LITFL • Life in the Fast Lane Medical Blog https://lifeinthefastlane.com Emergency medicine and critical care medical education blog Tue, 14 Aug 2018 14:19:03 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.8 https://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2017/03/LITFL_LOGO_Transparent_001.png?fit=32%2C32&ssl=1 LITFL • Life in the Fast Lane Medical Blog https://lifeinthefastlane.com 32 32 56961984 LITFL Review 342 https://lifeinthefastlane.com/litfl-review-342/ https://lifeinthefastlane.com/litfl-review-342/#respond Sun, 29 Jul 2018 21:40:35 +0000 https://lifeinthefastlane.com/?p=179063 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Welcome to the 342nd LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs

LITFL Review 342 Marjorie Lazoff, MD

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 342nd LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

Readers can subscribe to LITFL review RSS or LITFL review EMAIL subscription

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsA wonderful resource, free through the end of 2018: SAEM On Demand provides their Annual Meeting didactics from SAEM 2014 to the present online. For instance, check out Jennifer Carnell talk about tapping into the power of TAPSE in PE with her deep dive lecture from SAEM 2017. [MMS]

The Best of #FOAMed Emergency Medicine

  • A review of syncope rules from down under as well as a new rule to help us determine who is at risk. [AJB]
  • Enter the world of ketamine! Learn more about the pharmacology, myths and multiple uses of ketamine in the ED, which are vast and under appreciated. [MMS]
  • How does your department address the topic of transgender care? The latest EM Pulse podcast discusses challenges and concerns specific to transgender patients with some practical tips to improve care and make your ED more welcoming. [MMS]

The Best of #FOAMcc Critical Care and #FOAMres Resuscitation

  • The PAMPer trial demonstrates that receiving prehospital FFP instead of saline improves outcome in trauma patients See a quick video review by Dr. Mel Herbert and article abstract at NEJM. NNT = 10!! [AJB]

The Best of #FOAMus Ultrasound

The Best of #FOAMtox Toxicology

The Best of #FOAMim Internal Medicine

The Best of #FOANed Nursing

Reference Sources and Reading List

Brought to you by:

LITFL Review 342 Marjorie Lazoff, MD

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Funtabulously Frivolous Friday Five 246 https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-246/ https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-246/#respond Thu, 26 Jul 2018 23:32:15 +0000 https://lifeinthefastlane.com/?p=178839 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Funtabulously Frivolous Friday Five 246 - Just when you thought your brain could unwind on a Friday, some medical trivia FFFF.

Funtabulously Frivolous Friday Five 246 Neil Long

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 246

Readers can subscribe to FFFF RSS or subscribe to the FFFF weekly EMAIL

Question 1

What is so special about this watch and who invented the concept?

doplr pulse watch

  • It is the doplr physician’s pulse watch.
    • Pulsometer: As the second hand passes the 12 o’clock mark, take the pulse and count 15 beats. Read the corresponding number on the dial at the 15th beat.
    • Asthmometer: As the second hand passes the 6 o’clock mark, count five breaths and read the corresponding number on the dial at the fifth breath.
  • Robert Graves (1796-1853) had long been heralded as the uncredited inventor of the second-hand on watches. However his role was only to extol the virtues of the second hand in the accurate assessment of the pulse in the clinical setting…
  • It was English physician Sir John Floyer (1649-1734), in 1707 who invented the pulsometer watch and therefore the seconds hand. Floyer was renowned for his work on the study of the pulse and believed understanding a patient’s pulse was fundamental to elucidating a diagnosis. He developed the pulsometer watch with London watchmaker, Samuel Watson. It enabled him to become the first physician to study the pulse in his clinical practice. He published The Physician’s Pulse-watch Volume I 1707, Volume II 1710.
  • The Doplr Pulse Watch (2017) is the physician designed modern day medical equivalent.
  • Sir John was a little eccentric. He held many strong convictions regarding cold bathing and was able to persuade ‘worthy and obliging gentlemen‘ to contribute towards erecting a cold bath at Lichfield.

Physicians oft find it a difficult task to conquer the aversions of nice patients and to persuade them to use those medicines to which they have not been accustomed, until they have first convinced them that their medicines are both safe and necessary. I expect to find the same aversion to cold bathing.’ Floyer 1702

Question 2

William Henry Battle best known for his description of a mastoid ecchymosis as an indicator of a skull base fracture (Battle sign) also had an incision named after him, what operation was he performing?

  • Appendectomy 
  • William Henry Battle (1855-1936) was an English surgeon, who noted some patients developed hernias post appendicectomy and therefore modified the site of incision

“… incision 1.5 inches to the inside of the line semilunaris, and divided the aponeurosis of the external oblique with the sheet of the rectus. The rectus muscle was then drawn to the inner side, and the posterior layer of the sheath and transversals fascia exposed, the inner incision not corresponding to the external”.

  • He later responded that “this incision did absolutely prevent hernia”. [Reference]

Question 3

What is Basedow disease?

  • Immune hyperthyroidism (more commonly referred to as Graves disease or Parry disease.)
  • In March 1840, Karl Adolph von Basedow (1799-1854), described an association of exophthalmos, tachycardia, and goitre in four cases (Madamme F, G, C and Herr M) monitored over periods of 2, 5, 10 and 11 years. Described locally as the ‘Merseburger Triad‘ the condition was eponymised in 1858 as Basedow disease by Hirsch 1858;2:224-225
  • Von Basedow outlined the symptoms of hyperthroidism including intolerance to heat, profound sweating, diarrhea and weight loss in the presence of increased appetite.
  • Madame G and Madame F presented with symptoms of florid hyperthyroidism and exophthalmos and during the course of the disease, both were deemed to have become insane with Madame F admitted to a lunatic asylum.

‘There appeared an eminent protrusion of the eye balls, which by the way were absolutely healthy and had a completely full sight. In spite of this the sick woman was sleeping with open eyes and had a frightening appearance.’ Basedow 1840 (Madame G)

  • Herr M, was a 50-year-old man who in 1832 began feeling malaise and having diarrhoea. He suffered from ‘a heat of the blood‘, intense sweating, and oppression of the chest. He had a pale puffy countenance with protruding eyes (‘prominent like a crayfish’s eyes‘); the thyroid was enlarged; the patient was emaciated in spite of good appetite and continued to suffer from loose bowels.
  • Von Basedow described the connection between these symptoms and tried to explain the pathophysiological mechanisms. He proposed that the exophthalmos was due to an increase of the tissue behind the eye. He hypothesized that ‘dyscrasia of the blood‘ (i.e. mediated via the circulation) caused this tissue swelling and also the goitre. He described pretibial myxedema in two patients with thickened lower legs consisting of a ‘plastic brawn‘ not being impressible and not releasing fluid by puncture. Finally he described pregnancy as a most suitable cure! With symptom amelioration during, and exacerbation following pregnancy recorded in all of his three female patients.
  • In 1848, Basedow proposed the name Die Glotzaugen-cachexie [Goggle-eyed cachexia] for the constellation of symptoms he first described in 1840.

Question 4

In 1774 a young girl was the first in England to be successfully treated by this technique after falling from a window, what was it?

  • Cardioversion: Her heart was restarted with a direct current shock after 20 minutes.
  • The Rev. Mr Sowdon and Mr Hawes, apothecary, reported on the surprising effects of electricity in a case report of recovery from sudden death, published in the annual report of the newly founded Humane Society now the Royal Humane Society. The Society had developed from ‘The Institution for Affording immediate relief to persons apparently dead from drowning’. It was “instituted in the year 1774, to protect the industrious from the fatal consequences of unforseen accidents; the young and inexperienced from being sacrificed to their recreations; and the unhappy victims of desponding melancholy and deliberate suicide; from the miserable consequences of self-destruction.”
  • A Mr Squires, of Wardour Street, Soho lived opposite the house from which a three year old girl, Catherine Sophia Greenhill had fallen from the first storey window on 16th July 1774. After the attending apothecary had declared that nothing could be done for the child Mr Squires, “with the consent of the parents very humanely tried the effects of electricity. At least twenty minutes had elapsed before he could apply the shock, which he gave to various parts of the body without any apparent success; but at length, upon transmitting a few shocks through the thorax, he perceived a small pulsation: soon after the child began to sigh, and to breathe, though with great difficulty. In about ten minutes she vomited: a kind of stupor, occaisioned by the depression of the cranium, remained for some days, but proper means being used, the child was restored to perfect health and spirits in about a week. [Reference]
  • It is somewhat doubtful that the electricity resulted in ROSC as the child was likely unconscious from a head injury, that is unless she had commotio cordis.

Question 5

What is the ‘tattoo-to-teeth’ ratio and what does it indicate?

  • A general rule of thumb is that if the tattoo-to-tooth ratio (TTR) is greater than or equal to one, your patient is indestructible.
  • The higher the TTR score, the lower the likelihood of a terminal outcome.
  • A patient with a TTR of just two could be run over by a truck after being shot twice in the back outside of the bar in which he drank six-fifths of whiskey, and shortly after admission to the emergency department he would be demanding cigarettes and sexual favours from any nearby persons.

…and finally

Funtabulously Frivolous Friday Five 246 Neil Long

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Tropical Travel Trouble 011 Tonsillitis and the Bull https://lifeinthefastlane.com/tropical-travel-trouble-011-tonsillitis-and-the-bull/ https://lifeinthefastlane.com/tropical-travel-trouble-011-tonsillitis-and-the-bull/#respond Wed, 25 Jul 2018 04:20:46 +0000 https://lifeinthefastlane.com/?p=178808 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Tropical Case 011, It's just a case of tonsillitis, I've put them in short stay for review ...

Tropical Travel Trouble 011 Tonsillitis and the Bull Amanda McConnell

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

aka Tropical Travel Trouble 011

Peer Reviewers: Dr Jennifer Ho, ID physician QLD, Australia and Dr Mark Little, ED physician QLD, Australia.

You are working in far North Queensland and encounter a 20 year old Indigenous man with tonsillitis on your ED short stay ward round. He has been receiving IV penicillin and metronidazole overnight but is deteriorating and now cannot open his mouth beyond 1.5cm, and has a swollen neck (some might say ‘Bull neck’). In addition, he now has “gurgly” breathing. He is taken to OT to be intubated by ENT and they report a grade 4 airway with “large grey tonsils and moist scales”.

Questions:

Q1. What is your differential?

  • Viral pharyngitis
  • EBV
  • Group A Strep
  • Oral Candidiasis
  • Epiglottitis
  • Diphtheria
  • Ludwigs angina

Q2. What is the cause of this man’s tonsillitis?

  • Diphtheria.
  • The word diphtheria comes from the Greek word for leather, which refers to the tough pharyngeal membrane that is the clinical hallmark of infection.
  • Below is a collection of images of the ‘grey pseudomembranous plaque’. This plaque occurs in the tosillopharyngeal region in 2/3rds of cases but can involve the laryngeal, nasal and tracheobronchial areas. Image 1 is in fact your barn door ‘regular tonsillitis’ for comparison. Make sure these images are imprinted onto your cortex!
Viral Tonsilitis
Diphtheria
Diphtheria + swollen neck
Diphtheria
Diphtheria
Early Diphtheria

Q3. What is diphtheria and how is spread?

  • Diphtheria is caused by the gram-positive bacillus Corynebacterium diphtheriae or Corynebacterium ulcerans.
  • Diphtheria is spread by respiratory droplets or occasionally by direct contact with C. diphtheriae infected skin or an object/clothes. In some counties C.ulcerans moves from its cattle reservoir into the human population by the consumption of unpasteurised milk or close contact.
  • The incubation period of diphtheria is 2–5 days.

Q4. How would you confirm your clinical diagnosis?

Need to detect both the bacterium and the toxin. Asymptomatic pharyngeal carriage is relatively common therefore you could carry the toxin or the genes for the toxin but not have clinical disease.

  • Pharyngeal swab MC&S – Gram stain shows gram positive rods in a ‘Chinese character’ distribution for presumptive diagnosis. Swab the throat and under the membrane if possible. Label for diphtheria as this need to be grown on Loffler’s or Tindale’s media. For those of you who spend their time in the lab it is catalase positive, urease negative, cystinase positive, and pyrazinamidase negative.
  • Pharyngeal swab PCR – detect the DNA sequence encoding the A subunit of toxin. If negative this excludes diphtheria, if positive you also require a positive culture as the result only indicates the presence of the gene and not infectivity.
  • Other tests for toxins – there is a rapid enzyme immunoassay (EIA) for the detection of toxin and an Elek test which uses antitoxin impregnated filter paper laid over an agar culture of the organism (takes 24-48hrs to perform).
Corynebacterium diphtheriae

Q5. How does diphtheria cause harm?

  • C. diphtheriae attaches to mucosal epithelial cells. Here an exotoxin is released by endosomes causing a local inflammatory reaction followed by tissue destruction and cell necrosis.
  • Inflammation mediated lymphatic and haemotologic spread means the endotoxin travels throughout the body leading to potential damage to the:
    • Kidneys – renal failure and hypotension.
    • Myocardium – In some studies 2/3rds of patients will have myocarditis (ST-T wave changes, QTc prolongation and/or first degree heart block – typically as the local respiratory symptoms improve or 7-14 days after the onset of symptoms). C. diphtheria has also been implicated in endocarditis and mycotic aneurysms.
    • Nervous system – 75% of patients with severe disease will develop paralysis of the soft palate or posterior pharyngeal wall, cranial neuropathies and in some peripheral neuritis (weeks to months later) resulting in either mild weakness or complete paralysis.
  • The diphtheria endotoxin consists of 2 subunits – A and B.
    • The B subunit binds to a receptor on the surface of the host cell and then proteolytically cleaves the membrane lipid layer allowing the A subunit to enter the cell.
    • The A subunit then inhibits normal cell protein synthesis.

Q6. Who is at risk of contracting Diphtheria?

  • Diphtheria toxoid vaccination has been included in the childhood vaccination schedule since the 1920s in most developed countries. Therefore, those most at risk are the unimmunised.
  • Sporadic outbreaks are seen in mostly in disadvantaged groups who live in crowded conditions.
  • Adults and children under 5 are most at risk of dying from diphtheria with a mortality rate of up to 20%.
Diphtheria cases and DTP3 coverage

Q7. How does diphtheria present clinically?

  • C. diphtheriae can infect any mucosal cell. There are two main forms of the disease (plus an asymptomatic carrier state):

1. Respiratory diphtheria (nasal, pharyngeal and laryngeal):

  • Initially, patients present with URTI-like symptoms – pharyngitis, fever and cervical lymphadenopathy.
  • As the disease progresses they develop a swollen neck (“bull neck” – a sign of malignant infection) and a thick grey “pseudomembrane” forms over the tonsils (of note this will bleed if scraped).
  • The most common cause of death on day 3-5 of the illness is from airway obstruction or asphyxiation following pseudomembrane aspiration.
  • Exotoxin mediated myocarditis occurs in up to 60% and is the second most common cause of death. The overall mortality rate from diphtheria is 5-10% even when adequately treated.
  • In laryngeal diphtheria patients may only present with a cough and hoarseness as the larynx maybe the only site affected. Laryngoscopy will reveal a laryngeal pseudomembrane.
“Bull Neck”

2. Cutaneous diphtheria

  • Cutaneous diphtheria presents as a non-healing ulcer covered in a ‘dirty’ grey membrane. It occasionally progresses to respiratory diphtheria but this is rare due to a rapid response to treatment.

Q8. How do you treat diphtheria?

  • It is important to treat with both antibiotics and diphtheria anti-toxin (DAT) before confirmatory diagnosis as delay in administering the anti-toxin is associated with significantly increased mortality. If you suspect it, treat it immediately. There are commonly logistical delays on obtaining DAT, for example in Australia (it is only stocked in Brisbane), and there is limited worldwide supply due to ongoing outbreaks.
  • Isolate your patient and use universal and droplet precautions.
  • Secure airway pre-emptively.
  • IV antibiotics
    • Erythromycin PO or IV (40 mg/kg/day; maximum 2 gm/day – adults 500mg Q6 hours) for 14 days OR
    • Procaine penicillin G OD IM (300,000 U q12 hours <10kg and 600,000 U q12 hours >10kg), followed by oral penicillin V (250mg Q6 hours) for a total of 14 days.
    • Patient is non-infectious 24 hours after commencing antibiotics.
    • Repeat cultures at 24/48 hours and at 2 weeks after completion of treatment to prove eradication.
  • Diphtheria antitoxin (DAT)
    • DAT is manufactured as snake antivenom (hyper immunised horses), so administration is as per snake antivenom.
    • Neutralises the unbound exotoxin before it enters cells.
    • Dose according to clinical severity (20,000 – 120,000 units).
      • 20-40,000 for pharyngeal/laryngeal disease <48 hours
      • 40-60,000 for nasopharyngeal disease
      • 80-120,000 for >3 days of illness or diffuse neck swelling.
      • 20-40,000 skin lesions only after discussion with a specialist.
    • Complications as seen with snake antivenom : anaphylaxis and serum sickness.
    • Click for details on Diphtheria vaccination and antitoxin.

Q9. How do you prevent diphtheria?

  • Mass vaccination is the best form of prevention. WHO recommends a 3-dose primary vaccination series with diphtheria toxoid, followed by a booster dose.
  • Children in Australia and New Zealand receive up to 6 doses of DTPa vaccine (diphtheria, tetanus and acellular pertussis toxoid).
  • In adults, opportunistic booster doses are given with the ADT or Boostrix vaccines more commonly used for their tetanus and pertussis properties. Serb-Surveillance studies in the UK show 50% of adults over the age of 30 are susceptible and increasing to 70% in the elderly.
  • Those individuals who are in close contact with a person with diphtheria should be swabbed and given a booster vaccine as well as prophylactic antibiotics for 2 weeks (penicillin or erythromycin).
  • Patients with diphtheria in hospital should be placed in respiratory droplet isolation and their bedding and clothes decontaminated.

Case Resolution:

While in ICU the patient developed myocarditis with a complete heart block requiring a temporary pacing wire. He received DAT on day 3 of illness. Unfortunately, despite aggressive supportive therapy he developed multi-organ failure and passed away on day 16 of illness. 

References

LITFL Resources

Tropical Travel Trouble 011 Tonsillitis and the Bull Amanda McConnell

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LITFL Review 341 https://lifeinthefastlane.com/litfl-review-341/ https://lifeinthefastlane.com/litfl-review-341/#respond Sun, 22 Jul 2018 20:13:13 +0000 https://lifeinthefastlane.com/?p=178776 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Welcome to the 341st LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs

LITFL Review 341 Marjorie Lazoff, MD

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 341st LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

Readers can subscribe to LITFL review RSS or LITFL review EMAIL subscription

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsPARAMEDIC-2 epinephrine trial in out-of-hospital cardiac arrest was published recently in NEJM. Epi improved ROSC but bad neurological outcomes for survivors. What’s the take away? EM Nerd, First10EM, St. Emlyn’s, and R.E.B.E.L. EM each take on this question. [AJB, MMS]

 

The Best of #FOAMed Emergency Medicine

  • Insightful view on reducing missed ACS in a concise approach: think “ACS”:All symptoms, not just chest pain, electroCardiogram comparison and interpretation, and Stratify with HEART score. [MMS]
  • EM Cases welcomes Amal Mattu and cardiologist/electrophysiologist Paul Dorion to the program for a deep dive into tachydysrhythmias. [AS]
  • Learn this simple, yet elegant approach when encountering sinus tachycardia from Frank Lodeserto at R.E.B.E.L. EM. [MMS]

The Best of #FOAMcc Critical Care and #FOAMres Resuscitation

The Best of #FOAMus Ultrasound

The Best of #FOAMped Pediatrics

  • “Don’t pee on your friends,” and other valuable pearls for managing jellyfish envenomations can be found in this recent Peds EM Morsels. Deactivate, decontaminate, and denature the toxin and (after ABCs are secured) a hot shower may be more effective than morphine for the pain of a jellyfish sting. [TCN]

The Best of #FOAMim Internal Medicine

Reference Sources and Reading List

Brought to you by:

LITFL Review 341 Marjorie Lazoff, MD

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Calling all Educators!… Make a difference in ICU Education https://lifeinthefastlane.com/calling-all-educators-make-a-difference-in-icu-education/ https://lifeinthefastlane.com/calling-all-educators-make-a-difference-in-icu-education/#comments Sun, 22 Jul 2018 02:36:14 +0000 https://lifeinthefastlane.com/?p=178742 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Do you want to advance crit care education in Australia & New Zealand? Come to the (free) Clinician Educators Unconference, 10 October 2018!

Calling all Educators!… Make a difference in ICU Education Chris Nickson

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

It is an exciting time to be an Educator involved in critical care in Australia and New Zealand!

We now have an active interprofessional grassroots network working in collaboration with organisations such as CICM, ACCCN, ANZICS, ICN, ANZAHPE, and SMACC (among others!) to advance clinical education in critical care.

This Network seeks to:

  • promote and develop the Clinician Educator role
  • implement best practice education in critical care
  • foster education scholarship and research in critical care
  • provide capacity to consult on education issues in critical care
  • nurture a collaborative interprofessional approach to patient-centred education

On Wednesday, October 10th 2018, the day before the ANZICS ASM in Adelaide, we will be holding our first ICU Clinician Educators Unconference. The Unconference will involve facilitated interaction with known experts and practitioners using a deliberative dialogue approach. There will be scope for remote involvement via a live stream and Slack if you can’t attend in person.

This is the vision for this innovative free-to-attend event:

At the end of a productive day of working and learning together, we will have shared perspectives, developed a renewed sense of education priorities and their urgency, and created action plans for the work we can do together to advance critical care education. We will have seeded the creation of an active interprofessional community that has already begun to create real solutions to challenging problems. From this beginning, we will continue to grow and support each other as we create the future.

So, if advancing clinical education in critical care is your thing, join our Network (via this form: http://litfl.org/ANZCENform) and complete the Expression of Interest form (see below) ASAP (ideally by the end of July).

Whether you’re at the start or the end of your career and whether you are a nurse, a physio, a doctor, an academic educationalist, or something else, you are welcome to join us if you want to make a difference.

You can learn more about the Network here: http://litfl.org/ANZCENResources.

Calling all Educators!… Make a difference in ICU Education Chris Nickson

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Funtabulously Frivolous Friday Five 245 https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-245/ https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-245/#respond Fri, 20 Jul 2018 04:11:26 +0000 https://lifeinthefastlane.com/?p=178691 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Funtabulously Frivolous Friday Five 245 - Just when you thought your brain could unwind on a Friday, some medical trivia FFFF.

Funtabulously Frivolous Friday Five 245 Mark Corden

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 245

Readers can subscribe to FFFF RSS or subscribe to the FFFF weekly EMAIL

Question 1

What is a HeLa cell?

  • HeLa cells are an immortal cell line.
  • They were harvested from a patient called Henrietta Lacks (…He La)
  • They are the oldest and most commonly used human cell lines as they can grow indefinitely, be frozen and thawed, divided into batches and shared among laboratories.
  • Henrietta Lacks (1920-1951) was an African-American woman who’s aggressive cervical tumour was biopsied at John Hopkins Hospital in Baltimore, Maryland in 1951. Her cells were cultured by Georgo Otto Gey.  For years, Dr. Gey, a prominent cancer and virus researcher, had been collecting cells from all patients who came to The Johns Hopkins Hospital with cervical cancer, but each sample quickly died in Dr. Gey’s lab. What he would soon discover was that Mrs. Lacks’ cells were unlike any of the others he had ever seen: where other cells would die, Mrs. Lacks’ cells doubled every 20 to 24 hours.
  • Henrietta was never made aware that her cells were cultured for research, nor were her family notified or compensated for the commercial nature of the product, which was the standard at the time. Henrietta died later the same year aged 31 from metastatic disease. [Reference]
  • 1976 – Michael Rogers told the story of the HeLa cell line’s connection to Henrietta Lacks in Rolling Stone: ‘The Double-Edged Helix‘ March 25 1976
  • Check out the movie as well…  The Immortal Life of Henrietta Lacks

Question 2

In what year was smallpox declared eradicated?

  • 1980. 
  • Although the last natural case of Smallpox was in Somalia in 1977, it was declared eradicated by WHO in 1980. It was the first disease to be fought on a global scale.  By the end of the 1960’s smallpox was still endemic in Africa and Asia.>
  • The WHO Smallpox Eradication Programme ran from 1966-1980 and involved an active case identification and vaccination through the horn of Africa. [Reference]

Question 3

What is the oldest, continuously published, English language medical journal?

  • The New England Journal of Medicine.
  • 1812 – January 1, the first quarterly edition of the Journal was published under the rather lengthy title of The New England Journal of Medicine and Surgery and the Collateral Branches of Medical Science – Conducted by a number of physicians. This first edition included publications including; Remarks on Angina Pectoris; the Morbid Effects of Dentition; domestic opium; the dissection of a Blue Female Child; and A Dissertation on the proximate cause of Inflammation, with an attempt to establish a rational plan of cure.
  • 1823 – JVC Smith started the Boston Medical Intelligencer – devoted to the cause of physical education and to the means of preventing and curing diseases‘. However in 1827, with the publication of Volume 5 (1827-1828), the journal became insolvent.
  • 1828 – The editors of the New England Journal of Medicine and Surgery and the Collateral Branches of Medical Science purchased the Boston Medical Intelligencer and merged the publications to publish weekly with the new title of – Boston Medical and Surgical Journal (BMSJ).
  • 1928 – After 100 years of publications as the BMSJ, the Massachusetts Medical Society (who purchased the publication in 1921 for $1), renamed the publication the ‘New England Journal of Medicine (NEJM)’  – [NEJM 1928 Feb; Vol 198 (1):1-2]
  • Each of the dates on the NEJM logo represent the founding of the four key milestones in the journals history

Newer journal publication dates:

  • 1823 – The Lancet was first published October 5 1823 [Lancet 1823 Oct 05 Vol 1(1):1-36]
  • 1840 – The British Medical Journal was first published in October 3 1840 as ‘The Provincial Medical and Surgical Journal‘ [

Question 4

What underlying condition might make you want to treat a patient’s nose bleed by inserting nasal tampons made of salted pork?

  • Glanzmann thrombasthenia
  • Named after the Swis paediatrician Eduard Glanzmann (1887-1959)
  • In this condition the patient’s platelets contain defective or low levels of glycoprotein IIb/IIIa (GpIIb/IIIa), which is a receptor for fibrinogen. As a result, no fibrinogen bridging of platelets to other platelets can occur, and the bleeding time is significantly prolonged.
  • A Glanzmann thrombasthenia patient with epistaxis will bleed profusely…
  • An alternative approach, using nasal tampons consisting of salted pork, has been described in at least one case. How the pork works is unclear – it could that it is rich in tissue factor, or the salt may induce mucosal oedema and assist the tamponading effect of the pork ‘tampons’… or it could be coincidence. [Reference]
  • However, it’s not all doom and gloom, understanding of the role of GpIIb/IIIa in Glanzmann thrombasthenia led to the development of GpIIb/IIIa inhibitors, for the management of acute coronary syndrome. [Reference]

Question 5

How was viagra discovered?

  • By chance…
  • In the late 1980’s researchers at Pfizer were investigating the therapeutic potential of PDE5 (cGMP phosphodiesterase) enzyme inhibitors. Over 1500 chemicals were screened and tested over 4 years, resulting in sildenafil, which later acquired the trade name Viagra.
  • However, Pfizer’s scientests weren’t investigating sexual dysfunction. Viagra was being studied as a potential therapy for hypertension and angina. Unfortunately, Phase II trials of Viagra demonstrated that it was not suitable for the treatment of angina (of note, Viagra should not be used with nitrates for angina, as profound hypotension can occur). However, the patients themselves simply didn’t want to stop taking the drug. Pfizer’s researchers soon realised the reason for this: Viagra produced prolonged erections following sexual stimulation. The rest is history. [Reference]

…and finally

Funtabulously Frivolous Friday Five 245 Mark Corden

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Come to Critical Care Collaborative 2018! https://lifeinthefastlane.com/come-to-critical-care-collaborative-2018/ https://lifeinthefastlane.com/come-to-critical-care-collaborative-2018/#respond Tue, 17 Jul 2018 01:34:23 +0000 https://lifeinthefastlane.com/?p=178592 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Early bird rego for Critical Care Collaborative 2018 is closing soon - come learn the right stuff at the right price for registrars & nurses!

Come to Critical Care Collaborative 2018! Chris Nickson

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

This is a guest post by Diane Kelly, Intensivist and Educator at Epworth Healthcare, Melbourne.

The Critical Care Collaborative is a one-day conference with contemporary updates in Critical Care, delivered by entertaining engaging speakers, aimed at Intensive Care Registrars and Nurses…. why spend time searching for information when someone can just tell you about it? This year we are covering a very broad range of topics from Organ Donation and Obstetric ICU, to sepsis and ECMO.

It is great for those preparing for exams, with the most recent evidence presented in a very digestible way. It is definitely worth going to from a learning perspective, very reasonably priced, and proudly supported by ACCCN and ANZICS… and most of all it will be fun!

The venue this year is Pullman on The Park, East Melbourne, and the date to save is 17 August 2018.

Early Bird closes this week (22nd of July), so get in quick

Check out the programme and register via the ACCN website.

See you there!

Come to Critical Care Collaborative 2018! Chris Nickson

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LITFL Review 340 https://lifeinthefastlane.com/litfl-review-340/ https://lifeinthefastlane.com/litfl-review-340/#comments Mon, 16 Jul 2018 12:10:33 +0000 https://lifeinthefastlane.com/?p=178570 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Welcome to the 340th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the web

LITFL Review 340 Marjorie Lazoff, MD

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 340th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

Readers can subscribe to LITFL review RSS or LITFL review EMAIL subscription

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsSkeptic’s Guide to Emergency Medicine (SGEM) Xtra has posted Season #4 Book! Ken Milne continues in his quest to shorten the KT window in his latest season of the SGEM. (The first link also provides access to Books 1-3). [MMS]

 

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care and #FOAMres Resuscitation

The Best of #FOAMtox Toxicology

  • Poisonings treated (and caused by) the ICU are presented in this latest post from the Maryland CC Project. Josh D. King, MD reviews common toxicities that warrant ICU admission as well as their toxidromes. Novel antidotes and several iatrogenic toxicities are discussed as well. [TCN]

The Best of #FOAMus Ultrasound

  • We don’t often feature Twitter thread, but this is an amazing diagnosis made using #POCUS post op/ See this thread by @PARADicmSHIFT [CMD]
  • Resa Lewis in her AHRQ commentary discusses POCUS as powerful and intimately connected to patient safety. Its strength and limitations should be understood in the context of clinical evaluation to elevate its practice. [MMS]
  • Pneumatosis Intestinalis is an important sign in the diagnosis of intraabdominal pathology- and can be seen with POCUS. Thanks Sonostuff for the clip! [SO]

The Best of #FOAMped Pediatrics

The Best of #FOAMim Internal Medicine

  • Smallpox (variola) has been eradicated, but it remains in laboratories in the United States and Russia (and hopefully nowhere else). With herd immunity gone, the nightmare scenario now is a weaponized smallpox.. With that in mind, F. Perry Wilson, The Methods Man, takes us through tecovirimat, a newly FDA-approved treatment for smallpox. [RP]

The Best of #MedEdFOAM and #FOAMsim

Reference Sources and Reading List

Brought to you by:

LITFL Review 340 Marjorie Lazoff, MD

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Tropical Travel Trouble 010 Fever, Arthralgia and Rash https://lifeinthefastlane.com/tropical-travel-trouble-010-fever-arthralgia-and-rash/ https://lifeinthefastlane.com/tropical-travel-trouble-010-fever-arthralgia-and-rash/#respond Mon, 16 Jul 2018 03:08:25 +0000 https://lifeinthefastlane.com/?p=178442 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Tropical Case 010, Fever, Arthralgia and Rash in a traveller from Bali. What could it be?

Tropical Travel Trouble 010 Fever, Arthralgia and Rash Amanda McConnell

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

aka Tropical Travel Trouble 010

Peer Reviewer: Dr Jennifer Ho, ID physician QLD, Australia

You are an ED doc working in Perth over schoolies week. An 18 yo man comes into ED complaining of fever, rash a “cracking headache” and body aches. He has just hopped off the plane from Bali where he spent the last 2 weeks partying, boozing and running amok. He got bitten by “loads” of mosquitoes because he forgot to take insect repellent.

On examination he looks miserable, temp 39.8 °C, HR 115, BP 108/60, blanching maculopapular rash over his face, thorax, and flexor surfaces.

Questions:

Q1. What could this be?

  • Acute febrile illness in the returned traveller can be a number of diagnoses (not exhaustive):
    • Bacterial: strep throat, leptospirosis, toxic shock syndrome, rickettsia, typhoid, Melioidosis and meningitis.
    • Viral: Fifth disease, enterovirus, scarlet fever, hepatitis, zika, Chikungunya, Roseola, EBV, HIV seroconversion, West Nile virus, influenza, adenovirus, measles and Rubella.
    • Parasitic: malaria
    • Non infectious: ITP, Acute leukaemia, drug reaction and Kawasaki in the young.
  • Due to fact this is a tropical post the most likely culprit is an arbovirus (any disease transmitted by arthropods – insects).
  • There are three main groups of arbovirus presentations in humans:
    • FAR (Fever, arthralgia and rash – as in our patient),
    • CNS (central nervous system symptoms most predominantly an encephalitis e.g. Japanese encephalitis),
    • VHF (viral hemorrhagic fever e.g. Crimean-Congo hemorrhagic fever).
  • While it can be overwhelming the number of possibilities on presentation, a thorough travel history, history of presenting illness and examination will help you to narrow down your testing (yes this is why the ID team get you to order a raft of investigations as there is no other way). Travel health Pro is an excellent resource for looking up what travellers are at risk for including outbreaks and news for that country (I see Australia has a highly resistant Gonorrhoea at the moment!)
  • See the diagram below to narrow down your arbovirus differential.
Venn diagram of arboviruses from Dr Tom Solomon et al.

Q2. What is Dengue Fever and how do you contract it?

  • Dengue is the most common mosquito borne viral illness in humans. Derived from the Swahili word “dinga” which likely influenced the spanish word “dengue” meaning fastidious or careful which would describe the gait of someone with the bone pain of dengue fever.
  • Dengue viruses are single-stranded RNA viruses that belong to the genus Flavivirus.
  • The dengue virus comprises of four distinct serotypes (DEN-1, DEN-2, DEN-3 and DEN-4). Among them the “Asian” serotypes of DEN-2 and DEN-3 are frequently associated with severe disease accompanying secondary dengue infections. This may be because these strains are more virulent or antibodies against one dengue virus serotype (from a previous infection) enhance the entry of a second dengue virus into macrophages, leading to a more severe infection. The latter theory has made some scientists nervous about creating a vaccine only covering one strain.
  • Dengue virus is transmitted by the bite of the female Aedes genus mosquito found in tropical and sup tropical parts of the world. They are the same mosquitoes that transmit Zika virus, Yellow Fever and Chikungunya but are different to the mosquitoes that transmit malaria (Anopheles).
  • Annoyingly Aedes mosquitos feed during the day whereas Anopheles mosquitos feed at night. Hence the usual methods of mosquito nets +/- insecticide impregnation fail. Approximately 40-50% of the world’s population are at risk of contracting the virus.
  • The disease mainly affects children and travellers as adults develop immunity to the serotype in their area.
World map showing habitat suitability for Aedes mosquito.

Q3. What is the incubation period for Dengue Fever?

  • The incubation period for dengue fever is 3-14 days; usually 4-7 days – just long enough for a week in Bali!
  • Consider differentials if someone presents 2 weeks or more after returning from an endemic area.

Q4. How does Dengue Fever present clinically?

  • Dengue Fever has 3 stages of infection:
    • Febrile phase last 2-7 days (viraemic phase):
      • Dengue presents with sudden onset high fever (often up to 40.5°) with associated chills, severe ‘breakbone’ myalgia, arthralgia, retro-orbital pain and headaches. Additional GI symptoms (anorexia, nausea, vomiting and loose stool are common).
      • On day 2-5 after fever onset, a blanching maculopapular rash develops over the face, trunk and flexor surfaces. This rash usually last 2-3 days. In addition petechiae and ecchymoses may also be present.
      • A second measles-like (morbilliform) rash may appear within 1-2 days of defervescence (abatement of fever), this rash spares the palms and soles, and occasionally desquamates.
    • Critical (plasma leak) phase – riskiest time for developing complications:
      • If the temperature drops below 37.5 celsius during the first 3 to 7 days, some patients may experience an increase in capillary permeability as well as increased haematocrit levels.
      • This phase lasts 24 to 48 hours and can be associated with bleeding (epistaxis, vaginal, gastrointestinal, gums).
      • The mechanism is not well understood but in those patients who have greater capillary permeability they will rapidly develop tissue hypo perfusion and hypovolaemic shock. Pleural effusions, ascites, nephropathy and myocardial injury are all possibilities during this phase.
    • Recovery phase – where there is gradual reabsorption of the leaked fluid from the extravascular to the intravascular space:
      • The reabsorption takes 48 to 72 hours but some patients may develop a late appearance rash called “white isles on a red sea” accompanied by generalised parities.
      • Sinus bradycardia can also occur during this stage.
      • Full blood counts, haemocrit and platelets also recover.
Dengue phases

Q5. What is the modified dengue severity classification?

  • Previously Dengue Shock Syndrome (DSS) and Dengue Haemorrhagic Fever (DHF) where by DSS, was an acute increase in vascular permeability leads to extensive third spacing and plasma volume loss with associated clinical shock. If untreated it may lead to metabolic acidosis, cellular hypoxia and death. The hallmark features of DHF are vascular changes, thrombocytopaenia and coagulation disorders (DIC). A rising haematocrit with continually dropping platelets suggests the onset of shock.
  • Based on the DENCO study and multiple round the table discussions a new criteria was set to include ‘Dengue with warning signs’ as these patients often had a real possibility of progressing to severe disease:
Dengue classification WHO

Q6. How do you diagnose Dengue Fever?

  • Clinically if no tests are available (see diagram above), patient travelled through an at risk area with two symptoms. Can include a positive tourniquet test (sensitivity 58% and specificity 71%) as one of the symptoms.
    • 10 or more petechiae in a 1 square inch on the patients arm after 2 mins with a BP cuff inflated to their mid DBP and SBP. See how to do one here.
  • Bloods for dengue NS1 antigen +/- PCR and dengue serology. IgM and IgG will only start becoming positive after day 5.
  • Other tests to perform include:
    • Full blood count – leucopenia and thrombocytopenia are common. Monitor for a low haematocrit.
    • Coagulation studies – detect DIC.
    • LFT/albumin/protein – detect hypoproteinaemia; elevated AST/ALT.
    • CXR and Ultrasound if effusions and ascites are possible in patients in the critical phase.

Q7. How do you treat Dengue fever?

    • Dengue is usually a self-limiting illness.
    • Treatment is entirely supportive – fluids, analgesia, rest.
    • Avoid aspirin, NSAIDS, steroids, antibiotics and oral anticoagulants.
    • Patients who can tolerate adequate volume of oral fluids, passing urine every 6 hours and have no warning signs can be managed as an outpatient with follow up blood tests and a check for any warning signs every 24-48 hours after defervescence. Patients should be advised to return for medical attention if they develop any warning signs.

    • Patients who have Dengue without warning signs but have an associated disorder or social risk should be managed as an inpatient (e.g. social isolation, far from medical centre, pregnant, under 1 year of age, over 65 years, obesity, HTN, diabetes, asthma, renal failure, haemolytic disease, chronic liver disease, peptic ulcers and the use of anticoagulants).

    • Dengue with warning signs require inpatient monitoring +/- IV fluids along with close haemtocrit, blood count, platelet and electrolyte monitoring. IV fluids should be titrated along normal parameters of blood pressure, urine output, conscious state and an awareness of third space losses/complications.

  • Severe Dengue is a medical emergency that requires meticulous attention to fluid resuscitation in an intensive care setting.
    • 2 – 3 boluses of crystalloid at 20ml/kg is recommended prior to commencement of inotropes but this will be patient dependent (i.e. the elderly).
    • A sudden drop in haemotocrit but lack of clinical improvement may indicate major bleeding and necessitate transfusion.
    • If fibrinogen <100 mg/dl, transfuse 0.15 U/kg of cryoprecipitate.
    • If fibrinogen >100 mg/dl and PT and aPTT are more than 1.5x the standard reference values consider fresh frozen plasma 10 ml/kg.
    • Consider platelets for uncontrolled bleeding or emergent operations (platelets should be >50,000 mm3 for most operations or >100,000 for eye and neurosurgery). Patients can drop their platelet count to below 10,000 mm3, if stable only require strict bed rest.


Q8. How do you prevent Dengue Fever?

  • There is no commercially available vaccine at this stage.
  • Prevention consists of avoiding mosquito bites by using repellent, covering up, using indoor insect sprays and by not travelling to tropical/sub-tropical parts of the world e.g. Bali!

Case Resolution:

You strongly suspect Dengue Fever and a dengue antigen test confirms this the following day. Your patient improves with paracetamol and fluids and his platelet count is low-normal. You advise him to follow up with his GP for daily FBE/haematocrit and to return if his platelets are dropping or haematocrit is rising. You send him home to his Mum with paracetamol.

Further Reading

References

LITFL Resources

Tropical Travel Trouble 010 Fever, Arthralgia and Rash Amanda McConnell

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Funtabulously Frivolous Friday Five 244 https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-244/ https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-244/#respond Fri, 13 Jul 2018 14:37:59 +0000 https://lifeinthefastlane.com/?p=178434 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Funtabulously Frivolous Friday Five 244 - Just when you thought your brain could unwind on a Friday, some medical trivia FFFF

Funtabulously Frivolous Friday Five 244 Neil Long

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 244

Readers can subscribe to FFFF RSS or subscribe to the FFFF weekly EMAIL

Question 1

What is the Mandela effect?

  • A false memory, shaped by social reinforcement or false news and misleading photographs.
  • The name of the theory comes from self-described ‘paranormal consultant’ Fiona Broome in reference to her belief and of many people, feeling certain they could remember Nelson Mandela dying while he was still in prison back in the ’80s. Her explanation was about alternative realities but most commentators believe in the social reinforcement theory. [Reference]
  • One of the most famous examples that comes to mind is the Darth Vader line “Luke, I am your father.” He actually says, “No, I am your father.” [For more examples click here]

Question 2

What is the ‘Bix rule’?

  • The rule states: with SVT, in which visible P waves are situated midway between ventricular complexes, there is a probability that there is a P wave lurking within the QRS. Thus, it can be an atrial tachycardia or atrial flutter with a 2:1 AV conduction. [Reference]
  • The rule is named in honour of Viennese cardiologist, Dr Harold Bix who worked in Baltimore. [Reference]
Flutter 2:1 AV block

Question 3

If you were climbing Everest why might you see Osborn wave at you?

  • Because you are hypothermic. 
  • The Osborn wave or J wave is a positive deflection at the J point (negative in aVR and V1).
  • Typically seen in temps under 30 degrees Celcius but they can be a normal variant, due to medications, hypercalcaemia, neurological insults and idiopathic VF.
  • Eponymously named after John Jay Osborn (1917-2014) following his 1953 ‘current of injury‘ description in hypothermic dogs.

J waves in moderate hypothermia (30 degrees C)

Question 4

What would you use a facial Goniometer for?

Facial Goniometer, mid-19th century. Collin, Paris

  • A goniometer is any device that measures angles. A facial goniometer is specifically concerned with calculating the angle of the face from the jaw to the forehead. 
  • The instrument was introduced in the mid-19th century by anthropometrists. This particular example was made by Adolphe Collin, the well known surgical instrument maker from Paris. [Reference]

Question 5

What tropical disease did Homer call Dog-star fever?

  • Malaria
  • Homer was fascinated by the stars and linked the appearance of Sirius, the dog star (in late summer and Autumn) with malarial fever and misery. [Reference]

…and finally

Funtabulously Frivolous Friday Five 244 Neil Long

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MRaCC Alice Springs – a retrieval experience like no other! https://lifeinthefastlane.com/mracc-alice-springs-a-retrieval-experience-like-no-other/ https://lifeinthefastlane.com/mracc-alice-springs-a-retrieval-experience-like-no-other/#respond Wed, 11 Jul 2018 12:24:19 +0000 https://lifeinthefastlane.com/?p=178364 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Michelle Withers writes about the Medical Retrieval and Consultation Centre (MRaCC) in Alice Springs. Sounds like a great place to work!

MRaCC Alice Springs – a retrieval experience like no other! Chris Nickson

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

This is a guest post by Dr Michelle Withers (@desertoak), emergency physician at Alice Springs Hospital

On February 12th, 2018, a new and completely unique service went live in Alice Springs – the Medical Retrieval and Consultation Centre (MRaCC). The Central Australian Retrieval service has been operating from the Alice Springs Hospital in conjunction with RFDS in various guises for many years, and we were first accredited for training in 2006.

We already consider ourselves an ‘interesting‘ place to work, and we’ve been the subject of a previous LITFL article, and a number of Jellybean Podcasts.

The opening of MRaCC caused a seismic shift in how retrievals are handled in Central Australia, bringing all co-ordination together via the one service. Since we started operations, all clinics, stations, mines, and anyone else requiring emergency advice or evacuation in our (1.26 million km2) catchment area, now call a single number to contact MRaCC, which is staffed at all times by specialist retrieval clinicians.

Since the red dust has settled, we are seeing obvious benefits to patients – better and faster communication, earlier specialist input, the use of telehealth, and improved integration of care.

Something none of us had really anticipated though, was what it would be like to co-ordinate in a service where there is one hospital (where we all work) and one retrieval service (for which we all fly). Some of the unexpectedly satisfying things about this are continuity of patient care, and the collegial nature of the job. Let me explain further.

As the Medical Retrieval Consultant on a co-ordination shift in the MRaCC, I will usually have the duty flight doctor sitting in the office with me whilst awaiting tasking. That way, the flight doctor is involved with the pre-hospital consultations, engages with the pre-hospital staff, and discusses the plan with me before departing on an evacuation. They are also able to assist with taking consult calls, following up patients from previous retrievals, and (occasionally) with minor but life-sustaining tasks such as retrieving burritos for the team. The next day though, I could be the flight doctor with the roles reversed, and I may even get to fly to the clinic that I was talking to the previous day.

The RFDS flight nurses often drop into our office on their way to the hangar, the St John Ambulance station officers visit when passing through the hospital, and the ICU and ED consultants pop their heads in every now and then to see if there is anything needing their input. Sometimes, we even get visits from the medics, paediatricians or obstetricians – this has ABSOLUTELY nothing to do with the MRaCC coffee machine and comfy couch…

We work alternate weeks in MRaCC and our ‘base speciality’, so the critical care specialists on duty are often “us”. Even those that aren’t, work closely with us on a regular basis, and we all know each other fairly well. One of the best things about working as a specialist at the Alice Springs Hospital, is that (mostly) the different specialities actually work together to try and achieve the best outcomes for patients, rather than having silly disputes about whose bed card they should come in under. By the end of my shift, some of my patients (whom I may have already “met” on telehealth) will be in ED or ICU. I can follow them up, or even just have a brief chat with them, because we are based just next door to ICU and upstairs from ED. If they need transfer out to an interstate hospital, or medical repatriation to get back to country, MRaCC will co-ordinate that as well.

MRaCC photos

So, it really is a unique job, and would suit any enthusiastic critical care retrieval specialist (or fellow) who wants to get “out bush” and be part of consolidating a dynamic new service. We do all of the usual stuff as well – orientation, teaching, training (for ACEM, CICM and ACCRM), QI, and research. Watch the brief “official” video of the Central Australian Retrieval Training course, which forms part of our orientation programme, below. We even cater for those who don’t want to commit, offering three- or six-month sabbaticals, with the potential to extend if you like it. Oh, and if you are still in training – we also employ retrieval registrars!

If interested, drop me a line, or send an email to Tracy Walczynski, Director of Retrieval, at the addresses below. You never know…

Cheers, Michelle.

Further Details

MRaCC Alice Springs – a retrieval experience like no other! Chris Nickson

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LITFL Review 339 https://lifeinthefastlane.com/litfl-review-339/ https://lifeinthefastlane.com/litfl-review-339/#respond Mon, 09 Jul 2018 00:27:21 +0000 https://lifeinthefastlane.com/?p=178303 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Welcome to the 339th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the web

LITFL Review 339 Marjorie Lazoff, MD

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 339th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

Readers can subscribe to LITFL review RSS or LITFL review EMAIL subscription

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsFirst10EM features an excellent one-stop shop for reading up on the different types of biases that are commonly seen in the literature. [AS]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care and #FOAMres Resuscitation

  • Is there a better way to treat Torsades de Pointes? And does anyone (besides me) use atropine or isoproterenol to increase base heart rhythm rate and shorten QTc? [AJB]
  • Jo Davy discusses a now classic trial of balanced solutions vs starch in the critically ill – another great contribution to The Bottom Line. [SO]
  • Want to get faster and slicker at ECMO cannulation? A wire assistant is an essential part of the team, and the ED ECMO guys tell us how that works. [SO]
  • How asleep should patients be? Aron Hussid Ferreira discusses the adverse associations between deep sedation and mortality in the latest ICU revisited post. [SO]

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

  • Looking for a realistic vascular access simulator? Jason Bowman and Jacob Avila show a simple technique using a chicken breast and penrose drain. [MMS]
  • Download the free Google Play store #POCUS app Bulldog Sonobites, by @Yale_EUS, perfect for just-in-time learning [CMD]
  • Listen to @nobleultrasound talk about everyday uses of lung #POCUS from the folk at @ultrasoundpod [CMD]

The Best of #MedEdFOAM and #FOAMsim

  • Looking to start a wellness project at your shop? The WRaP EM team are developing “How to” guides on this. My personal favorite: the “Staff Resus Trolley”. [MMS]]

Reference Sources and Reading List

Brought to you by:

LITFL Review 339 Marjorie Lazoff, MD

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