Learning medicine can be tough.

At LITFL we are looking to expand some of the medical learning models to make them easier to digest and understand. To this effect we are developing:

• More medical illustrations and infographics with Prof Tor Eercleve such as The Brainstem Rule of 4 and ECG anatomy.
• More case based education resources
• A section to breakdown and analyse postgraduate medical exams starting with the FACEM fellowship
• Searching, sourcing and collating the exponentially growing amazing free resources already on the web with the weekly LITFL review, the Podcast database,

But what else??

Having a look on the web to review some fundamental chemistry I saw a couple of demonstrations of audiovisual knowledge sharing, though not sure how many of these ideas we can realistically incorporate into emergency medicine and critical care learning!

However, I love the concept of combining simple chemical principles with music and humor…expecially the dulcet tones and tunes of ZDoggMD…

http://www.youtube.com/watch?v=a45dXztokZM

Another option would be to ‘pimp‘ up the infographics to make them more ‘earthy‘ for our Gen Y med students…although I think it would be a stretch to define medical conditions in the same way that some chemical elements and pharmacopaeia are currently being defined

Finally on my exploratory voyage through chemistry-land I found a surprisingly useful visual display of location of the elements in the periodic table set to the classic tune by Tom Lehrer. Maybe a visuo-spatial approach to demonstrate some of the more rudimentary pathophysiological principles could be in order…

http://www.youtube.com/watch?v=GFIvXVMbII0

Of course we will not lose site of the reason we started this blog in the first place…

UCEM will continue its quest for world domination/ salvation,

The odd philosophical aside will still spring up,

Poetical bastardisation will march onwards,

Neologisms will be created,

and whimsical human encounters will be de-identified, further fictionalised and shared…

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

I’ve always thought ‘GP proceduralist’ is a very understated term for people who should really be considered the ‘MacGyvers of medicine’.

GP proceduralists in remote Australia are what most doctors were maybe eighty years ago — and what most of us dreamed of being when we went into medical school: having a baby? They’ll deliver it. Need an operation? They’ll gas you down (and they might even chop your leg off too). Got some bizarre disease no one’s ever heard of and you’re in the middle of nowhere? No worries, they’ll sort it out. You name it, if it has to be done, they’ll do it. These doctors are the princes of our profession.

[Apologies to female GP proceduralists, but 'princesses' doesn't sound right!]

Click image for source

So, why am I mentioning GP proceduralists?

Well, because of Casey Parker.

Casey Parker is a ‘GP proceduralist’ based in Broome, up on Western Australia’s wild north-west coast. He produces an enthralling blog called ‘Broome Docs‘, a ‘free educational blog for rural GP / proceduralists’. Casey has embraced the social media eLearning revolution and — as a result —  is digging up more valuable resources that the entire WA mining industry combined. Most of his cases would spasm the sphincters of even the most hardened critical care docs — even if Broome wasn’t a thousand miles from the nearest tertiary hospital.

Why would anyone want to live in Broome? (Photo by Gary Hayes - click image for source)

Here are some of my favourite posts on Broome Docs so far, check ‘em out — you won’t be disappointed!

• Clinical Case 014: “That’s not a knife….”
• Clinical Case 013: Big in Japan
• Clinical Case 011: Psych Transfer in extremis
• Clinical Case 009: Thor-racic Trauma
• Case 006: The Big Wet = Big headache
• Clinical Case 004 – Post-op PEEP++
• Can’t Intubate, Can’t Ventilate! The low down on code brown

Click image for source

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

A new intensive care educational and networking website is being launched this week, and I invite you all to check it out:

www.intensivecarenetwork.com

The website is aimed at Australasian trainees, but is also relevant to the global intensive care community. There’s some industry sponsorship (see the disclaimer below) which won’t influence site content but will allow the site to remain free to access.

We are putting up lots of our own material for the primary and fellowship exams of the College of Intensive Care Medicine, as well as for the paediatric fellowship exam.

We also have resources to help with research, training, clinical and non-clinical areas of our practice, and much more, which we will continue to update. We will have regular podcasts on a variety of topics later in the year.

We will also post vodcasts of our bi-monthly meetings, when we host guest speakers on useful topics such as burns, ECMO, rural ICU, and exam technique. Currently these meetings are held in Sydney — the first one by Dr Hergen Buescher on ECMO is being held today at St. Vincent’s — but later this year they will be held throughout Australia.

The forum will allow open discussions on a variety of topics, and encourage interaction from intensivists and critical care trainees from all over the world in a password-protected environment.

There is also a links section on the site on which we’ve tried to collate the best of what’s out there to save you trawling the net. And finally, there’s a calendar of events, with links to ICU courses and conferences in Australasia and overseas.

Please join up (the site has even been specially adapted for smart phones!), have a look, follow us on Twitter (@I_C_N) and befriend us on Facebook.

Oliver Flower FCICM
Royal North Shore Hospital, Sydney

Disclaimer:

• I am a co-contributor to the design and maintenance of this website and its content.
• The current sponsors of this website are CSL Biotherapies and Edwards Lifesciences. The sponsors do not determine the content of the website.

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

In this special episode of ‘Crime Scene Echocardiography: Vienna‘, the 123sonography team show how echocardiography can be used for good as they put their skills to the test and try to solve a mysterious case of dyspnea in a 39 year-old man.

As you will see, apart from our Austrian Sonography friends demonstrating that they have excellent taste in emergency medicine blogs,  they demonstrate that the patient appears to have a dilated cardiomyopathy on echo. Interestingly, it turns out that twenty-eight years previously he was accidentally shot in the chest and required an operation. Could his current cardiac condition be related to what happened all those years ago?

Watch the video — featuring ‘ballistic echocardiography‘ — and all will be revealed:

Makes you want to run out and start echo’ing everything that moves, eh… But what if you can’t tell an atrium from an armpit?

Well we’ve raved about the free video resources available on 123sonography.com before, but if you’re serious about getting to grips with echocardiography you might be interested to know that they have just launched their full online echocardiography course (registration is required, but a free trial is available). Judging from what I’ve seen so far, this elearning course may well help condemn traditional lecture-based and remote learning systems to history’s scrap heap. Here’s hoping…

On a lighter note, given such meritorius work, it appears that any nagging concerns that the sono-gurus from 123sonography.com are somehow linked to Hans Gruber and the bad guys from ‘Die Hard’, can be laid to rest… for now at least.

http://www.youtube.com/watch?v=tRIt6VqP0RI

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

I love trawling the web for educational resources, to see how other people are using technology to translate written text into visual landscapes…

Today I stumbled across what looks to be the first in a series of instructional videos on Ultrasound in the emergency department from a group of ED physicians in Nambour on the Sunshine Coast in Queensland

This video is a great example of an elegant teaching style, recorded and video and shared with the world – great work guys, will be following closely to see what you are up to next.

Ultrasound Guided Venous Access

http://www.youtube.com/watch?v=NQjVlElA8UU

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

At last, it’s here!

I’ve been waiting with baited (sorry, bated — thanks, Carroll!) breath for this website to become functional. After all, its by the guys who taught me everything I know about ultrasound (of course, you shouldn’t judge them by my own personal inadequacies…). But, let’s not muck around, it’s time to ‘Go West’ and become an (Ultrasound) Village Person!

http://www.youtube.com/watch?v=1wc-AQJ2MYo

Who’s in charge of the Ultrasound Village?

Ultrasound Village is fronted by James Rippey, Adrian Goudie and Greg Sweetman. This trifecta of Western Australian emergency physicians are passionate (is obsession too strong a word?) about the awesome potential of the clinical use of ultrasonography in emergency medicine. They each live and breathe ultrasound in their daily practice and each holds a much coveted Diploma in Diagnostic Ultrasound (that’s a DDU, not a DUD). What’s more they are evangelical educationalists who strive to spread ‘The Word’ about emergency ultrasound to all comers everywhere.

So, what’s to be found in the Ultrasound Village?

The Village elders aim to support training in clinician-performed bedside ultrasound all the way from novice to expert. They are doing this in a number ways through their easy-to-use, accessible and visually appealing website.

The first thing that must be mentioned is the Image library. It contains both normal anatomy and pathological cases, depicted as both image stills and videos. Its early days right now, but this promises to grow into an exceptional online learning resource.

I’ve already linked to many of the ocular ultrasound images in recent posts. Check out The Ocular Ultrasound Challenge, Flashing and Floating, and A Curtain Descends, to name but a few examples…

The library couples fantastic image examples with descriptions and technical tips. A great feature is the colour-coded images that spell out to even the biggest ultrasound dummy exactly ‘what’s what’ (after all, the creators of this site have even managed to teach me a thing or two…). The image library is open access, but if you register (which is free) you can use the images in ‘test yourself’ mode — a great learning feature.

Those who register will also soon be able to use the online Logbook to guide and document their journey from ultrasound imbecile to sonographic sorcerer.  Registration also allows access to a growing number of Educational Resources. These include short, instructive multimedia video lectures on emergency ultrasound topics (such as physics and artefacts, AAA, EFAST, early and late pregnancy, procedures and more) and there are quizzes to come. You can also keep up-to-date with information on the next ‘hands-on’ course — if you get the chance to attend one, don’t hesitate!

Disclamer — I have attended courses and assisted on courses by the Ultrasound Village team. I was an Emergency Medicine Ultrasound Registrar at Sir Charles Gairdner Hospital for 6 months in 2009, working under the supervision of Assoc Prof James Rippey and Prof Greg Sweetman.

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

Quick update on Aussie Fellowship education sites for all those of you who are nervously waiting to sit the written portion of your ACEM Fellowship examination…

There are an increasing number of resources available to candidates of varying quality

The Life in the Fast Lane team have created pages for VAQ, MCQ and SAQ comprising past questions and we are completing the Short, Long and SCE sections of the examination.

Here are some additional resources:

• Emergency Medicine Bloggers (ED and ER)
• Broad Complex: [Sunshine and Footscray Emergency Medicine Education site]
• NSW Combined Hospitals Fellowship Education [NSW Hospitals]
• EmergencyWeb: [Gold Coast Hospital]
• EDteaching.com [Austin and Northern Hospitals]
• CEMA [Cairns Emergency Medicine]
• Wellington Emergency Department [Wellington ED NZ]
• ACEM NZ Updates

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

Over the last year new LitFL posts have been dominated by things we call ‘Case-based Q&As‘ — you may wondering whats going on.

Don’t worry, LitFL is going to stay true to its quirky and eccentric medical blogging roots…

• Updates and interpretation of the latest in Web 2.0/3.0/4.0… and social medicine,
• UCEM will continue its quest for world domination/ salvation,
• The odd philosophical aside will still spring up,
• Poetical bastardisation will march onwards,
• Neologisms will be created,
• Whimsical human encounters will be de-identified, further fictionalised and shared,
• …and the case-based Q&As are going to keep on cranking too.

Personally, I like to learn by a problem-based approach using the Socratic Method (or positive pimping if you prefer), where an experienced learner/ teacher helps others through guided questioning and explanation. The Case-based Q&As are an attempt to extract the precious bodily fluids from this approach and distill them into an open-source and easily retrieved bottle of port (i.e. something that tastes good and is easy to swallow)… The emphasis on cases, though tenuous and borderline farcical at times, attempts to keep it real, relevant, interactive and interesting.

The question/answer show/hide format makes for easy revision, provides an easily comprehensible structure and allows readers to come back, revise and test their knowledge. Questions and answers can be easily cut-and-pasted into personal notes, edited and modified, or turned into flashcards for using spaced-repetition programs like Mnemosyne for those so inclined. Many of the answers are in two stages — a brief to-the-point bare bones answer, followed by a deeper explanation. In general, the focus is on what the clinician needs to know to take care of their patient and pass their exams — thus extraneous epidemiology and molecular underpinnings tend to be limited. Of course, we have an unabashed predilection for breaking our own rules…

The Case-based Q&As are ever growing, and the index is intermittently updated in a searchable table on the Clinical Cases page. The cases vary from core emergency medicine and critical care subjects that practitioners need to know like the backs of their hands, to more obscure and ‘out there’ topics — but why not? We see it all in this business.

The best case-based Q&As are those like Paul Young’s Pulmonary Puzzle 002 – Not just a PE; as the case evolves an incredible amount of diverse medical terrain is traversed, but the questions focus on the key messages and important learning points.

Many cases, like Laboratory Tester 003 – Seizures, hyponatremia and ADH, evolve from our own learning needs and differences of opinion at work, the clinical questions that arise as we try to do what is best for our patients and the controversies we encounter.

Other cases, like Trauma Tribulation 005 – Releasing the Roman Breastplate, are more conventional and designed to cover core knowledge requirements. Where possible the posts are referenced, usually with at least one of the ACEM or CICM Fellowship exam recommended texts (typically Rosen’s or Oh’s, respectively), unearthed gems from the primary literature and recent review articles, and/or the best online and open-source resources we can find on the web.

Oh, you have another question do you — what’s with the naming of the posts?

Well, we’ve finally settled on a system of giving each post a category name, like ‘Neurological Mind-boggler‘, and most posts will have another more post-specific name to keep things interesting. Some readers get upset when post titles give away the diagnosis and others are irritated by the formulaic category names.

The current system promises to annoy both parties in equal measure…

Finally, what’s the ultimate goal of all these ‘Case-based Q&As’ I hear you ask?

Well, the master plan is to build up an entire case-based curriculum for emergency medicine and intensive care catering for all levels of training. A ‘big ask’ I know, but hopefully in a few years we’ll be able to say, “Well, we knocked the bastard off”, just like New Zealand’s most famous bee-keeper once did. But, we’re not kidding ourselves — we know this is a task that will never end. I’d be disappointed if it did.

And now a postscript, a request. If you use these Case-based Q&A’s fire some feedback our way (even better if its constructive!). We want these resources to be useful and as good as anything out there — open-source or otherwise. If you want to submit a guest Case-based Q&A post having done some research on a relevant EM/ICU topic we will be happy to consider it if its quality stuff (contact the team here), and we’ll credit you as the author. For instance, you might want to create a revision aid for a teaching talk you’re going to give. Feel free to copy, re-use, modify and improve anything on LitFL for your own learning and teaching needs and do Hippocrates proud.

“To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art — if they desire to learn it — without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken the oath according to medical law, but to no one else.”
— from the Hippocratic Oath

Of course, if you learn something from these cases you may hear a knock on your door if we ever find ourselves totally skint… and feel free to ignore the ‘no one else’ part.

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

What happens when a gang of echocardiography gurus from Vienna get together to make a website?

123sonography, that’s what.

Franz Wiesbauer, Thomas Binder and colleagues have combined to produce a slick video-based teaching blog that comprehensively covers the practical art and science of echocardiography. This fantastic resource includes online echo tutorials; a blog, an echo atlas and echo games. It is great for both the newbie and the more expert echocardiography exponent as it covers the basics as well as more advanced topics.

As an example, check out this demonstration of the 2D echocardiographic features of pulmonary hypertension:

It is fantastic to see the emergence of new web-based medical education resources that are professionally produced and of the very highest quality. Registration is free but the full online course (still under development) will require paid subscription. Still, there is some really great content that can be accessed free of charge.

I highly recommend checking out 123sonography.

[Author's competing interest: none.]

Addendum:

The Life in the FastLane team are excited to announce that the 123 Sonography team (@123sonography) will be providing guest posts to the blog on all things sonographical, starting with some clinical cases with associated images, videos and simple explanations…

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

Elbow dislocations constitute 10% to 25% of all injuries to the elbow. The elbow is one of the most commonly dislocated joints in the body, with an average annual incidence of acute dislocation of 6 per 100,000 persons. Among injuries to the upper extremity, dislocation of the elbow is second only to dislocation of the shoulder.

Simple or Complex

Simple dislocations are described by the direction of the dislocated ulna. Posterior or posterolateral displacement of the ulna relative to the distal humerus is the most common simple dislocation with approximately 90% occurring this way (see image ). Rarer injuries include lateral and anterior displacements of the forearm.

When larger intra-articular fractures of the radial head, olecranon, or coronoid process occur with elbow dislocation, the injury is termed a complex dislocation.  Complex dislocations are much less common than simple dislocations. The risk of recurrent or chronic instability and posttraumatic arthrosis is increased significantly with complex dislocation.

AP and lateral Anterior Elbow Dislocation

Anatomy

The elbow joint  is one of the most inherently stable articulations. This stability is provided by the osseous and articular components with the shape and contour of the ulnohumeral articular surface providing anterior-posterior stability, varus/valgus, and rotatory stability. The capsuloligamentous components, which include the medial and lateral collateral ligaments and joint capsule, provide further stability by completing a structural ring about the elbow joint. Disruption of this ring is leads to elbow dislocation.

Finally the musculotendinous components, which include the muscles crossing the elbow joint, also contribute to the stability.

Lateral XR of Posterior Elbow Dislocation

AP XR of Posterior Elbow Dislocation

Evaluation

Patients present following a traumatic injury with swelling and deformity about the elbow. The mechanism of injury is usually a fall onto an outstretched hand.

TIP:  Elbow dislocation is sometimes confused with a supracondylar fracture. The two may be distinguished clinically by palpating for the equilateral triangle formed by the olecranon and epicondyles. This will be undisturbed in supracondylar fractures but distorted in elbow dislocations.

Neurovascular injury is uncommon, but should always be sought. Clinical evaluation should include median and ulna nerve function. Damage to the brachial artery can be assessed by palpating for a radial pulse.

After a complete examination, AP and lateral X-Rays of the elbow should be examined to determine the direction of the dislocation and to identify any associated fractures.

Clinical Evaluation of the Elbow dislocation

Management

Reduction can usually be carried out in the emergency department. It requires adequate muscular relaxation and appropriate analgesia. A fair amount of force is often required. Reduction may be achieved by correction of the medial or lateral displacement followed by strong traction on the forearm in the line of the limb. The arm may enlocate at this stage with a characteristic and satisfying reduction ‘clunk’. If not, firm pressure is applied posteriorly to the olecranon to bring it distally and anteriorly around the humeral trochlea. Traction should be maintained with the arm in moderate flexion, using counter-traction with the fingers. (see fig) Again a palpable ‘clunk’ will confirm reduction. Palpation should ensure the equilateral triangle formed by the olecranon and epicondyles is present.

TIP: After reduction, the elbow should be taken through a range of motion to evaluate joint stability. The elbow should be slowly extended and the angle at which tendency to redislocation occurs should be recorded. Most dislocated elbows are unstable to valgus stress (best tested in pronation to lock the lateral side).

X-Rays should then be performed in two planes, AP and lateral to ensure the reduction is concentric. Widening of the joint space may indicate entrapped osteochondral fragments. These patients should be referred to Orthopaedics for surgical debridement.

Note: Although X-Rays reveal periarticular fractures in 12% to 60% of cases, surgical exploration documents unrecognized osteochondral injuries in nearly 100% of acute elbow dislocations. Fortunately, the vast majority do not require operative intervention.

If the reduction is concentric and the joint is stable, the elbow should be splinted in 90 degrees of flexion. Patients should be followed up in 3-5 days with repeat X-rays to check reduction.

Complex dislocations

Complex elbow dislocation consists of both ligamentous and bony injuries. When one of the osseous or articular component structures of the elbow is disrupted, the risk of recurrent instability and arthrosis is greatly increased. Early mobilization of simple dislocations after closed reduction is associated with low risk of redislocation. These injuries, are more difficult to treat, and often have poorer results than simple dislocation. Fortunately they are much less frequent.

The radial head and coronoid process are the most commonly fractured structures in these injuries. Other structures that can be damaged include: medial and lateral collateral ligaments; medial and lateral condyles/epicondyles; transolecranon fractures and; posterior Monteggia fractures.

This disrupts the structural ring which provides stability to the elbow joint (see figure above). If there is evidence of disruption of one component of the ring, a second disruption is likely.

Note: The terrible triad consists of dislocation with associated radial head and coronoid process fracture.

Complex dislocations should have the same initial treatment- with clinical evaluation and reduction- as simple dislocations. They should all be referred to the inpatient Orthopaedic Surgery team for ongoing management, as they will require surgical repair.

Author Credit: Dr W G Blakeney

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