The LITFL Review 078

Welcome to the extravagant  77th 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

  • Ripper of the week is taken out by Rebuen over at Emergency Medicine Updates with his mind blowing post on  The Usual State of Readiness. In this Rueben discuss  having cognitive readiness in in critical situation, and says most of this can achieved through practicing invisible simulation. Remember: Memory fails when catecholamines are high; planning for emergency scenarios involves the development and deployment of emergency references.

The LITFL Review Top Picks

 Emergency Physicians Monthly

UMEM Educational Pearls

This weeks pearl is from EMCC guru Michael Winters on The Lung Transplant Patient in Your ED:

  • The number of lung transplant recipients is increasing.  With improved immunosuppressant medications, pts are living longer.  In fact, the 5-yr survival rate is now approximately 60%.
  • When evaluating a lung transplant pt who is < 1 yr following transplant, think about acute rejection and infection
  • Acute rejection occurs in up to 40% of pts, can present with cough, SOB, malaise, or hypoxia, and is treated with high-dose corticosteroids.
  • Infection
    • Bacterial infections usually occur in the early stages following transplant, with Pseudomonas the predominant organism
    • CMV is the most common organism affecting up to 33% of pts during the first year after transplant

The Poison Review

EmergencyLondon

This weeks grand round is by Ryan Arbeau presenting on The Disabled Athlete…

http://www.youtube.com/watch?v=9eI-q2ZJn2E

Radiology Signs

  • Subacute subdural haematoma - can be difficult to identify on non-contrast CT as the blood is isodense to brain parenchyma (the same density).
  • Ankle ABC’s. A nice neat approach to reducing ankle fractures. Do you X-ray be fore or after reduction?
  • What does A Bad Haircut and emergency medicine have in common? A lot actually…Worth reading especially junior doctors and nurses!
  • Steve provides us with a great introductory podcast into Non-invasive Ventilation, from when to, how to, and when not to use NIV!
  • Interesting Case: The Answer- The dang factor strikes again!
  • The Chest Tube Autotransfuser - Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting.

KeeWeeDoc

Dr Smith’s ECG Blog

Broome Docs

The LITFL Review Shout Out of the Week

thebluntdissection

This weeks shout-out goes to new Aussie blogging sensation- Chris Partyka over at thebluntdissection. Chris is a training ED Doctor with a passion for resuscitation, ultrasound and education. Check some some Chris post below;

Twee Dee and Twitical Care

#BCC3 @ red back anti venom placebo? The knee arthroscopy of the tox world?? http://t.co/qnDxV5mt
@I_C_N
IntensiveCareNetwork

News from the Fastlane

  • Michelle put us on our toes and challenges us ethically in Household Words Chapter 1.
  • Chris provides us with a fascinating video from Ben Goldace on Bad Pharma - A must watch!
  • Unfortunately no LITFL Review next week as I will be busy over at ICEN 2012.

The Final Words

  • “A true leader has the confidence to stand alone, the courage to make tough decisions and the compassion to listen to the needs of others. He does not set out to be a leader but becomes one by the quality of his actions and the integrity of his intent.”

 -Douglas MacArthur

  • “Patients don’t come to us for judgement. They come to us for care.”

-Greg Henry

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 — Adventure Medicine—  A Life at Risk — All LA Conference — Al Sacchetti’s Youtube — Bedside Ultrasound  Better in Emergency Medicine — Broome Docs — CCM-L.org — CLIC-EM — Critical Care Perspectives in EM — Dave on Airways —DrGDH — Dr Smith’s ECG Blog — ECG Academy —ECG of the WeekED Exam — EDTCC — EKG Videos — EM Basic — EM Core Content — EMCrit — Emergency Medical Abstracts —EMERJENCYWEBB –EmergencyLondon — Emergency Medicine Cases — Emergency Medicine Education — Emergency Medicine News  Emergency Medicine Ireland — Emergency Medicine TutorialsEmergency 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 — Practical Evidence— Priceless Electrical Activity — Procedurettes — PulmCCM.org — Radiology Signs — Radiopaedia — 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 — thebluntdissectionThe 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 — Ultrarounds — Ultrasound Podcast — UMEM Educational Pearls  — Ultrasound Village

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Podcast 83 – Crack to Cure – ED Thoracotomy

Post image for Podcast 83 – Crack to Cure – ED Thoracotomy

Crack to Cure

All the way back at podcast 36, I discussed traumatic arrest in the ED. In that episode, I laid out a general approach to patients coding from trauma, in this one I discuss only the performance of the procedure of ED thoracotomy.

This lecture was given at the 2012 ALLNYC EM Conference.

Here are the videos from the lecture:

Survivor Story

Our ultrasound fellow, Dan Lakoff, sent me this survivor story from a thoracotomy

Need the audio-only version? Right click here and choose save-as

Now on to the Vodcast…

Click here to view the embedded video.

You just read the post: Podcast 83 – Crack to Cure – ED Thoracotomy from EMCrit Blog - Emergency Department Critical Care.

Best of Craigslist: Advice from an ER doctor to drug seekers

Below is a rant from an ER doc on craigslist: (I edited out the bad words, I may have missed 1 or 2)

OK, I am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don’t have your vicodin, me because I’ve seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we’ll both be happier because you get out of the ER quicker.

The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like crap because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.

The second rule is pick a simple, non-dangerous, (non-verifiable) painful condition which doesn’t require me to do a four thousand dollar work-up in order to get you out of the ER. If you tell me that you headache started suddenly and is the ‘worst headache of your life’ you will either end up with a spinal tap or signing out against medical advice without an rx for pain medicine. The parts of the story that you think make you sound pitiful and worthy of extra narcotics make me worry that you have a bleeding aneurysm. And while I am 99% sure its not, I’m not willing to lay my license and my families future on the line for your butt. I also don’t want to miss the poor guy who really has a bleed, so everyone with that history gets a needle in the back. Just stick to a history of your ‘typical pain that is totally the same as I usually get’ and we will both be much happier.

The third rule (related to #2) is never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I’ve seen people in a 10/10 pain and you sitting there playing tetris on your cell phone are not in 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8. That means to me you are hurting by you might not be lying. (See below.)

The fourth rule is never ever ever lie to me about who you are or your history. If you come to the ER and give us a fake name so we can’t get your old records I will assume you are a worse douchetard than you really are. More importantly though it will really really piss me off. Pissing off the guy who writes the rx you want does not work to your advantage.

The fifth rule is don’t assume I am an idiot. I went to medical school. That is certainly no guarantee that I am a rocket scientist I know (hell, I went to school with a few people who were a couple of french fries short of a happy meal.) However, I also got an ER residency spot which means I was in the top quarter or so of my class. This means it is a fair guess I am a reasonably smart guy. So if I read your triage note and 1) you list allergies to every non-narcotic pain medicine ever made, 2) you have a history of migraines, fibromyalgia, and lumbar disk disease, and 3) your doctor is on vacation, only has clinic on alternate Tuesdays, or is dead, I am smart enough to read that as: you are scamming for some vicodin. That in and of itself won’t necessarily mean you don’t get any pain medicine. Hell, the punks who list an allergy to tylenol but who can take vicodin (which contains tylenol) are at least good for a few laughs at the nurses station. However, if you give that history everyone in the ER from me to the guy who mops the floor will know you are a lying douchetard who is scamming for vicodin. (See rule # 4 about lying.)

The sixth and final rule is wait your turn. If the nurse triages you to the waiting room but brings patients who arrived after you back to be treated first, that is because this is an EMERGENCY room and they are sicker than you are. You getting a fix of vicodin is not more important than the 6 year old with a severe asthma attack. Telling the nurse at triage that now your migraine is giving you chest pain since you have been sitting a half hour in the waiting area to try to force her into taking you back sooner is a recipe for making all of us hate you. Even if you end up coming back immediately, I will make it my mission that night to torment you. You will not get the pain medicine you want under any circumstances. And I firmly believe that if you manipulate your way to the back and make a 19 year old young woman with an ectopic pregnancy that might kill her in a few hours wait even a moment longer to be seen, I should be able to piss in a glass and make you drink it before you leave the ER.

So if you keep these few simple rules in mind, our interaction will go much more smoothly. I don’t really give a crap if I give 20 vicodins to a drug-seeker. Before I was burnt out in the ER I was a hippy and I would honestly rather give that to ten of you guys than make one person in real pain (unrelated to withdrawal) suffer. However, if you insist on waving a flourescent orange flag that says ‘I am a drug seeker’ and pissing me and the nurses off with your behavior, I am less likely to give you that rx. You don’t want that. I don’t want that. So lets keep this simple, easy, and we’ll all be much happier.

Sincerely,
Your friendly neighborhood ER doctor