You may remember that an interesting snapshot was taken of Mike Cadogan in early November while he was at the 2011 Essentials of Emergency Medicine conference in San Francisco. You may also remember that an honourary Fellowship of the Utopian College of Emergency for Medicine was on offer if a suggested caption met the required standard.

We are happy to inform you all that the bureaucratic cogs at Enlightenment Boulevard have finally turned. In fact just this morning, a homing pigeon flew into LITFL headquarters in Perth with a tiny scroll bearing the UCEM seal strapped to one of it’s birdy ankles.

And what was on that tiny scroll?

A special announcement, signed by Sir Hubert Ignatius Thompson III, that stated the newest Fellow of the Utopian College of Emergency for Medicine is:

Duncan Campbell F.UCEM

Duncan, the LITFL team salutes your fine achievement — you are a MUPPET no longer!

And, finally, here is said photograph of Mike Cadogan at Essentials adorned with the caption worthy of the most coveted Fellowship in medicine:

"The real, impressively hairlined Mike Cadogan showed up at EM Essentials showing off his ‘Bald Mike dummy’ puppetry skills."

There were lots of great captions suggested – choosing the best was beyond difficult – you can read them all here.

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

UCEM researchers revolutionise waiting room medicine with new study

Following recent industry headlines and continual expansion of the use of bedside ultrasound in emergency medicine, UCEM researchers have risen to the challenge of the impending 4h targets (‘No, it’s not the Four Hour Rule’ or NINTFHR) to develop a validated clinical decision-making tool to improve access to impatient specialists and their thick-mattressed beds.

Recognising that recent years have seen Emergency staff proving that no body part is beyond assessment with a mobile scanner and that this increased workload had the potential to de-skill and unemploy our superspecialist colleagues, researchers first ‘focused their crystals’ on previously unassessed body parts with the aim of finding one that might be useful for disposition decisions.

Initial trials with ‘Patient Hair Analysis – Qualitative, Objective or Facile Folly?’ (the PHAQ-OFF trial), although with initially promising results, did not yield a suitably discriminative outcome for widespread use and remains a research tool only.

Fig-1: Bedside hair ultrasound

Researchers then turned their attention to previously unappreciated clinical variables with impressive results.

Casenote Bedside Ultrasound (the CBU score)

Portable sonography of patient’s medical records with depth analysis proved to be a high-yield discriminator and predictor for general medical admission. Using a simple, reproducible single measure (thickness >1.3cm), the need for admission for >24h after exhaustive traditional clinical assessment was found to be over 90%, compared with >2 medical staff (including NESB), this subgroup also had high enough rates of admission to merit direct referral for full workup as an inpatient.

Fig. 2 demonstrating notal hypertrophy

Early resistance to this as a tool in the validation study from inpatient registrars was found to be mitigated by use of the triage notes and a more formal sounding title (e.g. ‘this patient presented with SOB and has a CBU score of 4.3 so requires admission’). Improved access to medical assessment unit beds in the study hospital allowed for rapid transfer immediately after the referral to the MAU, and this 100% admission rate from the ED proved this tool’s worth as a decision making aid.

Fig. 3 demonstrating a low-risk patient

Future research is planned to assess whether this can be used either directly from triage or as a prehospital direct admission tool, aided by patients wearing bracelets with their note dimensions clearly engraved so that ambulance officers can rapidly assess the severity of their illness.

Roving reporter: Dr Duncan Campbell

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

There are telltale signs that a professional college has finally come of age.

For instance, as a specialty matures, sub-specialities inevitably arise. Under the umbrella of Utopian Medicine, for instance, we have seen the inexorable rise of Waiting Room Medicine, Bus-stop Surgery and Seaside PR. Another unmistakable mark of maturity is the formalisation of a college’s educational roles.

F.UCEMs, PUPPETS and MUPPETS well remember how the pioneers of the Utopian College had to battle countless detractors and nay-sayers, and had to overcome many fiendish foes and obstinate obstacles to make the college what it is today. Among these challenges is how best to transmit the lessons learnt by the fondling members in the School of Hard Knocks to the naive and unknowing MUPPETS that follow in their footsteps.

Think back to a time before the luxury of the web and the golden age of social media meducation. Many of our forebears couldn’t even use crayons properly and were forced to chisel out the principles of their emerging specialty in tablets of sun-baked excrement using just their yellowed teeth and unmanicured fingernails. These pearls of wisdom, hard won by the ancients, must not be lost to future generations.

Indeed, the  UCEM Council Executive have motioned, with characteristic certitude, to ensure that the labours of the now aging and infirm fondling members were not in vain. They have decreed that selected F.UCEMs will be chosen to teach aspiring MUPPETS the art, science and comedy of utopian medical practice. From this day forth, members of this select group will be anointed with UCEM‘s new Diploma of Heutagogical Tutelage for the Failing Unwashed (DipHTFU). Yet very few have the necessary talent, capabilities and personality defects to be worthy of the DipHTFU post-nominals.

Requirements for the award of the DipHTFU:

• expertise in problem-based learning. Through an ability to recognise that the student is usually the problem, the HTFU diplomate achieves success where others flounder.
• the ability to ‘man up’ and teach andragogically, while recognising that some highly tense feeble underlings require a more pedagogical approach.
• an intuitive appreciation of the difference between formative and summative assessments, between norm and criterion referencing, and between eLearning and uLearning… and lots of other ridiculous terminology.
• mastery of multiple learning modalities, including visual, auditory and kinesthetic. The diplomate recognises when a poke in the eye, a clip around the ears or a kick in the ar$e will help a student learn.
• the mental toughness to withstand the bleating despair of pessimistic students who were always going to ace the test.
• the ability to teach on the run… students learn even when the diplomate is running away from them.
• abstinence from didaskalogenic activities.
• sado-masochistic tendencies — the pleasure of watching bumbling novices suffer as they fumble through a presentation of their approach to rectal foreign bodies, is offset by the exquisite pain of actually having to listen to what is being said.
• mountaineering experience, including guiding multiple groups of hopelessly timid fashionable underpant-wearers on successful ascents of Mount FACEM.
  or…
• one million dollars! 

Cheques may be addressed to:

Professor Harry Stickler,
Chair of Pedantry, School of Health and Information Technology,
Utopian College of Emergency for Medicine,
Enlightenment Boulevard,
near Pyongyang, North Korea

Special announcement!

Congratulations Trevor!

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

Please suggest a caption for this photo stolen from @emcrit:

An honourary Fellowship of the Utopian College of Emergency for Medicine could be in the offing if there is a suggestion of the requisite standard…

Addendum December 21 2011

We have a winner!… Find out the winning caption and who the newest F.UCEM is here.

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

Rumours abound that UCEM’s Professor Staghorn has recruited the one and only Professor Elemental to an honorary position on the Inquisitorial Disciplinary Committee. Having witnessed Elemental’s meritorius display in seeing off all chap hop rivals, Staghorn was keen to enlist another pair of fighting trousers to the taskforce dedicated to ensuring that UCEM’s professional standards are met.

http://www.youtube.com/watch?v=0iRTB-FTMdk

Of coure, one big advantage of being connected to the IDC is that one need never remove one’s fighting trousers.

Yet fighting trousers are useful for more than simply ensuring that MUPPETs and F.UCEMs tow the college line. Indeed, some fellows of the Utopian College have been putting their fighting trousers to good in other ways. For instance, ZDoggMD F.UCEM strapped on his pair to take on the Sucka MDs and other medical media whores that polute the American TV-ways:

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

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

The UCEM have recently relocated from Swarmington-on-the-Wold to the more picturesque setting of Enlightenment Boulevard thanks to the generosity of it’s fondling members and the subtly underhand and ever so slightly fraudulent work of our very own Chair of Indiscriminate Fines.

As fondling members will remember, the old College headquarters were woefully inadequate for the degree of eminence they housed.

UCEM Old College Head Quarters

Thankfully the move has gone well and the Executive Council have settled well into their new abode. It is hoped that these more salubrious environs will further the cogitations and cerebrations of the Council Members and will be partly justified by some obsequious curricula modifications.

UCEM Freshly Laundered Head Quarters

Unfortunately Molvania has not been formally assessed in the World Rankings for Total Deaths or in the World Life expectancy map.

As a result, the UCEM executive are lowering themselves to organize a number of travel excursions (paid for from the coffers of the fondling members) to try to find a more appropriate country to relocate the less important members of the UCEM board.

We are actively looking at the World Disease Health Rankings to find the country closest to the Utopian ideal (no cancer, no road traffic deaths or chronic disease). We understand this may take a long time to complete, but the College will endeavor to notify its members as soon as it is firmly settled in its new country of choice.

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

In response to a recent conversation with @Prof_Elemental regarding an engagement to perform at the upcoming Utopian Conference of Waiting Room Medicine, the Council executive have urged us to re-post the UCEM concept of Waiting Room Medicine to enhance global understanding…

• Learn more about the Utopian College (UCEM)
• An Interview with Sir Hubert Ignatious Thompson III
• Become a Fondling Member

With exponential Emergency Department over-crowding and spiraling waiting times, the Utopian College has produced a series of guidelines to assist fondling members. Ultimately, these Waiting Room guidelines will improve patient comfort and safety; facilitate early diagnosis and treatment (four minute rule) and expedite the global acceptance of Waiting Room Medicine.

Currently, non-Utopian waiting rooms often feel like cold ante-chambers to Hell with reefs of cigarette butts drifting under the non-smoking sign; agonizingly uncomfortable plastic chairs and strange clanking machines that intermittently spit out volcanic black fluid described as coffee, but tasting more like dilute tar.

The Utopian College Council Executive have delegated a task force implementation group sub-committee on Utopian Waiting Room Design. This sub-committee will report to the chief working party liaison group of the Utopian Medicine WorkFlow, which in turn reports to the steering committee of the UberGroups. This should create enough bureaucracy and red-tape to ensure that no suggested implementations in Waiting Room design will ever pass through the bowels of the financial re-design working group or cross the threshold of the ‘almost there‘ implementation committee.

The first draft of the Utopian Waiting Room redesign for the Waiting Room Medicine working party has been published online as a 3D walk-through at and is now available for discussion.

Five discrete areas have been incorporated in the first draft of the Utopian design and are outlined below. Additional areas will include Waiting Room Gynecology, Patients without discernible pathology and an area to asses patients for signs of imminent admission…

Feedback in the form of comments, and additional acronyms to be included will be taken into consideration and duly ignored for the second stage of the planning and implementation process. This second stage will co-incide with the inaugural Utopian Medicine Conference scheduled to be held on February 29th 2011 in Molvania (details to be announced later this year). The final Waiting Room design will be published in the Journal of Irreproducible Results.

Strategic Areas for Waiting Room Redesign

Coronary Chair Unit (CCU)

• Monitored chairs are placed in close approximation to, and in sight of, the Triage desk.
• All patients are fitted with defibrillation paddles on arrival and sat around the central defibrillation station.
• Patients then hold hands to create a ‘series‘ electrical circuit between the group.
• If a patient develops a shockable rhythm, the circuit is broken and a series of ILCOR derived shocks will be generated to all patients in the circuit.
• Patients deemed to be at risk of imminent collapse should be transferred to the ICU

Our organized approach to triage and waiting room evaluation for stable chest pain patients was safe and efficient. Although waiting room evaluation is not ideal, it may be a feasible contingency strategy for periods when ED crowding compromises access to the main department and the use of monitored chairs is required [Reference]

Imminent Collapse Unit (ICU)

• Situated immediately adjacent to the CCU and directly in front of the Triage window
• A central clearing of 4m x 4m is covered with strategically placed pillows, blankets and carpeted tiles
• Triage will be alerted to ICU patients by observing the high-stepping gait of patrons within the queuing community
• ICU patient management options are outlined in the UCEM Resuscitation Guidelines V1.07

Geriatric Observation, Mobility and Early Rehabilitation Unit (GOMER)

• The GOMER area includes three discrete units
• The first area comprises exercise bikes, treadmills and a selection of ambulatory devices.
  • Gerontologically challenged patients physically capable of moving towards the light are encouraged to choose an appropriate walking aid, and then directed towards the soft-fall area.
• A second area comprising a ‘Hamster wheel’ of doors is used to contain wandering patients without compromising already diluted staff time.
  • The Wanderer Containment Unit (WCU) comprises 8-10 doors which open onto each other in a circular arrangement.
  • This allows any wanderers to happily amble in circles for hours without the risk of getting out in to the road or becoming lost in the building.
  • The door in and out of the hamster wheel should be lockable and occasionally observed by the triage staff.
• The Happy Knitter Distraction Unit.

Time-distraction therapy can be employed to usefully disengage patients from their environment, disorientate them with respect to time (length of stay) AND afford the opportunity to increase the GDP of the department (Granny Dumping Productivity) by selling the beautiful creations at the TRIAGE shop

Patient Subduement area (PSA)

• The high walled, sound-proofed section of the waiting room – situated well away from the triage area
• Padded chairs, diodotic turnstile entry, soft-tiles, ambient music and lighting are the mainstay of this area
• For subsequent assessment after subduement please refer to the Psychiatric admission guidelines

Rarely Assessed or Monitored Patients (RAMP)

• Expandable area (depending upon local policy)
• Comfy seating and refreshments provided for attending ambulance officers; uncomfortable, inappropriately elevated trolleys provided for attending patients

TRIAGE

• The TRIAGE area is divided into sections determined largely by the general patient demographic and ability of staff to make up nonsensical acronyms
• In this prototype the College have defined consecutive streams of TRIAGE
  • Tearful Relatives Inquiring About Getting Examined
  • Totally Random Investigation And Granny Emporium

This area provides the ability to

• Prescribe and administer analgesia in a timely manner
• Provide scripts to prevent elopement
• Administer Utopian mediciations such as ListGran, DefTox, TTFU pills  and the PolyPill
• Reduce the length of stay for patients not requiring hospital admission
• Provide a caring environment in the case of mass overdosage

Waiting Room Medicine References:

• Scheuermeyer FX, Christenson J, Innes G, Boychuk B, Yu E, Grafstein E. Safety of Assessment of Patients With Potential Ischemic Chest Pain in an Emergency Department Waiting Room: A Prospective Comparative Cohort Study.
• Ann Emerg Med. 2010 May 23. [Reference]
• Pines JM, Pollack CV Jr, Diercks DB, Chang AM, Shofer FS, Hollander JE. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009 Jul;16(7):617-25. Epub 2009 Jun 22. [Reference]
• Handel DA, Fu R, Daya M, York J, Larson E, John McConnell K. The use of scripting at triage and its impact on elopements. Acad Emerg Med. 2010 May;17(5):495-500. [Reference]
• Pines JM, Shofer FS, Isserman JA, Abbuhl SB, Mills AM. The effect of emergency department crowding on analgesia in patients with back pain in two hospitals. Acad Emerg Med. 2010 Mar;17(3):276-83. [Reference]
• Russ S, Jones I, Aronsky D, Dittus RS, Slovis CM. Placing physician orders at triage: the effect on length of stay. Ann Emerg Med. 2010 Jul;56(1):27-33. Epub 2010 Mar 16. [Reference]

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

The learned Ameritous Professor Broughton-D’Lirium stirred briefly to pour himself a whisky and settled back into the Sunday colour supplement. The news these days has brought colour to his cheeks and quickened his pulse. At long last there has been a truly European epidemic, or ‘Eurodemic’ (an outbreak of truly EU-ge proportions), to use a term originally coined by Broughton-D’Lirium.

Perching his reading glasses closer to the tip of his nose, he re-read the word ‘STEC’, realising that it would be a mis-steak to think this had anything to do with meat. Unlike the BSE shenanigans of a previous decade, there were no mad cows in this unfolding drama; just confused Eurocrats.  And what a party they were having, trying to get to the bottom of a serious outbreak of diarrhoea, in a torrent of bloody motions, noting serious complications in the passing.

JB-D made a mental note to lace his next conference paper with new verbs like ‘to cucumber’ as a disparaging reflection on vegetables of mainly decorative and otherwise limited nutritional value. Thinking on it, he couldn’t work out why the German health authorities had seriously considered cucumbers as the cause of their woes when local practice was to peel the wretched things to get rid of that thoroughly indigestible skin. After all, who’d want to go eating something that actually looked like an E.coli in the first place?

Then there was the matter of the organic bean sprouts – “eats shoots and leaves” was clearly the motto of the Eurodemiologist, a professional germ-watcher whose job was to find just enough dirt on a named bacillus to demonise it, then strike camp to go chasing the next-most nasty bug.

Reaching the end of a boxed insert that helpfully summarised the milestones on the Eurodemic’s timeline, he turned to the opportunist fresh fruit advert on the facing page and realised that there would be no more of those disturbing health promotions that insisted you’d die a horrible death if you didn’t eat at least a sack of fresh, organic vegetables every day. Ever the one to read behind the headlines, Broughton-D’Lirium saw hints of a fruitarian conspiracy in the Eurodemic, and even worked out that the epicentre’s location close to Hamburg was a direct attack on a people named after the fast food icon; a body blow after previous STEC outbreaks associated with Hamburgers.   Shifting his gaze from the paper briefly, he reached for another plain oatmeal biscuit.

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

The Utopian College have been in slightly more disarray than usual with all the preparations for the upcoming Utopian Conference of Waiting Room Medicine.

As such they have been forced to call upon fondling members to submit their resume to fill the vacant position of General Secretary.

Unfortunately the resumes considered to date have been somewhat below par (see below). The College eagerly awaits direct correspondance from any fondling members able to perform the prestigious position of General Secretary.

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

Interest in the Defibritazer BP50KV continues to surge. Indeed, tickets to the Defibritzer demonstration at the eternally upcoming Waiting Room Medicine conference in Molvania have sold out many times over (is that legal?).  Amazingly, our sources within UCEM suggest that work has already begun on the Defibritazer BP50,000,000KV.

There is growing speculation that Dr. Electric ( aka Western Australia’s own Dr Peter Terren) will soon start working on the project in the aftershock of his stunning success on Australia’s Got Talent:

http://www.youtube.com/watch?v=LxbkiXJqWm4

Dr Electric was clearly onto something when he described his Tesla coil as ‘like a monstrous tazer’. Here is the view from his ‘safety camera’, featuring the original soundtrack from the performance:

http://www.youtube.com/watch?v=x2_zIlAybGo

But there are also many other obvious utopian medical applications of Dr. Electric’s energising work (these are just a few photos from Dr Terren’s www.tesladownunder.com website):

First, a cure for halitosis:

Second, enhanced car park security:

And then, finally, there’s waiting room tesla coil therapy (TCT) for irritable body syndrome:

A giant Tesla coil could soon be coming to an emergency department near you!

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