knowledge that you can legally go to Havana on a general visa. No special approval or visas are required.

What better way to visit Havana then in support of your Caribbean colleagues. In fact the first Mojito is on Mark ☺.  It will undoubtedly be an amazing event and I’m certain that you won’t be disappointed.

Mark:

I guess I’ll speak to the Aussies out there. Cuba is a long way but it’s a destination unlike any other and it’s changing as we speak.

My top travel tips:

• go through Canada- no visa required for those arriving in Cuba from Canada
• take lots of Euros, Canadian dollars or US dollars.
• take an Australian visa debit card to use at ATMs and be prepared to line up
• enjoy a Mojito or three on the back lawn of the “Hotel Nacional” at sunset
• start practicing your salsa

Photo by Jorge Royan (used with permission under CC license)

Find out more about the conference at
DevelopingEM
‘An emergency medicine conference with a difference’

The post Developing EM appeared first on Life in the Fast Lane medical education blog.

TechTool review of Reversing Warfain by HealthObs ltd on iOS   

Website: – iTunes - Website

Reversing Warfarin aims to help doctors manage their patients who are on warfarin.  It gives specific and clear guidance about what do to when faced with a raised INR, a bleeding patient, or a patient heading to theatre.

Guidance is based on the Australasian Society of Thrombosis and Haemostasis guidelines (2013) and the American College of Chest Physicians Guidelines (2012).

Design and User Interface

I really like the design of this app and the clear flow for users.

The index screen is intuitive and directs you to exactly where you need to go.  This means that you get information tailored to your specific patient very easily.  The main screens just show the essentials of patient care, but then it’s straightforward to view more information if needed.  A great user interface and very well thought-out

Reversing Warfarin on iPhone 1

Reversing Warfarin on iPhone 2

Reversing Warfarin on iPhone 3

Clinical Content

What seems like such a simple app actually has a large amount of helpful clinical info.  It deals with several key areas: raised INR; bleeding patient; patient for elective surgery; and patient for emergency surgery.

• The app asks for the relevant patient information and produces a clear and tailored plan for you to manage their warfarin dosing
• This plan can be formatted into a patient protocol and can then be emailed for printing
• The user can customise the settings according to their local hospital practice (change the type of heparin, prophylactic and treatment dose)
• You get clear guidance for immediate management, and further info for ongoing warfarin management

Cost

• Free

Room for Improvement

• Once you start creating a patient scenario there is no option to correct mistakes (i.e. change the weight) – you need to start over.  Would be good to have the option.  (A very minor point though in an otherwise well-designed app).

Overall

This is well-planned app that is very clear and simple for the user to form a reliable management plan.  This app achieves exactly what it sets out to do.

It is only useful in a very specific area of practice (even less so for me in Paeds ED) but it’s a good one to have on your phone for when you might need it

The post TechTool Thursday 028 appeared first on Life in the Fast Lane medical education blog.

Our currently highly irregular series of eminence-based evidence is finally back again – with the 31st edition:

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 11 recommended reads. Find out more about the R&R in the FASTLANE project here and check out the team of contributors from all around the world.

This edition’s R&R Hall of Famer

• Young NS, Ioannidis JP, Al-Ubaydli O. Why current publication practices may distort science. PLoS Med. 2008 Oct 7;5(10):e201. doi: 10.1371/journal.pmed.0050201. PubMed PMID: 18844432; PubMed Central PMCID: PMC2561077

This essay makes the underlying assumption that scientific information is an economic commodity, and that scientific journals are a medium for its dissemination and exchange. When subjected to an economic analysis the scientific publication process looks distinctly ugly… The authors make suggestions for a better way forward.

Recommended by Chris Nickson
Learn more: LITFL CCC – Publication Practices Distort Science

This edition’s R&R recommendations

Critical Care

• Ertmer C, Kampmeier T, Van Aken H. Fluid therapy in critical illness: a special focus on indication, the use of hydroxyethyl starch and its different raw materials. Curr Opin Anaesthesiol. 2013 Jun;26(3):253-60. doi: 10.1097/ACO.0b013e3283606b71. PubMed PMID: 23492982.

It takes a bunch of anaesthetists to nit pick their way to the bottom of the pharmacological differences between therapeutic agents. Leave the potatoes and grab your waxy maize … 6%HES may not yet be dead.

Recommended by Matthew Mac Partlin

• Holley A, Marks DC, Johnson L, Reade MC, Badloe JF, Noorman F. Frozen blood products: clinically effective and potentially ideal for remote Australia. Anaesth Intensive Care. 2013 Jan;41(1):10-9. Review. PubMed PMID: 23362885.

An exploration of the feasibilty of cryopreservation to extend the shelf life and facilitate the transport of blood products, while minimising post-thawing complications. Particularly relevant for remote and regional centres facing the challenge of occasional need for massive blood transfusion.

Recommended by Matthew Mac Partlin

• Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care. 2011 Mar 21;1(1):1. doi: 10.1186/2110-5820-1-1. PubMed PMID: 21906322; PubMed Central PMCID: PMC3159904

Great overview of the hemodynamic parameters we can use to guide fluid administration – warts and all.

Recommended by Chris Nickson

Emergency Medicine

• American College of Emergency Physicians; American Academy of Neurology. Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke in the emergency department. Ann Emerg Med. 2013 Feb;61(2):225-43. doi: 10.1016/j.annemergmed.2012.11.005. PubMed PMID: 23331647.

Like it or lump it, ACEP officially endorses tPA in stroke.

Recommended by Seth Trueger

• Canto JG, Rogers WJ, Goldberg RJ, Peterson ED, Wenger NK, Vaccarino V, Kiefe CI, Frederick PD, Sopko G, Zheng ZJ; NRMI Investigators. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012 Feb 22;307(8):813-22. doi: 10.1001/jama.2012.199. PubMed PMID: 22357832. [Free Full Text]

A tweet from a talk by Amal Mattu led me to this study based on a registry of over 1 million American patients. It is important because of this finding:“The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .001).”The rates of MI without chest pain are even higher in women <45 years of age. Burn your textbooks and reflect on the external validity of the historical mass of medical literature based on studies of white anglo-saxon males.

Recommended by Chris Nickson

• Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012 Oct 8;172(18):1377-85. PubMed PMID: 22911330.

EM is like a puppy: for life not just for Christmas. Burn out is a huge problem and this study documents that we’re winning the burn out race. Any solutions?

Recommended by Andy Neill
Learn more: EMI

• Serinken M, Eken C, Turkcuer I, Elicabuk H, Uyanik E, Schultz CH. Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blind controlled trial. Emerg Med J. 2012 Nov;29(11):902-5. doi: 10.1136/emermed-2011-200165. Epub 2011 Dec 20. PubMed PMID: 22186009.

Intravenous paracetamol works for renal colic – but should we use it?

Recommended by Andy Neill
Learn more: EMLON

Research and Critical Appraisal

Ultrasound and Imaging

• Aguilera AL, Volokhina YV, Fisher KL. Radiography of cardiac conduction devices: a comprehensive review. Radiographics. 2011 Oct;31(6):1669-82. doi: 10.1148/rg.316115529. Review. PubMed PMID: 21997988. [Free Full Text]

A well-written guide to detecting CCD (PPMs & ICDs) problems on plain films, with lots of helpful images and clear explanations. Gold for fellowship candidates.

Recommended by Matthew Mac Partlin, Chris Nickson

• Shokoohi H, Boniface K, McCarthy M, Khedir Al-tiae T, Sattarian M, Ding R, Liu YT, Pourmand A, Schoenfeld E, Scott J, Shesser R, Yadav K. Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Ann Emerg Med. 2013 Feb;61(2):198-203. doi: 10.1016/j.annemergmed.2012.09.016. Epub 2012 Nov 7. PubMed PMID: 23141920.

A well-instituted US-guided peripheral IV program will indeed decrease rates of central line insertion. Not groundbreaking but nice to have some solid evidence.

Recommended by Matthew Mac Partlin, Chris Nickson

• Teismann NA, Knight RS, Rehrer M, Shah S, Nagdev A, Stone M. The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization using a Standard Intravenous Catheter. J Emerg Med. 2013 Jan;44(1):150-4. doi: 10.1016/j.jemermed.2012.02.044. Epub 2012 May 11. PubMed PMID: 22579025.

We can put a peripheral IV in the internal jugular – but should we?

Recommended by Ryan Radecki
Learn more: EMLON

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of fame You simply MUST READ this!		R&R Hot stuff! Everyone ‘s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R WTF! Weird, transcendent or funtabulous!
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R Mona Lisa Brilliant writing or explanation

That’s it for now…

That should keep you busy for a week at least… 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.

The post R&R in the FASTLANE 031 appeared first on Life in the Fast Lane medical education blog.

aka American ER Doc Gone Walkabout… 022

An older gentleman with quite severe Parkinson’s hadn’t opened his bowels for about a week.  He came to the ER – solver of all problems. He had a nice normal pulse when  taken the old fashioned way – by placing the nurse’s trained fingers upon the radial pulse.  And, he – appropriate to the modern world of high tech – was placed on an ECG monitor – for constipation.  The ECG monitor showed a nice, regular, narrow complex tachycardia at 180 – exactly corresponding to his Parkinsonian tremor.  The nurse knew what was going on, the resident knew what was going on, the monitor tried to convince everyone otherwise – red flashing lights, clanging bells, ringing klaxons.  (Perhaps the monitor was actually trying to scare the sh!t out of the constipated patient – we should have let it go on longer to see if it would work.)  The nurses, techs, residents seemed quite content to continue working through the flashing lights, and the din.

Here’s my suggestion to you, as it was to them:  When one of your devices is providing you with information that you know to be, and are absolutely certain is, wrong and misleading:  TURN OFF THE F#@KING DEVICE!

The consultant (me) was so much happier and calmer with a dark monitor screen, no lights, no bells, no whistles.

On an unrelated note:  our new monitors have the ability to put whatever tracing you wish in whatever position you prefer on the monitor screen (our old monitors always had the ECG tracing on top, and the pulse ox on the 3rd line).  Last week, we had a patient who’s muscle tremor was repeatedly alarming, so one of techs very wisely just disconnected the ECG monitor and left the pulse oximeter connected – with a very nice pulse wave and good oxygen saturations.  And, to make life easier, moved the pulse ox from its traditional  3rd line onto the top line, previously reserved for the ECG monitor.  The consultant (for the Americans, that’s the attending) who shortly entered the room was perplexed at the healthy appearance of the patient, and the calmness of Lloyd, the tech, and all the others in the room – despite the wide complex ECG rhythm.  After providing a series of orders (does he have a pulse?,  check the potassium, let’s get the defibrillator pads on and the defibrillator in the room, give some mag, give this, do that) – the attending crawled away, tail between my legs, after being informed by Lloyd that the  pulse oximetry tracing was actually supposed to look like that, there was no ECG tracing, and that he correctly had surmised that the ECG monitor was giving us only misleading information and in anticipation of my future instructions had:  TURNED OFF THE F#@KING MONITOR.

Good on ‘ya, Lloyd.

The post Lies, Damned Lies and Monitors appeared first on Life in the Fast Lane medical education blog.

Sir Ken Robinson outlines 3 principles crucial for the human mind to flourish — and how current education culture works against them.

Great talk detailing how to get out of the educational “death valley” we now face, and how to nurture our youngest generations with a climate of possibility.

Creativity expert Sir Ken Robinson challenges the way we’re educating our children. He champions a radical rethink of our school systems, to cultivate creativity and acknowledge multiple types of intelligence

The post How to escape education’s death valley appeared first on Life in the Fast Lane medical education blog.

Mike Cadogan.
The Lynch Pin of FOAM getting Lynched at SMACC.
But its not all about one man.
Its not all about a small clique.
Or is it?
So I asked him.
Mike; its all a bit cliquey, isn’t it?
Mike; whats with all the drugs in sport?
Mike: Do you ever sleep or are there multiple clones of Mike Cadogan working away in dark rooms?
So Mike says……

The post JellyBean 006 appeared first on Life in the Fast Lane medical education blog.

I’ve been using many MedCalc on the iPhone for many years now and have almost come to consider it part of the phone itself.

Version 2.7 is now out and the authors, Pascal Pfiffner and Mathias Tschopp, have generously offered up 10 promo codes for the Pro version that runs on the iPad and 10 promo codes for the standard version. The standard calculator is $1.99 and the pro version is $4.99.

Find out all about the app here, follow @medcalc on Twitter, and check out the reviews on Precious Bodily Fluids.

To get a free promo code you’ll have to be fast — leave a comment below including your full name and email (email address will not be shown) and state what your favourite medical calculation is and I will email you a promo code (also state whether you’d like the Pro, the standard or either version).

Get calculating!

Disclosure: I have no conflicts of interest other than being a user of MedCalc and occasionally having to reply to challenging queries from Matthias on my blogposts…

The post MedCalc Magic appeared first on Life in the Fast Lane medical education blog.

The 4th International Advanced Care Planning and End of Life Care Conference has just been held in Melbourne, run by the ACPEL Society.

A keynote speaker was Professor Robin Taylor, Respiratory Physician from Dunedin Hospital, New Zealand. His team produced this video, entitled “A Good Death”, featuring a real patient, who is dying from COPD, and the efforts made to improve his care in the last stages of his life.

In the words of Professor Taylor:

“We wanted to make this film because we realized that the care we were providing to patients with respiratory disease at the end of life was missing the mark, and I don’t think we are alone. Two families expressed their appreciation but also their frustration at the way their loved ones had been looked after in Dunedin Hospital, and so we began to change the way we do things. We are now much more attentive to the issue of ‘dying well’, and we are still working at it. We believe that good end of life care is worth striving for. This film tells the story of one patient and his family.”

Think about this patient the next time you see a patient with ANY end-stage disease, and ask the question; “Just because we can provide a particular treatment, does it mean that we should?”

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Special thanks to Martin Cavanagh and his family for their generous and selfless contribution to medical education, and thank you to Professor Robin Taylor, for kindly allowing us to feature the video.

The post A good death… appeared first on Life in the Fast Lane medical education blog.

EMA Virtual Issue from Andrew Gosbell & Tony Brown

Research is important to emergency medicine as it provides the scientific underpinning for optimal patient care. A Primer for Clinical Researchers in the Emergency Department, a five part series guest edited by Professor Franz Babl, has been combined into a single FREE full-text online ‘Virtual Issue’

This Virtual Issue series addresses key topics for clinicians who conduct research as part of their work in the ED, including:

• Ethical and regulatory background
• Research science and conduct
• How to write a scientific paper
• Multicentre research
• How to describe data and basic medical statistics

This special online issue is a useful #FOAMed resource for the increasing numbers of emergency physicians participating in research activities.

The post Primer for Clinical Researchers in the Emergency Department appeared first on Life in the Fast Lane medical education blog.

TechTool review of SimpLog by Azher Merchant on iOS (iPhone)   

Website: – iTunes - Website

SimpLog allows you to keep track of patient follow-up from ED, so you will remember to chase results, call the patient to check their symptoms are improving or arrange follow up.  The idea is great but the execution of this app really lets the concept down

Design and User Interface

The ‘Simp’ clue in the title clearly flags up that this isn’t going to be a fancy app.   Actually the overall design is reasonable with clear graphics and an decent attempt at a colour scheme to brighten things up.  And the user interface works very well – it is intuitive and the app runs smoothly at all times

SimpLog on iPhone 1

SimpLog on iPhone 2

SimpLog on iPhone 3

Clinical Content

The app allows you to add a new task – enter the patient name, phone number, hospital number, notes for yourself, and a date.  This is then added to your list of tasks.  You can rearrange the order of the tasks or delete them.  A nice feature is that you can call directly through the app (although not entirely sure you’d want to call patients from your mobile anyway).

Cost

• $0.99 – I don’t think it is reasonable to charge for this app

Room for Improvement

• In a word….SECURITY.  This app’s purpose is to store patient details on your phone but the security is simply not up to the required standard (no matter where you are in the world).  I was able to set my username as ‘td’ and my password as ‘me’.  I suspect there will be no data encryption and there is certainly no remote wiping facility.  The world of patient data security standards is still a bit murky, but this app doesn’t even try.
• The iTunes info mentions that you can check off each task once complete but I couldn’t seem to work that out – without that function, it’s just an endless list.
• A date picker would make things easier – this is a simple function but if users are putting in a date for the task then the developer should use Apple’s pre-designed options.

Overall

I am loathe to discourage individual docs from innovating in IT, and I know how much effort can go into learning to code and build an app.  The developer asked me to review this app, so I have – although he is probably now regretting this.

Following up on ED patients is an area that I am particularly weak on, and I know it would improve my overall care to find out how patients are a few days after presentation.  So the aim of the app is a great one.

But it really doesn’t offer anything more than your ‘notes’ app does – except that it actively encourages you to unsecurely store patient data and it costs $0.99.

In its current form it is unfortunately unusable – security is essential.

The post TechTool Thursday 027 appeared first on Life in the Fast Lane medical education blog.

Welcome to the 103rd edition!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.

The Most Fair Dinkum Ripper Beaut of the Week

The Sono Cave

For those of you that love ultrasound or just learning – The Sono Cave is the ultimate EM blog for you. Check out these two awesome FOAMed cases from James over the past few weeks:

• Appendicitis with appendicolith

• Ultrasound of Acute Angle-Closure Glaucoma

The LITFL Review Top Picks

PHARM

• Minh teams up with two expert and brilliant minds of the prehospital retrieval field to discuss Patient preparation in retrieval medicine. 
• Avoiding the airway clean kill on a full moon - Minh goes through his approach to a difficult airway case!

Injectable Orange

• Respiratory Rate and Why SpO2 is Not the Same Thing! – The humble respiratory rate… something so easy to measure, something that can mean so much, but still something we get so wrong!

KI Doc

• Burr Holes in the Bush - Tim teams up with neurosurgeon Mark Wilson, and chat about how to be a  neurosurgeon out bush!

 TJdogma

• Paediatric Dermatology challenge - A rash in a 3 year old – to worry or not to worry?

boringem

• Point of care ultrasound: a hyperechoic future in Med Ed? - A brief introduction and some pearls on how to learn to use it!

EKG Videos

• Syncope leads to cardiac arrest within 15 minutes. What’s the diagnosis? Find out in 15 minutes!

http://www.youtube.com/watch?v=jQCPNoZjn00

Pediatric EM Morsels

• Plantar Puncture Wound - They are difficult to assess, can be deceptive, and prone to infection and complications – so check out this excellent summary and avoids these pitfalls!

Emergency Medicine Updates

• The Role of Percutaneous Cricothyrotomy: - Reuben shares with us his ‘Wire In Trachea Readiness’ technique !

 EMCrit

• This episode Scott discusses the benefits of using Sodium Bicarb - Acid-Base VI – Chloride-Free Sodium and there are a few!
  

Dr Smith’s ECG Blog

• Widespread ST Elevation. Activate the Cath Lab? - Or look for another cause?
• 2 hours of lecture from Sunday April 28 ECG Workshop – the Best of Smith at Best of Hennepin - check out the video below:

EMpills

• Anaphylactic shock, adrenaline and heart attack … - Could this be Kounis Syndrome?

SOCMOB

• SOCMOB How To: Jet Insufflation and Bougie Assisted Cric - Check out the videos:

http://www.youtube.com/watch?v=XMtPg6wkdKI

http://www.youtube.com/watch?v=G2neA9dvTeo

thebluntdissection

• in or out ??? - Can you pick the posterior shoulder dislocation?
• Quick Case #01 - Swollen left hand in a rugby player – ensure you get the lateral view and don’t miss this injury!

StEmylns

• Brilliant post from Simon on how to question the boss when you don’t think he’s right! How to cope when your registrar knows more than you do. - Simon shares how to get the best out of being in both sets of shoes!
• Is that IV really needed? - Ii’s time to pause before putting in that next cannula.

ER CAST

• Pulmonary embolism in pregnancy with Jeff Kline - Jeff Kline and Rob sit down and take a deep dive into what the evidence says on evaluating PE in the pregnant patient!

EM Basic

• Seizures - In this episode, Steve review’s all the important points about seizures including the confusing and difficult topic of pseudoseizures.

PulmCCM.org

•  Using procalcitonin to guide antibiotics for pneumonia - Clinical bottom line: Using procalcitonin levels to guide therapy does not seem to be associated with any harm and may benefit patients by decreasing antibiotic exposure, decreasing the duration of antibiotic treatment, and preventing the development of resistant microbes.

The Poison Review

• Case report: hemodialysis for dabigatran overdose - Haemodialysis can be difficult in these patients – but as this case shows it does have it benefits. 
• The Cinnamon Challenge - Beware: Cinnamon is a caustic irritant that can cause a hypersensitivity reaction or trigger an asthma attack. Most individuals who attempt to swallow a dry tablespoon-full experience coughing and gagging, along with burning of nasopharyngeal mucus membranes. Pneumothorax has occurred in a number of cases.

Emergency Medicine Ireland

• Standing Test for Long-QT syndrome - Yep something new! Remember: people with a long QT syndrome (LQTS) have an abnormal response in QTc with standing.

The Skeptics Guide to Emergency Medicine

• This is Spinal Tap - and whats the best evidence for preventing those post LP headaches!

Intensive Care Network

• Rosenberg on Immunosuppression - Alex Rosenberg manages to make a fairly dry subject understandable and relevant. 
• Hot Case #14 – I’m pregnant … HELLP! - A quick Q&A quiz from Mathew on HELLP Syndrome.

HQmeded.com

•  Advances in Resuscitation of Cardiac Arrest - Great update on were we are at with resuscitation in 2013 by Ken Lurie!

ToxTalk

• Episode 12 Ricin, Poison Mail, and the KGB - In this special edition episode the ToxTalk team discusses ricin and addresses some of the panic in the press including recent letters being sent to the US President and other officials.
• Episode 11 Libyan Methanol Disaster - Something for Aussie Docs to be aware of with a few cases being transported back from Indonesia for our management!

Broome Docs

• Lessons Hard Learned – Episode 8 with Dr Rob Orman - Rob shares a tough lesson, with plenty of pearls to be gained, and finishes of with some sound advice from both Casey and Rob on dealing with nurses.
• Medical Ethics Question - Take the pole, what would you do in this ethically challenging situation.
• Big Belly Baby Bleed – managing late-term Obstetric bleeding

EM Journey

• Another ‘Routine’ ECG - in a 19y old female with cellulitis of the right leg.

SCANCRIT

• Daily sedation interruption still controversial - Take home message: Implementing protocols that actively aims for light sedation is better than having no plan for sedation. There is no evidence daily interruptions adds anything to protocols for lightest possible sedation.
• LUCAS - nice video showing these devices are effective at delivering excellent CPR.

Academic Life in Emergency Medicine

• Excellent summary on using Death during Simulation - the pros and cons are summarised nicely!
• Trick of the Trade: Making the NG and NP procedures less painful- How to make your own intranasal lidocaine-oxymetazoline spray, and put your patients nares at ease. 
• Want to reduce the number of scans your blunt trauma patients receive? The SCRAP Rule: Indications for chest CT in blunt trauma.
• Transient Synovitis vs Septic Arthritis of the Hip - What imaging modality do you use? Nice review of the literature on which one will give you the answer!

EmergencyLondon

• Dr Gary Jourbet gives us an update in paediatric asthma management. 

http://www.youtube.com/watch?v=vFrBBZ-vskU

The Trauma Professional’s Blog

• Management of CSF Otorrhea/Rhinorrhea - Michael takles the controversie and gives us some sound advice on management!

The LITFL Review Shout Out of the Week

• Shout out of the week goes to the recent EM conference Resuscitation 2013! The team behind it includes hardcore FOAM exponents Amal Mattu, Haney Mallemat and Laleh Gharahbaghian – check out the tweets with the #resus13 hashtag. Here Edwin Leap (@EdwinLeap) shares with us his travels through a strange land called Emergistan:

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

The GMEP Cases of the week

Take ten minutes to learn everything you ever needed to know about bronchiolitis and croup. Great vodcast by Andrew Tagg

GMEP Video of the week GMEP Image of the week

• This weeks pic is from Chris Cresswell – for more on this case check out - Suddenly Swollen.

Twee Dee and Twitical Care

Had dream last night where I tried to fix the Earth's raised CO2 by turning the Moon into a giant BiPAP machine. Major mask fitting issues

May 3, 2013 5:44 pm via Twitter for iPhoneReplyRetweetFavorite

@thefourthcraw

Mike

News from the Fastlane

• Prepare To Be SMACCed! - Only a few more sleeps and the SMACC videos will be rolled out, and find-out what will be going on at SMACC2!
• What Motivates Us? - Awe-inspiring post from Gerrard!
• The team welcomes a new guest author with an post About Sports Concussion. 

The Final Words

A large curry and some beer has an incredibly sedative effect on me with no cardiovascular effects. The ideal induction agent?

April 20, 2013 6:21 am via Tweetbot for iOSReplyRetweetFavorite

@bungeechump

Chump

Hypotense and you give a challenge bolus and the BP drops more - think massive PE #Resus13

May 2, 2013 7:57 am via Tweetbot for iOSReplyRetweetFavorite

@Bodymender_n_ED

Bodymender

LITFL Review EM/CC Educational Social Media Round Up

Show Reference list

The post The LITFL Review 103 appeared first on Life in the Fast Lane medical education blog.

Ok, FOAMaholics you’ve waited long enough. I know, it’s been even worse for those of you that attended SMACC in person and have been suffering from SMACC withdrawal. The good news is, the wait is almost over. If you weren’t there and you’re still kicking yourself, you’re about to get a taste of SMACC. And if you were there, but found attending three concurrent sessions at once difficult (!), you get to see what people were raving about from the sessions you missed.

From next week all the edited video and audio recordings from the mind-boggling SMACC conference held in Sydney a month-and-a-half ago will become FOAM.

Image by @squartadoc – click image for source.

SMACC speakers will quite rightly get to to release their own talks first on their own websites, together with whatever supporting information and links they desire. But regardless of where they appear first, all the talks from SMACC are free to use and reuse for non-commercial educational purposes (with appropriate attribution of course) by one and all. That’s right, it’s all FOAM.

Scott Weingart from EMCrit.org talking SMACC

You’ll be able to follow the SMACCination of the FOAM world as new talks are released via The LITFL Review, the LITFL SMACC page, the SMACC website or other SMACC-affiliated blogs and podcasts. Alternatively follow me (@precordialthump), @I_C_N or @smacc2013 on Twitter for the latest news on SMACC.

Enjoy!

Team GB leading the way in SimWars

The post Prepare to be SMACCed! appeared first on Life in the Fast Lane medical education blog.

Concussion knowledge and application of practical guidelines in sport are based on current international concussion opinion ^1-3 . A recent exponential increase in the number of concussion publications in the literature has been summarized in these consensus documents. It should be noted that the science of concussion continues to evolve. Current paradigms should be critically evaluated and periodically reviewed.

Woman’s Lacrosse

What is concussion?

Concussion is a disturbance in the brain’s ability to acquire and process information. The reduced function of the brain represents damage to nerve cells (neurons). The neurons can be damaged by a direct blow to the head, which causes the brain to rotate and/or move forward and backward. Indirect impact to the body can transfer an impulsive force to the brain which damages neurons.

The effect that this has on the athlete can vary from person to person, depending on which part of the brain is affected. The impact can cause concussion signs visible to others.

Concussion should be suspected if these signs are observed: ⁴

• Unresponsiveness
• Upper limb muscle rigidity
• Upper limb spontaneous movement
• A fit / seizure soon after contacting the surface
• Balance difficulty
• Slow responses
• Vacant stare
• Confusion
• Disorientation
• Holding the head
• Facial injury
• Speech slurring

Minutes to hours after the impact injury the player may complain of:

• Headache
• Nausea / Vomiting
• Blurred vision
• Memory loss / difficulty
• Dizziness
• Tiredness
• Not feeling right
• Sensitive to bright light & loud noise

Days to weeks after the impact the player could have/feel:

• Sleep difficulty
• Persistent low grade headache
• Poor attention & concentration
• Sad or irritable or frustrated
• Tired easily
• Lethargic, low motivation

Minimum diagnostic criteria for concussion ⁵

• Physical signs occurring following an impact – LOC, convulsion, balance difficulty.
• Physical signs observed by others – slowness with Q’s, aggression, emotional lability, incorrect play, vacant stare, glassy eyes.
• Any concussion symptoms.
• Any neurological / balance and cognitive examination (poor planning, unable to switch mental set ⁶, impaired memory & learning ^7;8, reduced attention & processing information ^9-12, slow reaction times ^13-16

Concussion cannot be diagnosed at one point in time. Symptoms can evolve over time. Perform serial assessments over time and rule out other conditions that can mimic concussion.

The severity of traumatic brain injury is measured according to the Glasgow Coma Scale at 6h after head injury. In the neurosurgical spectrum of mild traumatic brain injury (mTBI) the Glasgow Coma Scale ranges from 13-15. mTBI is characterize by a neurological deficit and     structural injury seen on CT/MRI scan.

Athletes with concussion signs and symptoms have a Glasgow Coma Scale ranging from 14 – 15 and rarely is structural injury seen on CT/MRI.

Pathophysiology and Window of Vulnerability ^18;19

The following changes in the brain are implicated in concussion: Δ pattern of neuron conduction ^20-22; Δ glucose metabolism ^23-27; Δ membrane protein expression ^28-31; Δ blood flow. The net effect is an energy deficit characterized by an acidosis and reduced neuronal activity.

An indirect marker of brains energy balance is N – acetylaspartate (NAA). NAA is measured using proton magnetic resonance spectroscopy (MRS). NAA is an index of metabolic recovery after concussion in humans. ³² This can explain the why some athletes display significant cognitive problems while conventional scans lack sensitivity to detect neurotransmitters.

NAA levels were found to be decreased for up to 30 days after concussion, long after the athlete became asymptomatic. ³³ It was found that non concussed athletes may also have low NAA levels presumably due to sub concussive impacts. ³⁴ In simple terms, while there is not enough energy, the brain can’t make NAA. The glucose deficit can also cause mitochondrial dysfunction, more likely with a second impact during the window of vulnerability.  ³⁵

How common is concussion?

1.6 to 3.8 million concussions occur in sport per year in the United States. ³⁶ Across football codes in Australia, the probability of concussion is approximately 1 in 7.

Available Resources

For further information on concussion visit www.sportsconcussionaustralasia.com

 References

(1)    McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorak J, Echemendia RJ et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47(5):250-258.

(2)    Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013; 47(1):15-26.

(3)    Patricios J, Collins R, Branfield A, Roberts C, Kohler R. The sports concussion note: should SCAT become SCOAT? Br J Sports Med 2012; 46(3):198-201.

(4)    Kelly JP, Rosenberg JH. The development of guidelines for the management of concussion in sports. J Head Trauma Rehabil 1998; 13(2):53-65.

(5)    McCrory P, Meeuwisse WH, Echemendia RJ, Iverson GL, Dvorak J, Kutcher JS. What is the lowest threshold to make a diagnosis of concussion? Br J Sports Med 2013; 47(5):268-271.

(6)    Matser EJ, Kessels AG, Lezak MD, Jordan BD, Troost J. Neuropsychological impairment in amateur soccer players. JAMA 1999; 282(10):971-973.

(7)    Gronwall D, Wrightson P. Memory and information processing capacity after closed head injury. J Neurol Neurosurg Psychiatry 1981; 44:889-895.

(8)    Lovell M, Collins M, Bradley J. Return to play following sports-related concussion. Clin Sports Med 2004; 23(3):421-41, ix.

(9)    Gronwall D, Wrightson P. Cumulative effect of concussion. Lancet 1975; 2(7943):995-997.

(10)    Peterson CL, Ferrara MS, Mrazik M, Piland S, Elliott R. Evaluation of neuropsychological domain scores and postural stability following cerebral concussion in sports. Clin J Sport Med 2003; 13(4):230-237.

(11)    Hinton-Bayre AD. Choice of reliable change model can alter decisions regarding neuropsychological impairment after sports-related concussion. Clin J Sport Med 2012; 22(2):105-108.

(12)    Hinton-Bayre AD, Geffen G, McFarland K. Mild head injury and speed of information processing: a prospective study of professional rugby league players. J Clin Exp Neuropsychol 1997; 19(2):275-289.

(13)    Moriarity J, Collie A, Olson D, Buchanan J, Leary P, McStephen M et al. A prospective controlled study of cognitive function during an amateur boxing tournament. Neurology 2004; 62(9):1497-1502.

(14)    Makdissi M, Collie A, Maruff P, Darby DG, Bush A, McCrory P et al. Computerised cognitive assessment of concussed Australian Rules footballers. Br J Sports Med 2001; 35(5):354-360.

(15)    Warden DL, Bleiberg J, Cameron KL, Ecklund J, Walter J, Sparling MB et al. Persistent prolongation of simple reaction time in sports concussion. Neurology 2001; 57(3):524-526.

(16)    Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med 2003; 13(4):222-229.

(17)    McCrory PR, Berkovic SF. Concussion: the history of clinical and pathophysiological concepts and misconceptions. Neurology 2001; 57(12):2283-2289.

(18)    Hovda DA, Lee SM, Smith ML, Von SS, Bergsneider M, Kelly D et al. The neurochemical and metabolic cascade following brain injury: moving from animal models to man. J Neurotrauma 1995; 12(5):903-906.

(19)    Longhi L, Saatman KE, Fujimoto S, Raghupathi R, Meaney DF, Davis J et al. Temporal window of vulnerability to repetitive experimental concussive brain injury. Neurosurgery 2005; 56(2):364-374.

(20)    Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train 2001; 36(3):228-235.

(21)    Katayama Y, Becker DP, Tamura T, Hovda DA. Massive increases in extracellular potassium and the indiscriminate release of glutamate following concussive brain injury. J Neurosurg 1990; 73(6):889-900.

(22)    Shaw NA. The neurophysiology of concussion. Prog Neurobiol 2002; 67(4):281-344.

(23)    Fineman I, Hovda DA, Smith M, Yoshino A, Becker DP. Concussive brain injury is associated with a prolonged accumulation of calcium: a 45Ca autoradiographic study. Brain Res 1993; 624(1-2):94-102.

(24)    Kawamata T, Katayama Y, Hovda DA, Yoshino A, Becker DP. Lactate accumulation following concussive brain injury: the role of ionic fluxes induced by excitatory amino acids. Brain Res 1995; 674(2):196-204.

(25)    Yoshino A, Kawamoto M, Yoshida T, Kobayashi N, Shigemura J, Takahashi Y et al. Activation time course of responses to illusory contours and salient region: a high-density electrical mapping comparison. Brain Res 2006; 1071(1):137-144.

(26)    Yoshino A, Kawamoto M, Yoshida T, Kobayashi N, Shigemura J, Takahashi Y et al. Activation time course of responses to illusory contours and salient region: a high-density electrical mapping comparison. Brain Res 2006; 1071(1):137-144.

(27)    Yoshino A, Hovda DA, Kawamata T, Katayama Y, Becker DP. Dynamic changes in local cerebral glucose utilization following cerebral conclusion in rats: evidence of a hyper- and subsequent hypometabolic state. Brain Res 1991; 561(1):106-119.

(28)    Nilsson B, Nordstrom CH. Rate of cerebral energy consumption in concussive head injury in the rat. J Neurosurg 1977; 47(2):274-281.

(29)    Nilsson B, Nordstrom CH. Experimental head injury in the rat. Part 3: Cerebral blood flow and oxygen consumption after concussive impact acceleration. J Neurosurg 1977; 47(2):262-273.

(30)    Nilsson B, Ponten U. Exerimental head injury in the rat. Part 2: Regional brain energy metabolism in concussive trauma. J Neurosurg 1977; 47(2):252-261.

(31)    Nilsson B, Ponten U, Voigt G. Experimental head injury in the rat. Part 1: Mechanics, pathophysiology, and morphology in an impact acceleration trauma model. J Neurosurg 1977; 47(2):241-251.

(32)    Moreno A, Bluml S, Hwang JH, Ross BD. Alternative 1-(13)C glucose infusion protocols for clinical (13)C MRS examinations of the brain. Magn Reson Med 2001; 46(1):39-48.

(33)    Vagnozzi R, Signoretti S, Tavazzi B, Floris R, Ludovici A, Marziali S et al. Temporal window of metabolic brain vulnerability to concussion: a pilot 1H-magnetic resonance spectroscopic study in concussed athletes–part III. Neurosurgery 2008; 62(6):1286-1295.

(34)    Chamard E, Theoret H, Skopelja EN, Forwell LA, Johnson AM, Echlin PS. A prospective study of physician-observed concussion during a varsity university hockey season: metabolic changes in ice hockey players. Part 4 of 4. Neurosurg Focus 2012; 33(6):E4-E7.

(35)    Vagnozzi R, Tavazzi B, Signoretti S, Amorini AM, Belli A, Cimatti M et al. Temporal window of metabolic brain vulnerability to concussions: mitochondrial-related impairment–part I. Neurosurgery 2007; 61(2):379-388.

(36)    Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006; 21(5):375-378.

The post About Sports Concussion appeared first on Life in the Fast Lane medical education blog.

This 5 year old presented to ED with elbow pain and swelling after falling onto his left outstretched arm. The XR is shown.

Questions

What is the abnormality?

Answer

How do you grade this injury?

Answer

How is this managed?

Answer

References

The post Traumatic Elbow Swelling appeared first on Life in the Fast Lane medical education blog.

TechTool review of Read by QxMD Medical Software on iOS (iPad and iPhone)   

Website: – iTunes - Website

Thanks to @emtraveller I have only recently discovered Read by QxMD.  Read is simple but great.  It allows you to keep track of journal articles, browse through recent releases and share them with others.  It saves you trawling through individual journal sites.

Clinical Content

When you set up your free account, you get to select your specialty and then choose which journals you want in your article feed. Recent articles from the journals you have chosen appear in the ‘featured papers’ feed.  Alternatively you can browse by journal.  Other functions include:

• Add comments to the articles
• Mark the article as like or dislike (although I’m not sure what happens with this info)
• Mark articles as favourites (can view all favourites together)
• Download the full pdfs to view (some articles are only available in abstract form)
• Share with friends

Read on iPhone 1

Read on iPhone 2

Read on iPhone 3

Design and User Interface

The design suits the app.  It’s clear and easy to read but has some extra flourishes that make the design aesthetically pleasing (although I did think I had a crack on my screen for several minutes).  The user interface works on first glance, but the navigation did confuse me on a few occasions.

There isn’t simply a button to go back to the main index page (each time you have to choose whether you want to see ‘featured papers’, ‘my journals’, or ‘my collection’.  This is a small point but is annoying – every app should have an easy ‘home’ icon.

Cost

• Free

Room for Improvement

• It would be handy to be able to delete papers from your feeds to avoid clutter
• Some more explanation on how to use the app would help users like me – I feel I am missing out on some of the features.  For example, why does every article seem to have a ‘caution alert’ icon in the bottom right corner?
• Add in a simple home icon

Overall

This app is a free and simple way to access journal articles.  Small elements of the user interface make it a bit fiddly to use for me but these could be easily resolved.   In the end, it’s a great way to be able to keep up to date when you have a few minutes to spare.

The post TechTool Thursday 026 appeared first on Life in the Fast Lane medical education blog.

aka Postcards from the Edge 010

Each time we feature a ‘postcard from the edge’ from the somewhat infamous New Zealand-trained emergency physician Dr Sandy Inglis he is somewhere new — we last heard from him as a patient in Italy, now he is back in ancestral lands in Kwa-Zulu Natal.

Only 2 months have past in this, the wild west of Emergency Medicine, and yet the drama, the excitement, the frustration and the chaos make it feel like we have been here for years. I am employed here as the Head of Department for Emergency Medicine, plucked from the comfort of Australasian Emergency Medicine (EM) to come to this province of Kwa-Zulu Natal to make some sense of EM here. It is ironic that in this country where trauma kills more people than cancer and where 1200 died on the roads over last Christmas, EM, as a specialty is so undeveloped. I am one of only four EM physicians in this province and the only one in this town, serving a population of over one million. Other parts of the country are relatively flush though and nearly 100 EM physicians exist throughout the country. Academic EM abounds and registrar training is active, but we have a long way to go. “Casualties” are everywhere and, even here, I am at pains to explain to ED and in-patient colleagues alike, that casualty is dead and even ‘A&E’ is a dated term, but old habits die hard. Let me take you through some of what I went through to get here……

Despite being South African, holding a South African MBChB and being on the HPCSA (SA medical council) general register, as well as being a registered specialist in NZ, Australia and UK, my initial application to register as a specialist was declined; “lack of proof of training and specialist qualification’! What followed was a painful and drawn out exchange and a final review which successfully got me on the specialist register. Then my interview was the next hurdle. A telephonic interview to me in London; date change 3 times and then time changed twice; then the teleconference didn’t work, then it did; then I heard nothing for weeks (or was it months?). Then a colleague in the hospital managed to find and film my contract in the HR department and e-mail me the pics so I knew that I had a job! Then, despite calling the HR staff and requesting my contract it was never sent and on arrival I discovered that my original contract, signed by the highest authority, was in fact lost!

I arrived to start work on the 2nd January 2013; I was vaguely expected and on presentation to HR a few sheets of paper were thrust into my anxious hands to fill in. These were bank forms to ensure I got paid and overtime forms. On numerous later visits to HR to check progress further forms were issued in a torturous drip-feed fashion revealing departmental dysfunction beyond belief. Then, as if this wasn’t bad enough, on discovering that I had not been paid for January by mid February, I returned to HR to discover that HR had lost all of my paperwork and had to start the entire process again. Then to top it all, my ‘resettlement’ payment (outlined in my contract) to get me and my family and possessions to South Africa, was rejected by the hospital ‘cash-flow’ committee.

Then to work. My predecessor was still firmly entrenched in his (my) office as his was yet to be built. Thanks to this, we were obliged to share office, telephone and move internet cable from one computer to the other to check e-mail etc. We did the same for the printer. Parking for the HOD was hit and miss and if I didn’t arrive well before 0730h to claim my spot under the kitchens, where pipes drip old cooking oil and dirty dishwater onto your car, then I was traipsing around the campus through mud and debris to see where I could squeeze in.

With all the admin in order (I did get paid in late February!) its off to the ED. EM here is in its infancy. It has been born out of the surgical department and as such is very surgical with nothing like an ECG or nebuliser in site. The ED is essentially a trauma unit seeing an incredible volume of spectacular trauma; as much penetrating as blunt. Pedestrian MVA’s are prolific, knife wounds to every zone of the neck, belly, back, scalp and chest and bullets everywhere else. Trauma here is not sanitized or packaged on shiny yellow spinal boards with bright orange head-blocks; vehicles are unsafe; children sit unrestrained in front seats; seatbelt use is rare and airbags just don’t exist. There is no warning and trauma arrives brutal and bloody, in arms, dragged in, out of backseats, deformed limbs, battered brains, spilling guts. Burns are horrific and are mostly hot water in kids but electrical and lightening burns are common and, worse of all, are the explosive fire burns and the revenge acid burns where palliation is the only option. The trauma support in the hospital is excellent with world class trauma surgeons who balk at nothing. We work well with them. The surgical side is more challenging. Thanks to its surgical origins, the ED has inherited the so called “SOPD” and together with it, a sort of hotchpotch triage where everything that is not medical, comes. Medical (or triage) officers wade through everything from sprained ankles to 3-week-old abscesses to goiters to lipomas to foreign bodies, directing traffic, signing forms, booking clinics, taking bloods, phoning in-patient teams. It is a monster that the ED needs to shed fast but the surgeons are way ahead of us and plan only a name change for this inconvenient collection that impinges on time in theatre.

Adjacent to our 6 trauma beds are 8 medical resuscitation beds. These have been provided to be part of this token casualty (sorry ED) and, although staffed by ED nurses, are administered and run by the physicians with ED coming in to help with resuscitations, ACLS and ventilating patients, as there is no piped oxygen or suction on that side. The pathology here is beyond belief with HIV, TB, renal failure, very sick DKA’s, sepsis, CVA’s, seizures, CCF, all sorts of toxicology, etc, etc etc. We would love to look after this part of the department but with SOPD around our necks and limited staff, that option is on hold.

I am the only Emergency Medicine consultant in the department. I have my predecessor who is a retired surgeon who has made amazing progress thus far. He is also a wizard with hospital admin and committees. Otherwise, we have 4 medical officers, 3 registrars (and 2 out on rotation), 2 community service (post intern) docs and 3 interns. It is a small team to run a busy ED (and triage and SOPD) and we have changed the roster from the original 28hour shift (8am to midday the next day) to a 12 hour shift, a day off post call and a late start the next day. A classic ED roster is impossible with the numbers I have.

Mind-boggling, as Head of Department, is the enormous administrative burden and interminable meetings; strategic planning, leadership discussions, committees for everything from resusc to disaster to quality to adverse events….core standards, MANCO, HOD’s, and every other acronym you can imagine. It is a battle to stay in touch with the coalface but twice daily ward rounds in ED provide ample clinical exposure and a Monday ‘on the floor’ keeps the stethoscope swinging. The academic programme is impressive with ED CME meetings, radiology, ICU round, Reg teaching, M&M and more. Opportunities for research abound.
The biggest challenge now is to transform this trauma unit/SOPD into a fully fledged ED. I envisage a transition involving a move away from SOPD, embracing medical emergencies and then defining ourselves as a critical care ED seeing only Code (triage) reds. (triage 1&2). The Oz/NZ model will not work here. We would sink in a week! Focus on the reds; do it well and then review. We are working on core business for ED for the province; getting it right will be make or break.

You don’t come back to work in SA for the money. Not only is getting paid a battle but I just realised that my 3 week locum in Oz last year paid one third of my annual salary here this year. Put it this way; I could resign my post here and work as a volunteer, do 3×3 week locums in Oz and I would be earning about the same amount. One bonus here is a 13th cheque on your birthday month but then there is no CME allowance, no company car, no communications package and only 22 days leave per year. Luckily the cost of living is minimally cheaper!

Outside the hospital life is definitely different. South Africans live on the edge. Angst is everywhere; dogs bark incessantly; you run watching your back; we sleep barred, bolted and alarmed. Our telephone lines have been stolen twice, valued for their miles of expensive copper and armed response is the norm. Many live closeted in gated communities, secure behind high voltage electric wire and security guards. They live comfortable and immune from the drama that is South Africa.

Beyond all this is the joy of being in South Africa. Society here is not pampered, not protected, not predictable, like in NZ or Oz. The thrill of being part of a slightly unstable social experiment; rules are vague. The beaches are golden and isolated, ruffled only by the prints of a giant Leatherback turtle coming up to lay her precious load of eggs; rugged game parks harbour stalking lion, gangly giraffe and massive rhino in their lush green bush and majestic vultures soar silently high above the dramatic Drakensberg. Eland graze quietly on sweet pastures nestled below the krantzes of these massive mountains. One feels, acutely, the joy of being alive here. Nothing is taken for granted. The rich scent of African earth after a vicious electric storm; the deep choral voices of Zulu men singing; the sight of Inguni cattle, with their marble-like colouring, drifting down our street like apparitions.

We feel privileged to be a part of it…..

The post Emergency Medicine Kwa-Zulu Natal Style appeared first on Life in the Fast Lane medical education blog.

A 23-year-old man with no past medical history comes to the ED for pain and swelling around his forearm tattoo, which he received three days prior during a weekend-long celebration with his friends.  To help with the pain, he continued drinking when he arrived home.  His review of systems is unclear, and he may have had chills with some nausea over the past day.  He is a smoker and denies illicit drug use.

On arrival, T 99.9  HR 92 136/90  RR 20 SpO2 98% RA

In general, he is anxious but interactive in no acute distress.  His general exam is reassuring; the extremity shows no streaking, crepitus, or lymphadenopathy.  His tattoo is shown below:

Question

Which is the most likely diagnosis?

A. Aseptic inflammatory reaction
B. Subcutaneous ink diffusion
C. Contact dermatitis
D. Pyogenic infection

Answer

D