Much has been made of diagnosing potential abnormalities and consistent ‘normalities’ within the ECG of athletes.

However, little research has been afforded other significant ECG changes consistent with emotional disturbances manifesting as electrical pertubations within the electrocardiograph.

The LITFL team call upon the wider academic cardiological community to fund research into the under-diagnosed conditions of ‘calligraphitis‘ or literary heart syndrome and the positive electropenogram

Calligraphitis is often seen within the cardiac tracings recorded on the more sensitive and artistic members of our patient community.

Diagnostic criteria: Concordant, complex oscillatory changes throughout all leads.

Implied association: Patients presenting with calligraphitis are more often sensitive, caring individuals with strong artistic tendencies and prone to spontaneous outbursts of song, excessive rhyming and/or alliteration.

Professor Throckmorton, our new Head of the Committee Of Continuing Knowledge, has spent the last 13 years investigating Wolkenkuckucksheim and ithyphallic activity occurring in Electrocardiographs.

After an exhausting 12 month statistical analysis by the backroom boffins, the retrospective review of 26 832 ED cardiac tracings has finally been completed. The results of this BACCHUS-II trial are open to interpretation, lack little scientific credibility and are on the whole inaccurate. However, in this world of eminence based medicine where the statistics never lie it is prudent to take note of the studies findings.

• Resting Positive Electropenograms were recorded in 2.6% of the general population, 3.4% of inmates and 13% of administrators (p = 0.02; 95% confidence interval, 1-99%)
• The maximum prevalence of Positive Electropenograms occurred on Friday and Saturday evenings (80%) with a staggerring 93% on Public Holidays.

As yet it is uncertain as to what a positive Electropenogram might mean for the patient but some of the LITFL team have their theories…

EPG positive

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

Lest we forget…

I had the great fortune to pick up an original edition of “Diseases and Remedies – 1898″ on a recent second hand book shopping spree in Dunedin, New Zealand.

I love looking back through the old texts to revisit conditions we no longer see or infrequently treat. But my interest is not solely in the diseases we have virtually eradicated through vaccination programs and the advancement of modern medical treatment, but also as a reflection on those conditions that still trouble the modern day physician.

There is a lot we can still learn from the pharmaceutical and lifestyle interventions advocated in the old texts.

Firstly we can reflect upon older remedies which were in frequent use, but have been lost in the mists of time. Such pharmacopoeia may have potential benefit in modern day medicine if the active ingredient for success can be defined, processed and evaluated.

After all, we are still reliant on the pharmacological derivative of the foxglove (Digitalis purpurea) more than 200 years after William Withering brought it back to the worlds attention. Records indicate that the foxglove had been used for various purposes for many centuries but by 1745 had fallen into disrepute through injudicious use. Following the re-evaluation of digitalis in the treatment of dropsy (pulmonary oedema) modern medicine has done little more than to change the derivative plant type to Digitalis lanata

…in spite of opinion, prejudice, or error, Time will fix the real value upon this discovery, and determine whether I have imposed upon myself and others, or contributed to the benefit of science and mankind. - William Withering 1785

Secondly, it can be both disheartening and uplifting to read of the same generic plants/chemicals being advised for treatment 100+ years on…such as in the treatment of angina pectoris

Thirdly, we must never rest on our laurels…”we can never be certain…of anything“.

As our knowledge and understanding grows…we are able to define, then re-define the pathophysiological processes underpinning medical disease allowing us to further refine treatment remedies, preventative protocols and lifestyle adjustments.

“The Lord Privy Seal is neither a lord, nor a privy, nor a seal” and “‘seborrhoeic’ warts have no relationship to seborrhoea.”

I find some of the older, more literal descriptions, easier to visualise and empathise with. For example “Apoplexy” [unconsciousness or incapacity resulting from a cerebral haemorrhage or stroke]

Finally, “some things change…some stay the same”

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

Desperately Seeking Symmetry - Jad and Robert set out in search of order and balance in the world around us, and ask how symmetry shapes our very existence–from the origins of the universe, to what we see when we look in the mirror.

This striking Radiolab video made by Everynone was inspired by Radiolab’s Desperately Seeking Symmetry episode. Filmmakers Will Hoffman, Daniel Mercadante, and Julius Metoyer III play with our yearning for balance, and reveal how beautiful imperfect matches can be.

Energised by the evocative audio and inspirational images….

http://www.youtube.com/watch?v=zEQskIsHKT8

…one can look deeper

http://www.youtube.com/watch?v=b5ykdE7B-qQ

…searching for the exalted anticipatory pause

http://www.youtube.com/watch?v=BTOfEv0nWfA

…and the silent nod of acceptance and appreciation

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

The Necessary Evil of Examinations

In two weeks the next flock of lambs to the slaughter climbers on the biannual ascent of an educational Everest will be taking on the ACEM Fellowship Part II exams. These happy few are the fortunates who have already overcome the perils of the written examination, and must now stand face-to-face with their examiners for the clinical component.

Even Osler agreed that exams were something of a menace to the true student of medicine:

“Perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offense in the pathway of the true student.”
— William Osler, from Aequanimitas, 3rd edition, 1932.

Perhaps this is because no examination can be passed by knowing the subject matter alone. One must also master the ‘hidden curriculum’, the unwritten rules of engagement. Only the foolish, the preternaturally brilliant, or the interminably lucky dare remain ignorant of these invisible hurdles. As such, a great deal of effort must be spent, not only learning about how to care for patients and the manifestations of disease, but about how to pass the quiz. Of course, knowing how to play the game is, in itself, not enough. One must find a way to acquire the necessary knowledge.  For this, we must embrace what Osler has called the Philosopher’s Stone, that which turns base lead into gold, his Master Word: Work.

“With too many, unfortunately, working habits are not cultivated until the constraining dread of an approaching exam is felt, when the hopeless attempt is made to cram the work of two years into a six month’ session, with results only too evident to your examiners.”
— William Osler, from  Introductory Lecture on the Opening of the Forty-Fifth Session of the Medical Faculty, McGill University. 1877.

For all the sweat and tears that these perilous stumbling blocks extract, they are not without purpose. Examinations are an undeniable spur to action. They force us to investigate our deficiencies and expose our many weaknesses. When done as part of perfect preparation, we may be strengthened in time for the test, as well as for the rest of our careers.

“I do not know of any stimulus so healthy as knowledge on the part of the student that he will receive an examination at the end of his course. It gives sharpness to his dissecting knife, heat to his Bunsen burner, a well worn appearance to his stethoscope, and a particular neatness to his bandaging.”
— William Osler, from an address to medical students at the University of Pennsylvania, 1885.

So, ultimately, we must accept that examinations are necessary. Offensive rocks though they may be. Yet we do well to remember that examinations are just the toll gates at which we must all pay our dues as we embark on an endless journey. An endless journey in search of mastery in medicine.

“In its subject matter there is everything in its favour, and it is the easiest possible thing to carry out John Locke’s primary canon in education — arouse an interest… It is hard to name a dry subject in the curriculum. And yet in an audience of medical students such a statement nowadays raises a smile. Why? Because we make the examination the end of education, not an accessory in its acquisition. The student is given early the impression that he is in the school to pass certain examinations, and I am afraid the society in which he moves grinds this impression into his soul.”
— William Osler, from ‘An Introductory Address on Examinations, Examiners and Examinees. Lancet. 1913; 1047-50.

“If the license to practise meant the completion of his education how sad it would be for the practitioner, how distressing to his patients! More clearly than other the physician should illustrate the truth of Plato’s saying that education is a life-long process.”
— William Osler, from ‘The Importance of Post-graduate Study.’ Lancet. 1900 (2):73-75.

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

Thanks to a regular diet of vitamin FFFF, LITFL managed to fight off a malign malware miasma last week. Unfortunately, with the blog’s immune system occupied, FFFF 051 had to be delayed… But, finally, it’s here!

With two weeks of FFFF withdrawal symptoms kicking in, this week’s FFFF megadose might not be well tolerated by the usual route of administration. Feel free to experiment with other routes and let UCEM’s PR Supervisor know if the bioavailability is improved.

Questions

Can you match these opening lines or paragraphs to the appropriate book? Each book is somehow, often only tenuously, related to some aspect of medicine or previous LITFL posts…

Q1. Name the book that opens with:

“It was inevitable: the scent of bitter almonds always reminded him of the fate of unrequited love.”

Show answer

“We were somewhere around Barstow on the edge of the desert when the drugs began to take hold. I remember saying something like ‘I feel a bit lightheaded; maybe you should drive . . .’ And suddenly there was a terrible roar all around us and the sky was full of what looked like huge bats, all swooping and screeching and diving around the car, which was going about a hundred miles an hour with the top down to Las Vegas. And a voice was screaming, ‘Holy Jesus! What are these goddamn animals?’”

Show answer

Q3. Name the book that opens with:

“Far out in the uncharted backwaters of the unfashionable end of the Western Spiral arm of the Galaxy lies a small unregarded yellow sun. Orbiting this at a distance of roughly ninety-eight million miles is an utterly insignificant little blue-green planet whose ape-descended life forms are so amazingly primitive that they still think digital watches are a pretty neat idea.”

Show answer

“Life’s like a penis:
When it’s soft you can’t beat it;
When it’s hard you get screwed”

Show answer

“It was love at first sight. The first time Yossarian saw the chaplain he fell madly in love with him”

Show answer

Q6. Name the book that opens with:

“Dr. Iannis had enjoyed a satisfactory day in which none of his patients had died or got any worse.”

Show answer

Q7. Name the book that opens with:

“In eighteenth-century France there lived a man who was one of the most gifted and abominable personages in an era that knew no lack of gifted and abominable personages.”

Show answer

Q8. Name the book that opens with:

“The beginning is simple to mark.”

Show answer

Q9. Name the book that opens by quoting Daniel Defoe:

“It is as reasonable to represent one kind of imprisonment by another, as it is to represent anything that really exists by that which exists not.”

Show answer

Q10. Name the book that opens with:

“They’re out there. Black boys in white suits up before me to commit sex acts in the hall and get it mopped up before I can catch them.”

Show answer

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

One day, in a town not far from here, the Urology team were about to perform a radical prostatectomy on a middle aged man. He had a wry smile on his face, as we gassed him down. Must be the midazolam, thought the anaesthetist.

When he was fully asleep, he was stripped bare, but hidden in his jocks was a bit of paper. On that piece of paper there was a poem, which read…

Note to Dick Doc

Hey dear Doc,
I love my cock,
And have a girlfriend
Young and hot.

Now I may not be
The worlds best Bard,
But my girlfriend likes it
When I’m hard.

So I won’t ask
If you can spare a dime,
Perhaps another place,
And another time.

But my sex life
Is on upward curve,
So hey there buddy,
Can you spare a nerve?

This had the whole team in hysterics. The operation proceeded well, and the surgeon, presumably flattered by the effort, and unable to conceal his own aspirations at Shakespearean fame, composed his reply…

Response to Eric

Oh brave patient!
Your wishes are ancient!
With crafty words hidden
Down low, near forbidden.

A reminder to us,
The nerves are a must!
So to protect them for certain,
We raised up a curtain.

Now the Evil is gone,
Your member will live on.
A reminder to all
Who this disease will befall,
That with modern surgical skill,
We are sure to Fulfil!

The Anaesthetist, not to be outdone, composed her own response, although the final word may have been altered to protect the innocent.

Dear Eric

To save your bits,
We did our best!
Mother Nature
Must do the rest.

For your wit,
You do deserve
To keep the power
In the all-important nerve.

With some surgical finesse,
And a bit of luck.
Your lovely girlfriend
Will remain a lucky duck.

The Anaesthetic Registrar, having come back from his 12^th tea break for the morning, was rather proud of his contribution. He wrote…

Ode to Eric

Hi Eric!
You had us in hysterics,
You made us smile,
With your style.

So we shaved you there,
Because we care,
To get it right
Up, without a fight.

We did remember
To spare your member.
And with Viagra,
She’ll want to shag ya!

We wish you luck,
With every… year!

The poems were photocopied onto a double-sided A4 paper, and placed back “down there”.

Eric woke with a smile…

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

Learning about the life of Sir William Osler (1849-1919) is perhaps the ultimate lesson in how to live life and practice medicine. Yet, he doesn’t go to war, he doesn’t fight or kill anyone, he doesn’t change the Fates of Nations… How can reading about such a man be interesting?

Well, what Osler did do was that he did things ‘right’ — he constantly found ways to enjoy his life and work, he helped and inspired others, and despite an insane work schedule always made people feel like he had time for them. No one who learns of Osler can fail to be swept away by his incredible personal charisma and his infectious enthusiasm for both work and learning, and — I suspect — no one in medicine can afford not to be!
Probably the most accessible and up-to-date biography of Osler is by Canadian writer Michael Bliss: ‘William Osler: A Life in Medicine‘ (2002). Incidentally, Bliss also wrote an excellent book on ‘The Discovery of Insulin‘, which I also highly recommend.

The obsessive and compulsive oslerphile will want to wade through Harvery Cushing’s classic Pulitzer Prize-winning biography, “The Life of Sir William Osler“. This magnum opus was published in 1925 and  clocks in at well over a thousand pages and is littered with excerpts from the many letters of the great man himself. It took nearly all of my sleep-deprived intern year to read it, back in the day. An impressive online version is being put together here.

Aside from the traditional biographies, there are at least two other books on Osler that I recommend to all. The first is Silverman et al’s organized collection of over a thousand of Osler’s quotations, namely ‘The Quotatable Osler‘. Osler had a peerless mastery of the written word and his axioms and insights continue to resonant across the centuries. Secondly, there is Charles S. Bryan wonderful 1997 book, ‘Osler: Inspirations from a Great Physician‘. This unusual book is almost a self-help book based on the way that Osler lived life. It is a pleasure to read and provides highly nutritious food for thought.

These days, though, no one actually reads books.

So where should the webified Oslerphile turn for an fix of Osleriana? Fortunately, Osler is alive and well on the web. These resources demand your perusal:

• Osler’s Web — the website of the John P. McGovern Historical Collections & Research Center is the place to turn. If something is written by or about Osler and it is on the web, look here first.
• The Oslerian Archive at The American Osler Society — regular updates from the Oslerian world.
• Among Osler’s writings on the web are his biographical essays on the great physicians of the past in ‘An Alabama Student’ and his addresses to students, nurses and practitioners of medicine in ‘Aequanimitas‘.
• Whonamedit — The article on Osler is a great summary of the man’s life, and there are links to all of Osler’s eponyms.

Of course, there is much about Osler to be found on LifeInTheFastLane.com too:

• Aequanimitas — Osler’s inspired watch word and the basis of the opening post of my original blog before Aequanimitas started ‘living in the fast lane’.
• Egerton Y. Davis — meet Osler’s mischievous alter ego.
• Penis captivus — one of medicine’s greatest practical jokes and a priaprismic lesson in the flawed nature of the medical literature.
• Pimping in perspective — yes, even Osler was a pimp!
• The Breakfast Club — the source of my own case of Oslerophilia and an introduction to one of my greatest teachers.
• The Lessons of Osler —
  001 The Master Word
  002 Have fun and cultivate your sense of humo(u)r
  003 Learn the Art of Observation
  004 Treat the patient, not the disease

Once you’ve learned the Art of Observation, seeing what this image really shows will come as no surprise…

Photograph by luc.viatour

…  And, finally, I must not fail to mention the great-grandson of William Osler’s alter ego, UCEM’s very own Council Hygienist and PR Supervisor, the renowned psychiatric surgeon Egerton Y. Davis IV!

You can also follow him on Twitter.

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

The most recent co-med-ical  ‘Souffle of Awesome’ from ZDoggMD and Dr. Harry is Witch Doctor?, as featured in the 4th LITFL Review. It’s a bombastic parody of the stereotypes of different medical specialties backed up with brilliant, and sometimes dubious, beat-boxery. They mock the adrenaline-fueled ER, sorry ED, doc who expounds about his extreme extracurricular adventures while saving a patient’s life. They even go as far as accusing ER docs of using call signs like “Maverick” and, er, “Soft Serve”…

Well, the thing about stereotypes, is that, sometimes, there is a kernel of truth somewhere in there.

Let me introduce you to Exhibit A for the defence, Doctor…

Deniz Tek is an American-born guitarist, singer and songwriter who achieved greatest noteriety with the band Radio Birdman in the 1970s. He is considered by some as among the best rock guitarists in the world and, to quote Wikipedia, is “most known for exerting his burning Detroit style guitar influence over the punk rock genre in Australia”.

http://www.youtube.com/watch?v=BIkod60zViM

In the early 70s, Deniz studied medicine in New South Wales. He went on to practice emergency medicine and flight medicine. Although he traveled back to the States for a time, he still works as an emergency physician in Australia today.

But that wouldn’t be enough for him to have an entire LITFL blogpost dedicated to him. There’s more…

While Tek was Stateside he joined the US Marine Corps. He became a flight surgeon and flew backseat in F4 Phantoms. Rumour has it when a bunch of Hollywood screenwriters visited his squadron while doing research for a movie called ‘Top Gun’, they liked what they saw:

Which is lucky, because without the Iceman, the ‘Top Gun’ storyline wouldn’t have made much sense…

http://www.youtube.com/watch?v=ekXxi9IKZSA

[Hat tip to Bjorn Makein for first introducing me to the Deniz Tek legend]

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

In the mid-1980s Alastair Coutts was the surgeon for the Solomon Islands. In 1999 he described one of his more interesting cases in an article published in the BMJ.

The story starts with a telegram he received from Dr Bob Eason (who if I remember correctly, taught me clinical physiology back in medical school):

Fifty five year old lady. Acute extradural haemorrhage. Ipsilateral pupil up. Unconscious flexor pain responses. Boggey haematoma over left middle meningeal area. Any chance you can come plus equipment to evacuate clot. Helena Goldie Hospital would refund fares.
Dr Bob Eason

An adventurous 400 mile trip from Honiara to Munda, and its landing strip with no lights, ended with Alastair jumping on the back of Bob’s moped as they sped to the hospital. This is what he found when he got there:

The patient was deeply unconscious and both pupils were dilated; she made extensor movements to pain with only her left arm and had a large swelling over the left side of her head as a result of being hit by a falling coconut. Her Glasgow coma score was about 4, but at least she had a clear airway and was breathing.

Scan or no scan, it didn’t take a brain surgeon to figure out what was going on: an extradural hemorrhage and a coning patient. First Bob got the consent:

No operation—100% chance of dying, operation—99% chance of dying.

The family deliberated for ages, then agreed to proceed with a craniectomy. The operation was swift.

As soon as the clot had been evacuated the patient woke up, tried to get off the table, and promptly hit her head on the lamp, exclaiming, “The Lord be praised.” She lay back and the previously quiescent middle meningeal artery started spurting everywhere.

The patient was no longer coning — she was bleeding to death. Bob grabbed four bystanders and bled them, assuring Alastair that everyone in Munda was O positive.

Under the flickering lamp with minimal equipment in a small wooden hut, Alastair simply could not stop the bleeding. His patient was going to die. Then he looked up and saw Jesus.

Opposite me was a large Roviana male nurse who was chewing gum… he announced his name was Jesus.

Coutts had to think fast:

“Jesus, please could I have some of your chewing gum?” “Of course,” he said reaching into his shorts pocket for a fresh stick. “No, not that stuff, the stuff in your mouth,” I retorted. Incredulously, he opened wide and handed me his gum. With thumb and forefinger I skilfully rammed it into the left foramen spinosum. The bleeding stopped.”

Bob administered the new antibiotics that had been recently donated from New Zealand. Six months later Alastair reviewed his patient:

“She had a minor right sided hand weakness but wanted the bone back in her head.”

Reference

Coutts A. Chewing gum for extradural haemorrhage. BMJ. 1998 Dec 19-26;317(7174):1687. PMID: 9857127;   PMCID: PMC28750.

Hat tip to Trevor Jackson F.UCEM HTFU for directing us to the original paper.

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

I travelled across Australia last week by air from Perth in Western Australia to Cairns in the far north of Queensland. The 3500km trip involved a brief stop in Uluru (Ayers Rock). As I looked out of the window throughout the journey I saw the changing landscape and was amazed by the beauty and the vastness of the red/brown earth passing beneath me.

But I also started to develop a feeling of unease, some symptoms that I couldn’t quite explain. I was concerned, what was happening to me? Was it something I ate? What was it about this remakable trans-Australia journey that was doing this to me?

Luckily my symptoms resolved, but I was intrigued and perturbed. So in an attempt at self diagnosis I scoured the literature to find out about my condition.

I came up with this single case report which provides a fitting description and diagnosis. I will reproduce it here on Life in the Fast Lane for your educational benefit.

The day would soon arrive when I could not ignore the rash
I was obviously ill and so I called on Doctor Nash
This standard consultation would adjudicate my fate

I walked into his surgery and gave it to him straight

“Doc, I wonder if you might explain this allergy of mine

I get these pins and needles running up and down my spine

From there, across my body, it will suddenly extend

My neck will feel a shiver and the hairs will stand on end

And then there is that symptom that a man can only fear

It’s a choking in the throat and the crying of a tear”

Well, the doctor scratched his melon with a rather worried look

His furrowed brow suggested that the news to come was crook

“What is it Doc?” I motioned “Have I got a rare disease?

I’m man enough to cop it sweet so give it to me please”

“Well I’m not too sure” he answered, in a puzzled kind of way

“It seems you’ve got some kind of fever but it’s hard for me to say

When is it that you feel this most peculiar condition?”

I thought for just a moment and then I gave him my position

“Doc, I get it when I’m standing in an Anzac Day parade

And I get it when the anthem of my native land is played

I get it when Meninga makes a Kiwi-crunching run

And when AB grits his teeth to score a really gutsy ton

And I got it back in ‘91 when Farr-Jones held the Cup

And I got it when Japan was stormed by Better loosen Up

I get it when the Banjo takes me down the Snowy River

And Matilda sends me waltzing with a billy-boiling shiver

It hit me hard when Sydney was awarded with the Games

And I get it when I see our farmers fighting for their names

It flattened me when Bertrand raised the Boxing Kangaroo

And when Perkins won from lane eight, well, the rashes were true blue

So tell me Doc” I questioned “Am I really gonna die?”

He broke into a smile before he looked me in the eye

As he fumbled with his stethoscope and pushed it out of reach

He wiped away a tear and then he gave this stirring speech:

“From the beaches here in Queensland to the sweeping shores of Broome

On the Harbour banks of Sydney where the Waratah’s in bloom

From Uluru at sunset to the mighty Tasman Sea

In the Adelaide cathedrals, at the roaring MCG

From the Great Australian Bight up to the Gulf of Carpentaria

The medical profession call it ‘Green and Gold Malaria’

But forget about the textbooks son, the truth I shouldn’t hide

The rash that you’ve contracted here is ‘good old Aussie pride’

I’m afraid that you were born with it and one thing is for sure

You’ll die with it young man because there isn’t any cure”

 

Thank you to Rupert McCall for his case report.

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