Hi folks

After my article on recognising sick children, I got some tweets and ended up recording this podcast with Dr Natalie May, a British emergency medicine doctor in Manchester who has done specialised training in paediatric emergency medicine. We talk through her approach, discuss three cases and finish up on the topic of intraosseous access.

Check it out!

Minh

Now on to the Podcast

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

Filed under: Emergency medicine and critical care, Interviews of interesting people, prehospital and retrieval medicine podcast Tagged: critical-care, itunes, life-threatening, natalie-may, paediatric, recognition

Sharks beginning to smell blood in the water. Pradaxa lawsuits piling up and likely will result in giant class action suit. One law firm has 70 employees dedicated to Pradaxa litigation alone and the attorney can't even remember the name of the client the reporter called to ask him about.

Looks like the yolk's on you. Widely quoted study on how egg yolks are as dangerous as smoking cigarettes was based on a self-reported lifetime history of smoking and egg-eating. The study didn't take any other variables into account. A doctor who reviewed the data stated ""This is very poor quality research that should not influence patient's dietary choices."

I love reading stories like this. Patient comes back to thank ED staff that saved her life. Brings flowers for nurses and a sheet cake for the staff.

New Jersey hospital in dispute with Aetna over bills for patient services. When Aetna doesn't pay in full, the hospital sends bills for the difference to the patients. Aetna then turns around and tells patient not to pay the bills. And the bills are expensive.

Girlvet has a good explanation of why the medical home concept won’t work … no skin in the game.

Fear the bad outcome. Death of a beautiful philanthropist sparks lawsuit against psychiatrist for prescribing Seroquel, a medication that plaintiff's attorney John Harwell claimed caused her "sudden cardiac death" which was “the very kind of consequence warned against by the FDA in its required Black Box Seroquel warnings, the ones Dr. Bystritsky either ignored or of which he was ignorant.”
However the product insert for Seroquel has no "black box" warning for cardiac arrhythmias or sudden cardiac death, only a mention of increased mortality in elderly patients and noting that “the extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear.” In addition, Seroquel "was not associated with persistent" changes conduction of electrical impulses within the heart (QT interval prolongation).
Now what was that about being “ignorant,” counsel?

New medical breakthrough in Missouri. According to what doctors have told Missouri Representative Todd Akin, pregnancy from rape is "really rare." In "legitimate rapes," the body "has ways to try to shut that whole thing down." Because “pretend” rapes fool the body into leaving that whole thing running.
Waiting for follow-up confirmatory article on the topic from Jim Dwyer.
Akin later claimed he "misspoke" after getting blasted on social media, but never stated what he really meant to say.

Which party is really going to kill off Medicare? Democrats or Republicans?

I saw the headline "Officials allege $600M Ponzi scheme ..." and thought that the feds were finally going to expose everything that was wrong with Medicare. Then I realized the article was talking about some web site and the scam only involved millions of dollars, not billions of dollars.

This is a great case sent in my a reader who wishes to remain anonymous. We hope you find it as intriguing as we did!

After clearing up from a routine interfacility transfer, you're dispatched for a 77 year old female who is unresponsive at a local extended care facility. A BLS engine crew is enroute as well and has a few minute lead on your unit.

As you're arriving the engine crew hails you on a tac channel and relays that the patient is unresponsive, but breathing and they have put her on a NRB and are checking her blood glucose level.

You're directed to the room where the engine crew is completing their assessment of the patient. The facility staff states the patient was alert and oriented at 0600 when they did their rounds. However, when they came back at 0900 to give the patient breakfast and her morning medications they found her unresponsive.

Apparently, EMS is called frequently for this patient becoming unresponsive, although she does not know why. She hands you the patient's paperwork as the captain from the engine gives you the patient's vitals:

• GCS: 8 (E2 M2 V4)
• Pulse: 60, weak at the radials
• BP: 118/56
• RR: 16, clear bilateral lung sounds
• SpO2: 82% on room air, 94% on a non-rebreather
• BGL: 102 mg/dL (5.6 mmol/L)

As your partner helps the engine crew move the patient to your stretcher you read over her paperwork:

• PMHx: hypertension, osteoarthritis, renal cysts, urosepsis, advanced parkinson's disease, history of UTIs, dementia, history of plueral effusion, COPD
• Meds: hydrocodone, sorbitol, ferrous sulfate, dulcolak, prednisone, albuterol, ativan, heparin, aspirin, colace, sinemet, synthroid, tylenol, furosemide, potassium chloride, aricept, multi-vitamin, claritin, lactulose
• Allergies: cipro, septra, florinef, bactrim, levaquin, zoloft, gentamicin

A quick physical exam reveals moaning to painful stimuli, pinpoint pupils, whole body tremors, a foley catheter with adequate output amber in color. The remainder of the exam is unremarkable.

In the back of the unit you place the patient on nasal capnography while your partner places the patient on the monitor:

At this point your partner grabs the 12-Lead cable and begins placing electrodes while you acquire an IV.

You're 10 minutes from a local hospital, and 15 minutes from a cardiac center.

• What is our patient's rhythm?
• What does the patient's 12-Lead show?
• What are your treatment priorities?

Leave your answers below!

Looking for the conclusion? 77 year old female: Unresponsive – Discussion.

Introducing EM Basic Essential Evidence- your boot camp guide to emergency medicine literature. Each episode will review an important emergency medicine article from the ground up. We’ll review the study’s design, basic statistics, results, and wrap it up with some analysis to help you understand the study and how to put it into your everyday practice. The goal here is to provide a guide through the emergency medicine literature so you can read and understand the “must know” studies out there.

This is also the re-launch of EM Basic to a weekly podcast format.  Every monday morning, a new episode will be uploaded to start the week. Each week will alternate between a regular review episode and an essential evidence episode. For the essential evidence episodes, I will try to split up the episodes each month- one episode on a landmark article and one episode on a newer article that is making the rounds. I have a list of articles that I will be talking about but if there are any studies out there that you think I should cover, email me at steve@embasic.org.

For this first episode, we’ll talk about the famous Rivers sepsis study that started the push to early goal directed therapy for sepsis in the ED. Although I talked about this study a lot on the sepsis podcast a while back, we’ll talk more in depth about the study so you can really understand it.

Rivers NEJM Sepsis Study- website link (free full text)

Rivers NEJM Sepsis Study- PDF (direct download)

EM Basic Essential Evidence podcast- Rivers Sepsis NEJM

If you want to know how to teach students in the emergency department, and you need to know fast, you’re in luck.

Back in July 2009 EMRAP: Educator's Edition featured Amal Mattu (@amalmattu) talking about his top tips, pearls and pitfalls on Teaching in the ED.

Here are the top 10 take home messages that I got from listening to the master:

1. Teach less so that others learn more
   -- don't try to teach more than 4 things in a session.
2. Teach the right thing at the right time
   -- i.e. don't show someone how to draw the coagulation cascade at 4 in the morning!
3. Listen with your eyes and your ears, and make sure others do too!
4. Teach others how to learn so they can become responsible for their own learning
5. Set time-limited learning objectives
6. Use the 'What if?' technique of learning
   -- this helps to develop associations, keep things fun and guard against availability bias (only things that are easy to remember tend to spring to mind); e.g. "What if the patient with X is also on warfarin?"
7. Use the 'Hear hoof beats? Think of lions, tigers and bears!' technique
   -- what are the deadliest differential diagnoses for a presentation? In my part of the world I like to think of ‘Crocs, Stingers and Taipans!‘.
8. Don't be afraid of silence
   -- let the student come up with an answer.
9. Be specific about what the student did well and provide constructive feedback. Suggest how the student can address their learning needs.
10. Ask the student, "what did you do well, and what can you improve on?"

The post Ten Mattuisms on ED Teaching appeared first on iTeachEM.

Liebe Kollegen, wie häufig ist es (mir auch schon passiert), dass Patienten vehement die Ansicht vertreten, dass ihr Symptom, welches sie akut plagt, auf diese oder jene Erkrankung zurückzuführen ist. Und dies kann natürlich kräftig ins Auge gehen! Lesen Sie weitere .....

So im konkreten Fall: Die aufgetretenen Schmerzen waren letztendlich nicht auf eine orthopädische Ursache zurückzuführen, sondern auf einen akuten Myokardinfarkt, an dem der Betroffene verstarb. Und in einer richterlichen Entscheidung wurde festgelegt, dass in dieser Situation der behandelnde Arzt haftet. Lesen Sie selbst!

Was bedeutet das in der Situation in der Notaufnahme?
Zunächst einfach wachsam sein und sich nciht von Vordiagnosen bzw. Meinungen von Patienten ablenken lassen (Fixierungsfehler).

Dokumentieren Sie die erhobenen Daten in einer Art und Weise, so dass auch im Nachgang Ihre Entscheidungen nachvollzogen werden können. Dies bedeutet nicht, dass ellenlange Aufzeichnungen notwendig sind, sondern fokussiert niedergelegt ist, warum und wie Sie zu Entscheidungen gekommen sind. Gerne stehen wir Ihnen für Erklärungen zur Verfügung.

Il caso di cui voglio parlarvi oggi mi è capitato alcune settimane fa durante un turno notturno. Giorgio è un iperteso in trattamento con ACE inibitori che si è svegliato nella notte a causa di un...

[[ This is a content summary only. Visit my website for full links, other content, and more! ]]

Just made a smart ass comment about the great interest generated by our previous post over nasal FB removal then switch gears to catch up on some other blogs and, i dont believe it.... ring removal update

Academic Life in Emergency Medicine

Trick of the Trade: 
Use the elastic strap from an oxygen face mask to wrap the finger

It is 2 am again and you are about to see your next patient, a little old lady with abdominal pain and tachycardia. You want to take a detailed and thorough history from her in regards to her abdominal pain but … Continue reading →

What is your favorite hypertension numbers to treat in ED? there are a lots of controversies regarding the exact number to start treatment in ED but recent Cochrane review on mild HTN suggest that antihypertensive agents used in the treatment of adults with hypertension stage I (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs. They reviewed 11 RCTS with 8912 patients and they concluded this result. also 9% of patients stopped their medication due to side effects of meds. Now , we should share with our IM colleagues that do not panic with this numbers unless there are other reasons to start treatment.

Link to Cochrane

I was cleaning out my work bag tonight, getting ready for my first ER shift as an R2 in the morning, and I found a few scraps of paper where I had written down some patient quotes and stories. Of the ones that are still legible after my water bottle exploded in the bag…

 

Male patient: “I may have 18 kids, but I’m very selective as to whom I sleep with.”

 

Me: Is there any chance you are pregnant?

Female patient: Nah

Me: Are you sexually active

Female patient: Hell yeah

Me: Do you use any sort of birth control?

Female patient: Nah. Look, I know I’m not pregnant

Me: What makes you know that?

Female patient I’m not pregnant cause I don’t want to be. That’s all I need.

Me: Hmmmm, that’s not exactly how that works….

"Death is a pretty worrying outcome."

Andy Neill



full context:

@rfdsdoc @mdaware death is a pretty worrying outcome - any reason? certainly hypotension common but usually related to inf speed

— Andy Neill (@AndyNeill) August 19, 2012

Sudden Unexpected Death in Epilepsy (SUDEP) = sudden death of a patient with epilepsy, as a result of unexplained respiratory failure or cardiac arrest after seizures – not to be confused with respiratory failure secondary to status epilepticus Post mortem … Continue reading →

In most areas of life, it helps to be tall, and needing treatment for ARDS further proves the rule. Tall people are less likely to get harmful lung-distending tidal volumes during mechanical ventilation, simply by virtue of having bigger lungs. It’s bad enough that we intensivists might discriminate against the under-six-feet crowd (of which I [... read more]

Medication shortages are affecting many hospitals - we're low/out of prochlorperazine, injectable metaclopromide, etomidate, propofol, brevital - and one of the replacements we've recently been introduced to is "Propoven", a European manufacture of propofol.

Jeremiah Schuur, featured on EM Lit of Note for his timely critique of the inadequacy of the "quality" measure for non-contrast head CT, passes along a notification of a pre-ACEP conference in ED infection control practices.


Sponsored by AHRQ, ACEP, and infection control societies, find more information about the conference here:

http://edip.partners.org/conference/

Wer kann sich nicht erinnern an die leidige Geschichte mit dem aktivierten Protein C .... zwischenzeitlich vom Markt genommen. Oder der präoperativen Gabe von Betablockern vor nicht-kardialen Operationen oder von der intensivierten Insulintherapie bei Intensivpatienten.
All diesen Konzepten gemeinsam ist, dass dies die Ergebnisse von frühzeitig wegen positiver Effekte abgebrochenen klinischen Studien waren. All diese Konzepte gehören zwischenzeitlich der Vergangenheit an. Nachfolgende Studien konnten zeigen, dass die Effekte dieser Studien überschätzt oder überhaupt nicht vorhanden waren. Zusammenfassend muss leider festgestellt werden, dass offensichtlich durchaus auch Patienten geschadet wurde.

Wie kommt es dazu? Nun das hat offensichtlich diverse Gründe und die liegen einmal wieder in der Statistik. Schon der bekannte Statistiker Pocock hat 1989 auf diese Probleme hingewiesen. Aber wird natürlich nicht gehört.

Von den Autoren des BMJ Artikels wird detailliert auf einige Beispiele und auch auf die zugrundeliegenden statistischen Probleme eingegangen. Offensichtlich ist ein Hauptgrund, dass eine relevante Anzahl von klinischen Endpunkten eintreten muss, so dass die Aussagekraft der klinischen Studie tatsächlich verlässlich ist. Und dies war bei den oben genannten Studien nicht adäquat berücksichtigt.

Wie kommt es dazu?
Nun, diese "Meilensteinarbeiten" werden wegen der "Breaking News" meist in hervorragenden Journalen publiziert, erhalten weite Verbreitung (Zeitschriften, Magazine etc.) und blockieren teilweise unabhängige Studien, die ähnlcihe Fragestellungen verfolgen. Dies bedeutet, dass der Hype von theoretischen Ideen/Visionen ("availability bias") zu einer self-fulfilling prophecy führt. Vorsicht! Extrem gefährlich! Bin selbstverständlich auch schon reingefallen. Man muss aber seine Fehler nicht zweimal machen.

Was bedeutet dies nun für uns?
Es ist zwar gut, aktuelle Entwicklungen nicht zu verschlafen, aber man muss bei der Umsetzung nicht der Erste sein. Besser ist es, die Studien kritisch zu beleuchten, diese zu diskutieren, Folgestudien abzuwarten und erst dann die notwendigen Schritte zu ergreifen. Es muss nicht jede Woche eine neue Sau durchs Dorf gejagt werden. So long ......

That pretty much says it all about working in the ER!

This is my epiglottis.There are many like it but this one is mine..

What You are about to see is not endorsed by my employer. I performed the testing and recording on myself, in my own time and definitely not at work or during work time! I did not use any drugs or anaesthesia at all.

This shows my test components. A mini USB waterproof flexible endoscope 10mm bought for $20 at local electronics shop (on left of image). Disposable Trulite Miller 2 straight bladed laryngoscope ( on right of image) bought for $16 online . Personal Windows laptop.

Total consumables cost =$36 AU.

THE CHALLENGE = assemble components to make workable video laryngoscope device and record visualisation of my epiglottis WITHOUT USE OF ANY DRUGS OR ANAESTHESIA IN AN AWAKE SPONTANEOUSLY BREATHING SUBJECT (MYSELF!)

THE ASSEMBLY

Taped waterproof endoscope to distal end of barrel of Miller Blade

Assemble time to readiness to test = 2 minutes

TEST VIDEO

Notice how I used external laryngeal manipulation to improve view of the epiglottis. As Levitan says, intubation begins with epiglottoscopy, finding the epiglottis! I found mine today!

And I proved to myself that

1. Miller blade and sitting position is much more tolerable for awake epiglottoscopy than supine and Macintosh blade.
2. As the great pioneers of laryngoscopy taught, external laryngeal pressure is vital in epiglottoscopy
3. You do not necessarily need local anaesthesia or any drugs to perform awake epiglottoscopy with this assembled device
4. You can make a sub $50 video laryngoscope that effectively images the airway

THE TEST DEVICE WAS SAFELY DISPOSED OF AFTER USE.

Such experimental devices should be single use per person.

This assembled system is for testing purposes and research only as a proof of concept. IT IS STRONGLY ADVISED SUCH A DEMONSTRATED SYSTEM OR ASSEMBLED DEVICE IS NOT USED IN ANY CLINICAL SITUATION AT ALL.

DISCLAIMER : Any attempts to copy this technique or procedure is conducted at the own risk of the person so doing

Filed under: airway, Online critical airway training Tagged: epiglottis, laryngoscopy, video

In my state there is a program within medical assistance restricts those "who have used services at a frequency or amount that is not medically necessary and/or who have used health services that resulted in unnecessary costs to MA. Once identified, such recipients are placed under the care of a primary care physician/other designated providers who coordinate their care for a 24-month period."

This includes these people being required to go to only ONE assigned hospital for their care. Do they follow this program. OF COURSE NOT. They regularly come into our ER even though they are assigned to another hospital.

Here's the thing: If they go to a non-assigned hospital, unless it is a life threatening emergency, the bill will not be paid. Of course they have to have a medical clearance per our wonderful EMTALA regulations. After that they can be sent out the door to their assigned hospital. Does this happen? OF COURSE NOT. Docs still see them, order tests, etc. Why? WHO KNOWS.

Here's the thing, the person has no incentive to go to their assigned hospital. They don't care if it won't be paid. Even if they are billed, they won't pay it anyway. So in other words, this program is a joke. It no doubt spends thousands if not millions of dollars to run with no success.
Wonder why the health care system is going down the toilet? Here is one more reason...

 

The Australian Nursing Federation (ANF) is launching a new national campaign titled Australia's Nurses and midwives. You couldn't be in better hands. The aim is to raise the awareness of the often undervalued contribution nurses and midwives make in our health system. The campaign is the result of widespread consultation with nurses, midwives and assistants in nursing.

ANF Federal Secretary Lee Thomas:

"The campaign is partly in response to Australia's national nursing shortage and it will promote positive images of nursing and midwifery that will in turn attract people to the nursing and midwifery professions." (The) campaign features a two-minute cinema ad, showing real-life nurses and midwives filmed as they work at three different hospitals. In addition, there is a 60 second TV commercial airing this Sunday as well as a radio ad, which starts today. Other campaign material includes posters, leaflets, bumper stickers and a new campaign website. "We want this positive campaign to focus on the significant contribution nurses and midwives make to the health system every day, and the trust the community have in them to deliver safe patient care whilst they are being treated and cared for," ANF

The ads feature 22 nurses and midwives and the people they are caring for.

If you can not see the video above, here is the link:

Document Title: Early Career Nurses and Rural & Remote Nursing

Document type: Post

Author:Jerildene Smith

Author Bio:

I recently submitted this paper and chose rural and remote nursing as the research focus/topic as I have had to move away from my partner, family and friends to secure work.

I thought it might get people talking... and yes, it IS something you can do early in your career!

Twitter: Nil
Facebook: Nil
Email:eccsci@gmail.com
Website: Nil
Copyright: This work is licensed under a Creative Commons Attribution 3.0 Unported License.

---------------------------------

Early Career Nurses and Rural and Remote Nursing

Rural and Remote nursing is currently being discussed in terms of the
current workforce being maintained and preferably increased. Nursing
in general has projected staff shortages across all specialities, as
those retiring are not being replaced at the same rate, thus
exacerbating the rural and remote workforce shortages (Wakerman &
Davey 2008; Hegney et al. 2002; Lenthall et al. 2011; Witham 2000) and
leaving them in worse positions than those in the metropolitan areas.

Nurses who choose to specialise and/or work in rural and remote
communities not only have extended scopes of practice and associated
responsibilities, due to medical staff shortages, but have to contend
with issues such as: isolation (social and clinical), minimal support
(clinical and managerial), professional development, balancing
confidentiality while also maintaining social friendships in the
community and a major lack of resources: clinical and structural, to
name a few (Lenthall et al. 2011; Witham 2000; Wakerman & Davey,
2008).
All these factors have been researched and shown to have an impact in
nurses leaving rural and remote communities along with the perceived
stereotypes of clients (e.g. indigenous peoples are always drunk,
fighting etc) (Wakerman & Davey 2008). There is a dearth of research
in this area looking at strategies to try and minimise the above
mentioned factors.

While all of the above are important factors to consider when trying
to retain staff, what couldn't be found were reasons why nurses
choose to leave the metropolitan area and go rural and remote nursing
in the first place.
Research has shown previous exposure to the area as a student or a
professional growing up in a rural environment will be open to
returning to work in rural/remote practice as a professional (Hegney
et al. 2002; Kenny & Duckett 2003; Bennet et al. 2012).
Extensive research on transition to practice for grad nurses, and some
research on why grad nurses chose rural and remote practice as a
specialty for their grad year (Kenny & Duckett 2003) has been
undertaken but there was nothing showing why nurses chose rural and
remote practice after graduate level.

Losing my position in a busy Level 1 tertiary teaching hospital,
resulting from budget cuts, I suddenly found myself working in a
remote area of Western Australia. Never previously considered rural
and remote nursing, feeling that I was too much of a junior nurse, I
had no idea what to expect. I felt I needed more experience and the
completion of post graduate studies with clinical support before I
even thought about it as an option. Being settled with a family was
also a large factor.

The current position I have (Registered Nurse with specialisation in
A&E) I accepted as it was an immediate start and financial
considerations were a priority for our family.
I had no other preparation other than I was going to a place which was
2.5 hours from the nearest regional hospital, a doctor is not always
available (10/14 days; although he is contactable by phone when not
here), about 6 fellow nurses and it had on-site accommodation.
I had grown up in a semi-rural environment as a child, but that was
long ago. An information booklet has been prepared by the National
Rural Health Alliance Inc., titled "A brief guide to nursing in
rural and remote settings" but this was only found during a
literature review and search for this topic. My orientation package
from the West Australian Country Health Service (WACHS), had an
information booklet that was similar: however, I did not get this
until I arrived on my first day.

Underestimating things like: being homesick, the extent to which I
miss my family, familiarity of my home and its surroundings. Studying
post graduate without all the support and resources that are available
in a major centre. What it is like to work, live and socialise with
the people that surround you 24/7 (both nurses and the local
community). Being on call for extended periods of time and unable to
do things that you normally do on days off. Living onsite at the
hospital and being on call 24/7 if needed. Professional and social
isolation The sheer lack of resources, both structural (we do not have
half the resuscitation equipment a regional hospital would have) and
clinical (we only have 1 nurse who is X-ray competent, and no onsite
path lab).

The skills and variety I have obtained and dealt with is amazing.
I've assessed, consoled, sutured, dressed, backslabbed (Plaster of
Paris and fibreglass) and provided health education/advice and
medication to the community. I've dealt with a 18/40 week pregnant
woman threatening to abort and been appreciated and thanked multiple
times. I haven't been abused verbally or physically, once, the
entire time I've been here so far.
The NUM and clinical nurse are also a wealth of information and
support.

Bringing me to ask questions within the research topic such as; Why
don't more early career nurses choose rural and remote nursing?
Given that there is an extended scope of practice, why wouldn't a
nurse come out and increase their skills and knowledge base? Why are
there negative perceptions of the rural and remote communities,
especially regarding indigenous peoples? Are my reasons for transition
the same as others? What makes others transition to rural and remote
nursing when there are no mitigating factors (e.g. financial) to
consider it as an area of practice? What attracts early career nurses
to rural and remote nursing? Is rural and remote nursing seen as
something you do as a nurse when you are more 'experienced' &
'older'?

References:

Bennett, B, Barlow, V, Brown, J, Jones, D 2012, 'What do graduate
registered nurses want from jobs in rural/remote Australian
communities?, Journal of Nursing Management, vol.20, pp.485-490.

Hegeny, D, McCarthy, A, Rogers-Clark, C, Gorman, D 2002, 'Why nurses
are attracted to rural and remote practice', The Australian Journal
of Rural Health, vol.10, no.3, pp.178-186.

Kenny, A, & Duckett, S 2003, 'Educating for rural practice',
Issues and Innovations in Nursing Education Journal of Advanced
Nursing, vol.44, no.6, pp.613-622.

Lenthall, S, Wakerman, J, Opie, T, Dunn, S, MacLeod, M, Dollard, M,
Rickard, G, & Knight, S 2011, 'Nursing Workforce in very remote
Australia, characteristics and key issues', Australian Journal of
Rural Health, vol.19, pp.32-37.

Wakeman, J & Davey, C 2008, 'Rural and Remote Health Management:
'The next generation is not going to put up with this...' Asia
Pacific Journal of Health Management, vol.3, vol.1, pp.13-18.

Witham, H 2000, 'Remote and Rural Nursing: An Endangered
Profession?' Australian Nursing Journal, vol.7, no. 9, pp.18-21.

---------------------------------------

Nurseversity (pronounced: nurse-e-versity) is a growing repository of ad-hoc nursing education and discussion materials. It is by nurses..... for nurses.
You are highly encouraged to peer review, comment, correct and discuss anything offered on Nurseversity ...but please do so in a supportive, respectful and communal way.
You are also encouraged to contribute.
All works will be licensed to you under a Creative Commons Attribution 3.0 Unported License.

You might be a seasoned educator or an undergraduate who has just learned something new. Do not be intimidated or under-enthused.
It does not need to be dryly academic or ruthlessly evidence based, and references are optional.
This is free-form.
I am asking you all to throw it into the mix.
Any educational or discussion-stimulating material.
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Send your contributions (and a short bio) to: ian@impactednurse.com
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And if you appreciate the teaching....help spread the word on the social media links below.

A remote nurse asked me this week during a clinic training session, how I recognised if a child was sick or not.

Here are my thoughts and some resources

When my own children get sick, a few things commonly happen:

1. Stop eating and drinking. I dont care about the eating but lack of fluid intake worries me always
2. Get irritable and altered behaviour. cant sleep or sleep too much. As a health care provider you must ask very carefully about this and BELIEVE the child’s carer.
3. Breathe differently. Sick kids breathe harder. Really sick kids breathe shallower. Dead kids stop breathing. Shock affects breathing and is most earliest sign to look for in my opinion.
4. The VOMITING child always worries me. This is a red flag for pathway to deterioration in the sick child.
5. FEVER is a distractor from your assessment. You must look for 1-4 above first before considering FEVER. ABsence of 1-4 above with a fever, I dont get worried about usually (EXCEPT IN NEONATES)

Examination tips :

1. Observe first. Most of my gestalt for sick kids comes from observation alone. Look at breathing and activity/behaviour
2. I first listen to heart. Occasionally I get the diagnosis of Acute carditis from acute rheumatic fever ( a disturbingly common presentation in my region) from cardiac auscultation immediately. Also it helps before the child starts screaming
3. Then listen to lungs. Same reason: before the kid starts screaming. Leave all possibly painful parts of the exam till last!
4. Good look over for a rash
5. Ears next. Its not easy and you just have to do your best. Get carer to help hold child as still as possible. Video-otoscopy with a USB device to your laptop is great and aids carer confidence and often the child if old enough.
6. Nostrils next. Look for that pus coming out of a sinus ostia. Polyps can be seen in allergic conditions
7. Oral exam last including dentition, tonsils, mucosa for enanthem signs.
8. Urinalysis completes your workup .

Check out these useful free web resources

recognition of sick child powerpoint

Recognition of the sick child in ED guideline NSW

The video above is an advertorial but shows some useful footage of sick children to demonstrate the signs of critical illness. I am not sponsored by the company at all who makes that training course package!

 

regards

Minh

Filed under: Emergency medicine and critical care, Prehospital medicine, Rural medicine Tagged: child, recognition, sick

Patient presented to the ER today stating that the OB clinic told her 4 weeks ago that she was 6 weeks pregnant. They based this off of her last "period". Today she states that it feels like she is having contractions. I called labor and delivery and told them that she looks like is about term not newly pregnant and she is having contractions. The midwife says, "there is no way those are contractions. She is only 6 weeks along. Just send her home." Well, I did not do that. Instead I ordered an ultrasound. The results were a breech 39 1/2 week baby that looks like it is about to deliver. I called labor and delivery back and they took the patient to emergent c-section due to the baby being breech. The moral of story is: not everyone knows what a "normal period" is.

KNOW YOUR LOCATION

HAVE A LINE OF RETREAT

Whether its a trip down the corridor to the CT or MRI scanner or a flight into a remote location hundreds of miles from anywhere, the astute retrieval practitioner should be familiar with the geography, know the routes of escape/retreat and have backup plans

You need to know how long its going to take to drive a ventilated patient back to the air strip to load onto your fixed wing aircraft? Why? because you might run out of portable oxygen if you seriously underestimated the time!

That trip to the CT scanner..do you know how far it is, what obstacles might present themselves like dodgey lifts? Are you prepared to handle critical events en route and in the remote location like the CT scanner? What lines of communication and backup do you have established prior to leaving your ED or ICU? What is the physical layout of the CT room? Can you intubate normally there or do you have limited space so less staff able to assist?

NEVER ENTER A ROOM OR GO TO A REMOTE LOCATION WITHOUT KNOWING IF YOU CAN LEAVE IT IN A HURRY!

SO, study maps of your region, landing points in remote areas. Even better go and visit these areas in your spare time, talk to the people living there and ask about how past emergencies were handled. Same in your hospital. Walk the routes of passage to your CT or MRI from your ED and ICU. At start of shift, walk the routes again to see if anything has changed. Maybe some building work has started and has changed the route you would normally take.

And THEN DO FIRST AND SECOND RULE OF PHARM !

NOW HERE IS A GOOD EXAMPLE OF ALL THREE RULES OF PHARM. WATCH AND LEARN!

See how knowledge of London Traffic and roads is vital for a rapid road response..its not just using GPS device!

See how leadership and command skills provides effective CRM when the retrieval team arrives to the ambulance crew. Everyone in the ambulance has a role and knows it.

See how there is rapid but thorough checking of the intubation gear, drugs and procedure talk through.

 

The THIRD RULE OF PHARM

KNOW YOUR LOCATION

Minh

Filed under: Aeromedical retrieval, Emergency medicine and critical care, Prehospital medicine Tagged: awareness, location, PHARM, third-rule

Back for another open-mic weekend.

All weekend everyone is welcome to post any medically-related comments, questions, observations in the comments section.

Only rules are that there are no personal attacks and that the comments are medically-related.

Have a safe and enjoyable weekend.

Emergency and critical care health care professionals are awesome!

As part of the ongoing collaboration between emergency medicine/critical care professionals in the online space, the LITFL gang are collating all the resources to make life as easy as possible to get the amazingly high quality discussions, audio and visual materials to the seething throngs of hungry minds globally.

We are re-structuring our database of emergency medicine and critical care blogs, podcasts and feeds to provide the most functional and up to date information possible.

During this process we are analysing the social media platforms and tools used to best assist in the development of further resources in this area by providing some helpful hints, tips and tutorials to assist all budding bloggers to enter this space and hit the ground running.

First up we are starting with a review of all the podcasters and vodcasters providing audio stimulation to fill our long car journeys, meandering walks and idle minutes. An amazing group of dedicated individuals that donate hundreds of hours of resources – all in the name of #FOAM (free open access meducation)

One of the most surprising findings has been the difficulty encountered when trying to subscribe to a feed (outside of iTunes) and to follow each of the #FOAM resources on the social media channels. We have therefore created a table of all the most appropriate ways to follow each of the respective blogs including Twitter, Facebook, Google Plus, RSS feed, iTunes feed and for those still in web 1.0…an email contact. All this information can be found on each of the respective websites

EMCC Podcasters and Vodcaster List

EMCC Searchable Podcast Episode Database

 

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