LITFL Review 259

LITFL review

Welcome to the 259th 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 chunk of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsThe speaker wasted my time.’  So how do you deal with negative feedback on your presentation?  Our own Swami talks us through using negativity to spur us on to excellence. [CC]

The Best of #FOAMed Emergency Medicine

  • “First 10 in EM” features an excellent rapid review on the recognition and emergency management of thyroid storm. [AS]
  • A superb talk from Casey Parker on Bayes testing: using the test that will discriminate. [SL]
  • One of the most frequent ER procedures:  urine testing. But how much do you understand it and is it used correctly? A great look at the topic from HEFT EMCAST. [SL]
  • The Bottom Line features an excellent review of the POKER trial comparing propofol to ketofol. [AS]
  • Check out Core EM’s post on ankle fractures: diagnosis, management and pitfalls. [AS]

The Best of #FOAMtox Toxicology

  • The guys over at The Poison Review talk about a recent paper on ‘heroin OD’ and naloxone and why it is difficult to apply scientific results to drugs of recreation. [CC]

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

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Last update: Nov 28, 2016 @ 3:10 am

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Funtabulously Frivolous Friday Five 167

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 167

Question 1

What is Asturian leprosy?

  • Pellagra or vitamin B3 (niacin) deficiency as a result of a corn based diet (Noted in the Asturias community in Spain).
  • In 1915, back when such practices were legal and under the Surgeon General’s sanction in the USA, Dr. Goldberger offered prisoners of a southern prison freedom in return for cooperation in his experiment. Eleven healthy men volunteered, and were put on an all-corn diet. Goldberger kept the patients’ housing meticulously clean and regulated, from changing the sheets and clothing everyday to screening in the doors and windows. Three weeks into the diet, seven of the eleven men developed pellagra. The men actually begged to be put back in prison. Dr. Goldberger then supplemented their diets with other vegetables and fruit and the disease cleared up. [Reference]
  • Pellagra typically causes the 3 “D’s” – Diarrhoea, dementia and dermatitis.


Question 2

What condition did Andre The Giant have?

  • Acromegaly
  • There is a book called “As You Wish” about the making of The Princess Bride with stories about Andre The Giant (Fezzig). He called everyone “Boss” because he wanted to put them at ease. When filming, he got drunk and fell and broke a table and afterwards had a dedicated police unit follow him around for damage control. He took care of Robin Wright by using his hand as an umbrella for her when it was raining and he carried Wallace Shawn on his back while climbing.
  • His acromegaly gave him chronic pain and he wore a back brace throughout the entire movie
  • He sadly died of CHF a few years after its filming [Reference]

Question 3

What is the “Jake Leg“?

  • Refers to an organophosphate-induced delayed neuropathy (OPIDN) from consumption of Jamaican Ginger, aka Jake.
  • Jake leg affected thousands in the American South and Midwest during prohibition due to the adulteration of bootlegged Jamaican Ginger (~80% ethanol) with tri-ortho cresyl phosphate. [Reference]

Question 4

A competitive athlete asks for your advice about an embarrassing medical problem she has developed… a unilaterally swollen labia majora. What sport does she most likely compete in?

  • Cycling
  • She most likely suffers from a condition known as ‘bicyclist’s vulva’.
  • That’s right as if cyclist’s nipples, cycling-related peripheral neuropathies and saddle sores weren’t bad enough there is a condition known as ‘bicyclist’s vulva’.
  • Bayaens and colleagues described 6 cases in a 2002 paper in the BMJ (the patients cycled an average of 462.5 km per week). They all had unilateral lymphoedema thought to be due to compression of the inguinal lymphatics. [Reference]

Question 5

What did Brown-Sequard repeatedly inject himself at the age of 72, in order to rejuvenate himself?Édouard_Brown-SéquardÉdouard_Brown-Séquard

  • Extracts of guinea-pig testes.
  • He wrote “The day after the first subcutaneous injection, and still more after the two succeeding ones, a radical change took place in me . . . I had regained at least all the strength I possessed a good many years ago . . . My limbs, tested with a dynamometer, for a week before my trial and during the month following the first injection, showed a decided gain of strength . . . I have had a greater improvement with regard to the expulsion of fecal matters than in any other function . . . With regard to the facility of intellectual labour, which had diminished within the last few years, a return to my previous ordinary condition became quite manifest”
  • Brown-Séquard also reported that similarly dramatic benefits of extracts from rabbit and guinea pig testes had been observed in three men, aged 54, 56 and 68 years, whereas injections of water in two other men had had no effect. This has been proven to still be due to the placebo effect. [Reference]

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TechTool Thursday 070 D-Eye

TechTool review – D-Eye the ophthalmoscope for iPhones

Website:  – Facebook – iTunes – LinkedIn – Twitter – Website

D-eye is a smartphone solution to ophthalmoscopy, it converts your iPhone into a digital ophthalmoscope with the ability to either take still shots or record examinations in high definition. The examinations can then be stored securely in a cloud and shared with experts if required.


The app has undergone some important changes since I was first given this product. It now has the option of fast secure login with touch-id. The home screen gives you access to your previous examinations, adding a new patient but also importantly a glossary of ophthalmic conditions with a picture library of those diseases as an aide memoire.

Additionally the app has given the user the ability to use automatic features of focus and lighting during an examination or over-riding these and going manual. Certain lighting and iris colour can require you to go manual and this option has made my own examinations more successful.

User Interface




Uses and product testing:

What diseases can you find with the D-eye:

  • Glaucoma
  • Papilloedema
  • Hypertensive retinopathy
  • Retinal haemorrhages / detachments / Pigmentosa
  • Vitreous Detachment
  • Branch or central retinal vein occlusions
  • Central retinal artery occlusion


What does the literature say:

  • In the Journal of Hypertension September 2016 they found the following when the d-eye was compared to a traditional ophthalmoscope:
    • In 41 consecutive patients with hypertension no abnormalities were detected on the retina with a traditional ophthalmoscope by emergency physicians.
    • With the D-eye the emergency physicians reviewed the same patients and detected 17 patients with abnormalities (the gold standard was done by ophthalmologists who detected 19 patients with abnormalities).
  • How does the imaging compare to a slit lamp exam in diabetic retinopathy?
    • Overall exact agreement between the 2 methods was observed in 204 of 240 eyes (85%) (simple κ = 0.78; CI 0.71-0.84) and agreement within 1 step (DM is graded by 5 steps) was observed in 232 eyes (96.7%). Compared to biomicroscopy, the sensitivity and specificity of smartphone ophthalmoscopy for the detection of clinically significant macular oedema were 81% and 98%, respectively. [Reference]

Product testing:

Below is the D-eye company video and two test runs I did in suboptimal conditions. Firstly with my partner at home and second with a co-worker in our bright office, with patients I dilated their pupils and had comparable results to the d-eye product literature.

How much does it cost?

  • $435 AUD.
  • There are alternative products on the market but are currently going through crowdfunding and they are pitching at a similar price.
  • It is possible to convert your iPhone with the panoptic from Welch Allyn but the case is $230 AUD or $1700 AUD for the case and a panoptic head.

Room for Improvement

  • I suspect like the large majority of the population you will be waiting for it to be compatible with other models of phones.
  • A case that is easier to attach and detach without the use of an Allen key (in development). It also means you have to do away with your hard waterproof casing while you use the device as it requires close proximity to the camera.
  • To complete my ophthalmic testing the app would benefit from Ishihara plates and visual acuity testing.


I had grand plans to use this in a specific eye and ear institution, show you videos of diseases using the d-eye but while some of us are visionaries others our blinded to advances in medical education (excuse the puns, I had to put them in somewhere). However, this has meant instead of feverish product testing for 4 hours I have intermittently been using the device in my own emergency department for the past 6 months. These are my final thoughts:

  • The device is easy to attach (magnetic)
  • The app is easy to login, record, and specialists can review your images remotely
  • Version 2.0 of the app allows for better visualisation in patients with a darker iris. My tip is to dilate the pupil and use in a low light setting (too light and too dark ambient lighting produces poorer results).
  • It requires practise, like most things in medicine there is a technique and after 10+ examinations I found myself automatically using the D-eye instead of the ophthalmoscope attached to the wall which invariably has a bulb that is not working and poorer image quality.
  • Its flexibility is where it comes into its own, I’ve used it in the trauma and paediatric setting and for those in remote or 3rd world medicine where blindness is a leading curable co-morbidity this setup could save thousands.

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Research and Reviews in the Fastlane 161

Research and Reviews in the Fastlane

Welcome to the 161st 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 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern 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

R&R Hall of Famer - You simply MUST READ this!
Mayer RE. Applying the science of learning to medical education. Medical education. 44(6):543-9. 2010. PMID: 20604850

  • Richard Meyer provides a crystal clear explanation of his research-based cognitive theory of multimedia learning. This theory explains how people learn from words and pictures in terms of information processing. It has clear implications for how instructors should help learners learn: cut out extraneous crap (like distracting animations on slides), help learners hold information in their working memory (e.g. define key terms before explaining a process) and help learners make sense of what they are seeing and hearing (e.g. use pictures with words, instead of just words, and speak in a conversational style). This is a must read if you ever try to teach someone something… (Justin: I suspect these same techniques could be adopted to help improve our communication with patients.)
  • Recommended by Chris Nickson

The Best of the Rest

R&R Hot Stuff - Everyone’s going to be talking about this
Chen IC et al. Croup-induced postobstructive pulmonary edema. The Kaohsiung journal of medical sciences. 26(10):567-70. 2010. PMID: 20604850

  • Not all Croup is as easy as “Give ’em Dex and think about Racemic Epi.” Sometimes croup can become complicated by Negative Pressure Pulmonary Edema!
  • Recommended by Sean Fox
  • Read more Negative pressure pulmonary edema and croup (Pediatric EM Morsels)

R&R Trash - Must read, because it is so wrong!
Braun C et al. Bystander cricothyroidotomy with household devices – afresh cadaveric feasibility study. Resuscitation 2016. PMID: 27810460

  • Despite the conclusions these authors come to based on a cadaveric model (with no actual blood) bystanders should not be performing emergency cricothyroidotomies. I think we all knew this but these authors seem to think that with minimal or no training, anyone could perform this high-risk procedure with simple household items.
  • Recommended by Anand Swaminathan

Emergency Medicine
R&R WTF Weird, transcendent or funtabulous!” width=
R&R Eureka - Revolutionary idea or concept
Ranney ML et al. Tweet Now, See You In the ED Later? Examining the Association Between Alcohol-related Tweets and Emergency Care Visits. Academic emergency medicine. 23(7):831-4. 2016. PMID: 27062454

  • It may not actually help you, but I love this look at big data to predict busier times in emergency departments. The authors searched a sample of Twitter posts for terms considered to be “alcohol related” and compared those tweets to the number of visits at a single high volume urban emergency department that were deemed to be alcohol related. There was a statistical association with the number of alcohol related tweets and the number of alcohol related visits (but not non-alcohol related visits.) In case you were wondering, the alcohol related keywords were “alcohol, beer, wine, cocktail, booze, drunk, partying, clubbing, wasted, plastered, and tipsy”. Although this data is far from definitive, I think social media is an interesting potential source of medical information. Bottom line: If #plastered is trending, you might be in for a busy shift
  • Recommended by Justin Morgenstern

R&R WTF Weird, transcendent or funtabulous!” width=
Theobald JL wt al. The Beef Jerky Blues: Methemoglobinemia From Home Cured Meat. Pediatric emergency care. 2016. PMID: 27749634

  • Methemoglobinemia from inappropriately prepared homemade beef jerky! Cool!
  • Recommended by RPR
  • Read more: When cured meat kills (Emergency Medicine Literature of Note)

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.

Last update: Nov 24, 2016 @ 3:53 am

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Master the bronchoscope!

One of my favourite courses to teach on is the ‘Bronchoscopy for Critical Care‘ course. This is run by the Alfred ICU education team, led by my inspirational colleague Professor Dave Pilcher (@IntensiveDave). This course provides a fantastic ‘hands on’ learning experience covering all the key facets of bronchoscopy in critical care settings. The course is ideal for registrars with little hands on bronchoscopy experience, as well as consultants and other experienced  practitioners keen on a refresher.

There are still spots available at the next course in Melbourne on Friday 9 December 2016. Check out the programme and register here.

Hope to see you there!

Download (PDF?DL=1, Unknown)

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