War drives innovation and in this series, Michael Mosley travels from the frontline of war to the frontline of research to uncover the medical breakthroughs that are coming out of current conflicts. This is the second video in the Frontline series (see Frontline Friday Inspiration 1 for the first episode)

The survival rate in Afghanistan is the highest in the history of combat – but this means people are surviving with dreadful injuries. Michael wants to find out what medicine and technology can do to help rebuild their shattered lives. From mind-controlled prosthetics to growing spare body parts and face transplants, he explores the innovations which are helping both wounded troops and civilians to overcome life-changing injuries.

http://www.youtube.com/watch?v=JDdoqWZ9pdo

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

War drives innovation and in this series, Michael Mosley travels from the frontline of war to the frontline of research to uncover the medical breakthroughs that are coming out of current conflicts.

The first episode takes Michael to Camp Bastion hospital in Afghanistan to find out how medics have achieved the highest survival rate in the history of warfare. And in ER departments in the USA, he looks at the latest medical advances that could save thousands of lives both on and off the battlefield.

http://www.youtube.com/watch?v=_8rKzUk1wPg

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

Beware the foreign traveler!

Today we explore the evolving ‘furuncle‘ or boil. A simple enough beast to deal with under normal circumstances – but in the returning traveler…myriad possibilities raise their ugly heads…

The common or garden furuncle is usually associated with infection (commonly staphylococcus aureus) at the base of a hair follicle where purulent material extends through the dermis into the subcutaneous tissue, and is evident by a small abscess.

However, in the returning traveler furuncular myiasis caused by Dermatobia hominis must be on the differential diagnosis. Furuncular myiasis is endemic throughout Central and South America and produces boil-like lesions commonly misdiagnosed as a furuncle.

The furuncle has a central pore that intermittently exudes a serosanguinous discharge (the feces of the larva), and protrusion of the breathing tube of the larva frequently can be observed

The larvae are transmitted to vertebrate animals by hematophagous insects, most commonly mosquitoes, on whose abdomens the female botfly has deposited her eggs. When the blood-feeding vector encounters a warm-blooded animal, the change in temperature causes the botfly eggs to hatch. The larvae enter the vertebrate host either through a hair follicle, the bite site, or by directly burrowing in the skin. Over the next 4–18 weeks, the larva grows by eating the flesh of its host. At maturity it emerges from the wound, falls to the soil, and pupates.

Treatment

Although the botfly will, when mature, exit the site by itself, this is not usually acceptable to the patient…

Botflies, when properly diagnosed, either are surgically removed or asphyxiated and then manually removed. Many methods for extracting the larvae have been described for the treatment of furuncular myiasis.

http://www.youtube.com/watch?v=eMbPFr72S7k

Bacon Therapy

I think using bacon fat is a good idea. It doesn’t take too long (about three hours), doesn’t leave dead larvae under the skin (as oil occlusion, lignocaine infiltration or larvacide treatment may), it’s non-invasive (avoids the need for incision and drainage) and is cheap. However, it may not be suitable for extreme cases of Tumbu larva infestation as the female fly lays 100-300 eggs in several batches – that would need a lot of bacon.

Procedure: The furuncles are left covered with bacon fat. This encourages the larvae to exit the skin, either due to suffocation or an attraction to bacon. After about 3 hours the bacon fat is carefully removed with forceps at the ready to help fully extricate the larvae.

What you do with the bacon and the larvae afterward is your business. And if you’ve got myiasis, try to look on the bright side, things could always be worse…

Ocular myiasis - don't use bacon for this, it needs surgery. It is usually caused by a Screwworm rather than Tumbu fly or Bot fly larvae (although the larvum bottom right does look like Dermatobia hominis).

Asphyxiants

Duct Tape: Covering the location with adhesive tape results in partial asphyxiation and weakening of the larva, but is not recommended because the larva’s breathing tube is fragile and would be broken during the removal of the tape, leaving most of the larva behind.

Petroleum jelly or vaseline can also be applied over the location, which prevents air from reaching the larva, suffocating it. It can then be squeezed out.

Nail Polish: A larva has been successfully removed by first applying several coats of nail polish to the area of the larva’s entrance, weakening it by partial asphyxiation.

Procedure: Apply nail polish to the central pore of the nodule. This leads to partial asphyxiation of the larva causing it to retract its spines and attempt to reposition its breathing tube to reach air. Although the larva may succeed in penetrating the first few applications of nail polish, eventually it is trapped and asphyxiated. This facilitates subsequent manual extraction of the entire larva provided that it is grasped well down its length. The breathing tube is fragile and breaks easily, contraindicating the use of duct tape which some use for larva removal

References:

• Bringing home the bacon
• Bhandari, Ramanath; David P. Janos and Photini Sinnis (March 2007). “Furuncular myiasis caused by Dermatobia hominis in a returning traveler“. The American journal of tropical medicine and hygiene 76 (3): 598–9. PMC 1853312. PMID 17360891.
• Boggild, Andrea K.; Jay S. Keystone and Kevin C. Kain (August 2002). “Furuncular myiasis: a simple and rapid method for extraction of intact Dermatobia hominis larvae“. Clinical Infectious Diseases 35 (3): 336–338. doi:10.1086/341493. PMID 12115102

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

What do you do if you discover that a cheap generic drug… that Big Pharma has no interest in supporting… may save lives?

You do this:

http://www.youtube.com/watch?v=pIoYJUf1uls

Though the NNT for mortality is ‘only’ 67 — if given within 8 hours of severe trauma — tranexemic is cheap, widely available and likely to have few downsides. Furthermore, it may be more effective if given early (i.e. less than 3 hours).

Learn more about tranexamic acid for severe trauma here:

• Emergency Medicine Ireland — CRASH2
• LITFL Critical Care Drug Manual — Tranexamic Acid
• London School of Tropical Medicine and Hygiene — CRASH2 Trial website
• Resus.ME — How about prehospital tranexamic acid? and Tranexamic acid saves lives in trauma
• TheNNT.com — tranexemaic acid for severe trauma

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

You may have recently seen the LITFL post Teaching the Millenial Generation. This video lecture was an example of an interesting new type of peer-reviewed publication: the PeRL or ‘peer reviewed lecture’.

PeRLs are an exciting concept developed by the journal Academic Emergency Medicine that allow great video lectures to get due academic recognition, including a pubmed listing.

Here is the journal’s ‘PeRL’ on ‘PeRLs’:

Peer Reviewed Lectures from Academic Emergency Medicine on Vimeo.

You can learn more about PeRLs on the Society of Academic Emergency Medicine’s Facebook page. Get your video cameras out folks!

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

If you’re an educator, you’ve probably encountered the alien species that was born subsequent to 1980. These Gen Y’s are much decried by those with greyer hair for their lack of attention spans, sense of entitlement and unwilingness to graft.

“The children now love luxury; they have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise. Children are now tyrants, not the servants of their households. They no longer rise when elders enter the room. They contradict their parents, chatter before company, gobble up dainties at the table, cross their legs, and tyrannize their teachers.”
— attributed to Socrates by Plato.

But, perhaps, this generation of learners are simply most in tune with cutting edge ways of learning, as supported by education research…

Here is a great talk from Danielle Hart, MD from the Department of Emergency Medicine  at Hennepin County Medical Center. She tells us how the so-called ‘Millenial Generation’ learn best and how teachers can maximise their students’ learning by adapting to their needs. If your approach to teaching is centered on passive learning through lectures, then it is time to evolve!

The Millennial Generation & “The Lecture” from Academic Emergency Medicine on Vimeo.

Hat tip to LITFL’s best mate in Cape Town, Sa’ad Lahri.

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

Selected by MovieMaker Magazine as one America’s “coolest film festivals” the Disposable Film Festival was created in 2007 by Eric Slatkin and Carlton Evans to celebrate the creative potential of disposable video: short films made on everyday equipment like cell phones, pocket cameras, and other inexpensive video capture devices.

The Disposable Film Festival held their Health awards VIP screening November 10th 2011 and I had the great honour and pleasure to attend with @ZDoggMD for the award presentation.

You can review all the entries over on the Vimeo channel, but I wanted to share two inspirational (and completely different) videos that really struck me on the night.

Beautiful Princess

A film by Adonis Pulatus – amazing emotional, real-life roller-coaster of time-lapse photography

Grand Prize winner at Disposable Film Festival Health 2011

Honorable Mention at Disposable Film Festival Health 2011

…and a LITFL classic favourite from ZDoggMD

By Zubin Damania & Dr. Harry Duh

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

Do you still rely on your physical examination skills or put more faith in the test you order? Abraham Verghese present’s an awe-inspiring TED Talk on the power of the human hand in medicine and its use to touch, to comfort, to diagnose and to bring about treatment.

Has the patient in the bed become an icon for the patient in the computer?

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

Learn more about the teachings and brilliance of Joseph Bell in Smith, Bell and the Art of Observation.

Hat Tip: To Joe Lex over at Free Emergency Medicine Talks for also showing me this talk What the Pen Teaches the Stethoscope – By Abraham Verghese.

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

I challenge you to resist the urge to immediately send off a job application to the Greater Sydney Area Helicopter Emergency Medical Service (HEMS) after watching this video of a recent physician induction!

http://www.youtube.com/watch?v=VWuX8pV7Ceg

Hat tip to @Cliffreid from Resus.ME via EMCrit Podcast 058 – Interview with Cliff Reid – Part II

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

Ok, Ok, relax. Your thirst for more funtabulously frivolous trivia on the arcana of the physical examination is about to be quenched.

Fasten your seatbelts people, we’re about to launch into the 62nd edition of the FFFF!

Questions

Q1. Which sign of aortic regurgitation is named after a famous 19th century Irish physician who had a secret door made in his consulting room so that he could escape the accumulating masses of patients waiting for him?

Reveal the funtabulous answer!

Q2. Hydrophobia is characteristic of what condition?

Reveal the funtabulous answer!

Q3. What condition should you suspect if you shake a patient’s hand and he or she is unable to let go?

Reveal the funtabulous answer!

Q4. If a patient has a foot drop, how does assessing the ankle jerk reflex help determine the site of the lesion?

Reveal the funtabulous answer!

• Always check the ankle jerk reflex (S12 level via the tibial nerve)  in a patient with a foot drop because:

• if it is normal, then a common peroneal nerve lesion (L45S1) is likely.
  This is usually due to an injury at the neck of the fibula where the common peroneal nerve divides into its superficial and deep branches.
  If foot eversion is spared then the superficial peroneal nerve (L5S1)  is intact (innervates peroneus longus and brevis).
  An L5 root lesion can also cause foot drop and an intact ankle jerk, but there should also be weakness of knee flexion and foot inversion, as well as an L5 sensory deficit.
• if it is absent, then a lower motor neuron lesion affecting the sciatic nerve or lumbosacral plexus is likely.
  Such a lesion must involve nerve fibers that mediate the ankle jerk from the S12 level via the tibial nerve (a branch of the sciatic nerve), as well as nerve fibers that mediate ankle dorsiflexion from the L45 level via the deep peroneal nerve to tibialis anterior, extensor hallucis longus, extensor digitorum longus and extensor digitorum brevis.
• if it is hyperreflexic, an upper motor neuron lesion is present (e.g. stroke).

Sciatic nerve giving rise to the tibial and common peroneal nerves

• Causes of foot drop include:

• common peroneal nerve palsy
• sciatic nerve palsy
• lumbosacral plexus lesion
• L45 root lesion
• peripheral motor neuropathy
• distal myopathy
• motor neuron disease
• stroke (anterior cerebral artery or lacunar syndrome causing ‘ataxic hemiparesis’)

Easy, eh.

Q5. Why do left-handers find using a screwdriver more difficult than right-handers?

Reveal the funtabulous answer!

• The majority of screws have right-handed thread, meaning that they are tightened by clockwise rotation.
• Using one’s right-hand enables the powerful biceps brachii muscle to supinate the forearm to achieve clockwise rotation of the screw. This action is most effective when the elbow is flexed.
• Using the left-hand to turn a screw with right-handed thread requires pronation of the forearm. This is a weaker action than supination as biceps brachii does not assist in pronation.
• An exception is the screw on your left-sided bicycle pedal. Such screws are subject to anti-clockwise torque and are more likely to stay tight if they have a left-handed thread.
• Note the increased contraction of biceps brachii when the forearm is supinated (top) compared to when the forearm is pronated (bottom):

Biceps fully contracted during elbow flexion and forearm supination (Click image for source)

Biceps partially contracted during elbow flexion and forearm pronation (Click image for source)

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