Pediatric Pit Crew CPR

A reader asks, “Does your Pit Crew CPR process work for pediatrics?”

See also: Pit Crew CPR – The Explicit Details

The answer is, “Yes!” with some minor modifications. We are developing a class for Pediatric Pit Crew CPR. It has not yet been implemented so consider this a beta version. I hate to give a disclaimer but you should have your Medical Director review this Pediatric Pit Crew CPR concept and the accuracy of our airway chart before using it.

Some things to keep in mind:

Pediatric cardiac arrest is more likely to be respiratory or asphyxial so there is less emphasis on “patient’s side to first shock” as the arrest rhythm is more likely to be brady/asystole/PEA.

However, this rule is not absolute! Hopefully you will know something about the history of the arrest on your arrival. There’s a big difference between a child fished out from the bottom of a swimming pool and a child who was hit in the chest by a baseball.

In addition, for the pediatric population we should start chest compressions when the heart rate drops below 60 and there are signs of poor perfusion despite ventilation with oxygen.

Phase 1: Initiate compressions and ventilations

  • Confirm the patient is pulseless or peri-arrest
  • Start continuous chest compressions at the appropriate rate, depth, and recoil
  • Deploy the the appropriately sized BVM
  • Attach the capnography circuit between the mask and bag
  • Attach the other end of the capnography circuit to the cardiac monitor
  • Turn on the oxygen
  • Attach the BVM to oxygen and set for 15 LPM
  • Insert an appropriately sized OPA
  • Switch to 15:2
  • Make note of the initial ETCO2 reading
  • Note: You have just implemented the most important evidence based therapies!

broselow_tape-300x129

Phase 2: Attach combipads, measure child, and shock as needed

  • Expertly performed BLS should already be happening at 15:2
  • Deploy and test the suction unit
  • Power on the cardiac monitor and select the “cardiac arrest picklist”
  • Deploy the cables and attach the combipads
  • Coordinate the application of the pads with the rescuer on chest compressions
  • Note: Children > 10 kg get the adult combipads!
  • You should know if the rhythm is shockable after the application of the second pad (unlikely if asphyxial)
  • Measure the child with the Broselow tape (Remember: “red to the head”)
  • Announce the Broselow color and weight to the resuscitation team
  • Example: “The child is Broselow Blue at 20 kg”
  • If the rhythm is shockable charge the capacitor at 2 J/kg without interrupting chest compressions
  • Once the defibrillator is charged, announce “Stop CPR”
  • The person on chest compressions should “show hands” to indicate they are clear
  • Note: “I’m clear, you’re clear, we’re all clear” should be completely gone at this point in time
  • Push the shock button
  • Resume immediate post-shock compressions
  • Subsequent shocks should be administered at 4 J/kg
  • After 2 minutes of expertly performed BLS reassess heart rhythm and pulse

Broselow_King_Airways

Phase 3: Initiate IV/IO access, give epinephrine, and consider advanced airway

  • Continue expertly performed BLS
  • Initiate IV/IO access
  • Provide first does of epinephrine (0.01 mg/kg) – Use the Broselow tape!
  • Repeat every 3-5 minutes
  • Advanced airway management is acceptable if it does not interfere with expertly performed BLS
  • See chart that correlates LMAs and King LT-Ds to Broselow Color
  • Once an advanced airway is in place you should deliver asynchronous ventilations every 6 seconds (that’s slow)
  • Avoid hyperventilation!
  • Consider and treat reversible causes (Hs and Ts)

Phase 4: Post-resuscitation care

  • Once ROSC is identified (sudden rise in ETCO2, organized rhythm on the monitor, verified with pulse check)
  • Attach pulse oximetry and continue ventilating (maintain SpO2 at 96-99%)
  • Avoid hyperventilation!
  • Obtain blood pressure
  • Remove any wet clothing
  • Obtain baseline temperature
  • Perform mini-neuro exam (Can the patient follow commands?)
  • Check oxygen and re-evaluate airway
  • Safely convey the patient to the hospital
  • Whenever possible transport parents with the child

See also:

EMS 12-Lead podcast Episode #8: Jim Broselow, M.D. and the Artemis Pediatric Initiative

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science – Part 14: Pediatric Advanced Life Support

Airway Challenges in Children by Dr. Brent Myers (highly recommended)

Welcome new ALiEM-EMRA fellow Scott Kobner

EMRAWe are excited to announce our inaugural 2014-15 ALiEM-EMRA Fellow for Social Media and Digital Scholarship, Scott Kobner, who is a second-year medical student at New York University School of Medicine. Scott brings a unique perspective to ALiEM and the FOAM community. He has worn many hats in the past, which will serve him well towards being a more versatile and mature clinician. He has been an EMT and EMT trainer, a scribe, a child-life volunteer, and New York Free Clinic patient educator. His focus recently has been on improving patient education especially in the Emergency Deparmtent.

We were especially impressed with his initiative in creating a new blog and podcast site called Ed in the ED, which stands for Education in the Emergency Department. He seems to have identified an untouched niche in the online education community thus far in EM. Scott’s proposed project is to further develop this patient education website and podcast site with an eye towards bringing this topic more into the forefront of medical education and framing the discussions with the current literature.

Dr. Nikita Joshi (Fellowship Director) and I both independently jotted down “LOVE HIM” in our notes.

 

Scott, however, was not the only one with amazing ideas and star potential. We are also sad to have to turn down the others. We so wished that we could have brought ALL of them on our team. We hope that they re-apply, and/or connect with us down the road to let us know how you are doing. We are always happy to serve as a sounding board.

Please help us in welcoming Scott to our ALiEM team!

Author information

Michelle Lin, MD
Michelle Lin, MD
ALiEM Editor-in-Chief
Editorial Board Member, Annals of Emergency Medicine
UCSF Academy Endowed Chair for EM Education
UCSF Associate Professor of Emergency Medicine
San Francisco General Hospital

The post Welcome new ALiEM-EMRA fellow Scott Kobner appeared first on ALiEM.

What to do when you make a ‘big’ clinical mistake.

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Oh everyone makes mistakes.
Oh, yes they do
Your sister and your brother and your dad and mother too;
Big people, small people, matter of fact, all people!
Everyone makes mistakes, so why can’t you?
:: Sesame Street – Everyone Makes Mistakes Lyrics | MetroLyrics ::

I try to be a good nurse. I try pretty damn hard.
Even so, I have made many clinical mistakes as a nurse in my 29 year career.
Thankfully most of them have been insignificant. Some of them (on reflection) have been hilarious. A few of them have been more serious.
One or two of them have been BIG.

There are many reasons (that I wont go into here) why good nurses make bad mistakes.
But here is some guidance on what to do when you make mistakes on the i-don’t-even-want-to-think-about-it end of the spectrum.
I really hope you never do. But you probably will. So its good to think about how you will respond.

  1. Breathe.
  2. Respond.
  3. Immediate conversation (no matter how difficult) with patient.
  4. Seek help.
  5. Document.
  6. Report.
  7. Debrief.

Breathe.

There is nothing more awful than that initial kamikaze gut-dive when you realise you have just made a significant clinical mistake.

You may feel tachycardic, and clammy and nauseous. You may have a sudden feeling of dissociation from reality. Your brain may be completely frozen in disbelief, or in total panicked hyperdrive.

Remember to reset and re-boot. Take a deep breath.

You are not the first nurse to make a clinical error and you will by no means be the last.
But at this moment…..it is not about you. There is work to be done.

Respond.

Assess your patient for any immediate or potential consequences that need to be attended to. If you are unsure of what those consequences might be, seek senior assistance. Look at your patients ABC’s. Do a set of observations.

If there is no immediate threat to your patient, your brain might now want to make your problem go away.

I think everything is going to be OK here. No need to make a big issue out of this. Lets just let it slide.

Nobody is aware of this mistake. I certainly did not intend to do anything wrong here. Im tired and overworked and I don’t deserve to cop the resulting trouble. Besides, let’s just spare this person all the worry and forget about it.

This is a reaction, not a response.

But wait, you say, I would never do something like that. Well let me tell you from personal experience, that voice whispering in your ear and looking for the easy path around this situation is mighty sweet and convincing.

But the path of professional accountability does not go around. Only through.

Immediate conversation.

The most important thing to do now is to tell the patient exactly what happened.
As soon as is practically possible.
This will be a difficult conversation. Difficult because you will be feeling so goddamn awful and difficult because it is from this very place you will need to communicate fiercely and effectively.
You may need to have someone with you for support, but it is important that the conversation comes from you.

Try to keep it simple. State exactly what you did wrong. Do not try to justify, or explain why it happened. Do not belittle or over-exaggerate the issue.
Tell them what happened in plain, clear language.
Apologise. From the heart.
Tell them what you intend to do next.
Ask them if they have any questions or needs at this time.

Depending on the situation, the patients response (and that of their family) may range from understanding, to extreme anger, to anxiety and fear. These reactions may occur immediately or over time as they have time to process the information.
Under no circumstances adopt a defensive or argumentative stand. Listen to them.

Seek help.

If you have not done so up to this point, now is the time to seek some assistance. You should notify your team leader and/or senior medical staff of the incident.
They will need to be involved in communications with the patient and in some cases they may need to arrange for someone else to take over their care ( for example: you may need to have a break for a while, or feel unable to continue with caring for this person at this time, or the patient may refuse to have you continue with their care).

Document.

Accurate and contemporaneous documentation of the mistake should be completed in the patient notes. Your documentation around this event is very important and may be reviewed in detail in the future.
So it is important to have time and space to sit down and make a thorough account of what happened.

Again. Keep it clear and concise.
Only in the documentation I would advise you to objectively include any external events or environmental conditions that you feel may have contributed to the mistake being made. If there were any.
Examples of this might be things like workloads, interruptions to workflow, unfamiliarity with equipment, unclear written orders.

Also record the conversation that you had with the patient and your actions immediately afterwards.

It is also a good idea to make a personal ‘diary’ record of what happened. You dont need to do this immediately. Perhaps sometime over the next few days as the initial emotions settle.
This document should also consist of a factual timeline of what happened for future reference.
It can also include more of a narrative record of of your experience.

After all the documentation and reporting you have done, it might seem a bit onerous to write yet another account of the incident. Especially when you are feeling so rubbish.
But do not underestimate the cathartic effect of writing down your own account of what happened.
If the mistake was a ‘big’ one, a personal record will also be extremely useful to re-jig your memory of the actual events in the future should you need to do so. Sometimes you may be required to recall the incident months or even years down the track.

Report.

Your hospital may have reporting policies for incidents or errors (such as medication error reporting or critical incident reporting). These must also be completed.

Debrief.

OK. So now its about you.
You will probably be feeling pretty terrible at this stage. And, truth is, nothing I could write here could possibly make you feel any better.

As the wise folks from Sesame Street assure us, everyone makes mistakes. And that includes big ones. It does not make you a bad nurse. It does not make you a bad person.

The essential thing here, is to find a trusted, supportive colleague and talk to them about what happened.
It is perfectly normal to beat yourself up and question your abilities as a nurse afterwards.

You may also experience the following:

  • ruminating and replaying the event over and over in your thoughts.
  • decreased appetite
  • increased irritability and loss of concentration.
  • not wanting to go to work.
  • problems sleeping.
  • loss of self-esteem or confidence.
  • believing other staff no longer trust you, or are putting you down.

Again, these are all normal reactions that may be experienced after making a clinical error.
However, if they do not begin subsiding after a reasonable time, or if they intrude into your ability to function effectively as a nurse, you MUST seek professional support.
See your manager or senior staff to arrange this.

The long term sequelae will be different for each of us depending on the magnitude of the mistake and the support we receive afterwards.
It may be useful for you to reflect on why the error was made, and become active in developing any quality improvement solutions that might be implemented to lessen the chance of re-occurrence.
Sometimes it will lead to some ‘inner work’ examining some of your own practices or clinical behaviours that might be improved.

Your feelings about this mistake will probably never change.
But your relationship to those feelings will, over time, adjust. With support and self-reflection, the mistake (no matter how large) can be accepted for what it was.
Issues around any adverse outcomes from the mistake can be worked through, and the event can be integrated into your professional work making you even more accountable, compassionate and competent.

 


References: featured image via kevygee


 

 

My professional college beclowns itself

A fisking of a paranoid, ill-considered and frankly stupid idea a 9th grader would be ashamed to put forth. From the American College of Emergency Physicians ‘leadership’.

ACEP Clarifies Campaign Rules

By James M. Cusick, MD, FACEP

Chair, Candidate Forum Subcommittee of the ACEP Council

ACEP is a member-driven organization with a representative body of our peers – the ACEP Council – chosen through component bodies, including our chapters (1 representative per 100 members), our Sections of Membership, and other aligned organizations.

There follows some boilerplate language designed to get you to tune out.

None of this is aimed at the author, BTW, I have no doubt he was asked to write this and didn’t make this decision. This is about the College and a terrible decision that reflects poorly on it.

In addition, protections were incorporated into the rules to keep candidate interviews in ACEP publications. Our goal is to avoid candidates being put in the position of commenting on College policy without adequate preparation and to ensure that the campaign process is fair and equal for all candidates.

Wait, what? Candidate interviews for ACEP positions can only be in ACEP house organs? Is Stalin in charge? And for the rationale of “…being put in the position of commenting on College policy without adequate preparation and to ensure that the campaign process is fair and equal for all candidates” means ‘we intend to cover up for the candidates we really want to win, and the gaffes from the unworthy will be published in bold print, but rest assured if you’re our selection it’ll totally be glossed or even left out’.

Count on that. And that’s bollocks.

It’s the biggest horse shit this college has dumped in quite a while, and that isn’t how I want my college to represent itself because that’s how it represents me. Really, if you’re running for President of ACEP, you should be able to handle a non-coddled interview. Seriously, you’re going to say they’re too fragile to be interviewed ‘without adequate preparation…’ and then expect them to deal with legislators and their staffs who are dealing with skilled negotiators and people who know what they are there for? No thanks, I’d rather know the warts and all right up front, not filtered through the ACEP info-seive.

Certain candidates may unfairly benefit from coverage in non-ACEP publications, while some may be disadvantaged. In order to ensure a fair election, campaign questions and the vetting of candidates is the responsibility of ACEP, its Council and its Council Committees.

Umm, no, it’s the right of all of ACEP to know who’s running for office, what their unfiltered views are, and how they handle themselves with tough questions from tough questioners. It’s called campaigning, it’s not the pinewood derby. The very idea that ACEP can make an election totes fair by limiting the questions and answers to their own publications is laughable, were it not so tragically and pathetically sad. If you’re worried someone has an unfair advantage, Editorialize in ACEP Now, and their 150 avid readers can spread the word. But this entire approach is insulting to the intelligence and spirit of ER docs in our great nation.

(Any of you ER docs want to make sure your patients are only presented one at a time, with discreet illnesses and injuries, with a pre-selected choice card of correct diagnoses? No? It’s because we live and work in the real world, and that’s an absurd proposition, like this).

Also, and some may not be aware, but this is most likely a reaction to the excellent challenge by Dr. Greg Henry, ACEP Past-President and fixture asking for a robust questioning in his April 28, 2014 article ACEP, let’s set a real agenda. Read that article, and the kind of questions he wanted to ask, then you’ll see this in-house gag order for what it is: cover for their chosen.

If you’re a candidate for president and you buy into these rules, I know you’re not ready for the job.

If there are specific questions you would like asked of the candidates prior to the election, please send them to communications@acep.org. The Candidate Forum Subcommittee will consider them, the selected questions will be posed to candidates and their responses will be made public.

Really. You’re not only going to vet the answers and decide what goes out you’re going to control the questions, too? Here are a couple for you: a) boxers or briefs, and b) puppies or kittens?

I for one would like to have someone bathed in the knowledge of fights won and lost ask our presidential candidates hard questions about the tough choices facing ACEP, but we will absolutely not get it with this format. On purpose.

Hell, we’ll be lucky to find out if they like puppies.

 

via ACEP Clarifies Campaign Rules « The Central Line.

Research and Reviews in the Fastlane 036

R&R in the FASTLANE 010 RR IN THE FASTLANE LOGO 21 590x213

Welcome to the 36th 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 11 recommended readsThe R&R Editorial Team is Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find out more about the R&R in the FASTLANE project here and check out the team of contributors from all around the world.

This Edition’s R&R Hall of Famer

Emergency Medicine, Critical Care

R&R Hall of Famer Blue

Chatterjee S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564

  • This meta-analysis suggests potential mortality benefit in patients with haemodynamically stable pulmonary embolism with right ventricular dysfunction (intermediate-risk PE). However, this advantage must be tempered against the increased risk of major bleeding and intracranial haemorrhage associated with thrombolytic therapy, particularly for patients greater than 65yrs. Thrombolysis was also associated with a lower risk of recurrence of pulmonary embolism.
  • Recommended by: Nudrat Rashid, Anand Swaminathan, Salim R. Rezaie, Chris Nickson

The Best of the Rest

Emergency Medicine, Infectious diseases

R&R Game Changer? Might change your clinical practice

Stevens DL, Bisno a. L, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2014. PubMed ID: 24947530

  • For a common emergency department complaint, management of skin and soft tissue infections (SSTIs) is rife with dogma and marginal quality evidence. The IDSA released updated guidelines once again urging physicians to target streptococcus (i.e. no MRSA coverage) in most non-severe cases of non-purulent cellulitis, use an initial 5 day course of antibiotics in cellulitis, and only give antibiotics after incision and drainage to moderate/severe purulent infections (defined by systemic symptoms). Take a gander at the article for some excellent theoretical algorithms, recommendations on less common SSTIs (bubonic plague), and read these updates yourself, since even the recommendations persisting from the 2005 iteration still haven’t made it into practice.
  • Recommended by: Lauren Westafer

Emergency Medicine, ENT

R&R Eureka

2. Noble S, Chitnis J. Case report: use of topical tranexamic acid to stop localised bleeding. Emerg Med J. 2013 Jun;30(6):509-10. PubMed ID: 22833592.

  • Tranexamic acid has become a popular drug for dealing with difficult to control areas of bleeding including epistaxis and oral mucosa bleeding. Here, the authors discuss a case of bleeding from a nipple after piercing in a patient with hemophilia.
  • Recommended by: Sean Fox

Emergency Medicine

R&R Game Changer? Might change your clinical practice

3. Stiell IG et al. Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study. CMAJ 2014. PubMed ID: 24549125

  • This study found that a high percentage (49%) of patients with serious adverse outcomes after an ED visit for COPD were not initially admitted to the hospital. The authors used logistic regression to derive a decision instrument to aid in determining which patients with COPD exacerbation should be admitted based on risk stratification. The study does not show that admission improves outcomes but the instrument may prove useful for risk stratification if it is prospectively validated.
  • Recommended by: Anand Swaminathan

Emergency Medicine, Critical care, Anaesthetics

R&R WTF

Barends CRM ,Absalom AR. Tied up in science: unknotting an old anaesthetic problem. BMJ 2013;347:f6735. PubMed ID: 24335667

  • Anyone who has transferred a patient – whether from ED to CT, between theatre & ICU or between institutions will be familiar with one of the universal laws of transfer medicine – cables and lines will inevitably become tangled.

    But why?

    Clever physicists and topological mathematicians have the answer, with knot formation a function of the length of lines and their movement. It’s not exactly string theory in the sense of cosmology and quantum physics – but it’s highly relevant to anyone caring for a critical patient with multiple lines…

    A deeper dive for the maths geeks can be found here

    “Based on the observation that long, stiff strings tend to form a coiled structure when confined, we propose a simple model to describe the knot formation based on random “braid moves” of the string end. Our model can qualitatively account for the observed distribution of knots and dependence on agitation time and string length.”
  • Recommended by: Tim Leeuwenburg

Emergency Medicine

Partyka C, Taylor B. Review article: ventricular assist devices in the emergency department. EMA 2014; 26(2):104-12 PubMed ID: 24707998

  • Great FOAM review article on trouble shooting and management of patients who present with left ventricular assist devices (LVADs).
  • Recommended by: Anand Swaminathan, Chris Nickson
  • Learn more: Part man, part machine… – thebluntdissection

Critical Care, Respiratory

R&R Hot Stuff

6. Lee JM, Bae W, Lee YJ, Cho YJ. The efficacy and safety of prone positional ventilation in acute respiratory distress syndrome: updated study-level meta-analysis of 11 randomized controlled trials.Crit Care Med. 2014 May;42(5):1252-62. PubMed ID: 24368348

  • This meta-analysis elucidated the effect of prone positioning on overall mortality and associated complications.Ventilation in the prone position and duration of proning significantly reduced overall mortality in patients with severe ARDS. The major complications were pressure ulceration and airway problems.
  • Recommended by: Nudrat Rashid

Emergency Medicine, Critical Care

R&R Landmark

Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis? JAMA. 2006 Oct 25;296(16):2012-22. Review. PubMed PMID: 17062865

  • Techniques that reduce Post LP Headaches: (a) Use small gauge, atraumatic needles (b) Re-insertion of stylet before removal of needle (c) Patients DO NOT need bed rest after LP
  • Recommended by: Salim R. Rezaie

Airway

R&R Hot Stuff

R&R Game Changer? Might change your clinical practice

Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014; ePub. PubMed ID: 24859931

  • In this meta-analysis, ketamine was not shown to increase intracranial pressure in comparison to opiates in patients with ICP monitors. Although there were only 5 studies included and there was significant heterogeneity, the evidence showing that ketamine does not significantly raise ICP is far more robust than the evidence behind the old dogma.
  • Recommended by: Anand Swaminathan

Emergency, Critical Care, Ultrasonography

R&R Hot Stuff

Nazerian P et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014; 145(5):950-7PubMed ID: 24092475

  • Point of care multi-organ ultrasound in the hands of experienced Emergency Medicine sonographers is a promising modality for the diagnosis or exclusion of pulmonary embolism in place of CT scan. In this study a negative multi-organ ultrasound (lungs looking for subpleural consolidation, the heart looking for RV dilation and the lower extremities looking for DVT) along with ultrasound revealing an alternative diagnosis had a sensitivity of 100% when compared to CT scan as the gold standard. The study shows that CT scanning could be reduced by 50% with application of this modality.
  • Recommended by: Anand Swaminathan
  • Learn more: Multi-Organ US for PE (Ultrasound Podcast)

Infection Control

R&R Eureka

Rock C, Harris AD, Reich NG, Johnson JK, Thom KA. Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time?–a randomized controlled trial. Am J Infect Control. 2013 Nov;41(11):994-6. doi: 10.1016/j.ajic.2013.04.007. Epub 2013 Jul 24. PubMed ID: 17618418

  • This thought must cross every health care worker’s mind. Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of our time? This randomized controlled trial showed that hand hygiene before donning nonsterile gloves does not decrease already low bacterial counts on gloves. The utility of hand hygiene before donning non-sterile gloves may therefore be unnecessary.
  • Recommended by: Nudrat Rashid

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 should keep you busy for a week at least…
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. Thanks to our wonderful group of contributors!

The post Research and Reviews in the Fastlane 036 appeared first on LITFL.