The 19th edition of our series of eminence-based evidence:

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 reads. 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 week’s ‘R&R Hall of Famers’

• Kelly LE, Rieder M, van den Anker J. More codeine fatalities after tonsillectomy in north american children. Pediatrics. 2012 May;129(5):e1343-7. Epub 2012 Apr 9. Pubmed PMID: 22492761

You may have used codeine safely so far – but it’s a flawed medication and should be replaced in your practice.

Recommended by Ryan Radecki
Learn more: EM Literature of Note — Codeine, Potentially Unpredictably Lethal

This week’s R&R recommendations

Airway

Education

Emergency Medicine

Quirky, Weird and Wonderful

• Rossen R, Kabat H, Anderson J. P. Acute arrest of cerebral circulation in man. Arch Neurol Psychiat; 1943(50): 510-28

The Rossen study is shocking in its design, literally eye-popping in its technique and with consequently remarkable findings that obviously will never be duplicated in humans. The commentary by Smith (2007) is well worth reading.

Recommended by Reuben Strayer
Fulltext and Commentary

• Panesar NS, Graham CA. Does the death rate of Hong Kong Chinese change during the lunar ghost month? Emerg Med J. 2012 Apr;29(4):319-21. Epub 2011 Dec 28. PubMed PMID: 22205780.

Emergency Physcians examine death rates in Hong Knog. How about their awesome conclusion:”To protect their family, the Chinese women postpone death until after the hungry ghosts have been fed and hopefully banished forever.”

Recommended by Cliff Reid

Technology

Toxicology

• Kelly LE, Rieder M, van den Anker J. More codeine fatalities after tonsillectomy in north american children. Pediatrics. 2012 May;129(5):e1343-7. Epub 2012 Apr 9. Pubmed PMID: 22492761

You may have used codeine safely so far – but it’s a flawed medication and should be replaced in your practice.

Recommended by Ryan Radecki
Learn more: EM Literature of Note — Codeine, Potentially Unpredictably Lethal

• Korniyenko A et al. Visceral angioedema due to angiotensin-converting enzyme inhibitor therapy. Cleve Clin J Med 2011 May;78(5):297-304. Pubmed PMID: 21536824

Visceral angioedema caused by ACE inhibitors in another obscure, easily missed toxicologic cause of cryptic abdominal pain and vomiting, to be considered along with narcotic bowel syndrome and cannabinoid hyperemesis.

Recommended by Leon Gussow
Learn more: The Poison Review — Puzzling abdominal pain and vomiting? Consider ACE inhibitor-induced visceral angioedema
Fulltext

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of fame You simply MUST READ this!		R&R Hot stuff! Everyone ‘s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R WTF! Weird, transcendent or funtabulous!
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R Mona Lisa Brilliant writing or explanation

That’s it for now…

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.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

“Oh no,  not another goddam series of posts to follow on LITFL!”, you cry.

Relax would ya.

This is the first of an occasional series of posts where I’ll pull together a bunch of book recommendations from our beloved R&R crew. It seems that this posse of medical uber geeks likes to read stuff other than journal articles. I’ve asked them all which books they’d recommend emergency medicine and critical care should or must read — for whatever reason. I’ll be grouping them into loosely woven themes, but the recommendations can be anything — fiction, non-fiction, classic literature, self-help, poetry, comics, pop-up books… you name it.

The theme for the first edition of Books in the FASTLANE is:

‘Reading for kicks and giggles, sometimes amidst despair and darkness’

Here are the 5 recommendations:

Shit my Dad Says by Justin Halpern

“About a guy who moves back in with his father. Book is basically quotes from the dad, and they are funny as hell. His dad is a physician, I think, but this book isn’t medical. Just good old fashion family fun.”
— Rob Rogers

I read this book based on Rob’s recommendation and my zygomaticus majors were aching afterwards from the work out. Interestingly, my own father didn’t seem to think there was anything odd about the fatherly advice given in this book…

Catch 22 by Joseph Heller

“Outrageously funny – the original LOL. Despair and darkness.”
— Gerard Fennessy

“The book that was read, just at that epiphanal moment of angst-ridden teen-hood, which demonstrated that the world of adult-hood upon which one was just about to embark, was no better grounded in sense, than that of the one just about to be left. I will be forever grateful for the reminder that life is based upon the ridiculous, and the mostly meaningless. The medical references were also close to perfect.”
— Michelle Johnston

This is also one of my own all time favourites. From my own short stint in the NZ Army, I can assure this book is more realistic than it seems. Furthermore, the practice of emergency medicine and war seem to have a lot of features in common.

I hate myself and want to die. The 52 most depressing songs you’ve ever heard by Tom Reynolds.

“Had a bad day? plug in your ipad and read this. Funny, witty and not depressing at all!”
— Heike Geduld

I’ve added this to my reading list!

House of God by Samuel Shem

“This is the one book every medical student and intern in my generation seemed to have devoured. Scabrous and still wildly funny, it reads like an episode of “Marcus Welby” directed by Antonin Artaud. As John Updike pointed out in an introduction to the 1993 reprint, the novel “did for medical training what ‘Catch-22′ did for military life”. Absolutely indispensable, even 30 years later.”
— Leon Gussow

Without out doubt a must read for any doctor — it is still relevant. Check out this excerpt on ‘how not to diagnose amyloidosis’.

Dirk Gently’s Holistic Detective Agency by Douglas Adams

“Always difficult to choose the best novel by my favourite author ever. But this, slightly lesser known one, is pretty much perfect. Funny, lots of time bending, intensely well observed, and beautifully worded, has to get the prize, amongst his incomparable joys and gifts to the world.”
— Michelle Johnston

The early death of Douglas Adams was truly tragic. I wish he was still here. All of his books are brilliant – humorous and fanciful, but strangely spot on about the place of us humans in the universe I suspect. This is what happened when Doug met Struan Sutherland.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

This is a guest post from Dr Toby Fogg, Emergency Physician at Royal North Shore Hospital (RNSH) in Sydney and Retrieval Specialist with CareFlight. This is a follow up to his interview with Minh Le Cong featured in Airway Registry & Checklists in Audio. His website is AirwayRegistry.org.au.

How often does a junior medical officer (or in-fact one of your senior colleagues) in your ED have four attempts at intubating a patient before he, or she, finally succeeds?

How often do patients desaturate during RSI in your department?

Apnoeic oxygenation is all the rage but is it really being utilized?

We think we have a good idea of departmental performance but until we start collecting data on EVERY intubation, we will never have a reliable picture of what we do.

Without this reliable picture, we will never be able to target our education to improve our performance. We will never be able to evaluate new techniques or equipment.

I have been collecting data at RNSH for 2 years now and have data on over 400 episodes of intubation – here are some of the findings:

• Trauma accounts for 30% whilst strokes/ICHs and overdoses account for approximately 15% each.
• 20% occur when an EP is not around to supervise but we don’t have an increased rate of complications out of hours – cudos to the registrars!
• We don’t see many bariatric patients – only 3% had an estimated weight >109kgs.
• Our first pass success is 83%, and 87% of these first looks are undertaken by registrars or SRMOs. This doesn’t leave much practice for the specialists – 3 each per year on average! That makes me worry about skill fade.
• We found that the juniors who hadn’t done any time in anaesthetics had only a 50% success rate (and they were presumably given the easy ones to “have a go” on). We felt this was sub optimal and so have developed a credentialing package that involves an anaesthetic term to bed down basic airway skills and then a simulation session to learn to intubate sick patients in ED.
• Our laryngoscopy skills are a bit under par – 23% Cormack and Lehane 3-4!
• Naked intubation has been banned. I’d better explain – bougies (or stylets for the nonbelievers) are mandatory for all. As we have shown (again) that they do improve your chance of first pass success. The difficulty seems to lie in persuading the trainees that a patient who you think is going to be straightforward can easily trick you. Make life easy – optimise your preparation for first pass success.
• Desaturation occurs in 15% but 9% started off 2 attempts.

There are more graphs and data on the website AirwayRegistry.org.au, as well as a copy of the data collection sheet I use.

Since this project was launched onto the blogosphere a few weeks ago the interest has been phenomenal and I would encourage anyone who manages an airway in ED to get in touch with me. I’d be happy to enlist your department as a recruiting site for what I would love to turn into a multicentre database: The ANZEDAR – The Australia and New Zealand ED Airway Registry! (Suggestions for better acronyms gratefully accepted)

Finally I’d like to share a letter written to our DEMT by one of the junior registrars (permission granted). It will ring a few bells for most readers and underlines why it’s not the fancy laryngoscopes that count when the chips are down, it’s the basics that so often make a difference.

“I wanted to let you know about a positive solo experience I had on the ward during an ICU locum night shift at a private hospital. My airway/resus training at RNSH ED played a huge role in helping me to stabilise and save this patient’s life.

It was 0030 hrs in the morning when I was called to see an unrousable patient (who may have been that way for up to ten minutes prior). On arrival in the room I found a 60 yr. old lady with a heavily strapped right shoulder (after a shoulder arthoplasty that afternoon). She was unresponsive and clearly had an obstructed airway (grunting with paradoxical respiratory attempts). Not only was she blue, she was also obese, short necked, and had a small jaw. Her saturations at the time were 44% with HR 70, SBP 150.

I attempted to perform airway maneuvers and insert a Guedel airway – both of which failed to improve the saturations. She had trismus to compound the problem. No nasopharyngeal airways on the trolley. With a bag-valve mask I was able to ventilate her saturations up to 90% but no better (the saturations continued to fluctuate between 85 and 90%). There was significant resistance to ventilation.

A quick glance at the notes showed no significant PMHx and only morphine in recovery + a morphine PCA at the bedside. I gave 2 x200mcg Naloxone doses that failed to improve her GCS.

By this point I had an experienced ICU nurse + two very inexperienced orthopaedic nurses at the bedside helping during the arrest. There were no other doctors on site. I had one of the nurses phone the ICU consultant to let him know I would need to intubate the patient on the ward. He was 30 minutes away so advised to go ahead.

Sweat beads. Wet pits. Full backside of pants. My HR 179. Am now rethinking career choice.

I got a laryngeal mask brought down from the ICU in the event of a failed attempt (another piece of airway equipment not on the trolley). I gave the patient suxamethonium and propofol. The trismus relaxed and resistance to ventilation improved with muscular blockade and I was able move more air – saturations improved to 100%

I stuck a pillow under her shoulders (Toby Fogg trick I think), and then preloaded a bougie with an ETT. The airway was a grade 3 at first view. I manipulated the larynx and was able to see the cords – the ICU nurse was helpful with maintaining that view.

From there I was able to intubate the trachea with the bougie and pass the ETT without obstruction Capnography (old school litmus paper type capnography) was reading positive and saturations improved to 100%.

I took my first breath for the previous minute”

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

This a very cool project. How to make an ultrasound simulator on the cheap for use in training scenarios. We’ve already featured the first Australian implentation of this project (The Australian EDUS2 Project) in the 63rd LITFL Review. In yet another great video from SAEM2012, Paul Kulyk and Paul Olszynski the originators of this project tell the world what it’s all about:

Check out the EDUS2 website, where you can access the code, videos and design plans for free — all you need is to provide the hardware.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Relax it’s Friday!

Oh, you work shifts… never mind, another FFFF is here!

This week we find out how the Spanish health service intends to save 2 billion euros a year, what condition accounts for over 10 million courses of antibiotics each year in the US, and we learn about a clever Dutch physiologist, ego bias and micromorts.

Let’s dive on in…

Question 1

What new law was introduced in Spain in 2011, and is expected to save the Spanish health service over 2 billion euros a year?

Reveal the funtabulous answer!

Question 2

According to the CDC, each year in the United States over 10 million courses of antibiotics are prescribed for what condition?

Reveal the funtabulous answer!

Question 3

What is ego bias?

Reveal the funtabulous answer!

Question 4

In 1903, which Dutch doctor-physiologist developed a string galvanometer to graphically record the changes in electrical potential during contractions of the heart?

Reveal the funtabulous answer!

Question 5

What is a micromort?

Reveal the funtabulous answer!

Want An Easy Way To Score Higher On The FFFF?

It’s easy — write the questions yourself!
You can submit a question to the FFFF using this form.

Last week we defined funtabulous, this week — as gripping as this avalanche survival story is — we define ‘NOT funtabulous”:

http://www.youtube.com/watch?v=0pSBUXFJXiY

Hat tip to the fantastic blog ScanCrit which featured this video in a must read post on Avalanche Survival.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

In Become a Meducation Master! I told you about an exciting new course being held in Baltimore from November 11th to 16th 2012:

The International Emergency Medicine Faculty Development and Teaching Course, presented by the University of Maryland Department of Emergency Medicine.

Rob Rogers (@EMRAP_EE) has now produced this little video showing exactly what this course has to offer:

http://www.youtube.com/watch?v=NdVHjQHGCSw

Check out the course homepage at teach.umem.org for new details as they are confirmed, in addition to information about course costs and accommodation options.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The 18th edition of our series of eminence-based evidence:

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 reads. 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 week’s ‘R&R Hall of Famers’

• Levitan RM, Heitz JW, Sweeney M, Cooper RM. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med. 2011 Mar;57(3):240-7. Epub 2010 Jul 31. Review. PubMed PMID: 20674088

Levitan et al get into some great technical aspects of video and alternative devices for laryngoscopy. The point here is that while VL may make laryngoscopy easier, tube delivery and placement may paradoxically become more difficult, primarily because of the sharper angle between the blade and the trachea. Porn for airway enthusiasts.

Recommended by Seth Trueger

This week’s R&R recommendations

Airway

Critical Care

Emergency Medicine

Technology

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of fame You simply MUST READ this!		R&R Hot stuff! Everyone ‘s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R WTF! Weird, transcendent or funtabulous!
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R Mona Lisa Brilliant writing or explanation

That’s it for now…

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.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Mike Mallin is half of the enthusastic educational entertainment team that dreamed up and present the now legendary Ultrasound Podcast ( the other half being Matt Dawson). Mike was at SAEM2012, where he spoke about the history and educational philosophy behind their magnificent creation.

Check out what he has to say:

.. and don’t forget about their awesome One Minute Ultrasound App.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

For bloody ages now I’ve been meaning to give EM Lyceum a shout out. Fortunately, thanks to SAEM12 I can now easily let the creators of this interesting blog-based approach to emergency medicine education speak for themselves:

Check out the EM Lyceum for evidence-based debate on key and controversial topics in emergency medicine. Fans of the LITFL case-based Q&As will love the rough and tumble of the Lyceum. Our hats are off to the creators, Whitney K. Bryant and Anand Swaminathan.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Graham Walker is an emergency physician at the cutting edge of how our specialty interfaces with technology and social media. You know him, of course, from MDCalc, TheNNT and perhaps even his new blog Gmergency! Graham recently gave a talk at the Stanford Grand Rounds called ‘E-mergency Medicine’.

Here it is:

http://www.youtube.com/watch?v=qtkggenLmlE

You’d be stupid not to watch it.

Graham looks to the past to show how slow the spread of ideas used to be (think Semmelweis then Lister and Halsted) and compares it to the social media driven present (using EMCrit’s Delayed Sequence Intubation and the Best Use for a Bougie as examples). He cuts through the flaws of traditional peer review and suggests that social media-based crowd sourcing may be the way forward (although he highlights the potential pitfalls too). He also talks about his concept of a peripheral brain using a website as a readily accessible resource. Graham goes onto discuss the key resources he uses to stay up-to-date and keep learning: including the best blogs, podcasts and iphone apps. he finishes with his view of the future for emergency medicine academics and learning.

References:

• Full reference list for talk - Stanford Grand Rounds, May 9, 2012.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog