Clinical Problem Solving – Ausschlag, Haarzellleukämie, Fieber

Sie wissen ja vermutlich, dass ich absoluter Anhänger der Rubrik “Clinical Problem Solving” im New England Journal of Medicine bin. Didaktisch hervorragend aufbereitet, werden

auch schwierige und komplexe Fälle sehr praktisch anwendbar beschrieben. So auch hier bei einem Patienten mit therapierter Haarzellleukämie, der sich wegen Fieber, vesikulärem Ausschlag am Rücken und noch anderer Beschwerden vorstellt. Schrittweise führen die Autoren durch die Abklärung und dann auch Therapieversuche. Ich für mich habe wieder ein schon in die Tiefen des Gehirns verdrängtes Syndrom wiederentdeckt: Das “SWEET SYNDROM“. Auch differentialdiagnostisch gelegentlich in der Notfallversorgung zu erwägen.

Sie werden sich fragen, warum ich einen derartigen Fall in einem Blog zur Notfallmedizin vorstelle und bewerbe: Nun, wir sind immer wieder mit derartigen Fällen konfrontiert. Und auch wenn diese zur weiteren Abklärung dem Fachspezialisten zugewiesen werden, kann man aus derartigen Fällen viel über den Verlauf einer Erkrankung lernen. Außerdem zeigt es in brillianter Art und Weise auf, wie man über die Zeit schrittweise seine Arbeitshypothesen entwickeln kann, die Diagnostik anstossen und dann auch seine Arbeitshypothesen verwerfen kann. Aber, der Fall ist nicht nur didaktisch exzellent, er zeigt in brillianter Weise wie spannend Medizin sein kann. Voraussetzung ist natürlich, dass man Ressourcen hat … und das ist bei uns gelegentlich durch die Arbeitsbelastung, wie auch aktuell wieder bei uns am WE, häufig nicht so gegeben ist.

@WUSTL_EM #EMConf: #FOAMed Supplement No. 7

Welcome to @WUSTL_EM #EMConf, the #FOAMed Edition. The purpose of this weekly column is to identify #FOAMed resources that reinforce and expand on the concepts/facts discussed during weekly conference.  Please e-mail to share additional resources (or just post them as comments below).

1.  Starting the year off with Approach to Chest Pain
- See this RebelEM post reviewing the HEART score to risk stratify chest pain patients in the ED.
- EM Literature of Note reviewed the HEART score in this post.
- Review Amal Mattu's approach to low risk chest pain in this excellent podcast by ERCAST
- For some primary literature, you can review Hess et. al. (2012) on employment of a Shared Decision Making Aid to reduce OBS admission for stress testing.
- Don't miss this  recent article by Weinstock et. al. on the low risk for cardiac events for patients admitted to the hospital with two negative troponins and non-concerning EKG changes.

2. Resuscitation Fluids: A Primer
- Didn't follow the Glycocalyx explanation on the first go around?  I don't think most people do.  Don't worry, Life in the Fast Lane has this explanation of the glycocalyx and its role in critical illness which you can access here.
- Our own Evan Schwarz reviews the importance of fluid choice in sepsis here.
- Dr. Wessman recommended several New England Journal of Medicine  articles during his talk, including this one on resuscitation fluids and this one on Albumin vs. Crystalloids.

3. EMS: Systems of Care
The PHARM blog did an excellent job compiling & summarizing the results of the best articles in prehospital medicine in 2014.  You can access this list here. Amongst these articles was this one on how Statewide Regionalization of Care can lead to improved outcome in Cardiac arrest patients.

Finally, please take the time and go here to sign a petition supporting an Air Ambulance for Northern Ireland in memory of the great Dr John Hinds, master of prehospital medicine, teacher of many and tireless advocate for improvement and support of prehospital care.

4. Ultrasound: eFAST
- check out this entertaining "clarification" of the eFAST by Cliff Reid and the Ultrasound podcast team.

5. Patient Satisfaction
- see Emergency Medicine Cases on Effective Patient Communication, Patient Centered Care and Patient Satisfaction.


Research and Reviews in the Fastlane 090

Research and Reviews in the Fastlane

Welcome to the 90th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 8 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Respiratory, AirwayR&R Hall of Famer - You simply MUST READ this!
Frat JP et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. NEJM 2015; 372(23):2185-96. PMID 25981908

Two different takes on a potential game changer in how we initially manage hypoxic respiratory failure from our contributors.

  • “HFNC for acute hypoxemic respiratory failure improves mortality and patient comfort over BiPAP and standard oxygen therapy” — This is the headline you are going to see BUT is not the entire truth. Here are a few of the caveats….
    • There were significant exclusion criteria so these patients only had hypoxic respiratory failure (single organ failure).
    • Included a significant proportion of unilateral lung disease (not just ARDS patients) whose mortality is           historically a lot lower.
    • Significant (and unreported) cross-over rates between NIV and HFNC groups, and it’s unclear why tidal         volume targets were 7-10 cc/kg ideal body weight.Bottom line: HFNC should not replace or delay definitive   management (an ET tube) in patients with acute hypoxemic respiratory failure.
  • We know in hypercarbic respiratory failure (i.e. COPD & CHF Exacerbations), NIPPV decreases mortality and intubation rate. In this study in patients with hypoxemic respiratory failure without hypercarbia (majority of population with pneumonia), HFNC appears to be superior to both NIPPV & O2 with Face Mask and should be strongly considered as first line treatment.
  • Recommended by John Greenwood, Salim R. Rezaie

The Best of the Rest

Emergency MedicineZonfrillo MR et al. Emergency Department Visits and Head Computed Tomography Utilization for Concussion Patients From 2006 to 2011.Acad Emerg Med 2015. PMID: 26111921

  • Increasing awareness exists on concussions/mild traumatic brain injury (TBIs) and this correlates with an increase in ED presentations for concussions between 2006-2011. Similarly, there’s been an emphasis on use of clinical decision aids for mild head trauma during this period. Despite this, a significantly limited database review found there was an 11.1% absolute increase in the rate of head CT for concussion patients over this period despite apparent decreased injury severity, measured by ISS. Concussion/mild TBI certainly deserves increasing awareness but inappropriate imaging doesn’t behoove anyone and appears to be a growing problem in this realm.
  • Recommended by Lauren Westafer

Emergency MedicineBeam DM et al. Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. Acad Emerg Med 2015. PMID: 26113241

  • Venous thromboembolism (PE and DVT) are almost always managed in the US with an inpatient stay while anticoagulation is begun. However, there are likely low risk groups that can be discharged from the ED without a hospital stay. This study prospectively looks at 106 patients with either DVT or PE who were identified as low risk based on the Hestia criteria. All of the patients were started on rivaroxaban (a Factor Xa inhibitor) and none had VTE recurrence (while on anticoagulation), major bleeding events or death due to VTE. This study further supports outpatient management for low risk VTE but a randomized controlled trial is needed (keep your eye out for the MERCURY-PE study)
  • Recommended by Anand Swaminathan
  • Further reading: SGEM #126: Take me to the Rivaroxaban — Outpatient treatment of VTE (The Skeptics Guide to EM)

Research and critical appraisalHorowitz BZ, et al. Droperidol–behind the black box warning. Acad Emerg Med. 2002; 9(6):615-8. PMID: 12045077

  • An older, but outstanding blow by blow look at the cases which led to the FDA black box warning on droperidol in the U.S. The authors examine each case submitted and find some curiosities:-55 of the 93 deaths reported were submitted on the same day
  • The overwhelming majority of adverse event cases were reported with significantly higher doses of the drug than that routinely used in the EDThe authors also nicely summarize what we knew about alternative agents at the time of the editorial (2002), and is well worth reading for all those wondering why such a useful drug has been eliminated from the formulary at many hospitals. HT to Sean Nordt and Rob Orman for their discussion of the issue and editorial on ERCast.
  • Recommended by Jeremy Fried
  • Further reading: Art of the chemical takedown (ERCAST)

NeurologyAVERT Trial Collaboration group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 2015.  PMID: 25892679.

  • In a massive and well-conducted RCT of 2104 patients with stroke, they randomized half of them to very early mobilization (median of 18.5 hours to first mobilization vs 22.4 hours), and more intensive mobilization (31 minutes per day vs. 10 minutes per day) for longer (202 total minutes vs 70 total minutes). Depending on how you prefer to analyze the results, there was either no difference (on the “assumption-free ordinal analysis” that uses the whole Rankin scale) or evidence of harm in the adjusted analysis that dichotomized the outcome scale.This surprised me–I had assumed that we were nowhere near giving “too much” exercise to anybody in any ICU. Apparently there may be a downward limb of the exercise/benefit curve. Clearly we need some more RCTs, not just willy-nilly assertions that more exercise is better. BUT, we should also remember just how much more exercise the usual care in this trial got, compared to the amount of exercise my typical medical ICU patients get. I do NOT think this paper provides an excuse to stop mobilizing patients who are currently getting next to nothing.
  • Recommended by Jack Iwashyna

Critical CareHilton AK, Bellomo R. A critique of fluid bolus resuscitation in severe sepsis. Crit Care 2012; 16(1): 302. PMID: 22277834

  • The concept of the fluid bolus in resuscitation of the critically ill, especially in septic shock, is almost sacrosanct. Hilton and Bellomo tear down the facade that underpins this dogma. Read this and you will be left wondering what to believe… Is it time for a FEAST trial in adults in the developed world? In the meantime, continue to take the middle road in septic shock – judicious use of resuscitation fluids (e.g. 2-3 L at most in most adult patients) and early use of noradrenaline.
  • Recommended by Chris Nickson

Kornhall DK et al. Intentional oesophagealintubation for managing regurgitation during endotracheal intubation. Anaesth Intensive Care 2015; 43(3): 412-4. PMID: 25943615

  • Another case report demonstrating effective management of large gastric regurgitation during ETI by purposefully intubating the esophagus. An important technique to manage a difficult and dangerous scenario.
  • Recommended by: Reuben Strayer

Emergency Medicine
Salminen P et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis The APPAC Randomized Clinical Trial. JAMA 2015; 313(23): 2340-2348. PMID: 26080338

  • Can we treat acute, uncomplicated appendicitis with antibiotics alone? According to this RCT (can’t blind this one) the answer is yes. Antibiotics alone had a 72.7% success rate measured by the absence of needed appendectomy at 1 year. However, the failure rate (27.3%) exceeded their prespecified non-inferiority criteria of 24%. Appendectomy was successful in 99.6% of patients. Patients who underwent appy were much more likely to have complications (2.8% vs. 20.5%) but the vast majority of the appys were done by an open technique. Although we hoped this would answer the question, it has only added more. Antibiotics alone may be a reasonable 1st approach but we should expect a high failure rate if this strategy is pursued.
  • An antibiotics-first strategy for acute appendicitis had a failure rate of about 27% at one year – not bad, but longer-term follow-up for durability of cure is needed to endorse such a strategy.
  • Recommended by Anand Swaminathan, Ryan Radecki
  • Further reading: The era of appendectomy is not over (Emergency Medicine Literature of Note)

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 090 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Hacking Medical Education

Today, Thursday 9th of July 2015, I have the opportunity to speak to Australia’s medical students at The AMSA National Convention Melbourne 2015 about ‘Hacking Medical Education’. This post contains the resources for the talk.

The talk is dedicated to the memory of Dr John Hinds, who tragically died last weekend. The simplest advice one can give to any medical student is “Be like that guy – Dr John Hinds“. Ride on, John.

What do I mean by Hacking Medical Education?

Hacking means many things – all of which apply to this talk to some extent (especially the latter):

  • “gaining unauthorised access to data in a system…”
  • “cut with rough or heavy blows”
  • “to modify or write… in a skillful or clever way”

By medical education, I don’t only mean getting through medical school, but also (and more importantly) our lifelong path of learning in medicine.

HACK #1 Learn from Osler!

  • Becoming an Oslerphile
  • The Master Work is Work (unfortunately there are no shortcuts to learning!)
  • “Medicine is learned at the bedside… the patient is our first, last and only true teacher” a lesson from Osler via The Breakfast Club‘s Tim Koelmeyer
  • The key to learning is work, the key to work is to love it – have fun, see the comedic side of life and cultivate your inner Egerton Y. Davis!

HACK #2 Discover the hidden curriculum!

  • There are three at least three ‘hidden curricula':
    • the unintended things you learn from a course
    • the things you really need to know to pass the course (may be different from what is stated)
    • the ‘internal’ curriculum you need to develop to be the doctor you want to be and look after the patients in front of you
  • The Necessary Evil of Examinations (they are ‘rocks of offence’, however ‘assessment drives learning’)
  • FCICM Exam Preparation (preparation for an exam must be exam specific, this page outlines useful approaches for the Fellowship of the College of Intensive Care Medicine; however many of the suggestions and techniques are generalisable)
  • We don’t need no FOAM Curriculum (we need to develop our own ‘internal curricula’ that supplement those set for use by Universities and Colleges – FOAM resources can help here… see below!)

HACK #3 Apply cognitive science!

  • Effective learning techniques are not widely taught, are not widely known and are not widely performed
  • Cognitive science highlights some promising techniques, although definitive evidence of their effectiveness in the medical setting is generally lacking
  • We construct knowledge, it isn’t transferred
  • Use these techniques:
    • retrieval practice and take advantage of the ‘test effect’ (putting things into our brains isn’t that hard, being able to retrieve it at the right time can be – practice retrieval, ideally in the context in which you want to be able remember something)
    • spaced repetition (try to practice retrieval at just the time you are about to forget something to promote durable learning)
    • elaboration (channel your inner 3 year-old: ask ‘why?’ and explain things to yourself and others)
    • generation (test your knowledge of a topic before learning about it – ask yourself questions and try to predict what will be said before reading a section of a book or article)
    • reflection (reflect on your experience – combines retrieval practice and elaboration and is a way of giving feedback to yourself)
    • calibration (get objective feedback so you are not deluding yourself as a learning)
    • interleaved practice (mix up problem types and topics during practice to prepare you for the real world)
  • Learning by Spaced Repetition (I used software called Anki to help me remember key facts for exams)
  • Effective Learning Techniques Revealed (brief summary of the techniques given the thumbs by Dunlosky et al, 2013)
  • Dunlosky J, et al. Improving Students’ Learning With Effective Learning Techniques: Promising Directions From Cognitive and Educational Psychology. Psychological Science in the Public Interest, 2013; 14 (1): 4 DOI:10.1177/1529100612453266 [Free Full Text] (great review of the science of effective learning techniques)
  • Brown PC, Roedinger HL, McDaniel MA. Make It Stick. Harvard University Press, 14 Apr 2014 [Google Books] (excellent popularisation of the ‘new learning science’)
  • Education Theory for the #MedEd Clinician (key insights from Jonathan Sherbino, a master clinician educator)

HACK #4 Simulate!

  • good patient outcomes need more than individual competence, they need collective competence – team-based simulations can help achieve this
  • Hadfield, C. An Astronaut’s Guide to Life on Earth. Random House of Canada, 29 Oct 2013 [Google Books]
  • In situ simulation (simulation in the workplace, with real teams in the environment in which we work, rocks!)
  • Simulation-based learning helps develop essential non-technical skills: Crisis Resource ManagmentCommunication in a crisis and Speaking up

HACK #5 Join the FOAM Party!

  • Why FOAM? Facts, Fallacies and Foibles (my talk providing an overview of FOAM)
  • Nickson CP, Cadogan MD. Free Open Access Medical education (FOAM) for the emergency physician. Emerg Med Australas. 2014;26:(1)76-83. [pubmed] [Free Full Text]
  • FOAM (Free Open-Access Meducation homepage)
  • Is FOAM at fault? (FOAM is an adjunct, nothing replaces the bedside mentor!)
  • SMACC (the Social Media and Critical Care conference)
  • RAGE podcast (the Resuscitationist’s Awesome Guide to Everything)
  • INTENSIVE (the Alfred ICU’s education and knowledge translation blog)

HACK #6 Be a Critical Thinker!

HACK #7 Work Smarter and Get Things Done!


  • Learning medicine is hard work, learn to love it
  • Strive for mastery, not success
  • “It is up to us to save the world” – Peter Safar

The post Hacking Medical Education appeared first on LITFL: Life in the Fast Lane Medical Blog.

Noi, loro e la violenza. The Dark Side of the MEU (6a parte)

“Noi e loro. Dopotutto, siamo solo uomini.” Questo post potrebbe chiudersi così, con l’incipit della canzone più bella di The Dark Side of the Moon, l’album che ci fa da guida nel nostro viaggio nei lati oscuri della medicina d’emergenza. Us and them parla della violenza: la violenza nei rapporti con le altre persone, la […]

The post Noi, loro e la violenza. The Dark Side of the MEU (6a parte) appeared first on EM Pills.