Episode 7 Organophosphates

On this episode we discuss organophosphate poisoning including nerve agents and insectisides. Contributors include Matt Zuckerman, Steve Bird, and Adam Darnobid with a shoutout to Jason Hack.

Retrieval Simulation Cup 2012 Training video by Master Cliff Reid “Train hard,fight easy”

In a little over a weeks time, a gathering of retrieval practitioners will occur in Cairns, Queensland , Australia. They come from around the globe : New Zealand, USA, Malaysia, Australia. It will be the 24th Aeromedical Society of Australasia and Flight Nurses Australian conference

There will be the inception of a new Aeromedical Simulation Cup competition with 5 teams enrolled.

Master Cliff Reid of Greater Sydney Area HEMS, New South Wales Ambulance has been putting his entrusted team through a hard training regime of intense physical and simulation exercise. Watch their kungfu in this video. It is very strong.


THANKYOU TO THE COMPETITION SPONSORS

iSimulate( Competition prize sponsor of full ALSi kit and software one year subscription worth over $4800)

Watch carefully in the above video for use of the iSimulate ALSi product in training with GSA HEMS team. THE CHOICE OF CHAMPIONS IN TRAINING!

ALSi high fidelity medical simulator device pictured in background here ( encased in yellow portable monitor bag)

Drager Australia for loan of an Oxylog 3000 transport ventilator for the competition.

The competition action is going to be awesome. The GSA HEMS team in training epitomise the Three Rules of PHARM. Who will oppose them? Who can stand up to their resolve?

Train hard, fight easy.

Minh

 


Filed under: Aeromedical retrieval, Emergency medicine and critical care, Interviews of interesting people, Prehospital medicine Tagged: 2012, Cliff Reid, cup, GSA-HEMS, simulation

Fièvre jaune

C'est une infection virale due au virus amaril, appartenant comme la dengue aux Flavivirus. On a pu lui attribuer d'autres noms comme vomi noir (vomito negro) et peste américaine. Les premières descriptions ont été faites au XVIème siècle au Mexique. Elle est probablement beaucoup plus ancienne. Transmission C'est une arbovirose, elle est transmise par les [...]

Fair Payment?

This story is making the rounds on the internet recently.

A plastic surgeon is being sued by California State because she charges patients fees in excess of what insurance pays for her services. California’s lawsuit alleges that the doctor poses a “substantial, irreparable, and unjustified threat to the financial livelihood” of her patients.

In addition, the California Medical Board is attempting to revoke her medical license because she is allegedly engaging in “unprofessional conduct” by requiring patients visiting emergency rooms to sign agreements to pay her costs if their insurance companies didn’t.

I’m not going to try to justify the fees that the doctor charges. More than $12,000 to repair a fingertip is a lot of money.

However, with one caveat, I think that the actions taken by the state and the medical board are way out of line.

Suing a doctor and trying to revoke her license because she wants to get paid the asking price for her services? If people don’t want to pay her price, then don’t use her. Go see another “professional.”

You go to work at a new job where you agreed that you would be paid $50/hour. You work 40 hours, and expect to get a check for $2,000 at the end of the week. As you leave work Friday, your boss gives you a check for $200.
“Sorry,” he says, “if you don’t like it, you’ll have to go take it up with the company CEO. That’s all I’m paying you for your work.” The company CEO tells you “we pay other workers $5/hour, therefore we can pay you that much, also.”
You try to sue to get your money, but a court says it is against the law for you to demand to be fully reimbursed for your work because the corporation that reimburses your boss pays $5/hour, therefore it is legally entitled to pay you that same amount. Since you’ve already completed the work, you try to sue the company for your back wages. Then the state files a lawsuit against you because you filed a lawsuit against your employer.

Or imagine going into a lawyer’s office, agreeing to pay the lawyer his fee, receiving the services, then sending the lawyer a check for 10% of the total fee as payment in full. You’d be back in court so fast it would make your head swim.

That is the position this doctor is being put in. She performed the work at the patients’ request, the patients signed a form stating that they would pay her full price for her services, then, when she tried to collect the money from the patient after performing her services, the state stepped in and said that the doctor must agree to the amount a third party wanted to pay her.

The caveat in this whole mess is that the patients should know what they could end up paying the plastic surgeon before she renders her services. If that occurs, the patients get to decide whether or not the costs are worth the perceived benefits. If the patients agree to such costs, then they should be held responsible for paying the agreed-upon price.

The patients refused to have the emergency physician repair their wounds and demanded that they be treated by a “professional”. Now they’re accepting the “professional’s” services without planning on paying her the price that she asked?

Wonder why there are so many specialists who aren’t providing care to emergency department patients?

I also wonder whether specialists would be considered “unprofessional” if they required retainer fees before providing services. Would the state take action against them then? Lawyers do it all the time. No money, no representation.

Looks like a lot of patients are going to be stuck with us all of us sub-”professional” emergency docs for their emergency department treatment in California.

I wonder if this whole “we’ll pay you what WE think is fair” line of reasoning would work when the doctor went to pay her California state taxes …

It’s Grillin’ Time!

It’s summer and the BBQ’s are fired up! People are cooking up big, fat, juicy steaks. What does this mean?

Esophageal food bolus impactions!

Yes, last shift I saw not one, or two, but three people with porterhouse jammed in their gullets. The GI guy on call got lucky with one which I managed to get to pass with Glucagon but the other two required emergent trips to endoscopy.

Remember to chew your food thoroughly!

Trauma Course survey

Gday – slow week for Broome Docs – a few other big projects on the go, and a spot of fishing!

For a while there has been a few of us in the rural areas contemplating a new type of Trauma / Critical Care training course.

We have all done the APLS, EMST, ATLS……..  and know that the training is OK, but comes up short when we go back home and are faced with reality.  These courses are entry level, safe-practice based and valuable – however, they often ar not up to date with evidence, new trends in practice and tend to be a bit heavy on the theory / written word style of teaching.

So what do we want in a course?  There is now a survey out there to try and answer this: what do we – senior, front line docs want  in a weekend training course?

Amit Miani and Andy Buck  (both ED guys with interest in teaching) have created this survey https://www.surveymonkey.com/s/edexamtrauma  in order to hopefully create the ultimate educational experiencefor you – the doc on the ground.

So if you are an Aussie doc and want to help create a better type of training – please take 5 minutes to complete the survey.

Thanks

Casey

Call me ‘hospital ho,’ because I cheated on my workplace!

For 19 years since residency, I have worked in one facility and one facility only.  I have paced its halls and touched its walls, known every crack and heard every sound.  I have seen life and death, laughed and cried there.  And yet, I began to have a wandering eye…

Actually, I needed a little more immediate cash.  I began to flirt with…locums!

So, after some phone calls, some furtive, flirtatious e-mails, some letters and forms, I found myself at Hospital #2!  It was exciting and terrifying.  We had never met in person, I had only read about it online.

I packed a bag, and left my town behind.  When I saw Hospital # 2, I was intrigued.  Not what I expected, but not bad.  Certainly, available….if you know what I mean!

And after quick introductions, we spent the night together.

It wasn’t easy at first; the charting was odd, and the layout new.  The staff nice and professional, but not the ones I knew so well.  But it worked.

The next morning I left, rested and came back to do it all again!  I felt an odd kind of liberation, like a new man.  I had believed I could only practice in one place, that I would only be loved and accepted by one facility.

How wrong I was!  I am a  good doctor; and my skills go with me wherever I go; now matter how many times I cheat on my old, tried and true place of employment.

I’m home now; back to the routine.  But with a new found sense of adventure.  I feel free, I feel stronger…and I feel a little naughty (and a bit more financially stable) after my romp with Hospital #2.

Call me ‘hospital ho,’ but I’m going back again next month.

Because with one son going to college next year, and a few more kids behind, with reimbursements down and partners unwilling, and unable, to give up shifts, I’ll keep cheating….and getting paid for it.  As long as the money is good.

 

Aspirin – The Ultimate Anti-Inflammatory?

Picture
Aspirin is an anti-inflammatory which has many uses in medicine. A recent retrospective study looked at whether low-dose aspirin reduces mortality in patients with systemic inflammatory response syndrome (SIRS). All cause mortality was reduced from 17.2% to 10.9% There was an increase in renal injury from 2.9% to 6.2%, and in the group of patients with proven sepsis mortality was reduced from 42.2% to 27.4%. This study showed a strong association between aspirin and survival rates in the ICU in patients with SIRS and sepsis. The findings now need to be validated with a prospective randomized control trial.

References;
  1. Eisen D, Reid D et al. Acetyl salicylic acid usage and mortality in critically ill patients with the systemic inflammatory response syndrome and sepsis. Critical Care Medicine; 2012; 40(6); 1761-1767.

The LITFL Review 072

Welcome to the striking 72nd 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

Pediatric EM Morsels

  • Its not something your come across every shift but when you do its guaranteed to give you a catecholamine surge! That’s right the troubling  Post-Tonsillectomy Hemorrhage is one of the most challenging conditions you can come across. Sean has provided us with a short, sharp approach to managing this tricky presentation. Great post Sean , and well deserved for the top spot this week.

The LITFL Review Top Picks

Gmergency!

  • Graham provides with a link that gives us an amazing insights into what the ER faced when the Colorado shootings occurred, worth having a read off what the staff were confronted with in The Night the E.R. Staff Can Never Forget.

EM Literature of Note

  • Platelet Transfusion & Intracerebral Hemorrhage -It is not possible to say from the data whether the platelets do not show efficacy at treating the extension of the ICH, or whether the poor outcomes result from parallel transfusion-related complications.  The article concludes that withholding platelet transfusion should be considered to be within the standard of care.- Your thoughts on this?
  • Honey For Pediatric Cough -  We have to worry about drug companies interfering with efficacy of studies…..But hang on now we have to worry about the Honey Board of Israel as well!!! However with that said it does seem somewhat of a reasonable intervention for kids with coughs.

iTeachEM

  • Individual Interactive Instruction - ok laggards take this:  it is clear, we should all be embracing asynchronous learning and making it part of our training programs. Dont believe me read the post Chris makes some excellent points!
  • Crocs, Stingers and Taipans! - Great teaching game that encourages us all to develop the 'healthy paranoia' that is essential for emergency medicine excellence.
  • Flipping the Medical Classroom - lets not let medicine be last to adopt this method of teaching- its great that emergency medicine is leading the way here again!
  • RANT! Asthma: A Forgotten Therapy. Excellent take home pearl: Some patients predominantly have airway edema - these are patients with poor underlying asthma control and probably should be on long acting bronchodilators and high dose inhaled steroids - identify these people as those who are getting the meds for treatment of bronchospasm, but they are not improving.  You should give these people nebulized epinephrine.  Epinephrine works because it targets the airway edema.  It is a potent alpha agonist, it decreases respiratory mucosal hyperemia because it causes vasospasm, which decreases airway edema and can increase mucociliary clearance.
  • Steve provides us with low down on identifying and managing the patient with Hyponatremia in this weeks podcast.
  • What are the cause’s of radial nerve palsy - Ioana provides us with a list to consider and some treatment options- nice refresher!
  • SUDEP aka the The phenomenon of Sudden Unexplained Death in Epilepsy. Remember: The most important 'risk factors' seem to be poor seizure control and seizures occurring during sleep.
  • A Flying Kiwi! - KeeWeeDoc takes to the skies with his first prehospital retrieval case, manages the patient well and even gets to check out some amazing scenery, mountains, sheep what more could a kiwi want in paradise!

Dr Smith's ECG Blog

  • Graham poses the questions in this months article are we ready for  The Geriatric Tsunami thats washing through our emergency departments doors. Brilliant thought provoking writing by Graham on a very tough, confronting and challenging topic we are currently facing in emergency medicine.
  • Enoxaparin And Pregnancy  Bottom line: It is probably safe to give enoxaparin to pregnant women after trauma. However, it is unclear if the dose needs to be increased to achieve adequate prophylaxis.

Emergency Medicine Ireland

  •  If there isn’t enough awesome free medical resources out on the internet….Handy Andy has found another one the Emergency medicine handbook comes all the way from the republic of Cork!- Were’s that?

The LITFL Review Shout Out of the Week

The Emergency Medicine Resident Blog

Stumbled on another fairly new EM tumblr The Emergency Medicine Resident Blog By Bob Stuntzs a US emergency physician with a keen interest in resident education. You can follow Bob on Twitter @BobStuntz and check out some of his recent posts below:

Twee Dee and Twitical Care

Mike Tweet Jpeg

News from the Fastlane

  • Mike has put together the ultimate collection of FOAM EMCC Podcasts into a database for your easy access and listening pleasure. Check it out-Its gold!
  • Two great clinical post were published last week the fist on the ins and outs of Fingertip Injuries and the second is Getting A Leg Over highlight’s two great videos by George Douros on the application of a below knee plaster cast.

The Final Words

  • "Intellectuals solve problems, geniuses prevent them."

-Albert Einstein

  • "No problem can be solved from the same level of consciousness that created it."

-Albert Einstein

That's it for now...

Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you'd like to suggest something for inclusion in the next edition of The LITFL Review, email kane AT lifeinthefastlane.com

LITFL Review EM/CC Educational Social Media Round Up

123Sonography.com -- Academic Life in Emergency Medicine -- A Life at Risk -- All LA Conference -- Al Sacchetti’s Youtube -- Broome Docs -- CCM-L.org -- CLIC-EM -- Critical Care Perspectives in EM -- Dave on Airways --DrGDH -- Dr Smith's ECG Blog -- ECG Academy -- ED Exam -- EDTCC -- EKG Videos -- EM Basic -- EM Core Content -- EMCrit -- Emergency Medical Abstracts --EMERJENCYWEBB - Emergency Medicine Cases -- Emergency Medicine Education -- Emergency Medicine News -- Emergency Medicine Ireland -- Emergency Medicine Updates --Emergucate --EM Literature of Note -- empem.org  -- EMpills  -- Emergency Physicians Monthly -- EM Lyceum -- EMProcedures -- EMRAP --  EMRAP: Educators' Edition -- EMRAP.TV --  ER CAST -- Free Emergency Medicine Talks -- GMEP -- Gmergency! --  Greater Sydney Area HEMS -- HQmeded.com  -- ICU Rounds -- Impactednurse -- Intensive Care Network --iTeachEM - Keeping Up With Emergency Medicine -- KeeWeeDoc -- LipheLongLurnERdok  -- MDaware -- MD+ CALC  -- MedEDMasters  -- Medical Education Videos -- Medicina d'urgenza -- Medicine for the Outdoors -- Micrognome -- Movin' Meat -- Neurointensive Care -- Pediatric EM Morsels -- PEM ED -- PHARM -- Priceless Electrical Activity -- Procedurettes -- PulmCCM.org -- Resus.com.au -- Resus.ME -- RESUS Room -- Richard Winters' Physician Leadership -- SCANCRIT -- SCCM Blogs --  SCCM Podcast -- SEMEP -- SinaiEM -- SinaiEM Ultrasound --  SMART EM  --  SonoSpot -- StEmylns -- Takeokun --  The Central Line -- The Ember Project --The Emergency Medicine Resident Blog --  The NNT  -- The Poison Review -- The Sharp End -- The Short Coat --  The Trauma Professional's Blog -- The Underneaths of EM -- ToxTalk -- TJdogma -- Twin Cities Toxicology -- Ultrasound Podcast -- UMEM Educational Pearls  -- Ultrasound Village

The post The LITFL Review 072 appeared first on Life in the Fast Lane medical education blog.

Calloused knees, family and social media

I’ve been backing off of some of my social media posting.  I will still make comments, still put up links now and then. But I’ve had an epiphany of sorts. While I love a good argument, and while I find it vital to engage in the ‘marketplace of ideas,’ I quite frankly have more important things to do.

A few days ago I saw a gentleman in the ER who had knee pain.  He was in his 60s, and I looked at his painful knees; they were rough, and thickly calloused over his knee-caps.  They weren’t really swollen, but they were tender.

‘Are you a roofer?  Or do you install flooring?’ I asked.  I figured he had worn his knees down over years of hard work. I’ve seen it before.

‘No sir,’ he replied humbly, ‘I pray a lot.’

A smile crossed my face, and his.  And I told him that was wonderful.  I did, gently, suggest that God might also understand if he would pray from a chair, and he agreed with a laugh.

Sitting, typing away in discussions and arguments, posts and reposts, links and counter-links, I think I’m doing something important. And sometimes, it’s true.  Truth has to be defended.  And yet, as I type and argue, my patient was wearing his knees down in prayer.

God must love that man and his knees.  I doubt he’s nearly as impressed by my typing or clever turns of phrase.

And of course, there are other reasons for me to use my time more wisely.  They are my wife, and my rapidly maturing children.  Time is a fixed quantity.  What we give to one thing, we take from another.  How do I want to look back on my life?  As a man with lots of time logged online?  Or as a man who relished and cherished every second of his life with his family?  Is it better to share, to link, to friend, or to hug, to laugh, to run, to hide, to play and to talk with the flesh and blood children and beautiful wife before me?

I love social media.  I enjoy all of my contacts and friends!  And I’m grateful for their ideas, and that they read my own.  But let’s all have a little perspective.  Let’s all spend a little more time in prayer, in studying scripture.  And in loving, fiercely and passionately, the human beings right before us.

Maybe, when the kids are grown, there will be more time for social media.  Of course, by then, we should perhaps be praying even more!

Edwin

 

Doc – My Leg Hurts…..


A 28 year old male presents to the ED with severe pain to his leg after falling off his pushbike during a race.
His X-rays show no fractures, and he is admitted under the trauma service for analgesia and a tertiary survey.

The next morning his thigh is grossly swollen (see below), and he is unable to weight bear.


An MRI shows a encapsulated collection between the skin and the undelying fascia. 
What is this called, and how do you treat it?
This is a Morel Lavalle Lesion.
This is a degloving injury involving separation of the skin and subcutaneous tissue from the deep fascia following an acute traumatic injury.
It is commonly seen in the lower back, buttocks, greater trochanter, lateral thigh and pre-patellar space.


Management in the initial stages is with compression bandages. Once these lesions are well established or encapsulated, conservative management is rarely sucessful and surgical intervention is required. The traditional approach has been with open surgical debridement, but recently there has been some sucess with percutaneous drainage.

References;
  1. Tseng S, Tornettalll P. Percutaneous Management of Morel Lavallee Lesions. J Bone Joint Surg Am. 2006; 88(1); 92-96.

Between a rock and a heart place.

It was a particularly thick document.
As I stood and leaned over the stapler to get all my body weight over the palm of my hand, I realised I had assumed a sort of  CPR stance. Shoulders over hands. Elbows locked.  Bending from the hips.
One hard compression, CLACK-AK, and I checked to see if the stapler had penetrated the breadth of the papers.

Almost, but not quite there. Perhaps a pre-cordial thump was required.

But my extreme stapling pose must have released some muscle memories.
I miss that stance.

I have been taking a sabbatical from nursing for the last few months. Blowing out some rather recalcitrant cobwebs and refilling the sloshings of a tank at low mark.

I have been working on an eHealth project, a clinical portal.
The clinical portal is an application that integrates a whole bunch of discrete electronic patient management systems together in a sort of one-stop-shop for the clinician.

It is interesting work, a great bunch of people, more money than I was earning before and promise of more work and another pay rise at the end of the 6 months if I want it.

And soon I will have to think about letting them know if I intend to stay on. At least a while longer.
My head is telling me to stay. Less stress, more money, regular hours. I get to wear nice clothes to work. I smell nice.

Kelly is also urging me to stay, threatening to beat me repeatedly over the head with the Huon Pine rolling pin that we found on holidays in Tasmania many years ago, if I go back to the madness.
It sits in the top draw under the stove. Easy reach.

But my heart is in the emergency department.
Amongst all the stress and speed and crush. Amongst the daily bullshit battle to deliver quality care. Amongst the crazy as a wheel.
Amongst all that.....there is an inextinguishable incandescence of nurses and doctors and wardsmen and clerical staff who all are bound by that space.

Their work is phosphorous. And I miss them.

YEP – Traumamanagement

Die Behandlung von Trauma Patienten im Schockraum ist in Deutschland die Domäne der Kollegen der Unfallchirurgie und Anästhesie.In interdisziplinären Notaufnahmen oder in kleineren Häusern sehen sich gelegentlich auch Internisten dieser Aufgabe gegenüber. Entsprechend sollten NA-Ärzte idealerweise mit dem Thema "Trauma-Versorgung" vertraut sein (z.B. durch einen ATLS-Kurs).

In ihrem unterhaltsam gestalteten Artikel ,,Thoughts on the Resuscitation oft he Critically Ill Trauma Patient" fassen C.M.Meyers und S.Weingart die wichtigsten Prinzipien der Behandlung von stark blutenden Trauma-Patienten zusammen.

Dabei steht die ,,Tödliche Trias" aus Azidose, Hypothermie und Koagulopathie und deren Wechselwirkung im Mittelpunkt der Betrachtung. Diesen komplexen Pathomechanismus gilt es zu unterbrechen, was häufig schwierig genug ist, da inadäquate Maßnahmen die Todesspirale eher noch beschleunigen als unterbinden.

So führt beispielsweise die Transfusion von Kristalloiden und EKs zu einer weiteren Verdünnung des Blutvolumens und fördert dadurch die Koagulopathie. Wenn gleichzeitig die Infusionen/Transfusionen zu kalt sind, wird die Hypothermie verstärkt, was  ebenfalls die Gerinnungsstörung vorantreibt und ein Kontrollieren der Blutung erschwert.

Entsprechend wichtig ist die Substitution von Plasma bzw. Gerinnungsfaktoren und ein Erwärmen der infundierten Flüssigkeiten (Faustregel: 1 FFP pro 2EKs). Als Zielwert der Infusionstherapie wird ein MAP von ca. 65 mmHg angegeben (Ausnahme: SHT-Patienten), gewissermaßen als Kompromiss zwischen angemessener Gewebsperfusion und Hämostase (da ein unangemessen hoher Blutdruck ebenfalls das Verbluten des Patienten beschleunigen kann).

Auch die grundsätzliche Unzuverlässigkeit der rein Blutdruck orientierten Schock-Therapie wird in diesem Artikel verdeutlicht, da der RR-Wert eigentlich keinen verlässlichen Rückschluss auf die tatsächliche Durchblutung der Organe zuläßt (was auch an anderer Stelle in unserem bereits Blog thematisiert wurde).

Ein weiterer grundlegender Faktor der erfolgreichen Traumatherapie ist logischerweise ein Limitieren der Blutung, idealerweise schon vor der eigentlichen operativen Intervention, durch Anbringen einer Blutdruckmanschette (bei Extremitätenblutungen), einer Beckenschraube (bei pelvinen Frakturen) oder einer Blut stillenden Naht bei Kopfschwartenverletzungen.

Ziel der Schockraum-Behandlung muss also letztendlich das Kontrollieren der ,,Lethal Triad" und idealerweise der akuten Blutung sein, um so eine Stabilisierung des Patienten herbeizuführen.
Eine definitive Versorgung der verletzten Organe kann dann schließlich im OP erfolgen.
Insgesamt ein gelungener Artikel zum Thema Trauma-Management, was bei diesem Autorengespann auch nicht anders zu erwarten war. Für alte Hasen kann er eine willkommene Auffrischung wichtiger Prinzipien, für Anfänger ein wertvoller Einblick in der Grundlagen der Schockraum-Arbeit darstellen.

Welche Erfahrungen habt Ihr zu diesem Thema gemacht?
Welchen Prinzipien/Konzepten folgt ihr bei der ,,Trauma Resus"?

Educational Tech Commandments

To understand the technological implications for medical education – who better to learn from than the real educators, the teachers on the frontline…

Many of the problems we are facing in hospitals and Universities with the use of social media #FOAM and online collaborative resources – are already being tackled in schools with the students. I was able to relate to every issue raised during this rapid-fire presentation and equate it to our current technological translation issue.

Adam Bellow [Twitter - Website] presents his Tech Commandment’s rapid-fire 140 slide presentation at the #140edu in New York. Well worth a watch. Hopefully it will start a new collaboration between medical educators and school based educators.

“We can’t use facebook and Twitter in schools because they are dangerous…it is ironic that some of the greatest sources of education and learning such as YouTube and Twitter are blocked in over 90% of schools hospitals

“Collaboration” is THE 21st Century Skill. Collaboration is the way we have to learn to work together and our students will learn to work together and our students will learn to work together in the future. That is the most important thing we can teach them.”

Adam Bellow

http://www.youtube.com/watch?v=7vevGmzmWnI

The post Educational Tech Commandments appeared first on iTeachEM.

It is not a DumDum

Today was great day in the ER (sarcasm).  I was working triage and we had over 90 patients sign in over a 9 hour period.  Working triage means that I try to get labs and x-rays going on the more complex cases and discharge the easy cases.  All the easiest cases fell into 2 categories: sick for 2 hours or sick for at least 2 months — except for one case.  I called a 42-year-old gentleman back from the waiting room.  He took a seat on my triage bed.  As usual, I asked “what brings you in to see us today?”  ”I don’t feel good.”  I then questioned with “Oh, for how long and tell me the story.”  He goes on to tell me how he has had cold like symptoms for 3 weeks now and it is not getting any better.  He has not tried anything or sought medical care before now.  The reason he was coming in to the ER today was that he finally  got the day off and did not have anything else to do (this is the normal reason people come in at this ER).  So I start my exam.  I listen to his heart and lungs.  Then I look in his ears with an otoscope.  Everything is looking normal – surprise, surprise.  I then ask the patient to open his mouth so I can use the otoscope to look at his throat.  I position the otoscope, like normal, about 8 inches away from his mouth when I asked him to open up.  He proceeds to open his mouth and lean forward placing the entire head of the otoscope INSIDE his mouth and close his lips around it.  It looked like he had an extra-large dumdum sucker in his mouth.  After I pulled the otoscope out of his mouth, I just sat there looking at the otoscope wondering what I was going to do it.  At the same time, I was trying to think how many people’s ears it had been in and how many more people it will come in contact with.  I had never seen an otoscope used like a lollipop.  I included pictures below to see if you  can see any similarities that would make you want to stick an otoscope in your mouth.

 

 


Take the EDExam/ED Trauma Critical Care Trauma Education Needs survey & win!

Amit Maini (from ED Trauma & Critical Care) and I are working on an exciting new trauma education project.  To help with our research we're doing a survey to assess the trauma learning needs of medical professionals from all specialties.  If you complete the survey you can go into the draw to win a $50 iTunes, JBHiFi or Myer gift card (Australian residents only eligible for prize, but responses from all over the world will still be greatly appreciated!).

So if you've got a spare 5 minutes we'd really appreciate it if you could take the time to give us your feedback in this easy to complete survey.  Thanks!

Click here to take the survey. Thanks!

Course in Baltimore, Maryland

On November 12th, 2012 the 1st International Emergency Medicine Faculty Development and Teaching Course will begin in Baltimore, Maryland, USA. This course is dedicated to helping physicians from outside the US learn valuable skills in faculty development and medical education. Course content is being prepared now, and it is going to be spectacular. Did I say spectacular? Because I meant superb, superior, excellent…you get the point. The faculty at The University of Maryland Department of Emergency Medicine is delighted to be able to bring this exciting course in medical education to fruition and to “share with the world.” The course is going to be a cutting-edge educational extravaganza.

http://www.youtube.com/watch?v=VOgwh-cThIw

Course faculty includes:

Rob RogersAmal MattuTerry Mulligan, Mike Winters, Lee Wallis, Mike Bond, and much, much more

 

Venue for the 1st annual International Emergency Medicine Faculty Development and Teaching Course

The course is a week-long journey through medical education, teaching skills, and faculty development skills. Participants who come to the course will get lots of perks for attending the course, including establishing a relationship with Emergency Medicine faculty for ongoing mentoring. Course attendees are really in for an exciting, lively, and interactive week.

Here is a glimpse of what attendees will receive and be exposed to during the course:

The course starts on Sunday November 11th with a meet and greet dinner cocktail reception

Small group sessions and short lectures geared towards making you a more effective teacher and more productive faculty member

Exciting, dynamic, award-winning speakers and great topics

Interactive sessions not reliant on Power Point

Sessions on the use of social media in medical education and using technology to teach

Project mentoring-you bring the project, we bring the mentoring

Daily networking lunches where you will meet key players in The University of Maryland System

Course content on a USB drive

Handouts and pertinent articles

1st 10 registrants receive a free Doceri license

Free daily give-a-way prizes

Tours of the University of Maryland Hospital and Shock Trauma

One-on-one mentoring from Emergency Medicine faculty

Graduation dinner

Course certificate for participation in the live course

Mentoring from faculty even after the course is over and you have gone home

The course is aimed at international emergency physicians but is open to physicians from ANY country. Check out the course website to find out more information and to register for the course.

So, what are you waiting for? Seriously…go to the course website and check out the superb course we are putting on in Maryland.

The post Course in Baltimore, Maryland appeared first on iTeachEM.

PHARM Podcast 35 : Dr William Hinckley and the Air Medical Physician Association

Hi folks. I am pleased to do another interview with my mate in Cincinnati, Dr Bill Hinckley.

On this episode we talk about AMPA, Air Medical Physician Association. You should all join if you fly or do critical care transport work. I signed up straight after the interview.

We talk about some cool HEMS transport of STEMI patients to PCI research him and his mates have been doing. Here are the abstract links :

Acad Emerg Med. 2012 Feb;19(2):153-60. doi: 10.1111/j.1553-2712.2011.01273.x.

Ground emergency medical services requests for helicopter transfer of ST-segment elevation myocardial infarction patients decrease medical contact to balloon times in rural and suburban settings.

We finish up talking on prehospital USS and an airway trauma case.

Enjoy

Minh

Now on to the Podcast

Download: Bill_HInckley_AMPA.mp3


Right Click and Choose Save-as to Download the Podcast.


Filed under: Aeromedical retrieval, Emergency medicine and critical care, Interviews of interesting people, prehospital and retrieval medicine podcast Tagged: AMPA, hinckley, itunes, prehospital

Revisiting #ICEM2012 with @corbetron on Storify

I meant to link to this Storify piece by David Corbet on the remote delegate experience of NOT attending a major medical conference using the social media tools of Twitter and Storify to share and reverberate his experiences.

This is FOAM again – our reach is long, and our message is simple, useful and free.

http://storify.com/corbetron/distance-learning?utm_content=storify-pingback&utm_source=direct-sfy.co&awesm=sfy.co_n0HA&utm_medium=sfy.co-twitter&utm_campaign=


The FOAM project – more than the sum of it’s parts!

Mike Cadogan (@sandnsurf on Twitter, http://lifeinthefastlane.com , https://gmep.imeducate.com) is taking mighty leaps for mankind in creating a grand unifying resource for medical education (and particularly Emergency Medicine and Critical Care) by running with the FOAM concept germinated at ICEM 2012 over a pint or two of Guinness. He has coalesced the world of EM/CC blogging here: http://lifeinthefastlane.com/2012/08/foam-emcc-bloggers/

For those who say, “FOAM, what’s that?” I will explain – we believe FOAM is the future of medical education and asynchronous learning, and stands for Free Open Access Meducation

Mike’s groovy little FOAM logo


Not all ST elevation is STEMI

Reblogged from the underneaths of EM:

Click to visit the original post

This 53 year old man is an ex-smoker, with HTN well controlled by a single agent. He presented to the ED under duress from his wife and GP with intermittent atypical pain which is sometimes worse with exertion, has a slight pleuritic variation, and radiates to shoulders. He mentions a more severe pain 2 days ago lasting a couple of hours with onset at rest.

Read more… 27 more words

There is ST elevation in I, II and aVF (i.e. missing out III) and V5 and V6 (and a hint in V4). There is apparent ST depression in aVR, but as some of you point out, this actually represents PR elevation. Of note, III is NOT elevated, which makes an inferolateral STEMI pretty unlikely. One might also expect some ST segment depression in aVL, and clearly there is none. As mentioned in one comment, there is likely to be left atrial abnormality with an asymmetrically bifid P-wave most marked in II. The first TnT was 16....now what? Do you activate the cath lab? Is it clearly pericarditis, or could it be STEMI? Give me a plan...

Introducing the EM Basic App for Apple and Android

Hey everybody,

Today has one more big announcement for the EM Basic podcast.  Today is the launch of the EM Basic App for Apple and Android phones.  This app will allow you to stream all episodes of EM Basic and has the added benefit of having the show notes or the articles for the Essential Evidence episodes all in one place.

The cost?  Only 4.99 for a great resource to have handy on shifts.  Don’t worry- the podcast will still be available for free on iTunes and on this website but hopefully you will find this app useful to your everyday practice.  If anything, just know that it will help support the podcast as we start bringing you weekly content.  As always, email me at steve@embasic.org with any comments or suggestions about the app.

To access the PDFs for each episode, click the letter “e” in the bottom right hand corner of the episode page.

If you want to listen to a podcast on all of the details about accessing the app here it is:

EM Basic Apple and Adroid App Announcement Podcast

For Apple users:

Warning- there is no “EM Basic” app in the Apple App store- follow these directions to find the app.

1. Go to the app store and search for “podcast box.”  This is a free app that you download onto your device.

2. Once you have installed podcast box, open it up and either search for “EM Basic” on the front page or go to the “categories” button on the bottom, go to Science and Medicine, and click on EM Basic.

3. The app will ask you to confirm the purchase and you will be asked for your Apple ID password.  You will be charged as an “in App purchase” and you will get immediate access to everything in the app.

Here is the iTunes link for podcast box:

Podcast Box iTunes link

For Android users:

Warning- I have not yet seen the app function on an actual Android phone.  If there are problems, email me ASAP at steve@embasic.org and I will fix it as soon as I can

Here is a link to the app on Amazon.com:

EM Basic Android App

If you need directions on installing apps from Amazon on your Android- go to this link which has a short video and written directions on how to do it:

Amazon App Download Instructions


The Stick of the Issue (Marin IJ)



A Kiwi grade-schooler amazed his classmates with a remarkable feat of attraction. He suspended a spoon from his navel, held, as if floating, by an invisible attachment. An American preteen was the envy of her BFFs because she had a tongue bolt - achieved without the pain of piercing. How did they do it? Gorilla strength glue? Superhuman powers? Neither, actually, but rather a stalwart force present all around us but not usually within us. [START CUT] Fans of AMC's Breaking Bad will recognize this force as the same one that Walter White used to destroy the evidence police had linking him to methamphetamine production. More mundanely, most of us will recognize it as the molecular reaction that secures photos and to-do lists to our refrigerators. [END CUT] Magnetism. And although magnets are part of our daily lives, they are not always harmless - in fact can exert very powerful and destructive forces on the human body. You may not have heard about it yet, but around the globe there's a mini magnet problem. Here in the U.S., you might even call it an epidemic, with reports of magnet ingestions in children ages 0 to 17 having increased by approximately tenfold over the last ten years and resulted in hundreds of injuries and at least one known death.  
How can swallowing a magnet be worse than swallowing a marble or a bead? The stick of the issue has to do the remarkable force with which some magnets are attracted to one another - a force that can cause a lot of damage to gastrointestinal tissue when magnets travel through the gut to reunite with one another. Recently, a clinical report in the Lancet described two children (one aged 18 months and the other 8 years) with toy magnet ingestions. Both kids required surgeries  - one for significant intestinal injuries caused by the magnets' compressive "pull" forces  - which can be up to 1300 Gauss (by comparison, a typical refrigerator magnet exerts only 50 Gauss) - against the bowel wall.
A few months ago, the case of a ten-year old girl who ingested two toy magnets she had used to make her own "tongue piercing" received national news attention. While she avoided the pain of a real tongue piercing, she ended up short her appendix in the process. In Portland this past March, a three-year-old nearly died after swallowing 37 magnets. Inside her abdomen, the balls snapped together to form a ring - and tore at least four holes in her gastrointestinal tract.  
In these instances, the common and concerning characteristic was the ingestion of multiple neodymium ("rare earth") magnets. These neodymium magnets are a relatively new product - they were invented by General Motors in 1982 - and are five to ten times more powerful than traditional magnets. Still, solitary magnets, even of the neodymium variety, tend to pass through the gut without major incident. But multiple magnets, or magnets paired with other metal objects in the gut, pose a unique problem as, like young lovers, they have an insatiable desire to find and press up against each other. Some describe such magnets as "kissing magnets." And, like love-struck fools, kissing magnets will do anything to stay together, even, for example, pushing right through the linings of internal organs. If you can picture your anatomy; imagine two different loops of bowel with a magnet in each - straining to reach each other. As the magnets are drawn together they bring the loops of bowel tightly together and create connections or holes between them (known as fistulas or perforations). So, if you have kids, magnets are no toy.
For some time, pediatricians and consumer product safety groups have been warning about the dangers of kissing magnets. In fact, in 2008 the Consumer Product Safety Commission (CPSC) issued new standards for children's products and toys containing magnets. The standards require that the magnets be secured so that they will not fall out of the toy or become unattached.
Despite this, we're hearing about more and more kids swallowing magnets - especially neodymium magnets used as "stress relief" desk toys for adults. You may have seen these "Buckyballs" at your local Brookstone or thought of getting a set for your spouse. The magnets are generally sold in groups of 100 to 1000 and are replete with enticing shapes and colors. Although the products are labeled and designed for adults and contain prominent safety warnings, they can easily find their way into the hands and mouths of children. And while youngsters with developmental delay are known to be at higher risk for ingesting objects, many kissing magnet reports - such as a couple of those mentioned above - have occurred in developmentally normal children. As such, the CPSC has just recently filed suit to prevent the sale of Buckyball magnets by retailers.
But, whether such products stay on the market in the long-term or not, parents, caregivers and teachers should be aware of the risks. Thus, here are some helpful tips. First, be aware of the potential complications of magnets - just because they are small doesn't mean they aren't capable of exerting a lot of Gauss. Second, for those who might enjoy Buckyballs or related products - keep them at work rather than at home. Third, if you suspect that a child has ingested magnets, get him or her evaluated early - magnets show up quite clearly on x-ray but a child's symptoms won't show up until later - when the damage is already done. Medical providers and parents should be sure to report all cases of magnet ingestion. You can visit SaferProducts.gov to report (anonymously if you prefer) injuries related to magnets or other products. Accurate accounting of cases can help with efforts to educate the public and maintain safety in consumer products.

If you still feel a strong need to impress and amaze your friends... forget the spoons, tongue bolts, and Buckyball shapes. I suggest a different type of magnetism - one of personality - not potential perforation. 

RCP 2010: primeros cuestionamientos

"Más de 100 por minuto". Probablemente sea un buen ejemplo del dicho  "lo mejor es enemigo de lo bueno". Hace algunos días estábamos regresando de un PCR y la paramédico me consultó por qué yo insistía en que sus compresiones no deberían ser tan rápido (bordeando los 150 por minuto según el monitor). Me argumentaba [...]

Intensive Blood Pressure Control in ICH

Not much works to treat ICH - and this retrospective analysis of INTERACT1 tries to coordinate a couple leaps to pull a different spin out of old data.  Unfortunately, it's still a re-analysis of essentially a negative trial, and that limits its utility for the purists.

INTERACT1 randomized patients with ICH to either "intensive" blood pressure lowering or conventional treatment - most of whom received some BP control - and noted significant improvements in hematoma volume.  However, the 90-day safety/clinical outcomes data did not show any difference in mortality or dependency.  This publication reverses the strategy, taking a look at the associations between good clinical outcomes and hematoma volume - and finds that increases in hematoma volume at 24 hours clearly predict poor clinical outcomes.

So, if intensive BP control reduces hematoma expansion and reduced hematoma expansion improves clinical outcomes, then why was INTERACT1 negative?  I suspect we'll find out more when INTERACT2 is published....

"Hematoma growth and outcomes in intracerebral hemorrhage: The INTERACT1 study"

FOAM EMCC Bloggers

What better way to spend a weekend than analysing the world of #FOAM in emergency medicine and critical care?

Key pages updated include:

Yes, it is that time of the year again when we update our database pertaining to the world of EMCC (emergency medicine and critical care)

We started the collaboration project back in 2008 when we first reviewed the medical blogging ecosystem – and oh how that landscape has changed. For once where there was an arid land with dry scrub, now doth a veritable forrest grow.

Tor Ercleve 2012

Initially it was easy to find the few medical blogs in active existence and review their content, author and structure. When LITFL was but a seedling, the medical blogosphere was populated with 76 blogs spanning all specialties. These were mainly single author (73) personal blogs (68) with the exception of a few notable education based blogs (such as @DrVes - Clinical Cases blog). Indeed, there were only 9 blogs which ran predominantly educational content and most (56) blogs were written anonymously. In fact there was little way of actually determining either the credentials of the original author or the country of origin of the blog (until the advent of twitter that is…). LITFL followed most of these trends starting out as a personal medblog – sandnsurf.medbrains.net with no way of determining the authors real name or location

The 2012 review has seen significant changes in the medical blogging ecosystem and as a result only includes the rapidly growing field of emergency medicne and critical care blogs and podcasts. Our review covers 130 blogs in 17 different countries.

Such is the rate of growth that our manual data entry of the podcasts has become overburdened to the point of exhaustion and we now have to have submission forms for new EMCC blogs and individual EMCC podcast episodes. We have revamped the searchable podcast database and users are now able to search by blog name, geographic location, language and topic keywords to find the most appropriate podcast for them. We have made a good start on the database with >1800 podcasts now listed!

Whilst reviewing the EMCC blogs and podcasts we have made some significant changes to the way we display the blogroll.

  • Addition of Blog based Pages on Twitter, Facebook, Google Plus, Vimeo, YouTube and iTunes
  • Addition of RSS feeds and iTunes subscription feeds
  • Removal of blogs with no discernable signs of life for >6months
  • Updating the podcast database and adding new submission forms for the latest podcasts

Results:

Interesting findings form the survey include

  • EMCC blogs and podcasts have grown from 67 to 130 over the past 18 months
  • Increasing participation and information dissemination through social media
    • 77%Twitter (100/130)
    • 42%Facebook (55/130)
    • 20%Google + (26/130)
    • 15% – Media account such as YouTube or Vimeo (20/130)
  • …but interestingly 9% (12/130) failed to provide a valid RSS Feed for blog content
  • A legal disclaimer now exists on 86% of sites
  • An increasing number of blogs (21%) now have multiple authors
  • Audiovisual learning is on the rise with 20% of EMCC bloggers employing external multimedia and iTunes
  • There is better identification of authors with 94% of blogs and podcasts citing the full name, credentials, contact form and geographical location of blog authors
  • Blogging is an increasingly global collaborationwith over 17 countries represented:
    • USA (75), Australia (22), Canada (5), UK (4), New Zealand (4)
    • France (1), Chile (1), Germany (1), Croatia (1), Italy (3), Spain (3), Ireland (1), Israel (1), Malaysia (1), Latin America (1), Sweeden (1), Singapore (1), Scandanavia (1)

I am not sure exactly why there are so many EMCC blogs in existence, or why they are appearing with such rapidity. Maybe it is because a lot of our work is frontline, public, diverse and altruistic that there are so many stories and so many educational resources being shared freely and without reservation using the language of #FOAM.

If you think we have missed an awesome new EMCC  emergency medicine and critical care blog…let us know…

One page source feed

To stop the potential for information overload the next stage is to re-instate the live ’mixed feed‘ from all the blogs. This was initially created using Yahoo pipes and worked well for the first year or so, but was surpassed by the emergence of Medworm and the Feedly embedable unifying feed.  Unfortunately Feedly has stopped allowing the iframe embed and Medworm has stopped being updated (and is now not accepting submissions from new blogs).

We are still trying to find a solution to getting back a page which has a single feed for all the EMCC blogs. Any bright ideas gratefully accepted! Our current options include:

  1. Write some code to embed Feedly
  2. Re-create Yahoo pipes feed as a single feed (with a feed with icon, date, blog name and excerpt) and allow any blog to host the ‘unified feed
  3. Testing some simple embed options – but this is very slow indeed, and will get even slower with a list of 130 blogs!

vive la FOAM

FOAM Free Open Access Meducation

 

The post FOAM EMCC Bloggers appeared first on Life in the Fast Lane medical education blog.